Management of breast cancer

Dr. Mohammed TaofiqRegistrar,Department of Surgery,

UITH,Ilorin.

Outline...

•Introduction •Epidemiology •Risk factors•Surgical anatomy•Clinical features•Imaging •Biopsy•Pathology•Prognostic/predictive factors•Treatment •conclusion

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

Epidemiology...

•Prevalence is worldwide

•Incidence is higher in the developed world

• highest in North America,New Zealand /Australia

• lowest in Asia & Sub- Sahara Africa

Epidemiology...

•Mortality decreasing in the developed World

•Life time risk is 1 in 6 overall & 1 in 8 for invasive disease

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

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

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.

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%

Risk Factors

· BRCA 2 -Located on xsome 13

-Increase risk of male BCA

-Spectrum of associated BCA similar to non carriers

Risk factors....

Neoplastic conditions :Previous breast cancerOvarian cancerEndometrial CancerDCISLCIS

Risk factors...

•Benign breast diseases :Atypical lobular HyperplasiaAtypical ductal HyperplasiaComplex fibroadenomaSclerosing adenosisIntraductal papillomatosis

Risk factors...

Reproductive factors :•Menarche at < 13yrs•Nulliparity •Menopause > 50yrs•First full pregnancy > 30yrs•Less breastfeeding

Risk factors....

Surgical anatomy...

•Modified sebacious gland•Ectodermal origin•Borders•Fascia•The skin •Subcutaneous tisssue•The breast tissue : stromal &

epithelial•Blood supply and Lymphatics.

Surgical anatomy...

Clinical features....

Clinical features...

Imaging ...

•Mammography - Primary imaging modality - abnormality on mammographic

screening requires further

characterization - can show microcalcification <

100microM - pick lesion 1-2yrs b4 SBE or

CBE

Imaging ...

•Mammography - Screening : - asymptomatic Patient - mediolateral oblique (Side) - craniocaudal (Above) - Diagnostic : - new symptoms - additional views:Spot

compression

Magnification

Imaging...

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

•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

Biopsy...

•A clinically suspicious mass should be biopsized,irrespective of imaging findings

•FNAC

•Tissue Biopsy

•Open Biopsy

Other investigations...

•CXR•FBC•SERUM ALP•LFT•ABDOMINOPELVIC USS•BONE SCAN•HORMONE RECEPTOR STATUS•HER2 OVEREXPRESSION

Pathology ...

Molecular intrinsic subtypes...

•LUMINAL A - ER +, &/or PR+, HER2 – - Most common - Less aggressive - good prognosis - Hormone responsible - Increasing age

•LUMINAL B - ER+, &/or PR+ ,HER2 + - Worse prognosis than luminal A•BASAL LIKE - Triple Negative - Aggressive subtype - Younger ,pre-menopausal African

American

•HER2 + - Less common - Highly aggressive subtype - young age - African American - Outcome improved with HER2

targeted therapy

Staging ...

Staging ...

Staging....

Staging....

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

Predictive factors...

•ER/PR status

•HER2 gene amplification &/or Overexpression

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

•Adjuvant therapy : radiation therapy(RT), chemotherapy, hormonal and Targeted therapy

•Neo- adjuvant therapy

Role of surgery..

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

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.

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

Surgical options..

Contra-indications to BCS

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

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

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

Post Mastectomy RT- Indications

•Positive post mastectomy margins

•Primary tumors larger than 5cm

•Involvement of 4 or More LN

•Skin or Chest wall involvement

Side effects of RT...

•Fatigue•Skin desquamation•Breast pain•Breast swelling•Rib #•Pulmonary fibrosis•Cardiac dx•Secondary malignancies

Treatment of the Axilla...

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

Axillary treatment...

•ALND or SLNB

•SLNB :Indicated in clinically node Negative px

•Single modality for axillary treatment

ALND...

SLNB...

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

The NCCN guideline...

Treatment of advance breast cancer

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

Neo adjuvant therapy..

•Aim is to improve surgical outcome & surgical options

- operable BC,Increase the chances of BCS

-Inoperable, LABC: Achieving operability

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

Adjuvant chemotherapy...

Hormonal therapy...

Hormonal therapy...

recurrence dx...

•Post BCS : Total mastectomy + adjuvant chemotherapy or endocrine therapy

•Post MRM : local resection of recurrence where feasible + radiotherapy if no RT b4.

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

Conclusion...

•Breast cancer survival rates have increased significantly, particularly in younger women.

•The need for increased public awareness & early detection cannot be overemphasized.