carcinoma breast

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

CARCINOMA OF THE BREAST:

CARCINOMA OF THE BREAST Neeraj kumar Jain

CARCINOMA OF THE BREAST:

CARCINOMA OF THE BREAST Breast cancer is the most common cause of death in middle-aged women in western countries and developing countries.

Aetiological factors:

Aetiological factors Geographical: Carcinoma of the breast occurs commonly in the western world, accounting for 3–5% of all deaths in women. In developing countries it accounts for 1–3% of deaths. Age : Carcinoma of the breast is extremely rare below the age of 20 years but, there after, the incidence steadily rises so that by the age of 90 years nearly 20% of women are affected. Gender : Less than 0.5% of patients with breast cancer are male. Genetic : It occurs more commonly in women with a family history of breast cancer than in the general population.

Cont..Aetiology:

Cont.. Aetiology Diet: There is some evidence that there is a link with diets low in phytoestrogens . A high intake of alcohol is associated with an increased risk of developing breast cancer. Endocrine : Breast cancer is more common in nulliparous women and breast feeding appears to be protective. It is known that in postmenopausal women, breast cancer is more common in the obese. This is thought to be because of an increased conversion of steroid hormones to oestradiol in the body fat. Long-term exposure to the combined preparation of HRT does significantly increase the risk of developing breast cancer.

Incidences in carcinoma breast:

Incidences in carcinoma breast 30% of all female cancers. 20% of cancer related deaths in females. 2-4% bilateral. 2-5% hereditary. Lump is most common Presentation.(75%) 10% present with pain. 35%-45% with mutation of BRCA1 gene 70% blood spread occurs to bones.

Risk Factors :

Risk Factors BC in 1 st degree relatives. BC in contralateral breast. BRCA1/BRCA2 gene mutation. Obesity and alcohol intake. Gynaecomastia in male breast. Nulliparty . Early menarche and late menopause.

Pathology:

Pathology BC arising from Lactiferous ducts is called as DUCTAL CARCINOMA. BC arising from lobules is called as LOBULAR CARCINOMA. IN-SITU CARCINOMA is preinvasive carcinoma which has not breached epitheial basement membrane. They may be DUCTAL IN-SITU CARCINOMA (DCIS) LOBULAR IN-SITU CARCINOMA (LCIS). INVASIVE CARCINOMA can occur eventually.

CLASSIFICATIONS:

CLASSIFICATIONS DUCTAL CARCINOMA LOBULAR CARCINOMA 2.(a) In Situ Carcinoma DUCTAL CARCINOMA IN-SITU (DCIS) LOBULAR CARCINOMA IN-SITU (LCIS) (b)Invasive carcinoma. Invasive ductal carcinoma. Invasive lobular carcinoma.

PowerPoint Presentation:

3. Unilateral Bilateral 4. Unifocal Multifocal Multicentric

TYPES:

TYPES Scirrhous carcinoma:60% common Medullary carcinoma:also called “ encephaloid type” Inflammatory carcinoma/ lacatating carcinoma/mastitis carcinoma:most malignant type Colloid carcinoma:produces abundant mucin Paget’s disease of nipples Tubular, Papillary, Cribriform of ductal carcinoma. Atypical Scirrhous carcinoma Lobular insitu carcinoma Disease of Reclus:it is rare intracystic papilliferous carcinoma

Spread of breast cancer:

Spread of breast cancer Local spread The tumour increases in size and invades other portions of the breast. It tends to involve the skin and to penetrate the pectoral muscles and even the chest wall if diagnosed late. Lymphatic metastasis Lymphatic metastasis occurs primarily to the axillary and the internal mammary lymph nodes. Tumours in the posterior one third of the breast are more likely to drain to the internal mammary nodes. The involvement of lymph nodes has both biological and chronological significance. Involvement of supraclavicular nodes and of any contralateral lymph nodes represents advanced disease.

PowerPoint Presentation:

Spread by the bloodstream It is by this route that skeletal metastases occur, although the initial spread may be via the lymphatic system. In order of frequency the lumbar vertebrae, femur, thoracic vertebrae, rib and skull are affected and these deposits are generally osteolytic . Metastases may also commonly occur in the liver, lungs and brain and, occasionally, the adrenal glands and ovaries; they have, in fact, been described in most body sites.

Clinical Presentation :

Clinical Presentation Lump in breast most common in upper outer quadrant because breast tissue is more over there. Lump :Hard and Painless Some patient may present with Pain in breast. Discharge from Nipple. Ulceration and fungation over the breast in advance cases. Axillary LN enlargement

Cutaneous Manifestations of CA breast:

Cutaneous Manifestations of CA breast Peau D’ orange: due to obstruction of dermal lymphatic's. Dimpling of skin due to infiltration of ligament of cooper. Retraction of nipple Ulceration, discharge from nipple and areola. Skin Ulceration and fungation . Tethering of skin Cancer-en- cuirasse : skin of breast appear as armour coat.

Staging of Breast Carcinoma:

Staging of Breast Carcinoma The Manchester system of staging breast carcinoma was devised originally in 1940. It is an anatomical system. The stages are: STAGE I: breast only mobile tumour less than 5cm in diameter with or without local skin involvement STAGE II: tumour confined to breast nodes are involved but not fixed - palpable, mobile and ipsilateral STAGE III: locally advanced disease in breast or nodes tumour greater than 5cm diameter with involvement of: underlying muscle or skin wide of the tumour or Axillary node fixation STAGE IV: distant metastases other than the axillary nodes or satellite nodules on breast or supraclavicular nodal involvement

Manchester staging:

Manchester staging Tumour in the breast ,not involving pectoral or deeper plane. Skin involvement if present ,it is lesser than the size of tumour . Lymph node are not palpable. Same as stage 1 but with mobile, discrete, lymph node palpable in the ipsilateral axilla . Tumour fixed to pectoral muscle or skin involvement more than the tumour size or ipsilateral axillary lymph node adherent to each other or fixed Tumour fixed to chest wall ,skin involved wider than that of breast ,involvement of ipsilateral or contra lateral clavicular lymph node or opposite breast or opposite axillary LN , spread to bones ,lungs ,liver or inflammatory carcinoma of breast.

TNM definitions :

TNM definitions Primary Tumour (T): TX: Primary Tumour cannot be assessed T0: No evidence of primary Tumour Tis : Carcinoma in situ; intraductal carcinoma, lobular carcinoma in situ, or Paget's disease of the nipple with no associated Tumour. T1: Tumour 2.0 cm or less in greatest dimension T1mic: Microinvasion 0.1 cm or less in greatest dimension T1a: Tumour more than 0.1 but not more than 0.5 cm in greatest dimension T1b: Tumour more than 0.5 cm but not more than 1.0 cm in greatest dimension T1c: Tumour more than 1.0 cm but not more than 2.0 cm in greatest dimension T2: Tumour more than 2.0 cm but not more than 5.0 cm in greatest dimension T3: Tumour more than 5.0 cm in greatest dimension T4: Tumour of any size with direct extension to (a) chest wall or (b) skin , Note: Chest wall includes ribs, intercostal muscles, and serratus anterior muscle but not pectoral muscle. T4a: Extension to chest wall T4b: Edema (including peau d'orange ) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast T4c: Both of the above (T4a and T4b) T4d: Inflammatory carcinoma

Regional lymph nodes (N): :

Regional lymph nodes (N): NX: Regional lymph nodes cannot be assessed (e.g., previously removed) N0: No regional lymph node metastasis N1: Metastasis to movable ipsilateral axillary lymph node(s) N2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other orto other structures N3: Metastasis to ipsilateral internal mammary lymph node(s)

Pathologic classification (pN): :

Pathologic classification ( pN ): pNX : Regional lymph nodes cannot be assessed (not removed for pathologicstudy or previously removed) pN0: No regional lymph node metastasis pN1: Metastasis to movable ipsilateral axillary lymph node(s)pN1a: Only micrometastasis (none larger than 0.2 cm) pN1b: Metastasis to lymph node(s), any larger than 0.2 cmpN1bi: Metastasis in 1 to 3 lymph nodes, any more than 0.2 cm and allless than 2.0 cm in greatest dimension pN1bii: Metastasis to 4 or more lymph nodes, any more than 0.2 cm and all less than 2.0 cm in greatest dimension pN1biii: Extension of tumor beyond the capsule of a lymph nodemetastasis less than 2.0 cm in greatest dimension pN1biv: Metastasis to a lymph node 2.0 cm or more in greatest dimension pN2: Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures pN3: Metastasis to ipsilateral internal mammary lymph node(s)

Distant metastasis (M): :

Distant metastasis (M): MX: Presence of distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes )

AJCC stage groupings :

AJCC stage groupings Stage 0 Tis , N0, M0 Stage I T1,* N0, M0 *T1 includes T1mic Stage IIA T0, N1, M0 T1,* N1,** M0 T2, N0, M0 *T1 includes T1mic **The prognosis of patients with pN1a disease is similar to that of patientswith pN0 disease. Stage IIB T2, N1, M0 T3, N0, M0 Stage IIIA T0, N2, M0 T1,* N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 *T1 includes T1mic Stage IIIB T4, Any N, M0 Any T, N3, M0 Stage IV Any T, Any N, M1

Differential diagnosis of CA Breast:

Differential diagnosis of CA Breast Fibroadenosis Traumatic fat necrosis Tuberculosis of breast Blood good cyst Filariasis breast Mastitis Antibioma Galactocele Mondor’s disease Cystosarcoma phylloides Plasma cell Mastitis

Investigations:

Investigations Mammography USG of Breast FNAC Frozen section biopsy Corecut / Trucut Biopsy Excision biopsy

Other Investigations:

Other Investigations Chest X-ray USG Abdomen X ray spine Oestogen receptor study & Progestron receptor study Study of discharge MRI of Breast:to differntiate scar from recurrence Edge biopsy: only for ulceration and fungation Tumour markers : CA15/3 (normally less than 40U/ml) mainly for follow up periods MRI Spine /pelvis Radioisotope bone scan Sentinal LN biopsy CT SCAN of chest, abdomen, brain Ductography Thermography Liver function test

Newer investigations:

Newer investigations Stereotactic core biopsy using computer Mammography. Vaccum assisted biopsy using 11 – guage biopsy probe. Needle localised biopsy under mammographic guidance I 125 - seed localisation biopsy

Treatment of cancer of the breast:

Treatment of cancer of the breast The two basic principles of treatment are to reduce the chance of local recurrence and the risk of metastatic spread. Treatment of early breast cancer will usually involve surgery with or without radiotherapy. Systemic therapy such as chemotherapy or hormone therapy is added if there are adverse prognostic factors such as lymph node involvement, indicating a high likelihood of metastatic relapse. At the other end of the spectrum, locally advanced or metastatic disease is usually treated by systemic therapy to palliate symptoms, with surgery playing a much smaller role.

Management of operable breast cancer :

Management of operable breast cancer Achieve local control Appropriate surgery ■ Wide local excision (clear margins) and radiotherapy, or ■ Mastectomy ± radiotherapy (offer reconstruction – immediate or delayed) ■ Combined with axillary procedure ■ Await pathology and receptor measurements ■ Use risk assessment tool ; stage if appropriate Treat risk of systemic disease ■ Offer chemotherapy if prognostic factors poor; include Herceptin if Her-2 positive ■ Radiotherapy as decided above ■ Hormone therapy if oestrogen receptor or progesterone receptor positive

Surgery :

Surgery Surgery still has a central role to play in the management of breast cancer but there has been a gradual shift towards more conservative techniques, backed up by clinical trials that have shown equal efficacy between mastectomy and local excision followed by radiotherapy.

Mastectomy:

Mastectomy Mastectomy is indicated for large tumours (in relation to the size of the breast), central tumours beneath or involving the nipple, multifocal disease, local recurrence or patient preference. THE RADICAL HALSTED MASTECTOMY, which included excision of the breast, axillary lymph nodes and pectoralis major and minor muscles, is no longer indicated as it causes excessive morbidity with no survival benefit. The MODIFIED RADICAL (PATEY) MASTECTOMY is more commonly performed. SIMPLE MASTECTOMY involves removal of only the breast with no dissection of the axilla , except for the region of the axillary tail of the breast, which usually has attached to it a few nodes low in the anterior group.

Modified Radical (Patey)mastectomy:

Modified Radical ( Patey )mastectomy Patey mastectomy :The breast and associated structures are dissected en bloc and the excised mass is composed of: • the whole breast; • a large portion of skin, the centre of which overlies the tumour but which always includes the nipple; • all of the fat, fascia and lymph nodes of the axilla

PowerPoint Presentation:

Scanlon’s operation-is modified patey’s operation where in instead of removing pectoralis minor , it is incised to approach the affected level 3 LN. AUCHINCLOSS Modified Radical mastectomy-in it pectoralis minor muscle is left intact and level 3 LN are not removed.

Conservative breast cancer surgery:

Conservative breast cancer surgery This is aimed at removing the tumour plus a rim of at least 1 cm of normal breast tissue. This is commonly referred to as a wide local excision. The term lumpectomy should be reserved for an operation in which a benign tumour is excised and in which a large amount of normal breast tissue is not resected . A QUADRANTECTOMY involves removing the entire segment of the breast that contains the tumour. (QUART) Both of these operations are usually combined with axillary surgery , usually via a separate incision in the axilla . There are various options that can be used to deal with the axilla , including sentinel node biopsy, sampling, removal of the nodes behind and lateral to the pectoralis minor (level II) or a full axillary dissection (level III).

PowerPoint Presentation:

There is a somewhat higher rate of local recurrence following conservative surgery, even if combined with radiotherapy, but the long-term outlook in terms of survival is unchanged. Local recurrence is more common in younger women and in those with high grade tumours and involved resection margins. Patients whose margins are involved should have a further local excision (or a mastectomy) before going on to radiotherapy. Excision of a breast cancer without radiotherapy leads to an unacceptable local recurrence rate.

PowerPoint Presentation:

The role of axillary surgery is to stage the patient and to treat the axilla . The presence of metastatic disease within the axillary lymph nodes remains the best single marker for prognosis; however, treatment of the axilla does not affect long-term survival, suggesting that the axillary nodes act not as a ‘reservoir’ for disease but as a marker for metastatic potential. If mastectomy is performed it is reasonable to clear the axilla as part of the operation, but if a wide local excision is planned the surgeon should dissect the axilla through a separate incision. Axillary surgery should not be combined with radiotherapy to the axilla , because of excess morbidity. Removal of the internal mammary lymph nodes is unnecessary.

PowerPoint Presentation:

Toilet mastectomy -in locally advanced tumour,tumour with breast tissue whatever possible is removed to prevent futher fungation.it is often done after chemotheraphy . Skin sparing Mastectomy / key hole mastectomy .??

Complication of MRM/MASTECTOMY:

Complication of MRM/MASTECTOMY Pain and Numbness Injury /thrombosis of axillary vein. Seroma formation Flap necrosis / infection Lymphodema Axillary hyperaesthesia Winging of scapula Shoulder dislocation

Sentinel node biopsy:

Sentinel node biopsy This technique is currently becoming the standard of care in the management of the axilla in patients with clinically node-negative disease. The sentinel node is localised peroperatively by the injection of blue dye and radioisotope-labelled albumin in the breast. The recommended site of injection is in the subdermal plexus around the nipple although some still inject on the axillary side of the cancer. The marker passes to the primary node draining the area and is detected visually and with a hand-held gamma camera. The excised node can be sent for frozen-section histological analysis or touch imprint cytology (TIC) if preoperative diagnosis is sought.

Radiotherapy :

Radiotherapy Radiotherapy to the chest wall after mastectomy is indicated in selected patients in whom the risks of local recurrence are high. This includes patients with large tumours and those with large numbers of positive nodes or extensive lymphovascular invasion. There is some evidence that postoperative chest wall radiotherapy improves survival in women with node-positive breast cancer. It is conventional to combine conservative surgery with radiotherapy to the remaining breast tissue. Total dosage 5000cGY units. 200-cGY units daily 5 days a week for 6 weeks.

Hormone therapy:

Hormone therapy Tamoxifen has been the most widely used ‘hormonal’ treatment in breast cancer. Its is Antioestrogen & Dose 10mg BD for 5 years. Its efficacy as an adjuvant therapy was first reported in 1983 and it has now been shown to reduce the annual rate of recurrence by 25%, with a 17% reduction in the annual rate of death. The beneficial effects of tamoxifen in reducing the risk of tumours in the contralateral breast have also been observed, as has its role as a preventative agent.

Endocrine-Active Agents Used in the Treatment of Breast Cancer :

Endocrine-Active Agents Used in the Treatment of Breast Cancer CLASS COMMON EXAMPLES CLINICAL USE Selective estrogen receptor modulators (SERMS) Tamoxifen (20mg /day for 5 year) , raloxifene , toremifene Adjuvant therapy for metastatic disease Aromatase inhibitors (AIs ) Affects oestrogen production Anastrozole , letrozole , exemestane Adjuvant therapy for metastatic disease Pure antiestrogens Fulvestrant Second-line therapy for metastatic disease Luteinizing hormone–releasing hormone (LHRH) agonists Goserelin (3.6mg /28 days cycle for 2 years ) , leuprolide Adjuvant therapy [*] for metastatic disease Progestational agents Megestrol Second-line agent for metastatic disease Androgens Fluoxymesterone Third-line agent for metastatic disease High-dose estrogens Diethylstilbestrol Third-line agent for metastatic disease

Other therapy:

Other therapy Trastuzumab ( Herceptin ) is a humanized murine monoclonal antibody raised against the erb-B2 or HER-2 surface receptor.

Chemotherapy :

Chemotherapy Chemotherapy using a first-generation regimen such as a 6-monthly cycle of cyclophosphamide , methotrexate and 5- fluorouracil (CMF) will achieve a 25% reduction in the risk of relapse over a 10- to 15-year period.

Indications:

Indications In advanced CA Breast as a palliative procedure. In post op cases after simple mastectomy in stage 3 CA Breast with fixed axillary nodes. In Inflammatory CA Breast In stage 4 CA Breast In premenopausal age group with poorly differentiated tumours .

Drug regime:

Drug regime CMF – Cyclophosphamide , Metotrexate , 5-Fluorouracil. CAF- Cyclophosphamide , Adriamycin , 5-Fluorouracil. MMM- Methotrexate , Mitomycin -C , Mitozantrone . TAXANES-newer chemotherapeutic drugs.drugs are paclitaxel and docetaxel .

Follow up after surgery:

Follow up after surgery Clinical examination at regular interval. Yearly mammography of treated and contralateral breast is must. Bone scan/ CT chest ,abdomen / Tumour marker are done only if clinical suspension of spread or metastasis.

PowerPoint Presentation:

Thanking You

CLASSIFICATION OF BREAST CANCER:

CLASSIFICATION OF BREAST CANCER Tx Primary Tumour cannot be assessed T0 No evidence of primary Tumour Tis Carcinoma in situ ( ductal , lobular, and / or paget disease of the nipple without invasive carcinoma) T1 Tumour < 2 cm in greatest dimension T1 mic Microinvasion <= 0.1 cm in greatest dimension T1a Tumour > 0.1 cm but =< 0.5 cm in greatest dimension T1b Tumour > 0.5 cm but <= 1 cm in greatest dimension T1c Tumour > 1 cm but <= 2 cm in greatest dimension T2 Tumour > 2 cm but <= 5 cm in greatest dimension T3 Tumour > 5 cm in greatest dimension T4 Tumour of any size with direct extension to chest wall or skin, only as described below T4a Extension to chest wall, not including pectoralis muscle T4b Edema ( including peau d ‘ orange ) ulceration of the skin of the breast, or satellite skin nodules confined to the same breast T4c Both T4a and T4b T4d Inflammatory carcinoma

PowerPoint Presentation:

pNX Regional lymph nodes cannot be assessed pN0 No regional lymph node metastases pN1 Metastasis in 1 to 3 axillary lymph nodes, and / or in internal mammary nodes with microscopic disease detected by sentinel lymph node dissection but not clinically apparent ( not detected clinically or by noninvasive imaging techniques) pN1mi: Micro metastases (> 0.2 mm , none < 2.0 mm) pN1a : Metastases in 1 to 3 axillary lymph nodes pN1b: Metastases in internal mammary nodes pN1c : Metastasis in 1 to 3 axillary lymph nodes and in internal mammary lymph nodes. If associated with > 3 positive axillary lymph nodes, the internal mammary nodes are classified as pN3b to reflect increased Tumour burden pN2 Metastases in 4 to 9 axillary lymph nodes or in clinically apparent internal mammary lymph nodes in the absence of axillary node metastasis pN2a : Metastasis in 4 to 9 axillary lymph nodes ( at least one deposit > 2mm) pN2b : Metastasis in clinically apparent internal mammary lymph nodes in the absence of axillary lymph node metastasis pN3 Metastasis in >=10 axillary lymph nodes or in infraclavicular lymph nodes, or in clinically apparent ipsilateral internal mammary lymph nodes in the presence of >= 1 positive axillary lymph nodes; or in > 3 axillary lymph nodes with clinically negative microscopic metastasis in internal mammary lymph nodes; or in internal mammary lymph nodes; or in ipsilateral supraclavicular lymph nodes pN3a : Metastases in >=10 axillary lymph nodes (at least one deposit >2mm ) , or metastases to the infraclavicular lymph nodes. pN3b: Metastasis in clinically apparent ipsilateral internal mammary lymph nodes in the presence of >=1 positive axillary nodes; or in >3 axillary lymph nodes and in internal mammary lymph nodes with microscopic disease detected by sentinel lymph node dissection but not clinically apparent. pN3c: Metastases in ipsilateral supraclavicular lymph nodes

Manchester staging:

Manchester staging Tumour in the breast ,not involving pectoral or deeper plane.Skin involvement if present ,it is lesser than the size of tumour.Lymph node are not palpaple . Same as stage 1 but with mobile, discrete, lymph node palpable in the ipsilateral axilla . Tumour fixed to pectoral muscle or skin involvement more than the tumour size or ipsilateral axillary lymph node adhrent to each other or fixed Tumour fixed to chest wall ,skin involved wider than thatof breast ,involvement of ipsilateral or contralateral clavicular lymph node or opposite breast or opposite axillary LN , spread to bones ,lungs ,liver or inflammatory carcinoma of breast.

authorStream Live Help