breast disease and discussion, management.pptx

breast disease

1. Incidences in carcinoma breast 30% of all female cancers 20% of cancer related deaths in females 2–4% bilateral 2–5% hereditary Lump in the breast—most common presentation (75%) 10% presents with pain 35–45% with mutation of BRCA1 gene 70% blood spread occurs to bones Incidence in India is one in 100 women.

2. When cancer occurs in the breast of women under forty, it is more rapid in its progress than when the patient is older, and also more extensive; remote sympathy likewise takes place more readily in them than in the old, so that the operation succeeds better in the latter on this account. — John Hunter, 1728–1793

3. TNM STAGING OF CARCINOMA BREAST (AJCC 7th EDITION, 2010) Primary Tumour (T) T0 – No evidence of primary. Tis – Carcinoma in situ. Tis (DCIS) Ductal carcinoma in situ. Tis (LSCIS) Lobular carcinoma in situ. Tis (Paget’s) – Paget’s disease of the nipple not associated with invasive carcinoma or with DCIS/LCIS in the parenchyma T1 – Tumour less than 2 cm (20 mm) T1 mi – Microinvasion 1 mm or less in greatest dimension T1a – 1 – 5 mm T1b – 5 – 10 mm T1c – 10 – 20 mm T2 – 20 – 50 mm in greatest dimension T3 – >50 mm in greatest dimension T4 – Any size with direct extension to the chest wall or skin or both. T4a – Tumour of any size extending into the chest wall, not including only pectoralis muscle invasion/adhesion . T4b – Ulceration or ipsilateral satellite nodules and/or oedema including peaud’orange of the skin which do not meet the criteria for inflammatory carcinoma. T4c – T4a and T4b. T4d – Inflammatory carcinoma.

4. Regional Lymph Nodes (N) Fig. 8.58: Bilateral breast cancer operated. Nx – Regional nodes cannot be assessed N0 – No regional nodes involved N1 – Metastases to mobile ipsilateral level 1 and 2 axillary nodes N2 – N2a – Metastases in ipsilateral level 1 and 2 axillary nodes which are fixed to one another (matted) or other structures N2b – Metastases only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level 1 and 2 axillary nodes

5. Examination Investigations Pathological DIAGNOSIS

6. Physical Examination Inspection: Breast: asymmetry, mass, skin changes Nipple: retraction, inversion, or excoriation Palpation: Breast lump Regional nodes Systemic examination

7. LCIS DEFINITION Proliferation of small loosely cohesive cells in terminal duct- lobular unit, with or without involvement of terminal ducts PRESENTATION No specific clinical or mammographic abnormality Diagnosis made incidentally on microscopy

8. LCIS: MANAGEMENT Surveillance Chemoprevention: Tamoxifen Prophylactic B/L mastectomy Not necessary to obtain negative margins No role of RT

9. DCIS DEFINITION Proliferation of malignantly appearing mammary ductal epithelial cells without invasion of Basement Membrane PRESENTATION Palpable mass Pagets disease Incidental finding at biopsy Mammographically detected abnormality

10. DCIS: LOCAL MANAGEMENT BREAST Localized DCIS: BCT + RT Multicentric DCIS: Mastectomy AXILLA No role of routine SLNB SLNB only in candidates for mastectomy

11. DCIS: SYSTEMIC THERAPY 80% OF DCIS ER +ve Two benefits of ET Reduced local recurrence Prevention of development of new primary lesions in contralateral breast Follows same principles of ET Trials of tamoxifen Vs AI ongoing No role of CT

12. EARLY CARCINOMA DEFINITION St I & II LOCAL MANAGEMENT BCT+ RT Mastectomy ± breast reconstruction Equivalent survival with BCT & mastectomy Initial systemic therapy may allow BCT in large tumors T3N1 may also be treated similarly

13. EARLY CARCINOMA :BCT Absolute contraindications Pregnancy Multicentric/ diffuse tumor Prior therapeutic irradiation Relative contraindications CVD Tumor / breast size ratio

14. EARLY CARCINOMA: MASTECTOMY In pts with contraindication to BCT In pts who prefer mastectomy May be combined with IBR SLNB to be done Cytological confirmation of clinically +ve nodes required before axillary surgery Axillary irradiation: an acceptablealternative to axillary surgery

15. EARLY CARCINOMA: ADJUVANT CHEMOTHERAPY Benefit women irrespective of Age Hormonal status Adjuvant ET Multiple cycles advantageous (4-8) Anthracycline based regimens superior over CMF CT recommended for node +ve and higher risk node – ve patients Taxanes – modest advantages, role being studied

16. LABC & IBC DEFINITION Bulky tumors/ extensive nodal disease (T3-4/ N2-3) IBC: aggressive variant of LABC, presents with diffuse edema,erythema, rapid course & often without an underlying palpable mass

17. LABC & IBC: MANAGEMENT Substantial risk of metastasis, full workup before initiating therapy required Trimodality treatment: Neoadjuvant CT, Surgery, RT Anthracycline / Taxane based regimens appropriate as induction CT Postmastectomy RT mandatory despite complete pathological response to CT No surgery in IBC till complete response of inflammatory skin changes, may require pre-op RT

18. METASTATIC DISEASE May disseminate to almost every organ May present with systemic symptoms or found on examination or investigations Goal: decrease tumor burden, control of cancer related symptoms, prolongation & maintenance of QOL Therapy is not considered curative