2. Ca Breast(1).ppt.knowledge practice attitude

For the undergraduate medical student

1. Carcinoma of breast
Most common cause of death in middle aged
women.
Incidence – 1 in 8 US or 1 in 12 chances UK

2. Aetiology
1.Geographic
Mainly occur in Western counteries
2.Age
Rare <20yr
Incidence- increase with age
3.Gender
Male breast Ca -<0.5%
4.Genetic
Account for <5%
If FH +,risk of incidence-2-10times above baseline
Two main genes- BRCA 1& BRCA 2
Autosomal dominance
If gene + →50-80%risk

3. 5. Diet
Related with diets low in phytoestrogens
↑ alcohol intake → ↑ risk
6. Endocrine
More common in
-nulliparous women
-early menarche& late menopause
-age at 1st full term pregnancy
-no breast feeding
-obesity
-OC pills & HRT
7.Previous radiation

4. Pathology
Arises from epithelium of duct system
Mainly ductal and lobular carcinoma
Either in situ or invasive cancer
Depending on 3 factors (nuclear pleomorphism,
tubule formation and mitotic rate) degree of
differentation of tumour – described in 3 grades
Grade III - poorly differentiated

5. Histological types of breast cancer
Carcinoma in situ
Pre-invasive cancer
Either DCIS or LCIS
Develop into invasive cancer 20% of cases
Invasive carcinoma
Ductal carcinoma – most common type
Lobular carcinoma – 15% of cases
Diagnosed by immunohistochemical analysis using e-cadherin
antibody
Multifocal and bilateral

6. Rare histological types with better progonsis
Colloid carcinoma
Medullary carcinoma
Tubular carcinoma
Inflammatory carcinoma

7. Recent advances in pathology of breast
Estrogen & progesterone receptor staining –
routine
c-erb B2 (HER 2) staining
Detected by immunohistochemistry

Predict the response to monoclonal antibody
trastuzmab

8. Spread
Local
Invades other portions of breast
Lymphatic spread
Mainly to axillary and internal mammary lymph nodes
Lymph node metastases – marker for metastatic potential of
tumour
Blood spread
Main cause of skeletal metastases
Also to liver, lungs, brain, adrenal glands and ovaries

9. Staging
Manchester staging
TNM staging

10. TNM stage grouping
Stage 0TisN0M0(in situ breast cancer)
Stage IT1N0M0
Stage IIA T0N1 M0early invasive breast cancer
T2N0M0
Stage IIBT2N1 M0
Stage IIIAT0-2N2M0
T3N1-2M0advanced locoregional
Stage IIIBT4 anyNM0breast cancer
any TN3M0
Stage IVany Tany NM1- distant metastasis

11. Manchester Staging
It is a pure clinical staging
Stage I
Tumour
Confined to the breast
Skin involvement may be present
Skin involvement < tumour size
No chest wall or pectoral muscle involvement
Lymph node - absent
Metastases - absent

12. Stage II
Tumour
There may be just tethering of growth to pectoral
muscle
Lymph node
Ipsilateral mobile axillary lymph node
Metastases
Absent

13. Stage III
Tumour
Skin involvement > tumour size or
Fixed to pectoral muscle
Lymph node
Ipsilateral fixed axillary lymph node
Metastases - absent

14. Stage IV
Tumour
Fixed to chest wall
Lymph node
Supraclavicular lymph node involvement
Metastases
To opposite breast
Skin away from tumour
Distant organs

15. Clinical Features
1.Breast lump
-most common in upper outer quadrant
-painless , hard &fixed
-occurs spontaneously
-rapidly increase in size

2.Nipple abnormality
-blood stained discharge
-eczema like change in Paget's disease
-recent nipple retraction

16. 3.Skin changes
-Skin above the carcinoma – dimpling , puckering or tethering
-Ulceration & fungating growth – late case
-Peau-d-orange- due to cutaneous lymphatic oedema
-cancer-en-cuirasse – skin of chest is infiltrated by Ca (like a coat)
4. Systmic manifestation
-Bone – bone pain, pathological fractures
-Brain – features of increased ICP
-liver – jaundice, hepatomegly
-lungs – haemoptysis, dyspnoea & chest pain

17. 5. History of risk factors may present
- family history of Ca breast
- early menarchy & late menopause
- Nulliparity etc.

18. Investigations
For primary tumour
1.Triple assessment
consists of
a. clinical assessment – age + clinical exmination
b. Radiological imaging - Ultrasound scan + Mammography
c. Cytology or histological analysis of tissue sample
Mammography
Two views – craniocaudal (CC) & mediolateral oblique view
Features of malignancy on mammography
- a solid mass with or without stellate features
- asymmetric thickening of breast tissues
- clustered microcalcifications

19. Also used for needle (stereotactic) localization & needle biopsy
Recently digital mammography
Ultrasound scan
Can distinguish cystic from solid
Ultrasound of axilla- for guided percutaneous biopsy of suspicious glands
Biopsy or cytology
Can perform either FNAC or core needle biopsy
2. MRI – increasing interest because
to distinguish scar from recurrence in women with previous breast conserving
therapy
Useful as a screening tool in high-risk women

20. For staging & management
For early stage cancer – CXR, FBC & LFT
For locally advanced cancer – CXR, USS & isotope bone scan etc. are needed
Tissue specimen – checked for hormone receptor status & HER II status
Treatment
Two basic principles – to reduce the chance of local recrrence & risk of metastatic
spread
Must treat by multidisciplinary team approach

21. Pragmatic Classification of Breast
Cancer
Group Example Treatment
‘Very low risk’Screen-detected DCIS,
tubular or special type
Local
‘Low risk’ Node negative with
favourable histology
Locoregional with /
without Systemic
‘High risk’ Node positive or
unfavourable histology
Primary systemic
Locally advanced Large primary or
inflammatory
Primary systemic
Metastatic Primary systemic

22. Early Breast Cancer
To achieve local control, surgery either in the
form of
1.Wide local excision (conservative surgery) &
radiotherapy or
2.Metastectomy with or without radiotherapy

Combined with axillary procedure
To reduce risk of metastases
Chemotherapy
Radiotherapy
Hormone therapy

23. Surgery
Shifted towards breast conservative surgery
But mastectomy is indicated for
Large tumour
Central tumours beneath or involving the nipple
Multifocal disease
Local recurrence
Patient preference

24. Types of mastectomy
Halsted radical mastectomy
Modified Patey mastectomy
Simple mastectomy
Conservative surgery (wide local excision)
Removing of tumour + a rim of at least 1 cm of
normal breast tissue
Must combined with radiotherapy

25. Axillary surgery
Axillary status is best marker for prognosis
Aim – to stage the patient and to treat the axilla
All patients require axillary surgery
The options are
Sentinel node biopsy
Axillary clearance
Axillary sampling

26. Radiotherapy
Chest wall
- high grade, large, heavily node positive,
extensive lympho-vascular invasion
Breast
- remaining breast in conservative surgery

27. Adjuvant systemic therapy
Hormone receptor positive
Pre-menopausal
- 5yr of endocrine therapy, either 20 mg daily of
tamoxifen
Postmenopausal
- aromatase inhibitors

28. Node positive and higher risk node negative –
chemotherapy
CMF (6 monthly cycle)
Modern regime are
- AC
- ECF
- TAC

29. HER 2 positive
Biological treatment with Trastuzamab (Herceptin)
Prognosis
Tumour size and lymphnode status

Best indicator of prognosis

30. Screening
Screening with memmography > 50 years of age
– 30 % reduction of mortality

31. Treatment of advanced breast cancer
Advanced breast cancer consists of
1.Locally advanced breast cancer
2.Metastatic carcinoma of breast

32. Locally advanced breast cancer
Are those with advanced locoregional breast
cancer with no clinically detectable distant
metastases
Main treatment – systemic therapy either chemo
or hormonal therpay
To control of fungating tumour – surgery in the
form of ‘toilet mastectomy’ or radiotherapy is
required

33. Metastatic carcinoma of breast
Aim – not curative enhance the quality of life
Hormonal treatment – first line treatment
Various hormonal treatment
Tamoxifen

Ovarian suppression by surgery
Newer agents – anti-progestins, pure anti-oestrogens

34. Hormonal treatment is suitable for
Women with hormone receptor – positive cancers
Women with bone or soft tissue metastases only;
and
Women with limited and asymptomatic visceral
metastases

35. Chemotherpay is indicated in
Younger women
Women with symptomatic visceral metastases
Women with rapidly growing tumour
Hormone receptor negative and hormone
refractory case
Local treatment
Radiotherapy for painful bone metastases,
internal fixation of pathological fractures