1. BREAST CANCER AND ITS MANAGEMENT BY DR. SOHAIL ZAFAR PG-1/MO SURGICAL UNIT 1 SZMC/H RY. KHAN 1

2. Epidemiology Breast cancer is the most common cancer in women, with a lifetime risk of 1 in 8 women. 2 3. TRIPPLEASSESSMENT 3 4. SYMPTOMS PATIENT SEEKS MEDICAL ATTENTION WHEN: 4 5. OTHERSYMPTOMS Backache may be a symptom in breast cancer often in advanced breast cancer. NOTE: The General symptoms of any cancer are usually NOT present in BREAST CANCER. 5 6. HISTORY Duration of symptoms. Age at menarche. Number of pregnancies and age at first full-term pregnancy. Lactational history. Age at menopause or surgical menopause (i.e., oophorectomy). Prior history of breast biopsies or breast cancer. Mammogram history. Oral contraceptive and hormonal replacement therapy. Family history of breast and gynecologic cancer, including the age at diagnosis. This should include at least two generations as well as any associated cancers, such as ovary, colon, prostate, gastric, or pancreatic. HISTORY MUST INCLUDE: 6 7. RISKFACTORS A family history of breast cancer In a single first-degree relative is associated with a doubling of risk. If two first-degree relatives (e.g., a mother and a sister) have breast cancer, the risk is further elevated. Late age at first full-term pregnancy Women with a first birth after age 30 years have twice the risk of those with a first birth before age 18 years. High body-mass index after menopause Exposure to ionizing radiation Diet Oral Contraceptive Pill and HRT 7 8. RISKFACTORS BRCA1 & BRCA2 Screening for BRCA gene mutations should be reserved for women who have a strong family history of breast or ovarian cancer BRCA1 50% chance of developing a breast cancer, and a 20% chance of developing ovarian cancer. BRCA2 Mutations carry a lower risk for breast cancer and account for 4% to 6% of all male breast cancers Prior Breast Biopsies No increased risk is associated with adenosis, cysts, duct ectasia, or apocrine metaplasia. There is a slightly increased risk with moderate or florid hyperplasia, papillomatosis, and complex fibroadenomas. Atypical ductal (ADH) or lobular hyperplasia (ALH) carries a 4- to 5-fold increased risk of developing cancer. 8 9. CLINICALEXAMINATION Posture should be defined first. 1. Size 2. SYMMETRY 3. SKIN 4. NIPPLE & AREOLA 5. AXILLA 9 10. IMPORTANTPHYSICALSIGNSOFMALIGNANCY ON INSPECTION 10 11. CLINICALEXAMINATION Palpate the NORMAL BREAST FIRST. USE the FLAT of FINFERS. TEMPERATURE & TENDERNESS FIRST. IF LUMP is found note the followings: Site Size Surface Edge Consistency Mobility 11 12. CLINICALEXAMINATION Axillary lymph nodes are classified according to their anatomic location relative to the pectoralis minor muscle. Level I nodes. Lateral to the pectoralis minor muscle Level II nodes. Posterior to the pectoralis minor muscle Level III nodes. Medial to the pectoralis minor muscle and most accessible with division of the muscle Rotter's nodes. Between the pectoralis major and the minor muscles 12 13. CLINICALEXAMINATION 13 14. CLINICALEXAMINATION SUPRACLAVICULAR NODES ABDOMINAL EXAMINATION for HEPATOMEGALY ASCITIES NODULES IN THE POUCH OF DOUGLAS 14 15. BREASTIMAGING Breast Imaging Screening Imaging Screening Mammography Screening MRI in High Risks Diagnostic Imaging USG Mammography MRI 15 16. BREASTIMAGING 16 17. BREASTIMAGING THERE ARE TWO MAMMOGRAPHIC VIEWS CRANIOCAUDAL MEDIOLATERAL OBLIQUE 17 18. BREASTIMAGING 18 19. BREASTIMAGING 19 20. BREAST BIOPSY BIOPSY PALPABLE MASS FNAC CORE EXCISIONAL INCISIONAL NON- PAPPABLE MASS STEREOTACTIC USG NLB 20 21. BREASTBIOPSY FOR PALPABLE MASS Fine-needle aspiration biopsy (FNAB) is reliable and accurate, with sensitivity greater than 90%. FNAB can determine the presence of malignant cells and estrogen and progesterone receptor status but does not give information on tumor grade or the presence of invasion. Core biopsy is preferred over FNAB. It can distinguish between invasive and noninvasive cancer and provides information on tumor grade as well as receptor status. Excisional biopsy should primarily be used when a core biopsy cannot be done. It is performed in the operating room; incisions should be planned so that they can be incorporated into a mastectomy incision should that subsequently be necessary. Masses should be excised as a single specimen and labeled to preserve three-dimensional orientations. Incisional biopsy is indicated for the evaluation of a large breast mass suspicious for malignancy but for which a definitive diagnosis cannot be made by FNAB or core biopsy. For inflammatory breast cancer with skin involvement, an incisional biopsy can consist of a skin punch biopsy. 21 22. PRINCIPALOF CORE BIOPSY 22 23. TNMCANCERSTAGING 23 24. TNMCANCERSTAGING 24 25. TNMCANCERSTAGING 25 26. TNMCANCERSTAGING 26 27. TNMCANCERSTAGING 27 28. TNMCANCERSTAGING STAGE T N 2A 0 1 1 1 2 0 2B 2 1 3 0 3A 0 2 1 2 2 2 3 1 3 2 3B 4 0 4 1 4 2 28 29. CARCINOMAORIGIN 29 30. CARCINOMAPATHOLOGY 30 31. HISTOLOGICALTYPESOF CA BREAST CA BREAST NON- INVASIVE DCIS LCIS INVASIVE DUCTAL LOBULAR MEDULLARY MUCINOUS TUBULAR 31 32. Noninvasive(insitu)breastcancer DCIS and LCIS are lesions with malignant cells that have not penetrated the basement membrane of the mammary ducts or lobules, respectively. 32 33. DCIS DCIS, or intraductal carcinoma, is treated as a malignancy because DCIS has the potential to develop into invasive cancer. It is usually detected by mammography as clustered pleomorphic calcifications. Physical examination is normal in the majority of patients. It may advance in a segmental manner, with gaps between disease areas. It can be multifocal (two or more lesions >5 mm apart within the same index quadrant) or multicentric (in different quadrants). 33 34. Treatmentof DCIS 34 Assessment of NODES in DCIS : Sentinel lymph node biopsy may be considered when there is a reasonable probability of finding invasive cancer on final pathologic examination including (Size >4 cm, Palpable, or High grade) A positive sentinel node indicates invasive breast cancer and changes the stage of the disease; a completion axillary dissection is then indicated. 35. LCIS It may be multifocal and/or bilateral. LCIS has loss of E-cadherin (involved in cellcell adhesion), which can be stained for on pathology slides to clarify cases that are borderline DCIS versus LCIS. 35 36. Invasive Breast Cancer Histology consists of Five different subtypes. 1.Infiltrating Ductal (75% to 80%) 2.Infiltrating Lobular (5% to 10%) 3.Medullary (5% to 7%) 4.Mucinous (3%) 5.Tubular (1% to 2%) 36 37. Surgical optionsfor EARLYbreastcancer STAGES 1 2 3A 37 EARLY BREAST CANCER MASTECTOMY SIMPLE/TOTAL CHEMOTHERAPY 6 MONTHS AFTER MRM CHEMOTHERAPY 6 MONTHS AFTER BCS CHEMOTHERAPY 6 MONTHS BEFORE AND AFTER RADIATION 38. Management of Axilla Approximately 30% of patients with clinically negative exams will have positive lymph nodes in an axillary lymph node dissection (ALND) specimen. The presence and number of lymph nodes involved affect staging and thus prognosis. Thus, sentinel lymph node biopsy was developed to provide sampling of the lymph nodes without needing an ALND. 38 39. Axillary LymphNode Dissection(ALND) Patients with clinically positive lymph nodes, with positive SLN should undergo ALND for local control. ALND involves the following: Removal of level I and level II nodes and, if grossly involved, possibly level III nodes. Motor and sensory nerves are preserved unless there is direct tumor involvement. An ALND should remove 10 or more nodes. The number of nodes identified is often pathologist dependent. Patients with 4 or more positive lymph nodes should undergo adjuvant radiation to the axilla. Selective patients with 1 to 3 positive nodes may also benefit from radiation therapy to the axilla. 39 40. AdjuvantChemotherapy Adjuvant chemotherapy is given in appropriate patients after completion of surgery. All node-positive patients should receive adjuvant chemotherapy. Regimens are guided by the tumor biomarkers. Typical regimens comprise four to eight cycles of a combination of cyclophosphamide and an anthracycline, followed by a taxane administered every 2 to 3 weeks. 40 41. LocallyAdvancedBreastCancer(LABC) Patients should receive neoadjuvant chemotherapy (often cyclophosphamide combined with an anthracycline and taxane), followed by surgery and radiation. The high response rates seen with this regimen for stage IIIB allow modified radical mastectomy to be carried out, with primary skin closure. Adjuvant radiation to the chest wall and regional nodes and adjuvant chemotherapy follow surgery. SLNB may be used in selected patients with clinically negative axilla. Approximately 20% of patients with stage III disease present with distant metastases after appropriate staging has been performed 41 42. LABC 42 43. INFLAMMATORY CA Inflammatory CA (T4d) This is characterized by erythema, warmth, tenderness, and edema (peau d'orange). It represents 1% to 6% of all breast cancers. An underlying mass is present in 70% of cases. Associated axillary adenopathy occurs in 50% of cases. It is often misdiagnosed initially as mastitis. Skin punch biopsy confirms the diagnosis. Approximately 30% of patients have distant metastasis at the time of diagnosis. Inflammatory breast cancer requires aggressive multimodal therapy because median survival is approximately 2 years, with a 5-year survival of only 5%. 43 44. INFLAMMATORY CA 44 45. THANK You!! ANY QUESTIONS?? 45