• Like
BM
Upcoming SlideShare
Loading in...5
×
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
3,508
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
361
Comments
0
Likes
3

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Surgical Options for the Treatment of Breast Cancer Helen Krontiras, M.D. Assistant Professor University of Alabama School of Medicine
  • 2. History Physical Examination
    • Questions regarding presenting symptom
    • Questions regarding risk factors
    • Past medical history
    • Family history
    • Review of systems
    • Masses
    • Skin changes
    • Nipple changes
    • Nipple discharge
    • Lymphadenopathy
  • 3. Risk factors for breast cancer
    • Gender
    • Age
    • Personal history of breast cancer
    • Reproductive and menstrual history
    • Breast density
    • Family history of breast cancer
    • Genetic factors
    • Proliferative breast disease
    • Diet and lifestyle factors
  • 4. Breast Imaging
    • Mammogram
    • Ultrasound
    • (MRI)
  • 5. Biopsy
    • Incisional
      • Core biopsy
        • Palpation
        • Image Guided
          • Stereotactic
          • Ultrasound guided
    • Excisional
      • Operative removal of entire lesion
  • 6. Histology
    • Lobular carcinoma in situ
    • Ductal carcinoma in situ
    • Invasive ductal carcinoma
    • Invasive lobular carcinoma
  • 7. Lobular Carcinoma in situ
    • Usually diagnosed as an incidental finding
    • Marker for increased risk for breast cancer
    • If found on core biopsy, excision warranted to rule out coexisting cancer
    • Management
      • Surveillance
      • Chemoprevention
      • Bilateral Total Prophylactic Mastectomy
  • 8. Ductal Carcinoma in situ
    • Stage 0, pre-invasive
    • By definition, does not spread to the axillary lymph nodes
    • Usually detected mammographically as microcalcifications
    • Surgical treatment similar to invasive breast cancer
  • 9. Invasive ductal carcinoma
    • Most common, 75% of all breast cancers
    • AKA IDC, infiltrating ductal
    • Increased spread to axillary nodes with increase in size
  • 10. Invasive lobular carcinoma
    • 5-10% of all breast cancers
    • Usually presents as an ill defined thickening
    • May be mammographically occult
  • 11. Inflammatory breast cancer
    • Variant with rapid onset
    • Poor prognosis
    • Erythema, edema of the overlying skin (peau d’orange) secondary to tumor within the dermal lymphatics
    • Treatment is chemotherapy followed by surgery and or radiation
  • 12. Paget’s Disease
    • Benign appearing eczematoid lesion of the nipple
    • Caused by large malignant cells (Paget's cells) which arise from the ducts and which invade the surrounding nipple epithelium.
    • Usually due to an intraductal carcinoma
    • An underlying palpable mass usually indicates invasive ductal carcinoma
  • 13. Phyllodes Tumor
    • Rare, 0.5%- 1% of breast cancers
    • A fibroepithelial tumor of unpredictable behavior
    • Treatment is wide local excision with
    • 2cm margins, no role for chemotherapy or radiation therapy
    • Like other stromal tumors, lymph node metastasis is rare
  • 14. Earlier stage - better survival Stage
  • 15. Lumpectomy + Mastectomy Neoadjuvant Chemotherapy (SLN BX before,surgery after) Clinical Stage I or II Invasive Breast Cancer SLN BX AND Total + SLN BX Modified Radical
  • 16. Mastectomy Neoadjuvant Chemotherapy ClinicalStage III Invasive Breast Cancer Radiation Therapy
  • 17. Breast Cancer Treatment Local Systemic
  • 18. Local Therapy Breast Axilla
  • 19. Local Therapy Surgery Radiation Therapy
  • 20. Breast
    • Mastectomy
    • Breast conservation
    • Neoadjuvant chemotherapy
  • 21.  
  • 22. Mastectomy
    • Total Mastectomy
      • With or without reconstruction
      • With or without sentinel lymph node biopsy
        • Remove only the breast
    • Modified Radical Mastectomy
      • With or without reconstruction
        • Remove the breast and axillary lymph nodes
  • 23. Mastectomy with reconstruction
    • Total or MRM plus (immediate or delayed)
    • TRAM (Transverse Rectus Abdominis Myocutaneous flap)
        • Free – deep inferior epigastric
          • Thorocodorsal, subscpular, circumflex scapular
          • Internal mammary, thoracoacromial, lateral thoracic
        • Pedicled – superior epigastric
    • Latissimus dorsi myocutaneous flap
    • Expander/Implant
  • 24.  
  • 25. Breast Conservation Therapy
    • Lumpectomy + Radiation Therapy
    • Remove the bulk of the tumor surgically and to use moderate doses of radiation therapy to eradicate any residual cancer
    • Goal
      • Preserve cosmetic outcome
      • Provide survival equivalent to mastectomy
      • Provide low rate of local recurrence
  • 26. BCT vs Mastectomy
    • Since 1970, 7 prospective randomized
    • studies demonstrate equivalent outcome
    • regardless of surgical choice for patients with Stage I or II disease
  • 27. Radiation Therapy
    • External beam
    • Daily therapy for 6 weeks
    • Side effects
      • Skin changes
      • Pulmonary toxicity
      • Cardiotoxicity
  • 28. Contraindications to breast conservation therapy
    • Absolute
      • 2 or more primary tumors in separate quadrants
      • Diffuse malignant appearing calcifications
      • History of previous irradiation to the breast region
      • Pregnancy
      • Persistent positive margins
  • 29. Contraindications to breast conservation therapy
    • Relative
      • History of collagen vascular disease
      • Multiple gross tumors in the same quadrant and indeterminate calcifications
      • Large tumor in a small breast
      • Breast size
    Winchester et al, Ca Cancer J Clin, 1998
  • 30. Contraindications to breast conservation therapy
    • The following should not prevent patients from being candidates for BCT:
      • Presence of clinical or pathologic involvement of axillary lymph nodes
      • Tumor location
      • Family history
  • 31. Neoadjuvant chemotherapy
    • Chemotherapy given before surgery
    • Shrink the tumor
    • In Vivo assessment of response to chemo
    • No survival advantage or disadvantage
  • 32. Therapy of Regional Nodes
    • Axillary Node Dissection
    • Sentinel Lymph Node Biopsy
  • 33. Axillary Node Dissection
    • Typically Levels I and II
    • 10 – 30 lymph nodes removed
    • 15-20% incidence of lymphedema
  • 34. Silverstein, The Breast Journal 4:324, 1998 Positive axillary lymph node versus T stage
  • 35. Sentinel node biopsy
    • The sentinel node is the first node to receive lymphatic drainage from a primary breast cancer and reflects the status of the entire nodal basin
      • Identifies the node(s) most likely to contain cancer
      • Lessens the morbidity of lymph node staging (3-4% incidence of lymphedema)
      • More detailed pathologic analysis with H&E
      • Axillary node dissection for those with positive sentinel nodes
  • 36. Sentinel node biopsy                                                   
  • 37. Systemic Therapy Cytotoxic Chemotherapy Endocrine Monoclonal antibody
  • 38. Adjuvant therapy
    • The administration of chemotherapy or radiation therapy after primary surgery of breast cancer to kill or inhibit clinically occult micrometastases or residual disease
  • 39. Adjuvant therapy recommendation
    • Tumor size ER status Nodal Status Recommendation
    • < 1 cm +/- - None required
    • >1 cm + - Tam +/- Chemo
    • - - Chemo
    • Any size + + Tam +/- Chemo
    • - + Chemo
  • 40. Chemotherapy
    • Adriamycin/ Cytoxan (AC) x 4
    • Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6
  • 41. SERM Selective estrogen receptor modulators
    • Tamoxifen
    • For those with ER (estrogen receptor) positive breast cancer
    • Prescribed for 5 years
    • Antiestrogenic and estrogenic effects
    • Side effects
        • Hot flashes
        • Vaginal dryness, discharge
        • Increased risk of endometrial cancer
        • Increased risk of thromboembolic events
        • Cataracts
  • 42. Aromatase inhibitors
    • Blocks aromatase enzyme peripherally
    • For those with ER positive disease
    • Less side effects than tamoxifen
    • May be more effective for treatment and prevention
      • Arimidex
      • Femara
      • Exemestane
  • 43. Herceptin (trastuzumab)
    • Monoclonal antibody that targets the Her2neu gene
    • Her2neu is overexpressed in 25% of breast cancers
    • Codes for a growth factor
    • Clinical trials indicate that Herceptin may increase the effectiveness of chemotherapy without added toxicity