Breast AnatomyBreast Anatomyplease reviewplease review

Macroscopic anatomy

Conventional partition

4 quadrants Areola Axillary part Inframamary

fold

Functional structure of the breast

Please review physiology

3 ESENTIAL COMPONENTS Glandular tissue Connective tissue Fatty tissue

– Their proportions varies significantly with • Age• Nutrition status• Pregnancy/Post-

partum/Lactation

Microscopic structure

11.Glandular tissue– Produces milk as final

product– 15-20 lobules

completely separated, with radial disposition around the nipple

– Galactofore ducts – nipple (small dilated area in the areola, opening in the nipple)

Microscopic structure

22 Conective tissue– Creates structure/

support– Included are the

suspensory ligaments – Connects the breast to

the skin and fascia of the pectoralis major

Microscopic structure

33 Fatty tissue– Participates to the

structure of the breast– Anterior, posterior and

within the lobules– Varies according to

diet and can produce major variations in the volume of the breast

Areola

Specialized skin adapted for lactation

Nipple in the middle Sebaceous glands visible on

the surface (Montgomery) Contains smooth muscles

which participate in milk evacuation during lactation

Highly innervated area

Male breast

Rudimentary, areola and nipple

Glandular tissue + fatty tissue are – most often- rudimentary or absent. Normal <2cm

Breast development

Significant changes in volume and shape according to – Age– Physiologic status

In adolescence structure becomes nodular and the volume and structure changes during menstrual cycle.

Aging

Volume diminishes Changes in structural

proportions – glandular tissue diminishes and is replaced by fat

Changes in position due to loss in the elasticity of suspensor structures

Loss of axillary hair Sclerosing of ducts

Blood vessels and lymphatics

Please review anatomy

Axilary lymph nodes

Please review anatomy

Congenital malformations

Breast develops from the mammary folds (ectodermic epithelium) on a virtual line (axilla – inguinal ligament)

On this line mammary buds develop and regress spontaneously

At birth – breast is fully developed and may produce milk under maternal hormonal influence (first days crises)

Congenital anomalies – Congenital anomalies – number and positionnumber and position

Amastia

One of the mammary bud lack of development

Polymastia

Frequent malformations

More gland with incomplete development

On the axillary line

Mammary ectopy Supranumerary breast

may have complete structure and milk secretion

May generate diseases like a normal gland

Ately - Politely

Congenital absence of the nipple

Breast can be normal in structure

Lactation is impossible

More nipples with or without areola

With or without breast tissue

Abnormal positions of the nipple

Difficulties during breast feeding

Major confusion = retraction of the nipple characteristic of breast cancer

Abnormalities in shape Abnormalities in shape and volumeand volume

Atrophy– Dystrophy– Trauma (including

surgical)– Congenital –

associated with atrophy of pectoralis major

– Infections– After radiation

Hipertrofia mamara– Uni/bilateral– Excessive growth?– In

• Endocrine pathology• Obesity

Surgical cure– Esthetic reason – Psychological reason

Hypotrophy– Reversed form

hypertrophy– Uni/bilateral– Mycromasty

Surgical correction for esthetic reasons

Asymmetry– Major difference

between left and right breast

– Esthetic and psychological problems

– Easy to solve: surgical reduction or breast implant

Gynecomasty– Normal/pathologic not mathematical

limit– Uni/bilateral– Primary gonadal dysfunction or

secundary endocrine imbalance – Adolescent?! ~ normal– Surgical removal

Trauma of the breast Breast contusion

– Acute compression on the costal grid – During lactation lesions are more complex:

• Large galactofore ducts may break• Increases risk of infection

Steatonecrosis of fat tissue- Residual lesion after contusion- Aseptic necrosis of fat tissue – fat liquefy – pseudocysts

form and finally = fibrotic scarClinical examination: hard nodule, not well delimited –

frequent confused with malignancies RESECTION BIOPSY

Traumatic lesions of the breast

Wounds– Most frequently stab wounds (precordial area)– In non-lactating breast – no special problem– Lactating breast

• Wound involving galactofore ducts – high risk of infection

• Intra-glandular dissemination via ducts

• Fistula – require the mother to stop lactation

Inflammatory lesionsInflammatory lesions

Major forms

According to type of tissue– Mastitis: primary infection of glandular

structures – Paramastitis (perimastitis) inflammation of

connective tissue surrouding glandular structures

Types– Acute– Chronic

Mastitis

Ethology– Almost exclusively during lactation, usually

in the first 2-3 weeks– More frequently after the first child and in

women with neglect in the care of the breast (local contamination in all cases)

– Bacteria penetrate through small lesions produced in the area of the areola and affect-later on- structures in surrounding tissues

Mastitis – stages of development

GALACTOFORITIS– Isolated infection of galactofore ducts (one or more

then one lobules)PRESENTATION:• Increase in the volume of the breast• Pain, both spontaneous and on mombilization.

Accentuated during breast feeding• Pressure on the nipple: milk + puss through one orifice: differential

diagnosis BUDIN sign• Non significant general signs of inflammation- fever 38• No axillary lymph nodes enlargements at this stageEVOLUTION:

- breast feeding should stop (ATB) + breast emptying.- potentially reversible after antibiotics and anti-inflammatory drugs- may progress to abscess formation

Mastitis - stages BREAST ABSCESS

– Suppurative inflammation progresses in connective tissue outside glandular mass

CLINICAL PRESENTATION:• Accentuated local signs + general signs of

inflammation

• Breast is extremely painful

• Deformation of the breast: globally enlarged but also not regular shape (small abscesses are more prominent in contour)

• Budin sign = present

• Venous stasis – visible veins on the surface of the breast

• Lymphangitis but no inflammatory lymph node enlargements

MastitisBREAST ABSCESS

– Treatment: ATB + surgical drainage– Recurrent infection : more then one

lobule infected in different evolution stages – serial abscess formation

– Possible diffusion of infection in the fatty tissues surrounding the breast

• PARAMASTITIS• BREAST FLEGMONOUS

INFECTION

Paramastitis

Inflammation of the fatty tissue of the breast by inoculation– Direct– Complication of mastitis

Forms:– Areolas abscess– Subcutaneous abscess– Retro-mammary abscess

Areolas abscess

Acute inflammation of glands on the surface of the areola

CLINICAL PRESENTATION:• Small tumor in the area of the areola

• Very thin skin – tendency to evacuate spontaneously

• Lactation should be discontinued

Subcutaneous abscess

Develops subcutaneous Associates lymphangitis Easy to observe collection, superficial, is

drained or spontaneous fistulisation

Retro-mammary abscess

Inflammation of the fat in the back of the breast Ethiology: mastitis developed in a lobule situated

deep in the breast Well developed inflammation signs SPECIFIC: the breast appears as pushed forward

due to inflammation behind– Floating sensation– Very painful when mobilized

CHRONIC CHRONIC INFLAMMATIONINFLAMMATION

Forms

Hard (wood-like) chronic mastitis (evolution of an acute mastitis)

Galactocele Tuberculosis history of Sifilis medicine

Hard (wood-like) mastitis Evolution of an acute form Tendency to develop very slowly New findings

– Hard nodules– Orange-skin appearance (adherence to skin)– Permanent retraction of the nipple– Lymph node enlargements

Confusion with breast cancer

Galactocele

Particular form of chronic mastitis developing during lactation

Pseudocyst- cavity of the abscess communicates with one or more large ducts. Contains milk or milky secretion– Pressure on the nipple – secretion containg

puss and milk

Galactocele Exploration

– ASYMETRIC breast enlargement– ”tumor” with a regular surface– Fluctuence– Painless– Deformable– Thumb print– No inflammatory signs– Secretion contains milk

+ puss

Dystrophic lesionsDystrophic lesions1. Fibrocystic disease1. Fibrocystic disease2. Solitary cyst2. Solitary cyst

Fibrocystic disease (Reclus)

Most frequent disease of the breast Hormonal influence (most frequent 30-50

year and unlikely during menopause) Determined factor: estrogen or an

imbalance between estrogen and progesteron

Microscopic lesions Typical epithelial lesions are encountered also in

the normal breast but have been classified as pathological

Typical lesions: – Cysts (macro and microscopical)– Papilomatosis– Adenosis– Fibrosis– Epithelial duct

hyperplasis

Clinical presentation

Numerous “tumors” uni-/bilateral with no or few symptoms = PAIN is the most important one and points for explorartion of the breast

Nipple discharge Symptoms vary during cycle, aggravates

premenstrual, nodules change in shape and size and may also disappear.

Differential diagnosis

Pain breast Variations in symptoms cancer Mammography may help (not beneficial in very

young women – breast structure too dense to allow for a good evaluation)

Ultrasound + Doppler is probably the best method of evaluation

Guided biopsy in cases with doubtful lesions

Treatment

Surgical biopsy if any doubt Limited excision under local or general

anaestesia Punction for decompression of large cysts

(+cytology) FOLLOW UP

Prognostic

Alternating periods of rest and exacerbation of symptoms

Auto-examination of the breast and seek medical advise if changes develop

Risk of cancer is minimally increased only in patients with epithelial dysplasia

Solitary cyst

Dystrophic lesion in young women 30-40 years Large cystic TUMOR with no signs of

maligancy. Malignant characteristics would be apparent in such a size.

CYST (hard, very hard, well circumscribed) US: liquid content Treatment : punction to evacuate and clinical

follow-up

DefinitionsDefinitions

Breast cancer is a growth of abnormal cells usually within Breast cancer is a growth of abnormal cells usually within the the ductsducts (which carry the milk to the nipple) or (which carry the milk to the nipple) or lobuleslobules (glands  (glands for milk production) of the breast. for milk production) of the breast.

In more advanced stages of the disease, these out-of-control In more advanced stages of the disease, these out-of-control cells invade nearby tissues or travel throughout the body to cells invade nearby tissues or travel throughout the body to other tissues or organsother tissues or organs

How does breast cancer develop?How does breast cancer develop?

1. Normal ducts1. Normal ducts2.  Intraductal Hyperplasia2.  Intraductal Hyperplasia3.  Atypical Ductal Hyperplasia3.  Atypical Ductal Hyperplasia4.  Ductal Carcinoma 4.  Ductal Carcinoma In SituIn Situ5.  Invasive Ductal Cancer5.  Invasive Ductal Cancer

EpidemiologyEpidemiologyIncidence and prevalenceIncidence and prevalence

Each year the disease is diagnosed in over one million Each year the disease is diagnosed in over one million women worldwide and is the cause of death in over women worldwide and is the cause of death in over 400,000 women, second leading cause of death in women400,000 women, second leading cause of death in women

Breast cancer can occur in men, although the incidence is Breast cancer can occur in men, although the incidence is much lower, amounting to around 1% of all breast much lower, amounting to around 1% of all breast cancers.cancers.

Risk factorsRisk factors

Age;Age; Nearly 80% of all newly diagnosed Nearly 80% of all newly diagnosed invasive breast cancer cases occur in women invasive breast cancer cases occur in women aged 50 and older and is less common in aged 50 and older and is less common in premenopausal women. premenopausal women.

Family history of breast cancer.

Paget´s disease accounts for 1% of all breast CA, is associated with an infiltrating, and intraductal carcinoma.

Genetic factors;Genetic factors; some cancers have a some cancers have a genetic component and can be genetic component and can be inherited. inherited.

– It is estimated that between 5 and It is estimated that between 5 and 10% of breast cancer can be 10% of breast cancer can be attributed to one of two attributed to one of two predisposing genes:predisposing genes:

– BRCA1BRCA1 on chromosome 17.

– BRCA2BRCA2 on chromosome 13.Mutations in these genes are Mutations in these genes are

associated with a lifetimeassociated with a lifetime

BRCA MutationsBRCA Mutations

Risk factorsRisk factors Hormone factors:Hormone factors:

– Early menarcheEarly menarche women who started their period before 12 years of women who started their period before 12 years of age.age.

– Late menopauseLate menopause women who go through menopause after age 55 women who go through menopause after age 55– Pregnancy historyPregnancy history: women who have their first child after the age of

30 or who have had fewer pregnancies or no pregnancies.

Breast densityBreast density: women with less fatty, denser breasts, which are normally older women, have an increased chance of breast cancer.

Obesity after menopauseObesity after menopause women who were overweight based on a body mass index (BMI) greater than 25 are 1 to 2 times more likely to die from breast cancer than women with a normal BMI.

Risk factorsRisk factors Ionizing radiation; In 2005, the National

Toxicology Program classified X radiation and gamma radiation as known human carcinogens.

Compelling scientific evidence points to some of the 100,000 synthetic chemicals in use today as contributing to the development of breast cancer, either by altering hormone function or gene expression.

Risk factorsRisk factors

There is broad agreement that exposure over time to estrogens in the body increases the risk of breast cancer.

Hormone replacement therapy (HRT) and hormones in oral contraceptives increase this risk – limited increase with oral contraceptives

Risk factorsRisk factors

Breast diseaseBreast disease– Atpyical Hyperplasia– Intraductal carcinoma in situ– Intralobular carcinoma in situ

DietDiet– Fat– Alcohol

PathologyPathology

Types of breast cancer

In situIn situ– Intraductal (DCIS)– Intralobular (LCIS)

InvasiveInvasive– Infiltrating ductal carcinoma– Tubular carcinoma– Medullary carcinoma– Mucinous carcinoma

In Situ Breast Cancer

In Situ Breast Cancer remains within the ducts or lobules of the breasts.This type of cancer is only detected by mammograms – not by a physical examination.If the cancer is in the duct it is called Ductal Carcinoma in situ.If the cancer is in the lobule of the breast, it is called Lobular Carcinoma in situ.

This type of cancer is most common among pre-menopausal women.There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other.

Infiltrating Breast Cancer

Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule.This type of cancer forms a lump that can eventually be felt by a physical examination.

Breast cancer cells cross the lining of the milk duct or lobule, and begin to invade adjacent tissues. This type of cancer is called "infiltrating cancer." In this picture, you can see the breast cancer cells invading the milk duct. http://www.bcdg.org/

More on Infiltrating Breast Cancer

Infiltrating cancer of the duct

Called “Infiltrating Ductal Carcinoma”It is the most common type of breast cancer.Cancer cells that are invading the fatty tissue around the duct, they stimulate the growth of non-cancerous scar like tissue that surrounds the cancer making it easier to spot.

Infiltrating cancer of the lobules

Called “Infiltrating Lobular Carcinoma”Occurs when cells stream out in a single file into the surrounding breast tissue.This type of cancer is harder to detect on a mammogram because there is no fibrous growth.

Other Types of Breast Cancer

Cystosarcoma PhyllodesInflammatory Cancer

Accounts for less than one percent of all breast cancers and looks as though the breast is infected.

Breast Cancer During PregnancyPaget’s Disease

TNM Criteria

T = Primary TumorTis = carcinoma in situT1 = less than 2 cm in diameterT2 = between 2 and 5 cm in diameterT3 = more than 5 cm in diameterT4 = any size, but extends to the skin or chest wall

N = Regional Lymph nodesN0 = no regional node involvementN1 = metastasis to movable same side axillary nodesN2 = metastasis to fixed same side axillary nodesN3 = metastasis to same side internal mammary nodes

M = Distant MetastasisM0 = no distant metastasisM1 = distant metastasis

Stage 1

Tumor < 2.0 cm in greatest dimension

No nodal involvement (N0)

No metastases (M0)

Stage II

Tumor > 2.0 < 5 cm

or Ipsilateral axillary

lymph node (N1) No Metastasis (M0)

Stage III

Tumor > 5 cm (T3) or ipsilateral axillary lymph nodes

fixed to each other or other structures (N2)

involvement of ipsilateral internal mammary nodes (N3)

Inflammatory carcinoma (T4d)

Stage IV (Metastatic breast cancer)

Any T Any N Metastasis (M1)

Screening and Screening and SymptomsSymptoms

SCREENINGSCREENING

Clinical examination Performed by doctor or

trained nurse practitioner Annually for women over 40 At least every 3 years for

women between 20 and 40 More frequent examination

for high risk patients

Mammography X-ray of the breast Has been shown to save

lives in patients 50-69 Data mixed on

usefulness for patients 40-49

Normal mammogram does not rule out possibility of cancer completely

Mammography

American Cancer Society recommends:

Women (asymptomatic) 40 years of age and older should have a mammogram every year.

Thermograph Thermograph is one

of the newest ways to detect breast cancer.

Thermograph is a thermal image of the breast tissue.

It can also detect cancer before the traditional mammogram can.

Breast Self Examination Opportunity for woman to

become familiar with her breasts

Monthly exam of the breasts and underarm area

May discover any changes early

Begin at age 20, continue monthly

When to do BSE Menstruating women- 5 to 7 days after

the beginning of their period Menopausal women - same date each month Pregnant women – same date each month Takes about 20 minutes Perform BSE at least once a month Examine all breast tissue

Why don’t more women practice BSE?

Fear Embarrassment Youth Lack of knowledge Too busy,

forgetfulness

Abnormal signs and symptoms

PuckeringDimplingRetractionNipple dischargeThickening of skin or lump or “knot”Retracted nipple

Abnormal signs and symptoms

Change in breast sizePain or tendernessRednessChange in nipple positionScaling around nipplesSore on breast that does not heal

Common Symptoms A change in how the breast or nipple feels

– Lump or thickening in or near the breast or in the underarm area

– Nipple tenderness

A change in how the breast or nipple looks – Change in the size or shape of the breast – Nipple turned inward into the breast– Change in the skin of the breast (“orange” skin,

scaly, red, or swollen)

Nipple discharge (fluid)

How is Breast Cancer Diagnosed?How is Breast Cancer Diagnosed?

Screening and/or diagnostic mammography Ultrasound MRI scan Biopsy is necessary to confirm a diagnosis Blood tests are often used to determine if

the cancer has spread outside the breast Additional tests may be used to determine

stage

Methods of Detection

Clinical exam by MD or nurseMammographyMonthly breast self-exam

(BSE)

Diagnostic alternativesDiagnostic alternatives Screening – abnormal image requiring

histology Nodule: discovered during BSE requires

clinical examination + immaging + histology

Nodule discovered during clinical examination (same)

LARGE tumor with clinical characteristics of breast cancer – diagnostic obvious, BUT immaging and histology compulsory

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Conventionell Conventionell MammographyMammography

ScreeningScreening A A mammogrammammogram is an is an

x-ray of the breast, x-ray of the breast, may find tumors that may find tumors that are too small to feel. are too small to feel.

May find ductal May find ductal carcinoma in situ, carcinoma in situ, abnormal cells in the abnormal cells in the lining of a breast duct, lining of a breast duct, which may become which may become invasive cancer in some invasive cancer in some women. women. 85

Mammogram Main radiographic examination for

breast cancer detection

Breast cancer Lesions can be either:– Microcalcifications

– Nodules : typically irregular lesion

There could be false negative or false positive

May be used along with a mammogram to evaluate breast abnormalities.

Performed by a radiologist

Allows images from almost any orientation

Excellent at imaging cysts

Helps for a guided biopsy or FNA

Explores a suspicious lymph node.

Limits: – lacks the detail of conventional mammography

– Unable to image microcalcifications

-> not approved as a screening tool for breast cancer diagnosis

Ultrasound

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Ultrasonography- Diagnosis

Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tissue in women with nonspecific thichening

Doppler effect

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Biopsy- Biopsy- DiagosisDiagosis

If the clinical breast exam, mammogram or ultrasound shows an area of possible concern, a biopsy is usually the next step.

A biopsy is the removal of cells or tissues of concern so that they can be viewed under a microscope and further tested by a pathologist.

8923-04-21

Needle Aspiration Needle aspiration Cytology

Nature of cells: cancerous or

not– Advantages: rapid, minimal

discomfort, no incision

complicating local therapy,

immediate results

– Limits: no difference between in

situ from and invasive cancer,

false-negative

Biopsy Biopsy « tru-cut », mamotome Histology

– Advantages: rapid, minimal to moderate discomfort, no surgical incision, guided by ultrasound

– Limits: false-negative, sampling error with larger lesions

DIAGNOSIS

92

To determine if the breast cancer has spread to the lungs.

93

A common place for breast cancer to spread is to the bones.

A bone scan is often done to assure there is no detectable metastasis to the bones.

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positron emission positron emission mammography (a PEM scan)mammography (a PEM scan)

The PEM system’s The PEM system’s camera and detectors are camera and detectors are closer to the area closer to the area affected with cancer, affected with cancer, which produces a very which produces a very sharp, detailed image of sharp, detailed image of tumors and cancerous tumors and cancerous tissue.tissue.

With PEM, cancers can With PEM, cancers can be seen as small as 1.5 – be seen as small as 1.5 – 2mm, about the width of 2mm, about the width of a grain of ricea grain of rice

94

95

MRI combines the use of MRI combines the use of powerful magnets and radio powerful magnets and radio wave pulses. wave pulses.

Used to detect breast cancer in some women at higher risk

MRI can also be used before surgery to identify areas of the breast affected by the tumor.

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PreventionPrevention No intervention can completely prevent cancer; there are

ways to reduce risk Prophylactic mastectomy (preventive removal of breasts)

and prophylactic oophorectomy (preventive removal of ovaries) for women at high risk

Chemoprevention (drugs that lower breast cancer risk) with tamoxifen (Nolvadex) or raloxifene (Evista)

Risk assessment tools can help those without strong family history discover risk of developing breast cancer

How is Breast Cancer Treated?

Treatment depends on stage of cancer More than one treatment may be used Surgery Radiation therapy Chemotherapy Hormone therapy Targeted therapy

Factors Considered in Treatment Decisions

The stage and grade (how different cancer cells look from healthy cells) of the tumor

The tumor’s hormone receptor status (estrogen receptor [ER], progesterone receptor [PR]) and human epidermal growth factor receptor-2 (HER2) status

Genetic description of the tumor

The presence of known mutations to breast cancer genes

The woman’s menopausal status, age, and general health

Cancer Treatment: Surgery

Generally, surgery to remove the tumor followed by radiation therapy is initial treatment

For invasive cancer, lymph nodes are removed and evaluated

More invasive surgery (such as mastectomy) is not always better; discuss with your doctor

Breast reconstruction (plastic surgery) is an option after mastectomy

Principles of Surgery

Early Breast Cancer– Targets: breast and nodes– Objectives: to remove the tumor, to get histologic

data Curative treatment

Advanced and metastatic breast cancer– Target: assessible mass – Objectives: to reduce tumor volume, to remove one

isolated metastasis (pulmonary or liver), to treat complications of the disease (spinal compressions…)

Palliative treatment

Partial Mastectomy Partial Mastectomy (Lumpectomy)(Lumpectomy)

Contraindications– A. Previous history of Radiation Therapy– B. More than one cancer in same breast– C. Large tumor, small breast, cosmetic

deformity– D. Nipple involvement

Surgery TermsSurgery Terms

Excisional Biopsy vs. Lumpectomy Partial Mastectomy vs. Lumpectomy Incisional Biopsy

MastectomyMastectomy

Difference betweenTotal (simple) MastectomyModified Radical Mastectomy

Skin Sparing MastectomySkin Sparing Mastectomy Skin sparing

mastectomy preserves the majority of the breast skin and the inframammary fold

The entire nipple and areola are removed

Radical MastectomyRadical Mastectomy

Is Radical Mastectomy still in use? What is it?

Subcutaneous MastectomySubcutaneous Mastectomy

Is Subcutaneous Mastectomy a cancer operation?

How does it differ from Total Mastectomy?

Sentinel Node BiopsySentinel Node Biopsy

Major advance Almost no risk of lymphedema Blue dye Nuclear medicine

Sentinel Lymph Node Biopsy Quickly becoming the

gold standard May be as accurate or

more accurate than ALN dissection while limiting the complications and costs

Involves injection off Technitium-99 sulfur colloid and or 1% isosulfan blue dye

ReconstructionReconstruction

Tissue expander Latissimus dorsi TRAM

Reconstruction: Tissue expander

Encapsulated silicone implant reconstruction corrected with tissue expansion. The capsule is first excised, and the tissue expander is used to create an oversized pocket for the implant.

Reconstruction: Latissimus Dorsi

following autogenous latissimus reconstruction w/o implant. Opposite breast reduction mammoplasty required for symmetry.

Reconstruction: TRAM

following left free TRAM reconstruction. Skin replacement included all skin between scar & inframammary fold. Nipple reconstruction, opposite mastopexy done at separate procedure.

Breast Reconstruction in the Skin Sparing Mastectomy

TRAM flap Latissimus flap Implant/Expander Silicone is preferred

and is available on study protocol

Tram flap with nipple reconstruction and tatooing

Cancer Treatment: Adjuvant Cancer Treatment: Adjuvant TherapyTherapy

Treatment given in addition to surgery to reduce the risk of recurrence

May include radiation therapy, chemotherapy, targeted therapy, and hormone therapy

Cancer Treatment: Radiation Cancer Treatment: Radiation TherapyTherapy

The use of high-energy x-rays to destroy cancer cellsThe use of high-energy x-rays to destroy cancer cells

Usually used to treat breast cancer after surgeryUsually used to treat breast cancer after surgery

External-beam: outside the bodyExternal-beam: outside the body

Internal: uses implants inside the bodyInternal: uses implants inside the body

More precise ways to direct radiation to the tumor and More precise ways to direct radiation to the tumor and shorter treatment courses are being studied in clinical trialsshorter treatment courses are being studied in clinical trials

Side effects may include fatigue, swelling, and skin changesSide effects may include fatigue, swelling, and skin changes

Radiotherapy principles

Objectives– Eradicate residual disease thus reduce local

recurrence – Increase DFS (disease free survival) and OS

(overall survival)

Radiation therapy warranted after breast-conservative surgery

Sometimes indicated after mastectomy

TREATMENT

Systemic treatment: principles Systemic treatment is recommended under

certain circumstances based on prognostic factors and guidelines

Treatment objectives: – Reduce the distant metastasis – Increase Time to progression (TTP), – Prolong overall survival

In all cases of LABC or MBC Principles:

– Chemotherapy – Endocrine therapy – Targeted therapies

TREATMENT

Cancer Treatment: ChemotherapyCancer Treatment: Chemotherapy

Use of drugs to kill cancer cellsUse of drugs to kill cancer cells

May be given before surgery to shrink a large May be given before surgery to shrink a large tumor (neoadjuvant chemotherapy) or after tumor (neoadjuvant chemotherapy) or after surgery to reduce the risk of recurrence surgery to reduce the risk of recurrence (adjuvant chemotherapy)(adjuvant chemotherapy)

A combination of medications is often usedA combination of medications is often used

Cancer Treatment: Hormone Cancer Treatment: Hormone TherapyTherapy

Used to lower risk of recurrence for cancers that test positive for ER and/or PR

Tamoxifen is a common hormone therapy effective in many premenopausal and postmenopausal women

Aromatase inhibitors (AIs) are also used alone or following tamoxifen use as treatment for postmenopausal women, including anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)

Tamoxifen and AIs also used for metastatic cancer; fulvestrant (Faslodex) is another option

Targeting the Estrogen Pathway

Block receptorSERM (selective estrogen

receptor modulators)Tamoxifen treatment

Raloxifene prevention

Decrease ligandAromatase inhibitors

OopherectomyGnRH analogs

Cancer Treatment: Targeted Cancer Treatment: Targeted TherapyTherapy

Treatment that targets genes, proteins, or tumor cell environment that helps cancer grow and survive

HER2-targeted therapy: trastuzumab (Herceptin) for HER2-positive breast cancer either with or after adjuvant chemotherapy; lapatinib (Tykerb) plus capecitabine (Xeloda) for advanced or metastatic cancer

Anti-angiogenic therapy (blocks blood vessels): bevacizumab (Avastin) for metastatic or recurrent breast cancer

Drugs that block bone destruction (bisphosphonates)