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 t...
 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 ...
 Incidence in Asia is highest in Pakistan
 In 70%, cause is unknown
 Certain risk factors are there
 Most of the cases...
 Old Age
 Early menarche
 Late menopause
 First child birth (>30
years)
 Nulliparous
 Personal history of
breast can...
 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)
 Cytolo...
 Clinical Evaluation – Lump and regional
nodes
 Imaging (ultrasound <35 years old or
mammography >35 years old)
 Cytolo...
 Best done a week after the period, when
breasts are not tender or retaining fluid
 Stand in front of a mirror with hand...
 Palpate breast in quadrants or in a circular
motion
 Repeat palpation exam when lying down
 Check axillary tail of eac...
 Hard, irregular and painless
 Malignant masses are painful in only 10-
15% of patients.
 Skin dimpling
 Nipple retrac...
 X-ray of breast for detection of tumors
too small to be palpated
 First (baseline) between ages 35-40 years.
 Annually...
 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 relia...
ER Positive ER Negative
Proportion of
patient
75% 25%
Mean age (Years) 63 57
<50 years 20% 35%
≥50Years 80% 65%
>2 cm 29% ...
 Detailed clinical history
 Thorough physical examination
 Diagnostic workup
 Treatment
 Surgical
 Chemotherapy
 Ra...
 Routine blood examination
 CXR, USG abdomen or CT Chest and abdomen
 FNAC, Core needle biopsy
 Bone scan
 ER/PR and ...
 To cure the disease and improve the survival
 Relief of symptoms
 To minimize the risk of recurrence
 Return to a qua...
 DCIS may never invade but long term data shows
that 30-50% do invade in 10 years if left untreated .
 Total Mastectomy ...
 20-25% LCIS invade in 10-20 years.
 Annual physical examination & annual
bilateral mammography appears to be the
best m...
 Treatment depends on following factors:
 Clinical extent
 Pathological characteristics
 Prognostic factors
 Patient ...
 Two surgical options:
 Breast conservation Surgery (BCS)
 Modified Radical Mastectomy (MRM).
 MRM should be considere...
 Pre-treatment ofTru-Cut biopsy
 Tumor localization with surgical clips
 Sentinel Lymph Node (SLN) biopsy for
clinicall...
 If SLN negative before neoadjuvant: omit
axillary clearance
 If SLN positive before neoadjuvant: axillary
clearance req...
 pCR (26%) was observed more in patients
who completed Neoadjuvant chemotherapy
(NSABP-27)
 If neoadjuvant is not comple...
 BCS rate higher after neoadjuvant
 However, no disease specific survival
advantage as compared to adjuvant
chemotherapy...
 Both clinical and pathological response (26%)
was higher in AC-T arm as compared to AC
(14%) arm
 Docetaxel was not sup...
 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...
 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 ...
 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...
 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...
 If not giving chemo, then best to start within
4-6 weeks.
 If chemo is being given then should be
started within 4-6 we...
 Arm or breast edema
 Breast fibrosis
 Painful mastitis or myositis
 Pneumonitis.
 Apical pulmonary fibrosis
 Rib fr...
 Chemo, irradiation, surgery and hormonal
therapy are the options
 MRM is the best option for all resectable
tumors.
 N...
 Lesion > 5 cm
 Any skin, fascial or skeletal muscle involvement
 Poorly differentiated tumors??
 Positive or close su...
 Increasing tumor size
 Higher histological grade
 Presence and number of lymph node
metastases
 Estrogen-receptor neg...
Tamoxifen
x 5 years
ER(-)PR(-)ER(+) or PR(+)
no further
treatment
surgery +/- radiation +/- chemotherapy
Tamoxifen
contrai...
 Reduced the risk of recurrence annually by
39%
 Reduces the risk of annual mortality by 31%
 MA-17 trial showed the su...
 Mastectomy is the best option.
 Irradiation to chest wall only ?
 Due to low nodal metastasis, irradiation to
axilla i...
 Our patient needs detailed counseling that
surgery is not the only treatment
 Surgery if done well in time will be the
...
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
Management of carcinoma breast
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Management of carcinoma breast

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Management of carcinoma breast

  1. 1. Dr. Asghar H. Asghar, FCPS Oncologist, KIRAN, Karachi
  2. 2.  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
  3. 3.  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.
  4. 4.  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
  5. 5.  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)
  6. 6.  Familial  Fifty  Female  FattyAcids (saturated)  Fortune
  7. 7. stage 5-year survival rate 0 93% I 88% IIA 81% IIB 74% IIIA 67% IIIB 49% IIIC 41% IV 15%
  8. 8.  Clinical Evaluation – Lump and regional nodes  Imaging (ultrasound <35 years old or mammography >35 years old)  Cytology or Histology
  9. 9.  Clinical Evaluation – Lump and regional nodes  Imaging (ultrasound <35 years old or mammography >35 years old)  Cytology or Histology
  10. 10.  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
  11. 11.  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
  12. 12.  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
  13. 13.  X-ray of breast for detection of tumors too small to be palpated  First (baseline) between ages 35-40 years.  Annually after age 40.
  14. 14.  Highly sensitive test  Sensitivity is reduced in young women due to the presence of high glandular tissue
  15. 15. Mammographic Findings
  16. 16.  Differentiate solid vs cystic lesions  Sensitivity 75%  Specificity 97%
  17. 17. • Simple • Easy to perform • Cheap • Not time consuming • Negative FNAC doesn’t exclude cancer
  18. 18. • It is needed when FNAC is negative • Also simple • Done on OPD basis • No operation • Mild local anesthesia • More reliable than FNAC
  19. 19. 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
  20. 20.  Detailed clinical history  Thorough physical examination  Diagnostic workup  Treatment  Surgical  Chemotherapy  Radiotherapy  HormonalTherapy  TargetedTherapy
  21. 21.  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
  22. 22.  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
  23. 23.  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.
  24. 24.  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
  25. 25.  Treatment depends on following factors:  Clinical extent  Pathological characteristics  Prognostic factors  Patient age (menopausal status)  Patients preference and the psychological profile
  26. 26.  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.
  27. 27.  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
  28. 28.  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
  29. 29.  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
  30. 30.  BCS rate higher after neoadjuvant  However, no disease specific survival advantage as compared to adjuvant chemotherapy in stage-II
  31. 31.  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
  32. 32.  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
  33. 33.  pCR more in favor ofTrastuzumab  26% vs 65%
  34. 34.  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
  35. 35.  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
  36. 36.  Adjuvant online
  37. 37.  Mandatory in breast conservational surgery  Mandatory after MRM if >5 cm, node positive, close margin,
  38. 38.  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.
  39. 39.  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.
  40. 40.  Arm or breast edema  Breast fibrosis  Painful mastitis or myositis  Pneumonitis.  Apical pulmonary fibrosis  Rib fracture (rare)
  41. 41.  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.
  42. 42.  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
  43. 43.  Increasing tumor size  Higher histological grade  Presence and number of lymph node metastases  Estrogen-receptor negative  Progesterone-receptor negative  HER-2-neu positive
  44. 44. 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
  45. 45.  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)
  46. 46.  Mastectomy is the best option.  Irradiation to chest wall only ?  Due to low nodal metastasis, irradiation to axilla is not advocated.
  47. 47.  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

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