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Management of carcinoma breast
 

Management of carcinoma breast

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    Management of carcinoma breast Management of carcinoma breast Presentation Transcript

    • Dr. Asghar H. Asghar, FCPS Oncologist, KIRAN, Karachi
    •  It is the most common cancer in female  Second leading cause of cancer death after CA lung  Worldwide incidence more than one million per year  90,000 in Pakistan  40,000 expire in Pakistan
    •  Age 20-29: 1 in 2,000  Age 30-39: 1 in 229  Age 40-49: 1 in 68  Age 50-59: 1 in 37  Age 60-69: 1 in 26  Ever: 1 in 8  Source: American Cancer Society Breast Cancer Facts & Figures, 2005-2006.
    •  Incidence in Asia is highest in Pakistan  In 70%, cause is unknown  Certain risk factors are there  Most of the cases are diagnosed in stage III and IV  People don’t want to consult doctors due to certain stigma
    •  Old Age  Early menarche  Late menopause  First child birth (>30 years)  Nulliparous  Personal history of breast cancer  Family history in 1st degree relatives  Post-menopausal HRT  Previous suspicious breast biopsy  Hereditary syndromes (BRCA-1 & 2)
    •  Familial  Fifty  Female  FattyAcids (saturated)  Fortune
    • stage 5-year survival rate 0 93% I 88% IIA 81% IIB 74% IIIA 67% IIIB 49% IIIC 41% IV 15%
    •  Clinical Evaluation – Lump and regional nodes  Imaging (ultrasound <35 years old or mammography >35 years old)  Cytology or Histology
    •  Clinical Evaluation – Lump and regional nodes  Imaging (ultrasound <35 years old or mammography >35 years old)  Cytology or Histology
    •  Best done a week after the period, when breasts are not tender or retaining fluid  Stand in front of a mirror with hands on hips  Look for signs of dimpling, swelling, soreness on palpation, or redness  Repeat this with arms over head
    •  Palpate breast in quadrants or in a circular motion  Repeat palpation exam when lying down  Check axillary tail of each breast for enlarged lymph glands  Check nipples and area just beneath to it  Gently squeeze nipples to detect any discharge
    •  Hard, irregular and painless  Malignant masses are painful in only 10- 15% of patients.  Skin dimpling  Nipple retraction  Bloody or watery discharge  Possibly fixed to the skin or chest wall
    •  X-ray of breast for detection of tumors too small to be palpated  First (baseline) between ages 35-40 years.  Annually after age 40.
    •  Highly sensitive test  Sensitivity is reduced in young women due to the presence of high glandular tissue
    • Mammographic Findings
    •  Differentiate solid vs cystic lesions  Sensitivity 75%  Specificity 97%
    • • Simple • Easy to perform • Cheap • Not time consuming • Negative FNAC doesn’t exclude cancer
    • • It is needed when FNAC is negative • Also simple • Done on OPD basis • No operation • Mild local anesthesia • More reliable than FNAC
    • ER Positive ER Negative Proportion of patient 75% 25% Mean age (Years) 63 57 <50 years 20% 35% ≥50Years 80% 65% >2 cm 29% 41% ≤2 cm 65% 50% Anderson WF et al. Breast Cancer Res Treat 2002; 76: 27–36
    •  Detailed clinical history  Thorough physical examination  Diagnostic workup  Treatment  Surgical  Chemotherapy  Radiotherapy  HormonalTherapy  TargetedTherapy
    •  Routine blood examination  CXR, USG abdomen or CT Chest and abdomen  FNAC, Core needle biopsy  Bone scan  ER/PR and HER-2 neu status  Ki-67, CA-15-3  Echocardiography/MUGA scan  p53, BRCA-1 and BRCA-2
    •  To cure the disease and improve the survival  Relief of symptoms  To minimize the risk of recurrence  Return to a quality of life as before diagnosis  To minimize cosmetic issues
    •  DCIS may never invade but long term data shows that 30-50% do invade in 10 years if left untreated .  Total Mastectomy (TM) or Lumpectomy (L) with or without radiation.  Radiotherapy should be considered for women with DCIS where conservation is desired.  Axillary lymph node dissection is not necessary in the management of most patients with DCIS.
    •  20-25% LCIS invade in 10-20 years.  Annual physical examination & annual bilateral mammography appears to be the best management option  Lumpectomy or total mastectomy with or without contra-lateral prophylactic mastectomy  Close follow-up in the key point
    •  Treatment depends on following factors:  Clinical extent  Pathological characteristics  Prognostic factors  Patient age (menopausal status)  Patients preference and the psychological profile
    •  Two surgical options:  Breast conservation Surgery (BCS)  Modified Radical Mastectomy (MRM).  MRM should be considered in:  Patient preference, no cosmetic problem.  Large tumor in small breast.  High risk for local recurrence.  Diffuse micro-calcification or multi-centric disease.  Unreliable for further follow0up.
    •  Pre-treatment ofTru-Cut biopsy  Tumor localization with surgical clips  Sentinel Lymph Node (SLN) biopsy for clinically negative axilla  Tru-cut or FNAC or SLN biopsy for clinically positive axilla
    •  If SLN negative before neoadjuvant: omit axillary clearance  If SLN positive before neoadjuvant: axillary clearance required  If SLN not done before neoadjuvant: axillary clearance required
    •  pCR (26%) was observed more in patients who completed Neoadjuvant chemotherapy (NSABP-27)  If neoadjuvant is not complete then will be completed in adjuvant setting  No role of further chemotherapy if completed neoadjuvant
    •  BCS rate higher after neoadjuvant  However, no disease specific survival advantage as compared to adjuvant chemotherapy in stage-II
    •  Both clinical and pathological response (26%) was higher in AC-T arm as compared to AC (14%) arm  Docetaxel was not superior to AC in DFS and OS
    •  Paclitaxel x4 F/B FECx4  Paclitaxel x 4 +Trastuzumab x 24 weekly F/B FEC x 4  No. of patients 42  All were treated in neoadjuvant setting  J Clin Oncol. 2005 Jun 1;23(16):3676-85. Epub 2005 Feb 28
    •  pCR more in favor ofTrastuzumab  26% vs 65%
    •  Many trials have been done in post- menopausal ER positive patients  Improved clinical response and higher rate of BCS in patients who used AIs as compared to SERMs  Letrozole and Anastrozole has superior results
    •  Pre-meno. Node +ve and ER –ve pts:  FAC, AC-T,TC, CMF for 4-6 months.  Pre-meno. Node +ve and ER +ve pts:  Chemo + HT (Goserline/Ovarian Ablation,Tamoxifen, Anastrazole)  Pre-meno. Node –ve & ER +ve pts:  Chemo + HT  Post-meno. Node +ve and ER -ve pts:  Chemo only. No HT  Post-meno. Node –ve & ER +ve pts:  Chemotherapy + HT
    •  Adjuvant online
    •  Mandatory in breast conservational surgery  Mandatory after MRM if >5 cm, node positive, close margin,
    •  It is indicated in the following:  Three or more metastatic lymph node.  Any lymph node > 2.5 cm  Involvement of apex of axilla  < 10 lymph node removed??  Gross extra-capsular tumor extension.
    •  If not giving chemo, then best to start within 4-6 weeks.  If chemo is being given then should be started within 4-6 weeks after completion of chemo.
    •  Arm or breast edema  Breast fibrosis  Painful mastitis or myositis  Pneumonitis.  Apical pulmonary fibrosis  Rib fracture (rare)
    •  Chemo, irradiation, surgery and hormonal therapy are the options  MRM is the best option for all resectable tumors.  Neoadjuvant chemotherapy with or without hormone therapy is also another good option.
    •  Lesion > 5 cm  Any skin, fascial or skeletal muscle involvement  Poorly differentiated tumors??  Positive or close surgical margins (<1 mm).  Lymphatic permeation, matted L.N or > 3 LN involved.  < 10 LN removed  Gross extracapsular tumor extension
    •  Increasing tumor size  Higher histological grade  Presence and number of lymph node metastases  Estrogen-receptor negative  Progesterone-receptor negative  HER-2-neu positive
    • Tamoxifen x 5 years ER(-)PR(-)ER(+) or PR(+) no further treatment surgery +/- radiation +/- chemotherapy Tamoxifen contraindicated and postmenopausal Adjuvant Treatment AIs x 5 years AIs x ? years High RiskLow Risk no further treatment
    •  Reduced the risk of recurrence annually by 39%  Reduces the risk of annual mortality by 31%  MA-17 trial showed the survival advantage with extended use of Letrozole (Femara) compared with placebo  Another good options inAIs now available is Aromasin (Exemestane)
    •  Mastectomy is the best option.  Irradiation to chest wall only ?  Due to low nodal metastasis, irradiation to axilla is not advocated.
    •  Our patient needs detailed counseling that surgery is not the only treatment  Surgery if done well in time will be the turning point for success  Multidisciplinary team approach is the key point in this management  Without this, we can say that our patient may not be receiving adequate treatment