breast cancer awatif

BREAST CANCER

By WAN AWATIF

OUTLINE

• Introduction• Risk factors• Clinical features• Staging• Investigation• Management

INTRODUCTION

• The common cause of death in middle-aged women in Western countries.

• in women amongst all races from the age of 20 years in Malaysia for 2003 to 2005.* Breast cancer is most common in the Chinese, followed by the Indians and then, Malays.* Breast cancer formed 31.1% of newly diagnosed cancer cases in women in 2003-2005.

RISK FACTORS

BREAST CARCINOMA – RISK FACTORS

BREAST CARCINOMA – RISK FACTORS

BREAST CARCINOMA – RISK FACTORS

CLINICAL FEATURES

• Breast lump• Dry scaling / red weeping.• Blood stained nipple discharge• Painless• Site : commonly in the upper outer quadrant• Tumour fixation : - -Breast distortion-flattening of contour-dimpling or puckering of the overlying skin-Nipple retraction• Nipple eczema in Paget’s disease

• Firm to hard in consistency• Irregular and indistinct edge • Mobile, softer and well circumscribed (esp in

mucoid and medullary ca)• In advanced :Skin ulcerationInfiltrationOedema

Must palpate axillae and supraclavicular

areas

BREAST - SKIN CHANGES

• Retracted nipple• Asymmetry• Skin changes

BREAST – SKIN CHANGES

• Swelling• Skin necrosing• Inflammation

CLASSIFICATION – BREAST CARCINOMA

NON-INVASIVE/IN SITU CARCINOMA

Intraductal carcinoma Lobular carcinoma in situ

INVASIVE CARCINOMA Infiltrating ( invasive )

duct carcinoma – NOS Infiltrating ( invasive )

lobular carcinoma Medullary carcinoma

Colloid (mucinous) carcinoma Papillary carcinoma Tubular carcinoma Adenoid cystic carcinoma Secretory carcinoma Inflammatory carcinoma Carcinoma with metaplasia

PAGET’S DISEASE OF THE NIPPLE

DUCTAL CARCINOMA IN SITU• Most DCIS detected by calcifications

on mammography/mammographic density - periductal fibrosis surrounding a DCIS/rarely palpable mass/ nipple discharge/incidental finding on a biopsy for another lesion.

• Spreads through ducts & lobules extensive lesions entire sector of a breast.

• DCIS – involves lobules – acini distorted, unfolded appear as small ducts.

PAGET’S DISEASE OF NIPPLE

INVESTIGATION- TRIPLE ASSESSMENT

54. NICE guidelines 2009; 55. KCE Belgian guideline, 2007

Triple Assessment

• All patients presenting with breast symptom should have a full clinical examination

• If a localised abnormality is present, >>> mammography and /or ultrasound examination

• >>>>core and /or FNAC depending on the clinician’s, radiologist’s and pathologist’s experience.

55. Belgian Guideline 2007

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• In young women (< 40 years old), ultrasound should be the initial imaging modality as part of the triple assessment

• a screening tool• Detects:- Lumps- changes in breast tissue - calcifications too small to be found in a physical exam.• Soft tissue radiographs are taken by -placing the breast in direct contact with ultrasensitive film• Very safe investigation -expose to low-voltage.• Sensitivity increases with age (breast become less dense)• Screening procedure

– monitoring patients at high risk for breast ca– Women > 40 years

• 5% of Br Ca can be missed.• Mammogram: does not exclude Br Ca.

MAMMOGRAPHY

• Useful in young women with dense breast.• Distinguish cysts from solid lession• Localise impalpable areas of breast pathology• Not useful as a screening tool

ULTRASOUND

• 3 ways– Fine needle aspiration– Core needle biopsy– Incisional / excisional open biopsy

• Microscopic examination

BIOPSY

Core Biopsy (CB) in combination with Fine Needle

Aspiration Cytology (FNAC)

Core biopsy in combination with FNAC may be used where facility and expertise are available

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Others

• Baseline investigation• detection of metastatic disease:

– liver function tests – serum calcium – chest radiograph – isotope bone scan – liver ultrasound scan – CT brain - in cases where suspicion is great clinically

TNM CLASSIFICATION

Stage I : T1 N0 M0Stage II A : T1 N1 M0 / T2 N0 M0Stage II B : T2 N1 M0 / T3 N0 M0Stage III A : T1 N2 M0 / T2 N2 M0 /

T3 N1 M0 / T3 N2 M0Stage III B : T4 any N M0 / any T N3 M0Stage IV : any T any N M1

MANCHESTER SYSTEM

•distant metastases other than the axillary nodes or •satellite nodules on breast or •supraclavicular nodal involvement

EARLY BREAST CA

Stage I : T1 N0 M0 Stage IIA :

• T0 N1 M0 • T1 N1 M0 • T2 N0 M0

Stage IIB - T2 N1 M0

Breast conservation is appropriate. It is an

alternative to Mastectomy

Breast conservation

• Removal of the tumour only• tumour should be <4cm in size for BCT.• >>>> radiotherapy. • Patient should be willing to take radiotherapy and come for

regular follow up. • Absolute contraindications: Pt’s wish to avoid radiotherapy Multifocal invasive breast breast cancer Large tumour in a small breast Widespread of ductal carcinoma in situ. (DCIS)• Then pt needs to do a mastectomy.

RADIOTHERAPY

• Improving local control• After BCT for early invasive BC

MASTECTOMY1. Radical Mastectomy (Halsted)

• Stage III, IV• Excision of pectoralis major muscle, excision of

breast, axillary LN, pect. major & minor• no longer indicated

2. Simple mastectomy - – removes breast only, with no dissection of axilla

(except for axillary tail - usually attached to a few LN in the anterior group)

MASTECTOMY

Indications:large tumour ( in relation to breast size)central tumours beneath or involved the nipplelocal recurrenceabsolute C/I to radiotherapypt’s preference skin/ collagen vascular disease that may be complicated by radiotherapyinavailability of radiotherapy facilities or non-compliance with radiotherapy

Indications:large tumour ( in relation to breast size)central tumours beneath or involved the nipplelocal recurrenceabsolute C/I to radiotherapypt’s preference skin/ collagen vascular disease that may be complicated by radiotherapyinavailability of radiotherapy facilities or non-compliance with radiotherapy

3. Modified Radical Mastectomy:1. Patey • the whole breast• large portion of skin, the centre of which overlies the tumour,

but always include the nipple• all of the fat, fascia, LN of axilla• preservation of axillary vein & nerves to serratus anterior,

pectoralis major & latissimus dorsi

4 Total mastectomy w/ or w/o radiation:1. Crile – Total mastectomy2. Mc Whirter – Total mastectomy and radiation (Axilla, • supraclavicular and

internal mammary nodes)

5. Subcutaneous Mastectomy:• Nipple is retained / for T1s

6. Quandrantectomy, axillary, radiotherapy (QUART)

• Quadrant of the breast that has the CA is resected• (quadrant of breast tissue, skin

and superficial pectoralis fascia)• Unacceptable cosmetic result

AXILLARY TREATMENT• At least 4 of LN from axillary fat for analysis.• Can be done w or w/o the removal of pectoralis minor muscle.• Axillary sample- removal of 4/> LN from proximal ant/ pectoral

& central gp of draining LN in axilla• Axillary dissection: dissecting the axilla to various anatomical

levels-– level I: removal of LN lateral to inferior border of pec.

Minor– level II : removal of level I LN & those behind & in front of

pec. Minor– level III : removal of all the lymphatic tissue

• Axillary clearance ; level III axillary dissection

complications of axillary treatment:intraoperative- damage to nervespostoperative- wound complications, lymphoedema

BREAST RECONSTRUCTION

• By plastic surgeons or specialist breast surgeons.• Method is depend on shape of contralateral

breast and chest wall.• Can be made either of a silicone implant or

autologous material or both methods.• Indicated for;

– < 55 yrs old– DCIS, LCIS & Stage I & II BC– pt who are undergoing prophylactic mastectomy

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• Chemotherapy:– Cyclophosphamide, metrotrexate , 5-fluorouracil (CMF) = gold

standard. – combination of chemotherapeutic agent containing

doxorubicin can be used– Administration of chemotherapy ( 2/> agents) improves

survival rate– Side effect: nausea, vomiting, myelosuppression, alopecia,

thrombocytopenia, exercise intolerance

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• Hormonal Therapy:Anti-estrogen:

a. Tamoxifen – a non-steroidal anti-estrogenic compound that compete w/ estrogen at receptor site. – Estrogen receptor assay should be

determined; if negative chance of success is very low

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Mechanism of action of tamoxifenas an antitumor agent

Local effects - independent of oestrogen receptor

+

-

stromalcell

Increase TGFβ

Anti-estrogen effects - blockage of estrogen receptor

Decrease TGF TGFαα

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Aromatase inhibition withinthe breast tumour cell

ANDROGENS OESTROGENS

P-450 Aromatase+ NADPH-cytochrome P-450 reductase

(Testosterone, androstenedione,16-OH-testosterone)

(Oestradiol, oestrone)

Aromatase Inhibitors

tumourgrowth

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Therapeutic Approach for Breast Cancer

A. Carcinoma in Situ:1. DCIS:

a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifenb. Total mastectomy w/ or w/o tamoxifenc. Breast-conserving surgery w/o radiation therapy

2. Lobular Carcinoma in Situ:a. Observation after diagnostic biopsyb. Tamoxifen to decrease the incidence of subsequent breast cancerc. Bilateral prophylactic total mastectomy, w/o axillary dissection

Follow - up

• ALL pts with BC should be F/U• Objectives of F/U:

– support & counselling– detect potentially curable conditions ( such as

local recurrence of cancer in the breast following BCT & to detect new cancers in opposite breast)

– manage pts in whom metastatic develops, & to determine outcome

• During F/U:– history, P/E– advise pt to do BSE monthly– annual mammography after therapy for primary

BC– after BCT, the first mammogram should be

performed 6 months after completion of radiotherapy

THANK YOU