Breast Cancer

BREAST CARCINOMAby

Students of

MEDICAL COLLEGE KOLKATA

(batch 2011)

1

INTRODUCTION

• Breast cancer is the second most common cancer in India.

• The incidence of breast cancer is increasing in the developing world due to increase life expectancy, increase urbanization and adoption of western lifestyles.

• Although some risk reduction might be achieved with prevention, these strategies cannot eliminate the majority of breast cancers that develop in low- and middle-income countries where breast cancer is diagnosed in very late stages.

• Therefore, early detection in order to improve breast cancer outcome and survival remains the cornerstone of breast cancer control.

2

Pathology of breast carcinomaBY

AMIYA GOPAL RANJA

& RAJARSHI BANERJEE

3

RISK FACTORS

Age: peak at 75-80 years

Age at menarche:20% more risk in women reaching menarche <11 years of age compared to menarche at >14 years of age

Age at first live birth: more risk of nulliparous women or women >35 years of age at their first birth

First degree relatives with breast cancer: 13% women with breast cancer have one affected first degree relative, and 1% have two or more

Atypical hyperplasia in prior breast biopsies

Oestrogen exposure: postmenopausal women having HRT have 1.2 -1.7 fold greater risk, adding progesterone increase it even further

Breast density

Radiation exposure: women having radiation in their teens and early 20s have 20%-30% more risk of developing carcinoma

Obesity: decreased risk in obese women <40 years but more in case of post menopausal obese

Carcinoma of contralateral breast

Race/Ethnicity4

AETIOLOGY AND PATHOGENESIS

• Major risk factors for development of breast cancers are hormonal and genetic

• It can be therefore divided into

Hereditary carcinoma-Associated with germline mutations

Sporadic carcinoma-probably related to hormonal exposure

5

MOST COMMON SINGLE GENE MUTATIONS ASSOCIATED WITH HEREDITARY SUSCEPTIBILITY TO BREAST CANCERGENE(LOCATION)AND SYNDROME

% OF SINGLE GENE HEREDITARY CANCERS

BREAST CANCER RISK BY AGE 70

FUNCTIONS COMMENTS

BRCA1(17q21)Familial breast and

ovarian carcinoma

52% 40-90% Tumour suppressorTranscriptional regulationRepair of ds DNA breaks

Carcinomas are poorly differentiated and triple negative with p53 mutation

BRCA2(13q12-13)Familial breast and

ovarian carcinoma

32% 30-90% Tumour suppressorTranscriptional regulationRepair of ds DNA breaks

Biallelic germline mutations cause a rare form of Fanconi anaemia

P53(17p13.1)Li Fraumeni

3% >90% Tumour suppression with critical roles in cell cycle control, DNAreplication, repair and apoptosis

Most commonly mutated gene in sporadic breast carcinoma

CHEK2(22q12.1)Li Fraumeni

5% 10-20% Cell cycle checkpoint kinase, activates BRCA1 and p53,repair of DNA damage

May increase risk after radiation exposure

6

SPORADIC BREAST CANCER

• The major risk factors for sporadic breast cancer are related to

Hormone exposure

Gender

Age at menarche and menopause

Breast feeding

Exogenous oestrogens

• The majority of sporadic cancer occur in postmenopausal women and are ER positive.

7

PRECANCEROUS LESIONS

Pathologic lesion Relative risk Absolute lifetime risk

NON PROLIFERATIVE BREAST CHANGES(FIBROCYSTIC CHANGES)

1.0% 3%

PROLIFERATIVE DISEASE WITH ATYPIAAtypical ductal hyperplasia(ADH)Atypical lobular hyperplasia (ALH)

4-5% 13-17%

CARCINOMA IN SITUDuctal carcinoma in situLobular carcinoma in situ

8-10% 25-30%

8

DISTRIBUTION OF HISTOLOGIC TYPES OF BREAST CANCER

TOTAL CANCERS PERCENTAGE

CARCINOMA IN SITU Ductal carcinoma in situ (DCIS) Lobular carcinoma in situ (LCIS)

15-30 80 20

INVASIVE CARCINOMA No special type carcinoma Lobular carcinoma Tubular carcinoma Mucinous carcinoma Medullary carcinoma Papillary carcinoma Metaplastic carcinoma

70-85 79 10 6 2 2 1 <1

9

DUCTAL CARCINOMA IN SITU (DCIS)

• Among mammographically detected carcinomas almost half are DCIS

• DCIS consists of a malignant clonal population of cells limited to ducts and lobules by basement membrane

• DCIS can spread throughout ducts producing extensive lesions involving an entire sector of breast

10

Histologically DCIS have been divided into 4 architectural subtypes…

• Solid pattern-filling and plugging of the ductal lumina with tumour cells.

• Comedo pattern-centrally placed necrotic debris surrounded by neoplastic cells in the duct.

• Papillary pattern-has formation of intraductal papillary projections of tumour cells which lack a fibrovascular stalk.

• Cribriform pattern-recognised by neat punch out fenestrations in the intraductal tumour.

LOBULAR CARCINOMA IN SITU (LCIS)

• It is always an accidental finding as it is not associated with calcification or stromal reactions

• The cells are identical to invasive lobular carcinoma and share genetic abnormalities like loss of E-Cadherin expression

• LCIS almost always expresses ER and PR but overexpression of HER2/neu is not observed

12

13

LCIS DCIS

Age (years) 44 to 77 54 to 58

Incidence 2 to 5% 5 to 10%

Clinical signs nil Mass,pain.discharge

Mammographic signs nil calcification

Multicentricity 60 to 90% 40 to 80%

Bilaterality 50 to 70% 10 to 20%

Subsequent carcinoma:

Invasive type 25 to 35% 25 to 70%

Histology of invasive Ductal Ductal

(Thus the subsequent invasive carcinomathat develops is 65 percent ductalorigin and not lobular type)

TREATMENT OF CIS

oLCIS: observation with or without tamoxifen

oDCIS:

Limited disease : lumpectomy + radiotherapy

≥ 2 quadrants involved : Mastectomy

14

INVASIVE CARCINOMA ,NO SPECIAL TYPE• This includes the majority of carcinomas and can be divided into five

major types on the basis of Gene Expression Profiling. They are

Luminal A (40-50% of NST cancer): ER positive and HER2/neu negative

Luminal B (15-20% of NST cancer): triple positive cancers

Normal breast like (6-10%):ER positive, HER2/neu negative with gene expression pattern similar to normal tissue

Basal like (13-25%):Absence of ER,PR and HER2/neu i.e. triple negative

HER2 positive (7-12%):ER negative but HER2/neu positive

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INVASIVE CARCINOMA ,NO SPECIAL TYPE

Mastectomy specimen containing a very large invasive ductal carcinoma of the breast. To the right, the nipple can be seen on the pink skin, while in the centre of the picture a large blue and pink swelling or tumour can be seen. At the edges of this surgical specimen fat tissue (orange/red) can be observed.

Typical macroscopic (gross) appearance of the cut surface of a mastectomy specimen containing an invasive ductal carcinoma of the breast (pale area at the centre).

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RISK ASSESSMENT AND RISK PREVENTION

By

RAMIJ RAJA

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INTRODUCTION

The breast cancer risk assessment tool is an interactive tool designed by scientists at NATIONAL CANCER INSTITUTE (NCI) and THE NATIONAL SURGICAL ADJUVANT BREAST AND BOWEL PROJECT (NSABP) to estimate a women's risk of developing invasive breast cancer

18

RISK ASSESSMENT MODELS

GAIL MODEL CLAUS MODEL

Data derived from Breast Cancer Detection Demonstration Project study

Cancer and Steroid Hormone Study

Family history characteristics FDR with breast cancer • FDR or SDR with breast cancer• Age of onset in relatives

Other characteristics • Current age• Age at menarche• Age at first live birth• Number of breast biopsies• Atypical hyperplasia in biopsies• Race

Current age

Strength IncorporatesRisk factors other than family history

Incorporates• Paternal and maternal history• Age of onset• Familial history of ovarian

carcinoma19

RISK ASSESSMENT MODELS

GAIL MODEL CLAUS MODEL

Limitations • Underestimates risk in hereditary families

• Number of breast biopsies without atypical hyperplasia may cause inflated risk estimates

Does not incorporate• Paternal family history of breast

cancer or any family history of ovarian cancer

• Age at onset of breast cancer in relatives

• All known risk factors for breast cancer

• May underestimate risk in hereditary families

• May not be applicable to all combinations of affected relatives

Best application • For individuals with no family history of breast cancer or one FDR with breast cancer, aged ≥50 y

• For determining eligibility for chemoprevention studies

For individuals with no more than two FDRs or SDRs with breast cancer

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RISK PREVENTION

Screening mammography

o Routine use of Screening mammography of >50 year old female decreases mortality by 33%

o Recommendation-Baseline mammography at the age of 35 and from 40 year annually

21

RISK PREVENTION

SERMs therapy-by Tamoxifen , Raloxifen

o Should be given if relative risk is > 1.7

o Both drugs reduce the risk of developing breast cancer by approx. 50%

o After a mean follow up period of 4 years, the incidence of breast cancer was reduced by 49%

22

RISK PREVENTION

Prophylactic mastectomy

o Reduces the risk >90%

o The benefit of Prophylactic mastectomy differed substantially according to breast cancer risk conferred by mutations

o For women with an estimated life time risk of 40% Prophylactic mastectomy adds 3 years of life whereas for women with an estimated life time risk of 85% Prophylactic mastectomy adds >5 years of life

23

INVESTIGATIONS AND PROGNOSTIC FACTORS

BY

AMBITA MONDAL

& SUDIPTO SAHA

24

Triple assessment

• Breast self examination

• Mammography

• FNAC

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INVESTIGATIONS

• For confirmation of diagnosis

Imaging

Mammography

USG

MRI

Biopsy

FNAC

Tru cut biopsy

26

INVESTIGATIONS• To stage the disease-metastatic workup

CT scan chest

X-ray chest

Whole body bone scan

Upper abdominal USG

LFT

Sentinel node biopsy

• To know the general condition

Complete haemogram

Serum albumin, sugar, urea, creatinine

ECG,Echo and Pulmonary function test for elder patients

27

Mammography

Most frequently done investigation

• Procedure

A selenium coated x-ray plate is used directly in contact with the breast which is exposed to low voltage& high amperage x-ray

• Two views-Medio-lateral & cranio-caudal

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Mammography

Indications

• For screening of women >40 years or earlier in a young women with strong family history

• To characterize breast lump

• To exclude multicentricity if BCS planned

• Specimen mammography to assess completeness of surgery

• Mastalgia

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Mammography

Findings

• Benign lesions- round ,punctate , popcorn like etc.

• Highly suspicious lesions-Pleomorphic, heterogeneousSolid mass with irregular edges,

spiculationLong tentacles- tentaculationFine scattered calcification- micro

calcificationDistortion of architectural pattern of the

breastAsymmetrical thickening of breast tissue

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Mammography

Advantages

• Non invasive

• Minimum hazards of radiation

Disadvantage• 10% false positive rate and 7% false

negative rate in mammography. Hence, biopsy is a must.

• LCIS may be missed in mammography

• Mammography is inconclusive in women under 35 due to dense breast tissue.

BI RADS (Breast Imaging-Reporting And Data System) category:

Score Assessment Follow up

0 Incomplete assessment Needs additional imaging

1 Negative Continue regular screening(>40 yrs.)

2 Benign findings Same as above

3 Probably benign Follow up study after 6 month

4 Suspicious of carcinoma Core biopsy may be required

5 Highly suggestive of carcinoma

Core biopsy is must

6 Known biopsy proven carcinoma

Biopsy confirms presence of cancer before treatment begins 31

USG

• In premenopausal women with dense breast tissue , USG is a better imaging modality to detect breast lesion than mammography

• USG can detect the mass as solid or cystic

• No radiation(done in Pregnancy) , cheap, easily available

• USG guided aspiration of breast may be done

• May demonstrate solid lesion in breast but cannot detect lesion less than 1 mm in diameter.

32

MRI

INDICATIONS

• To differentiate scar from recurrence

• To image breasts of women with implants

• To evaluate the management of axilla and recurrent disease

• Lesion indeterminate by ultrasonography and mammography.

• To screen breasts of young women with strong family history or carrying known genetic mutation

33

Trucut biopsy• Core needle biopsy has become the standard of care for biopsy of breast

lesion(may be USG or mammography guided if not palpable)

• A histological diagnosis of invasive or non invasive carcinoma may be made

• The tumour grade and any lymphovascular invasion may be assessed

• The ER/PR and Her2-neu status may also be assessed

• TECHNIQUE

After antiseptic cleaning & draping , local anaesthesia with inj. 2%lignocaine hydrochloride is given

A small stab incision in skin and a 11gauge core needle biopsy needle is inserted into the lesion to obtain sample.

34

FNAC

• It is done with 23gauge needle and material is collected on a slide ; a smear is made using 100% alcohol

• Minimum 6 aspirations are done

• Giemsa , pap, H&E stains are used

FNAC Mammography

Sensitivity 90-98% 90%

Specificity 98-100% 90%

False negative 2-10% 7%

False positive Near 1-5% 10%

FNAC Scoring

Co No epithelial cells

C1 Scanty epithelial cells , benign

C2 Benign cells

C3 Atypical cells

C4 Suspicious cells

C5 Malignant cells

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TNM Classification

Primary Tumour (T)

• 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

36

TNM Classification

Primary Tumour (T)

• 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

37

TNM Classification

Primary Tumour (T)• T4 Tumour of any size with direct extension to the chest wall and/or to the

skin (ulceration or skin nodules)

• Note: Invasion of the dermis alone does not qualify as T4

• 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 carcinoma38

TNM Classification

Regional Lymph Nodes (N) • 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; or 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

39

TNM Classification

Regional Lymph Nodes (N)

• 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)

40

TNM Classification

Distant Metastases (M)

• Mx-Metastases cannot be assessed

• Mo-No metastasis

• M1-Distant metastasis

41

Staging

Stage 0

Stage I

Stage IIA

Stage IIB

Tis N0 M0

T1 N0 M0

T0 N1 M0

T1 N1 M0

T2 N0 M0

T2 N1 M0

T3 N0 M0

T0 N2 M0

T1 N2 M0

T2 N2 M0

T3 N1 M0

T3 N2 M0

T4 N0 M0

T4 N1 M0

T4 N2 M0

Any T N3 M0

Any T Any N M1

Stage IIIA

Stage IIIB

Stage IIIC

Stage IV

PROGNOSTIC FACTORS

Major Prognostic Factors Invasive vs In-situ Distant metastases Lymph node metastases Tumour size Locally advanced disease Inflammatory carcinoma

Minor prognostic factors Histologic subtype Histologic grade(Scarff-

Bloom-Richardson) ER & PR HER2/neu receptor Lymphovascular invasion Proliferative rate DNA content Respond to neoadjuvant

therapy Gene expression profiling 43

NEOADJUVANT THERAPYIN CA BREAST

BY

ANAND KUMAR

44

What is Neoadjuvant Therapy?

Neoadjuvant therapy involves giving chemotherapy or hormonaltherapy before surgery to patients with non metastatic primary breastcancer which is potentially inoperable.

Origin

• The use of neoadjuvant chemotherapy has its origins in themanagement of inoperable locally advanced breast cancer.

• Preoperative chemotherapy was initially introduced to downsizepatients and enable successful local treatment.

Advantages

• It changes the timing of treatment and can change surgical options.

• It can shrink a tumour enough so that lumpectomy plus radiationtherapy becomes an option to mastectomy.

Disadvantages

• Neoadjuvant therapy does not increase survival (compared toadjuvant therapy).

• No increase in Overall Survival (OS) of the patient compared toadjuvant chemotherapy.

Factors to Consider

• Will it convert requirement of a mastectomy to a lumpectomy?

• Whether there is nodal involvement?

• Whether there is distant metastasis?

Results of NeoadjuvantTherapy

Clinical Response

Clinical response measures howmuch of the tumour reduces in sizefrom its original that can be assessedclinically. If it disappears completelythen it is termed a Complete ClinicalResponse (cCR).

• Its grades are -

Size of tumour after therapy to initial

Response

0% to 25% Complete responder

25% to 75% Partial responder

75% to 100% Resistant disease

> 100% Progressive disease

Pathologic Response

• Pathologic response describes how much of the tumour is left in thebreast and lymph nodes after neoadjuvant therapy.

• Pathological complete response (pCR) is defined as the absence ofresidual invasive cancer on hematoxylin and eosin evaluation of thecomplete resected breast specimen and all sampled regional lymphnodes following completion of neoadjuvant systemic therapy.

Treatment Response Assessment

A specialized MRI software has been used to mark the improvement in a breast cancer patient on neoadjuvanttherapy.

Neoadjuvant Hormone Therapies

• Some breast cancer cells need oestrogen and/or progesterone to grow.

• All tumours are checked for hormone receptors. The receptor status is checked by testing the tumour tissue removed during a biopsy.

• Most breast cancers are hormone-receptor positive. Hormone therapies are only used to treat hormone receptor-positive breast cancers.

Neoadjuvant Hormone Therapies

• It may also have a role in the treatment of women who are not candidates for chemotherapy due to other health problems or advanced age.

• It may also be an option for women with low grade tumors and invasive lobular breast cancer.

• Most young women with large tumors are treated with chemotherapy rather than hormone therapy, even if their tumors are ER-positive.

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Drugs Used in Hormone Therapy

Regimen of Neoadjuvant chemotherapy

CMF REGIMENCyclophosphamide – 100 mg/m2 oral (14 days)Methotrexate – 40 mg/m2 i.v. (1, 8th day)5-Fluorouracil – 400 mg/m2 i.v. (1, 8th day)* For 3 cycles* Each cycle being 28 days

More decrease in recurrence is seen on substituting anthracyclines(Adriamycin or Epirubicin), i.e. FAC or FEC regimens.

57

Neoadjuvant Therapy For Her2-neu positive Breast Cancers

Trastuzumab

Pertuzumab

• If one gets neoadjuvant trastuzumab, she will likely also have trastuzumab after surgery (adjuvant trastuzumab).

• Trastuzumab is not usually given at the same time as anthracycline-based chemotherapy, neither in the neoadjuvant nor the adjuvant setting.

• Pertuzumab is only used as a neoadjuvant therapy and is not given after surgery.

58

After The Neoadjuvant Therapy

To check the response to neoadjuvant therapy, several tests are done , including-

a clinical breast exam,

a mammogram,

a breast MRI , and/or

an ultrasound.

Some surgeon plan the surgery in the much same way as if there was no neoadjuvant therapy(they ignore initial staging),but the trend should be – always plan surgery before giving neoadjuvant therapy.

59

After the Neoadjuvant Therapy

• Before neoadjuvant therapy is started the area of the initial breast lump is delineated with radio opaque clips.

• This is important as neoadjuvant therapy shrinks the original tumourbut some cancerous cells remain embedded in the fibrous tissue surrounding the shrunken tumour and need to be resected during surgery.

Clipping

Technique of Lumpectomy after NeoadjuvantTherapy

After completion of neoadjuvant therapy the lumpectomy is done keeping in mind the clips inserted.

An area covering the entire lump originally present along with tissue 1 cm away from the clips is resected out.

Sentinel Node Biopsy & Neoadjuvant Therapy

• A sentinel node biopsy will be done either before neoadjuvanttherapy begins or after neoadjuvant therapy, at the time of breast surgery.

• The sentinel node biopsy checks for cancer in the lymph nodes in the axilla.

• It is unclear whether it is better to have a sentinel node biopsy before or after neoadjuvant therapy. There are pros and cons to each and the best timing is still under study. .

63

BY

PURNENDU MUKHERJEE

SURGERY FOR CA BREAST

64

DIFFERENT MODES OF SURGERY

Breast(Primary)

1. Breast Conservation Surgery

2. Simple mastectomy

3. Modified radical mastectomy

4. Radical Mastectomy

Axillary

1. Sentinel lymph node biopsy

2. Axillary lymph node dissection

65

Conservative Breast Cancer Surgery

A) Wide local excision/Lumpectomy

INDICATIONS:

Early breast carcinoma(stage I & II) where tumour size < 4 cm and well differentiated cytology

Breast tumour ratio is very important criteria.

Contraindications

Absolute

• Multicentric tumour

• History of previous breast irradiation

• Pregnancy

• Persistent positive margins after reasonable surgical attempts.

• Centrally located tumour

Relative

1.Collagen vascular disease

2.Poor socioeconomic strata(follow up?)

3.Size >4 cm

4.Family history positive

Conservative breast cancer surgery

Salient points:

• It is removal of unicentric tumour with 1 cm clearance margin.

• The placement of surgical clips at lumpectomy enables visualization of lumpectomy cavity.

• Specimen is marked after placing in orientation grid and mammography is done followed by frozen section biopsy to look for margin clearance .At least 2 mm clearance is needed for adequacy.

Conservative breast surgery

• If margin remains positive after biopsy, cavity brushing is done .After a maximum of 2 cavity brushing ,if margin is still positive mastectomy is required.

• In addition to being equivalent to oncologic safety ,lumpectomy appears to offer advantage with regard to asthetic outcomes and quality of life.

Specimen mammography

The specimen mammogram contains suspicious mass seen on peroperative image.

CONSERVATIVE BREAST SURGERY

B)Quadrantectomy:

It is done as a part of QUART(quadrantectomy, axillary dissection, and radiotherapy)therapy(by Veronesi from Italy ).

• It includes removal of entire segment /quadrant with 2-3 cm normal breast tissue clearance along with axillary dissection (level I and II)and radiotherapy to breast area.

• It is not advocated now a days as there is no outcome benefit.

CONSERVATIVE BREAST SURGERY

DISADVANTAGES:

1. Higher rate of local recurrence .

2. Needs radiotherapy after surgery.

3. It needs strict surveillance of post operative patient.

MASTECTOMYMastectomy What is it? Indications Comment

Simple Mastectomy Surgical removal of the whole of breast tissue superficial to the pectoral fascia

Advanced Breast Carcinoma(M1), also called Toilet Mastectomy

Often followed by radiotherapy to axilla as no pathological staging of axilla is performed.

Radical HalstedMastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia, both pectoralis muscles and axillary lymph nodes

Now it is obsolete, but few surgeons prefer it for male breast tumour

Causes excessive morbidity with no survival benefit, not performed nowadays.

Modified Radical Mastectomy

Surgical removal of the whole of breast tissue including the pectoral fascia and level I, II &/or level III axillary lymph nodes

Locally Advanced Breast Carcinoma(T3,T4,N2)

Most widely practised surgery.

73

MODIFIED RADICAL MASTECTOMY:

• Most acceptable and most widely practised surgery.

• Advantages over radical mastectomy:

o Good postoperative cosmetic appearance

o Maintain motor activity in the arm

o Low rate of postoperative arm oedema

o Easy postoperative breast reconstruction

74


• It is of 3 types:

1. Patey’s Modified Radical Mastectomy :- Pectoralis major muscle is preserved and Pectoralis minor removed

2. Scanlon’s Modified Radical Mastectomy :– Pectoralis minor muscle is divided but not removed.

3. Auchincloss’ Modified Radical Mastectomy :– Pectoralis minor is retraced but not divided.

Auchincloss’ Modified Radical Mastectomy is widely practiced nowadays.

75


INCISION

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

76


• Anatomical boundaries of MRM:

Lateral - anterior margin of latissimus dorsi muscle

Medial - sternal border

Superior - clavicle

Inferior – up to upper ¼ th of rectus sheath.

77


78


• Three important structures should be preserved:

1. Axillary vein

2. Bell’s nerve(long thoracic nerve)

3. Cephalic vein

79


• A complete axillary block dissection should include node clearance up to level III:

Level I:located lateral to Pectoralis minor muscle.

Level II:located beneath the Pectoralis minor muscle.

Level III:located medial to Pectoralis minor muscle.

80


• Complications of MRM:

PEROPERATIVE

oAnesthetic complications

oHemorrhage

oInjury to nearby nerves & muscles

POSTOPERATIVE

Early:

oSeroma/lymph collection(30-50%)

oSecondary infection

81


oFlap necrosisoPain & numbnessoShoulder dysfunctionoWinging of scapulaLate:oLymphedemaoLymphangiosarcoma(Stewart treve’s syndrome)3-5 yr after lymphedema developmentIpsilateral limbMultiple subcutaneous noduleRequire amputation

82

AXILLARY SURGERY

• Role of axillary surgery in CA breast is debated, but it is accepted that presence of metastatic disease within axillary lymph nodes is still the best single marker for prognosis.

• In early breast carcinoma, if there is no clinically apparent nodes and the disease is not multicentric, then sentinel node biopsy is considered.

• Otherwise Complete Axillary Dissection is done.

83

AXILLARY SURGERY

SENTINEL NODE BIOPSY:

• Sentinel means guard. Sentinel node is the first lymph node to get enlarged in malignancies.

• Indication:

Early breast cancer with clinically node negative axilla.

• Procedure:

On the day prior to surgery, the radioactive colloid (Technetium 99m sulfur or radioalbumin) is injected using a tuberculin syringe into three to four separate sites at the cancer area or subdermally proximal to cancer; the node biopsied using hand-held gamma camera peroperatively.

Alternatively during surgery methylene blue is injected into the tumor and the sentinel node identified and sent for frozen section biopsy. 84

AXILLARY SURGERY

SENTINEL NODE BIOPSY:

• Interpretation:

1. If –ve: no axillary block dissection is required.

2. If +ve: axillary block dissection is done.

• Fallacy of sentinel lymph node biopsy: 3% show skip malignancy

85

Reconstruction surgeryGoal of reconstructive surgery after mastectomy are wound closure and breast reconstruction.Methods of reconstruction Insertion of breast implants or expanders -best for small breastFlap reconstruction if a more radical removal of skin and

subcutaneous tissue has been doneo Latissimus dorsi musculocutaneous flap (LD flap )o Transversus abdominis muscle flap (TRAM flap )Flap with implant or expanders

Nipple is created using nipple sharing from contralateral nipple using composite graft .

Reconstruction surgery

Latissimus dorsi flap

In original position In new location location

Breast implants

• Technically simple

• Achieves symmetry easily

• Implant in submuscular plane is better whenever muscle is not removed during surgery

• Subcutaneous implant is placed in case of radical mastectomy.

• Silicon gel implants or saline implants are used.

Adjuvant THERAPY for carcinoma of breast

BYADITYA SARKAR

& SANJOY MONDAL

89

Adjuvant therapy for breast cancer is any treatment given after

primary therapy to increase the chance of long-term disease free

survival.

What is adjuvant therapy for breast cancer?

90

ADJUVANT THERAPY

Radiotherapy Systemic therapy

Chemotherapy

Hormonal therapy

91

RADIOTHERAPY IN CA BREAST

To the Chest Wall To the Axilla

• T3,T4 tumour >5cm• Residual disease-LABC • Positive margin• After conservative surgery• Higher risk group• Inflammatory carcinoma

• 4 or more nodes positive • Extranodal spread• Axillary status not

known(inadequate sample)

INDICATIONS:

92


Accelerated Partial Breast Irradiation (APBI)• Only to the lumpectomy bed • By increasing the radiation fraction size and

decreasing the target volume in a shorter period.

• APBI is generally defined as radiation therapy that uses daily fraction doses greater than 2 cGy delivered in less than 5 weeks

93

RADIOTHERAPY IN CA BREASTBrachytherapy in Breast Cancer- It refers to use of radiation sources in or close to the tumour.

External Radiotherapy –

• Sites: breast area, axilla (in selected patients like if axillary dissection is not done or more than 4 positive axillary nodes) internal mammary and supraclavicular area

• Total dosage 5000 cGY units200-cGY units daily 5 days a week for 6 weeks.

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A. Comprehensive chest wall and regional lymph node radiation therapy.

B.cross-sectional view showing the tangential field.

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ADJUVANT HORMONAL THERAPY Principles: It is used in ER/PR positive patient in all age groups It gives Prophylaxis against carcinoma of opposite Breast It is not used in ER negative Patients The Drugs are Categorised as follows: 1st line- Anti oestrogen Tamoxifen

2nd line- Aromatase inhibitor ,Prevent the synthesis of oestrogen by blocking aromatase inhibitor enzyme which converts androstenedione to oestradiol on adrenals.

1st generation: Aminoglutathemaide2nd generation: Anastrozole, Letrozole,

3rd line: Progestogens-megestrol acetate 400mg per day

4th line: Androgen fluoxymesterone 30 mg daily 96

Tamoxifen:Oestrogen Receptor Antagonist20mg once daily for 5 years Half life is 7 days Used commonly in Premenopausal women Adverse Effects: Flushing, tachycardia, Sweating, vaginal atrophy, itching, bone pain Advantages: Reduces recurrence rate by 25% Equally effective in male breast carcinoma Cheap easily available less toxic

Advantage of AHT: It is relatively safe easy to administer Used in metastatic carcinoma of breast

ADJUVANT HORMONAL THERAPY

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Indications:

• Tumour size >1cm• Tumour size <1cm with ER negative,HER-2

Positive, high grade• Lymphovascular or perinural invasion

ADJUVANT CHEMOTHERAPY

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• Adjuvant Chemotherapy refers to administration of cytotoxic drugs to women after breast cancer surgery to eliminate undetectable distant spread.

• 1st line drugs used-

• 2nd line drugs- Taxanes Paclitaxel docetaxel

• 3rd line drugs- Gemiticabine

CMF regime CAF regime MMM regime

Cyclophosphamide Cyclophosphamide Methotrexate

Methotrexate Adriamycin Mitomycin-C

5-Fluorouracil 5-Fluorouracil Mitozantrone

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Adjuvant Trastuzumab therapy:

Transtuzumab: A monoclonal antibody against tyrosine kinase receptor(HER-2) is administrated in patients with HER-2 +ve Patients to improve Disease Free Survival(DFS)

Dose: Loading 4mg/kg

Maintenance: 2mg/kg for 9 weeks


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Chemotherapy: Infections and bruise or bleed easily, less energy loss of

appetite, nausea, vomiting, diarrhoea, or mouth sores.Chemotherapy drugs, Anthracyclines can increase the risk of heart problems.

Trastuzumab: Trastuzumab can induce nausea, vomiting, hot flashes, and joint pain. Trastuzumab can also increase the risk of heart problems.

Radiation therapy: Skin in the area treated by radiation may become red, dry, tender, and itchy, and the breast may feel heavy and tight.

SIDE EFFECTS OF ADJUVANT THERAPY

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Hormonal therapy: Hot flushes, vaginal discharge, and nausea.

Tamoxifen also increases the risk of cataract development .

Aromatase inhibitors: Hot flashes, vaginal dryness, and other symptoms of menopause joint pain (arthralgia) or muscle pain (myalgia) during treatment

SIDE EFFECTS OF ADJUVANT THERAPY

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• Adjuvant chemotherapy is given orally (by mouth) or by injection

into a blood vessel. It is given in cycles, consisting of a treatment period followed by a recovery period. The number of cycles depends on the types of drugs used. Adjuvant chemotherapy usually does not last for much more than 6 months.

Trastuzumab is given by infusion into a blood vessel every 1 to 3 weeks for a year.

How is adjuvant therapy given, and for how long?

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• Hormonal therapy is usually given orally, as a pill.

Most women who undergo hormonal therapy take tamoxifen every day for 5 years.

Some women may take an aromatase inhibitor every day for 5 years instead of tamoxifen.

Some women may receive additional treatment with an aromatase inhibitor after 5 years of tamoxifen.

• Radiation therapy is given after mastectomy is divided into small doses given once a day over the course of several weeks.

How is adjuvant therapy given, and for how long?

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SUMMARY OF MANAGEMENT OF BREAST CA

• Early breast carcinoma(T1,T2,N0,N1):

o BCS + sentinel node biopsy/Axillary LN dissection(as indicated) + adjuvant radiotherapy and chemotherapy(as indicated)………RECENT TREND

• Locally Advanced Breast Carcinoma(T3,T4,N2):

o NACT(to know to response of drugs that will be given as adjuvant) + MRM(BCS if possible) + Adjuvant therapy

• Advanced breast carcinoma:

o Hormone therapy as toxicity less;chemotherapy if given,with one drug;Toilet mastectomy if needed.

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THANK YOU

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Health & Medicine

Breast Cancer