carcinoma of breast


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Dr Sajid's presantation

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carcinoma of breast

  1. 2. Breast carcinoma By Dr:Sajid Ali Abbasi Topic Presentation
  2. 3. <ul><li>Modified sweat gland </li></ul><ul><li>Greater part of gland lies in sup: fascia </li></ul><ul><li>Small part pierces deep fascia i.e. axillary tail </li></ul><ul><li>It has protuberant part & axillary tail </li></ul><ul><li>Protuberant part extends vertically from 2 nd -6 th ribs & Horizontally from lat:border of sternum to midaxillary line </li></ul><ul><li>Thin layer of Mammary tissue extends from clavicle above to 7 th – 8 th rib below and from midline to the edge of L.D post: </li></ul><ul><li>Axillary tail can be seen pre-menstrualy or during lactation. </li></ul>Anatomy
  3. 5. <ul><li>Parenchyma of breast consist of 15 to 20 lobes </li></ul><ul><li>Each lobe is made up of 20-40 lobules </li></ul><ul><li>Lobules are basic structural units of mammary glands </li></ul><ul><li>consist of variable number of </li></ul><ul><li>alveoli </li></ul><ul><li>1O to over 1OO lobules empty into lactiferous duct. </li></ul><ul><li>Each lactiferous duct is provided just prior to its termination a dilated ampulla i.e. reservoir for milk or abn: discharge </li></ul>Lobes and ducts
  4. 6. <ul><li>Breast is supported and attached to chest wall by these ligaments </li></ul><ul><li>Hollow conical projections </li></ul><ul><li>Account for the dimpling of the skin overlying carcinoma </li></ul>Ligaments of Cooper
  5. 7. <ul><li>Pigmented circular area that surrounds base of nipple </li></ul><ul><li>Contains involuntary muscles </li></ul><ul><li>Areolar epithelium contains numerous sweat & sebaceous glands </li></ul><ul><li>Sebaceous glands enlarge during pregnancy & serve to lubricate nipple during lactation. </li></ul>Areola
  6. 8. <ul><li>Erectile structure which points outward </li></ul><ul><li>Covered by thick skin with corrugations </li></ul><ul><li>Near its apex lie the orifices of lactiferous ducts </li></ul><ul><li>Nipple contains smooth muscle fibers arranged concentrically and longitudinally </li></ul>Nipple
  7. 10. <ul><li>Med: by memory branch of int:thoracic artery </li></ul><ul><li>Ant:by intercostal branch of int:thoracic artery </li></ul><ul><li>Lat:by mammary br of lat thoracic +lat br of 2-5 post:intercostal arteries & thoraco acromial br of axillary artery </li></ul>BLOOD SUPPLY
  8. 11. <ul><li>Vein follows arteries </li></ul><ul><li>Converge towards the nipple where they form anastomatic venous circle </li></ul><ul><li>Sup:veins drain into int: thoracic vein </li></ul><ul><li>Deep veins drain into int: thoracic,axillary & post: intercostal vein </li></ul><ul><li>Derived from ant:and lat:cutaneous branches of 2-6 intercostal nerves </li></ul>VENOUS DRAINAGE NERVE SUPPLY
  9. 12. <ul><li>Lymphatics of the breast drain predominantly into axillary & internal mammary lymph nodes </li></ul><ul><li>Axillary nodes receive approx. 85% of drainage </li></ul><ul><li>Ant axillary or pectoral nodes drain lateral quadrant of breast </li></ul><ul><li>parasternal l.nodes drain lymph from medial quadrant </li></ul><ul><li>inferior quadrant’s lymph may pass deeply in to abdominal lymph nodes </li></ul><ul><li>The sentinel l.node is defined as first axillary node draining the breast. </li></ul>LYMPHATIC DRAINAGE
  10. 14. <ul><li>Global Carcinoma. </li></ul><ul><li>Common cause of death in middle aged women in western countries. </li></ul><ul><li>200 times more common in females </li></ul><ul><li>The disease is fatal in 25 % of the cases </li></ul><ul><li>2nd most common cause of death (after Ca lung) </li></ul><ul><li>1 million women newly diagnosed each year </li></ul><ul><li>Less incidence in Asia </li></ul>Breast carcinoma introduction
  11. 15. <ul><li>As is the case with all cancers, cause of breast cancer is also unknown </li></ul><ul><li>Three sets of influences appear to be important </li></ul><ul><li>mutation in tumor suppressor genes i-eBRCA1&BRCA2 </li></ul><ul><li>Endogenous estrogen excess or hormonal imbalance </li></ul><ul><li>exogenous estrogens </li></ul><ul><li>irradiation </li></ul>2:Hormonal influances 1:Genetic changes 3:Environmental factors Pathogenesis
  12. 16. <ul><li>Common in western world accounting for 3-5%of all deaths in women </li></ul><ul><li>In developing countries it accounts <3 per cent of deaths. </li></ul><ul><li>Extremely rare before 20 years </li></ul><ul><li>Risk of ca breast increasing with age </li></ul><ul><li>Decreased incidence after the menopause </li></ul><ul><li>< 1 per cent are males </li></ul><ul><li>It occurs more commonly in women with family history </li></ul>Epidemiology and Risk factors Geographical Age Gender Genetics
  13. 17. <ul><li>More common in obese </li></ul><ul><li>Link between diets low in phyto-oestrogens & Soya is ass: with ca </li></ul><ul><li>High saturated fat diet, red meat </li></ul><ul><li>Inc: alcohol intake – inc: risk </li></ul><ul><li>Longer reproductive span inc:risk ( early menarche, late menopause ) </li></ul><ul><li>Nulliparity inc:risk ( higher number of pregnancies is protective ) </li></ul><ul><li>Oral contraceptives inc:risk </li></ul><ul><li>Prolonged exposure to ex:estrogens postmenopausally i.e. HRT inc risk </li></ul><ul><li>Breast feeding is protective </li></ul>DIET Endocrine
  15. 19. <ul><li>85% of ca arises in ducts, thus ductal ca is most common variant </li></ul><ul><li>Most frequently upper outer quadrant is involved </li></ul><ul><li>lobular ca occur in up to 15% of cases </li></ul><ul><li>Breast cancers are divided in to… </li></ul><ul><li>DCIS </li></ul><ul><li>LCIS </li></ul><ul><li>Lobular </li></ul><ul><li>Medullary </li></ul><ul><li>Colloid </li></ul><ul><li>Tubular </li></ul><ul><li>Inflammatory Ca </li></ul>Classification 1-Non Invasive (IN SITU) 2-Invasive
  16. 20. <ul><li>In situ carcinoma is pre-invasive ca </li></ul><ul><li>Usually asymptomatic </li></ul><ul><li>Both i.e. DCIS,LCIS are markers of late development of invasive ca </li></ul><ul><li>LCIS is usually multifocal and bilateral </li></ul><ul><li>Best treatment is for in situ ca is subject of number of on going clinical trials </li></ul>Non Invasive (IN SITU)
  17. 21. <ul><li>Usually associated with DCIS </li></ul><ul><li>Ca produce desmoplastic response which replaces normal breast fat thus forms hard palpable mass </li></ul><ul><li>Advanced ca may cause i.e. dimpling of skin, retraction of nipple, fixation of chest wall </li></ul><ul><li>Usually associated with LCIS </li></ul><ul><li>More frequently metastasize than ductal ca </li></ul><ul><li>Usually multiple and bilateral </li></ul>Invasive carcinoma 1:Invasive ductal ca 2:Invasive lobular ca
  18. 22. <ul><li>Comprises of about 2% of cases </li></ul><ul><li>Clinically resemble fibroadenomas </li></ul><ul><li>Rare subtype often present as well circumscribed mass </li></ul><ul><li>Tumor cells produce abundant quantity of extracellular mucin </li></ul>3:Medullary ca 4:colloid(mucinous) ca
  19. 23. <ul><li>It rarely present as palpable mass </li></ul><ul><li>Microscopically ca consist of well formed tubules </li></ul><ul><li>Lymph node metastasis is rare </li></ul><ul><li>Prognosis is excellent </li></ul><ul><li>Highly aggressive, most of tumor have distant metastasis </li></ul><ul><li>Fortunately rare </li></ul><ul><li>Usually without palpable mass </li></ul><ul><li>Presents as painful, swollen & warm breast </li></ul><ul><li>May mimic breast abscess </li></ul><ul><li>Prognosis is extremely poor </li></ul>5:Tubullar ca 6:Inflammatory Ca
  20. 24. <ul><li>Superficial manifestation of an underlying breast Ca </li></ul><ul><li>Presents an eczema like condition of nipple or areola </li></ul><ul><li>First there is erosion of nipple </li></ul><ul><li>Eventually nipple disappear </li></ul><ul><li>MICROSCOPICALLY- Loose ovoid cells with clear abundant & pale staining cytoplasm </li></ul>Paget’s disease of nipple
  21. 25. <ul><li>1: Fixation to chest wall – cancer –en- cuirasse </li></ul><ul><li>2:retraction or dimpling of skin </li></ul><ul><li>3:localized lymphedema </li></ul><ul><li>4:Peau d’orange(orange peel) </li></ul>Features common to all invasive cancers
  22. 26. orange-peel appearance- peau d’ orange.
  23. 27. <ul><li>Pt often Presents with hard Painless lump </li></ul><ul><li>Nipple may be deviated, displaced, retracted or destroyed. </li></ul><ul><li>Mild aches & Pricking sensation </li></ul><ul><li>Distortion of shape of breast </li></ul><ul><li>General malaise & loss of weight </li></ul><ul><li>Change in size of breast </li></ul><ul><li>Backache, caused by infiltration & collapse of lumbar vertebrae. </li></ul>Clinical Presentation
  24. 28. <ul><li>Invades other portion of breast, skin, pectoral muscle and chest wall. </li></ul><ul><li>Primarily to axillary L.N. & internal mammary chain of lymph nodes </li></ul><ul><li>In advanced stage– supra clavicular with contra latera lL.Ns may also be involved. </li></ul><ul><li>Through this route metastases occur in skeleton, liver, lungs and brain </li></ul>The Spread Local Spread Lymphatic spread Bloodstream
  25. 29. SKELETAL <ul><li>SKELETAL </li></ul><ul><li>L - Lumber vertebrate </li></ul><ul><li>F - Femur </li></ul><ul><li>T - T.vertebrae </li></ul><ul><li>R- RIBS </li></ul><ul><li>S- Skull </li></ul><ul><li>Metastasis may occur in liver,lungs & brain </li></ul>
  26. 30. <ul><li>Two traditional systems of classification </li></ul><ul><li>I. The Manchester system </li></ul><ul><li>II.The international union against cancer i.e. TNM Staging system. </li></ul>
  27. 31. <ul><li>Growth confined to breast </li></ul><ul><li>Growth confined to breast and affected lymph nodes in ipsilateral axilla </li></ul><ul><li>a) Large skin involvement or peau d’orange but limited to breast </li></ul><ul><li>b) Tumor fixed to pectoral muscles, but not chest wall </li></ul><ul><li>c) ipsilateral lymph nodes matted together or fixed to chest wall </li></ul><ul><li>a) Wide skin involvement of breast </li></ul><ul><li>b) Complete fixation of tumor to chest wall </li></ul><ul><li>c) Distant metastasis </li></ul>Manchester system Stage1 Stage II Stage III Stage IV
  28. 32. <ul><li>TIS ca in-situ </li></ul><ul><li>T1 <2cm </li></ul><ul><li>T2 2-5cm </li></ul><ul><li>T3 >5cm </li></ul><ul><li>T4 tumour of any size </li></ul><ul><li>N0 No nodal involvement </li></ul><ul><li>N1 Mobile involved axillary nodes </li></ul><ul><li>N2 Fixed involved nodes </li></ul><ul><li>N3 Inv ipsilateral supraclavicular nodes </li></ul><ul><li>M0 No metastasis </li></ul><ul><li>M1 +ve distant metastasis </li></ul>TNM CLASSIFICATION PRIMARY Tumor Nodal involvement Metastasis
  29. 33. <ul><li>Ca in situ or tumor less than 2 cm in size with no nodal involvement </li></ul><ul><li>Tumor of less than 2cm in size with mobile involved lymph node </li></ul><ul><li>Tumor of 2-5cm in size with fixed involved lymph node +no known distant metastasis </li></ul><ul><li>Any tumor, any nodal involvement with Known distal metastasis </li></ul>Staging according to TNM Stage1 Stage2 Stage 3 Stage4
  30. 34. Diagnosis should be made by combination of 1:clinical assessments 2:radiological imaging 3:cytological or thru histological analysis DIAGNOSIS
  31. 35. <ul><li>it own does not exclude breast ca </li></ul><ul><li>It is very safe investigation </li></ul><ul><li>sensitivity of test inc with age as the breast becomes less dense </li></ul><ul><li>Useful in young women with dense breast in whom mammograms are difficult to interpret </li></ul><ul><li>Useful in distinguishing cystic from solid lesions </li></ul><ul><li>Useful to localized in impalpable lumps </li></ul>CLINICAL IMAGING 1.Mammography 2.Ultrasound
  32. 36. <ul><li>Gold standard for imaging the breast of Patients with implants </li></ul><ul><li>PT’s with suspected recurrent disease </li></ul><ul><li>Useful as a screening tool in high risk women </li></ul><ul><li>least invasive technique of obtaining cell diagnosis </li></ul><ul><li>False negatives do occur thru sampling error </li></ul><ul><li>Invasive ca can’t be distinguished from in situ disease </li></ul>3.MRI 4.FNAC
  33. 37. <ul><li>To reduce the chance of local recurrence </li></ul><ul><li>To reduce the risk of metastatic spread </li></ul><ul><li>Surgery </li></ul><ul><li>Radiotherapy </li></ul><ul><li>Adjuvant systemic therapy </li></ul>MANAGEMENT Two basic principles of treatment TREATMENT MODALITIES
  34. 38. <ul><li>Two Aspects of surgery </li></ul><ul><li>Mastectomy </li></ul><ul><li>Conservative breast surgery </li></ul><ul><li>INDICATIONS </li></ul><ul><li>Large tumor related to size of the breast </li></ul><ul><li>Central tumor beneath the areola or involving nipple </li></ul><ul><li>Multi focal disease </li></ul><ul><li>Local recurrence </li></ul><ul><li>Patients preference </li></ul>SURGICAL TREATMENT 1:Mastectomy
  35. 39. <ul><li>Removal of breast tissue with axillary tail usually attached with few lymph nodes of anterior axillary group </li></ul><ul><li>No dissection of axilla </li></ul><ul><li>Simple mastectomy is often followed by radiotherapy </li></ul>TYPES OF MASTECTOMY 1)Simple Mastectomy
  36. 45. <ul><li>It includes </li></ul><ul><li>Excision of whole breast </li></ul><ul><li>All axillary lymph nodes </li></ul><ul><li>All fat and fascia of the anterior chest wall </li></ul><ul><li>Excision of pectoralis major and minor muscles. </li></ul><ul><li>More commonly performed </li></ul><ul><li>Excised Mass is composed of </li></ul><ul><li>Whole breast </li></ul><ul><li>Large portion of skin overlies the tumor and nipple </li></ul><ul><li>All fat, fascia, and lymph nodes of axilla </li></ul><ul><li>Pectoralis minor muscle divided or retracted </li></ul><ul><li>With preserving of axillary vein, nerve to serratus anterior & lattissimus dorsi </li></ul>2)RADICAL MASTECTOMY (HALSTED) 3) Modified radical (Patey mastectomy)
  37. 46. <ul><li>Small tumor related to the size of breast </li></ul><ul><li>Availability of radiotherapy facility </li></ul><ul><li>Patient preference </li></ul><ul><li>Involves removal of lump or tumor with rim of 1cm normal breast tissue. </li></ul><ul><li>Term lumpectomy is reserved for operation in which benign tumour is excised and large amount of normal breast is not resected </li></ul><ul><li>Removing the entire segment of the breast which contain the tumor. </li></ul><ul><li>Radiotherapy to the remaining breast tissue </li></ul><ul><li>Quadrantectomy, axillary dissection & radiotherapy is known as QUART </li></ul>Conservative breast surgery 1) WIDE LOCAL EXCISION 2) Quadrantectomy
  38. 47. <ul><li>INDICATION </li></ul><ul><li>After mastectomy </li></ul><ul><li>High grade tumour </li></ul><ul><li>Large nodal involvement </li></ul><ul><li>Multifocal disease </li></ul><ul><li>Extensive lymphovascular invasion </li></ul><ul><li>AIM: </li></ul><ul><li>To delay the relapse </li></ul><ul><li>To prolong the survival </li></ul><ul><li>Indications: </li></ul><ul><li>Lymph node positive women </li></ul><ul><li>Poor prognosis </li></ul><ul><li>Hormonal receptor positive women </li></ul><ul><li>Old patient </li></ul>ADJUVANT SYSTEMIC THERAPY Radiotherapy
  39. 48. <ul><li>Tamoxifen is widely used hormonal treatment </li></ul><ul><li>If pat is premenopausal get benefit from 2omg daily of tamoxifen </li></ul><ul><li>New aromatase inhibitors i.e.anastrozole,letrozole etc are used if pat is post menopausal </li></ul><ul><li>It reduces risk of cancer in contra lateral breast </li></ul><ul><li>Other hormonal agents are being developed i.e. LHRH </li></ul><ul><li>The aim of this Rx is to shrink tumor to enable breast preserving surgery. </li></ul><ul><li>6 months cycles of cyclophosphamide, methotrexate and 5-FU achieve 25% reduction in risk of relapse </li></ul><ul><li>Chemotherapy may be considered in node –ve pts if there is hi risk of recurrence </li></ul><ul><li>This Rx is confined to premenopausal women. </li></ul>HORMONAL THERAPY CHEMOTHERAPY
  40. 49. Thank You