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Outlines
• Epidemiology of CA Breast
• Clinical manifestations
• Management according to NCCN guidelines
(Stage-wise)
BREAST CANCER IN THE WORLD
Breast cancer is second only to lung cancer as a cause of cancer deaths
1.15 million new cases
470 000 deaths
Half of the global burden in low- and medium-resourced countries
CLINICAL MANIFESTATIONS
5
Most common: lump or thickening in breast. Often painless
Change in color or appearance of areola
Redness or pitting of skin over the breast, like the skin of an orange
Discharge or bleeding
Change in size or contours of breast
American Joint Committee on Cancer
t< 2 cm,no nodes
t 2 to 5 cm, +/-nodes
matted lymph nodes,variable tumor size
distant metastases
MANAGEMENT OF LCIS
BIOPSY:• FNA• Core Biopsy• Incisional biopsy• Excisional biopsy (Tumor + surgical margins)
ADVISES For RISK REDUCTION:
• Modify life style• Hormonal Therapy: Anti-estrogen• Surgery• Follow-up care
SURGERIES
B/L Simple Mastectomy with reconstruction surgery
Indication:
•Family history of CA Breast•Relatives having mutations in BRCA1 and BRCA2•Ovarian cancer
FOLLOW-UP
•Mammography: every year after age of 50
•CBE: every 6 to 12 months
•Self examination awareness
•Breast MRI
Ductal Carcinoma in situ (DCIS)
13Illustration © Mary K. Bryson
Ductal cancer cells
Normal ductal cell
• Medical history
• Physical examination
• Diagnostic mammography
• Biopsy
• Hormone receptor test
• Genetic counseling
Management
• Lumpectomy alone
• Lumpectomy with radiotherapy (EBRT)– (Breast conserving therapy)
• Total Mastectomy – (with or without breast reconstruction)
• Sentinel lymph node biopsy
BREAST RECONSTRUCTION
• After Lumpectomy– Volume displacement
• After mastectomy– Skin sparing mastectomy– Time for reconstruction
Nipple Replacement
• Remade nipple:– From surrounding tissue– Vulva– Thigh– Other nipple
• fake nipple
Breast conserving surgery
–Pros• Skin’s natural look is kept• Quicker healing• Intact sensation so better
psychological satisfaction
–Cons• Asymmetry• Radiation required• May need second surgery
Breast reconstruction
–Pros• Reconstruct whole breast• Less worry about recurrence• Less likely to need radiation
–Cons• Loss of breast• Longer healing• Serious side effects e.g: edema
RISK REDUCTION
Modify life style
Hormonal therapy
Follow-up• Mammography (every 6months)• CBE• Self examination• Breast MRI
Invasive Lobular Carcinoma (ILC)
27Illustration © Mary K. Bryson
Lobular cancer cells breaking through the wall
WORK-UP• Medical history
• Physical examination
• Blood test: CBC, LFTs
• Imaging: – mammography, – u/s,– MRI,– bone scan,– CT Chest, – Abdominal/pelvic CT scans
• C.A cell tests: – Hormone receptor tests– HER2 receptor test
• Lymph node biopsy
• Genetic counseling
• Fertility counseling
SURGERIES
• Breast conservative surgery: Lumpectomy
• Total mastectomy
(With or without breast reconstruction)
• Surgeries for Lymph node– Sentinel lymph node dissection– Axillary dissection
NEOADJUVANT THERAPY
• Chemotherapy
• Radiotherapy
-In whole breast
-Partial breast
• Hormonal therapy
• INVESTIGATIONS
• SURGERIES
– BCT: Lumpectomy with radiation
– Total mastectomy (with or without breast reconstruction)
– Lymph nodes dissection
HORMONAL THERAPY
• Anti-estrogen: Tamoxifen and Toremifene
• Aromatase inhibitors:
• Hormones: high dose megestrol acetate, flurymesterone, ethinyl estradiol
• Ovarian ablation (through B/L oophrectomy or radiation)
• Ovarian suppression: LNRH agonist e.g: Goserelin, Leuprolide
CHEMOTHERAPY
• Alkylating agents:– carboplatin, cisplatin, cyclophosphamide
• Anthracyclins: – Doxorubicin, epirubicin
• Antimetabolites: – flurouracil, methotraxate, gematabine etc
• Microtubule inhibitors: – Docetexal, emtansine, eribulin, paclitaxel
TARGETED THERAPY
• Trastuzumab and pertuzumab
• Ado-transluzmab
• Lapatinib
• Bevicizumab
• everolimus