BM
-
Upload
uabsurgclrk -
Category
Health & Medicine
-
view
3.528 -
download
3
description
Transcript of BM
Surgical Options for the Treatment of Breast Cancer
Helen Krontiras, M.D.Assistant Professor
University of Alabama School of Medicine
History Physical Examination
• Questions regarding presenting symptom
• Questions regarding risk factors
• Past medical history • Family history• Review of systems
• Masses• Skin changes• Nipple changes• Nipple discharge• Lymphadenopathy
Risk factors for breast cancer
Gender Age
Personal history of breast cancerReproductive and menstrual history
Breast densityFamily history of breast cancer
Genetic factorsProliferative breast disease
Diet and lifestyle factors
Breast Imaging
Mammogram
Ultrasound
(MRI)
Biopsy
• Incisional– Core biopsy
• Palpation • Image Guided
– Stereotactic– Ultrasound guided
• Excisional– Operative removal of entire lesion
Histology
Lobular carcinoma in situ
Ductal carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma
Lobular Carcinoma in situ
• Usually diagnosed as an incidental finding
• Marker for increased risk for breast cancer
• If found on core biopsy, excision warranted to rule out coexisting cancer
• Management– Surveillance– Chemoprevention– Bilateral Total Prophylactic Mastectomy
Ductal Carcinoma in situ
• Stage 0, pre-invasive
• By definition, does not spread to the axillary lymph nodes
• Usually detected mammographically as microcalcifications
• Surgical treatment similar to invasive breast cancer
Invasive ductal carcinoma
• Most common, 75% of all breast cancers
• AKA IDC, infiltrating ductal
• Increased spread to axillary nodes with increase in size
Invasive lobular carcinoma
• 5-10% of all breast cancers
• Usually presents as an ill defined thickening
• May be mammographically occult
Inflammatory breast cancer
• Variant with rapid onset
• Poor prognosis
• Erythema, edema of the overlying skin (peau d’orange) secondary to tumor within the dermal lymphatics
• Treatment is chemotherapy followed by surgery and or radiation
Paget’s Disease
• Benign appearing eczematoid lesion of the nipple
• Caused by large malignant cells (Paget's cells) which arise from the ducts and which invade the surrounding nipple epithelium.
• Usually due to an intraductal carcinoma• An underlying palpable mass usually indicates
invasive ductal carcinoma
Phyllodes Tumor
• Rare, 0.5%- 1% of breast cancers
• A fibroepithelial tumor of unpredictable behavior
• Treatment is wide local excision with
2cm margins, no role for chemotherapy or radiation therapy
• Like other stromal tumors, lymph node metastasis is rare
Earlier stage - better survival
0102030405060708090
100
% 5
-year su
rviv
al
I IIA IIB IIIA IIIB IV
Survival
Stage
Lumpectomy +
Mastectomy
Neoadjuvant Chemotherapy (SLN BX before,surgery after)
Clinical Stage I or II Invasive
Breast Cancer
SLN BX
AND
Total + SLN BX
Modified Radical
Mastectomy
Neoadjuvant ChemotherapyClinicalStage III
Invasive Breast Cancer
Radiation Therapy
Breast Cancer Treatment
Local Systemic
Local Therapy
Breast Axilla
Local Therapy
SurgeryRadiation Therapy
Breast
Mastectomy
Breast conservation
Neoadjuvant chemotherapy
Mastectomy
• Total Mastectomy– With or without reconstruction– With or without sentinel lymph node biopsy
• Remove only the breast
• Modified Radical Mastectomy – With or without reconstruction
• Remove the breast and axillary lymph nodes
Mastectomy with reconstruction
Total or MRM plus (immediate or delayed) TRAM (Transverse Rectus Abdominis Myocutaneous flap)
Free – deep inferior epigastric Thorocodorsal, subscpular, circumflex scapular Internal mammary, thoracoacromial, lateral thoracic
Pedicled – superior epigastric Latissimus dorsi myocutaneous flap Expander/Implant
Breast Conservation Therapy
Lumpectomy + Radiation Therapy• Remove the bulk of the tumor surgically and
to use moderate doses of radiation therapy to eradicate any residual cancer
• Goal– Preserve cosmetic outcome – Provide survival equivalent to mastectomy– Provide low rate of local recurrence
BCT vs Mastectomy
Since 1970, 7 prospective randomized
studies demonstrate equivalent outcome
regardless of surgical choice for patients with Stage I or II disease
Radiation Therapy
• External beam
• Daily therapy for 6 weeks
• Side effects– Skin changes– Pulmonary toxicity– Cardiotoxicity
Contraindications to breast conservation therapy
Absolute 2 or more primary tumors in separate
quadrants Diffuse malignant appearing calcifications History of previous irradiation to the breast
region Pregnancy Persistent positive margins
Contraindications to breast conservation therapy
Relative History of collagen vascular disease Multiple gross tumors in the same quadrant
and indeterminate calcifications Large tumor in a small breast Breast size
Winchester et al, Ca Cancer J Clin, 1998
Contraindications to breast conservation therapy
The following should not prevent patients from being candidates for BCT:
Presence of clinical or pathologic involvement of axillary lymph nodes
Tumor location Family history
Neoadjuvant chemotherapy
Chemotherapy given before surgery
• Shrink the tumor
• In Vivo assessment of response to chemo
• No survival advantage or disadvantage
Therapy of Regional Nodes
• Axillary Node Dissection
• Sentinel Lymph Node Biopsy
Axillary Node Dissection
• Typically Levels I and II • 10 – 30 lymph nodes
removed• 15-20% incidence of
lymphedema
Silverstein, The Breast Journal 4:324, 1998
Positive axillary lymph node versus T stage
Sentinel node biopsy
• The sentinel node is the first node to receive lymphatic drainage from a primary breast cancer and reflects the status of the entire nodal basin– Identifies the node(s) most likely to contain cancer– Lessens the morbidity of lymph node staging (3-4%
incidence of lymphedema)– More detailed pathologic analysis with H&E– Axillary node dissection for those with positive sentinel
nodes
Sentinel node biopsy
Systemic Therapy
CytotoxicChemotherapy
Endocrine
Monoclonal
antibody
Adjuvant therapy
The administration of chemotherapy or radiation therapy after primary surgery of breast cancer to kill or inhibit clinically occult micrometastases or residual disease
Adjuvant therapy recommendation
Tumor size ER status Nodal Status Recommendation
<1 cm +/- - None required
>1 cm + - Tam +/- Chemo
- - Chemo
Any size + + Tam +/- Chemo - + Chemo
Chemotherapy
• Adriamycin/ Cytoxan (AC) x 4
• Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6
SERMSelective estrogen receptor modulators
Tamoxifen• For those with ER (estrogen receptor) positive
breast cancer• Prescribed for 5 years• Antiestrogenic and estrogenic effects• Side effects
• Hot flashes• Vaginal dryness, discharge• Increased risk of endometrial cancer• Increased risk of thromboembolic events• Cataracts
Aromatase inhibitors
• Blocks aromatase enzyme peripherally• For those with ER positive disease • Less side effects than tamoxifen• May be more effective for treatment and
prevention– Arimidex– Femara– Exemestane
Herceptin(trastuzumab)
• Monoclonal antibody that targets the Her2neu gene
• Her2neu is overexpressed in 25% of breast cancers
• Codes for a growth factor
• Clinical trials indicate that Herceptin may increase the effectiveness of chemotherapy without added toxicity