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carcinoma of breast

carcinoma of breast



Dr Sajid's presantation

Dr Sajid's presantation



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    carcinoma of breast carcinoma of breast Presentation Transcript

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