Breast Cancer Seminar

8/2/2019 Breast Cancer Seminar

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Breast Cancer

Presented by: Ola Nemri


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Most common cancer in females.

The crude incidence rate for female breast cancer was30.2/100,000.

F:M = 95:1


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Pathology

BreastCA

Ductal

85%

DCIS invasive

Lobular

15%

LCIS invasive


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Carcinoma in situ LCIS,DCIS

Pre-invasive cancer, that hasnt breached

the BM.

Now accounts for over 20% of cancer

detected by screening in the UK.

May be cured with surgery, without the

need for radiotherapy.


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Invasive cancer will go on to develop in at

least 20% of the cases.

Lobular carcinoma tends to be multifocal

in the same breast, and bilateral.


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Inflammatory carcinoma:

Rare.

Highly aggressive.

Presents as painful, swollen breast, which is warm with

cutaneous edema, because of blockdge of the sub-dermal lymphatics with carcinoma cells.

DDx with breast abcess.

Dx by biopsy

Treat with aggressive chemo and radiotherapy, and

salvage surgery.


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Pagets disease of the nipple

A superficial manifestation of an underlying BreastCA.

Presents as an eczema-like condition of the nipple andthe areola, which slowly erodes.

An underlying carcinoma will sooner or later becomeclinically evident.

Dx by biopsy, paget cells in epidermis.

DDx with nipple eczema.**


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Clinical presentation

An approach to Breast cancer


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Risk Factors Age:

The risk increases with increasing age, rare below the ageof 20Y.

Genetic factors:

Familial like P53, BRCA-1, and BRCA-2.

Non-Familial like C-erb.

Hormonal:

Late age of 1st pregnancy**.

Nulliparity. Early menarche, late menopause.

Obesity.

Long term exposure to HRT.

Gynecological CA.


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Diet:

Obesity and alcohol.

Geographic location; more common in the western world.

Pre-existing condition:

Cancer in the contralateral breast.

Exposure to radiation (hodgkin).


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Approach to Breast cancer

Triple assessment

1- Detailed history and physical examination.

2- Diagnostic imaging by Mammography and/or

Ultrasound scanning.

3- Cytology or Histology.


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Triple assessment/History

Age. Symptoms

Painless Breast MassHx of a mass.

Skin changes: Ulceration, nipple changes.

Bloody Nipple Discharge.

The breast may become harder, or change in shape.

Pain or Pricking sensation.

Arm swelling, or axillary lump.

Symptoms of Mets. (backache, pathological fx, Cough,Headache, Abdominal pain)


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Parity, and age at 1st pregnancy.

Menstrual pattern and relation to complaint.

Family history.

Risk factors.


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Triple assessment/Exam

Breast examination Inspection: Nipple changes (Retraction, Destruction,

discharge, eczema) ,skin tethering or dimpling ,skinulceration, Peau dorange ,dilated veins .

Palpation: Size and site(UOQ in 60%),surface,consistence, Fixation to the skin or underlying muscle

Dont forget the axillary tale and the contralateralbreast.**

Axillary LN.

General examination of the chest and abdomen.

.


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***


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Triple assessment/Imaging

-Mammography:Screening

Diagnostic

Follow up patients for recurrence.

The sensitivity of the mammogram is in the 90%

range.Cancers missed by mammography are in the range

of 10-30%.The Sensitivity increases with age.Signs of malignancy: :Area of increased density.

MicroCalcification.

Distortion of the parenchyma .

Speculated mass.


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Triple assessment/Imaging

2-UltrasoundUseful in young woman.

Can determine whether a lesion is solid orcystic.

Can define the size, contour, or internal textureof the lesion.

3- MRI:

Useful to differentiate between scar andrecurrence , Imaging for women with implants,Evaluate patients with axillary metastases orchest wall involvement.


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Triple assessment/Cytology &

Histology Fine-Needle aspiration Cytology

Reliable, least invasive, Accurate, Sensitivity > 90%.

It differentiates between benign and malignant cells, cells shapeand size, and nuclei..

Disadvantage: falseve may occur, invasive cancer cant be

distinguished from CIS.

Core Biopsy

Distinguish between invasive and non invasive cancer"histology"

Provide information of tumor grade and receptors ER,PR.

Excisional biopsy, usually for benign conditions.


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Tumor Biomarker

Hormone receptors:

oEstrogen receptors.

oProgesterone receptors.

C-erbB2 (growth factor receptor) bad prognosticfactor

Goodprognosticfactor


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Thespread of Breast CA Local spread:

Other portions of the breast. Skin, Pectoral muscle and Chest wall.

Lymphatic metastasis :

Axillary LN.

Internal mammary chain of LN.(post 1/3)

Supraclavicular LN.

Contralateral LN.

Notes: The involvement of LN is not just a chronological event, but rathermarker for metastatic potential of the cancer (micrometastasis).

Spread by blood stream:

Bone, (lumber, femur, thoracic, rib, skull)osteolytic lesion.

liver, lung, brain,skin, adrenal glands, ovaries.


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Staging of Breast CA

Careful clinical examination.

Chest X-ray.

Chest /Abdomen CT.

Isotope bone scan.


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TNM Staging

T

T1 10cm. Any tumor with infiltration or ulceration larger than its diameter.

N

N0no palpable axillary nods. N1 mobile palpable axillary nods. N2 fixed axillary nods.

N3 palpable supraclavicular nods, arm oedema.

M M0 no evidance of distant mets.

M1 distant mets.


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Treatment of Breast CA

Basic principles:

Reduce the chance of local recurrence.

Reduce the risk of metastatic spread.

S1, S2(early)surgery , radiotherapy.

systemic therapy if bad Px or+ve LN.

Aim to cure S3, S4(late)systemic therapy, small role for

surgery.

palliative


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Surgery

Indication for mastectomy:

1. Large tumor.

2. Central tumor beneath or involving thenipple.

3. Multifocal disease.

4. Local recurrence.5. Patient preference.


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Types of surgery

Radical Halsted mastectomy.

Modified radical mastectomy(patey):

Includes: *the whole breast.

*large portion of the skin overlying the

tumor with the nipple.

*all of the fat, fascia and LN of theaxilla.


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Conservative breast cancer surgery(wide local

excision):

Remove the tumor +safety margin at least 1cm.

Quadrantectomy :

Remove the entire segment that contains the tumor.

Axillary LN in conservative surgery,..sentinel node

Bx, sampling, remove the nods behind and lateral tothe PM, or full dissection through a separate incision.


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Axillary surgery is for staging, treat the axillaand prognosis.

Axillarry surgery shouldnt be combined withradiotherapy to the axilla, it increases thamorbidity.

High rate of local recurrence in conservativesurgery**, young pt, and high grade tumors.


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Complications of mastectomy

General vs. local /Immediate vs. late.

Seroma: accumulation of serous/lymphatic fluidunderneath the breast flaps and in the axilla.

Hematoma.

Intercostal brachial nerves are usually divided,may result in numbness in the upper arm and underthe arm of the surgical site.

. Lymphedema, R/O recurrence.

Psychological.


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Radiotherapy

Indicated in pt whom the risk of local

recurrence is high. Large tumor , large

number of +ve nods, extensivelymphovascular invasion.


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Systemic therapy ,for micrometastasis

A. Chemotherapy

1. Adjuvant chemotherapy:After locoregional surgery.

2. Neoadjuvant chemotherapy:Before surgery in a locally advanced carcinoma, aiming to

reduce the size of the tumor to get a more conservativesurgery.


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Commonly used agents

Cyclophosphamide hemorhegic cystitis.

Methotrexate.

5-flurouracil.

Doxorubicin. cardiotoxic.

Herceptin (Trastuzamab) humanized monoclonalantibody directed against HER2, is active against

tumors containing C-erb GF receptor.


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B. Hormonal therapy:

In estrogen and progesterone receptor +ve tumors.

Used to reduce the rate of recurrence and tumor in the

contralateral breast.

Tamoxifen LHRH agonist, ovarian suppression in

premenopausal.

Oral Aromatase inhibitor (anastrazole)forpostmenopausal pt.


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Follow up of Breast CA

Yearly or 2-yearly mammography of thetreated and contralateral breast.

CXR, CBC, LFT.


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Screening for Breast CA

Familial breast cancer..


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The Male Breast

Gynecomastiao Idiopathic, uni/bi, at puberty.

o Hormonal , adrenal and pituitary disease,

paraneoplastic lung ca, steroid therapy.

o Liver disease, failure to metabolize estrogen.

o Drugs, digitalis, spironolactone, cimetidine.

o Klinefelter syndrome.

Treatment in a healthy pt is reassurance, if not,

mastectomy.


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Carcinoma of the male breast

Less than 0.5% of all cases.

Known predisposing factors are

gynecomastia and excess exogenous and

endogenous estrogen. Treatment as in female.


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Thank you.

Breast Cancer Seminar

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