Teaching Project Gp Year 4 New

8/4/2019 Teaching Project Gp Year 4 New

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Breast cancer,brief recap

Investigations

andManagement-

and their role inBreast cancer

CASE STUDYInteractivemanagement

discussion

Quiz


2/23

BRIEF RECAP!


3/23

Pathology Epidemiology

Risk Factors Presentation

BreastCancer


4/23

Most breast cancers areeither:

DUCTAL orLOBULAR

Carcinoma can be invasiveor in situ.


5/23

Paget's disease of breast is an infiltratingcarcinoma of the nipple epithelium andrepresents about 1% of all breast cancers.

Inflammatory carcinoma occurs in under 3%all cases with a rapidly growing, sometimespainful mass enlarging the breast and causingthe overlying skin to become red and warm.There may be diffuse infiltration of tumour.
http://www.patient.co.uk/DisplayConcepts.asp?WordId=PAGET%20S%20DISEASE%20OF%20BREAST&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=PAGET%20S%20DISEASE%20OF%20BREAST&MaxResults=50


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It represents almost 1 in 3 of all malignancies in women.

75% of new cases are aged over 50 years.

The death rate from breast cancer is falling. This is probably due to better treatment butmammography may also be detecting cases earlier.

In less than 1% of cases there is simultaneous bilateral breast cancer.

Breast cancer can occur in men, usually in men aged over 50 years.


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8/23

Breast lump

Breast pain

Change in the sizeor shape of the

breast

Ulceration of the

breast skin

ADVANCED

Occasionally-Fungating mass

Bone pain,

Pathological #

Jaundice

Dimpling of the

breast skin

Involution orinversion of thenipple

Nipple dischargeor bleeding

Axillary

lymphadenopathy


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10/23

?

??

?


11/23

Triple assessment

Clinical examination

A radiological assessment mammography or ultrasound (usually

combined)

A pathological assessment cytology

and/or core biopsy

sensitivity

andspecificity>90%


12/23

TX means that the tumour size cannot be assessed

T1 - The tumour is no more than 2 centimetres (cm) acrossT2 - The tumour is more than 2 centimetres, but no more than 5centimetres acrossT3 - The tumour is bigger than 5 centimetres across

T4 Any size tumour involving chest wall or skin ( imflammatory breastcancer also)

The N stages (nodes)N0 - No cancer cells found in any nearby nodesN1 MOBILE axillary lymphadenopathy ie not stuck to surrounding

tissuesN2- Fixed axillary lymph nodes and/or mammary lymph node involvementN3


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SurgicalTreatment

Followup

Pathologicalassessment andstaging to directadjuvant therapy

ADJUVANT

THERAPY

Disease that can be fully removed by surgery T1-3 N0-1


14/23

All patients require complete removal of the 1 tumour:WLEMASTECTOMY

WLE= removal of tumour mass with limited margin of uninvolvedsurrounding tissue (~0.5-1cm). This is now the most commonlyperformed procedure for early breast cancer.

MASTECTOMY = preferred if e.g. patient would prefer, inflammatory

carcinoma, large tumour in small breast, multifocal primaries etc.

Breast reconstruction can be offered either at time of primary surgeryor later- TRAM flap, lat dorsi flap and implants.


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AXILLARY CLEARANCE/DISSECTION-Complete staging of axillaProvides regional control of disease and no need for RTDisadvantages outweigh benefits in the lower risk patientsSIDE EFFECTS- painful arm, lymphoedema, sensory loss, debilitatingshoulder stiffness

AXILLARY SAMPLING- At least 4 nodes If surgeon is suspicious, perhaps will remove morePatient with +ve sample may then have axillary clearance, or morecommonly RT to the axillaLess morbidity in node negative patients than with a full clearance

SENTINEL NODE BIOSPY-Patients with unidentified lymphadenopathyIdentification and removal of first draining lymph nodeInjection of blue dye and radio-labelled colloidAny stained node/s removed


16/23

Usually after surgery, unless patient is having

chemotherapy.Some women may not need at all e.g. Mastectomy withvery low risk recurrence.Recommended for all women with breast conserving

surgery. 5 WEEK course, treatment to the whole breast

AXILLARY RADIOTHERAPY= SAMPLING maybeCLEARANCE NO

Can offer to the SCF if patient lymph node +ve more than

4 nodes


17/23

WHO NEEDS ADJUVANT THERAPY??Women with NODE +VE BREAST CANCER.

Take into account tumour grade, node status etcDecision making- clinical judgementNPI NOTTINGHAM PROGNOSTIC INDEX - sum of the tumour size(cm x 0.2) + lymph node stage + histological gradeGood prognosis= less than 3.4Poor= more than 5.4

CHEMOTHERAPYBIOLOGICAL THERAPYENDOCRINE THERAPY


18/23

Greater benefit to younger patients

all women under the age of 70yrs should be considered foradjuvant chemo.

6 month cycle using a combination of drugs seems to be thepreferred.

E/CMF

Can be given as a Neo-adjuvant


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IE HORMONAL AGENTS

Only works if ER +ve!!

may be used as the only treatment if comorbidities , ie over 70sUp to 5 yr treatment durationTamoxifenstops oestrogen from binding to oestrogen-receptor-positive cancer cells.

Aromatase inhibitorsPost menopausal oestrogen suppression

Ovarian ablation or suppressionGoserelin- a lutenising hormone-releasing hormone agonist (LHRHa).Offer to women who refuse chemotherapy. (Option of choice= chemo +

tamoxifen)


20/23

HER-2 +ve breast cancerHERCEPTIN (trastuzamab)Inpatient3 week intervals for 1 yrASSESS CARDIAC FUNTION BEFOREHAND!! Do not give if

less than LVEF less than 55%3 monthly echoSTOP if LVF drops by 10% and below 50


21/23

IE broadly speaking, T4, N2

Median survival exceeds 2 years

Staging investigations should include:

CXR, isotope bone scan

Liver US or CT scan


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15-20% present with metastatic disease

PALLIATION IS THE AIM

ER +VE longer survivalCommon sites= lung, pleura, bone, brain

CHEMOTHERAPY- MODERATE RESPONSER adiotherapy- Bone pain, soft tissue disease, and certain metastasesBISPHOSPHONATES


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