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Management of breast cancer by moh'd taofiq bak

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Management of breast cancer by moh'd taofiq bak

  1. 1. Management of breast cancer Dr. Mohammed Taofiq Registrar,Department of Surgery, UITH,Ilorin.
  2. 2. Outline...• Introduction• Epidemiology• Risk factors• Surgical anatomy• Clinical features• Imaging• Biopsy• Pathology• Prognostic/predictive factors• Treatment• conclusion
  3. 3. Introduction...• Most frequently diagnosed life –threatening cancer in women• Leading cause of cancer death inwomen• A major public health issue globally - 1 million new cases annually - 400,000 annual death - 4.4 million living with the dx
  4. 4. Epidemiology...• Prevalence is worldwide• Incidence is higher in the developedworld• highest in North America,NewZealand /Australia• lowest in Asia & Sub- Sahara Africa
  5. 5. Epidemiology...• Mortality decreasing in the developedWorld• Life time risk is 1 in 6 overall & 1 in 8for invasive disease
  6. 6. Risk factors... Precise etiology is unknown• Age : rises sharply with age,rare in <25yrs• Sex : 100x commoner in female• Race/ethnicity : commoner in whites• Family history : most widely recognizedbreast cancer risk factors 5-10% of all breastcancers are hereditary
  7. 7. Risk factors... Family history :• One or more first degree relative withbreast or ovarian cancer• Breast cancer occurring in an affectedrelative < 50yrs• Male relative with breast cancer• BRCA1 and BRCA2 mutations• Ataxia- telangiectasia heterozygotes• Ashkenazi Jewish descent
  8. 8. -20 -30% women with BCA have atleast onerelative witness BCA-Only 5- 10% of BCA patient have an identifiablepredisposed factor-BRCA 1 & 2 account for 3- 8% of BCA & 15 &20% of familiar cases.
  9. 9. Risk factors·BRCA 1-TSG located on xsome 17-Life time risk of developing BCA & Ovarian CA85% & 40%-Mastectomy reduces the risk of BCA by 95%
  10. 10. Risk Factors· BRCA 2 -Located on xsome 13 -Increase risk of male BCA -Spectrum of associated BCA similar to noncarriers
  11. 11. Risk factors.... Neoplastic conditions : Previous breast cancer Ovarian cancer Endometrial Cancer DCIS LCIS
  12. 12. Risk factors...• Benign breast diseases : Atypical lobular Hyperplasia Atypical ductal Hyperplasia Complex fibroadenoma Sclerosing adenosis Intraductal papillomatosis
  13. 13. Risk factors... Reproductive factors :• Menarche at < 13yrs• Nulliparity• Menopause > 50yrs• First full pregnancy > 30yrs• Less breastfeeding
  14. 14. Risk factors....
  15. 15. Surgical anatomy...• Modified sebacious gland• Ectodermal origin• Borders• Fascia• The skin• Subcutaneous tisssue• The breast tissue : stromal & epithelial• Blood supply and Lymphatics.
  16. 16. Surgical anatomy...
  17. 17. Clinical features....
  18. 18. Clinical features...
  19. 19. Imaging ...• Mammography - Primary imaging modality - abnormality on mammographicscreening requires furthercharacterization - can show microcalcification <100microM - pick lesion 1-2yrs b4 SBE orCBE
  20. 20. Imaging ...• Mammography - Screening : - asymptomatic Patient - mediolateral oblique (Side) - craniocaudal (Above) - Diagnostic : - new symptoms - additional views:SpotcompressionMagnification
  21. 21. Imaging...
  22. 22. Imaging ...• Ultrasonography - further xterize amammographically detectedabnormality - to identify a cystic mass - alternative to mammography indense breast - USS guided biopsy - measure & clip a lesion prior to neoadjuvant chemotherapy - improved specificity when usedappropriately
  23. 23. • MRI - Xterization of an indeterminatelesion - Detection of occult breastcancer in px with carcinoma in anaxillary LN - Evaluation of suspectedmultifocal or bilateral tumor
  24. 24. Biopsy...• A clinically suspicious mass should bebiopsized,irrespective of imaging findings• FNAC• Tissue Biopsy• Open Biopsy
  25. 25. Other investigations...• CXR• FBC• SERUM ALP• LFT• ABDOMINOPELVIC USS• BONE SCAN• HORMONE RECEPTOR STATUS• HER2 OVEREXPRESSION
  26. 26. Pathology ...
  27. 27. Molecular intrinsic subtypes...• LUMINAL A - ER +, &/or PR+, HER2 – - Most common - Less aggressive - good prognosis - Hormone responsible - Increasing age
  28. 28. • LUMINAL B - ER+, &/or PR+ ,HER2 + - Worse prognosis than luminal A• BASAL LIKE - Triple Negative - Aggressive subtype - Younger ,pre-menopausal AfricanAmerican
  29. 29. • HER2 + - Less common - Highly aggressive subtype - young age - African American - Outcome improved with HER2targeted therapy
  30. 30. Staging ...
  31. 31. Staging ...
  32. 32. Staging....
  33. 33. Staging....
  34. 34. Prognostic factors...• Axillary LN status• Tumor size• Lymphatic / vascular invasion• Patient age• Histologic grade• Histologic subtypes• Response to neo-adjuvant therapy• ER/PR status• HER2 gene amplification &/oroverexpression
  35. 35. Predictive factors...• ER/PR status• HER2 gene amplification &/or Overexpression
  36. 36. Treatment ..• Multimodality & Multidisciplinary• Surgery is the primary treatmentmodality- early stage,cured with surgery alone• Aim of surgery is complete resectionof the primary tumor with negative margins& pathologic staging of the tumor & Axilla
  37. 37. • Adjuvant therapy : radiationtherapy(RT), chemotherapy, hormonal andTargeted therapy• Neo- adjuvant therapy
  38. 38. Role of surgery..
  39. 39. DCIS• Surgical resection + or – radiation• ALND or SLNB not routinelyrecommended• Tamoxifen Only approved agent in px rxwith BCS• A precusor of invasive dx.• Account for 5% of male breast cancer
  40. 40. LCIS• Observation & close follow up carewith or without tamoxifen• Bilateral mastectomy with or withoutreconstruction• Risk of invasive cancer is low(25-30%)& equal in both breast.
  41. 41. Treatment- Early Breast Cancer(I &II or T1-3,N0-1,M0)• Loco – regional disease : surgery &/orradiation therapy• Systemic disease : one or combinationof chemotherapy,hormonal or biologictherepy
  42. 42. Surgical options..
  43. 43. Contra-indications to BCS
  44. 44. Indications for Mastectomy·Tumor size > 5cm·Multicentric cancers·Local recurrence ffg BCS·Centrally located tumours·No facillity for radiotherapy
  45. 45. INDICATIONS FOR MASTECTOMY*prior radiation therapy to the breast or chest wall*Radiotherapy contraindicated In pregnancy*Inflammatory breast cancer*Persistent positive pathologic Margin*Active connective tissue dx
  46. 46. Radiotherapy ...• Routine in BCS,May be indicated postmastectomy• Aim is eradication of local residualsubclinical dx & minimize local recurrencerates• 2 approaches : EBRT or PBI
  47. 47. Post Mastectomy RT- Indications• Positive post mastectomy margins• Primary tumors larger than 5cm• Involvement of 4 or More LN• Skin or Chest wall involvement
  48. 48. Side effects of RT...• Fatigue• Skin desquamation• Breast pain• Breast swelling• Rib #• Pulmonary fibrosis• Cardiac dx• Secondary malignancies
  49. 49. Treatment of the Axilla...
  50. 50. Indications for ALND*Preoperative diagnosis of +ve ALND*Prior Inadequate ALND*+ve Intraoperative SLNB*Failed Mapping of SLNB*Clinically suspicious nodes at surgery
  51. 51. Axillary treatment...• ALND or SLNB• SLNB :Indicated in clinically nodeNegative px• Single modality for axillary treatment
  52. 52. ALND...
  53. 53. SLNB...
  54. 54. Adjuvant systemic therapy...• Aim is to prevent recurrence & improveoverall survival• Choice of therapy depend on : - hormone status - menopausal status - HER2 status - risk of recurrence & potentialbenefit• Combination therapy
  55. 55. The NCCN guideline...
  56. 56. Treatment of advance breast cancer
  57. 57. LABC...• Advance primary tumor ie > 5cm• Skin &/or chest wall involvement• Advance regional LN involvement• IBC Multimodality Rx involvingsurgery,radiotherapy and systemic therapy Neoadjuvant systemic therapy isusual
  58. 58. Neo adjuvant therapy..• Aim is to improve surgical outcome &surgical options - operable BC,Increase the chancesof BCS -Inoperable, LABC: Achievingoperability
  59. 59. LABC• Locoregional Rx is based on tumorresponse to neodjuvant• Consist of surgery-either mastectomyor BCS & post operative RT• surgery should be done ONLY if amacroscopically complete resection ispossible
  60. 60. Adjuvant chemotherapy...
  61. 61. Hormonal therapy...
  62. 62. Hormonal therapy...
  63. 63. recurrence dx...• Post BCS : Total mastectomy +adjuvant chemotherapy or endocrinetherapy• Post MRM : local resection ofrecurrence where feasible + radiotherapy ifno RT b4.
  64. 64. Metastatic disease..• Aim is to palliate symptoms,prolongsurvival,maintain QOL• Visceral metastasis- poor prognosis• Chemotherapy is indicated for hrmeinsensitive MBCA• Hormone therapy preferred when everapplicable
  65. 65. Conclusion...• Breast cancer survival rates haveincreased significantly, particularly inyounger women.• The need for increased publicawareness & early detection cannot beoveremphasized.

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