BY STUDENTS OF MEDICAL COLLEGE, KOLKATABATCH 2011( gr. ‘D’; 187-197)

BREAST CARCINOMA

TOPICS OF DISCUSSION01. INTRODUCTION,EPIDEMIOLOGY & RISK FACTORS ,BY SHAHBAZ AHMAD

02. PATHOLOGY OF BREAST CARCINOMA , BY MASUDA KHATUN

03. CLINICAL FEATURES , BY RAKIB SAIKH

04. INVESTIGATIONS, BY SALMA NASRIN

05. TNM STAGING, BY MANABENDRA MANDAL

06. SURGICAL ANATOMY AND SURGERIES , BY SAYAN SAHA

07. BREAST CONSERVATION THERAPY , BY MD KHALILULLAH

08. RADIOTHERAPY , BY TARIK AZIZ BISWAS

09. CHEMOTHERAPY & HORMONAL THERAPY, BY REGIA SULTANA

10. TREATMENT PROTOCOL, BY SAYEEDA ZAHAN

11. PROGNOSIS , PREVENTION & RECENT ADVANCES, BY IMDADUL HOQUE.

INTRODUCTION

BY SHAHBAAZ AHMEDROLL NO.-193

International situation

• Worldwide, breast cancer is the most common invasive cancer in women.

• The incidence of breast cancer is lowest in less-developed countries and greatest in the more-developed countries.

• The number of cases worldwide has significantly increased since the 1970s(mainly due to lifestyle changes)

EPIDEMIOLOGY IN INDIA

• What makes us worried about the trend of breast cancer in India???

• 1)Age shift• 2)Rising number of cases• 3)Late presentation• 4)Lack of awareness and screening

The horizontal line lower down represents the age groups: 20 to 30 years, 30 to 40 yrs and so on. And the vertical line represents the percentage of cases.

Age shift: Breast cancer now more common in 30's and 40's

Rising incidence of breast cancer in India

Breast cancer is now the most common cancer in most cities in India, and 2nd most common in the rural areas.

RISK FACTORS

• HORMONAL• Increased exposure to estrogen• Factors that increase the number of menstrual cycles(early

menarche,nulliparity,late menopause)• Exercise and longer lactation period are protective(factors that

decrease the number of menstrual cycles are protective).• Older age at first live birth is also a risk factor.• Obesity increases the risk.• OCP do not increase the risk. • Hormone replacement therapy in postmenopausal women

increase the risk.

NON-HORMONAL RISK FACTORS

1.Chest wall irradiation2.Diet- eg.foods with high fat content alcohol consumption3.Sex-women are 100 times at a greater risk than men4.Age-More common in 35 to 75 years of age.5.History of breast cancer6.Benign breast disease eg. Atypical ductal hyperlasia Intraductal papilloma7.Geographical-Disease of white western women

8.Genetic risk factors a)BRCA 1 and 2 gene mutation b)Cowden’s disease c)Ataxia telengiectasia d)Li-Fraumeni syndrome

• BRCA gene• Mechanism- .Both BRCA genes are tumor suppressor genes that produce

proteins that are used by the cell in an enzymatic pathway that makes very precise, perfectly matched repairs to DNA molecules that have double-stranded breaks.

.Harmful mutations in any of these genes disable the gene or the protein that it produces.

BRCA GENE

BRCA 1• Located on chromosome 17• Associated with invasive

ductal carcinoma• Poorly differentiated• Hormone receptor negative• Early age of onset• Bilateral• Also associated with

ovarian,colon and prostate cancers.

BRCA 2• Located on chromosome 13• Associated with invasive

ductal carcinoma• Well differentiated• Hormone receptor positive• Early age of onset• Bilateral• Also associated with

ovarian,colon,prostate,pancreas,bladder cancers

RISK ASSESSMENT MODELS• GAIL MODEL• The Breast Cancer Risk Assessment Tool (the Gail model) was

designed by researchers at the National Cancer Institute and the National Surgical Adjuvant Breast and Bowel Project as a tool for health care providers.

• The tool calculates a woman's risk of developing breast cancer within the next five years and within her lifetime (up to age 90). It takes into account seven key risk factors for breast cancer.

• Age• Age at first period• Age at the time of the birth of her first child (or has not given birth)• Family history of breast cancer (mother, sister or daughter)

• Number of past breast biopsies• Number of breast biopsies showing atypical hyperplasia• Race/ethnicityWomen with a five-year risk of 1.67 percent or higher are classified as "high-risk.“• It gives the average risk for a group of women with similar risk factors.• LIMITATIONS• The Breast Cancer Risk Assessment Tool does not give a good estimate of

risk in some women including those with:1)A personal history of invasive breast cancer, ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS) 2)A strong family history of breast cancer, who may have an inherited gene mutation

Claus model

• Is based on empiric data from the Cancer and Steroid Hormone Study

• Consists of a series of tables that provide risk estimates for women with a positive family history of breast cancer

• Estimates a woman’s risk of breast cancer based on her current age, the number of first- and second-degree relatives with breast cancer (up to two); and their age at onset.

BENEFITS• The Claus Model includes:• Paternal family history • Age at diagnosis of relatives

• LIMITATIONS OF THE CLAUS MODEL• Is not suitable for use with women who have three

or more relatives with breast cancer• Does not take into account other risk factors

PATHOLOGY OF BREAST CARCINOMA

BY MASUDA KHATUN

ROLL NO-196

CLASSIFICATION

In situ carcinoma Invasive carcinoma

Duct carcinoma in situLobular carcinoma in situ

Invasive duct carcinomaInvasive lobular carcinomaMedullary carcinomaColloid carcinomaPapillary carcinomaTubular carcinomaInflammatory carcinomaCarcinoma with metaplasia

DUCT CARCINOMA IN SITU

• Proliferation of malignant mammary ductal epithelial cells without any invasion to basement membrane

• Predominantly occurs in female breast • Accounts for 5% of male breast cancer

atypical hyperplasia of ductal epithelium filling of duct Tumor size 3-5 cm Palpable mass 30-75%Nipple discharge 30%

4 types- comedo pattern Solid pattern Papillary pattern Cribriform patternRisk of invasive carcinoma is five fold

increased, in ipsilateral breast and in same quadrant-DCIS is anatomical precursor of invasive carcinoma

DUCTAL CARCINOMA IN SITU: COMEDO TYPECENTRAL ZONE OF NECROSIS WITH CALCIFICATION

DUCTAL CARCINOMA IN SITU: CRIBRIFORM TYPEWITH ROUND REGULER ‘’COOKIE CUTTER” SPACES,LUMENS ARE FILLED WITH CALCIFYING SECRETORY MATERIAL

DUCTAL CARCINOMA IN SITU: SOLID PATTERNDUCTS ARE COMPLETELY FILLED AND DISTORTED LOBULES

DUCTAL CARCINOMA IN SITU: PAPILLARY PATTERNDELICATE FIBROVASCULER CORE EXTENDED INTU DUCTS

LOBULAR CARCINOMA IN SITU

Origin-terminal duct lobular unitLacks cell adhesion protein E-cadherin-

discohesive and round cellsNormal nucleocytoplasmic ratioMucin positive signet cellsRarely distorts underlying architecture

LOBULER CARCINOMA IN SITU

SALIENT FEATURES OF DCIS AND LCIS

LCIS DCIS

AGE 44-47 54-58

INCIDENCE 2-5% 5-10%

CLINICAL SIGN NONE MASS,PAIN,DISCHARGE

MAMMOGRAPHIC SING

NONE MICROCALCIFICATION

MULTICENRICITY 60-90% 40-80%

LCIS DCIS

BILATERALITY 50-70% 10-20%

AXILLARY METASTASIS

1% 1-2%

SUBSEQUENT CARCINOMA

INCIDENCE

25-35%

25-70%

LATERALITY BILATERAL IPSILATERAL

INTERVAL TO DIAGNOSIS

15-20 YRS

5-10 YRS

HISTOLOGIC TYPE DUCTAL DUCTAL

INFILTRATING DUCT CARCINOMA-NST

INCIDENCE- 80% of breast cancersAXILLARY LYMPH NODE METASTASIS- 60%5th to 6th decadeTUMOR-firm to hard, irregular border, central

streaks of chalky white stroma, foci of calcification

Well, modarate and poorly differentiated varieties

INFILTRATING DUCT CARCINOMA : ACCORDING TO GENE EXPRESSION PATTERN

ER HER2/neuLuminal A Positive Negative

Luminal B Positive Positive

Normal basal like

Positive Negative

Basal like Negative Negative

HER2 over expression

Negative Positive

INFILTRATING DUCT CARCINOMA

INFILTRATING LOBULER CARCINOMA

• Incidence-10%• Bilateral and multicentric• Dyscohesive infiltrating cells in single file

pattern• Signet ring cell-intra cytoplasmic mucin

droplet

INFILTRATING LOBULER CARCINOMA

OTHER IMPORTANT TYPES

• MEDULLARY CARCINOMA : Brain like consistency Triple negative receptor pattern better 5 year survival • COLLOID CARCINOMA extra cellular mucin pool better prognosis

MEDULLARY CARCINOMA

COLLOID CARCINOMAMALIGNANT CELL LIE WITHIN POOLS OF EXTRA CELLULER MUCIN

• INFLAMMATORY CARCINOMAMost aggressiveCommon in pregnancy and lactationMimics acute mastitisDuctal or lobular typeRapid metastasis

PAGET’S DISEASE OF NIPPLE

Superficial manifestation of invasive or non invasive ductal carcinoma

Pagets cell with hyper chromatic nuclei and cytoplasmic halo

Crusted, scaly lesion, ulceration and destruction of nipple

PAGET’S DISEASE OF NIPPLE

CLINICAL FEATURES OF BREAST CARCINOMA

~BY RAKIB SAIKHROLL NO.-189

SYMPTOMS A LUMP OR AREA OF THICKENED TISSUE

OF BREASTA CHANGE IN SIZE OR SHAPE OF ONE OR

BOTH BREASTDISCHARGE FROM THE NIPPLE ; MAY BE

BLOOD STREAKEDA LUMP OR SWELLING EITHER OF ARMPITS RASH ON OR AROUND NIPPLE CHANGE IN APPEARANCE OF NIPPLE

LATE SIGN AND SYMPTOMSWHEN CANCER GROWS LARGER OR SPREAD

TOOTHER PARTS OF BODY

BONE PAIN LOSS OF APPETITE WEIGHT LOSS JAUNDICE HEADACHE DOUBLE VISSION MUSCLE WEAKNESS

PHYSICAL EXAMINATION OF BREAST

IT IS CARRIED OUT IN DIFFERENT POSITIONWITH THE ARMS BY THE SIDE OF THE BODYWITH ARMS RAISED STRAIGHT OVER THE HEADWITH THE HAND ON HER WAIST (PRESSING AND

RELAXING)WITH PATIENT BENDING FORWARDSUPINE POSITION

BREAST INSPECTIONBOTH THE BREASTS ARE INSPECTED IN THEIR ENTIRETY AND FOLLOWING POINTS ARE NOTED

POSITION : WHETHER DISPLACED IN ANY DIRECTION SIZE AND SHAPE : WHETHER LARGER OR SMALLER

THAN ITS FELLOWANR PUCKERING OR DIMPLING ?IN PRESENCE OF A SWELLING OR ULCER ,DETERMINE

ITS POSITION,SIZE, SHAPE AND SURFACE

SKIN OVER THE BREASTLOOK FOR

COLOUR AND TEXTUREENGORGED VEINSDIMPLE,RETRACTION OR

PUCKERING;OFTEN NOTICE IN SCIRRHOUS CA

PEAU D’ ORANGE APPEARANCE OF SKIN

ULCERATION AND FUNGATION

NIPPLE INSPECTIONLOOK FOR

POSITION : IN CA ,THE NIPPLE OF AFFECTED SIDE DRAWN UP TOWARDS THE LUMP

SIZE AND SHAPE :IS IT PROMINENT ,FLATTENED OR RETRACTED

SURFACE :LOOK FOR ANY CRACKS ,FISSURE OR ECZEMA

DISCHAGE

AREOLALOOK FOR

COLOURSIZE : DIMINUTION OF SIZE IS SOMETIMES SEEN IN

SCIRRHOUS CASURFACE AND TEXTURE : LOOK FOR

CRACK ,FISSURE,ULCER,SWELLING OR DISCHAGE. IN PAGETS DISEASE ,AREOLA BECOMES BRIGHT RED IN EARLY STAGE AND IS DESTROYED LEAVING A RED WEEPING ULCER.

AXILLA & SUPRACLAVICULAR FOSSA SHOULD BE INSPECTED FOR ANY SWELLING DUE TO ENLARGED LYMPH NODES

PALPATION OF BREASTON PALPATION THE FOLLOWING POINTS SHOULD BE NOTED

LOCAL TEMPERATURE & TENDERNESS : WARM & TENDER

SWELLING IN INFLAMMATORY CARINOMA

SITUATON :COMMONLY FOUND IN UPPER & OUTER QUADRANT

NUMBER

SIZE & SHAPE : USUALLY UNEVEN IN CARCINOMA

SURFACE : USUALLY UNEVEN

MARGIN : WELL DEFINED

PALPATION OF BREAST

CONSISTENCY : WHETHER CYSTIC, FIRM ,HARD OR STONY HARD. CARCINOMA IS

STONY HARD IN CONSISTENCY FLUCTUATION : IF CYSTIC ,FLUCTUATION IS POSITIVE TRASLUMINATION TEST : OPAQUE IN SOLID TUMOUR WHEYHER FIXED TO THE SKIN ,BREAST TISSUE OR UNDERLYING

STRUCTURES

EXAMINATION OF LYMPH NODE

LEVEL I : ANTERIOR ,POSTERIOR & LATERAL

GROUP OF LN

LEVEL II : CENTRAL GROUP OF LN

LEVEL III : APICAL GROUP OF LN

INVESTIGATION OF CA BREASTBY SALMA NASRIN

ROLL NO. -195

• Any patient presented with a breast lump or other symptoms suspicious of carcinoma , the diagnosis should be made by the so-called Triple Assessment , which includes:

1. clinical assessment, 2. radiological imaging and 3.a tissue sample taken for either cytological or histological

analysis.

The positive predictive value (PPV) of this combination should exceed 99.9 per cent

INVESTIGATIONS

• FOR CONFIRMATION OF DIAGNOSIS:

A. IMAGING i) Mammography ii) Ultrasonography(USG) iii) Magnetic Resonance Imaging(MRI) B. BIOPSY i) Fine Needle Aspira- tion Cytology(FNAC) ii) Trucut Biopsy iii) Open Biopsy

• FOR STAGING AND METASTATIC WORK-UP:

i) CT Scan Chest ii) Chest X-RAY iii)Abdominal USG iv) Whole Body Bone Scan v) Sentinel Node Biopsy vi) PET-Scan

MAMMOGRAPHY

SCREENING Asymptomatic women > 40 years Positive family history

Two views:-

1. Mediolateral Oblique ( For outer quadrants + axilla) 2. Cranio-caudal (For medial quadrants)

DIAGNOSTIC Indicated for pain

and/or Lump, discharge etc

Suspicious findings of

carcinoma of breast: 1.Solid irregular mass 2. Spiculation 3. Microcalcification 4. Architectural distortion 5. Asymmetrical thickening

of breast tissues etc.

Fig: A small, spiculated mass is seen in the right breast with skin tethering in mammography (CC view)

Advantages: 1. Non-invasive 2. Minimum radiation hazards 3. Can be used as screening

tool.Disadvantages: 1. False Positivity around

5%. 2. Not ideal for younger

women.

ULTRASONOGRAPHY

• Particularly useful in young women with dense breasts in whom mammograms are difficult to interpret.

• Used to distinguish cysts from solid lesions

• To localise impalpable areas of breast pathology.

• Axillary lymph nodes can be assessed. Fig: Ultrasonography images of

malignant breast lesions

• ADVANTAGES 1. Cost -effective, 2. No radiational hazards 3. Can guide FNAC and

Core biopsy.

• DISADVANTAGE: Not ideal for lesions of

1 cm diameter or less.

Fig: USG showing benign cystic lesion

Fig: USG showing malignant irregular lesion

MRIINDICATIONS:1.When axillary nodes are positive for malignancy but primary is unknown.2. To distinguish scar from recurrence

in women who have had previous breast conservation therapy.

3. To assess for multifocality and multicentricity.

4. Best imaging modality for the breasts of women with

implants.5. Useful as a screening tool in high-

risk women (because of family history).

CORE NEEDLE BIOPSY The method of choice to

sample palpable/non-palpable image- detected breast abnormalities.

Can be performed under Stereotactic ( mammographic) Ultrasonographic or MRI guidance. PROCEDURE: Local anaesthesia

small incision insertion of 11 gauge needle sample obtained with vacuum assistance. Fig: USG guided core needle biopsy

ADVANTAGES:1. Permits the analysis of breast

tissue architecture which can not be done by FNAC.

2. Low complication rate, minimal scarring, and a lower cost compared with excisional breast biopsy.

3. Hormone receptor status can be assessed.

DISADVANTAGES: Sampling error may occur.

Fig: Lobular carcinoma in situ in core needle biopsy

FNAC

The least invasive technique of obtaining a cell diagnosis and is rapid and very accurate.

DISADVANTAGES: 1. Can not differentiate

between invasive and non-invasive cancer.

2. Hormone receptor status cannot be assessed.

Fig: FNAC showing ductal carcinoma cells.

INVESTIGATION ALGORYTHM FOR CA BREAST

ROUTINE TESTS: 1. Complete blood count: ?anaemia 2. Chest X-Ray: metastatic features 3.LFT: any increase in ALP

A suspicious case DIAGNOSTIC TESTS: of CA breast

METASTATIC WORK-UPS

DIAGNOSTIC TESTS

Mammography ( score4/above)

Core Needle Biopsy Features suggestive of If diagnosis remain equivocal carcinoma despite imaging +core biopsy

Immunohistochemistry o ER, PR status Incisional Biopsyo HER-2/neu statuso KI-67 Index etc Confirmation

METASTATIC WORK-UP

1. Axillary Lymph Node assessment USG of axilla Sentinel Lymph Node Biopsy

2. Chest X-Ray Cannon Ball appearance Lymphangiectasia3. USG of Abdomen ( if hepatospleenomegaly and/or raised ALP) 4. Whole Body Bone Scan ( in case of stage T3 and T4/ bone

pain /increased ALP)5. CT–scan of chest and abdomen

Fig: Cannon Ball Appearance in Chest X-ray.Fig: Whole Body Bone Scan

TNM staging~BY MANABENDRA MONDAL ROLL NO.-192

PRIMARY TUMOUR

• TX Primary tumour cannot be assessed

• T0 No evidence of primary tumour • Tis Carcinoma in situ • Tis (DCIS) Ductal carcinoma in situ • Tis (LCIS) Lobular carcinoma in situ • Tis (Paget’s) Paget’s disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget’s disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget’s disease should still be noted

• T1 tumour ≤ 20 mm in greatest dimension • T1mi tumour ≤ 1 mm in greatest dimension • T1a Tumour > 1 mm but ≤ 5 mm in greatest dimension • T1b Tumour > 5 mm but ≤ 10 mm in greatest dimension • T1c Tumour > 10 mm but ≤ 20 mm in greatest dimension

• T2 Tumour > 20 mm but ≤ 50 mm in greatest dimension

• T3 tumour > 50 mm in greatest dimension

• T4 Tumour of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules)• T4a Extension to the chest wall, not including only Pectoralis muscle adherence/invasion • T4b Ulceration and/or ipsilateral satellite nodules and/or oedema (including peau d’orange) of the skin, which do not meet the criteria for inflammatory carcinoma • T4c Both T4a and T4b • T4d Inflammatory carcinoma

REGIONAL LYMPH NODES• NX Regional lymph nodes cannot be assessed (for example, previously removed) • N0 No regional lymph node metastases

• N1 Metastases to MOVABLE ipsilateral level I, II axillary lymph node(s)

• N2 Metastases in ipsilateral level I, II axillary lymph nodes that are CLINICALLY FIXED OR MATTED; / in clinically detected ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases • N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures • N2b Metastases only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary lymph node metastases

• N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement; or in clinically detected ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement

• N3a Metastases in ipsilateral infraclavicular lymph node(s)

• N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)

• N3c Metastases in ipsilateral supraclavicular lymph node(s)

DISTANT METASTASIS

MX: Metastasis cannot be assessedM0: There is no sign of cancer spreadcM0(i+): There is no sign of cancer on physical

examinations or x-rays but cancer cells are present in blood, bone marrow or lymph nodes far away from breast

M1: Distant detectable metastasis

STAGING

• Stage 0: Tis N0 M0

• Stage IA: T1 N0 M0• Stage IB: T0 N1mi M0 or T1 N1mi M0

• Stage IIA: T0 N1 M0 or T1 N1 M0 or T2 N0 M0

• Stage IIB: T2 N1 M0 or T3 N0 M0

• Stage IIIA: T0 N2 M0 or T1 N2 M0 or T2 N2 M0 or T3 N1 M0 or T3 N2 M0

• Stage IIIB: T4 N0 M0 or T4 N1 M0 or T4 N2 M0

• Stage IIIC: Any T N3 M0

• Stage IV: Any T Any N M1

TREATMENT OF BREAST CARCINOMA

Sayan Saha Roll No.-187

TREATMENT OF BREAST CARCINOMA

• LOCOREGIONAL THERAPY

SURGERY RADIOTHERAPY

• SYSTEMIC THERAPY CHEMOTHERAPY HORMONAL THERAPY MONOCLONAL

ANTIBODY

These are used singly or in combination

TREATMENT DEPENDS UPON:-

• AGE• SIZE OF THE TUMOR• AXILLARY LN STATUS• STAGE OF MALIGNANCY• BIOLOGIC

AGRESSIVENESS• RECEPTOR STATUS OF

TUMOR• MULTICENTRICITY &

MULTIFOCALITY

• MENSTRUAL STATUS• SIZE OF BREAST• AVAILABILITY OF

RADIOTHERAPY• PATIENT’S CHOICE• PROPHYLACTIC/

THERAPEUTIC/PALLIATIVE

SURGICAL ANATOMY

ANATOMY OF BREAST

BLOOD SUPPLY OF BREAST

LYMPHATIC DRAINAGE OF BREAST

Cont…..

SURGICAL DIVISION OF LYMPHNODES OF AXILLA

SURGERY

SURGERY AVAILABLE:-

1.TOTAL(SIMPLE) MASTECTOMY2.TOTAL MASTECTOMY WITH AXILLARY CLEARENCE3.HALSTED RADICAL MASTECTOMY4.MODIFIED RADICAL MASTECTOMY i) PATEY’S OPERATION ii)SCANLON’S OPERATION iii)AUCHIONCLOSS OPERATION5.BREAST CONSERVATION SURGERY

TOTAL (SIMPLE) MASTECTOMY

Surgical removal of whole breast tissue superficial to pectoral fascia.

Axillary radiotherapy as no pathological staging performed Structures removed:- tumor + breast tissue + nipple &areola + skin.

TOTAL MASTECTOMY WITH AXILLARY CLEARENCE

TOTAL MASTECTOMY with level I axillary LN clearence

NIPPLE AND AREOLA SPARING SURGERY:- Tumor 2-3 cm away from alveolar border Smaller breast size and minimal ptosis No prior breast surgery BMI<40KG/M2

No tobacco use No breast irradiation No collagen vascular disease

RADICAL MASTECTOMY OF HALSTED

TISSUE REMOVED: Tumor + entire breast + areola& nipple + skin over

tumor + pectoralis major & minor + fat + fascia + level I,II,III axillary lymph node + few digitaions of serratus anterior

TISSUE PRESERVED:Axillary veinBell’s nerveCephalic vein

COMPLICATIONS: Lymphedema & Lymphangiosarcoma

MODIFIED RADICAL MASTECTOMY

STRUCTURES REMOVED:-Tumor + breast tissue + skin , nipple, areola + level I,II,III LN(

level III not all variety) + pectoralis minor(except AUCHINCLOSS MRM)

STRUCTURES PRESERVED:- Nerve to serratus anterior Nerve to latissimus dorsi Intercostobrachial nerve Axillary vein Cephalic vein Pectoralis major muscle

MODIFIED RADICAL MASTECTOMY

it is of 3 types:-1.PATEY’S MODIFIED RADICAL MASTECTOMY:- Pectoralis major preserved but pectoralis minor removed Level III LN removed

2.SCANLON’S MODIFIED RADICAL MASTECTOMY:- Pectoralis minor incised and divided Level III LN removed3.AUCHINCLOSS MODIFIED RADICAL MASTECTOMY:-Pectoralis minor retracted and left intactLevel III LN not removed It is practiced nowadays widely.

STEPS OF MODIFIED RADICAL MASTECTOMY

Anaesthesia Patient position Antiseptic dressing &

draping Incision Two transverse elliptical

incisions, including the nipple areola complex and skin overlying the tumor together with skin margins that lie 1-2 cm from the cephalic and caudal extents of the tumor.

Raising skin flap• Skin & subcut. fat from

mammary tissue• Ideal thickness 7-8mm• Bleeding stop by

diathermy• ExtentRaising the breast• Separate breast tissue

from fascia covering pectoralis major.

• Breast is lifted above from boundary: Laterally : anterior margin of latissimus dorsi medially : mid sternal line Superiorly : subclavius muscle Inferiorly : 2-3 cm inferior to infra-mammary fold

Axillary dissection:-• P. major retracted and

lateral border of P. minor is cleared by removing level l LN & areolar tissue

• If PATEY’S MRM : pectoralis minor muscle dissected & level l,ll,lll LN cleared.

• If AUCHINCLOSS MRM: Pectoralis minor is retracted & upto level ll LN is cleared

• Lymphatics & tissue removal should not done superior to axillary vein.

Done when sentinel lymphnode biopsy is positive

Hemostasis secured & drains are placed

Sutured

COMPLICATIONS OF MODIFIED RADICAL MASTECTOMY

PEROPERATIVEo Anaesthetic complicationso Hemmorhageo Injury to nearby nerves & muscles POSTOPERATIVEEARLYo Seroma/lymph collection(30-50%)o Seconday infection

o Flap necrosiso Pain & numbnesso Shoulder dysfunctiono Winging of scapulaLATEo Lymphedemao Lymphangiosarcoma(stewart treve’s syndrome) 3-5 yr after lymphedema

development Ipsilateral limb Multiple subcutaneous

nodule Require amputation

WINGING OF SCAPULAFLAP NECROSIS

PROLONGED LYMPHEDEMA

BREAST RECONSTRUCTION

Patient have undergone modified radical mastectomy WHY? MRM PSYCHOLOGICAL STRESS BR RESULT

Ideal candidate??

TYPES:-IMMEDIATE:-Early stage of malignancy where neoadjuvant therapy works good & no need to give post operative radiotherapyMaximum amount of breast skin preservedCost-effectiveDELAYED:- (AFTER 3-9 MONTH)INDICATION: 1.locally advanced disease 2.post operative radiation requiredADVANTAGE: 1. post operative radiation allowed 2. Avoid fibrosis and flap necrosis where TRAM flap is used

TYPES OF FLAP

1.PEDICLED FLAP Latissimus dorsi

myocutaneous flap

TRAM flap

2.FREE FLAP TRAM flap Gluteus maximus

myocutaneous flap Anterolateral thigh flap

3.SILICON COMPOUND GEL prosthesis under pectoral muscle

4.EXPANDABLE SALINE PROSTHESIS

COMPLICATIONS OF FLAP

SURGICAL OPTIONS FOR BREAST RECONSTRUCTIONS

• Prosthetic only reconstrutions1.saline/silicon prosthesis• Autologus & prosthetic reconstructions2.Thoraco epigastric flap with implant3.Latissimus dorsi flap with implantAutologus reconstruction4.TRAM5.Extended latissimus dorsi flap6.Free TRAM7.DIEP & SIEP flap8.SGAP & IGAP flap

TRAM flap Most commonly used in post mastectomy breast

reconstruction Superior epigastric artery gives the blood supply

LATISSIMUS DORSI FLAP

ALLOPLASTIC MATERIALS

• ARTIFICIAL SILICONE FLAP • EXPANDABLE SALINE PROSTHESIS

ARTIFICIAL SILICONE GEL FLAP PLACED UNDER PECTORALIS MAJOR MUSCLE

BREAST CONSERVATION THERAPY

BY MD. KHALILULLAHROLL NO. - 190

BREAST CONSERVATION THERAPY

BREAST CONSERVATION involves: 1. Resection of the primary breast cancer with a margin

of normal appearing breast parenchyma. 2.Adjuvant radiation therapy 3.Assessment of regional lymph node status BCT- the standard treatment for stage 0, I and II invasive

breast cancer. Other terms that refer excision of primary breast cancer with

preservation of the breast: lumpectomy, partial mastectomy, tylectomy, quadrantectomy, wide local excision etc.

WHY B.C.T. IS PREFERABLE?

ADVANTAGES OF B.C.T.:

1.Similar survival rate compared to total mastectomy.

2.Improved quality of life and asthetic outcome.

3.Allows preservation of breast shape and skin as well as preservation of sensation

4.provides psychological advantage.

INDICATION OF B.C.T.

Stage I and stage II invasive breast cancer. It can also be done in stage IIIA T3N1M0. Factors favouring breast conservation surgery: 1. Smaller monocentric tumour, 2. Younger age, 3. Treatment carrying in specialised centre, 4. Favourable physical factors, 5. Localisation of tumour, 6. Patient compliance

ELIGIBILITY FOR BREAEST CONSERVATION

Those criteria are responsible for decreased local recurrence after BCT.

• 1. Tumour size: up to 5 cm , with clinically positive nodes

• 2. Margins: At least 2-3mm clear margin should be obtainable.

• 3. Histology: Invasive lobular and cancers with extensive intraductal components.

• 4. Patients’ Age : Local recurrence is higher for younger women.

CONTRAINDICATION OF BCT

ABSOLUTE : 1. Locally wide spread disease 2. Multicentricity 3. Diffuse ( malignant ) microcalcification 4. Pregnancy of 1st or 2nd trimester 5. Persistently positive surgical margin 6. Patients with mutation on BRCA1 and BRCA2 gene 7. Already irradiated thoracic wallRELATIVE: 1. Large Tumour/Breast ratio 2. Collagen vascular disease (except rheumatoid arthritis) 3. Tumour location

METHODS BREAST CONSERVATIVE THERAPY

WIDE LOCAL EXCISION LUMPECTOMY(LUMPECTOMY) + +SENTINEL LYMPH QUART i.e. AXILLARY DISSECTION NODE BIOPSY QUADRANTECTOMY+RADIOTHERAPY +RADIOTHERAPY +AXILLARY DISSEC- TION+RADIOTHERAPY

CTART

CHEMOTHERAPY

+RADIOTHERAPY

WIDE LOCAL EXCISIONIt is removal of unicentric tumour with 1 cm clearance margin. PRINCIPLES: Incision made directly over the lump. Skin flap should not be raised. Normal breast parenchyma of 1 cm clearance with excision of tumour

done. Pectoral fascia – not opened (usually). The tumour specimen i.e. removed, should be 1. Marked after placing in orientation grid 2. Assessed by specimen radiography 3.looked for clearance margin by Frozen Section Biopsy Drain not placed, deeper cavity not closed/obliterated. Skin closed cosmetically. Along with this, axillary dissection through separate incision and

radiotherapy to breast and chest wall is given.

WIDE LOCAL EXCISION

SENTINEL LYMPH NODE BIOPSY: -Standard care in the management of the axilla in patient with clinically

node negative disease. - Localisation of sentinel lymph node(SLN): By injection of patent blue dye

and radioisotope-labelled albumin in the sub-dermal plexus around the nipple or over the peri-tumour region.

- Diagnosis can be made by: a)Frozen section analysis b)Touch imprint cytology c) molecular method ( cytokeratin

. -19)

Interpretation : i) If node is detected negative, no further nodal dissection is needed.

ii) If positively detected, axillary block dissection is done( for SLN in axilla).

• Sensitivity: 90% for patent blue dye 95%for Tc 99 labelled albumin.

QUADRANTECTOMY

Removal of entire segment /quadrant with ductal system with 2-3 cm normal breast tissue clearance.

Done as a part of QUART therapy which also includes axillary dissection ( level I and II ) through separate incision and radiotherapy to breast area.

COSMETIC CHALLENGES

Several deformities can occur due to Resection of primary tumour using an incision directly over

the tumour, Closing the skin with out re-approximating any breast tissue.

1. Volumetric deformity 2. Retraction deformity3. Skin-pectoral muscle adherence 4. Lower pole deformityREMEDY : Oncoplastic surgeries.

DISADVANTAGES OF BCT

o Higher chance of

recurrence, even after RT.o Needs radiotherapy after

surgery.o Equal psychological

morbidity as with total mastectomy but here due to fear of recurrence.

RADIOTHERAPY IN BREAST CARCINOMA

-PRESENTED BY TARIK AZIZ BISWAS ROLL NO: 191

INDICATION

CONSERVATIVE BREAST SURGERYTOTAL MASTECTOMYMODIFIED RADICAL MASTECTOMYBONE SECONDARIESATROPHIC SCHIRROUS CARCINOMA

RADIOTHERAPY IN BREAST CONSERVATIVE SURGERY

RADIATIONS FOLLOWING LUMPECTOMY

DURATION : 6 -7 WEEKS

INITIAL RADIATION INCLUDES ENTIRE BREAST FOR FIRST 5 -5 ½ WEEKS.

‘BOOST’ RADIATION FIELD INCLUDES THE TISSUE IMMEDIATELY

SURROUNDING THE SITE OF INITIAL TUMOUR FOR LAST 1- 1 ½ WEEKS.

THERAPY BEGINS 3 TO 6 WEEKS FOLLOWING SURGERY IF NO

CHEMOTHERAPY PLANNED.

IF CHEMOTHERAPY PLANNED, RADIATION BEGINS 4 WEEKS FOLLOWING

COMPLETION OF CHEMOTHERAPY

POST MASTECTOMYRADIOTHERAPY

DURATION : 5 TO 6 ½ WEEKS OF DAILY THERAPY

RADIATION INCLUDES CHEST WALL TISSUE AND

DRAINING LYMPH NODE

THE NEED FOR A ‘BOOST’ FIELD WITHIN CHEST

WALL TISSUES IS DETERMINED BY TUMOUR

FACTOR AND PRESENCE/ABSENCE OF

RECONSTRUCTION .

POST MODIFIED RADICAL MASTECTOMY RADIOTHERAPY

RECOMMENDED TO PATIENT WITH :

FOUR OR MORE AXILLARY LYMPH

NODE INVOLVED(STAGE 1 & 2)

LOCALLY INVASIVE TUMOUR

CHARACTERISTICS & INFLAMMATORY

CANCER (T3 OR T4 )

TUMOUR CELLS WITHIN THE DEEP

MARGIN OF RESECTION.

TYPES OF RADIATIONI. EXTERNAL RADIATION : MOST COMMON TYPE OF

RADIATION ,TYPICALLY GIVEN AFTER LUMPECTOMY AND SOMETIMES MASTECTOMY.

II. INTERNAL RADIATION

III. INTRAOPERATIVE RADIATIONBRACHYTHERAPY :RADIATION TO THE

BREAST BY PLACE RADIOACTIVE SEEDS INTO BREAST TISSUE.

PARTIAL BREAST IRRADIATION : RADIATION THERAPY THAT USING BOTH EXTERNAL BEAM THERAPY & BRACHYTHERAPY

CRITERIA : SMALL LESSION (< 3 cm) NON LOBULAR INVASIVE

HISTOLOGY SINGLE FOCUS LESSION NEGATIVE SURGICAL MARGIN < 3 LN INVOLVED WITHOUT

EXTRACAPSULAR EXTENSION

CONTRAINDICATION CONNECTIVE TISSUE

DISEASE SUCH AS SCLERODERMA OR VASCULITIS

PREGNANT ALREADY HAD

RADIATION TO THAT AREA OF BODY

SIDE EFFECTS HEAVINESS AND

SWELLING IN BREAST WEAKNESS LYMPHEDEMA SUNBURN TYPE SKIN

IRRITATION CARDIAC TOXICITY

CHEMOTHERAPY & HORMONAL THERAPY

BYREGIA SULTANAROLL NO.-197

INTRODUCTIONChemotherapy and/or endocrine therapy improves survival in those women who are at greatest risk of relapse.

The choice of adjuvant systemic therapy will be based on known prognostic factors including: • Nodal status• Histological grade and tumour size• Oestrogen receptor/progesterone receptor status• Menopausal status

HORMONAL THERAPY

Principles: • Used in ER/PR +ve patients only• All age groups included now• Relatively safe• Easy to administer• Adequate prophylaxis against Ca of opposite breast • useful in metastatic carcinoma• Reduces recurrence-improves quality of lives and

longevity

MEDICAL• Oestrogen receptor antagonist-

Tamoxifen,raloxifen• Progesterone receptor antagonist• Oral aromatase inhibitor-

letrozole, anastrozole,exemestane,aminoglutethimide

• Androgens-inj. Testosterone propionate fluoxymestrone• LHRH agonists-Goserelin (medical

oophorectomy)• Progestogen- medroxyprogesterone acetate

SURGICAL• Ovarian ablation by-1) Surgery (bilateral oophorectomy)2) Radiation • Adrenalectomy• Pituitary ablation

• Anti oestrogen 1. Tamoxifen given for 5 years or more to be started only after completion of chemotherapy given in pre and post menopausal women After binding to estrogen receptors in the

cytosol ,tomoxifen blocks the uptake of estrogen by breast tissue.

toxic effects like bone pain,hot flushes,nausea,vomiting,fluid retention.

long term risk is endometrial carcinoma

2.Raloxifenit is selective oestrogen receptor antagonistit reduces endometrial carcinoma

AROMATASE INHIBITORSgiven in post menopausal women inhibits the enzyme aromatase,so oestrogen

synthesis is reduced side effects are cardiac problems,osteoporosis

Commonly used aromatase inhibtors:a. aminoglutethimideb. Letrozole,anastrozole

• Aminoglutethimide: Blocks synthesis of oestrogen-medical adrenalectomy. Cortisone supplement is needed.

• Letrozole: Non-steroidal competitive inhibitor of aromatase it reduces oestrogen level by 98% More expensive,more effective side effects are vaginal bleeding,vaginal dryness,night sweats,hot

flushes,osteoporosis

CHEMOTHERAPY Approach

Adjuvant therapy neoadjuvant therapy palliative therapy-in early breast cancer -in locally advanced -in advanced/-stage I & II breast cancer(LABC) metastatic cancer T1NI,T2N1,T3N0 -stage IIIA,IIIB -stage IV

ADJUVANT CHEMOTHERAPY

Considered in all cases of early breast cancer irrespective of-• Menopausal status• Hormone receptor status• Nodal status

Indication• <0.5 cm in size, node -ve: minimal benefit and not recommended• 0.5-1 cm in size,node -ve : given if she has unfavourable

prognostic features• >1cm in size,hormone receptor -ve: chemotherapy is appropriate

DRUG REGIMEN• 1st line drugs:Anthracyclines- Cyclophosphamide Adriamycin 5 fluorouracil Epirubicin • 2nd line drugs:Taxanes-Paclitaxel Docetaxel

• 3rd line drugs:Gemcitabine

Duration: 6 cycles 3 weekly or, 4 cycles 3 weekly

Side effects: alopecia, bone marrow suppression cystitis megaloblastic anaemia GIT disturbances nephritis

NEOADJUVANT THERAPY• It refers to administration of drugs prior to surgery to reduce

locoregional burden of tumour.• Indication:

-large operable tumour -micrometastasis

After neoadjuvant therapy response of tumour is assessed.it may be- complete clinical response(cCR):the growth becomes impalpable

clinically. Partial pathological response(pPR):the resected specimen shows viable

microscopic disease in a patient with cCR. Complete pathological response(cPR):if no microscopic growth is seen.

NEOADJUVANT CHEMOTHERAPYo ER/PR –ve patients respond better.o Good general condition of patient is needed.o Trastuzumab can be given alongwith neoadjuvant

setting.

Advantages downstage the disease Increases chances of breast conservationEarly systemic control is achieved Inoperable tumour becomes operable

ANTI HER 2/neu THERAPY

Drugs a. Trastuzumabb. Pertuzumabc. Bevacizumabd. Lapitinab

TRASTUZUMAB

• It is a monoclonal antibody against tyrosine kinase receptor(HER 2 receptor)

• Administered in HER 2 +ve patients• It has cardiac side effects.• When it is combined with taxane based chemotherapy

it improves disease free survival by 50% If one gets trastuzumab as neoadjuvant she has to

receive trastuzumab after surgery also. Where as pertuzumab is not given after surgery.

• BEVACIZUMAB Vascular growth factor receptor inhibitor

• LAPITINAB inhibit both HER2 and EGFR

Treatment protocol

BY SAYEEDA ZAHANROLL NO - 194

IN SITU CARCINOMA

AIM

Prevent or detect at an early stage of invasive cancer

MANAGEMENT

DCIS (DUCTAL CARCINOMA IN SITU):

>4 cm of disease More than one quadrant

MASTECTOMY

NO

LUMPECTOMY FOLLOWED BY RADIOTHERAPY

YES

Low grade DCIS,solid,cribriform,papillary, <0.5 cm of disease

LUMPECTOMY without RADIOTHERAPY

LCIS (LOBULAR CARCINOMA IN SITU)

BILATERAL MAMMOGRAPHY

•Second carcinoma

BILATERAL MASTECTOMY

•Limited carcinoma•No second carcinoma

I. FOLLOW UPII. CHEMOTHERAPY

WITH TAMOXIFENE III. BILATERAL

MASTECTOMY

EARLY BREAST CARCINOMA

AIM

Achieve possible cureControl of local diseases in the breast and

axillaeConservation of local form and functionPrevention of delay of the occurrence of

distant metastasesPrevention of local recurrence

MANAGEMENT

BREAST CONSERVING SURGERY with assessment of axillary lymph node status followed by radiotherapy

MASTECTOMY with assessment of axillary lymph node status ,if

Prior radiation therapy to breast and chest wall Involved surgical margin or unknown margin status Multicentric diseaseCollagen vascular diseases

ADJUVENT CHEMOTHERAPY

INDICATION :

• Node positive cancers• Cancers that are >1cm• Node negative cancer of >0.5cm when adverse

prognostic features are present

REGIMENS :

A. HER2-Neu + disease

Single agent therapy : trastuzumab alone or trastuzumab and taxane

Combination therapy : AC-Paclitaxel plus trastuzumab : AC-Docetaxel plus trastuzumab

B. HER2-Neu – disease : CMF regimen (cyclophosphamide, methotrexate, 5-FU ) : AC regimen (adriamycine, cyclophosphamide)

C. ER/PR+disease : Tamoxifene therapy

LOCALLY ADVANCED CARCINOMA OF BREAST

AIM

• Prevent distant metastases• Prevent local recurrences

MANAGEMENTNeoadjuvent chemotherapy -anthracycline basedResponse assessment

LACB

Neoadjuvent chemotherapy

RESPONSE NO RESPONSE

Bilateral mammography

RESPONSE NO RESPONSE

If operable chemotherapyMastectomy

Adjuvent radiotherapy

Response no response If operable not operable

Mastectomy Radiotherapy Adjuvant If operable

radiotherapy mastectomy

Hormone treatmement if ER/PR positive

METASTATIC CARCINOMA OF BREAST

AIM

• Improve quality of life • Relieve pain of secondaries like bone, lungs• Relieve neurological problems like

convulsions, space occupying cranial problems• Other symptomatic relief

MANAGEMENT

Metastatic breast carcinoma with systemic diseases

ER/PR+ ER/PR- HER2-Neu+ HER2-Neu-

ER/PR+

Visceral or epidural diseases

YES NO

CHEMO-THERAPY PRE POST

MENOPAUSAL MENOPAUSAL

PREMENOPAUSAL : Tamoxifene +/- ovarian ablation

POSTMENOPAUSAL : Aromatase inhibitor

• Tamoxifene• Fulvestrant• Medroxy-progesterone

ER/PR- HER2-Neu-

CHEMOTHERAPY

HER2-Neu+

ER/PR+ ER/PR-

trastuzumab trastuzumab(single or (single or Combition) combination) orAromataseinhibitor

NOTE THE FOLLOWING

• Bone secondaries : bisphosphonate • Pleural effusion : - intercostal tube drainage - pleurodesis• Causes of death in carcinoma of breast : 1. secondaries in lung : heamoptysis, : respiratory failure 2. spine involvement : quadriplegia 3. secondaries in brain 4. cancer cachexia

INFLAMMATORY BREASTCARCINOMA

– T4d locally advanced carcinoma of breast ( stage IIIb) neoadjuvent chemotherapy and radiotherapy surgery ( if downstaged ) + axillary clearence

CARCINOMA OF BREAST IN PREGNANCY

A. 1ST TRIMESTER : - MRM (modified radical mastectomy) - if axillary node positive

Termination of pregnancy + chemotherapy

B. 2ND TRIMESTER : - MRM / BCS* -Chemotherapy

carefullyC. 3RD TRIMESTER : - MRM / BCS* - after delivery chemotherapy suppression of lactation

*HERE RADIOTHERAPY IS GIVEN AFTER DELIVERY

NOTE THE FOLLOWING :

Hormonal treatment is contraindicated : TERATOGENIC

Radiotherapy is also not givenMRI is the investigation of choiceCan become pregnant 2 yrs after

completion of treatment

FOLLOW UP

Clinical examination in detail @regular intervalYearly / 2 yearly mammography of the treated

and contra lateral breast Bone scan , CT chest/abdomen , tumor

markers – not routinely done

TREATMENT OF RECURRENCE

• PREVIOUS MASTECTOMY

ChemotherapyAntiestrogentherapyRadiotherapy ( if previously not received )

• PREVIOUS LUMPECTOMY

Mastectomy with reconstruction Chemotherapy Antiestrogen therapy

PROGNOSIS,PREVENTION & RECENT ADVANCES IN BREAST CARCINOMA

-PRESENTED BYIMDADUL HOQUEMEDICAL COLLEGE, KOLKATAROLL NO-188

PROGNOSTIC FACTORS

MAJOR FACTORSINVASIVE VS IN-SITUDISTANT METASTASESLYMPH NODE METASTASESTUMOUR SIZELOCALLY ADVANCED DISEASEINFLAMMATORY CARCINOMA

MINOR FACTORS

HISTOLOGIC SUBTYPEHISTOLOGIC GRADEER & PRHER2/ neu RECEPTORLYMPHOVASCULAR INVASIONPROLIFERATIVE RATEDNA CONTENTRESPOND TO NEOADJUVANT THERAPYGENE EXPRESSION PROFILING

PREVENTION

PRIMARY LEVEL OF PREVENTION: NO OR LIMIT ALCOHOLMAINTAIN A HEALTHY DIETAVOID LONG-TERM HORMONE THERAPYSTAY PHYSICALLY ACTIVEEAT FOODS HIGH IN FIBRESEMPHASIZES OLIVE OILAVOID EXPOSURE TO PESTICIDES

SECONDARY LEVEL OF PREVENTION

BREAST SCREENING LEADS TO EARLY DIAGNOSIS OF BREAST CANCER. IT CAN BE DONE BY FOLLOWING WAYS-

BREAST SELF EXAMINATION(BSE) BY THE PATIENT.EXAMINE BOTH BREASTS.REMIND THE PATIENT THAT 90% OF BREAST

LUMPS ARE NOT CANCER.IF ANY DOUBTFULL SWEELING IS

PALPABLE,CONSULT THE SURGEON.AMERICAN CANCER SOCIETY RECOMMENDS

MONTHLY BSE AFTER 20 YEARS OF AGE.PALPATION BY A PHYSICIAN.MAMMOGRAPHY.

MAMMOGRAPHIC SCREENING

DONE IN- ASYMPTOMATIC WOMEN OVER THE AGE OF 40 YEARS

WHO ARE AT A AVERAGE RISK OF BREAST CANCER.ASYMPTOMATIC WOMEN UNDER THE AGE OF 40

YEARS WHO HAVE POSITIVE FAMILY HISTORY OF BREAST CARCINOMA.

DONE IN A 3 YEAR INTERVAL.

REDUCES CAUSE-SPECIFIC MORTALITY BY UPTO 30%.

ADVANTAGES:

CAN DETECT SMALL TUMOURS.AVOIDS EXPENSIVE & TOXIC

TREATMENT FOR ADVANCED CANCER.EXTRA YEARS OF PRODUCTIVITY.REASSURANCE IF NEGATIVE.LIFE YEARS GAINED BECAUSE MORE

CURABLE EARLY CANCERS DETECTED.

DISADVANTAGES:EXPOSURE TO RADIATION.FALSE POSITIVITY AROUND 5%.COST OF ADDITIONAL CASES TREATED.MORBIDITY OF TEST.‘OVERDIAGNOSIS’, eg. DCISANXIETY IN POSITIVE.FALSE REASSURANCE OF FALSE NEGATIVE.

IF SCREENING TEST IS POSITIVE, THEN WHAT TO DO?

CHEMOPREVENTION:TAMOXIFEN.RALOXIFEN.

PREVENTIVE SURGERY:PROPHYLACTIC MASTECTOMY

↓ BREAST CANCER BY 95%

PROPHYLACTIC SALPINGO-OOPHORECTOMYIF PRE-MENOPAUSAL,50% ↓ IN BREAST

CANCER.

RECENT ADVANCES IN BREAST CARCINOMA

ETIOLOGY OF BREAST CANCER:EFFECT OF EXERCISE,WEIGHT GAIN OR LOSS,DIETGENETIC TESTING FOR BRCA1 & BRCA2 GENE MUTATION‘SISTER STUDY’ FUNDED BY NATIONAL INSTITUTE OF

ENVIRONMENTAL HEALTH SCIENCES(NIEHS)

CHEMOPREVENTION:RETINOIDS – NATURAL OR SYNTHETIC FORMS OF VIT-A

HAVE THE ABILITY TO DESTROY THE GROWTH OF CANCER CELLS. EFFECTIVE IN PREMENOPAUSAL WOMEN AND THOSE WHOSE TUMOURS AREN’T ERTROGEN POSITIVE.

.

FLAXSEED- HIGH IN LIGNAN, A NATURALLY OCCURING COMPOUND THAT LOWERS CIRCULATING ESTROGENS IN THE BODY. DECREASES ESTROGEN PRODUCTION-ACTS LIKE TAMOXIFEN-INHIBIT THE GROWTH OF BREAST CANCER TUMOURS.LIGNANS ARE ALSO ANTIOXIDANTS WITH WEAK ESTROGEN-LIKE CHARACTERISTICS.THESE CHARACTERISTICS MAY BE THE MECHANISM BY WHICH FLAXSEED WORKS TO DECREASE HOT FLUSHES.

NEW IMAGING TESTS:SCINTIMAMMOGRAPHY(MOLECULAR BREAST

IMAGING)PET SCAN

TREATMENT:ONCOPLASTIC SURGERYNEW CHEMOTHERAPY DRUGS- PARP

INHIBITORSTARGETED THERAPIES

HER2/neu TARGETTING DRUGS-TRASTUZUMAB,PERTUZUMAB,ADO-TRUSTUZUMAB EMTANSINE, LAPATINIB

ANTI-ANGIOGENESIS DRUGS-BEVACIZUMAB

OTHER TARGETTED DRUGS-EXEMESTANE,LETROZOLE

BISPHOSPHONATES-PAMIDRONATE,ZOLEDRONIC ACID

DENOSUMABVITAMIN-D

THANK YOU