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Ca breast
 

Ca breast

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RADIOTHERAPY

RADIOTHERAPY

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    Ca breast Ca breast Presentation Transcript

    • Carcinoma Breast Epidemiology, diagnosis and management Overview
      • Statistics
      • Most common Ca in women in developed countries. The lifetime risk (upto age 85)
      • 1940 - 5% - one in 20;
      • 2000- 12.6% - one in 8 .
      • Incidence India- 80,000 per year, worldwide incidence 1.2 million (WHO)
      • Death – 2 nd leading cause of cancer death. 40,000 in US per year, worldwide much higher
      • Age specific incidence- steep increase after 35 yrs, max at 75-80 yrs.
      • High incidence among Caucasians; less common among Asians
      • Increasing frequency; steep increase in 80s with mammo; marginal fall over the last few years.
      • Etiology
      • Hereditary (10% of pts have 1 st deg relatives)
      • Genetic mutations- BRCA 1, 2
      • Radiation- esp. during childhood- mantle RT upto 20% incidence by 50 y.
      • Benign disease- proliferative, with atypia
      • Previous h/o breast ca
      • Diet- obesity; dietary fat, anti-ox.- inconclusive.
      • Hormonal factors- increased risk with excess exposure to estrogens; Progesterone containing OCPs
    • Risk factors
      • High risk-
      • Age, previous history of breast Ca, family history, atypical hyperplasia, Nulliparous women, radiation
      • Low risk- Menstrual history, estrogens, DM, alcohol.
      • Early pregnancy, Asian race, early menopause reduce the risk.
    • Risk factor models
      • Gail model: ( www.nci.nih.gov ) Uses the following criteria: -current age -age at menarche -age at first child birth -no. of first degree relatives with breast ca -no. of previous benign biopsies -atypical hyperplasia in a prev. biopsy -race
    • Pathology
      • In-situ Carcinomas- DCIS, LCIS; Paget’s disease of nipple
      • Invasive Cas- Invasive Ductal Ca (80%) Invasive lobular Ca (10%) Other invasive Cas- Medullary, papillary, tubular, cribriform, metaplastic, squamous, adenoid cystic, mucinous, secretory, undifferentiated.
    • DCIS
      • Without e/o invasion
      • Progresses to invasive if untreated
      • Usual diagnosis by mammo (asymptomatic)
      • Histologically- Comedo vs Non- Comedo (papillary, cribriform, micropapillary, solid)
      • Treatment= excision with negative margins, then RT; Tamoxifen
      • Prognosis- 95 + % cure rates
    •  
    • Paget’s disease
    •  
    • LCIS
      • Commonly B/L, multifocal
      • Diagnosis by biopsy; incidental
      • Increased risk of malignancy- 1%/year, reaching 17-20% life long risk
      • No treatment required -follow up with CBE, annual mammo;
      • tamoxifen/raloxifene decrease risk of Ca.
    • Other pathologic characteristics
      • Grade ( modified SBR)
      • Estrogen, Progesterone receptor
      • Her2/neu expression
      • Other markers- S- phase Ki-67 DNA ploidy
      Her 2 amplification by FISH Estrogen receptor +vity by IHC
    • Spread of breast cancer
      • Modes of Spread
      • Direct invasion- into chest muscles, wall, skin/nipple-areola.
      • Lymphatic- Locoregional - axilla, supraclavicular, infraclavicular and Internal mammary
      • Blood- Bones, lungs, liver, brain– Distant metastasis- stage IV
      • Clinical symptoms-
      • L ocal- Lump, discharge, skin/nipple changes, axillary, arm swelling, ulcer
      • Pain, tenderness- Inflammatory Ca
      • Distant- back ache, cough, breathlessness, headache, vomiting, anorexia, etc.
      • O/E – lump-hard, irregular , nipple retraction, peau de orange/puckering.
      • Nipple discharge, axillary nodes
    •  
    •  
      • Diagnosis
      • FNAC/biopsy of the lump/gland- histology and receptor status studies
      • Her 2 /neu, DNA ploidy, S phase # - prognostic indicator studies
      • Evaluation- CBC, RFT, LFT, ALP, S. Ca++, Cardiac evaluation, mammography
      • Metastatic work up- CXR, USG A+P, Bone scan, ? PET. CT thorax, brain- only if symptoms suggestive .
      • Breast cancer screening
      • Women who undergo breast cancer screening mammograms have demonstrated significantly reduced deaths from the disease due to early detection and treatment.
      • SCREENING METHODS
      • Breast self examination ( BSE )
      • Clinical breast examination - by physicians
      • Mammograms
      • Ductal Lavage – investigational
      • Others– Breast Scintigraphy, USG, or MRI
      •  
      • Mammography
      • An X-ray photograph of the breast
      • The technique has been in use for about thirty years
      • Safe and highly accurate
      • Low kV (25-30 kV), high mA (25-100)
      • Combined with sonography
      • Probably the most important tool doctors have
      • To diagnose
      • To evaluate
      • To follow women who've had breast cancer.
    •  
      • Identifies breast cancers too small to palpate on physical examination- 0.5 cm
      • (classified as T 1 lesion, with high curability)
      • Different types of calcifications within the breast tissue are visualized, which may be or may not be cancerous.
      • Reported as a BI-RADS category ( 1 to 5; 5= highly suspicious; 0- incomplete, 6- proven Ca).
      •  
    •  
    •  
        • All women 50+ (?40+) should get the benefit of annual mammograms and CBEs. Sonography might be added.
        • With serial mammograms it is possible to detect earliest lesions
        • Mammograms can save lives as most of the early breast cancers are curable
    • Staging
      • TNM – clinical & pathological
      • T stage - T1- < 2 cms in size T2- 2-5 cms T3- >5 cms T4- with chest wall (4a), skin (4b), both (4c), or inflammatory ca (4d)
      • N stage (clinical) N1- ipsilateral movable axillary nodes N2- ipsilateral matted/fixed nodes; clinically apparent ipsilateral IMNs in absence of axillary nodes N3- ipsilateral infraclavicular, clinically apparent ipsilateral IMNs in presence of axillary nodes, ipsilateral supraclavicular nodes
      • Stage grouping
      • I T1N0M0
      • IIA T2N0M0, T1N1M0
      • IIB T3N0M0, T2N1M0
      • IIIA T3N1-2M0, T2N2M0
      • IIIB T4N0-2M0
      • IIIC anyTN3M0
      • IV anyTanyNM1
    • Treatment
      • Depends on: Stage Hormone receptor status Her2/neu receptor status Age
      • Early stage (EBC)
      • Locally advanced (LABC)
      • Metastatic disease
    • Treatment modalities- Sx
      • BCS vs MRM
      • Contraindications to BCS- 1. multifocal disease 2. extensive microcalcifications 3. unable to get negative margins 4. prior RT 5. Pt preference Relative- CVDs, large tumors, large breasts, pregnancy,
      • Role of Sentinel l. n. biopsy-
    • Treatment modalities- ChemoRx
      • Required for most patients.
      • Curative: Neoadjuvant or adjuvant; Combination chemo- Anthracycline based; Paclitaxel added for high risk cases; 6-8 cycles (4 months)
      • Palliative: single or combination chemo
    • Treatment modalities- RT
      • Definitive : usually adjuvant;
      • Must after BCS, in mastectomy patients with high risk of Local recurrence (large tumors, >4 axillary l.n. +, positive margins, etc)
      • 45-50 Gy to whole breast/chest wall; followed by boost to the tumor bed (in BCS) to 10-16 Gy
      • +/- RT to axillary, Supraclavicular l.n.
      • Palliative : for specific symptoms- bone mets, brain mets, etc.
    • Treatment modalities- HT
      • Only in Hormone Receptor +ve cases
      • SERMS- Tamoxifen, Raloxifene
      • Aromatase inhibitors- Letrozole, anastrazole, exemestane
      • GnRH analogues- leuprolide, goserelin
    • Treatment modalities- MAb
      • Trastuzumab- monoclonal antibody against Her2/neu receptor; used in Her2/neu positive cases only
      • Lapatinib (T K I)
    • Early breast cancer (EBC)
      • Breast conservation(lumpectomy/wide excision) with axillary clearance or MRM
      • Followed by adjuvant RT + Chemotherapy +/- Hormonal therapy
    • Locally advanced breast cancer (LABC)
      • Large tumors, Difficult to get clearance,
      • Patient wishes to conserve the breast
      • Neo adjuvant/upfront chemotherapy followed by reassessment and surgery + Adjuvant RT + Chemotherapy +/- Hormones
    • Metastatic Ca breast at presentation
      • Palliative treatment
      • 1. Chemotherapy- single or combination chemo
      • 2. Surgery – Toilet mastectomy only if fungating/ulcerative/painful lump
      • 3. Radiation- In Bone and brain metastasis- for symptomatic relief of pain/ raised ICP
      • 4. Hormonal- for HR +ve cases, with oligometastases with no requisite for immediate response
      • 5. Supportive treatment
      • Commonly used chemo drugs
      • Adriamycin
      • Cyclophosphamide
      • Paclitaxel
      • Docetaxol
      • Capecitabine
      • 5 Fluro uracil
      • Methotrexate
      • Prognosis-
      • 1. Stage - nodal status, number of nodes
      • 2. ER/PR receptor status 3. Her 2/neu receptor status 4. other histological features: Grade, size, presence of LVSI, S phase, DNA ploidy 5. Site of mets- Bone vs other sites, size of mets, etc.
      • Survival
      • I stage – 85-90%
      • II stage - 65-70 %
      • III stage - 35 %
      • IV stage- 10 %
    •  
    • THANK YOU