Management of breast cARCINOMA - PowerPoint Presentation

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Management of breast cARCINOMA

Presented by:Dr. Iram NaseerModerated by:Prof .Iqbal Aziz

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BREAST CARCINOMA

•Breast cancer is most commonmalignancy in female •Second to lung cancer•Now the mortality rate is↓owing to early detection

•

Etiology of the vast majorityof breast cancer is unknown

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RISK FACTORSAge

smokingpoor dietPersonal history of breast disFamily historyGenetic predispositionRadiation exposureExcess weight

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Early menarcheLate menopause

Older age pregnancyRaceHormone therapyBirth control pillsLack of exerciseNullipara

Not breast feeding

AlcoholPrecancerous breast

changes

(

atypical

hyperplasia)

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Diagnosis of breast cancer

History • breast mass • breast pain • nipple discharge • nipple or skin retraction • axillary mass or pain • arm swelling • symptoms of possible metastatic spread

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Past medical history of breast disease

Family history of breast andother cancers with emphasis on gynaecological cancersReproductive history• age at menarche • age at first delivery • number of pregnancies, children and miscarriages • age at onset of menopause

• history of hormonal

viz OCP

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Breast self exam

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Physical examination

Breast mass – size – location (specified by clock position and distance from the edge of the areola) – shape – consistency – fixation to skin, pectoral muscle and chest wall –

multiplicity

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Skin changes

– erythema (location and extent) – oedema (location and extent) – dimpling – infiltration– ulceration

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nipple changes

– retraction – erythema – erosion and ulceration – discharge (specify)nodal status – axillary

nodes on both sides (number, size, location and fixation to other nodes or underlying structures

) – supraclavicular

nodes

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RADIOLOGICAL INVESTIGATIONS

Mammography Nuclear Imaging(scintimammography) Ultrasonography Doppler Flow Studies Thermography Magnetic resonance imaging PET Scan

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Mammography

Mammography is a special type of x raycan demonstrate microcalcifications smaller than 100 μmReveals a lesion , 1-2 years before it is palpablesupportive to biopsy

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Types of mammography :

screening Diagnosticdone in asymptomatic women Diagnostic mammography is performed in symptomatic women

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FINDINGS IN MAMMOGRAPHY

MASSESSpace occupying lesion Round or oval- benign Irregular - malignant CALCIFICATIONS <0.5mmheterogenous

mass

microcalcificatn

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Mammogram – Difficult Case

•Heterogeneously dense breast •Cancer can be difficult to detect with this type of breast tissue •The fibroglandular tissue (white areas) may hide the tumor •The breasts of younger women contain more glands and ligaments resulting in dense breast tissue

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Mammogram – Easier Case

With age, breast tissue becomes fattier and has fewer glands Cancer is relatively easy to detect in this type of breast tissue

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Ultrasound screening

 supplement to mammography use in routine screening of general populationrole in young patients and high risk patients

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•As a screening device, fail to detect microcalcifications

•performed primarily to differentiate cystic from solid lesions •Ultrasonography is also useful for guiding the aspiration of cysts to provide cytologic specimens in FNAC

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Magnetic Resonance Imaging

Modality for detecting breast cancer in women at high risk and in younger women. Detection of occult breast carcinoma in a patient

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Evaluation of multifocal or bilateral tumor •Evaluation of invasive CA•Evaluation of suspected, extensive, high-grade carcinoma

•Monitoring of the response to neoadjuvant chemotherapy •Detection of recurrent breast cancer• Best modality for the breasts of women with implants

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Contraindications to MRI

Sensitivity to gadoliniumPatient's inability to lie prone(Marked kyphosis) Marked obesity Extremely large breastsSevere claustrophobia

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Positron Emission Tomography

It is the most sensitive and specific of all the imaging modalities for breast disease At present, its main use to detect recurrenceAlso useful in multifocal disease, in detecting axillary involvement and in cases of systemic metastases

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• Assist in identification of nonaxillary

lymph node metastasis (ie: internal mammary or supraclavicular lymph nodes) for staging locally advanced and inflammatory breast cancer before starting neoadjuvant therapy •Most expensive and least widely available.

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Thermography

Transmission of heat from the breast, and in malignant lesions results from the hypervascularity Using special heat scanners it is possible to mark “hot” perfusion sites on filmResults are variable and inaccurate, sensitivity is less than 50 percent and it is not advocated as a routine screening method, because it is unable to detect minimal breast cancer.

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FNAC (Fine Needle Aspiration)•Can be done for non-palpable masses

•FNAC takes individual cells

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Tru-cut (Core Biopsy) Needle

Used for:• T≥ 3 cm• operable case

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W.H.O. Classification of Carcinoma of the Breast

Non invasive carcinomaDuctal carcinoma in situLobular carcinoma in situPaget's disease of the nipple (without mass)

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Invasive carcinomaInvasive ductal

carcinoma -- 80%Invasive lobular carcinoma – 10%Mucinous carcinoma -- 2%Medullary carcinoma – 5%Papillary carcinoma -- 1%Tubular carcinoma – 1%Adenoid cystic carcinomaSecretory (juvenile) carcinomaApocrine carcinomaCarcinoma with metaplasia

(

metaplastic carcinoma)Inflammatory carcinoma

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Ductal carcinoma in situ

-originat from terminal duct lobular Units-C\P: mass .pain . discharge-ipsilateral-common(25-70%)

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Lobular carcinoma insitu

-no clinical sign-no microcalcifictionsby mammogram-bilateral-less(25-35%)

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Invasive ductal carcinomas

• Clinical presentation-Hard, irregular lumpPeau d’orangeInflammation of nippleUlceration of nipple

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Invasive lobular carcinoma less common than IDC

 C/F:palpable Mass mammographic irregularBordersbilateral and multicentric

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Medullary carcinomas

•common in 6th decadewell- circumsribed mass with rapid growth• 4%• Originates in large ductsthe lesion is deep and mobile.

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Paget’s disease-Affecting nipple and

areola-Eczema like condition-female>40-1-2%of breast cancer

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Breast mass behind the areola

Hyperplasia of all layersof the epidermis thickening of epidermis followed byulceration of the skin

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Staging: without mass → Stage 0 (carcinoma

insitu) with mass → according to mass sizePrognosis: Good due to:1. Early diagnosis2. Slow rate of growth

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Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) accounts for between 1 percent and 6%The 5-year survival rate for patients with IBC is between 25-50%

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IBC has a high risk of recurrence

Aggressive kind of breast cancerIBC affects women at an average age of 59Black women are more likely than white women

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The Effect of Tumor Size on Survival

Survival

Tumor Size

As tumor size increases, the chance of survival decreases

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Staging of Breast Cancer•

The American Joint Committee on Cancer(AJCC) has designated staging by TNM• T= tumor size• N = lymph node involvement• M = metastasis

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TNM•

Tx No evidence of primary tumor• Tis Carcinoma in situ• T1 Tumor 2cm or <• T2 2 to 5 cm• T3 T> 5cm• T4a extension to chest wall• T4b edema (including peau d’orange), ulceration of skin, satellite nodules

• T4c T4a + T4b

• T4d Inflammatory carcinoma

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Regional lymph nodes• N0 no regional lymph node metastasis

• N1 Movable ipsilateral axillary lymph node• N2 Fixed ipsilateral axillary lymph n. or internal mammary lymph nodes• N3 -ipsilateral supraclavicular lymph node. -Fixed

ipsilateral

axillary lymph n. and

İnternal

mammary lymph nodes

-

İpsilateral

infraclavicular

lymph node.

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Distant metastasis• M0 - no distant metastasis

• M1 - distant metastasis

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Stage 1• Tumor < 2.0 cm in greatest dimension

• No nodal involvement (N0)• No metastases (M0)• 5-year survival- 87%

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Stage II• Tumor > 2.0 < 5 cm

• Ipsilateral axillary• lymph node (N1)• No Metastasis (M0)• 5-year survival- 75%

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Stage III (Locally advanced)• Tumor > 5 cm (T3)

• or ipsilateral axillary lymph nodes fixed toeach other or other structures (N2)• involvement of ipsilateral internal mammary nodes (N3)• Inflammatory carcinoma (T4d)• 5-year survival- 46%

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Stage IV (Metastatic breast cancer)• Any T

• Any N• Metastasis (M1)• 5-year survival- 13%

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Stage Grouping

Stage 0 Tis

Stage I T1 N0 M0

Stage II T1 N1 M0

T2 N0,1 M0

T3 N0 M0

Stage III Any Worse But M0

Stage IV Any with M1

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SURGICAL

• Radical Mastectomy• Modified RadicalMastectomy• Simple/TotalMastectomy• Breast ConservingSurgery

CHEMOTHERAPY

•

Neo-Adjunctive

Chemotherapy

•

Adjunctive

Chemotherapy

•

Chemotherapy for

Advanced

Metastatic Disease

RADIATION

•

Intra-operative

Irradiation

•

External beam

Radiotherapy

•

Brachytherapy

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SURGERYLumpectomy

Partial or segmental mastectomySimple mastectomyModified radical mastectomySentinel lymph node biopsyAxillary lymph node dissection

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Lumpectomy Surgically removing the

tumor and a smallmargin of healthy tissue around it Followed by radiation therapy May Include removal ofaxillary lymph nodes

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Partial/Segmental MastectomyExcision of mass along with

some portion of breast tissueQuadrantectomy excision of affected quadrant of the breast tissue

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TOTAL/SIMPLE

MASTECTOMY

62

Tissues

removed

:

Tumour,

entire

breast,

areola,

nipple,

skin

over

breast,

Axillary

tail

of

Spence,

Pectoral

fascia

Tissues

retained

:

NO

Axillary

Dissection

Subjected

to

Radiotherapy

later

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Total mastectomy with axillary clearance

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Common

procedure

Tissues

removed:

Axillary

fat

,

Axillary

fascia

,

Axillary

LN

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Modified Radical mastectomy

Tissues

removed:TM

+

Clearance

of

Axillary

LN

+ Pectoralis

minor

Tissues

preserved

:

Nerve

to

Serratus

anterior,

Nerve

to

Latissimus dorsi,

Intercostobrachial

nerve,

Axillary

Vein,

Cephalic

Vein,

Pectoralis

major

muscle

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Sentinel lymph node biopsy:

cancer has spread to the lymph nodes under the arm A blue dye/radioactive substance is injected in orderto identify the sentinel lnwhich drainslymph from the tumor They are then removed.

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 Axillary

lymph node dissectionabout 10 to 40 lymph nodes are removedUsually done at the same time of mastectomy or breast-conserving surgery

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Adjuvant therapy:

After surgeryChemotherapyhormone therapyRadiation therapyNeo-adjuvant therapy:Before surgeryReduce tumorsRadiation therapyChemo therapy

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TreatmentI- Early breast cancer:Non invasive (Stage 0)→ Surgery ± Adjuvant

(postoperative) therapyStage I & II → Surgery + Adjuvant therapy II- Advanced breast cancer:Stage III (Locally advanced) → Neoadjuvant (preoperative) therapy + SurgeryStage IV (Metastatic) → Systemic therapy ± LimitedSurgery

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Early Breast CancerStage I & IISurgery

◦ removing the area of concern and some normaltissue surrounding it is called a lumpectomy◦ removing the breast is called a mastectomy(most women with breast cancer will not need thebreast removed)◦ lymph nodes from under the arm may beremoved with either surgery

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Early Breast CancerStage I & IIRadiation

Standard treatment after a lumpectomy to reduce the chance of the breast cancer coming back in thesame breastIt is also called local treatment because it affects only the area being treated with radiation

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Late Breast CancerStage III (Locally Advanced)

 First• Neo adjuvant chemotherapy (3-4 cycles) Then• Surgery Then• Post operative chemotherapy (6 cycles) Then• Post operative radiotherapy

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Late Breast CancerStage IV (Metastatic)

 Palliative systemic therapy is the Main line of treatment

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Breast ReconstructionIntegral part of modern daybreast cancer management

 Silicone Implants Lattissimus Dorsi myocutaneous flap Rectus abdominus

myocutaneous flap

Gluteal

Free Flap

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Hormone Treatment◦ growth of many breast

cancers can be blocked bytaking hormone therapy◦Tt is in the form of a pillwhich is taken for 5yrs◦recommended for womenwho have a breast cancerthat is sensitive to hormones

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ER positive disease

PremenopausalTamoxifen for 5 yearsPostmenopausalTamoxifen for 5 yearsfollowed by letrozole

for

5yrsAromatase

inhibitor

(

letrozole

,

anastrozole

,

exemestane

for

5 years)

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Chemotherapy• Treatment with one or more

cytotoxic antineoplastic drugs•Either curative or preventive•Used in conjugation withradiation therapy or surgery• Chemotherapeutic agentsact by killing cells

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Side effects:•

Immunosuppression andMyelosuppression• Gastrointestinal distress• Anemia• Fatigue• Hair loss• Peripheral Neuropathy

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Radiation Therapy• It involves medical use

of ionizing radiation,used in cancer Tt• It can be used as aCurative or adjuvant• Ionizing radiation workby damaging the DNAof cancerous tissuesleading to cellular death

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Side effectsNausea

vomiting LymphedmainfertilityFibrosis of exposed tissueHair lossdryness of mouthDryness of eyes

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Prognosis of breast carcinomas• Major prognostic factors

 Tumor Size lymph nodes statusNuclear gradeAgeThe location of the tumor its spread

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“To go fast,

go alone.To go far, go together.”