Breast cancer
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Breast cancer

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Breast cancer Breast cancer Presentation Transcript

  • BREAST CANCERWorldwide incidence in females* Western Europe 67.4 Eastern Europe 36.0 Japan 28.6 Australia/ New Zealand 71.7 South Central Asia 21.2 Northern Africa 25.0ARGENTINA Southern Africa 31.5 Central America 25.5 North America 86.3 *Incidence per 100,000 population. Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
  • NEOPLASIA DE MAMA 2011 1.1 MILLONES DE CASOS NUEVOS DIAGNOSTICADOS/AÑO 10 % DE TODOS LOS NUEVOS CA EN EL MUNDO 410.000 DEFUNCIONES ANUALES REPRESENTAN EL 1,6 % DE TODAS LAS DEFUNCIONES ANUALES DE MUJERES. ES UN PROBLEMA DE SALUD URGENTE EN REGIONES DE ALTOS RECURSOS Y ESTA AUMENTANDO EN LAS REGIONES DE BAJOS RECURSOS HASTA EN UN 5 %. (OMS) A PESAR DEL AUMENTO DE CASOS DIAGNOSTICADOS, EL NUMERO DE MUERTES ES MENOR GRACIAS A DETECCION TEMPRANA Y MEJORAS EN LOS TRATAMIENTOS.
  • BREAST CANCER5-year relative survival rates by race 87 98 White 78 23 All Stages Localized 71 Regional African 89 Distant American 62 14 0 20 40 60 80 100 120 % Surviving 5 Years Landis SH, et al. CA Cancer J Clin. 1999;49:8-31.
  • BREAST CANCERNatural history  Highly variable in different patients  Relatively slow growth rate  Median survival without treatment: 2.8 yrs  Generally present several years by time of diagnosis  Long preclinical period enables early detection Henderson IC. American Cancer Society Textbook of Clinical Oncology. 1995;198-219.
  • BREAST CANCERRisk factors  Age  Family history of breast cancer  Prior personal history of breast cancer  Increased estrogen exposure – Early menarche – Late menopause – Hormone replacement therapy/oral contraceptives  Nulliparity  1st pregnancy after age 30  Diet and lifestyle (obesity, excessive alcohol consumption)  Radiation exposure before age 40  Prior benign or premalignant breast changes – In situ cancer – Atypical hyperplasia – Radial scar Henderson IC. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;198-219. Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616. Trichopoulos D, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;231-257.
  • BREAST CANCERScreening Breast self-examination Examination Mammography—the by physician only modality shown to decrease mortality
  • BREAST CANCERBreast inspection Skin dimpling
  • BREAST CANCERBreast palpation
  • BREAST CANCERRegional node assessment
  • BREAST CANCERGoals of mammography screening  Earlier diagnosis in asymptomatic individuals  Reduction of mortality due to detection at earlier stage Age Mortality Reduction (%) 40-49 17% 15 years post-screening 50-69 25%-30% 10-12 years post-screening 70+ Insufficient data PDQ: Screening for breast cancer for health professionals: http://Cancernetnci.nih.gov/. Accessed November 28, 1999.
  • BREAST CANCERScreening (high-risk)  Annual mammogram, beginning 5 yrs before age of youngest affected relative at time of diagnosis – High familial risk – BRCA 1/2-positive Tripathy D, Henderson IC. Current Cancer Therapeutics. 3rd ed. 1999;123-129.
  • BREAST CANCERScreening mammography  Reduces mortality by 26% in women aged 50-74  Supports view that early diagnosis and treatment can prevent metastasis  ACS recommends – 1st screening mammography by age 40 – Mammography every 1 to 2 years between the ages of 40 and 49 – Mammography annually thereafter Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616. Fink DJ, Mettlin CJ. American Cancer Society Textbook of Clinical Oncology. 2nd ed. 1995;128-193.
  • BREAST CANCERSigns and symptoms at presentation  Mass or pain in the axilla  Palpable mass  Thickening  Pain  Nipple discharge  Nipple retraction  Edema or erythema of the skin
  • BREAST CANCERAnatomical site SUPERO EXTERNO Upper innerUpper outer NippleAxillary tail Central portion Lower innerLower outer RIGHT
  • BREAST CANCER
  • BREAST CANCERMammography
  • BREAST CANCERUltrasonography
  • BREAST CANCERLiver metastasis
  • BREAST CANCERMRI scan
  • CÁNCER DE MAMAFACTORES A TENER EN CUENTA AL DIAGNOSTICO INICIAL:• EDAD• ESTADO HORMONAL (PRE/POST)• DIAMETRO TUMORAL (T)• ESTADO GANGLIONAR (N)• DETERMINACION DE RECEPTORES HORMONALES• DETERMINACION DE HER 2• GRADO HISTOLOGICO/PERMEACION VASCULAR• PS
  • BREAST CANCERBiopsy techniques for palpable andmammographically detected masses  Excisional biopsy (usually outpatient) – Tumor size and histologic diagnosis  Core-cutting needle biopsy (in-office) – Histologic diagnosis  Fine-needle aspiration (in-office) – Cytologic diagnosis Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
  • BREAST CANCERPathology  Non-invasive carcinoma in situ – Ductal carcinoma in situ (DCIS) – Lobular carcinoma in situ (LCIS)  Invasive carcinoma – Infiltrating ductal or lobular carcinoma – Medullary, mucinous, and tubular carcinomas  Uncommon tumors – Inflammatory carcinoma – Paget’s disease Dollinger M, et al. Everyone’s Guide to Cancer Therapy. 1997;356-384.
  • BREAST CANCERPathology: Non-invasive DCIS & LCIS DCIS LCIS Abnormal mammogram Microscopic characterization on biopsy Clustered microcalcifications Solid proliferation of small or non-palpable masses cells with uniform round to oval nuclei 30% risk of invasive cancer 37% chance of subsequent at 10 years at or near invasive cancer original biopsy site DCIS – ductal carcinoma in situ. LCIS – lobular carcinoma in situ. Harris J, et al. Cancer: Principles & Practice of Chemotherapy. 5th ed. 1997;1557-1616. Love S, Barsky SH. Cancer Treatment. 4th ed. 1995;337-340.
  • BREAST CANCERIncidence of major histologic types Percent of all invasive carcinomas 80% 10% 5% Infiltrating Lobular Medullary Hendersn IC. American Cancer Society Textbook & Clinical Oncology. 1995;198-219.
  • BREAST CANCERInvasive ductal carcinoma
  • BREAST CANCERSpread to lymph nodes Supraclavicular Subclavicular Mediastinal Distal (upper) axillary Internal mammary Central (middle) axillary Interpectoral (Rotter’s) Proximal (lower) axillary
  • BREAST CANCERSites of distantmetastases Brain Lymph nodes Pleura Skin Lung Liver Bone
  • BREAST CANCERTNM stage grouping Stage 0 Tis N0 M0 Stage I T1* N0 M0 Stage IIA T0 N1 M0 T1* N1** M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0, T1,* T2 N2 M0 T3 N1, N2 M0 Stage IIIB T4 Any N M0 Any T N3 M0 Stage IV Any T Any N M1 * Note: T1 includes T1 mic. ** Note: The prognosis of patients with N1a is similar to that of patients with pN0. Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
  • BREAST CANCERTumor definitions TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor T1 Tumor 2 cm or less in greatest dimension T1mic Microinvasion more than 0.1 cm or less in greatest dimension T1a Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimension T1b Tumor more than 0.5 cm but not more than 1 cm in greatest dimension T1c Tumor more than 1 cm but not more than 2 cm in greatest dimension T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension T3 Tumor more than 5 cm in greatest dimension T4 Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below T4a Extension to chest wall T4b Edema (including peau d’orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast T4c Both (T4a and T4b) T4d Inflammatory carcinoma Used with the permission of the American Joint Committee on Cancer (AJCC®), Chicago, Illinois. The original source for this material is the AJCC® Cancer Staging Manual, 5th edition (1997) published by Lippincott-Raven Publishers, Philadelphia, Pennsylvania.
  • BREAST CANCERStage I T1 N0 M0 T1a: T 0.5 cm T1b: 0.5 cm < T 1 cm T1c: 1 cm < T 2 cm T1 T 2 cm N0 = no regional lymph node metastasis M0 = no distant metastasis
  • BREAST CANCER Stage IIA T0 T1 } N1 M0 T2 N0 M0T0 No evidence T2 of tumor 2 cm < T < 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) M0 = no distant metastasis
  • BREAST CANCERStage IIBT2 N1 M0 T3 N0 M0 T3 T > 5 cm N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b M0 = no distant metastasis
  • BREAST CANCERStage IIIA T0 T1 N2 M0T3 N1 M0 T2 T3 Metastasis to ipsilateral axillary lymph node(s) N1 = movable N2 = fixed to one another or to other structures M0 = no distant metastasis
  • BREAST CANCER Stage IIIB T4 any N M0 Any T N3 M0 T4Tumor of any sizewith direct extensionto chest wall or skinT4d = inflammatorycarcinoma N3 = metastasis to ipsilateral internal mammary lymph node(s) M0 = no distant metastasis
  • BREAST CANCERStage IV Any T any N M1 M1 = distant metastasis (including metastases to ipsilateral supraclavicular, cervical, or contralateral internal mammary lymph nodes)
  • BREAST CANCER5-year survival as function of the numberof positive axillary lymph nodes 80% 60% 5-Year Survival 40% 20% 0% 0 1 2 3 4 5 6-10 11-15 16-20 >20 Number of Positive Nodes Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1557-1616.
  • CÁNCER DE MAMAMOMENTOS PARA TRATAMIENTODIAGNOSTICO: INICIAL METASTASICO PROGRESION RECAIDO RECURRENTETRATAMIENTO: “MEDICINA BASADA EN LA EVIDENCIA”
  • CÁNCER DE MAMAFACTORES A TENER EN CUENTA AL DIAGNOSTICO INICIAL:• EDAD• ESTADO HORMONAL (PRE/POST)• DIAMETRO TUMORAL (T)• ESTADO GANGLIONAR (N)• DETERMINACION DE RECEPTORES HORMONALES• DETERMINACION DE HER 2• GRADO HISTOLOGICO/PERMEACION VASCULAR• PS
  • NEOPLASIA DE MAMA 2011NORMAS DE LA OMS1)DETECCION TEMPRANA Y ACCESO A LA ATENCION2)DIAGNOSTICO Y PATOLOGIA3)TRATAMIENTO Y ASIGNACION DE RECURSOS4)SISTEMAS DE ATENCION DE SALUD Y POLITICAPUBLICA.PILARES DEL TRATAMIENTOCIRUGIA RADIOTERAPIA QUIMOTERAPIA MEDICINA PALIATIVA INVESTIGACION CLINICA!!
  • HORMONOTERAPIAMODULADORES SELECTIVOS DE RECEPTORDE ESTROGENO: TAMOXIFENO TAROMIFENOABLACION OVARICA: ANALOGOS LHR GOSERELIN/LEUPROLIDE OOFORECTOMIAPROGESTAGENOS: ACETATO DE MEGESTROL ACETATO DE MEDROXIPROGESTERONA
  • HORMONOTERAPIAINHIBIDORES DE AROMATASAS: ANASTRAZOL LETROZOL EXAMESTANEANTIESTROGENOS PUROS (ER DOWN REGULATORS): FULVESTRANT
  • ONCOLOGYCancer biologyTumor growth and detection 1012 cancer cells Number of 109 Diagnostic threshold (1cm) time Undetectable Detectable cancer cancer Limit of Host clinical death detection
  • ONCOLOGYPrinciples of chemotherapyAction sites of cytotoxic agents Antibiotics Antimetabolites S (2-6h) G2 (2-32h) Vinca alkaloids M Mitotic inhibitors (0.5-2h) Taxoids Alkylating agents G1 Cell cycle level (2- h) G0
  • ONCOLOGYPrinciples of chemotherapyAction sites of cytotoxic agents DNA synthesis Antimetabolites DNA Alkylating agents DNA transcription DNA duplication Mitosis Intercalating agents Cellular level Spindle poisons
  • QUIMIOTERAPIAANTRACICLINAS: DOXORRUBICINA EPIRRUBICINA MITOXANTROMA DOXORRUBICINA LIPOSOMALAGENTES ALQUILANTES: CICLOFOSFAMIDA
  • QUIMIOTERAPIAALCALOIDES DE LA VINKA: VINORELBINE (EV/VIA ORAL)TAXANOS: PACLITAXEL DOCETAXELEPOTILONAS: IXABEPILONA
  • QUIMIOTERAPIAOTROS: 5 FLUORURACILO CAPECITABINE METOTREXATO GEMCITABINE
  • ONCOLOGYPrinciples of chemotherapyAim of combination therapy INCREASED EFFICACY ACTIVITY SAFETY Different mechanisms of action Compatible side effects Different mechanisms of resistance
  • ONCOLOGYPrinciples of chemotherapySide effects of chemotherapy Alopecia Mucositis Pulmonary fibrosis Nausea/vomiting Cardiotoxicity Diarrhea Cystitis Local reaction Sterility Renal failure Myalgia Myelosuppression Neuropathy Phlebitis
  • TOXICIDAD: * NEUTROPENIA (PANCITOPENIA) * NEUTROPENIA FEBRIL * ALOPECIA * NAUSEAS Y VOMITOS * REACCIONES HIPERSENSIBILIDAD * NEUROTOXICIDAD * NEFROTOXICIDAD * CARDIOTOXICIDAD * PIEL Y FANERAS * NEUMONITIS INTERSTICIAL * DIARREA * RETENCION DE LIQUIDO * ASTENIA / ANOREXIA
  • COMPLICACIONES DE LA RADIOTERAPIA I
  • COMPLICACIONES DE LA RADIOTERAPIA II RESOLUCION
  • THE END MUCHAS GRACIAS.