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Breast- introduction, benign diseases and carcinoma breast


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Like the playlist in YouTube, in this presentation I have combined three of my presentation into one for the benefit of medical students and surgical trainees. The first presentation regading introduction to breast pathologies, second regarding benign breast lesions and the third one is regarding Carcinoma Breast. Hope you will enjoy this.

Published in: Health & Medicine
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Breast- introduction, benign diseases and carcinoma breast

  1. 1. BREAST INTRODUCTION AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  2. 2. Must To Know Core Clinical Problems
  3. 3. BREAST ▪ Surgical Anatomy ▪ Surgical Physiology ▪ Symptomatology ▪ Approach to a patient with breast pathology ▪ Investigations
  4. 4. ANATOMY ✓ Breast consists of glandular tissue, ducts, supporting muscular tissue, fat, blood vessels, nerves, and lymphatic vessels. ✓ Glandular tissue consists of 15 to 25 lobes, each of which drains into a separate excretory duct that terminates in the nipple ✓ Each lobe is subdivided into 50 to 75 lobules, which drain into a duct that empties into the excretory duct of the lobe ✓ Each duct dilates as it enters the base of the nipple to form a milk sinus. This serves as a reservoir for milk during lactation ✓ Cooper ligaments are the fibrous connections between the inner side of the breast skin and the pectoral muscles.
  5. 5. ANATOMY
  6. 6. PHYSIOLOGY ✓ At birth, branching system of ducts emptying into a developed nipple ✓ At puberty, glandular tissue begins to develop beneath the areola. ✓ Major physiologic change related to the menstrual cycle is engorgement ✓ With pregnancy, neuroendocrine control of the breasts starts. Suckling produces nerve impulses that travel to the hypothalamus. ✓ The hypothalamus  anterior pituitary to secrete prolactin, glandular tissue to produce milk. ✓ The hypothalamus also posterior pituitary to produce oxytocin, muscle cells surrounding the glandular tissue to contract and force the milk into the ductular system.
  7. 7. Breast- Symptoms ▪ Lump or lumpiness ▪ Mastalgia or Mastodynia- Cyclic or Noncyclic ▪ Nipple Discharge
  8. 8. Breast- Symptoms ▪ Lump or lumpiness ▪ Benign or Malignant ▪ Triple assessment
  9. 9. Breast- Symptoms ▪ Mastalgia or Mastodynia ▪ Cyclical usually associated with menstrual cycle and pain more during 3 to 5 days before menstruation Ex: fibrocystic disease ▪ Breast is subjected to the influence of Estrogen and progesterone hormones every month ▪ Noncyclical mastalgia due to inflammatory lesions like mastitis and breast abscess or chestwall problem like costochondritis
  10. 10. Breast- Symptoms ▪ Nipple Discharge ▪ Colour -Blood Ductal papilloma &Ductal carcinoma -PurulentBreast abscess -Greenish Fibroadenosis & Ductectasia -Milky Galactocele, Prolactenemia ▪ Spontaneous ▪ Segmental expression
  11. 11. Breast-Investigations • Staging Investigations • Xray Chest • Abdominal Ultrasound/ CT abdomen • Radionucleide Bone Scan • CT Brain • PET Scan • Radiological Investigations • Ultrasonography • Mammography • Pathological Investigations • Fine Needle Aspiration Cytology FNAC • Core Needle Biopsy Trucut Biopsy • Needle Localisation Biopsy • Stereotactic Biopsy • Open Biopsy Incisional& Excisional • Sentinel node Biopsy
  12. 12. BREAST Benign Breast Diseases AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical college Melaka 75150 Malaysia
  13. 13. SYMPTOMS
  14. 14. Causes for Symptoms
  15. 15. Classification of BBD
  16. 16. BBD-Benign Breast Diseases ✓Amastia & Athelia ✓Mastalgia- Fibrocystic disease ✓Fibroadenoma & Breast Cysts ✓Fat Necrosis ✓Duct Ectasia ✓Phyllodes tumor ✓Galactocele ✓Mastitis & Breast Abscess ✓Mondor’s disease ✓ Breast is host to a spectrum of benign and malignant diseases. ✓ Benign breast conditions are universal phenomena among women. ✓ It accounts for 80% of clinical presentation related to the breast.
  17. 17. BBD- Amastia & Athelia ✓Breast tissue with or without a nipple or just nipple and areola alone can occur any where along the milk line ✓The milk line extends from the axilla to groin ✓ Total lack of breast tissue( amastia) or of nipple (athlelia) is unusual ✓supernumerary nipples -polythelia & breast- polymasita are quite common ✓Unilateral amastia is often associated with absence of the pectoral muscles Poland’s syndrome POLAND’S SYNDROME
  18. 18. BBD-Fibrocystic Disease ✓Breast is a dynamic organ undergoing periods of development and involution throughout a woman’s reproductive life. ✓Affects premenopausal women and is characterized by cyst formation, hyperplasia of duct epithelium (epitheliosis), enlargement of lobules (adenosis) and fibrosis, which may vary in extent and degree in any one breast. ✓This condition is the result of abnormal response to hormonal changes and can be associated with menstrual irregularities. ✓Ill–defined area of induration or firm swelling, often painful prior to menstruation. (cyclical mastalgia)
  19. 19. BBD-Fibrocystic Disease ✓1. Cyst formation ✓2. Epitheliosis— Hyperplasia of duct epithelium ✓3.Adenosis— Proliferation of lobular epithelium ✓4. Fibrosis—It represents involutional change
  20. 20. Fibrocystic Disease- Treatment ✓Reassurance, simple analgesia and a supportive bra often help. ✓Gamma-lineolic acid(evening primerose oil) 3 to 4 Gm/day for 3to4 months ✓Occasionally Danazol- anti gonadotrophin, Tamoxifen- anti estrogen or Bromocriptine- prolactin inhibitor are required ✓Danazol 200- 300 mgm/day reduced to 100mgm/day from day 14 to 28 days of menstruation ✓Mammography and ultrasonography typically show normal breast tissue. ✓Despite negative imaging studies, a biopsy should be performed to r/o malignancy
  21. 21. Fibroadenoma ✓Fibroadenoma is a benign tumor of breast consisting of glandular and connective tissue elements. ✓Commonest benign breast tumor. The typical patient is 15 to 35 yrs ✓Well-circumscribed, solid masses represent hyperplastic lobules. ✓Smooth, encapsulated mass that is freely mobile- “breast mouse”- rubbery in consistency and non-tender. ✓USG shows a mass with smooth margins; Trucut biopsy confirms the diagnosis ✓Fibroadenomas >2cms size or those with inconclusive biopsy should be excised
  22. 22. Fibroadenoma
  23. 23. Fibroadenoma USG Breast: Hypoechoic lesion Smooth partially lobulated margin Mammogram: Popcorn Calcification in Involuting Fibroadenoma
  24. 24. BREAST CYSTS ✓Commonly occurs between age 30 to 50 ✓Is due to non-integrated involution of stroma & epithelium ✓Appearance: blue-domed cyst (single/ multiple; unilateral/ bilateral) ✓Treatment: ✓Fluid aspiration (greenish-yellow; can be sent fluid cytology) ✓Hemorrhagic fluid and recurrent cysts can be excised for histological exam to r/o Carcinoma
  25. 25. PHYLLODES TUMOR ✓Other names: cystosarcoma phyllodes, serocystic disease of Brodie ✓Usually occurs in age > 40 ✓Presentation: Very large, firm, mobile, non-tender lump with uneven lobulated surface. ✓Wide variation in appearance (from benign to potentially malignant) ✓Treatment: enucleation/ wide excision/ mastectomy ✓Rarely becomes sarcoma LEAF LIKE
  26. 26. DUCT ECTASIA ✓Is a peri-ductal inflammation with duct dilation ✓Presentations: MARD (mass, abscess, retraction, discharge) ✓Subareolar mass ✓Slit-like nipple retraction ✓Brown/ green/ blood-stained nipple discharge ✓Abscess & fistula just below & around areola ✓Treatment: Hadfield’s operation, wide excision of all affected ducts, shave off below nipple
  27. 27. DUCTAL PAPILLOMA ✓This benign lesions of the lactiferous duct wall occur centrally beneath the areola In 75% of cases. ✓They most commonly produce a bloody nipple discharge, some times associated with pain ✓They are solitary proliferation of ductal epithelium ✓Intraductal papillomas should be treated by excision of a duct as a wedge resection. ✓Treatment: simple excision (microdochectomy)
  28. 28. FAT NECROSIS ✓Occurs following blunt injury to breast (may be acute/ chronic), usually in obese, middle-aged females ✓Painless, firm, fixed mass with ill-defined margins ✓May even have skin tethering & nipple retraction ✓This condition is also difficult to clinically distinguish from Ca (hence, FNAC/ core biopsy is needed) ✓Treatment: Surgical excision, the excised mass is an infiltrative yellowish white mass
  29. 29. GALACTOCELE ✓Is a solitary sub-areolar cyst filled with milk during lactation. ✓ Formed by obstruction to a duct in the puerperium . The milk retained proximal to the obstruction eventually becomes cheese-like ✓Appears as a painless lump weeks – months after cessation of breast feeding ✓Complication Infection ✓Treatment Aspiration or Surgical Excision
  30. 30. CHRONIC MASTITIS ✓Chronic intramammary abscess: Pus encapsulated by thick-walled fibrous tissues. Difficult to clinically distinguish from Ca. ✓TB breast: Presents with multiple chronic abscesses & sinuses. A/w active pulmonary TB/ cervical adenitis. Bacteriological & pathological confirmation are required. Treatment: anti-TB drugs ✓Chronic granulomatous mastitis, Actinomycosis breast
  31. 31. ACUTE MASTITIS BREAST ABSCESS ✓Is usually due to Staph Aureus & a/w lactation ✓Breast mastitis is an infection that commonly affects women who are breast-feeding (especially during the first two months after childbirth) but can occur in all women at any time ✓ Sore & cracked/ inverted nipple is the route of infection, the usual mode of infection is via the nipple, the infection being carried by suckling infant’s nasopharynx. ✓ Part or all of the breast is intensely: painful, hot, tender, red, and swollen ✓The breasts are growing more tender, and the fever is becoming more pronounced.
  32. 32. ACUTE MASTITIS BREAST ABSCESS ✓Ultrasound: used to localize the abscess ✓FNAC: used to exclude underlying carcinoma especially in chronic Breast abscess where the abscess become encapsulated with a thick fibrous capsule & the condition can’t be distinguished from a carcinoma without a biopsy. ✓Needle Aspiration: to confirm presence of pus. ✓Mammogram: to exclude underlying carcinoma.
  33. 33. ACUTE MASTITIS BREAST ABSCESS ✓ MANAGEMENT: ✓ Simple Needle Aspiration: using a wide bore needle under local anesthesia. ✓Guided drainage: under image control with radiological or ultrasound techniques a tube drain can be inserted & left until the cavity has collapsed. ✓Surgical drainage: it is the most certain method, not only can all loculi be reached, but also dead tissue can be removed. The cavity is then dressed regularly & left open to heal by secondary intention.
  36. 36. MONDOR’S DISEASE ✓Superficial thrombophelebitis of vein over breast & chest– thoracoepigastric artery ✓Thrombosed subcutaneous cord attached to skin ✓Self limiting condition ✓Treatment is restricted arm movement
  37. 37. BENIGN BREAST DISEASES ✓Benign breast disorders & diseases are common ✓The aetiopathogenesis is complex and not fully understood ✓Lump and pain are the most common complaints ✓Evaluation is done by Triple assessment ✓Histological risk factors for future malignancy are relative and not absolute risk factors ✓Treatment is based on the natural history of clinical problems ✓Treatment must be tailored to individual needs
  40. 40. CARCINOMA BREAST AN OVERVIEW AN OVRVIEW Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia
  41. 41. OBJECTIVES • Etiopathogenesis • Types & Clinical features • Investigations • Staging • Treatment of EBC, LABC&ABC • Prognosis and Followup
  42. 42. Etiopathogenesis Incidence of Sporadic, Familial, and Hereditary Breast Cancer Sporadic breast cancer 65–75% Familial breast cancer 20–30% Hereditary breast cancer 5–10% BRCA1 a 45% BRCA2 35% p53 a (Li-Fraumeni syndrome) 1% STK11/LKB1a (Peutz-Jeghers syndrome) <1% PTENa (Cowden disease) <1% MSH2/MLH1a (Muir-Torre syndrome) <1% ATMa (Ataxia-telangiectasia) <1% Unknown 20%
  43. 43. Risk Factors Major factors Gender Age Previous breast cancer Family history and genetic predisposition (BRCA 1 or 2 mutations) Intermediate factors Alcohol and diet Endocrine factors: Early menarche Late menopause Hormone replacement therapy Nulliparity and elderly primi Irradiation Benign proliferative breast disease (e.g. multiple papillomatosis) Smoking & OCPs not a risk factor
  44. 44. TYPES Classification of Primary Breast Cancer Noninvasive Epithelial Cancers Lobular carcinoma in situ (LCIS) Ductal carcinoma in situ (DCIS) Invasive Epithelial Cancers (Percentage of Total) Invasive lobular carcinoma (10%-15%) Invasive ductal carcinoma Invasive ductal carcinoma, NOS (50%-70) Tubular carcinoma (2%-3%) Mucinous or colloid carcinoma (2%-3%) Medullary carcinoma (5%) Invasive cribriform carcinoma (1%-3%) Invasive papillary carcinoma (1%-2%) Adenoid cystic carcinoma (1%) Metaplastic carcinoma (1%)
  45. 45. Clinical Presentation • Paget’s Disease of the Nipple • Skin Tethering/dimpling/puckering • Peau d’Orange • Skin Ulceration / Fungation • Visible / Palpable Lump • Hard Consistency • Non Tender • Low mobility • Axillary Lymphnodes+ • Nipple Retraction • Nipple Discharge
  46. 46. Clinical Presentation The location of breast cancer is as follows: Upper outer quadrant: 60% Central area: 12% Lower outer quadrant: 10% Upper inner quadrant: 12% Lower inner quadrant: 6%
  47. 47. Clinical Presentation
  48. 48. Clinical Presentation Peau d’ orange Appearance
  49. 49. Clinical Presentation Skin dimpling and puckering are inspectory findings Tethering is due to infiltration of Astley cooper’s ligaments and is confirmed by palpation
  50. 50. Clinical Presentation Nipple retraction- Recent, Unilateral, circumferential infiltration and fibrosis of lactiferous ducts
  51. 51. Clinical Presentation Nipple discharge suggestive of malignancy if: 1. Spontaneous 2. Unilateral 3. From single duct 4. Bloody discharge 5. Associated with mass 6. Age > 40 yrs
  52. 52. Skin Ulceration
  53. 53. Paget’s disease of nipple ✓Eczema like condition ✓Malignant cells in the subdermal layer ✓Red flat ulcer, nipple erosion
  54. 54. Paget’s disease of nipple Paget’s Disease Eczema of Nipple Unilateral Bilateral Itching absent Itching present Absence of oozing Presence of oozing Scales & Vesicles absent Scales & Vesicles present Nipple destroyed Nipple intact Underlying lump may be present No underlying lump present Edges are distinct Edges are indistinct No response to treatment Responds to treatment Occurs at menopaus( old age) Seen in lactating women( young women)
  55. 55. Investigations “The choice of initial diagnostic evaluation after the detection of a breast lump should be individualised for each patient according to the age, perceived cancer risk and characteristics of the lesion.”
  56. 56. Investigations- Triple Assessment
  57. 57. Investigations • Staging Investigations • Xray Chest • Abdominal Ultrasound/ CT abdomen • Radionucleide Bone Scan • CT Brain • Radiological Investigations • Ultrasonography • Mammography • Pathological Investigations • Fine Needle Aspiration Cytology FNAC • Core Needle Biopsy Trucut Biopsy • Needle Localisation Biopsy • Stereotactic Biopsy • Open Biopsy Incisional& Excisional • Sentinel node Biopsy
  58. 58. Investigations- Mammography • Dense opacity • Irregular and Ill- defined margins • Asymmetry • Clustered pleomorphic microcalcification • Architectural distortion • Stellate or spiculated appearance
  59. 59. Investigations- Mammography
  60. 60. Investigations- Ultrasonography • High frequency 7MHz probe is used although 10 to 13MHz preferable • Differentiate solid and cystic lesions • Malignant appearing masses 1.Irregular margins 2.Hypoechoic 3.Posterior acoustic shadow 4.Vertical growth appearance (TALLER than wide) MASS SHADOW
  61. 61. Investigations- FNAC • 1.5 inch 22 gauge needle attached to a 10 ml syringe is used • With or without image guidance • FNAC-DISADVANTAGES 1. FALSE NEGATIVE rate high 2. Inadequate specimen 3.Requires skilled cytopathologist 4. Cannot differentiate in situ vs invasive lesions
  62. 62. Investigations- Trucut Biopsy Core Needle Biopsy • Done using a 14 gauge needle or Tru cut needle • ADVANTAGES 1. Lower FALSE negative rates 2. Doesn't need specially trained cytopathologist 3. Adequate samples are obtained 4.Can differentiate in situ vs invasive lesions 5.Can confirm-ER/PR/Her 2 neu status
  63. 63. Investigations-For Nonpalpable Lump Image Guided Biopsies 1.USG guided FNAC or core needle biopsy(if mass is visualised) 2. Needle localising biopsy 3. STEREOTACTIC needle biopsy (when no mass present but micro calcifications seen mammographically)
  64. 64. Investigations-Sentinel Node Biopsy • LYMPHAZURIN BLUE DYE • Tch99 SULPHUR COLLOID • Accuracy 99% PORTABLE GAMMA CAMERA
  65. 65. Investigations-Sentinel Node Biopsy INDICATIONS • High-risk IN SITU cancer, non- palpable breast cancer • T1 or T2 carcinoma and especially good prognosis tumors (mucinous, papillary and adenoid cystic) CONTRAINDICATIONS • Altered drainage of Augmentation surgery • Recent mammoplasty and pregnancy • Allergy to dye or radiocolloid • Inflammatory Ca • Axillary mets Absolute
  66. 66. Other Investigations 1.CXR-PA VIEW 2.CT CHEST 3.USG – ABDOMEN AND PELVIS 4.SKELETAL SURVEY/ Tc99 BONE SCAN 5.MRI BREAST- Voluminous breast/ Implant rupture 6.PET SCAN- Follow up to detect residual disease 7.Tumor Marker- CA- 15/3
  67. 67. AJCC Staging/TNM Staging T (Primary Tumor) Tis Carcinoma in situ (lobular or ductal) T1 Tumor <2 cm T2 Tumor >2 cm, <5 cm T3 Tumor >5 cm T4 Tumor any size with extension to the chest wall or skin N (Nodes) N0 No regional node involvement N1 Metastasis to 1-3 axillary nodes N2 Metastasis to 4-9 axillary nodes N3 Metastasis to >10 axillary nodes M (Metastasis) M0 No distant metastasis M1 Distant metastasis
  68. 68. TNM Staging ▪ Stage 1 and stage 2 – EBC ▪ Stage 3 – LABC ▪ 3a- T3, N 1,2, ▪ 3b- T4, ANY N ▪ 3c- N3, ANY T ▪ Stage 4- ABC
  69. 69. Management –Multimodality Treatment ▪ Surgery ▪ Curative ▪ Palliative ▪ Radiotherapy ▪ Chest Wall ▪ Axilla ▪ Supraclavicular ▪ Chemotherapy ▪ Hormonal Therapy
  70. 70. Management •Stage 1 & 2 • Breast conservation treatment- BCT ✓ Lumpectomy ✓ Wide local excision ✓ Quadrantectomy ✓ Axillary dissection ✓ Radiotherapy • Modified radical mastectomy- MRM EBC •Stage 3 • MRM+Adjuvant RT+ Adjuvant CT +/- HT • Neoadjuvant CT+MRM+ Adjuvant RT &CT+/- HT LABC •Stage 4 •Toilet Mastectomy • Adjuvant RT & CT +/- HT ABC
  71. 71. Management –ECB RT after BCT
  72. 72. Management –LABC Classification of LABC •LABC Operable at Presentation •T3, N1, M0 •LABC Inoperable at Presentation •T4, Any N, M0 •Any T, N2 or N3, M0 •Inflammatory Carcinoma of Breast •T4d, N0, M0
  73. 73. Management –LABC Treatment of Operable LABC 1. MRM → Adjuvant Radiotherapy (RT) & Adjuvant Systemic Chemotherapy (CT) +/- Hormone Therapy (HT) 2. Neoadjuvant CT→ To attempt to Down-Stage lesions for Breast Conservation Surgery Tumor Responding → BCS → CT,RT +/- HT Non-responders → MRM → CT with RT +/- HT
  74. 74. Management –LACB Treatment of Inoperable LABC Aim of Treatment: To make the disease operable and achieve loco – regional control, hence improve patients quality of life Neoadjuvant CT → MRM → CT & RT +/- HT Advantages of Neoadjuvant CT To make the tumor operable To assess tumor response to CT
  75. 75. PROGNOSTIC FACTORS 1.Axillary nodal status( most important) 2.Tumour size 3.ER/PR Status – Both positive- good prognosis 4.Histological grade of tumour 5.Her 2neu overexpression – aggressive malignancy- poor prognosis 6.Proliferating rate 1.DNA flow cytometry – aneuploid – poor prognosis 2.S phase fraction – low S phase – good prognosis
  76. 76. PROGNOSTIC FACTORS 5 yr survival – Ca Breast Stage 1 – 90% Stage 2 – 70% Stage 3 – 40 % Stage 4 – 20 %
  77. 77. NOTTINGHAM PROGNOSTIC INDEX- NPI The index is calculated using the formula: NPI = [0.2 x S] + N + G Where: S is the size of the index lesion in centimetres N is the node status: 0 nodes = 1, 1-4 nodes = 2, >4 nodes = 3 G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3 NPI Score Prognosis 5yr survival 2 to 2.4 Excellent 93% 2.4 to 3.4 Good 85% 3.4 to 5.4 Moderate 70% > 5.4 Poor 50%
  78. 78. Adjuvant Chemotherapy To deal with occult metastasis Always use combination chemotherapy More effective in pre-menopausal CT + HT > CT / HT alone Drugs used: Cyclophosphamide Methotrexate 5 – FU Anthracyclines: Doxorubicin, Epirubicin Taxanes: Paclitaxel, Docitaxel Schedule used commonly: CAF q21d x 6cycles Cyclophosphamide: 500mg/m2 D1 5 – FU: 500mg/m2 D1 & D8 Doxorubicin: 50mg/m2 D1 Regimen of choice: TAC Good efficacy irrespective of ER/PR/HER-2 neu
  79. 79. Neo Adjuvant Chemotherapy CT given before Local Control of disease It does not provide any survival advantage Helps decide response of tumor to CT Indications: 1.To downstage Operable LABC for BCT 2.To downstage Inoperable LABC for operability 3.Inflammatory Breast Cancer 4.In EBC, to improve cosmetic appeal after BCS, for large tumor in small breast
  80. 80. Neo Adjuvant Chemotherapy ▪Usually 2 – 4 cycles are given till maximum shrinkage is achieved ▪Choice of drugs are the same as for Adjuvant CT – CAF / TAC ▪If tumor is resistant then non cross resistant drugs can be used as second line CT
  81. 81. Hormone Therapy ▪ER+/PR+ → 80% chance of favorably response to HT ▪All (pre/post menopausal) patients with ER/PR+ LABC should undergo HT for 5yrs. ▪Can be given in combination with CT ▪Most commonly used agent → Tamoxifen Dose: 20mg/day, Oral for 5 Yrs Side effects: Hot flushes, sexual dysfunction, endometrial cancer, thromboembolism Raloxifene- drug of choice
  82. 82. Hormone Therapy Class Agents Selective estrogen receptor modulators (SERMS) Tamoxifen, Raloxifene, Toremifene Aromatase inhibitors Anastrozole, Letrozole, Exemestane Pure antiestrogens Fulvestrant LHRH agonists Goserelin, Leuprolide Progestational agents Megestrol Androgens Fluoxymesterone High-dose estrogens Diethylstilbestrol
  83. 83. Hormone Therapy Trastuzumab or Herceptin ▪Monoclonal antibody that targets the HER-2 neu oncogene ▪Her 2 neu codes for a growth factor that is overexpressed in 25% to 30% of breast cancers ▪Her 2 neu over-expression indicates aggressive nature of malignancy. ▪Trastuzumab may be used for Her 2 neu positive tumours in adjuvant or neo adjuvant setting
  84. 84. Radiotherapy Indications for PMRT(Post Mastectomy Radio Therapy) : 1. >4 Positive axillary nodes 2. Tumour size > 5 cm 3. Positive surgical margins 4. As a part of LABC PROTOCOL
  85. 85. Followup ▪ Monthly self examination of the breast ▪ Regular physical examination following mastectomy is necessary ▪ Every 4 months for years 1 and 2, ▪ Every 6 months for years 3 through 5, ▪ Every 12 months thereafter ▪ Contralateral mammogram yearly ▪ Routine bone scans, skeletal surveys, CT of abdomen and brain- Not necessary, Yield is low
  86. 86. Treatment Algorithm Early Breast Carcinoma
  87. 87. Treatment Algorithm Advanced Breast Carcinoma