Breast carcinoma by Dr. Aryan

Carcinoma of breast presentation, clinical findings, investigations and treatment

1. Breast carcinoma

2. Introduction Is the most common cause of death in middle aged women in western countries In E ngland and Wales, 1 in 12 women will develop the disease during their lifetime

3. Aetological factors Geographical: common in western world Age: extremely rare below the age of 20 years Gender: Less than 0.5 per cent in male Diet: low phyto -estrogen, high alcohol intake Genetic Endocrine: long term HRT Previous radiation

4. Other risks factors Menarche Age, early menarche is a risk Age at f irst Live Birth Lack of breast feeding is a risk First-Degree Relatives with Breast Cancer Carcinoma of the contralateral breast or endometrium Obesity in old age ~ increase in estrogen Environmental Toxins Tobacco

5. Pathogenesis Genetic changes Mutation of proto- oncogen ( o verexpression of HER2 Mutation of tumor supressor gene ( BRCA1,BRCA2 ) in breast epithelium 2. Hormonal Influence / Sporadic Breast Cancer E ndogenous /exogenous estrogen excess or hormonal imbalance  cause mutations or generate DNA-damaging free radicals  Tumor.

6. Total Cancers Per Cent In Situ Carcinoma * 15–30 Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma 70–85 No special type carcinoma ("ductal") 79 Lobular carcinoma 10 Tubular/cribriform carcinoma ( Better prognosis than average) 6 Mucinous (colloid) carcinoma ( Better prognosis than average) 2 Medullary carcinoma ( Better prognosis than average) 2 Papillary carcinoma 1 Metaplastic carcinoma, (Squamous)

7. Spread of breast cancer Local spread : to the skin, the pectoral muscles and even the chest wall if diagnosed late Lymphatic : primarily to the axillary and the internal mammary lymph nodes Blood stream : skeletal metastases, liver, lungs, brain, adrenal, ovaries

8. Clinical features Found most frequently in the upper outer quadrant Discrete, painless, movable mass Will present as: Hard lump, which may be associated with indrawing of the nipple Locally advanced cases: skin involvement with peau d’orange or frank ulceration and fixation to the chest wall

9. TNM classification T0 — No evidence of primary tumor Tis — Carcinoma in situ T1 — Tumor ≤20 mm in greatest dimension T1mi — Tumor ≤1 mm in greatest dimension T2 — Tumor >20 mm but ≤50 mm in greatest dimension T3 — Tumor >50 mm in greatest dimension T4 — Tumor of any size with direct extension to the chest wall and/or the skin

10. N0 – no palpable lymph node N1 – ipsilateral axillary lymph node palpable N2 – ipsilateral axillary node palpable and fixed N3 – ipsilateral supraclavicular nodes palpable M0 — No clinical or radiographic evidence of distant metastases M1 — Distant detectable metastases

11. Staging Stage 0-TisN0M0 Stage 1 A - T1 N0 M0 Stage 1B -TO N1mi MO -T1 N1mi M0 Stage 2 A -T0 N1 MO -T1 N1 M0 -T2 N0 M0 Stage 2B -T2 N1 M0 -T3 N0 M0 Stage 3 A -T0 N2 M0 -T1 N2 M0 -T2 N2 M0 -T3 N1 M0 -T3 N2 M0 Stage 3 B - T4 N0 M0 - T4 N1 M0 -T4 N2 M0 Stage 3 C - Any T N3 M0 Stage 4 -Any T Any N M1

12. Prognosis

13. Receptor status To predict the respond to hormonal therapy To predict prognosis Hormone r eceptors - Estrogen receptor - Progesterone receptor

14. HER2/NEU Membrane tyrosine kinase receptor and marker of cellular proliferation, expressed in up to 30% of cases Current assay of HER2/ NEU by IHC stain, FISH

15. Surgical management Types: Radical surgery Radical Halsted Mastectomy Modified Radical ( Patey ) Mastectomy Simple Mastectomy Conservative breast cancer surgery

16. Mastectomy Removal of the whole breast Indications:- Large tumours Central tumours beneath/involving nipple Multifocal disease Local recurrence or patient preference

17. Simple mastectomy Removal of only the breast + Region of the axillary tail of breast No dissection of the axilla

18. Radical Halsted Mastectomy Includes excision of: The breast Axillary lymph nodes Pectoralis major and minor muscles No longer indicated

19. Radical mastectomy

20. Modified radical ( Patey ) mastectomy Breast and associated structures  dissected en bloc Excised mass is composed of: Whole breast Large portion of skin centre overlies the tumor but always includes the nipple All of the fat, fascia and lymph nodes of the axilla

21. Modified radical ( Patey ) mastectomy Pectoralis minor muscle is either divided or retracted Axillary vein and nerves to the serratus anterior and latissimus dorsi are preserved Intercostal brachial nerves are usually divided.

22. Modified radical ( Patey ) mastectomy Wound is drained using a wide-bore suction tube Early mobilisation of the arm and physiotherapy Most patients are able to resume light work or housework within a few weeks

23. Conservative breast cancer surgery AKA wide local excision Aim:- removing the tumour plus a rim of at least 1 cm of normal breast tissue Retention of the breast

24. Quadrantectomy Removes the entire segment of the breast containing the tumour Lumpectomy A benign tumour is excised Large amount of normal breast tissue is not resected Both of lumpectomy & Quadrantectomy are usually combined with axillary surgery Via a separate incision in the axilla

25. Role of axillary surgery Stage the patient and to treat the axilla Presence of metastatic disease within the axillary lymph nodes  best single marker for prognosis Major determinant of appropriate systemic adjuvant therapy But treatment does not affect long-term survival

26. Options to deal with axilla Includes: Sentinel node biopsy Sampling Removal of the nodes behind and lateral to the pectoralis minor or A full axillary dissection

27. Sentinel node biopsy Standard of care in the management of the axilla In patients with clinically node-negative disease Sentinel node is localised peroperatively by the injection of patent blue dye and radioisotope labelled albumin in the breast

28. Fig:- Sentinel Node Biopsy

29. Contd … Excised node can be sent for frozen-section histological analysis or touch imprint cytology (TIC) In patients with no tumour involvement of sentinel node Further axillary dissection can be avoided

30. Chemotherapy and Hormonal therapy

31. Hormonal Therapy Given to women with hormone receptor-positive tumours Tamoxifen (widely used ) Reduces the annual rate of reoccurrence and death rate Reduces risk of tumors in contralateral breast Optimal duration of treatment  5 years

32. LHRH agonist for pre-menopausal receptor positive women Induce a reversible ovarian suppression Has same effects as surgical or radiation induced ovarian ablation Oral Aromatase For post-menopausal women treatment of recurrent disease Has been shown superior to Tamoxifen

33. Chemotherapy First generation regimen (CMF) Cyclophosphamide; methotrexate; 5-fluorouracil 25% reduction in the risk of relapse over 10 to 15 years period No longer considered adequate adjuvant chemotherapy Modern regimen Anthracyclin (doxorubicin or epirubicin ) and texanes

34. Given to lymph node-positive and node-negative patient if the prognostic factors are + nt (tumor grade  high risk of recurrence ) Combined hormonal and chemotherapy has additive effect Hormonal therapy is started after completion of chemotherapy to reduce side effect High dose chemotherapy in heavy lymph node involvement has no advantage

35. Primary Chemotherapy (NEOADJUVENT) Aim  “to shrink the tumor to enable breast-conserving surgery to be performed” Successful in upto 80% of cases Not associated with improvements in survival compared to conventional therapy

36. How to give and for how long Chemotherapy: Route  O ral or IV Given in cycles, consisting of a treatment period followed by a recovery period. No. of cycles depends on the types of drugs used N ot given for much more than 6 months Hormonal therapy: every day for 5 years

37. References Norman S. Williams et a l, Bailey & Love’s Short Practice of Surgery, 25 th & 26 th Edition Kumar et al, Robins Basic Pathology, 9 th Edition Upto date version 21.2

38. THANK YOU