Ca breast ug lecture ajay khanna department of surgery. ims, bhu, varanasu
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Carcinoma of the breast has several risk factors including age, family history, and benign breast diseases. Pathologically, it can be ductal or lobular carcinoma in situ or invasive. It commonly spreads to lymph nodes, bones, liver, lungs and brain. Staging involves tumor size, nodal involvement and metastasis. Investigations include imaging, biopsies and markers. Treatment involves surgery, chemotherapy, radiation, hormone and targeted therapies depending on stage and biomarkers. Prognosis depends on stage, with 5 year survival rates from 90% in stage 1 to 20% in stage 4 metastatic disease.
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Ca breast ug lecture ajay khanna department of surgery. ims, bhu, varanasu
- 2. Risk Factors Absolute • Age • CA in opposite breast • Familial • BRCA 1 and 2 • Benign Breast Disease ADH • DCIS, LCIS Relative • Living in Developed countries • Obesity • High Alcohol • Smoking • Nulliparity • Early Menarche • Late Menopause • Less Breast Feeding • Late child birth • HRT
- 3. Pathology • Ductal Carcinoma: – In situ, – Invasive • Lobular Carcinoma: – in situ, • invasive • Invasive Ductal Variety – NOS (No special Type) 70% – Tubular – Colloid – Medullary – Cribriform – Papillary – Adenoid cystic – Metaplastic
- 4. Pathology • Unifocal : One site • Multifocal : Multiple foci in same quadrant • Multicenteric : Multiple foci in different quadrant in same breast
- 6. Bloom Richardson Grading System
- 8. Metastasis • Local • Lymphatics • Hematogenous – Bones : Lumbar vertebrae, Femur, End of long bones, Thoracic Vertebrae, Ribs, skull in order – Liver, lungs, Brain, Adrenal, Ovaries • Transcoelomic
- 9. Clinicopathological Types • Scirrhous 60% • Medullary 5% • Inflammatory Carcinoma 2% • Atrophic Schirrhous • Colloid • Paget’s Disease • Tubular/Papillary/Cribriform
- 10. Clinical Presentation • Lump • Nipple Discharge • Ulceration, Fungation • Axillary Nodes • Lymphoedema • Chest pain, Haemoptysis • Bony pain, Pathological fracture • Jaundice • Headache, vomiting
- 11. Clinical Examination of Breast • Palpation is most Important • Best Position to Examine • How to palpate Breast • Best time to palpate the Breast
- 12. Skin Changes in CA Breast • Peau d’ orange : Obstruction of dermal lymphatics. Hair follicles burried inside oedema • Ulceration • Satellite Nodules • Dimpling : Cooper ligament infiltration • Retraction of Nipple : Infiltration of Lactiferous duct • Cancer en cuirrasse
- 13. Differential Diagnosis • Fibroadenoma • Fibroadenosis • Traumatic Fat Necrosis • Chronic mastitis • Antibioma • Phyllodes Tumor • Tuberculosis • Granulomatous Mastitis
- 15. Staging of Breast Cancer • Primary Tumor T2 Tumor size > 2cm, but 5cm T3 Tumor size > 5cm T4 Tumor of any size with direct extension to chest wall or skin T4a Extension to chest wall, not including pectoralis muscle T4b Edema (including peau d’orange), or ulceration of the skin, or satellite skin nodules confined to the same breast T4c Both T4a and T4b T4d Inflammatory carcinoma
- 16. Staging of Breast Cancer • Stage grouping Stage Tumo r size Nodal involvement Distant Metastasis 0 Tis N0 M0 I T1 N0 M0 IIA T2 N0 M0 T1-0 N1 M0 IIB T3 N0 M0 T2 N1 M0 IIIA T3 N1 M0 T0-3 N2 M0 IIIB T4 N0-2 M0 IIIC any T N3 M0 IV any T any N M1
- 17. Triple Assessment 1.Clinical Breast Examination 2.Imaging- Ultrasound all ages / Mammography above 35 years 3.Fine needle aspiration cytology/or Core Biopsy Diagnostic accuracy for a lump = 100%
- 18. Investigations for any suspected Cancer • Investigations to make/Confirm Diagnosis • Investigations for metastatic work up • Investigations for fitness of patients for therapy
- 19. Investigations • X-ray Chest • CT Chest • USG abdomen • X-ray of suspected bone/ Skeltal Survey/Bone Scan • ER/PR/HER/Ki 67 • MRI Breast • Tumor Markers CA15/3, CEA, CA 27-29 • PET Scan
- 20. Other Investigation • Sentinel Node • CT Scan chest, abdomen, Brain • Ductography • Ductoscopy • Types of Biopsies : – FNAC – Core Needle Biopsy/Core/Trucut – Stereotactic Core Biopsy – Vacuum Assisted Biopsy – Needle localization Biopsy – Punch/wedge in ulcerated tumor
- 21. Mammogram Classification System • Breast Imaging Reporting and Data System (BI-RADS) Category 0 Need additional imaging evaluation Screening situation. Need additional magnification views, spot compression, U/S, etc. Category 1 Negative No findings to comment on. Category 2 Benign finding Calcified fibroadenomas, secretory calcifications, cysts, lipomas, hamartomas, etc. Category 3 Probable benign finding — short interval follow-up suggested Not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability. Category 4 Suspicious abnormality – biopsy should be considered Do not have the characteristic morphologies of breast CA, but have definite probability of being malignant Category 5 Highly suggestive of malignancy — appropriate action should be taken Characteristic of breast cancer.
- 22. Types of Breast Cancer • Early Breast Cancer • Locally Advanced Breast Cancer • Metastatic Breast Cancer
- 23. Types of Treatment • Surgery • Radiotherapy • Chemotherapy • Hormonal Treatment • Targeted Therapy
- 24. Treatment SURGICAL • Radical Mastectomy • Modified Radical Mastectomy • Simple/Total Mastectomy • Breast Conserving Surgery CHEMOTHERAPY • Neo-Adjunctive Chemotherapy • Adjunctive Chemotherapy • Chemotherapy for Advanced Metastatic Disease RADIATION • Intra-operative Irradiation • External beam Radiotherapy • Brachytherapy Dr.NidhiAhya(MPT-CVRPT) 24
- 25. Surgery • Modified Radical Mastectomy – Patey’s – Scanlon – Auchincloss • Breast Conservation Surgery – Lumpectomy – Segmentectomy – Quadrantectomy • Radical Mastectomy (Halstead) • Toilet Mastectomy • Skin Sparing Mastectomy
- 26. Breast Conserving Surgery This involves – Lumpectomy- Surgical removal of lump, margin of normal tissue surrounding lump. May include sampling or removal of axillary lymph nodes. Segmental Mastectomy- Excision of mass along with some portion of breast tissue Quadrectomy – excision of affected quadrant of the breast tissue
- 27. Early Breast Cancer Stage 1 and 2 • Surgery – MRM – BCS • Chemotherapy (Adjuvant) • Radiotherapy (Must in BCS) • Hormonal Treatment
- 28. Locally Advanced Breast Cancer (LABC) (Stage 3) AJCC Stage III • IIIA: T3, N1-N2. T0-T3, N2. • IIIB: T4, N0-N2. • IIIC: T0-T4, N3. 28
- 29. LABC. Treatment • Usual approach: Neoadjuvant chemotherapy, Surgery (MRM), additional chemotherapy, and consolidative Radiation therapy. • HER-2 positive cancers should receive trastuzumab based therapy. • Hormone receptor positive cancers should receive adjuvant endocrine therapy. • Addition of paclitaxel to anthracycline based therapy improves long term outcomes for LABC / IBC. • All patients with LABC / IBC should be routinely treated with post mastectomy radiation therapy. 29
- 30. LABC. Inflammatory breast cancer • 1% to 5%. • Aggressive variant of LABC. • Clinicopath entity – diffuse erythema and edema (peau d’orange), often without an underlying palpable mass. • Usually in Young age • Findings involve most of skin of breast. • Rapid onset and progression. • Often initially mistaken as infection. • Tumor emboli in dermal lymphatics. 30
- 31. Locally Advanced Breast Cancer • Neo adjuvant 3-6 cycles • Surgery (Usually MRM) • Adjuvant Treatment • Radiotherapy • Hormonal Treatment (Tamoxiphen/ AI)
- 32. Metastatic Breast Cancer Stage 4 • Systemic Treatment – Chemotherapy – Hormonal
- 33. Prognosis • Stage 1 : 90% 5 Year Survival • Stage 2 : 70% 5 Year Survival • Stage 3 : 40% 5 Year Survival • Stage 4 : 20% 5 Year Survival