CA Breast

CA BREASTCA BREASTBY BY

DR. ZAKARIYA RASHIDDR. ZAKARIYA RASHID

Diagnostic OptionsDiagnostic Options CBECBE Imaging modalities.Imaging modalities.

Radiographic.Radiographic. Sonographic.Sonographic. Magnetic Resonance.Magnetic Resonance.

Tissue sampling.Tissue sampling. For palpable massesFor palpable masses

`FNAB`FNAB Core biopsyCore biopsy Excisional biopsyExcisional biopsy Incisional biopsy.Incisional biopsy.

For non palpable massesFor non palpable masses Stereotactic core biopsyStereotactic core biopsy Vacuum assisted biopsyVacuum assisted biopsy Needle localization biopsyNeedle localization biopsy Emerging Techniques.Emerging Techniques.

DIAGNOSISDIAGNOSIS S/S involve three major compartement:S/S involve three major compartement:

Glandular parenchyma:Glandular parenchyma: MassMass Asymmetric NodularityAsymmetric Nodularity PainPain

Nipple-Areolar Complex:Nipple-Areolar Complex: DischargeDischarge RashRash Distortion of shapeDistortion of shape

Breast skin:Breast skin: Erythema&EdemaErythema&Edema

MammographyMammography Screening mammogram:Screening mammogram:

Annually after 40 yrs.Annually after 40 yrs. In pts with known BRCA mutation annually after 25-30yrs.In pts with known BRCA mutation annually after 25-30yrs. In pts with strong family history.In pts with strong family history. Grading Breast lesion:Grading Breast lesion:

1=negative1=negative 2=Benign appearing2=Benign appearing 3=Probably benign lesion3=Probably benign lesion 4=Findings suspicious of CA breast biopsy recommended.4=Findings suspicious of CA breast biopsy recommended. 5=Highly suspicious of malignancy.5=Highly suspicious of malignancy.

Diagnostic mammogram:Diagnostic mammogram: Indicated for:Indicated for:

a questionable breast massa questionable breast mass To see other suspicious lesions& contralateral breast.To see other suspicious lesions& contralateral breast. To search for an occult CA breast in pts with metastatic axillary LN.To search for an occult CA breast in pts with metastatic axillary LN. To follow the females with CA breast undergoing BCT.To follow the females with CA breast undergoing BCT.

Mammographic findings suggestive of malignancy are spiculated Mammographic findings suggestive of malignancy are spiculated masses & linear microcalcifications & architectural pattern. masses & linear microcalcifications & architectural pattern.

SonographicSonographic Differentiate between Solid and Differentiate between Solid and

cysticcystic USG guided FNAC from the cyst USG guided FNAC from the cyst

wallwall It is performed in relatively younger It is performed in relatively younger

age group.age group.

Breast BiopsyBreast Biopsy For palpable masses :For palpable masses :

F.N.A.B.F.N.A.B. Sensitivity is >90%.Sensitivity is >90%. It does not give information about grade & invasion of It does not give information about grade & invasion of

tumor.tumor. ER & PR can be determined by immunohistochemistry.ER & PR can be determined by immunohistochemistry.

Core Biopsy Indications include :Core Biopsy Indications include : Lack of concordance b/w imaging findings & histology.Lack of concordance b/w imaging findings & histology. ADHADH Radial scar.Radial scar.

Excisional Biopsy.Excisional Biopsy. Incisional Biopsy. Incisional Biopsy.

cont. cont.

For non palpable masses:For non palpable masses: Stereotactic core biopsy:Stereotactic core biopsy:

Indications.Indications. Technique.Technique. Contra-indications.Contra-indications.

Vacuum assisted Biopsy.Vacuum assisted Biopsy. NLB>NLB> Iodine-125 seed localization biopsy. Iodine-125 seed localization biopsy.

Evaluation of other Breast Evaluation of other Breast SymptomsSymptoms

Breast Pain :Breast Pain : Uni-lateral.Uni-lateral. Focal.Focal. CBECBE USG Breast.USG Breast. Core tissue Biopsy.Core tissue Biopsy. Secondary Mammogram.Secondary Mammogram.

Nipple Discharge.Nipple Discharge. It is usually unilateral, spontaneous & Bloody.It is usually unilateral, spontaneous & Bloody. Cytology.Cytology. Subareolar Excisional Biopsy is indicated in :Subareolar Excisional Biopsy is indicated in :

When cytology reveals cellular atypia.When cytology reveals cellular atypia. Inrtaductal lesion seen on USG.Inrtaductal lesion seen on USG. Persistently discharging single duct. Persistently discharging single duct.

BREAST CA ; BREAST CA ; CELLULAR,BIOCHEMICAL&MOLECULACELLULAR,BIOCHEMICAL&MOLECULA

R BIOMARKERSR BIOMARKERS.. Breast cancer progression is the result of cumulative effect Breast cancer progression is the result of cumulative effect

of successive discrete genetic alterations lead to a gradual of successive discrete genetic alterations lead to a gradual transition from normal to Premalignant to malignant.transition from normal to Premalignant to malignant.

BRCA-1&2 .BRCA-1&2 . 5-10% cases are caused by cancer susceptibility genes.5-10% cases are caused by cancer susceptibility genes. 56-85% life time risk of developing breast ca.56-85% life time risk of developing breast ca. 15-45% life time risk of ovarian ca.15-45% life time risk of ovarian ca. These are high grade,receptor negative and aneuploid.These are high grade,receptor negative and aneuploid. Strategies for prevention of ca breast in BRCA carriers Strategies for prevention of ca breast in BRCA carriers

include :include : Prophylactic mastectomy & reconstruction.Prophylactic mastectomy & reconstruction. Prophylactic oophorectomy and HRT.Prophylactic oophorectomy and HRT. Intensive surveillance for breast ca .Intensive surveillance for breast ca . Chemoprevention.Chemoprevention.

Screening mammogram. Screening mammogram.

Prognostic & Predictive Prognostic & Predictive BiomarkersBiomarkers

The biomarkers are biological alterations The biomarkers are biological alterations in tissue that occur b/w initiation & cancer in tissue that occur b/w initiation & cancer developement.developement.

These are :These are : Proliferative changes.Proliferative changes. Histologic changes.Histologic changes. Genetic alterations.Genetic alterations.

These include:These include: Proliferative markers:PCNA,Ki-67.Proliferative markers:PCNA,Ki-67. Apoptic indicators :bcl-2 and bax/bcl-2 ratio.Apoptic indicators :bcl-2 and bax/bcl-2 ratio. Angiogenic indicators :VEGF.Angiogenic indicators :VEGF. Growth Factor receptors :EGFr,HER-2/neu,p53.Growth Factor receptors :EGFr,HER-2/neu,p53.

cont.cont.

HER-2/neu Receptor:HER-2/neu Receptor: HER-2/neu gene amplification carries poor prognosis.HER-2/neu gene amplification carries poor prognosis. Anti-HER-2/neu antibodies in combination with Taxanes.Anti-HER-2/neu antibodies in combination with Taxanes. Use of adenoviral E1A to suppress HER-2/neu gene Use of adenoviral E1A to suppress HER-2/neu gene

transcription.transcription. Angiogenic Factors:Angiogenic Factors:

VEGFVEGF Extracellular matrix protein receptors-------integrins.Extracellular matrix protein receptors-------integrins. Matrix metalloproteases.Matrix metalloproteases.

Antiangiogenic Factors:Antiangiogenic Factors: Anti VEGF antibody.Anti VEGF antibody. VEGF receptor inhibitor.VEGF receptor inhibitor. MMP inhibitorsMMP inhibitors Antiintegrin antibody.Antiintegrin antibody. Vascular targeting agent-------Fixes complement and causes Vascular targeting agent-------Fixes complement and causes

vasculitis.vasculitis.

Prognostic & Predictive Prognostic & Predictive Factors.Factors.

Tumour Factors.Tumour Factors. Host Factors.Host Factors.Nodal statusNodal status AgeAgeTumour sizeTumour size Menopausal statusMenopausal statusCytologic/nuclear Cytologic/nuclear gradegrade

Family HistoryFamily History

Vascular invasionVascular invasion Previous breast ca.Previous breast ca.Pathologic stagePathologic stage ImmunosuppressionImmunosuppressionHR statusHR status NutritionNutritionDNA contentDNA content Prior chemotherapyPrior chemotherapyExt. Intraductal Ext. Intraductal comp.comp.

Prior radiotherapyPrior radiotherapy

Cont.Cont.

Nottingham Nottingham Prognostic index:Prognostic index: NPI=(Tumour size NPI=(Tumour size

in cm x0.2)+Lymph in cm x0.2)+Lymph node stage(1=no node stage(1=no node,2=1-3 LN node,2=1-3 LN positive,3=4 or positive,3=4 or more node more node involved)involved)+Grade(1,2 or 3).+Grade(1,2 or 3).

>5.4

2.4-5.4

<2.4

Ductal CA in situ.Ductal CA in situ. >50% of breast cancers diagnosed with screening mammograph.>50% of breast cancers diagnosed with screening mammograph. 15-20% of all diagnosed female breast cancers.15-20% of all diagnosed female breast cancers. Pathophysiology:Pathophysiology:

Pre-invasive cancer.Pre-invasive cancer. Two broad categories:Two broad categories:

Comedo Type.:Comedo Type.: Necrotic cellular debris within duct.Necrotic cellular debris within duct. Numerous mitosis & large pleomorphic nuclei.Numerous mitosis & large pleomorphic nuclei. Absence of specific architectural changesAbsence of specific architectural changes Denser collection of microcalcification.Denser collection of microcalcification.

Non-Comedo Type :Non-Comedo Type : Lack of central necrosis.Lack of central necrosis. Low mitotic rate.Low mitotic rate. ER-positive.ER-positive. Fewer microcalcification.Fewer microcalcification.

Low ,medium & high grade.Low ,medium & high grade.

Prognostic Index for Prognostic Index for DCIS.DCIS.

ScoreScore 11 22 33Size(cm)Size(cm) <1.5 <1.5 1.5-4 1.5-4 >4>4Margins(cMargins(cm)m)

>1>1 1-0.11-0.1 <0.1<0.1

HistologyHistology Low Low without without necrosis necrosis

IntermediatIntermediateeWith With necrosisnecrosis

High High gradgradee

DiagnosisDiagnosis Screening mammogram:Microcalcification.Screening mammogram:Microcalcification. P/C stereotactic core biopsy.P/C stereotactic core biopsy. Vaccum assisted aspiration biopsy.Vaccum assisted aspiration biopsy. Excisional biopsy: Excisional biopsy:

1 cm Margins of the excised lesion ,beyond the 1 cm Margins of the excised lesion ,beyond the extent of disease indicated by pre-operative extent of disease indicated by pre-operative mammography, should be free of disease.mammography, should be free of disease.

Excised lesions are marked at six surgical Excised lesions are marked at six surgical margins & should be send for frozen-section.margins & should be send for frozen-section.

Small titanium clips are used to mark the margins Small titanium clips are used to mark the margins of biopsy cavity for subsequent radiotherapy & is of biopsy cavity for subsequent radiotherapy & is helpful if the re-excisiopn is required.helpful if the re-excisiopn is required.

Re-excision of the lesions with margins within Re-excision of the lesions with margins within 0.5cm of the tumour.0.5cm of the tumour.

Cont.Cont. Additional treatement.Additional treatement.

Lesions <0.5cm,favourable histology clear surgical Lesions <0.5cm,favourable histology clear surgical margins.---------close surveillance.margins.---------close surveillance.

Lesions b/w 0.5-2.5cm, favourable histology, clear Lesions b/w 0.5-2.5cm, favourable histology, clear surgical margins.-------post op. radiotherapy.surgical margins.-------post op. radiotherapy.

Lesions>2.5cmLesions>2.5cm Wide excision with 1cm tumour free margins.+Post- Wide excision with 1cm tumour free margins.+Post-

op. radiotherapy.op. radiotherapy. Risk factors contributing for consideration of simple Risk factors contributing for consideration of simple

mastectomy.mastectomy. Younger pts.Younger pts. Multifocal disease.Multifocal disease. Larger lesions relative to breast size.Larger lesions relative to breast size. Strong family history.Strong family history. Unfavourable histology.Unfavourable histology.

Cont.Cont.

SLND:SLND: DCIS >2.5cm with DCIS >2.5cm with

comedo histology.comedo histology. Multifocal disease.Multifocal disease. Microinvasion.Microinvasion. Multicentric Multicentric

disease.disease. Systemic Systemic

adjuvant adjuvant therapytherapy. .

Lobular CA in situ.Lobular CA in situ. Hormonal Influence.Hormonal Influence. Higher frequency of Higher frequency of

ER-positive tumours.ER-positive tumours. Diagnosis is purely Diagnosis is purely

incidental.incidental. Pre-malignant Pre-malignant

condition.condition. Close surveillance.Close surveillance. Bilateral mastectomy.Bilateral mastectomy. Prophylaxis with Prophylaxis with

Tamoxefin.Tamoxefin.

Lobular hyperplasia

Atypical hyperplasia

Lobular ca in situ

surgery

Radiotherapy

Systemic therapy

Surgical TherapySurgical Therapy Breast conservation.Breast conservation.

Tumours upto 5cm can be managed .Tumours upto 5cm can be managed . Local recurrence rate after BCT & radiotherapy is less Local recurrence rate after BCT & radiotherapy is less

than 10%.than 10%. Pts with recurrence require mastectomy and less often Pts with recurrence require mastectomy and less often

re-excision.re-excision. Lumpectomy without radiation has higher recurrence Lumpectomy without radiation has higher recurrence

but can be avoided in low risk pts like:but can be avoided in low risk pts like: Low grade.Low grade. Small size.Small size. Adequate resection margins.Adequate resection margins. Special histologic Type.Special histologic Type. Presence of good prognostic features in Primary cancers.Presence of good prognostic features in Primary cancers. Negative SLNB.Negative SLNB.

Cont.Cont.

Contra-indications:Contra-indications: Larger tumours in relatively small Larger tumours in relatively small

breast.breast. Females previously irradiated.Females previously irradiated. Multifocal &Multicentric.Multifocal &Multicentric. Pregnancy.Pregnancy. Collagen vascular disease.Collagen vascular disease. Positive resection margins.Positive resection margins. Pts with BRCAI & II.Pts with BRCAI & II.

Cont. Cont.

BCT with radiotherapy:BCT with radiotherapy: In all cases <45yrs.In all cases <45yrs. >45yrs------tumour >1cm.>45yrs------tumour >1cm.

BCT without radiotherapy:BCT without radiotherapy: >45yrs.>45yrs. <1cm.<1cm. Well differentiated.Well differentiated. Tubular,Papillary,Mucinous.Tubular,Papillary,Mucinous.

Types of BCT :Types of BCT : Wide local Excision.Wide local Excision. Segmentectomy.Segmentectomy. Quadrentectomy.Quadrentectomy. Needle localization Excision for impalpable tumour.Needle localization Excision for impalpable tumour.

Axillary Surgery.Axillary Surgery. Axillary LN status is important prognostic factor Axillary LN status is important prognostic factor

for survival.for survival. Clinically palpable LN.Clinically palpable LN.

F.N.A.C. to confirm.F.N.A.C. to confirm. Neo-adjuvant chemotherapy.Neo-adjuvant chemotherapy. Axillary clearance-upto level III.Axillary clearance-upto level III. Complications.Complications. Post op. radiotherapy .Post op. radiotherapy .

Clinically negative LN.Clinically negative LN. No axillary evaluation is required in pts with low risk for No axillary evaluation is required in pts with low risk for

axillary metastasis(<5%) which includes tumours axillary metastasis(<5%) which includes tumours <1cm,tubular,mucinous & papillary variety and elderly <1cm,tubular,mucinous & papillary variety and elderly females with small cancer.females with small cancer.

In all other pts with invasive carcinoma:SLNB & ALNS. In all other pts with invasive carcinoma:SLNB & ALNS.

Cont.Cont.

SLNB:SLNB: Indications:Indications:

Early invasive & node negative.Early invasive & node negative. Procedure.Procedure. Complications.Complications. Contra-Indications.Contra-Indications.

Pre-operative chemotherapy & Pre-operative chemotherapy & radiotherapy.radiotherapy.

EVALUATION OF EVALUATION OF LYMPH NODESLYMPH NODES

Adjuvant Systemic Adjuvant Systemic TherapyTherapy

Pts. are at risk of developing either local or Pts. are at risk of developing either local or distant metastasis.distant metastasis.

Risk is assessed from different prognostic Risk is assessed from different prognostic factors:factors: Size.Size. LN status.LN status. Estrogen Receptor status.Estrogen Receptor status. Grade.Grade. Lymphovascular invasion.Lymphovascular invasion.

Aim is to eliminate micrometastasis,thus Aim is to eliminate micrometastasis,thus reducing the risk of recurrence & metastasis.reducing the risk of recurrence & metastasis.

Treatement can be given in the form of:Treatement can be given in the form of: Adjuvant.Adjuvant. Neo-adjuvant.Neo-adjuvant.

Currently available treatement Currently available treatement optionsoptions..

ChemotherapyChemotherapy Hormone therapyHormone therapy Biological TherapyBiological Therapy

Cont.Cont.

Decision is based on:Decision is based on: Disease related factors:Disease related factors:

Tumour size.Tumour size. LN status.LN status. Lymphovascu;ar invasion.Lymphovascu;ar invasion. Receptor status.Receptor status. Grade.Grade.

Pt related factors:Pt related factors: AgeAge Menopause.Menopause. Fitness. Fitness.

ChemotherapyChemotherapy Benefit is independent of nodal & menopausal status.Benefit is independent of nodal & menopausal status. Absolute improvement is more for node positive pt.Absolute improvement is more for node positive pt. Benefit is less for pts >70yrs.Benefit is less for pts >70yrs. Combinations used:Combinations used:

CMF.CMF. MF.MF. CAF.CAF. AC-----TAC-----T

Adverse effects.Adverse effects. G.I. disturbance.G.I. disturbance. Alopecia.Alopecia. Hematological suppression.Hematological suppression. Fertility and ovarian function is affected >40yrs in Fertility and ovarian function is affected >40yrs in

Cyclophosphamide containing regimens.Cyclophosphamide containing regimens. Induction of second cancers(hematological).Induction of second cancers(hematological). Cardiac Toxicity Cardiac Toxicity

Endocrine Endocrine TherapyTherapy

Drugs Targeting Estrogen and It’s Receptor Drugs Targeting Estrogen and It’s Receptor in Breast Cancerin Breast Cancer

EstrogenEstrogen

Cell Cell Growth Growth and and DivisionDivision

Estrogen Receptor

SERMS (tamoxifen, SERMS (tamoxifen, raloxifene), SERDS raloxifene), SERDS (fulvstrant)(fulvstrant)

Aromatase Aromatase inhibitors, ovarian inhibitors, ovarian suppressionsuppression

Hormonal Therapy Hormonal Therapy Tamoxefin.Tamoxefin.

Beneficial in pts with ER+ve irrespective ofBeneficial in pts with ER+ve irrespective of Age.Age. LN status.LN status. Menopausal.Menopausal.

For older pts adding CT is not helpful due to For older pts adding CT is not helpful due to additional toxicity.additional toxicity.

Adverse effects:Adverse effects: Vasomotor Symptoms.Vasomotor Symptoms. Decrease cholesterol.Decrease cholesterol. Increase thrombosis.Increase thrombosis. Bone loss in pre-menopausal pts.Bone loss in pre-menopausal pts. Bone protecting in post-menopausal pts.Bone protecting in post-menopausal pts.

Cont. Cont.

Ovarian ablation.Ovarian ablation. In pre-menopausal pts.In pre-menopausal pts. Benefit is independent of nodal status.Benefit is independent of nodal status. Methods :Methods :

Surgery.Surgery. Radiation.Radiation. LHRH agonists.LHRH agonists.

It exists as an alternative to CT or as optimal It exists as an alternative to CT or as optimal endocrine therapy.endocrine therapy.

Treatement by LHRH agonist (Goserelin) in S/C Treatement by LHRH agonist (Goserelin) in S/C depots monthly.depots monthly.

Treatement is reversible with preservation of Treatement is reversible with preservation of fertility. fertility.

Menopausal symptoms.Menopausal symptoms.

Cont.Cont.

Aromatase inhibitor:(Anastrozole)Aromatase inhibitor:(Anastrozole) Beneficial in post-menopausal females.Beneficial in post-menopausal females. It inhibits the conversion of adrenal androgens It inhibits the conversion of adrenal androgens

into estradiol and estrone.into estradiol and estrone. Less severe side-effects.Less severe side-effects. Increase risk of fractures due to effect in bone Increase risk of fractures due to effect in bone

mineral density.mineral density. Alternative first line therapy where potential Alternative first line therapy where potential

risk for Tamoxefin is present.risk for Tamoxefin is present. Switching to aromatase inhibitor after 2-3 yr Switching to aromatase inhibitor after 2-3 yr

use of Tamoxefin. use of Tamoxefin.

Aromatase Aromatase InhibitorsInhibitors

Adrenal HormonesAdrenal Hormones

CortisolCortisol AndrostenedioneAndrostenedione AldosteroneAldosterone

EstradiolEstradiol

TestosteroneTestosteroneEstroneEstrone

Aromatase inhibitors block Aromatase inhibitors block post-menopausal estrogen post-menopausal estrogen productionproduction

Anastrozole (Arimidex)Anastrozole (Arimidex)Letrozole (Femara)Letrozole (Femara)Exemestane (Aromasin)Exemestane (Aromasin)

Biological TherapyBiological Therapy Target the factors which allow the Target the factors which allow the

cancer cells to grow and survive and cancer cells to grow and survive and spreadspread

. Adjuvant therapy containing . Adjuvant therapy containing Doxorubicin is effective.Doxorubicin is effective.

Anti-HER-2/neu antibodies in Anti-HER-2/neu antibodies in combination with Taxanes.combination with Taxanes.

Use of adenoviral E1A to suppress HER-Use of adenoviral E1A to suppress HER-2/neu gene transcription2/neu gene transcription

The HER Family of The HER Family of ReceptorsReceptors

HER1EGFR

HER2 HER3

HER4

Tumor CellTumor Cell

•Trastuzumab (Herceptin)Trastuzumab (Herceptin)•Pertuzumab (Omnitarg)Pertuzumab (Omnitarg)

•LapatinibLapatinib

•Erlotinib (Tarceva)Erlotinib (Tarceva)•Gefitinib (Iressa)Gefitinib (Iressa)•Cetuximab (Erbitux)Cetuximab (Erbitux)

Drugs Targeting HER-2 in Drugs Targeting HER-2 in Breast CancerBreast Cancer

HER-2

nucleus

cancer cell

cell division

Trastuzumab (Herceptin) Anti-HER-2 Antibody (IV)

HER-2 Oncogene: overexpressed in HER-2 Oncogene: overexpressed in 20-25% of breast cancers20-25% of breast cancers

Lapatinib (Tykerb) Dual HER-1/HER-2 (oral) Tyrosine Kinase Inhibitor

Multidisciplinary Cancer Breast

Management Natural History of DiseaseNatural History of Disease • • Most cases of stage III breast Most cases of stage III breast

cancer were once stage I breast cancercancer were once stage I breast cancer •• In poor countries, more than half of In poor countries, more than half of

patients have locally advanced or patients have locally advanced or metastatic disease at the time of metastatic disease at the time of diagnosisdiagnosis

– – Lack of educationLack of education – – Lack of screeningLack of screening


Management

Clinical Presentation Clinical Presentation ofof

Stage III Breast Stage III Breast CancerCancer

Peau d’orange Large mass, edema, and erythema


Management Clinical Presentation of Stage III, LocallyAdvanced (Inoperable) Disease

Large primary breast cancer Locally advanced breast cancer


Management Stage Classifications for LocallyAdvanced Breast Cancer

Stage IIB T2 N1 M0

T3 N0 M0Stage IIIA T0 N2 M0

T1 N2 M0T2 N2 M0T3 N1 M0T3 N2 M0


Management Stage Classifications for LocallyAdvanced Breast Cancer (cont.)

Stage IIIB T4 N0 M0

T4 N1 M0

T4 N2 M0

Stage IIIC Any T N3 M0

Stage IV Any T Any N M1

Locally Advanced Locally Advanced CarcinomaCarcinoma

Stage lll and Inflammatory breast Carcinoma.Stage lll and Inflammatory breast Carcinoma. Combination CT (CAF)has dramatic Combination CT (CAF)has dramatic

regression of breast lesion in 65-70% percent regression of breast lesion in 65-70% percent of cases.of cases.

With induction responses following 2-6 drug With induction responses following 2-6 drug cycles an extended simple mastectomy with cycles an extended simple mastectomy with level l nodal dissection should be done.level l nodal dissection should be done.

Peripheral lymphatics,skin flaps and central Peripheral lymphatics,skin flaps and central and apical LN group are treated with and apical LN group are treated with comprehensive radiation therapy. comprehensive radiation therapy.

Cont.Cont.

Multimodal approach in stage lll Multimodal approach in stage lll decreases the chest wall recurrence decreases the chest wall recurrence to 4-10%.to 4-10%.

And improve the 5 year survival to And improve the 5 year survival to 45 %.45 %.

,and 10 year survival to 28 %. ,and 10 year survival to 28 %.


Management Neoadjuvant Chemotherapy•Concept developed concurrently with adjuvant chemotherapy in the 1970s•Treatment for locally advanced breast cancer(stage III disease)•Allows for immediate assessment of tumor response•Allows for the evaluation of new and novel agents


Management Neoadjuvant Chemotherapy (cont.)

•Goals:– Decrease tumor size– Minimize surgery– Establish tumor sensitivity

•Appropriate treatments:– Chemotherapy– Tamoxifen or aromatase inhibitors– Radiation therapy


Management Clinical Rationale for Preoperative Chemotherapy:

•Excellent response rates for locally advanced breast cancer• Efficacy of adjuvant chemotherapy for node- negative breast cancer• Equivalent survival for breast-conserving surgery and mastectomy


Management Advantages ofNeoadjuvant Chemotherapy

•Increased rate of breast-conserving surgery•Earlier treatment of micrometastases•Treatment serves as in vivo chemosensitivity assay•Improved rates of local control and disease-free survival


Management Factors Influencing Decision to UseNeoadjuvant Chemotherapy in

Operable Breast Cancer•Does the patient need adjuvant chemotherapy based on information known prior to surgery?•Would neoadjuvant chemotherapy potentially alter the extent of resection?•Does the patient desire breast preservation?•Would treatment benefit from knowledge of in vivo chemosensitivity?


Management Radiation Therapy after Mastectomy

According to Consensus Statement developed by American Society for Therapeutic Radiology and Oncology (ASTRO)•Radiation therapy should be part of the treatment for stageIII breast cancers and for disease that involves four or more lymph nodes•At a minimum, the chest wall and the supraclavicular fossa should be treated with doses of at least 50 Gy

Oncoplastic Breast Oncoplastic Breast Surgery(OBS)Surgery(OBS)

It includes all approaches of plastic It includes all approaches of plastic and Re-constructive surgery aimed at and Re-constructive surgery aimed at achieving tumour resection with achieving tumour resection with satisfactory margins in conservative satisfactory margins in conservative treatement.treatement.

It attempted to minimize potential It attempted to minimize potential deformities and to obtain best deformities and to obtain best possible cosmetic results,without possible cosmetic results,without compromising resection marginscompromising resection margins

ClassificationClassification Post-mastectomy breast re-constructionPost-mastectomy breast re-construction

ImmediateImmediate DelayedDelayed

Conservative Post surgery Breast Re-Conservative Post surgery Breast Re-constructionconstruction ImmediateImmediate DelayedDelayed

Re-construction of chest wall and soft tissue Re-construction of chest wall and soft tissue deformities after surgical treatement of deformities after surgical treatement of LABC and extensive local recurrence.LABC and extensive local recurrence.

CA Breast

Health & Medicine

Transcript of CA Breast