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Breast Problems...

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  • 1. BREAST
  • 2. Breast Lymphatic drainage 1.Level I- nodes located lateral to or below the lower border of the p. minor 2. Level II- nodes located deep to or behind the p. minor 3. Level III- nodes located medial to or above the upper border of the p. minor
  • 3. Gynecomastia
    • - Presence of a female type mammary gland in the male
    • - Excess of estrogen in relation to circulatory testosterone
    • - Does not predispose the male breast to CA
  • 4. Pathophysiologic Mechanism of Gynecomastia
    • 1. Estrogen excess states
    • 2. Androgen deficiency states
    • 3. Drug-related conditions that initiate gynecomastia
    • 4. Systemic disease with idiopathic mechanism
  • 5. Treatment:
    • 1. Medical therapy
    • 2. Subcutaneous mastectomy- if refractory to medical tx
  • 6. Mammography
    • Useful for:
    • 1. Examinations of an indeterminate mass that presents as a solitary lesion suspicious of CA
    • 2. Examination of an indeterminate mass that cannot be considered a dominant nodule
    • 3. Follow-up examination of breast cancer treated by conservative surgery
    • 4. Follow-up of examinations of contralateral breast following mastectomy for CA
    • 5. Evaluation of the large fatty breast in the symptomatic patient
  • 7. Mammography
    • Findings suggestive of CA
    • 1. Presence of a mass with spiculated or irregular margins
    • 2. Presence of fine stippled calcification
  • 8. Mammography
    • NCI Recommendation
    • Age 50 & older
    • - Mammography every 1-2 year and
    • annual clinical BE
    • Age 40-49
    • - Screening mammography for those at
    • RISK
  • 9. Mammography
    • Prospective randomized studies of routine mammographic screening confirms:
    • 1. 40 % reduction for Stage II disease
    • 2. 30 % increase in survived in patient found
    • to have CA
  • 10. Ultrasound
    • Value:
    • 1. Resolution of equivocal mammography
    • 2. Diagnosis of cystic disease
    • 3. Demonstration of solid abnormalities with
    • specific echogenic features
  • 11.  
  • 12. Inflammatory and Infectious Disorders
    • Bacterial Infectious
    • 1. Acute Mastitis
    • - Puerperal or lactational mastitis
    • - Most common offending organisms: S.
    • aureus
    • - Infection tends to be localized &
    • suppurative
  • 13. Acute Mastitis Treatment
    • 1. Discontinuance of lactation to enable resolution of the inflammatory process
    • 2. Presuppurative - antibiotic
    • 3. Suppurative - Surgical drainage
  • 14. Chronic Mastitis
    • - Recurrent abscess formation
    • - Multiple skin sinus
    • - Simulate breast CA
    • - Most common offending organisms: TB bacilli
    • - Treatment:
    • 1. Biopsy to r/o CA
    • 2. Anti-koch’s regimen
  • 15. Benign Lesions
    • 1. Fibrocystic change/disorders
    • - Localized estrogen sensitivity
    • - Diffuse, often bilateral breast pain
    • - Pain accentuated just before menstruation
    • - Not a risk factor for breast CA
    • - May present as a single dominant cyst
  • 16. Fibrocystic Change/Disorders Treatment
    • 1. Analgesics
    • 2. Danazol/Tamoxifen- anti-estrogen: 60% cure rate
    • 3. Dominant cyst- aspiration
  • 17. Benign Lesions
    • 2. Fibroadenoma
    • - 2nd-3rd decade
    • - Relationship to estrogen sensitivity
    • - Well-defined, rubbery mass
    • - No premenstrual tenderness
    • - Stop growing when they reach 2-3 cms.
    • - No risk for malignancy
  • 18. Fibroadenoma Treatment :
    • 1. FNAB
    • 2. Observation <25 y/o
    • 3. Excision biopsy >25 y/o
  • 19. Benign Lesions
    • 3. Intraductal papilloma
    • - Most common cause of a bloody nipple discharge(70%)
    • - Located beneath the areola
    • - Usually solitary and <1 cm. In size
    • - Increased risk for CA for multiple papilloma
    • - Treatment: Excision
  • 20. Benign Lesions
    • 4. Fat Necrosis
    • - Usual history of trauma to the chest or breast
    • - Affects women with pendulous breast
    • - Mass and skin dimpling
    • - Mammography-Coarse calcification
    • - No risk for cancer
    • - Treatment: Excision
  • 21.  
  • 22. Ten Leading Sites of Cancer in Females, 1998, Philippines 25.9% 12.6% 7.4% 5.8% 5.7% 4.1% 3.9% 3.7% 2.9% 2.9%
  • 23. Ten Leading Sites of Cancer in Males in 1998, Philippines 26.7% 12.3% 6.4% 5.2% 4.9% 4.8% 4.6% 3.9% 3.6% 2.4%
  • 24. Ten Leading Sites of Cancer in 1998, Both Sexes, Philippines 15.6% 13.2% 7.3% 6.3% 4.4% 4.1% 3.6% 3.6% 3.1% 2.9%
  • 25. Breast Cancer
    • Etiology
    • 1. Family history
    • 2. High dietary fat intake
    • 3. Obesity
    • 4. Late menopause (> 45 y/o)
    • 5. Infertility & nulliparity
    • 6. History of primary breast CA
    • 7. Irradiation to chest
    • 8. Germs- Line mutations
    • 1.) BRCA 1 Chrom. 17q21
    • 2.) BRCA 2 Chrom. 13q12-13
    • 9. Certain breast diseases
    • a. Atypical hyperplasia
    • b. Lobular carcinoma in situ
    • c. Ductal carcinoma in situ
  • 26. Breast Cancer
    • Natural history
    • Untreated patients
    • 5 yr. SR- 18 %
    • 10 yr. SR- 3.6
    • Metastatic disease- most common cause of death
    • Affects the age group 45-65 y/o
    • 40-50 % are located in the upper outer quadrant
    • Hard, non-tender mass on presentation
    • Skin dimpling, nipple retraction, bloody nipple discharge, palpable axillary lymph nodes
  • 27. Breast Cancer
    • Axillary LN are involved progressively from Level I to Level II to Level III
    • Nodal status-most important prognostic correlate for recurrent disease & survival
    • - Number of positive of axillary lymph nodes and location of the positive axillary lymph node
  • 28. Breast Cancer
    • Sites of Distant Metastases
    • 1. Bone
    • 2. Lung
    • 3. Pleura
    • 4. Soft tissue
    • 5. Liver
  • 29. Breast Cancer Biopsy
    • 1. Palpable lesions
    • 1. Incisional bx
    • 2. Excisional bx
    • 3. Tru-cut biopsy
    • 4. Fine needle aspiration
    • 2. Non palpable lesions
    • - Localization followed by biopsy
  • 30. Stages are Defined by TNM Classification
    • Primary Tumor (T)
    • Tx Primary tumors cannot be assessed
    • To No evidence of primary tumors
    • TIS Carcinoma in situ
    • T1 Tumor 2 cm.or less is greatest dimension
    • T2 Tumor > 2 cm. but < 5 cm.
    • T3 Tumor > 5 cm.
    • T4 Tumor of any size with direct extension to chest wall of skin; includes inflammatory carcinoma
  • 31. TNM Staging
    • Regional lymph node (N)
    • Nx Regional lymph nodes cannot be assessed
    • N0 No regional lymph node metastasis
    • N1 Metastasis to movable ipsilateral axillary lymph node (s)
    • N2 Metastasis to ipsilateral axillary lymph nodes fixed to one another or to other structure
    • N3 Metastasis to ipsilateral internal mammary lymph nodes;
    • supraclavicular lymph node
  • 32. TNM Staging
    • Distant Metastases
    • Mx Presence of distant metastases cannot be assessed
    • M0 No distant metastases
    • M1 Distant metastases
  • 33. TNM Staging
    • Stage 0 Tis No Mo
    • Stage I T1 No Mo
    • Stage 2A To N1 Mo
    • T1 N1 Mo
    • T2 No Mo
    • 2B T2 N1 Mo
    • T3 No Mo
    • Stage 3A To N2 Mo
    • T1 N2 M1
    • T2 N2 Mo
    • T3 N1,N2 Mo
    • 3B T4 Any N Mo
    • 3C Any T N3 Mo
    • Stage IV Any T Any N M1
  • 34. Breast Cancer Histopathology
    • A. Non infiltrating (In Situ) Carcinoma of Ductal and Lobular Origin
    • 1.Lobular CA in Situ
        • observed only in females
        • > 90 % are premenopausal
        • 90 % ER positive
        • 25-35 % will develop breast CA
        • majority of future invasive CA are ductal
        • important features : multicentricity & bilaterality
  • 35.
    • 2. Ductal Carcinoma in Situ
    • - Among menopausal women
    • - 25-70% risk for invasive CA
    • - Future cancers are observed in the ipsilateral breast and in the same quadrant
    Breast Cancer Histopathology
  • 36.
    • B. Infiltrating Malignancies
    • 1. Paget’s Disease of the nipple
    • - Chronic eczematoid eruption of the nipple
    • - Good prognosis
    Breast Cancer Histopathology
  • 37.
    • 2. Infiltrating Ductal Carcinoma w/ productive
    • fibrosis
    • - Most common form of breast CA (75-80%)
    • - Affects the 40-60 years old age group
    • - Commonly presents as a solitary,
    • hard, non-tender, ill-defined mass
    • - Profound desmoplastic response- skin
    • dimpling
    • - Important feature is multicentricity
    Breast Cancer Histopathology
  • 38.
    • 3. Medullary carcinoma
    • - Soft, hemorrhagic bulky mass
    • - Better 5 yr. SR than invasive ductal or
    • lobular CA
    Breast Cancer Histopathology
  • 39.
    • 4. Mucinous Carcinoma (Colloid CA)
    • - Presents as a bulky, mucinous tumor
    • - Cut surface glistening & gelatinous
    Breast Cancer Histopathology
  • 40.
    • 5. Tubular Carcinoma
    • - Most differentiated variant of breast CA
    • - 100 % long term survival rate
    Breast Cancer Histopathology
  • 41.
    • 6. Papillary Carcinoma
    • - Lowest frequency of axillary nodal
    • involvement
    • - 5 & 10 yr. SR approaches Tubular CA
    Breast Cancer Histopathology
  • 42.
    • 7. Lobular Carcinoma
    • - originate from terminal ductules of the
    • lobule
    • - high propensity for bilaterality,
    • multicentricity & multifocality
    Breast Cancer Histopathology
  • 43.
    • 8. Inflammatory Carcinoma
    • - Carries the worst prognosis
    • - Features of erythema, peau d’ orange
    • & skin ridging w/ or w/o a palpable
    • mass
    • - Subdermal lymphatics and vascular
    • channels are permeated w/ foci of highly
    • undifferentiated tumor
    Breast Cancer Histopathology
  • 44. HVB
  • 45. Breast Cancer Treatment
    • Local Control
    • 1. Surgery
    • 2. Radiation
    • Systemic Control
    • 1. Chemotherapy
    • 2. Hormonal Therapy
  • 46. BREAST CANCER Historical Perspectives
    • Sir James Paget (1863)- Excision
    • Charles Moore (1876)- Total mastectomy + Axillary dissection
    • Richard van Volkman (1875)- Same a above + removal of the pectoral fabric
  • 47. BREAST CANCER Historical Perspectives
    • Halsted (1882)- Classical Radical Mastectomy
    • Removes:
    • 1. Whole breast
    • 2.Overlying skin
    • 3. Axillary LN
    • 4. Pectoralis muscles
    • - Gold standard for the next 50 years
  • 48. BREAST CANCER Historical Perspectives
    • Wangenstein & Urban (1956)-Super radical mastectomy
    • Includes:
    • 1. CRM
    • 2. Supraclavicular LN
    • 3. Int. mammary LN
    • 4. Mediastenal LN
    • 5. 1/2 of sternum and ribs 2-5
  • 49. BREAST CANCER Historical Perspectives
    • Patey and Madden (1965) - Modified Radical Mastectomy
    • Components:
    • 1. Total mastectomy
    • 2. Axillary LN dissection
  • 50. BREAST CANCER Historical Perspectives
    • Veronesi & Fischer (1980) - Conservative breast surgery
    • Components:
    • 1. Quadrantectomy/Lumpectomy
    • 2. Axillary sampling
    • 3. Radiation of the breast
  • 51. CONSERVATIVE BREAST SURGERY
    • SR
    • Study Stage Treatment No. 5 yr 10 yr
    • Milan 1 QUART 352 92 79
    • 1 Rad. Mast. 349 90 78
    • WHO 1 QUART 88 95
    • 1 MRM 91 91
    • NSABP I,II Lumpty/Rtx 625 83
    • I,II MRM 586 79
    • NCI I,II Lumpty/Rtx 112 88
    • I,II MRM 103 84
  • 52. Contraindications to Breast Conservative Surgery
    • 1. Tumor greater than 5 cm
    • 2. Poorly defined tumor
    • 3. Large tumor in a small breast
    • 4. Pregnancy’
    • 5. Previous irradiation in the same site
    • 6. Multiple tumors within the breast confirmed to be malignant
    • 7. Diffuse microcalcifications on mammography
    • 8. Tumor involves skin or chest wall
  • 53.  
  • 54. Breast Cancer Treatment
    • A. In Situ Disease
    • 1. LCIS-Lobular carcinoma in situ
    • - Marker for increased risk rather than
    • an inevitable precursor of invasive
    • disease
    • - Options:
    • 1. Observation
    • 2. Bilateral mastectomy
  • 55. Breast Cancer Treatment
    • 2. DCIS - Ductal carcinoma in situ
    • - Precursor of invasive disease
    • - Options:
    • 1. Total mastectomy - gold standard
    • 2. Conservative breast surgery -
    • (lumpectomy, quadrandectomy,
    • segmental mastectomy) & irradiation
  • 56. Breast Cancer Treatment
    • Stage I & Stage II
    • Options:
    • 1. Breast Conservative Surgery- (Lumpectomy/quadrandectomy /segmental mastectomy) w/ separate axillary node dissection and irradiation
    • 2. Modified radical mastectomy (Total mastectomy w/ axillary dissection)
  • 57. Breast Cancer Treatment
    • Stage 3 A
    • Options:
    • 1. Modified Radical Mastectomy
    • 2. Induction chemotherapy + MRM +
    • Radiation
  • 58. Induction Chemotherapy
    • - C hemotherapy given before the initiation of local therapy
    • - Also called neoadjuvant or preoperative chemotherapy
    • - Advantages:
    • 1. Reduction of the initial tumor burden before surgery
    • 2. Ability to treat the potential systemic disease w/o delay
    • 3. Ability to asses the response of the tumor to the treatment being rendered
  • 59. Breast Cancer Treatment
    • Stage 3 B - (LABC including Inflammatory CA)
    • Induction Chemotherapy
    • - Good response MRM Radiation
    • - Poor response Radiation MRM
  • 60. Breast Cancer Treatment
    • Stage IV
    • Radiation &/or
    • palliative (hygienic mastectomy ) + chemotherapy &/or hormonal therapy
  • 61. Breast Cancer Treatment
    • Adjuvant Therapy
    • A. Chemotherapy
    • B. Hormonal therapy
    • C. Radiation
  • 62. Chemotherapy
    • - Improves 5 yr. SR up to 30 %
    • Fischer - Thiotepa
    • - L- PAM
    • BONNADONA- CMF
    • - combination most commonly used
    • - 12 cycle in 6 months
    • SWOG - FAC/AC
    • - more effective than CMF but w/
    • more toxicity
  • 63. Hormonal Manipulation
    • 1. Ablation - Oophorectomy
    • - Adrenalectomy
    • - Hypophysectomy
    • 2. Additive - Parodoxical effects of high estrogen dosage
    • 3. Anti-estrogen –
    • - Tamoxifen
    • - Diethylstilbestrol
    • - Aminogluthetimide
    • - Aromatase inhibitors- Letrozole,
    • Anastrazole
  • 64. Hormonal Therapy
    • Tamoxifen
    • - Most common form of hormonal therapy
    • - Absence of toxicity and profound side effects
    • - Adverse effect- Less than 5%
    • 1. Endometrial CA
    • 2. Thromboembolic events
    • - Given at 20 mg. daily
    • - Duration: 5 years
  • 65. Hormonal Therapy
    • Hormonal Receptors
    • - Specific proteins in the cytosol of breast CA
    • - Estrogen and progesterone receptors
    • - ER and PR activity is a measure of hormonal responsiveness of the index tumor or metastatic foci of disease
    • - Degree of positivity is proportional to the differentiation and histologic subtype of the lesion
  • 66. Hormonal Therapy
    • Markers:
    • 1. Estrogen receptor
    • 2. Progesterone receptor Response rate
    • ER + 80%
    • PR +
    • ER + 27%
    • PR -
    • ER - 45%
    • PR +
    • ER - 10%
    • PR -
    > > > >
  • 67. Radiotherapy
    • 1. Component of conservative breast
    • surgery
    • 2. Stage III & IV
    • 3. Recurrent cancer
    • 1. Local-chest wall
    • 2. Distant-bone metastases
  • 68. Breast Cancer Adjuvant Therapy
    • Premenopausal Chemo tx
    • Node (+)
    • Postmenopausal Tamoxifen
    • ± Chemo tx
    • < 1 cm - No Tx
    • Chemotx
    • Node (-) Premen Tamoxifen
    • ER(+) Postmen Tamoxifen
    • > 1 cm
    • ER(-) Chemo tx
  • 69. Factors that Affect Prognosis and Selection of Therapy
    • 1. Age of the patient
    • 2. Stage of the disease
    • 3. Pathologic characteristics of the primary tumor
    • 4. ER & PR receptor level
    • 5. Measures of proliferative capacity
    • 1. Thymidine labelling index
    • 2. Ploidy pattern / S phase
    • 6. Menopausal status
    • 7.General health
  • 70.  
  • 71. Breast Cancer Follow-up
    • - 80 % recurrence w/in the first 5 years
    • - Evaluation should be individualized
    • - 65-85% of recurrences detected by history & PE
    • - Improved survival among breast cancer patients who later become pregnant
  • 72. Breast Cancer Follow-up
    • Recurrences:
    • 1. Local- 10-30 %
    • 2. Distant- 60-70 %
    • 3. Local & distant- 10-30 %
  • 73. Locally Recurrent Breast Cancer
    • A. Breast conservative surgery
    • - rarely associated with distant
    • metastases
    • - recurrence remains curable in the
    • majority of cases
    • - Treatment: Salvage MRM
    • - 60 - 70% 5 yr. disease free SR
  • 74. Locally Recurrent Breast CA
    • B. Modified Radical Mastectomy
    • - Frequently associated w/ distant
    • metastases
    • - Treatment: Surgical excision +
    • radiotherapy
    • - Median survival - 2-3 yrs.
  • 75. Metastatic Breast Cancer
    • - Generally cannot be cured
    • - Median survival - 2 yrs.
    • - Selection of initial treatment depends whether the patients tumor is hormonally sensitive or not
  • 76. Metastatic Breast Cancer
    • Metastatic breast cancer
    • ER (+) ER (-)
    • Unknown
    • Premenopausal Postmenopausal
    • Tamoxifen
    • Nonresponders Responders
    • 1. Oophorectomy
    • 2. DES, Progesterone
    • CHEMOTHERAPY
  • 77. Metastatic breast cancer
    • Results of Chemotherapy for metastases
    • - Favorable response in 2/3 of patients
    • - Complete response in 15 %
  • 78. Breast Cancer and Pregnancy
    • - Diagnosis typically more difficult
    • 1. Low level of suspicion- young age
    • 2. Nodular changes during pregnancy
    • 3. Inc. density makes mammography less accurate
    • - Diagnosis frequently delayed
    • - Poor prognosis
    • - When matched for tumor stage, pregnant women with breast cancer have the same prognosis as the non- pregnant patient
  • 79. Breast Cancer and Pregnancy
    • Treatment
    • - Treatment decisions are influenced by their timing w/ respect to the specific trimester of pregnancy
    • - Numerous studies have shown that terminations of pregnancy in hopes of minimizing hormonal stimulation of the tumor has shown no benefit to maternal survival
    • - Goal should be curative treatment of the breast cancer w/o injury to the fetus
  • 80. Breast Cancer & Pregnancy
    • Treatment
    • - Mod. Radical mastectomy can be undertaken at any point during pregnancy
    • - Breast conservative surgery complicated by the fact that radiotherapy is contraindicated during pregnancy. Option in the third trimester.
    • - Chemotherapy
    • 1. No risk during the 2nd and 3rd trimester
    • 2. During the Ist trimester asso. w/ an increased
    • evidence of spontaneous abortion & congenital
    • malformation
  • 81. Phylloides Tumor
    • - Present at a median age of 50
    • - Mammographically indistinguishable from fibroadenoma
    • - Treatment :
    • 1. Benign - Excision/total mastectomy
    • 2. Malignant - Total mastectomy
    • - no role for radiotherapy, hormonal
    • therapy & chemotherapy
  • 82. Carcinoma of the Male Breast
    • - Less than 1% of all breast cancer
    • - Peak evidence 60 - 69 years of age
    • - Tumor commonly ER (+)
    • - Stage for stage have the same survival rate as women
    • - Overall prognosis is poor because of the advanced stage of the disease at diagnosis
    • - Treatment:
    • l. Modified Radical Mastectomy
    • 2. Radiotherapy for ulcerative & high grade tumor
  • 83. http://crisbertcualteros.page.tl