Breast Cancer Management

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Breast Cancer Management

  1. 1. Breast Cancer Management Abdul Basit FRCS Keele Medical School Friday 02 March 2012
  2. 2. Further Information • Memorial Sloan Kettering Hospital • Cancer Research UK.This presentation can be seen on Linked-in And Slideshare.com
  3. 3. Lactational Breast Abscess Copyright J Michael Dixon, Lucy R Khan
  4. 4. Abscess drainage under USS
  5. 5. Peri-areolar abscess incision and drainage Copyright J Michael Dixon, Lucy R Khan
  6. 6. Incision & drainage under L.A. Copyright J Michael Dixon, Lucy R Khan
  7. 7. Names mentioned today in breast surgery Paget’s disease Sir James Paget 1874Surgeon St. Barttholomew’s Hospital,London Ligaments of Cooper Sir Astley Cooper 1845 Surgeon Guy’s Hospital, London Glands of Montgomery William Montgomery 1837 Obstetrician, Dublin, Ireland
  8. 8. Ductal CancerDuctal Carcinoma of no special Type 80 % Lobular Cancer 10 %
  9. 9. Age and Risk of Breast Cancer • Up to age 25 1: 15000 • Up to age 30 1: 2000 • Up to age 40 1: 200 • Up to age 50 1: 50 • Up to age 60 1: 22 • Up to age 70 1: 14 • Up to age 80 1: 10 Life Time Risk 1: 8
  10. 10. Sensitivity of Mammography by Age Age Sensitivity 30 - 39 0.58 40 – 49 0.75 50 - 59 0.92 60 - 69 0.93 70+ 0.87 Kerlikowske K, Grady D, Barclay J, Sickles EA, Ernster V (1996) Effect of age, breast density, and family history on the sensitivity of first screening mammography. JAMA 276: 33-38
  11. 11. Hormones affecting the breast
  12. 12. Age Range 692 Operated Breast Cancer patients250 203200 186150 123 99100 5250 26 3 0 <30 30-39 40-49 50-59 60-69 70-79 ≥80 University Hospital of North Staffordshire 2009 -2010
  13. 13. Figure 1.1: The 20 most commonly diagnosed cancers(excluding non-melanoma skin cancer), UK, 2007 Breast Lung Colorectal Prostate N-H-LMalignant melanoma Bladder Kidney Oesophagus Stomach Pancreas Uterus Leukaemias Ovary Oral Brain with CNS Multiple myeloma Liver Cervix Male Female Mesothelioma Other 0 10,000 20,000 30,000 40,000 50,000 Number of new cases
  14. 14. Breast cancer is not the number one killer Cause of Death in Females 2009 35000 30000 25000Number 20000 15000 10000 5000 0
  15. 15. Life time risk of 1:847,700 new cancers per annum (2008) < 50yrs 20% 50-70yrs 50% only 33% are NHSBSP detected >70yrs 30% Rising Incidence over 25 years – 50% increase (75-122/100,000) Falling mortality – 15% decrease (42-27/100,000) over 550,000 ‘survivors’ 8 out of 10
  16. 16. TamoxifenUse of chemotherapy in pre-menopausal women and Radiotherapy in WLE
  17. 17. Hormonal Therapy 5 yearsTamoxifen 20mg daily for all womenOnly for post-menopausal women There is a choice of Aromatase Inhibitors(A.I.) Anastrazole Letrazole Examestane (Primary Hormonal Therapy)
  18. 18. Neo- AdjuvantADJUVANTPrimary Hormonal Therapy
  19. 19. Age related breast lumps
  20. 20. TOTAL MASTECTOMY VERSUS LUMPECTOMY(Wide Local Excision)
  21. 21. Wide Local Excision
  22. 22. TWENTY-YEAR FOLLOW-UP OF A RANDOMIZED TRIAL COMPARING TOTAL MASTECTOMY, LUMPECTOMY, AND LUMPECTOMY PLUS IRRADIATION FOR THE TREATMENT OF INVASIVE BREAST CANCER BERNARD FISHER, M.D.,ABSTRACTIn 1976, we initiated a randomized trialto determine whether lumpectomy with or withoutradiation therapy was as effective as total mastectomyfor the treatment of invasive breast cancer. N Engl J Med, Vol. 347, No. 16 · October 17, 2002 · www.nejm.org
  23. 23. Wide Local Excision (WLE) with Sentinel Lymph Node Biopsy (SLNB)
  24. 24. The Volume of Heart Irradiated
  25. 25. J Clin Oncol 17:101-109. 1999by Andre´ Fortin et al. American Society of Clinical Oncology.
  26. 26. Wide Local Excision
  27. 27. Management of the axilla Abdul Basit et al Diagnosis of breast cancer Clinical Breast Cancer March 2011 Ultrasound of axilla Suspicious Gland (S) Normal Glands Core Needle Biopsy (USS-CNB) Sentinel Lymph Node BiopsyPositive Gland Negative Gland (SLNB) Positive SLNB Negative SLNBAxillary Clearance (No further axillary treatment)
  28. 28. Axillary lymph Glands
  29. 29. Blue Sentinel Node
  30. 30. Breast Cancer is potentially curable Early DetectionNottingham Prognostic Index (NPI) < 4.4Size 20 mmGrade 3Node Negative 10 year disease free survival = over 80 %R.W. Blamey*, S.E. Pinder, G.R. Balla, I.O. Ellis, C.W. Elston, M.J.Mitchell, J.L. HaybittleThe Breast Institute, Nottingham City Hospital, Nottingham E U R O P E A N J O U R N A L OF CA N C E R 4 3 ( 2 0 0 7 ) 1 5 4 5 –1 5 4 7
  31. 31. Multidisciplinary Team • Pathologist • Radiologist • Oncologist • Surgeon • Breast Care Nurses
  32. 32. 10 Things you must know before you can plan treatment for breast cancer• Age• Size of tumour 1  Margins of clearance• Type of tumour  Lympho-vascular invasion• Grade of tumour 2  Immunohistochemistry - 3• Lymph Node3 ER PgR Her2 Positive Negative  Health & Performance StatusIf Pos, how manynodes out of how many ?  Menopausal Status 1,2,3 = Nottingham Prognostic Index (NPI)
  33. 33. Tumour Histological GradesGrade 1 Grade 2 Grade 3
  34. 34. IHC -3ER PgR Her-2
  35. 35. Ki - 67
  36. 36. Angiolymphatic space invasion
  37. 37. my Ki-67 is 98%....same thing, when my oncologist said"this is the fastest growing tumor Ive ever seen"..didnthelp me much considering he is now retired and a worldreknown breast cancer specialist.....I too had no node involvemnet. I was dx Jan of 08...mynew oncologist wants to do preventitive chemo again in2 yrs...I am doing it, because chemo does work greatagainst the aggresive cells....I am clean and clear right now....triple negative as well..
  38. 38. Educating health promoting behavioursWeight reductionPhysical activity and exercise 30 minutes most days.Having first child before the age of 30Breast feeding for 6 months during reproductive life Stockphoto.comDiet – Less saturated and animal fat - more Fruit & Veg •Less processed and red meat - more fish •Less refined flour and sugar - more fibreAvoiding hormones in the ‘pill’ , HRT and IVF
  39. 39. Ductal Carcinoma-in-Situ (DCIS) J Cuzick, SE Pinder, IO Ellis. Lancet Oncology 7 December 2010 The UK/ANZ DCIS trial1694 Patients followed by yearly bilateral mammography for a median of 12 years 376 Events (22%) tamoxifen significant reduction in all contralateral events. older women benefit more from radiotherapy than younger women.
  40. 40. Total events in 12 years n =376 DCIS Invasive 197 (12%) 163 (10%)Ipsilateral 174 (10%) 122 (10%)Contralateral 17 (1%) 39 (2%) Annual rate of a breast event = 2 % ALL DIAGNOSED BY SURVELLIANCE RADIOLOGY
  41. 41. Risk factors Family history of breast cancer in relatives Age at onset of breast cancer. • Bilateral disease. • Degree of relationship (first or greater). • Multiple cases in the family (particularly on one side). • Other related early-onset tumours (for example, ovary, sarcoma).• Number of unaffected individuals (large families with many unaffected relatives will be less likely to harbour a high-risk gene mutation).
  42. 42. Known Risk Factors Gail Claus Tyrer-Cuzick Prediction (Amir E, Evans . J Med Genet (2003) 0.48 0.56 0.81 Personal Information Age 20 -70 years Yes Yes Yes Body Mass Index (BMI) No No Yes Waist to Hip Ratio No No No Alcohol Intake (0-4 units daily) No No No Hormonal /Reproductive Factors Age at Menarche Yes No Yes Age at first live birth Yes No Yes Age at menopause No No Yes Hormonal replacement No No No Oral Contraceptive No No No Breast Feeding No No No Plasma Oestrogen No No No Personal Breast Disease Breast biopsies Yes No Yes Atypical Ductal Hyperplasia Yes No Yes Lobular Carcinoma in situ Yes No Yes Breast Density No No NoFamily history First degree relative Yes Yes Yes Second degree relative Third degree relative No Yes Yes Age of the onset of breast cancer No No No Bilateral breast cancer No Yes Yes Male breast cancer No No Yes Ovarian cancer No Yes Yes No No Yes Evans and Howell Breast Cancer Research 2007 9:213
  43. 43. W om an s age i s 39 y ears . R i s k a fte r 1 0 y e a r s i s 1 1 .9 9 %. Ag e a t m e n a r ch e w a s 1 3 y e a r s . 1 0 y e a r p o p u l a ti o n r i s k i s 1 .4 7 2 %. Ag e a t fi r s t b i r th w a s 3 3 y e a r s . L i fe ti m e r i s k i s 3 7 .8 4 %. Pe r s o n i s p r e m e n o p a u s a l . L i fe ti m e p o p u l a ti o n r i s k i s 9 .8 3 8 %. H e i g h t i s 1 .7 m . Pr o b a b i l i ty o f a B R CA1 g e n e i s 7 .4 1 8 %. W e i g h t i s 6 4 kg . Pr o b a b i l i ty o f a B R CA2 g e n e i s 6 .1 4 6 %. W o m a n h a s n e v e r u s e d H R T. ? ? 39 39 3937.5%30.0%22.5% Pe rsona l risk Popula tion risk15.0%7.5%0.0% 39 49 59 69 79
  44. 44. “Lifetime risk is not very useful on itsown—after all there’s a 1 in 1 life time chance that you will die of something or other”
  45. 45. Christina Applegate wikipedia.org in 2010On August 19, 2008, it was announced that Applegate was cancer free after a double mastectomy , even though cancer was found in only one breast. She has an inherited genetic fault, a BRCA1 mutation. Her mother, Nancy Priddy is a breast cancer survivor
  46. 46. TRIPLE ASSESSMENT ImagingHistory and HistopathologyExamination Diagnostic accuracy approaching 99%
  47. 47. Lead Time Bias Age 55 Age 50 SymptomaticScreen detected presentation 10mm size Age 80 25mm size
  48. 48. Thank you for your attention
  49. 49. What are the risk factors?Known risk factors for breast cancer are:being femaleincreasing ageprevious history of breast cancerhaving proven benign breast disease in the pastnot breastfeeding long termcurrent use of hormone replacement therapyhaving a family history of breast cancerhaving no children or few childrenhaving children at late ages (especially over 30)early pubertyhaving a later menopauseobesity (for post-menopausal women only)high consumption of alcohol
  50. 50. If you have ESTROGEN RECEPTOR POSITIVEBREAST CANCER or a history of breast cancer inthe family and have taken IVF or long-termHRT, there is a high probability that you have anestrogen metabolism impairment andwere unable to process these medications
  51. 51. Each person processes medication differently. Some women can not process (or metabolize) estrogen correctly so when they take certain pharmaceuticals, such as fertility drugs,the inability to process estrogen correctly can become carcinogenic.

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