MANAGEMENT OF EARLY BREAST CANCER.pptx

Periampullary_carcinoma_–diagnosis_with_staging,_preoperative (2).pptx

1. MANAGEMENT OF EARLY BREAST CANCER BY- Dr. himanshu modanawal Third year pgt

2. BREAST Composed of 15-20 lobes which are each composed of several lobules. Fibrous bands of connective tissue travel through the breast-cooper’s lig . Mature female breast-extend from 2-3 rd ribs to 6-7 th ribs and transversely from lat border of sternum to ant axillary line.

3. BLOOD SUPPLY Principal blood supply from-perforating branches of internal mammary artery, lateral br of post intercostal arteries and br from axillary artery. Others- 2 nd 3 rd and 4 th anterior intercostal perforators and br of internal mammary artery arborize as medial mammary artery. Veins- 1> perforating br of internal thoracic vein 2> br of post i/c veins 3> tributaries of axillary vein Others- batson venous plexus from vertebrae

4. lymphatics Predominently drain into axillary and internal mammary lymph nodes. Axillary-85% drainage 1- lateral- along the axillary vein 2- anterior- along the lateral thoracic vessels 3- posterior- along the subscapular vessels 4- central- embedded in fat in the centre of axilla 5- apical- lie above the p minor tendon in continuity with the lateral nodes. course = all groups apical supraclavicular sub clavian great veins via the thoracic duct.

5. Level 1- lateral to lateral border of p minor Level 2- posterior to p minor Level 3- medial and above the p minor and include subclavicular nodes. Rotter’s nodes- lymph nodes in the space between p major and p minor.

6. Epidemiology of breast cancer Most common site-specific cancer in women and leading cause of death from ca for women age 20 to 59yrs. Women from heavily industrialized or western countries have a higher breast ca burden. But the mortality is higher in under developed nations.

7. Risk factors for breast cancer Based on high socio economic status Advancing age Western countries Alcohol intake High fat diet, obesity State of hyper estrogenemia early menarche, late menopause, nulliparity , late first full term pregnancy Positive family history .

8. Risk factors for breast cancer Positive history of malignancy Genetic mutations( brca mutations- brca 1 & 2) Hormonal replacement therapy h/o therapeutic radiation exposure( if total radiation > 60 gy , then the risk of malignancy is increased ) Ocp and smoking-not significant Long duration of breast feeding –protective.

9. Risk assessment models CLAUS MODEL GAIL MODEL MC used MORE INFO ABOUT FAMILY HISTORY Includes No of breast biopsy Age at menarche No of first degree relative with CA breast Age at first live birth BASED ON- Decades of life Based on first and second degree relative with CA breast Their ages at diagnosis

10. Diagnosis of breast cancer It involves the triple assessment that includes- Clinical examination Radiology ( usg for <40 yrs ), mammography (for >40 yrs ) and mri (for high risk patient) Biopsy ( fnac and core needle biopsy)-IOC IOC for staging-pet ct Ppv of triple assessment- 99.9 %

11. Examination of breast Method of clinical examination 1-Dial clock ( best) 2- vertical strike 3- horizontal strike

12. Mammography CRANIO CAUDAL VIEW MEDIO LATERAL OBLIQUE VIEW RECENTLY 3D MAMMOGRAPHY/BREAST TOMOSYNTHESIS-MORE SENSITIVE

13. BIRADS SCORE CATEGORY MANAGEMENT RISK OF CANCER inclusive Additional imaging n/a 1 negative Routine screening Essentially 0% 2 benign Routine screening Essentially 0% 3 Probably benign Short interval follow up every 6 months >0% but <=2 % 4 suspicious Tissue diagnosis 4a low 2-10% 4b-moderate,10-50% 4c,high,50-94% 5 Highly suspicious Tissue diagnosis >=95% 6 Biopsy proven Surgical excision when clinically appropriate NA

14. Ajcc classification -8 th edition Ajcc has recently modified the tnm system for breast cancer. Lcis has been removed from tnm staging.

15. STAGE Size of tumour and other characteristics of tumour T1 Upto 2 cm T2 >2-5 cm T3 >5 cm T4a Extension to chest wall(chest wall is formed by ribs, intercostal muscels,serratus anterior) T4b Ulceration Edema including Peau D orange Satellite nodules These changes are confined to the same breast. T4c T4a+T4b T4d Inflammatory breast cancer N ot included in T4- Involvement of dermis Nipple retraction/deviation Involvement of p major/p minor

16. LYMPH NODE(N) STAGING N1 Ipsilateral level 1 & 2 mobile N2a Ipsilateral level 1 & 2 Fixed/matted LN N2b Internal mammary nodes N3a Ipsilateral infraclavicular LN N3b I/L axillary + internal mammary LN N3c I/L supraclavicular LN

17. METASTASIS M0 No mets M1 Distant mets

18. STAGING OF CA BREAST STAGE 1 T1 STAGE 2a T0-1,N1 T2 STAGE 2b T2N1 T3 STAGE 3a T0-2,N2 T3, N1-2 STAGE 3b T4, N0-2 STAGE 3c T any, N3 STAGE 4 T any, N any, M1 Two lumps in same breast-staging is based on size of bigger lump Lump in each breast-each breast lump is staged separately Breast lump with involvement of C/L LN- METASTATSIS

19. Updates in breast cancer staging Isolated tumour cells( itc ) :- <=0.2 mm cluster or <200 cells Micrometastasis - >0.2 mm but <=2.0 mm or cluster of > 200 cells If the sln have isolated tumour cells or micrometastasis , it is considered as negative.

20. What is early breast cancer ? Breast cancer that has not spread beyond the breast or the axillary lymph nodes. This includes stage 1,stage 2a, 2b breast cancers.

21. Treatment protocol for early breast cancer Multidisciplinary approach should be used for the management. (it improves overall survival) Breast conservative surgery + sentinel ln biopsy+ radiotherapy If bcs is contraindicated- simple/total mastectomy + sentinel ln biopsy Types of bcs - 1- lumpectomy 2- wide local excision with 1 cm margin ( rEf - mastery of surgery- 5 th edition ) 3- quadrantectomy

22. Oncoplastic breast surgery Volume displacement- the tumour is resected. after displacing the breast tissue, the defect is closed. Done till 10-15% of breast resected. Volume replacement- The tumour is resected. the volume is replaced using a flap. Done if > 15 % of volume is resected. VOLUME DISPLACEMENT SURGERY

23. flaps mc used flap – tram flap ( inferior epigastric artery and vein) Best flap- diep flap (deep inferior epigastric perforator flap ) Others- ld flap lateral thigh flap Thoraco epigastric flap Gluteal flap Rubens flap-based on deep circumflex iliac artery

24. Contraindications of bcs ABSOLUTE RELATIVE PREGNANCY H/O collagen vascular diseases(scleroderma, lupus) 2 or >2 tumour in different quadrants or diffuse malignant appearing micro calcification Multiple tumours in same quadrant Persistently + ve margins Large tumour in small breast History of exposure of therapeutic radiation Large pendulous breast (difficult to give uniform dose of radiotherapy) Centrally located tumour

25. Sentinel ln biopsy in breast cancer Sln = first ln which receives lymph directly from tumour Indications – clinically non palpable axillary ln 2 techniques. 1- blue dye technique (1 % lymphazurin / isosulfan blue or methylene blue) 2- radioactive colloid technique ( tC 99 labelled Sulphur ) Max accuracy- when both techniques are combined together.

26. Sentinel ln biopsy in breast cancer Complications- Mc = skin tattooing Mc injured nerve- intercosto -brachial nerve Contraindications – palpable ln, prior axillary surgery, chemotherapy, radiotherapy, multifocal breast ca

27. radiotherapy Indications— Bcs Labc 4 or more ln + ve + ve margins Dose- total therapeutic radiation = 40-50 gry 1.8-2 gry / day 5 days a wk for 4-6 wks

28. chemotherapy Indications— 1- + ve lymph node 2- labc 3- er , pr – ve ,her 2 neu + ve 4- symptomatic visceral mets 5- hormone therapy refractory cases Traditional regimen for ct - caf / cmf C-cyclophosphamide A-Adriamycin F-5fu M-methotrexate

29. Usually 6 cycles of ct is given. Adriamycin resistant breast ca- taxanes given Taxanes resistant- ixabepilone Her 2 neu + ve – trastuzumab , 2 nd line = lapatinib

30. Breast cancer Follow up History + physical examination- every 3-6 months 1 st 3 year Every 6-12 months for 4 th to 5 th year Anually thereafter Mammography- Anually Beginning no earlier than 6 months of radiotherapy. Breast self examination- monthly Pelvic examination- annualy Reference- de vita 10 th edition Asco 2006 updated guideline Md Anderson handbook of surgical oncology-5 th edition

31. Prognostic factors Most important – stage ( tnm staging) Single most important –axillary ln status Most important in metastatic breast ca- er , pr status Nottingham prognostic index- Npi = (0.2 * tumour size) + ln stage + tumour grade To select patient for adjuvent therapy Blum Richardson grading- Tubule formation Nuclear pleomorphism mitosis Van- nuys prognostic index- Micro calcification Size of tumour Width of margin Age of patient Grade of tumour

32. references 1- Schwartz’s principles of surgery 2- bailey & love’s short practice of surgery 3- sabiston textbook of surgery 4- de vita 10 th edition 5- md Anderson handbook of surgical oncology-5 th edition

33. … THANK YOU ….