Breast Cancer Management (nnnnnnn2).pptx

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1. Breast Cancer Management By Dr Ijigu(R4) Moderator : Dr Ashenafi( Consultant General Surgeon) 10/11/2022 Breast Ca Management by Ijigu 1

2. Outlines Epidemiology Risk factors for breast cancer Risk assessment of breast cancer Screening of breast cancer Diagnosis of breast cancer Staging of breast cancer Treatment of breast cancer Technique of MRM 10/11/2022 Breast Ca Management by Ijigu 2

3. Epidemiology Globally, breast cancer is the most frequently diagnosed malignancy and the 2nd leading cause of cancer death in women Predominately a disease of high -income countries where overall rates are nearly three times higher than in middle - to low -income countries The incidence rates are highest in North America, Australia/New Zealand, and in western and northern Europe, and lowest in Asia and SSA 10/11/2022 Breast Ca Management by Ijigu 3

4. Cont … 10/11/2022 Breast Ca Management by Ijigu 4

5. In Ethiopia Over a period of 7 years, January 2013–January 2019, there were 3002 new patients with cancer registered in the oncology unit of HUCSH Of which five hundred fifty-nine (18.6%) were patients with breast cancer Of this, 548 (98%) were women The median ages of the patients were 38 (IQR: x1–x3)  years The peak age of incidence of breast cancer in this study was between 3 rd  and 5 th  decades (30–49 years) which accounts 321 (57.4%) of all cases 10/11/2022 Breast Ca Management by Ijigu 5

6. Risk factor of breast cancer 10/11/2022 Breast Ca Management by Ijigu 6

7. Risk Assessment Models The average lifetime risk of breast cancer for new born U.S. women is 12.5% The longer a woman lives without cancer, the lower her risk of developing breast cancer Thus , a woman age 50 years has an 11% lifetime risk of developing breast cancer, and a woman age 70 years has a 7% lifetime risk of developing breast cancer 10/11/2022 Breast Ca Management by Ijigu 7

8. Cont … 10/11/2022 Breast Ca Management by Ijigu 8

9. Breast Cancer Screening Routine use of screening mammography in women ≥50 years reduce mortality by 25 % USPSTF recommended biennial screening mammography for women 50 to 74 years old R ecommended against screening for women 40 to 49 years old or older than 75 years R ecommended screening with MRI Younger women with a previous breast cancer significant family history of breast cancer histologic risk factors for breast cancer equal to a 20% lifetime risk 10/11/2022 Breast Ca Management by Ijigu 9

10. Cont … Average risk women a woman is considered to be at average risk if she doesn’t have a personal history of breast cancer, a strong family history of breast cancer , a genetic mutation known to increase risk of breast cancer (such as in a  BRCA   gene) has not had chest radiation therapy before the age of 30 ACS recommend: Women between 40 and 44  have the option to start screening with a mammogram every year. Women 45 to 54  should get mammograms every year. Women 55 and older  can switch to a mammogram every other year, or they can choose to continue yearly mammograms Screening should continue as long as a woman is in good health and is expected to live at least 10 more years 10/11/2022 Breast Ca Management by Ijigu 10

11. Cont … High risk women Women who are at  high risk  for breast cancer based on certain factors should get a  breast MRI and a mammogram every year, typically starting at age 30: women who Have a lifetime risk of breast cancer of about 20% to 25% or greater, based mainly on family history known   BRCA1 or BRCA2 gene mutation   (   genetic testing ) a first-degree relative with a  BRCA1  or  BRCA2  gene mutation, and have not had genetic testing themselves Had radiation therapy to the chest when they were between the ages of 10 and 30 years Have Li- Fraumeni syndrome, Cowden syndrome, or Bannayan -Riley- Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes 10/11/2022 Breast Ca Management by Ijigu 11

12. Risk-reduction interventions Lifestyle Modifications Maintain a healthy weight throughout life Adopt a physically active lifestyle Consume a healthy diet, with an emphasis on plant foods Limit consumption of alcohol Risk-Reduction Surgery Bilateral Total Mastectomy Women with a BRCA1/2, TP53, PTEN, CDH1, or STK11 mutation or, Women with a history of LCIS who desire intervention. Risk-Reduction Agents Recommended for women ≥35 years of age only Tamoxifen, raloxifene , anastrozole , exemestane 10/11/2022 12 Breast Ca Management by Ijigu

13. Clinical Evaluation History : age, a reproductive history - age at menarche & menopause , and history of pregnancies - age at first full-term pregnancy, previous history of breast biopsy with pathologic findings specific breast complaint, history of a mass , pain, nipple discharge , and any skin changes. If a mass is present- ask how long it has been present and whether it has grown or changes with the menstrual cycle If a cancer diagnosis is suspected, constitutional symptoms- bone pain, weight loss, respiratory changes, and similar clinical indications can direct investigations that could reveal evidence of metastatic disease 10/11/2022 Breast Ca Management by Ijigu 13

14. Cont … P/E: 10/11/2022 Breast Ca Management by Ijigu 14

15. FNAC If FNA demonstrates malignancy, a CNB is still required for definitive histologic diagnosis before surgical intervention FNA is unable to distinguish between in situ and invasive disease In the setting where neoadjuvant therapy is to be utilized, a clip must be placed in the positive node 10/11/2022 Breast Ca Management by Ijigu 15

16. MRI It is useful for identifying the primary tumor in the breast in patients who present with axillary lymph node metastases without mammographic evidence of a primary breast tumor (unknown primary tumor) I n patients with Paget disease of the nipple without radiographic evidence of a primary tumor For assessing the extent of the primary tumor, particularly in young women with dense breast tissue E xtent of residual disease after lumpectomy with positive margins F or evaluating for the presence of multifocal or multicentric cancer F or screening of the contralateral breast and for evaluating invasive lobular cancers 10/11/2022 Breast Ca Management by Ijigu 16

17. Mammogram On a mammogram, DCIS can present as microcalcifications , a soft-tissue density , or both T wo different classes of microcalcifications : ( a) linear branching-type microcalcifications , which are more often associated with high–nuclear-grade, comedo -type lesions ( b) fine, granular calcifications, which are primarily associated with micropapillary or cribriform lesions of lower nuclear grade 10/11/2022 Breast Ca Management by Ijigu 17

18. Breast Ultrasound 10/11/2022 Breast Ca Management by Ijigu 18 The American College of Radiology developed the breast imaging reporting and data system (BIRADS), which categorizes mammographic findings as follows: BIRADS 0- incomplete or further imaging needed BIRADS 1- negative (no findings) BIRADS 2- benign appearance BIRADS 3- probably benign appearance, short interval follow-up recommended (< 2% risk) BIRADS 4- findings suspicious for breast cancer (20% to 35% risk) 4a mildly suspicious 4b intermediately suspicious 4c moderately suspicious BIRADS 5- findings highly suspicious for breast cancer (>90% chance of malignancy) BIRADS 6- known biopsy proven malignancy

19. In Ethiopia Histology of Breast Ca 10/11/2022 Breast Ca Management by Ijigu 19 Invasive ductal carcinoma was the leading 309 (55.3%) histologic type followed by 185 (33.1%) lobular carcinoma . One hundred seventy-seven (31.7%) were moderately differentiated and 155 (27.7%) were poorly differentiated . Three hundred seventy-two (66.5%) were advanced breast cancer (Stages III and IV). Trends of breast cancer showed the case load is continuously increasing The majority were advanced breast cancer occurring at an early age by the time diagnosis made Invasive ductal carcinomas were the predominant one

20. Staging 10/11/2022 Breast Ca Management by Ijigu 20

21. Planning Surgical Treatments In the absence of metastatic disease, the first intervention for patients with early-stage breast cancer is surgery for excision of the tumor and surgical staging of the regional lymph nodes Patients with locally advanced and inflammatory breast cancers should receive systemic therapy before surgery 10/11/2022 Breast Ca Management by Ijigu 21

22. Selection of Surgical Therapy Mastectomy and breast-conserving therapy Patients who desire breast-conserving surgery must be willing to attend postoperative radiation therapy sessions and to undergo postoperative surveillance of the treated breast A significant factor in determining whether breast-conserving therapy is feasible is the relationship between tumor size and breast size 10/11/2022 Breast Ca Management by Ijigu 22

23. Mastectomy tumors that are large relative to breast size tumors with extensive calcifications on mammography tumors for which clear margins cannot be obtained on wide local excision tumors in patients with contraindications to breast irradiation Patient preference for mastectomy or a desire to avoid radiation 10/11/2022 Breast Ca Management by Ijigu 23

24. Breast-conserving therapy Tumor Size: lumpectomy is considered when the tumor, regardless of size, can be excised with clear margins and an acceptable cosmetic result Margins : no ink on tumor should be used as the standard for an adequate margin in invasive breast cancer Histology: Invasive lobular cancers and cancers with an extensive intraductal component can be treated with lumpectomy if clear margins can be achieved Patient Age: Local recurrence rates after breast-conserving surgery are higher for younger women than for older women but rates are reduced in patients of all ages with the use of radiation therapy 10/11/2022 Breast Ca Management by Ijigu 24

25. Management of ALH and LCIS 10/11/2022 Breast Ca Management by Ijigu 25 LCIS is an indicator for increased breast cancer risk of approximately 1% per year, or approximately 20% to 30% at 15 years Lobular architecture is maintained in LCIS, but all acini are distended and the cells are monomorphic with uniform nuclei Calcifications, mitoses, and necrosis are rare In ALH, as opposed to LCIS , not all of the acini are abnormal or all of the acini are involved but not all of them are distended, and there may be residual lumina

26. Treatment 10/11/2022 Breast Ca Management by Ijigu 26 Options Includes: lifelong surveillance bilateral total mastectomies with immediate reconstruction for selected women with a strong family history after appropriate counselling pharmacologic risk reduction with anti- estrogen treatment

27. TREATMENT OF DUCTAL CARCINOMA IN SITU Is contained within an intact basement membrane and without access to lymphatic or vascular channels Accounts for approximately 25% of all newly diagnosed breast cancers Most cases of DCIS are detected as an area of clustered calcifications on a screening mammogram without an associated palpable abnormality Rarely manifests as a palpable mass or as unilateral , single-duct nipple discharge Findings on mammography include clustered calcifications without an associated density in 75% of patients , calcifications coexisting with an associated density in 15 %, and a density alone in 10% 10/11/2022 Breast Ca Management by Ijigu 27

28. Cont … Mastectomy Local recurrence of DCIS is ∼1% to 2% per year when treated with BCS versus 1% to 2% lifetime when treated with mastectomy The survival rates with either treatment are the same, 98% to 99 % Reasons to select total mastectomy for treatment of DCIS include the following: Diffuse suspicious mammographic calcifications suggestive of extensive disease Inability to obtain clear margins with breast-conserving surgery Likelihood of a poor cosmetic result after breast-conserving surgery Patient not motivated to comply with follow-up surveillance imaging Patient choice Contraindications to radiation therapy 10/11/2022 Breast Ca Management by Ijigu 28

29. Cont …Breast-Conserving Therapy Requires resection to microscopically clear margins(2mm) adjuvant whole breast radiation therapy to decrease the risk for local recurrence hormonal therapy in patients with ER-positive DCIS can decrease further the risk for local recurrence and development of new contralateral and ipsilateral breast cancers Van Nuys criteria 10/11/2022 Breast Ca Management by Ijigu 29

30. Cont … After adding together the score from each of these factors, patients are classified into three categories: low-risk (score of 4-6) BCS without radiotherapy is recommended intermediate-risk (score of 7-9) BCS with radiotherapy is recommended high-risk (score of 10-12) mastectomy is recommended 10/11/2022 Breast Ca Management by Ijigu 30

31. Cont … when ALND was performed during mastectomy for DCIS, positive nodes were found in 3.6 % Sentinel node surgery is currently recommended in patients undergoing mastectomy for DCIS because 20% to 30% of patients with DCIS on a diagnostic CNB are found to have invasive cancer In BCS for DCIS, sentinel node surgery is considered for patients with larger areas of DCIS(palpable), high-grade histology or high suspicion of micro invasion & exhibits comedo -type necrosis 10/11/2022 Breast Ca Management by Ijigu 31

32. Sentinel Lymph Node Dissection 10/11/2022 Breast Ca Management by Ijigu 32 The sentinel node is the most likely node to contain metastatic disease, if present In sentinel node surgery, radiolabeled colloid, blue dye, or both are injected into breast tissue at the site of the primary tumor; the material passes through the lymphatics to the first draining node(s), where it accumulates performed with injection of the mapping agents that can be injected subareolar position or in a subdermal location overlying the site of the primary tumor

33. Cont … 10/11/2022 Breast Ca Management by Ijigu 33 Using a peritumoral injection technique, approximately 70% of patients have drainage to the axilla 20% have drainage to the axilla and the internal mammary nodal basin 2% to 3% have drainage to the internal mammary nodal basin alone 8% do not show any drainage to the regional nodal basins In the operating suite, 3 to 5 mL of blue dye can be injected peritumorally , and the injection site is massaged to facilitate passage of the dye through the lymphatics A handheld gamma probe is used to localize transcutaneously the area of increased radioactivity

34. Cont … 10/11/2022 Breast Ca Management by Ijigu 34 patients with positive sentinel nodes showed that 53% of patients have additional positive nodes at ALND In the case of micrometastatic disease in the sentinel nodes, the rate of nonsentinel node involvement is 20%, and for patients with isolated tumor cells, it is less than 12%

35. ALND 10/11/2022 Breast Ca Management by Ijigu 35 ALND remains the standard of care for patients with: locally advanced breast cancer or inflammatory breast cancer positive sentinel node who are scheduled for mastectomy positive sentinel node who are scheduled for accelerated partial breast irradiation (PBI) clinically positive nodes as well as a positive sentinel node after neoadjuvant chemotherapy

36. Cont … 10/11/2022 Breast Ca Management by Ijigu 36

37. Radiation Therapy after BCS radiation therapy after breast conserving surgery should be considered as a standard WBI radiation therapy after lumpectomy has consisted of a 6- to 8-week treatment course APBI may be performed with brachytherapy catheters, balloon catheters, or external-beam radiation(within wk ) b ut is limited to women with no more than 3 cm of DCIS invasive stage I or II breast cancer limited nodal disease (≤3 lymph nodes) who underwent margin-negative lumpectomy 10/12/2022 Breast Ca Management by Ijigu 37 APBI is limited to women with no more than 3 cm of DCIS or invasive stage I or II breast cancer and limited nodal disease (≤3 lymph nodes) who underwent margin-negative lumpectomy

38. Post mastectomy Radiation Therapy For patients with T1N0 or T2N0 breast cancer, mastectomy and SLND provide effective local control, and radiation therapy is not required P atients with stage III breast cancer have high rates of locoregional recurrence after treatment with a modified radical mastectomy and adjuvant or neoadjuvant chemotherapy patients with four or more positive lymph nodes or other features characteristic of stage III disease should be counselled to undergo radiation therapy 10/11/2022 Breast Ca Management by Ijigu 38

39. Cont … Postmastectomy radiation therapy only for patients with stage II disease patients with extracapsular extension lymphovascular invasion age 40 years or younger close/positive surgical margins a nodal positivity ratio (ratio of positive nodes to total nodes examined) of 20% or greater patients who have undergone less than a standard level I or II axillary dissection. 10/11/2022 Breast Ca Management by Ijigu 39

40. TREATMENT OF LOCALLY ADVANCED 10/11/2022 Breast Ca Management by Ijigu 40 Patients with locally advanced breast cancer includes: large primary tumors (>5 cm) tumors involving the chest wall and skin involvement ulceration or satellite skin nodules inflammatory carcinoma bulky or fixed axillary nodes clinically apparent internal mammary or supraclavicular nodal involvement (stages IIB, IIIA, and IIIB disease )

41. Cont … 10/11/2022 Breast Ca Management by Ijigu 41 Current management includes surgery, radiation therapy, and systemic therapy, with the sequence and extent of treatment determined by specifics of the patient’s circumstance

42. Early Stage Breast Cancer 10/11/2022 Breast Ca Management by Ijigu 42 Workup for patients with clinical stage I or stage II breast cancer is usually limited to a complete history and physical examination , a chest radiograph, and evaluation of serum liver chemistries The treatment approach consists of local regional therapy with surgery and radiation therapy when indicated Surgical options include breast conservation therapy including segmental mastectomy followed radiation therapy or total mastectomy with or without reconstruction

43. Locally Advanced Breast Cancer 10/11/2022 Breast Ca Management by Ijigu 43 Approximately 10% to 20% of all patients with breast cancer have stage III disease with one-quarter of these patients initially inoperable at the time of diagnosis The standard of care in patients with locally advanced breast cancer is a neoadjuvant systemic therapy approach followed by surgery and adjuvant radiation therapy If postoperative chemotherapy is planned, it should precede radiation therapy to avoid interrupting the treatment of systemic disease given distant metastasis is the most frequent form of treatment failure. Adjuvant hormonal therapy is routinely offered to all patients with hormone receptor-positive tumors

44. Cont … 10/11/2022 Breast Ca Management by Ijigu 44

45. INFLAMMATORY BREAST CANCER 10/12/2022 Breast Ca Management by Ijigu 45 inflammatory breast cancer is rare, accounting for approximately 1% to 5% of all breast tumors, it is the most aggressive subtype of breast cancer The pathologic hallmark of inflammatory cancer is the presence of tumor cells within dermal lymphatics Neoadjuvant therapy, mastectomy, and radiation therapy, with endocrine therapy for ER-positive tumors and trastuzumab for HER-2–positive tumors

46. Cont … 10/11/2022 Breast Ca Management by Ijigu 46

47. Distant Metastases (Stage IV) 10/11/2022 Breast Ca Management by Ijigu 47 To prolong survival and enhance a woman’s quality of life Endocrine therapies that are associated with minimal toxicity are preferred to cytotoxic chemotherapy in ER-positive disease C andidates for initial endocrine therapy include women with hormone receptor-positive cancers who do not have immediately life threatening disease (or “visceral crisis ”) Systemic chemotherapy is indicated for women with hormone receptor-negative cancers, “visceral crisis,” and hormone-refractory metastases

48. MRM 10/11/2022 Breast Ca Management by Ijigu 48 is a surgical procedure that removes all breast tissue and lymphatic-bearing tissue in the axilla(levels I, II, and III (apical) axillary lymph nodes), preserves the pectoralis major muscle Anatomic boundaries of the modified radical mastectomy are: anterior margin of the latissimus dorsi muscle laterally midline of the sternum medially subclavius muscle superiorly caudal extension of the breast 2 to 3 cm inferior to the inframammary fold inferiorly

49. MRM Cont … it is important to have an incision that provides good exposure to the axilla and reduces skin redundancy The incision should include the skin overlying the tumor in cases where the tumor is close to the skin and a 1- to 2-cm margin around the tumor and include the previous biopsy site 10/11/2022 49 Breast Ca Management by Ijigu

50. Incision The location of the tumor determines the type of incision required for the mastectomy an elliptical incision is made, incorporating the nipple-areola complex, and extending towards the axilla 10/11/2022 50 Breast Ca Management by Ijigu

51. Cont … 10/11/2022 Breast Ca Management by Ijigu 51

52. AXILLARY DISSECTION 10/11/2022 Breast Ca Management by Ijigu 52 Subsequently, an axillary lymph node dissection is performed The dissection proceeds from lateral to medial, with complete visualization of the anterior and inferior aspects of the axillary vein The most lateral extent of the axillary vein is identified, and the areolar tissue of the lateral axillary space is elevated as the vein is cleared on its anterior and inferior surfaces The areolar tissues at the junction of the axillary vein and the anterior edge of the latissimus dorsi muscle, which include the lateral and subscapular lymph node groups (level I), are cleared

53. Cont … 10/11/2022 Breast Ca Management by Ijigu 53

54. Skin closure 10/11/2022 Breast Ca Management by Ijigu 54

55. Post op Catheters are retained in the wound until drainage diminishes to <30 mL per day Seromas beneath the skin flaps occur in 30%, Patients after an MRM should be placed in a breast binder or an Ace wrap following their surgery significant lymphedema occur approximately 20% but can be as high as 50% to 60% when postoperative radiation is employed 10/11/2022 55 Breast Ca Management by Ijigu

56. SYSTEMIC THERAPY FOR BREAST CANCER Metastatic disease is the principal cause of death from breast cancer Systemic therapy is used to treat and prevent recurrence of microscopic metastatic breast cancer For patients with stage I to III invasive breast cancer, the goal of treatment is cure The risk of systemic recurrence increases with increasing stage of disease The biologic characteristics of an individual tumor also influence the risk of systemic recurrence 10/11/2022 Breast Ca Management by Ijigu 56

57. Cont … The most commonly used breast cancer biomarkers—ER, PR, and HER-2—not only affect prognosis but also predict response to different systemic therapies Tumours that have no ER or PR expression and with high levels of HER-2 are associated with worse cancer outcomes than that of strongly positive for ER and PR and have negative or normal levels of HER-2 10/11/2022 Breast Ca Management by Ijigu 57

58. Cont … 10/12/2022 Breast Ca Management by Ijigu 58

59. Cont … The Oncotype DX assay was developed from a candidate pool of 250 genes and narrowed to a specific 21-gene panel validated first in patients with ER-positive, lymph node–negative breast cancer and stage of cancer is I, II, or IIIA 10/11/2022 Breast Ca Management by Ijigu 59

60. Cont … 10/11/2022 Breast Ca Management by Ijigu 60 measure the amount of 21 specific genes in the tumor tissue 16 of the genes are cancer-related; the other 5 are used as "reference" genes  Based on the amount of each of these genes, a score is assigned This is called the Recurrence Score (RS ), t his score is on a scale of 0-100 A postmenopausal women with positive or negative nodes : A score of 0-25 a low risk of recurrence, no need chemotherapy A score of 26-100 a high risk of recurrence, chemotherapy indicated

61. Cont … 10/11/2022 Breast Ca Management by Ijigu 61 A premenopausal women with negative nodes : A score of 0-15 - a low risk of recurrence, no chemotherapy A score of 16-25- a low to medium risk of recurrence, there may be a small benefit to adding chemotherapy A score of 26-100- a high risk of recurrence, need chemotherapy A premenopausal women with positive nodes : A score below 26, there is a benefit to adding chemotherapy and ovarian suppression along with hormone therapy A score of 26-100 - a high risk of recurrence, chemotherapy indicated

62. Cont … 10/12/2022 Breast Ca Management by Ijigu 62

63. 10/12/2022 Breast Ca Management by Ijigu 63

64. Cont … 10/11/2022 Breast Ca Management by Ijigu 64

65. HER-2–Based Targeted Therapy HER-2 gene amplification or protein overexpression occurs in approximately 20% to 25% of breast cancers Trastuzumab is a humanized monoclonal antibody developed to target the extracellular domain of the HER-2 receptor When used as a single agent for treatment of metastatic breast cancer, response is 30 % Trastuzumab combined with chemotherapy is more effective 1 year of treatment is standard of care 10/11/2022 Breast Ca Management by Ijigu 65

66. Endocrine Therapy One of the original targeted therapy approaches was the use of oophorectomy to reduce systemic estrogen production as a treatment for breast cancer . Most breast cancers (>60%) express ER or PR or both interruption of the production of estrogen or the ability of estrogen to interact with the ER has been associated with improved DFS and OS for women with metastatic breast cancer 10/11/2022 Breast Ca Management by Ijigu 66

67. Tamoxifen Tamoxifen is a selective ER modulator that has antagonistic and weak agonistic effects For premenopausal or perimenopausal women, tamoxifen for 5 years is recommended After 5 years, if the patient is still premenopausal , she should be offered an additional 5 years of tamoxifen therapy 10/11/2022 Breast Ca Management by Ijigu 67

68. Cont … 10/11/2022 Breast Ca Management by Ijigu 68

69. Aromatase Inhibitors AIs purely block the final step of conversion of hormones into estrogen Selective AIs, which include anastrozole , exemestane , and letrozole , are unable to suppress ovarian function completely in a premenopausal or perimenopausal woman and are restricted for use in postmenopausal women 10/11/2022 Breast Ca Management by Ijigu 69

70. Neoadjuvant Systemic Therapy for Operable Breast Cancer A dministration of systemic chemotherapy or endocrine therapy before surgery can result in a significant reduction in tumor size convert inoperable tumors to operable ones make tumors that would require mastectomy amenable to lumpectomy shrink larger tumors to allow an improved cosmetic outcome with breast conserving surgery 10/11/2022 Breast Ca Management by Ijigu 70

71. Cont … no survival advantage in patients who received preoperative doxorubicin and cyclophosphamide chemotherapy versus the same regimen delivered postoperatively The breast conservation rate was higher in women completing neoadjuvant chemotherapy recurrence in women who underwent neoadjuvant therapy followed by lumpectomy was not significantly different from the rate of in-breast recurrence in women who underwent lumpectomy before adjuvant chemotherapy 10/11/2022 Breast Ca Management by Ijigu 71

72. Cont … 10/11/2022 Breast Ca Management by Ijigu 72

73. TREATMENT OF SPECIAL CONDITIONS Paget Disease accounts for 1% or less of breast malignancies It is characterized clinically by nipple erythema and irritation with associated pruritus and may progress to crusting and ulceration Paget cells do not invade through the dermal basement membrane and are categorized as carcinoma in situ More than 95% of patients with Paget disease have an underlying breast carcinoma Treatment of Paget disease includes mastectomy with axillary staging or wide local excision of the nipple and areola to achieve clear margins, axillary staging, and radiation therapy 10/11/2022 Breast Ca Management by Ijigu 73

74. Male Breast Cancer Breast cancer infrequently occurs in men It accounts for just 0.8% of all breast cancers and less than 1% of all newly diagnosed cancers in men The median age at diagnosis is 68 years, 5 years older than that in women. Risk factors include increasing age, radiation exposure, factors related to abnormalities in estrogen and androgen balance (testicular disease, infertility, obesity , and cirrhosis), and genetic predisposition, including Klinefelter syndrome(47,XXY) , family history, and BRCA2 gene mutations 10/11/2022 Breast Ca Management by Ijigu 74

75. Cont … 90% of male breast cancers are invasive ductal carcinomas The majority of men with breast cancer have a breast mass , and when matched for age and stage, survival is similar to that in women 80 % are ER positive, 75% are PR positive , and 35% overexpress HER-2, the remaining 10% are DCIS Treatment of carcinoma in the male breast is similar to that in the female breast prognostic factors include nodal involvement, tumor size, histologic grade, and hormone receptor status Adjuvant endocrine therapy with tamoxifen or AIs is indicated for patients with node-positive disease and high-risk patients with node-negative disease 10/11/2022 Breast Ca Management by Ijigu 75

76. Locally Recurrent Breast Cancer 10/11/2022 Breast Ca Management by Ijigu 76 5 % to 10% at 8 to 10 years have been reported for patients after breast conservation those who have had mastectomy and those who have had lumpectomy Women treated previously with mastectomy undergo surgical resection of the local-regional recurrence and appropriate reconstruction Chemotherapy and antiestrogen therapy are considered, and adjuvant radiation therapy is given if the chest wall has not previously received radiation therapy Women treated previously with a BCS undergo a mastectomy and appropriate reconstruction Chemotherapy and antiestrogen therapy are considered depending of the hormone receptor status

77. Surveillance 10/11/2022 Breast Ca Management by Ijigu 77 If a DCIS is associated with calcifications on preoperative imaging , a mammogram should be considered after lumpectomy and prior to radiation therapy to rule out residual microcalcifications Mammography was obtained 4 to 6 months after the completion of radiation therapy Follow-up after BCS with or without radiation therapy should be: annual or biannual physical examination annual mammography for the first 5 years , with an annual physical examination and mammogram thereafter

78. Prognosis 10/11/2022 Breast Ca Management by Ijigu 78 The 5-year relative survival by race was reported to be 90.4% for white women and 78.7% for black women The 5-year survival rate for patients with localized disease (61% of patients) is 98.6 % for patients with regional disease (32% of patients), 84.4% for patients with distant metastatic disease (5% of patients), 24.3%

79. References 10/11/2022 Breast Ca Management by Ijigu 79

80. 10/11/2022 Breast Ca Management by Ijigu 80 Thank you!