BREAST

6,894 views

Published on

Breast Problems...

Published in: Health & Medicine
0 Comments
10 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
6,894
On SlideShare
0
From Embeds
0
Number of Embeds
23
Actions
Shares
0
Downloads
41
Comments
0
Likes
10
Embeds 0
No embeds

No notes for slide

BREAST

  1. 1. BREAST
  2. 2. Breast Lymphatic drainage 1.Level I- nodes located lateral to or below the lower border of the p. minor 2. Level II- nodes located deep to or behind the p. minor 3. Level III- nodes located medial to or above the upper border of the p. minor
  3. 3. Gynecomastia <ul><li>- Presence of a female type mammary gland in the male </li></ul><ul><li>- Excess of estrogen in relation to circulatory testosterone </li></ul><ul><li>- Does not predispose the male breast to CA </li></ul>
  4. 4. Pathophysiologic Mechanism of Gynecomastia <ul><li>1. Estrogen excess states </li></ul><ul><li>2. Androgen deficiency states </li></ul><ul><li>3. Drug-related conditions that initiate gynecomastia </li></ul><ul><li>4. Systemic disease with idiopathic mechanism </li></ul>
  5. 5. Treatment: <ul><li>1. Medical therapy </li></ul><ul><li>2. Subcutaneous mastectomy- if refractory to medical tx </li></ul>
  6. 6. Mammography <ul><li>Useful for: </li></ul><ul><li>1. Examinations of an indeterminate mass that presents as a solitary lesion suspicious of CA </li></ul><ul><li>2. Examination of an indeterminate mass that cannot be considered a dominant nodule </li></ul><ul><li>3. Follow-up examination of breast cancer treated by conservative surgery </li></ul><ul><li>4. Follow-up of examinations of contralateral breast following mastectomy for CA </li></ul><ul><li>5. Evaluation of the large fatty breast in the symptomatic patient </li></ul>
  7. 7. Mammography <ul><li>Findings suggestive of CA </li></ul><ul><li>1. Presence of a mass with spiculated or irregular margins </li></ul><ul><li>2. Presence of fine stippled calcification </li></ul>
  8. 8. Mammography <ul><li>NCI Recommendation </li></ul><ul><li>Age 50 & older </li></ul><ul><li>- Mammography every 1-2 year and </li></ul><ul><li>annual clinical BE </li></ul><ul><li>Age 40-49 </li></ul><ul><li>- Screening mammography for those at </li></ul><ul><li>RISK </li></ul>
  9. 9. Mammography <ul><li>Prospective randomized studies of routine mammographic screening confirms: </li></ul><ul><li>1. 40 % reduction for Stage II disease </li></ul><ul><li>2. 30 % increase in survived in patient found </li></ul><ul><li>to have CA </li></ul>
  10. 10. Ultrasound <ul><li>Value: </li></ul><ul><li>1. Resolution of equivocal mammography </li></ul><ul><li>2. Diagnosis of cystic disease </li></ul><ul><li>3. Demonstration of solid abnormalities with </li></ul><ul><li>specific echogenic features </li></ul>
  11. 12. Inflammatory and Infectious Disorders <ul><li>Bacterial Infectious </li></ul><ul><li>1. Acute Mastitis </li></ul><ul><li>- Puerperal or lactational mastitis </li></ul><ul><li>- Most common offending organisms: S. </li></ul><ul><li>aureus </li></ul><ul><li>- Infection tends to be localized & </li></ul><ul><li>suppurative </li></ul>
  12. 13. Acute Mastitis Treatment <ul><li>1. Discontinuance of lactation to enable resolution of the inflammatory process </li></ul><ul><li>2. Presuppurative - antibiotic </li></ul><ul><li>3. Suppurative - Surgical drainage </li></ul>
  13. 14. Chronic Mastitis <ul><li>- Recurrent abscess formation </li></ul><ul><li>- Multiple skin sinus </li></ul><ul><li>- Simulate breast CA </li></ul><ul><li>- Most common offending organisms: TB bacilli </li></ul><ul><li>- Treatment: </li></ul><ul><li>1. Biopsy to r/o CA </li></ul><ul><li>2. Anti-koch’s regimen </li></ul>
  14. 15. Benign Lesions <ul><li>1. Fibrocystic change/disorders </li></ul><ul><li>- Localized estrogen sensitivity </li></ul><ul><li>- Diffuse, often bilateral breast pain </li></ul><ul><li>- Pain accentuated just before menstruation </li></ul><ul><li>- Not a risk factor for breast CA </li></ul><ul><li>- May present as a single dominant cyst </li></ul>
  15. 16. Fibrocystic Change/Disorders Treatment <ul><li>1. Analgesics </li></ul><ul><li>2. Danazol/Tamoxifen- anti-estrogen: 60% cure rate </li></ul><ul><li>3. Dominant cyst- aspiration </li></ul>
  16. 17. Benign Lesions <ul><li>2. Fibroadenoma </li></ul><ul><li>- 2nd-3rd decade </li></ul><ul><li>- Relationship to estrogen sensitivity </li></ul><ul><li>- Well-defined, rubbery mass </li></ul><ul><li>- No premenstrual tenderness </li></ul><ul><li>- Stop growing when they reach 2-3 cms. </li></ul><ul><li>- No risk for malignancy </li></ul>
  17. 18. Fibroadenoma Treatment : <ul><li>1. FNAB </li></ul><ul><li>2. Observation <25 y/o </li></ul><ul><li>3. Excision biopsy >25 y/o </li></ul>
  18. 19. Benign Lesions <ul><li>3. Intraductal papilloma </li></ul><ul><li>- Most common cause of a bloody nipple discharge(70%) </li></ul><ul><li>- Located beneath the areola </li></ul><ul><li>- Usually solitary and <1 cm. In size </li></ul><ul><li>- Increased risk for CA for multiple papilloma </li></ul><ul><li>- Treatment: Excision </li></ul>
  19. 20. Benign Lesions <ul><li>4. Fat Necrosis </li></ul><ul><li>- Usual history of trauma to the chest or breast </li></ul><ul><li>- Affects women with pendulous breast </li></ul><ul><li>- Mass and skin dimpling </li></ul><ul><li>- Mammography-Coarse calcification </li></ul><ul><li>- No risk for cancer </li></ul><ul><li>- Treatment: Excision </li></ul>
  20. 22. Ten Leading Sites of Cancer in Females, 1998, Philippines 25.9% 12.6% 7.4% 5.8% 5.7% 4.1% 3.9% 3.7% 2.9% 2.9%
  21. 23. Ten Leading Sites of Cancer in Males in 1998, Philippines 26.7% 12.3% 6.4% 5.2% 4.9% 4.8% 4.6% 3.9% 3.6% 2.4%
  22. 24. Ten Leading Sites of Cancer in 1998, Both Sexes, Philippines 15.6% 13.2% 7.3% 6.3% 4.4% 4.1% 3.6% 3.6% 3.1% 2.9%
  23. 25. Breast Cancer <ul><li>Etiology </li></ul><ul><li>1. Family history </li></ul><ul><li>2. High dietary fat intake </li></ul><ul><li>3. Obesity </li></ul><ul><li>4. Late menopause (> 45 y/o) </li></ul><ul><li>5. Infertility & nulliparity </li></ul><ul><li>6. History of primary breast CA </li></ul><ul><li>7. Irradiation to chest </li></ul><ul><li>8. Germs- Line mutations </li></ul><ul><li>1.) BRCA 1 Chrom. 17q21 </li></ul><ul><li>2.) BRCA 2 Chrom. 13q12-13 </li></ul><ul><li>9. Certain breast diseases </li></ul><ul><li>a. Atypical hyperplasia </li></ul><ul><li>b. Lobular carcinoma in situ </li></ul><ul><li>c. Ductal carcinoma in situ </li></ul>
  24. 26. Breast Cancer <ul><li>Natural history </li></ul><ul><li>Untreated patients </li></ul><ul><li>5 yr. SR- 18 % </li></ul><ul><li>10 yr. SR- 3.6 </li></ul><ul><li>Metastatic disease- most common cause of death </li></ul><ul><li>Affects the age group 45-65 y/o </li></ul><ul><li>40-50 % are located in the upper outer quadrant </li></ul><ul><li>Hard, non-tender mass on presentation </li></ul><ul><li>Skin dimpling, nipple retraction, bloody nipple discharge, palpable axillary lymph nodes </li></ul>
  25. 27. Breast Cancer <ul><li>Axillary LN are involved progressively from Level I to Level II to Level III </li></ul><ul><li>Nodal status-most important prognostic correlate for recurrent disease & survival </li></ul><ul><li>- Number of positive of axillary lymph nodes and location of the positive axillary lymph node </li></ul>
  26. 28. Breast Cancer <ul><li>Sites of Distant Metastases </li></ul><ul><li>1. Bone </li></ul><ul><li>2. Lung </li></ul><ul><li>3. Pleura </li></ul><ul><li>4. Soft tissue </li></ul><ul><li>5. Liver </li></ul>
  27. 29. Breast Cancer Biopsy <ul><li>1. Palpable lesions </li></ul><ul><li>1. Incisional bx </li></ul><ul><li>2. Excisional bx </li></ul><ul><li>3. Tru-cut biopsy </li></ul><ul><li>4. Fine needle aspiration </li></ul><ul><li>2. Non palpable lesions </li></ul><ul><li>- Localization followed by biopsy </li></ul>
  28. 30. Stages are Defined by TNM Classification <ul><li>Primary Tumor (T) </li></ul><ul><li>Tx Primary tumors cannot be assessed </li></ul><ul><li>To No evidence of primary tumors </li></ul><ul><li>TIS Carcinoma in situ </li></ul><ul><li>T1 Tumor 2 cm.or less is greatest dimension </li></ul><ul><li>T2 Tumor > 2 cm. but < 5 cm. </li></ul><ul><li>T3 Tumor > 5 cm. </li></ul><ul><li>T4 Tumor of any size with direct extension to chest wall of skin; includes inflammatory carcinoma </li></ul>
  29. 31. TNM Staging <ul><li>Regional lymph node (N) </li></ul><ul><li>Nx Regional lymph nodes cannot be assessed </li></ul><ul><li>N0 No regional lymph node metastasis </li></ul><ul><li>N1 Metastasis to movable ipsilateral axillary lymph node (s) </li></ul><ul><li>N2 Metastasis to ipsilateral axillary lymph nodes fixed to one another or to other structure </li></ul><ul><li>N3 Metastasis to ipsilateral internal mammary lymph nodes; </li></ul><ul><li>supraclavicular lymph node </li></ul>
  30. 32. TNM Staging <ul><li>Distant Metastases </li></ul><ul><li>Mx Presence of distant metastases cannot be assessed </li></ul><ul><li>M0 No distant metastases </li></ul><ul><li>M1 Distant metastases </li></ul>
  31. 33. TNM Staging <ul><li>Stage 0 Tis No Mo </li></ul><ul><li>Stage I T1 No Mo </li></ul><ul><li>Stage 2A To N1 Mo </li></ul><ul><li>T1 N1 Mo </li></ul><ul><li>T2 No Mo </li></ul><ul><li>2B T2 N1 Mo </li></ul><ul><li>T3 No Mo </li></ul><ul><li>Stage 3A To N2 Mo </li></ul><ul><li>T1 N2 M1 </li></ul><ul><li>T2 N2 Mo </li></ul><ul><li>T3 N1,N2 Mo </li></ul><ul><li>3B T4 Any N Mo </li></ul><ul><li>3C Any T N3 Mo </li></ul><ul><li>Stage IV Any T Any N M1 </li></ul>
  32. 34. Breast Cancer Histopathology <ul><li>A. Non infiltrating (In Situ) Carcinoma of Ductal and Lobular Origin </li></ul><ul><li>1.Lobular CA in Situ </li></ul><ul><ul><ul><li>observed only in females </li></ul></ul></ul><ul><ul><ul><li>> 90 % are premenopausal </li></ul></ul></ul><ul><ul><ul><li>90 % ER positive </li></ul></ul></ul><ul><ul><ul><li>25-35 % will develop breast CA </li></ul></ul></ul><ul><ul><ul><li>majority of future invasive CA are ductal </li></ul></ul></ul><ul><ul><ul><li>important features : multicentricity & bilaterality </li></ul></ul></ul>
  33. 35. <ul><li>2. Ductal Carcinoma in Situ </li></ul><ul><li>- Among menopausal women </li></ul><ul><li>- 25-70% risk for invasive CA </li></ul><ul><li>- Future cancers are observed in the ipsilateral breast and in the same quadrant </li></ul>Breast Cancer Histopathology
  34. 36. <ul><li>B. Infiltrating Malignancies </li></ul><ul><li>1. Paget’s Disease of the nipple </li></ul><ul><li>- Chronic eczematoid eruption of the nipple </li></ul><ul><li>- Good prognosis </li></ul>Breast Cancer Histopathology
  35. 37. <ul><li>2. Infiltrating Ductal Carcinoma w/ productive </li></ul><ul><li>fibrosis </li></ul><ul><li>- Most common form of breast CA (75-80%) </li></ul><ul><li>- Affects the 40-60 years old age group </li></ul><ul><li>- Commonly presents as a solitary, </li></ul><ul><li>hard, non-tender, ill-defined mass </li></ul><ul><li>- Profound desmoplastic response- skin </li></ul><ul><li>dimpling </li></ul><ul><li>- Important feature is multicentricity </li></ul>Breast Cancer Histopathology
  36. 38. <ul><li>3. Medullary carcinoma </li></ul><ul><li>- Soft, hemorrhagic bulky mass </li></ul><ul><li>- Better 5 yr. SR than invasive ductal or </li></ul><ul><li>lobular CA </li></ul>Breast Cancer Histopathology
  37. 39. <ul><li>4. Mucinous Carcinoma (Colloid CA) </li></ul><ul><li>- Presents as a bulky, mucinous tumor </li></ul><ul><li>- Cut surface glistening & gelatinous </li></ul>Breast Cancer Histopathology
  38. 40. <ul><li>5. Tubular Carcinoma </li></ul><ul><li>- Most differentiated variant of breast CA </li></ul><ul><li>- 100 % long term survival rate </li></ul>Breast Cancer Histopathology
  39. 41. <ul><li>6. Papillary Carcinoma </li></ul><ul><li>- Lowest frequency of axillary nodal </li></ul><ul><li>involvement </li></ul><ul><li>- 5 & 10 yr. SR approaches Tubular CA </li></ul>Breast Cancer Histopathology
  40. 42. <ul><li>7. Lobular Carcinoma </li></ul><ul><li>- originate from terminal ductules of the </li></ul><ul><li>lobule </li></ul><ul><li>- high propensity for bilaterality, </li></ul><ul><li>multicentricity & multifocality </li></ul>Breast Cancer Histopathology
  41. 43. <ul><li>8. Inflammatory Carcinoma </li></ul><ul><li>- Carries the worst prognosis </li></ul><ul><li>- Features of erythema, peau d’ orange </li></ul><ul><li>& skin ridging w/ or w/o a palpable </li></ul><ul><li>mass </li></ul><ul><li>- Subdermal lymphatics and vascular </li></ul><ul><li>channels are permeated w/ foci of highly </li></ul><ul><li>undifferentiated tumor </li></ul>Breast Cancer Histopathology
  42. 44. HVB
  43. 45. Breast Cancer Treatment <ul><li>Local Control </li></ul><ul><li>1. Surgery </li></ul><ul><li>2. Radiation </li></ul><ul><li>Systemic Control </li></ul><ul><li>1. Chemotherapy </li></ul><ul><li>2. Hormonal Therapy </li></ul>
  44. 46. BREAST CANCER Historical Perspectives <ul><li>Sir James Paget (1863)- Excision </li></ul><ul><li>Charles Moore (1876)- Total mastectomy + Axillary dissection </li></ul><ul><li>Richard van Volkman (1875)- Same a above + removal of the pectoral fabric </li></ul>
  45. 47. BREAST CANCER Historical Perspectives <ul><li>Halsted (1882)- Classical Radical Mastectomy </li></ul><ul><li>Removes: </li></ul><ul><li>1. Whole breast </li></ul><ul><li>2.Overlying skin </li></ul><ul><li>3. Axillary LN </li></ul><ul><li>4. Pectoralis muscles </li></ul><ul><li>- Gold standard for the next 50 years </li></ul>
  46. 48. BREAST CANCER Historical Perspectives <ul><li>Wangenstein & Urban (1956)-Super radical mastectomy </li></ul><ul><li>Includes: </li></ul><ul><li>1. CRM </li></ul><ul><li>2. Supraclavicular LN </li></ul><ul><li>3. Int. mammary LN </li></ul><ul><li>4. Mediastenal LN </li></ul><ul><li>5. 1/2 of sternum and ribs 2-5 </li></ul>
  47. 49. BREAST CANCER Historical Perspectives <ul><li>Patey and Madden (1965) - Modified Radical Mastectomy </li></ul><ul><li>Components: </li></ul><ul><li>1. Total mastectomy </li></ul><ul><li>2. Axillary LN dissection </li></ul>
  48. 50. BREAST CANCER Historical Perspectives <ul><li>Veronesi & Fischer (1980) - Conservative breast surgery </li></ul><ul><li>Components: </li></ul><ul><li>1. Quadrantectomy/Lumpectomy </li></ul><ul><li>2. Axillary sampling </li></ul><ul><li>3. Radiation of the breast </li></ul>
  49. 51. CONSERVATIVE BREAST SURGERY <ul><li>SR </li></ul><ul><li>Study Stage Treatment No. 5 yr 10 yr </li></ul><ul><li>Milan 1 QUART 352 92 79 </li></ul><ul><li>1 Rad. Mast. 349 90 78 </li></ul><ul><li>WHO 1 QUART 88 95 </li></ul><ul><li>1 MRM 91 91 </li></ul><ul><li>NSABP I,II Lumpty/Rtx 625 83 </li></ul><ul><li>I,II MRM 586 79 </li></ul><ul><li>NCI I,II Lumpty/Rtx 112 88 </li></ul><ul><li>I,II MRM 103 84 </li></ul>
  50. 52. Contraindications to Breast Conservative Surgery <ul><li>1. Tumor greater than 5 cm </li></ul><ul><li>2. Poorly defined tumor </li></ul><ul><li>3. Large tumor in a small breast </li></ul><ul><li>4. Pregnancy’ </li></ul><ul><li>5. Previous irradiation in the same site </li></ul><ul><li>6. Multiple tumors within the breast confirmed to be malignant </li></ul><ul><li>7. Diffuse microcalcifications on mammography </li></ul><ul><li>8. Tumor involves skin or chest wall </li></ul>
  51. 54. Breast Cancer Treatment <ul><li>A. In Situ Disease </li></ul><ul><li>1. LCIS-Lobular carcinoma in situ </li></ul><ul><li>- Marker for increased risk rather than </li></ul><ul><li>an inevitable precursor of invasive </li></ul><ul><li>disease </li></ul><ul><li>- Options: </li></ul><ul><li>1. Observation </li></ul><ul><li>2. Bilateral mastectomy </li></ul>
  52. 55. Breast Cancer Treatment <ul><li>2. DCIS - Ductal carcinoma in situ </li></ul><ul><li>- Precursor of invasive disease </li></ul><ul><li>- Options: </li></ul><ul><li>1. Total mastectomy - gold standard </li></ul><ul><li>2. Conservative breast surgery - </li></ul><ul><li>(lumpectomy, quadrandectomy, </li></ul><ul><li>segmental mastectomy) & irradiation </li></ul>
  53. 56. Breast Cancer Treatment <ul><li>Stage I & Stage II </li></ul><ul><li>Options: </li></ul><ul><li>1. Breast Conservative Surgery- (Lumpectomy/quadrandectomy /segmental mastectomy) w/ separate axillary node dissection and irradiation </li></ul><ul><li>2. Modified radical mastectomy (Total mastectomy w/ axillary dissection) </li></ul>
  54. 57. Breast Cancer Treatment <ul><li>Stage 3 A </li></ul><ul><li>Options: </li></ul><ul><li>1. Modified Radical Mastectomy </li></ul><ul><li>2. Induction chemotherapy + MRM + </li></ul><ul><li>Radiation </li></ul>
  55. 58. Induction Chemotherapy <ul><li>- C hemotherapy given before the initiation of local therapy </li></ul><ul><li>- Also called neoadjuvant or preoperative chemotherapy </li></ul><ul><li>- Advantages: </li></ul><ul><li>1. Reduction of the initial tumor burden before surgery </li></ul><ul><li>2. Ability to treat the potential systemic disease w/o delay </li></ul><ul><li>3. Ability to asses the response of the tumor to the treatment being rendered </li></ul>
  56. 59. Breast Cancer Treatment <ul><li>Stage 3 B - (LABC including Inflammatory CA) </li></ul><ul><li>Induction Chemotherapy </li></ul><ul><li>- Good response MRM Radiation </li></ul><ul><li>- Poor response Radiation MRM </li></ul>
  57. 60. Breast Cancer Treatment <ul><li>Stage IV </li></ul><ul><li>Radiation &/or </li></ul><ul><li>palliative (hygienic mastectomy ) + chemotherapy &/or hormonal therapy </li></ul>
  58. 61. Breast Cancer Treatment <ul><li>Adjuvant Therapy </li></ul><ul><li>A. Chemotherapy </li></ul><ul><li>B. Hormonal therapy </li></ul><ul><li>C. Radiation </li></ul>
  59. 62. Chemotherapy <ul><li>- Improves 5 yr. SR up to 30 % </li></ul><ul><li>Fischer - Thiotepa </li></ul><ul><li>- L- PAM </li></ul><ul><li>BONNADONA- CMF </li></ul><ul><li>- combination most commonly used </li></ul><ul><li>- 12 cycle in 6 months </li></ul><ul><li>SWOG - FAC/AC </li></ul><ul><li>- more effective than CMF but w/ </li></ul><ul><li>more toxicity </li></ul>
  60. 63. Hormonal Manipulation <ul><li>1. Ablation - Oophorectomy </li></ul><ul><li> - Adrenalectomy </li></ul><ul><li> - Hypophysectomy </li></ul><ul><li>2. Additive - Parodoxical effects of high estrogen dosage </li></ul><ul><li>3. Anti-estrogen – </li></ul><ul><li> - Tamoxifen </li></ul><ul><li>- Diethylstilbestrol </li></ul><ul><li>- Aminogluthetimide </li></ul><ul><li> - Aromatase inhibitors- Letrozole, </li></ul><ul><li>Anastrazole </li></ul>
  61. 64. Hormonal Therapy <ul><li>Tamoxifen </li></ul><ul><li>- Most common form of hormonal therapy </li></ul><ul><li>- Absence of toxicity and profound side effects </li></ul><ul><li>- Adverse effect- Less than 5% </li></ul><ul><li>1. Endometrial CA </li></ul><ul><li>2. Thromboembolic events </li></ul><ul><li>- Given at 20 mg. daily </li></ul><ul><li>- Duration: 5 years </li></ul>
  62. 65. Hormonal Therapy <ul><li>Hormonal Receptors </li></ul><ul><li>- Specific proteins in the cytosol of breast CA </li></ul><ul><li>- Estrogen and progesterone receptors </li></ul><ul><li>- ER and PR activity is a measure of hormonal responsiveness of the index tumor or metastatic foci of disease </li></ul><ul><li>- Degree of positivity is proportional to the differentiation and histologic subtype of the lesion </li></ul>
  63. 66. Hormonal Therapy <ul><li>Markers: </li></ul><ul><li>1. Estrogen receptor </li></ul><ul><li>2. Progesterone receptor Response rate </li></ul><ul><li>ER + 80% </li></ul><ul><li>PR + </li></ul><ul><li>ER + 27% </li></ul><ul><li>PR - </li></ul><ul><li>ER - 45% </li></ul><ul><li>PR + </li></ul><ul><li>ER - 10% </li></ul><ul><li>PR - </li></ul>> > > >
  64. 67. Radiotherapy <ul><li>1. Component of conservative breast </li></ul><ul><li>surgery </li></ul><ul><li>2. Stage III & IV </li></ul><ul><li>3. Recurrent cancer </li></ul><ul><li>1. Local-chest wall </li></ul><ul><li>2. Distant-bone metastases </li></ul>
  65. 68. Breast Cancer Adjuvant Therapy <ul><li>Premenopausal Chemo tx </li></ul><ul><li>Node (+) </li></ul><ul><li>Postmenopausal Tamoxifen </li></ul><ul><li>± Chemo tx </li></ul><ul><li>< 1 cm - No Tx </li></ul><ul><li>Chemotx </li></ul><ul><li>Node (-) Premen Tamoxifen </li></ul><ul><li>ER(+) Postmen Tamoxifen </li></ul><ul><li>> 1 cm </li></ul><ul><li>ER(-) Chemo tx </li></ul>
  66. 69. Factors that Affect Prognosis and Selection of Therapy <ul><li>1. Age of the patient </li></ul><ul><li>2. Stage of the disease </li></ul><ul><li>3. Pathologic characteristics of the primary tumor </li></ul><ul><li>4. ER & PR receptor level </li></ul><ul><li>5. Measures of proliferative capacity </li></ul><ul><li>1. Thymidine labelling index </li></ul><ul><li>2. Ploidy pattern / S phase </li></ul><ul><li>6. Menopausal status </li></ul><ul><li>7.General health </li></ul>
  67. 71. Breast Cancer Follow-up <ul><li>- 80 % recurrence w/in the first 5 years </li></ul><ul><li>- Evaluation should be individualized </li></ul><ul><li>- 65-85% of recurrences detected by history & PE </li></ul><ul><li>- Improved survival among breast cancer patients who later become pregnant </li></ul>
  68. 72. Breast Cancer Follow-up <ul><li>Recurrences: </li></ul><ul><li>1. Local- 10-30 % </li></ul><ul><li>2. Distant- 60-70 % </li></ul><ul><li>3. Local & distant- 10-30 % </li></ul>
  69. 73. Locally Recurrent Breast Cancer <ul><li>A. Breast conservative surgery </li></ul><ul><li>- rarely associated with distant </li></ul><ul><li>metastases </li></ul><ul><li>- recurrence remains curable in the </li></ul><ul><li>majority of cases </li></ul><ul><li>- Treatment: Salvage MRM </li></ul><ul><li>- 60 - 70% 5 yr. disease free SR </li></ul>
  70. 74. Locally Recurrent Breast CA <ul><li>B. Modified Radical Mastectomy </li></ul><ul><li>- Frequently associated w/ distant </li></ul><ul><li>metastases </li></ul><ul><li>- Treatment: Surgical excision + </li></ul><ul><li>radiotherapy </li></ul><ul><li>- Median survival - 2-3 yrs. </li></ul>
  71. 75. Metastatic Breast Cancer <ul><li>- Generally cannot be cured </li></ul><ul><li>- Median survival - 2 yrs. </li></ul><ul><li>- Selection of initial treatment depends whether the patients tumor is hormonally sensitive or not </li></ul>
  72. 76. Metastatic Breast Cancer <ul><li>Metastatic breast cancer </li></ul><ul><li>ER (+) ER (-) </li></ul><ul><li>Unknown </li></ul><ul><li>Premenopausal Postmenopausal </li></ul><ul><li>Tamoxifen </li></ul><ul><li>Nonresponders Responders </li></ul><ul><li>1. Oophorectomy </li></ul><ul><li>2. DES, Progesterone </li></ul><ul><li>CHEMOTHERAPY </li></ul>
  73. 77. Metastatic breast cancer <ul><li>Results of Chemotherapy for metastases </li></ul><ul><li>- Favorable response in 2/3 of patients </li></ul><ul><li>- Complete response in 15 % </li></ul>
  74. 78. Breast Cancer and Pregnancy <ul><li>- Diagnosis typically more difficult </li></ul><ul><li>1. Low level of suspicion- young age </li></ul><ul><li>2. Nodular changes during pregnancy </li></ul><ul><li>3. Inc. density makes mammography less accurate </li></ul><ul><li>- Diagnosis frequently delayed </li></ul><ul><li>- Poor prognosis </li></ul><ul><li>- When matched for tumor stage, pregnant women with breast cancer have the same prognosis as the non- pregnant patient </li></ul>
  75. 79. Breast Cancer and Pregnancy <ul><li>Treatment </li></ul><ul><li>- Treatment decisions are influenced by their timing w/ respect to the specific trimester of pregnancy </li></ul><ul><li>- Numerous studies have shown that terminations of pregnancy in hopes of minimizing hormonal stimulation of the tumor has shown no benefit to maternal survival </li></ul><ul><li>- Goal should be curative treatment of the breast cancer w/o injury to the fetus </li></ul>
  76. 80. Breast Cancer & Pregnancy <ul><li>Treatment </li></ul><ul><li>- Mod. Radical mastectomy can be undertaken at any point during pregnancy </li></ul><ul><li>- Breast conservative surgery complicated by the fact that radiotherapy is contraindicated during pregnancy. Option in the third trimester. </li></ul><ul><li>- Chemotherapy </li></ul><ul><li>1. No risk during the 2nd and 3rd trimester </li></ul><ul><li>2. During the Ist trimester asso. w/ an increased </li></ul><ul><li>evidence of spontaneous abortion & congenital </li></ul><ul><li>malformation </li></ul>
  77. 81. Phylloides Tumor <ul><li>- Present at a median age of 50 </li></ul><ul><li>- Mammographically indistinguishable from fibroadenoma </li></ul><ul><li>- Treatment : </li></ul><ul><li>1. Benign - Excision/total mastectomy </li></ul><ul><li>2. Malignant - Total mastectomy </li></ul><ul><li>- no role for radiotherapy, hormonal </li></ul><ul><li>therapy & chemotherapy </li></ul>
  78. 82. Carcinoma of the Male Breast <ul><li>- Less than 1% of all breast cancer </li></ul><ul><li>- Peak evidence 60 - 69 years of age </li></ul><ul><li>- Tumor commonly ER (+) </li></ul><ul><li>- Stage for stage have the same survival rate as women </li></ul><ul><li>- Overall prognosis is poor because of the advanced stage of the disease at diagnosis </li></ul><ul><li>- Treatment: </li></ul><ul><li>l. Modified Radical Mastectomy </li></ul><ul><li>2. Radiotherapy for ulcerative & high grade tumor </li></ul>
  79. 83. http://crisbertcualteros.page.tl

×