introduction, classification and prevention of breast cancer byShuvam

breast cancer seminar

1. Breast Carcinoma Speaker: Shubham Kumar Gupta Student, 3 rd Prof. MBBS (Part-II)

2. BIG PICTURE… LYMPHATIC DRAINAGE OF BREAST EPIDEMIOLOGY & RISK FACTORS SCREENING MODALITIES BREAST BIOPSY TECHNIQUES TNM STAGING EARLY BREAST CANCER LOCALLY ADVANCED BREAST CANCER HORMONAL STATUS AXILLARY LYMPH NODE DISSECTION BREAST CA METASTASIS CA BREAST DURING PREGNANCY PAGET’S DISEASE OF BREAST INFLAMMATORY BREAST CA

3. AXILLARY GROUPS OF LYMPH NODES

4. LEVEL RELATION TO PECTORALIS MINOR INCLUDES I LATERAL ANTERIOR, POSTERIOR, LATERAL II SUPERFICIAL / DEEP CENTRAL LNs, ROTTER’S LN* III MEDIAL APICAL * Although AJCC considers them to be axillary LNs, they are not so from an anatomical point of view.

5. Lymphatic Drainage of Breast

6. Epidemiology EPIDEMIOLOGY - Worldwide : Most common cancer in women Leading cause of death from cancer for women aged 20-59 yrs. 29% of all newly diagnosed cancers in females 14% of the cancer-related deaths in women. EPIDEMIOLOGY - India (2012) : Accounts 27% of all malignant cases. Incidence rate 25.8 per lakh population For every 2 women newly diagnosed with breast cancer, one lady is dying of it. [ 144937 / 70218 = 2.06 = round it off to  2]

7. RISK FACTORS FOR BREAST CA Non-Modifiable: Geographical factors Age Menstrual factors Genetic predisposition Family history History of irradiation

8. Modifiable: Reproductive factors Obesity Alcohol HRT Decreased physical activity RISK FACTORS FOR BREAST CA

9. RISK FACTORS FOR BREAST CA Histological risk factors: Proliferative Breast disease Atypical ductal Hyperplasia Atypical lobular hyperplasia Lobular Carcinoma- insitu (LCIS)

10. Risk Assessment Model (Gail) Developed from case-control data in the Breast Cancer Detection Demonstration Project; aka the Gail model). Incorporates age, age at menarche, age at first live birth, the number of breast biopsy specimens, any history of atypical hyperplasia, and number of first-degree relatives with breast cancer. Predicts the cumulative risk of breast cancer according to decade of life. Underestimate the risk for a BRCA1 or BRCA2 mutation carrier . Not used in women with a diagnosis of LCIS or DCIS.

11. CLASSIFICATION OF BREAST CANCER NON-INVASIVE EPITHELIAL CANCERS LCIS DCIS/INTRA-DUCTAL CA – Papillary, Cribriform , Solid, Comedo INVASIVE EPITHELIAL CANCERS (% OF TOTAL) Invasive Lobular Ca (10%) Invasive Ductal Ca Tubular Ca (2%) Mucinous Ca (2%) Medullary Ca(5%) Invasive Cribriform Ca (1-2%) Invasive Papillary Ca (1-2%) Adenoid Cystic Ca (1%) Metaplastic Ca (1%) Invasive ductal Ca, NOS (50-70%) MIXED TUMORS Carcinosarcoma Angiosarcoma Adenocarcinoma

12. SCREENING MODALITIES Self-examination of breast Clinical breast evaluation Mammography Ultrasonography Breast MRI (newest recomd .) # Lifetime Risk Assessment screening  is looking for  cancer  before a person has any  symptoms . This can help find cancer at an early  stage . When  abnormal   tissue  or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread. Early detection remains the primary defense available to patients in preventing the development of life-threatening breast cancer, although advances in imaging technology and disagreements over recommended schedules have complicated the issue of screening.

13. Breast Self-Examination (BSE) What to look for? Irregular changes in the size and shape of breast Lump in the breast Irregularity in nipple discharge or tenderness Awkward changes in the skin of the breast Benefits: Early detection remains the primary defense available to patients in preventing the development of life-threatening breast cancer For 50-74 year group  30% reduction in mortality For 40-49 year group  17% reduction in mortality

14. Clinical Breast Evaluation (CBE) A complete bilateral breast examination should be performed to look for : Variation in breast size Fungating masses Dimpling or retraction of the skin Nipple inversion or excoriation (classic finding of Paget's disease of the breast, which also does not present as a breast mass). Look for axillary lymph node enlargement.

15. MAMMOGRAPHY Discussion of when to begin & how often to undergo screening mammography has now become a more individualized discussion with patients taking into account their breast cancer risk & personal risk tolerance .

16. BI-RADS BIRADS Category Description Likelihood of malignancy Recommendation Need more information 2-10% Further imaging needed 1 Normal 0.05-0.1% Routine screening mammography 2 Benign 0.05-0.1% Routine screening mammography 3 Probably benign 0.3-1.8% Short-term follow-up (6 months) 4 Highly suspicious 10-55% Biopsy 5 Malignant 60-100% Biopsy 6 Known Cancer 100% Treat malignancy

17. USG Assist in suspicious lesion detected on mammography or physical examination Useful in the guidance of biopsies. Differentiating cystic from solid breast masses Breast cancer screening specifically in women with dense breast tissue Limitations as screening test : Failure to detect microcalcifications Poor specificity (34 %)

18. MRI Highly sensitive to detect malignant changes in the breast. (independent of breast density ) American Cancer Society MRI screening criteria : BRCA mutation First-degree relative with BRCA  carrier but untested Lifetime risk approximately 20-25% or greater, Radiation to chest when aged 10-30 years Associated syndromes MRI has limited use as a screening tool: Cost. 10-fold higher cost than mammography Poor specificity (26%)  false-positive results

19. Risk Management Chemoprophylaxis : Tamoxifen R aloxifene . Prophylactic mastectomy : Reduce the chance of developing breast cancer by 90%. BRCA1 and BRCA2 mutation carriers treated with prophylactic mastectomy

20. Breast Biopsy techniques FNAC / FNAB Core Needle Biopsy (CNB) Incisional Biopsy Excisional Biopsy Stereotactic core biopsy Vacuum-assisted biopsy