Periampullary_carcinoma_–diagnosis_with_staging,_preoperative (2).pptx

1. MANAGEMENT OF EARLY
BREAST CANCER
BY- DR. HIMANSHU MODANAWAL
THIRD YEAR PGT

2. BREAST
• COMPOSED OF 15-20 LOBES WHICH ARE EACH COMPOSED OF SEVERAL
LOBULES.
• FIBROUS BANDS OF CONNECTIVE TISSUE TRAVEL THROUGH THE BREAST-
COOPER’S LIG.
• MATURE FEMALE BREAST-EXTEND FROM 2-3RD RIBS TO 6-7TH RIBS AND
TRANSVERSELY FROM LAT BORDER OF STERNUM TO ANT AXILLARY LINE.

3. BLOOD SUPPLY
• PRINCIPAL BLOOD SUPPLY FROM-PERFORATING BRANCHES OF INTERNAL MAMMARY ARTERY,
LATERAL BR OF POST INTERCOSTAL ARTERIES AND BR FROM AXILLARY ARTERY.
• OTHERS- 2ND 3RD AND 4TH ANTERIOR INTERCOSTAL PERFORATORS AND BR OF INTERNAL
MAMMARY ARTERY ARBORIZE AS MEDIAL MAMMARY ARTERY.
• VEINS- 1> PERFORATING BR OF INTERNAL THORACIC VEIN
2> BR OF POST I/C VEINS
3> TRIBUTARIES OF AXILLARY VEIN
OTHERS- BATSON VENOUS PLEXUS FROM VERTEBRAE

4. LYMPHATICS
• PREDOMINENTLY DRAIN INTO AXILLARY AND INTERNAL MAMMARY LYMPH
NODES.
• AXILLARY-85% DRAINAGE
• 1- LATERAL- ALONG THE AXILLARY VEIN
• 2- ANTERIOR- ALONG THE LATERAL THORACIC VESSELS
• 3- POSTERIOR- ALONG THE SUBSCAPULAR VESSELS
• 4- CENTRAL- EMBEDDED IN FAT IN THE CENTRE OF AXILLA
• 5- APICAL- LIE ABOVE THE P MINOR TENDON IN CONTINUITY WITH THE
LATERAL NODES.
• COURSE = ALL GROUPS APICAL SUPRACLAVICULAR SUB CLAVIAN
GREAT VEINS VIA THE THORACIC DUCT.

5. • LEVEL 1- LATERAL TO LATERAL BORDER OF P MINOR
• LEVEL 2- POSTERIOR TO P MINOR
• LEVEL 3- MEDIAL AND ABOVE THE P MINOR AND INCLUDE SUBCLAVICULAR
NODES.
• ROTTER’S NODES- LYMPH NODES IN THE SPACE BETWEEN P MAJOR AND P
MINOR.

7. EPIDEMIOLOGY OF BREAST CANCER
• MOST COMMON SITE-SPECIFIC CANCER IN WOMEN AND LEADING CAUSE OF
DEATH FROM CA FOR WOMEN AGE 20 TO 59YRS.
• WOMEN FROM HEAVILY INDUSTRIALIZED OR WESTERN COUNTRIES HAVE A
HIGHER BREAST CA BURDEN.
• BUT THE MORTALITY IS HIGHER IN UNDER DEVELOPED NATIONS.

8. RISK FACTORS FOR BREAST CANCER
BASED ON HIGH SOCIO ECONOMIC STATUS
• ADVANCING AGE
• WESTERN COUNTRIES
• ALCOHOL INTAKE
• HIGH FAT DIET, OBESITY
STATE OF HYPER ESTROGENEMIA
• EARLY MENARCHE,
• LATE MENOPAUSE,
• NULLIPARITY,
• LATE FIRST FULL TERM PREGNANCY
POSITIVE FAMILY HISTORY.

9. RISK FACTORS FOR BREAST CANCER
POSITIVE HISTORY OF MALIGNANCY
GENETIC MUTATIONS( BRCA MUTATIONS- BRCA 1 & 2)
HORMONAL REPLACEMENT THERAPY
H/O THERAPEUTIC RADIATION EXPOSURE( IF TOTAL RADIATION > 60 GY, THEN
THE RISK OF MALIGNANCY IS INCREASED)
OCP AND SMOKING-NOT SIGNIFICANT
LONG DURATION OF BREAST FEEDING –PROTECTIVE.

10. RISK ASSESSMENT MODELS
CLAUS MODEL GAIL MODEL
MC used MORE INFO ABOUT FAMILY HISTORY
Includes
• No of breast biopsy
• Age at menarche
• No of first degree relative with CA breast
• Age at first live birth
BASED ON-
• Decades of life
• Based on first and second degree relative
with CA breast
• Their ages at diagnosis

11. DIAGNOSIS OF BREAST CANCER
• IT INVOLVES THE TRIPLE ASSESSMENT THAT INCLUDES-
• CLINICAL EXAMINATION
• RADIOLOGY (USG FOR <40 YRS), MAMMOGRAPHY (FOR >40 YRS) AND MRI (FOR
HIGH RISK PATIENT)
• BIOPSY (FNAC AND CORE NEEDLE BIOPSY)-IOC
• IOC FOR STAGING-PET CT
• PPV OF TRIPLE ASSESSMENT- 99.9 %

12. EXAMINATION OF BREAST
METHOD OF CLINICAL EXAMINATION
1-DIAL CLOCK ( BEST)
2- VERTICAL STRIKE
3- HORIZONTAL STRIKE

13. MAMMOGRAPHY
CRANIO
CAUDAL VIEW
MEDIO
LATERAL
OBLIQUE
VIEW
RECENTLY 3D
MAMMOGRAPHY/BREAST
TOMOSYNTHESIS-MORE
SENSITIVE

14. BIRADS SCORE CATEGORY MANAGEMENT RISK OF CANCER
0 inclusive Additional imaging n/a
1 negative Routine screening Essentially 0%
2 benign Routine screening Essentially 0%
3 Probably benign Short interval follow
up every 6 months
>0% but <=2 %
4 suspicious Tissue diagnosis 4a low 2-10%
4b-moderate,10-
50%
4c,high,50-94%
5 Highly suspicious Tissue diagnosis >=95%
6 Biopsy proven Surgical excision
when clinically
NA

15. AJCC CLASSIFICATION -8TH EDITION
• AJCC HAS RECENTLY MODIFIED THE TNM SYSTEM FOR BREAST CANCER.
• LCIS HAS BEEN REMOVED FROM TNM STAGING.

16. STAGE Size of tumour and other characteristics of tumour
T1 Upto 2 cm
T2 >2-5 cm
T3 >5 cm
T4a Extension to chest wall(chest wall is formed by ribs, intercostal
muscels,serratus anterior)
T4b Ulceration
Edema including Peau D orange
Satellite nodules
These changes are confined to the same breast.
T4c T4a+T4b
T4d Inflammatory breast cancer
Not included in T4-
Involvement of dermis
Nipple retraction/deviation
Involvement of p major/p minor

17. LYMPH NODE(N) STAGING
N1 Ipsilateral level 1 & 2
mobile
N2a Ipsilateral level 1 & 2
Fixed/matted LN
N2b Internal mammary nodes
N3a Ipsilateral infraclavicular LN
N3b I/L axillary + internal mammary LN
N3c I/L supraclavicular LN

18. METASTASIS
M0 No mets
M1 Distant mets

19. STAGING OF CA
BREAST
STAGE 1 T1
STAGE 2a T0-1,N1
T2
STAGE 2b T2N1
T3
STAGE 3a T0-2,N2
T3, N1-2
STAGE 3b T4, N0-2
STAGE 3c T any, N3
STAGE 4 T any, N any, M1
Two lumps in same breast-staging is based on size of bigger lump
Lump in each breast-each breast lump is staged separately
Breast lump with involvement of C/L LN- METASTATSIS

20. UPDATES IN BREAST CANCER STAGING
• ISOLATED TUMOUR CELLS(ITC) :- <=0.2 MM CLUSTER OR <200 CELLS
• MICROMETASTASIS- >0.2 MM BUT <=2.0 MM OR CLUSTER OF > 200 CELLS
• IF THE SLN HAVE ISOLATED TUMOUR CELLS OR MICROMETASTASIS, IT IS
CONSIDERED AS NEGATIVE.

21. WHAT IS EARLY BREAST CANCER ?
• BREAST CANCER THAT HAS NOT SPREAD BEYOND THE BREAST OR THE AXILLARY
LYMPH NODES.
• THIS INCLUDES STAGE 1,STAGE 2A, 2B BREAST CANCERS.

22. TREATMENT PROTOCOL FOR EARLY BREAST
CANCER
• MULTIDISCIPLINARY APPROACH SHOULD BE USED FOR THE MANAGEMENT. (IT
IMPROVES OVERALL SURVIVAL)
• BREAST CONSERVATIVE SURGERY + SENTINEL LN BIOPSY+ RADIOTHERAPY
• IF BCS IS CONTRAINDICATED- SIMPLE/TOTAL MASTECTOMY + SENTINEL LN
BIOPSY
• TYPES OF BCS-
• 1- LUMPECTOMY
• 2- WIDE LOCAL EXCISION WITH 1 CM MARGIN (REF- MASTERY OF SURGERY- 5TH
EDITION )

24. ONCOPLASTIC BREAST SURGERY
• VOLUME DISPLACEMENT-
• THE TUMOUR IS RESECTED.
• AFTER DISPLACING THE BREAST TISSUE, THE
DEFECT IS CLOSED.
• DONE TILL 10-15% OF BREAST RESECTED.
• VOLUME REPLACEMENT-
• THE TUMOUR IS RESECTED.
• THE VOLUME IS REPLACED USING A FLAP.
• DONE IF > 15 % OF VOLUME IS RESECTED.
VOLUME
DISPLACEMEN
T SURGERY

25. FLAPS
• MC USED FLAP – TRAM FLAP ( INFERIOR EPIGASTRIC ARTERY AND VEIN)
• BEST FLAP- DIEP FLAP (DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP )
• OTHERS-
• LD FLAP
• LATERAL THIGH FLAP
• THORACO EPIGASTRIC FLAP
• GLUTEAL FLAP
• RUBENS FLAP-BASED ON DEEP CIRCUMFLEX ILIAC ARTERY

26. CONTRAINDICATIONS OF BCS
ABSOLUTE RELATIVE
PREGNANCY H/O collagen vascular diseases(scleroderma,
lupus)
2 or >2 tumour in different quadrants or
diffuse malignant appearing micro
calcification
Multiple tumours in same quadrant
Persistently +ve margins Large tumour in small breast
History of exposure of therapeutic radiation Large pendulous breast (difficult to give
uniform dose of radiotherapy)
Centrally located tumour

27. SENTINEL LN BIOPSY IN BREAST CANCER
• SLN = FIRST LN WHICH RECEIVES LYMPH DIRECTLY FROM TUMOUR
• INDICATIONS – CLINICALLY NON PALPABLE AXILLARY LN
• 2 TECHNIQUES.
• 1- BLUE DYE TECHNIQUE (1 % LYMPHAZURIN / ISOSULFAN BLUE OR METHYLENE
BLUE)
• 2- RADIOACTIVE COLLOID TECHNIQUE (TC 99 LABELLED SULPHUR )
• MAX ACCURACY- WHEN BOTH TECHNIQUES ARE COMBINED TOGETHER.

28. SENTINEL LN BIOPSY IN BREAST CANCER
COMPLICATIONS-
• MC = SKIN TATTOOING
• MC INJURED NERVE- INTERCOSTO-BRACHIAL NERVE
• CONTRAINDICATIONS – PALPABLE LN, PRIOR AXILLARY SURGERY,
CHEMOTHERAPY, RADIOTHERAPY, MULTIFOCAL BREAST CA

30. RADIOTHERAPY
INDICATIONS—
• BCS
• LABC
• 4 OR MORE LN +VE
• +VE MARGINS
• DOSE- TOTAL THERAPEUTIC RADIATION = 40-50 GRY
• 1.8-2 GRY/ DAY
• 5 DAYS A WK FOR 4-6 WKS

31. CHEMOTHERAPY
INDICATIONS—
• 1- +VE LYMPH NODE
• 2- LABC
• 3- ER , PR –VE ,HER 2 NEU +VE
• 4- SYMPTOMATIC VISCERAL METS
• 5- HORMONE THERAPY REFRACTORY CASES
TRADITIONAL REGIMEN FOR CT- CAF / CMF
• C-CYCLOPHOSPHAMIDE
• A-ADRIAMYCIN
• F-5FU
• M-METHOTREXATE

32. • USUALLY 6 CYCLES OF CT IS GIVEN.
• ADRIAMYCIN RESISTANT BREAST CA- TAXANES GIVEN
• TAXANES RESISTANT-IXABEPILONE
• HER 2 NEU +VE – TRASTUZUMAB, 2ND LINE = LAPATINIB

33. BREAST CANCER FOLLOW UP
• HISTORY + PHYSICAL EXAMINATION-
• EVERY 3-6 MONTHS 1ST 3 YEAR
• EVERY 6-12 MONTHS FOR 4TH TO 5TH YEAR
• ANUALLY THEREAFTER
• MAMMOGRAPHY-
• ANUALLY
• BEGINNING NO EARLIER THAN 6 MONTHS OF RADIOTHERAPY.
• BREAST SELF EXAMINATION- MONTHLY
• PELVIC EXAMINATION- ANNUALY
• REFERENCE- DE VITA 10TH EDITION
• ASCO 2006 UPDATED GUIDELINE
• MD ANDERSON HANDBOOK OF SURGICAL ONCOLOGY-5TH EDITION

34. PROGNOSTIC FACTORS
• MOST IMPORTANT – STAGE ( TNM STAGING)
• SINGLE MOST IMPORTANT –AXILLARY LN STATUS
• MOST IMPORTANT IN METASTATIC BREAST CA- ER , PR STATUS
• NOTTINGHAM PROGNOSTIC INDEX-
• NPI = (0.2 * TUMOUR SIZE) + LN STAGE + TUMOUR GRADE
• TO SELECT PATIENT FOR ADJUVENT THERAPY
• BLUM RICHARDSON GRADING-
• TUBULE FORMATION
• NUCLEAR PLEOMORPHISM
• MITOSIS
• VAN- NUYS PROGNOSTIC INDEX-
• MICRO CALCIFICATION
• SIZE OF TUMOUR
• WIDTH OF MARGIN
• AGE OF PATIENT
• GRADE OF TUMOUR

35. REFERENCES
• 1- SCHWARTZ’S PRINCIPLES OF SURGERY
• 2- BAILEY & LOVE’S SHORT PRACTICE OF SURGERY
• 3- SABISTON TEXTBOOK OF SURGERY
• 4- DE VITA 10TH EDITION
• 5- MD ANDERSON HANDBOOK OF SURGICAL ONCOLOGY-5TH EDITION

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