management of breast cancer by moh'd taofiq bak
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Management of breast cancer
Dr. Mohammed TaofiqRegistrar,Department of Surgery,
UITH,Ilorin.
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Outline...
•Introduction •Epidemiology •Risk factors•Surgical anatomy•Clinical features•Imaging •Biopsy•Pathology•Prognostic/predictive factors•Treatment •conclusion
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Introduction...
•Most frequently diagnosed life – threatening cancer in women
•Leading cause of cancer death in women
•A major public health issue globally - 1 million new cases annually - 400,000 annual death - 4.4 million living with the dx
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Epidemiology...
•Prevalence is worldwide
•Incidence is higher in the developed world
• highest in North America,New Zealand /Australia
• lowest in Asia & Sub- Sahara Africa
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Epidemiology...
•Mortality decreasing in the developed World
•Life time risk is 1 in 6 overall & 1 in 8 for invasive disease
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Risk factors...
Precise etiology is unknown•Age : rises sharply with age,rare in <
25yrs•Sex : 100x commoner in female•Race/ethnicity : commoner in whites•Family history : most widely recognized
breast cancer risk factors 5-10% of all breast
cancers are hereditary
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Risk factors...
Family history :•One or more first degree relative with
breast or ovarian cancer•Breast cancer occurring in an
affected relative < 50yrs•Male relative with breast cancer•BRCA1 and BRCA2 mutations•Ataxia- telangiectasia heterozygotes•Ashkenazi Jewish descent
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Risk factors
-20 -30% women with BCA have atleast one relative witness BCA
-Only 5- 10% of BCA patient have an identifiable predisposed factor
-BRCA 1 & 2 account for 3- 8% of BCA & 15 & 20% of familiar cases.
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Risk factors
·BRCA 1-TSG located on xsome 17
-Life time risk of developing BCA & Ovarian CA 85% & 40%
-Mastectomy reduces the risk of BCA by 95%
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Risk Factors
· BRCA 2 -Located on xsome 13
-Increase risk of male BCA
-Spectrum of associated BCA similar to non carriers
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Risk factors....
Neoplastic conditions :Previous breast cancerOvarian cancerEndometrial CancerDCISLCIS
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Risk factors...
•Benign breast diseases :Atypical lobular HyperplasiaAtypical ductal HyperplasiaComplex fibroadenomaSclerosing adenosisIntraductal papillomatosis
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Risk factors...
Reproductive factors :•Menarche at < 13yrs•Nulliparity •Menopause > 50yrs•First full pregnancy > 30yrs•Less breastfeeding
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Risk factors....
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Surgical anatomy...
•Modified sebacious gland•Ectodermal origin•Borders•Fascia•The skin •Subcutaneous tisssue•The breast tissue : stromal &
epithelial•Blood supply and Lymphatics.
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Surgical anatomy...
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Clinical features....
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Clinical features...
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Imaging ...
•Mammography - Primary imaging modality - abnormality on mammographic
screening requires further
characterization - can show microcalcification <
100microM - pick lesion 1-2yrs b4 SBE or
CBE
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Imaging ...
•Mammography - Screening : - asymptomatic Patient - mediolateral oblique (Side) - craniocaudal (Above) - Diagnostic : - new symptoms - additional views:Spot
compression
Magnification
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Imaging...
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Imaging ...
•Ultrasonography - further xterize a mammographically
detected abnormality - to identify a cystic mass - alternative to mammography in dense breast
- USS guided biopsy - measure & clip a lesion prior to neoadjuvant chemotherapy
- improved specificity when used appropriately
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•MRI - Xterization of an indeterminate
lesion - Detection of occult breast
cancer in px with carcinoma in an axillary LN
- Evaluation of suspected multifocal or bilateral tumor
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Biopsy...
•A clinically suspicious mass should be biopsized,irrespective of imaging findings
•FNAC
•Tissue Biopsy
•Open Biopsy
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Other investigations...
•CXR•FBC•SERUM ALP•LFT•ABDOMINOPELVIC USS•BONE SCAN•HORMONE RECEPTOR STATUS•HER2 OVEREXPRESSION
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Pathology ...
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Molecular intrinsic subtypes...
•LUMINAL A - ER +, &/or PR+, HER2 – - Most common - Less aggressive - good prognosis - Hormone responsible - Increasing age
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•LUMINAL B - ER+, &/or PR+ ,HER2 + - Worse prognosis than luminal A•BASAL LIKE - Triple Negative - Aggressive subtype - Younger ,pre-menopausal African
American
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•HER2 + - Less common - Highly aggressive subtype - young age - African American - Outcome improved with HER2
targeted therapy
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Staging ...
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Staging ...
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Staging....
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Staging....
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Prognostic factors...
•Axillary LN status•Tumor size•Lymphatic / vascular invasion•Patient age•Histologic grade•Histologic subtypes•Response to neo-adjuvant therapy•ER/PR status•HER2 gene amplification &/or
overexpression
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Predictive factors...
•ER/PR status
•HER2 gene amplification &/or Overexpression
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Treatment ..
•Multimodality & Multidisciplinary
•Surgery is the primary treatment modality-
early stage,cured with surgery alone
• Aim of surgery is complete resection of the primary tumor with negative margins & pathologic staging of the tumor & Axilla
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•Adjuvant therapy : radiation therapy(RT), chemotherapy, hormonal and Targeted therapy
•Neo- adjuvant therapy
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Role of surgery..
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DCIS
•Surgical resection + or – radiation
•ALND or SLNB not routinely recommended
•Tamoxifen Only approved agent in px rx with BCS
•A precusor of invasive dx. •Account for 5% of male breast cancer
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LCIS
•Observation & close follow up care with or without tamoxifen
•Bilateral mastectomy with or without reconstruction
•Risk of invasive cancer is low(25-30%) & equal in both breast.
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Treatment- Early Breast Cancer(I &II or T1-3,N0-1,M0)
•Loco – regional disease : surgery &/or
radiation therapy
•Systemic disease : one or
combination of chemotherapy,hormonal or biologic therepy
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Surgical options..
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Contra-indications to BCS
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Indications for Mastectomy
·Tumor size > 5cm
·Multicentric cancers
·Local recurrence ffg BCS
·Centrally located tumours
·No facillity for radiotherapy
·Risk reduction in high risk patient·Male breast cancer
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INDICATIONS FOR MASTECTOMY
*prior radiation therapy to the breast or chest wall
*Radiotherapy contraindicated In pregnancy
*Inflammatory breast cancer
*Persistent positive pathologic Margin
*Active connective tissue dx
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Radiotherapy ...
•Routine in BCS,May be indicated post mastectomy
•Aim is eradication of local residual subclinical dx & minimize local recurrence rates
•2 approaches : EBRT or PBI
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Post Mastectomy RT- Indications
•Positive post mastectomy margins
•Primary tumors larger than 5cm
•Involvement of 4 or More LN
•Skin or Chest wall involvement
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Side effects of RT...
•Fatigue•Skin desquamation•Breast pain•Breast swelling•Rib #•Pulmonary fibrosis•Cardiac dx•Secondary malignancies
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Treatment of the Axilla...
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Indications for ALND
*Preoperative diagnosis of +ve ALND
*Prior Inadequate ALND
*+ve Intraoperative SLNB
*Failed Mapping of SLNB
*Clinically suspicious nodes at surgery
*Neoadjuvant chemotherapy*Axillary local recurrence
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Axillary treatment...
•ALND or SLNB
•SLNB :Indicated in clinically node Negative px
•Single modality for axillary treatment
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ALND...
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SLNB...
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Adjuvant systemic therapy...
•Aim is to prevent recurrence & improve overall survival
•Choice of therapy depend on : - hormone status - menopausal status - HER2 status - risk of recurrence & potential
benefit•Combination therapy
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The NCCN guideline...
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Treatment of advance breast cancer
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LABC...
•Advance primary tumor ie > 5cm•Skin &/or chest wall involvement•Advance regional LN involvement•IBC Multimodality Rx involving
surgery,radiotherapy and systemic therapy Neoadjuvant systemic therapy is
usual
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Neo adjuvant therapy..
•Aim is to improve surgical outcome & surgical options
- operable BC,Increase the chances of BCS
-Inoperable, LABC: Achieving operability
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LABC
•Locoregional Rx is based on tumor response to neodjuvant
•Consist of surgery-either mastectomy or BCS
& post operative RT
• surgery should be done ONLY if a macroscopically complete resection is possible
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Adjuvant chemotherapy...
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Hormonal therapy...
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Hormonal therapy...
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recurrence dx...
•Post BCS : Total mastectomy + adjuvant chemotherapy or endocrine therapy
•Post MRM : local resection of recurrence where feasible + radiotherapy if no RT b4.
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Metastatic disease..
•Aim is to palliate symptoms,prolong survival,maintain QOL
•Visceral metastasis- poor prognosis
•Chemotherapy is indicated for hrme insensitive MBCA
•Hormone therapy preferred when ever applicable
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Conclusion...
•Breast cancer survival rates have increased significantly, particularly in younger women.
•The need for increased public awareness & early detection cannot be overemphasized.