the global breast cancer burden.
? India has a long way to go!
? See the images below and listen to the discussion and you wil
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understand why.
?
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? Why is the mortality so high?? more patients turn up in later stages.
? What are the reasons for late presentations?
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? lack of awareness,
? shyness on part of patients,
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? social stigma,? ignorance of doctors
So what do we learn today?
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WHO prediction for breast cancer in India
? For the years 2015, there will be an estimated 1,55,000 new cases of
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breast cancer and about 76000 women in India are expected to die ofthe disease. The gap only seems to be widening, which means, we
need to work aggressively on early detection.
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RISK FACTORS? Three main groups:
? Major
? Intermediate and
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? MinorMajor risk factors
? Gender
v100 times more common in women than in men.
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? AgevVery rare before the age of 20 and rare below 30 years.
vThe incidence of breast cancer doubles every 10 years until the
menopause.
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? Previous breast cancer
? Family history and genetic predisposition
Intermediate risk factors
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? Diet and alcohol intake
? Endocrine factors
?Increased duration of exposure to endogenous estrogens.
?Early age of menarche (age< 12), late age of menopause (>
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55), and late age at first pregnancy (> 30),nulliparity,HRT,OCPs.
?Lifetime number of menstrual cycles.
? Irradiation
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Minor and controversial risk factors? Body size
? Stress
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Genetics of breast cancerBRCA 1
BRCA 2
? BRCA-1 is located on chromosome 17q.
? BRCA-1?associated breast cancers are invasive ductal carcinomas, are
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poorly differentiated, and are hormone receptor?negative.
? BRCA-2 is located on chromosome 13q .
? BRCA-2?associated breast cancers are invasive ductal carcinomas, are
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well differentiated and express hormone receptors.
PATHOLOGY
Why?
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? Paramount importance in establishing the diagnosis of the tumour.
? It also helps determine the patient's prognosis
? There are many methods of pathologically classifying breast cancer;
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most are based on whether the tumour is invasive or non-invasiveand whether it is derived from the duct system or the lobule.
Ductal carcinoma of the breast
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Most common form of breast cancer accounting for 85 to 90 per cent of all cases.
Lobular carcinoma of the breast
subdivided into in situ and invasive forms
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Clinical scenarios? A 38 years old lady (with a history of breast cancer in her sister) presented with a
4 cm lump in her right breast which turned out to be a cancer and had a few
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enlarged axil ary nodes. She had noticed the lump only a few months back.However, on evaluating all past records, doctor found one mammogram done 2
years back (was advised by her gynecologist), just for screening; she did not
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have any lump or other symptom then. In that mammogram, there was a small
area of stippled microcalcification, which was very suspicious (Stippled
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microcalcifications are pathognomonic for cancer) . The radiologist had alsomentioned it in the report. But since there was no palpable lump, her gynecologist
told her, not to worry. She didn't do anything for that for the next 2 years, and
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finally, was detected with cancer in the same site, in a minimum of clinical stage
2B. Finally after surgery, 5 (out of 27) nodes were positive for cancer and this
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placed her in stage 3A. So please understand here, the gynecologist advised themammogram, but did not not know how to interpret or act, and the lady, who
would have otherwise been detected with cancer of stage 1 and would have had
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more than 90% chance of 10 years survival, now ended up with stage 3A and wil
have about 60% chance of 5 year survival. So two years of wait have definitely
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decreased her life by 5 years.? A 32 years old lady presented with a history of heaviness in breast before the
periods as well as pain in the breast for a few days before the periods. On clinical
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examination, breasts were normal, except for slightly engorged. Again here, her
family doctor had advised her mammography (I wouldn't have advised her
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mammography, if at all needed, I would have gone for an ultrasound of the breastfirst). On the ultrasound which was done with the mammogram, there were
multiple cysts of varying sizes in both the breasts, from few mil imetres to 8 to 9
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mil imetres. She was overtly worried about cancer, and had already taken opinion
from one surgeon and one gynecologist. One had advised surgery (!!) and the
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other had given some non specific medications. Al the doctor did was toreassure her, that this was nothing to worry about (She was visibly more worried
about the cancer than the symptoms of pain and heaviness she had). The doctor
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assured her that this was not cancer, this did not require surgery, this occurs in
many women of her age - some have more symptoms while some have less
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symptoms, and that over a period of time, it wil all settle. Gave her somesymptomatic medications and some vitamin supplements and believe me, after
three months, she was almost settled of symptoms and was very happy. Not that
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medications worked or something, but it was the re assurance that worked.
CLINICAL FEATURES
? A lump
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? Changes in the skin may be the sole presenting symptom.? Puckering .
? Peu d'orange .
? Ulceration .
? Nipple distortion and inversion .
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? A unifocal or bloodstained nipple discharge.Diagnosis
? Fine-needle aspiration cytology
? Core biopsy
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? MammographyTNM definitions
Primary Tumour
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? Tx ? Primary tumour cannot be assessed? To ? No evidence of primary tumor
? Tis ? Carcinoma in situ
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? T1 ? Tumor 2 cm or less
? T2 ? 2 ? 5 cm tumor
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? T3 ? Tumor 5 cm and above? T4 ? Extn. to chest wal / skin
Regional lymph node involvement - clinical
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NX ? Regional lymph nodes cannot beassessed.
No ? No regional lymph nodes.
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N1 ? Movable ipsilateral axil ary nodes.
N2 ? Fixed ipsilateral axil ary nodes.s
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N3 ? Ipsilateral internal mammary nodesRegional lymph node involvement -
pathological
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? pNX ? Regional lymph nodes cannot be assessed.
? pNo ? No regional lymph node metastasis.
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? pN1 ? Movable ipsilateral axil ary node metastasis.? pN1a ? Micrometastases (< 0.2 cm )
? pN1b ? Metastases ( > 0.2 cm )
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? i) 1 ? 3 nodes
? i ) 4 or more nodes
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? i i) extending beyond the capsule (< 2 cm)? iv)Metastases to nodes ( > 2 cm )
? pN2 - Fixed ipsilateral axil ary nodes
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? pN3 ? Ipsilateral internal mammary nodes
Distant Metastases
? Mx ? Distant metastases cannot be assessed.
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? Mo ? No distant metastases.? M1 ? Distant metastases ( ipsilateral
supraclavicular lymph nodes )
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AJCC / UICC Stage grouping
? St 0 - Tis
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NoMo
? St 1 ? T1
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No
Mo
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? St 2aTo
N1
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Mo
T1 N1
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MoT2
No
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Mo
? St 2b
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T2N1
Mo
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T3
No
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MoAJCC / UICC Stage grouping
? St 3a
To N2 Mo
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T1 N2 Mo
T2 N2 Mo
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T3 N1 MoT3 N2 Mo
? St 3b
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T4 any N Mo
any T N3 Mo
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? St 4any T any N M1
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STAGING
? The Manchester system (1940)
? Stage I. Tumour confined to breast. Any skin involvement covers an
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area less than the size of the tumour.
? Stage II. Tumour confined to breast. Palpable, mobile axillary nodes.
? Stage II . Tumour extends beyond the breast tissue because of skin
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fixation in an area greater than the size of the tumour or because of
ulceration. Tumour fixity underlying fascia.
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? Stage IV. Fixed axillary nodes, supraclavicular nodal involvement,satellite nodules or distant metastases.
MANAGEMENT
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Management of non-invasivebreast cancer
Stage 0
LCIS
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? Because LCIS is considered a marker for increased risk rather than an
inevitable precursor of invasive disease, the current treatment of LCIS
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is observation with or without tamoxifen.? The goal of treatment is to prevent or detect at an early stage the
invasive cancer.
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? There is no benefit to excising LCIS, as the disease diffusely involves
both breasts and the risk of invasive cancer is equal for both breasts.
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The use of tamoxifen as a risk-reduction strategy should beconsidered in women with a diagnosis of LCIS.
DCIS
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? Women with DCIS and evidence of widespread disease (two or more
quadrants) require mastectomy.
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? For women with limited disease, lumpectomy and radiation therapyare recommended.
? Low-grade DCIS of the solid, cribriform, or papillary subtype, which is
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less than 0.5 cm in diameter, may be managed by lumpectomy alone.
? Adjuvant tamoxifen therapy is considered for all DCIS patients.
? Simple mastectomy
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? 95% cure rate? Rarely relapse, due to micro-invasive cancer
? No need for axillary dissection
? Wide excision alone--30% recurrence at 5 years
? Wide excision + radiotherapy--15% recurrence at 5 years
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Early Invasive Breast Cancer
Stage I, IIa, or IIb
T1?3, N0?1 tumors.
? Treatment of the breast and axilla
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? Pathological staging to direct adjuvant therapy? Adjuvant therapy--endocrine, chemotherapy, radiotherapy
? Follow-up
Breast surgery
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? Quadrantectomy removes the primary cancer with a margin of 2.0
cm of normal breast tissue.
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? Lumpectomy is the removal of the tumour mass with a limitedportion of normal tissue (1 cm).
? MRM
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INDICATIONS OF BCS? T1,T2lesions, N0/N1,M0 disease.
? Tumor>4cm in a large breast.
? Single clinical and mammographic lesion.
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? Patient should be willing tomaccept the chances of recurrence.CONTRA INDICATIONS OF BCS
? T4,N2 Lesions
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? Patients choice? Multifocal/Multicentric disease
? Tumor size high as compared to breast size.
? Extensive calcification on mammography
? Pregnancy
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? Persistent positive margins? Patient's contraindication to radiotherapy.
Treatment of the axil a
? Surgery
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? --sentinel node biopsy:? --removal of first node which contains secondary deposit
? --use either blue dye or 99MTc colloid
? --negative sentinel node avoids clearance
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Loco-regional radiotherapy? Reduce the risk of local recurrence after BCS
? Irradiation of axilla--not required if clearance performed
? Radiation to axilla may cause lymphodema and brachial neuropathy
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Adjuvant endocrine therapy? 60% of breast cancers are oestrogen receptor positive
? Ovarian ablation
? Side-effects of tamoxifen--menopausal symptoms
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? --endometrial cancer, 4-fold increase in risk? LHRH agonists
Adjuvant chemotherapy
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? CMF (cyclophosphamide, methotrexate, 5FU)? Anthracycline regimes may be better
? Taxanes based regimes
Management of local y advanced
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breast cancerStage II a or II b
? The probability of metastatic disease is high (>70%).
? A combination of neoadjuvant chemotherapy, surgery and
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radiotherapy is commonly used.
Management of metastatic
breast cancer
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? Aim is palliation? If hormone-sensitive, bony disease--may survive years .
? Visceral, ER-negative disease has bad prognosis
? Usual sites--lung, liver, bone, brain
? Rare sites--choroid, pituitary
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? Combination of endocrine therapy, chemotherapy, radiotherapy andsymptomatic tt is given.
SENTINAL LYMPH NODE BIOPSY
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SENTINEL NODE CONCEPTBased on the hypothesis lymph flow is orderly,
predictable & tumor cells spread sequentially
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Sentinel node is the first node encountered by
the tumour cells
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The sentinel node is in the direct pathway ofthe primary tumour
Advantages of sentinel node biopsy
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? Minimally Invasive
? Low Cost
? low morbidity
? Nodal metastasis outside axil a detected
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? obviates the need for ALND without compromising staging &local control
Disadvantages of Sentinel node Biopsy
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? Has a False negative rate of 6% (ALND3%)? Not useful in clinically involved axil a
? Not useful in pregnancy & lactation
? Cannot be done in multifocal / multicentric breast carcinomas
? Cannot be done in patients with previous breast surgery on the
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same side
Technique
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Blue dye isosulfan blue (or)technitium labelled colloidal albumin with
gamma camera and probe can be used
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Sub dermal injectionA single dose of 0.2 ml of the dye is
injected at the tumour site sub-dermally
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one day prior to surgery
Peri tumour injection
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Dye injected at four sites.Larger volumes are given
Removal of dye or tracer is slower due to
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scanty lymph supply of breast
parenchyma
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imaged 1 to 2 hrs after injectionSENTINEL LYMPH NODE DISSECTION
WITH DYE TECHNIQUE
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Blue lymphatics leading to SLN are traced
Discolouration of breast and blue urine
ISOTOPE TECHNIQUE
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Probe guided surgery is superior
Useful for intra-operative localisation
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After removal of SLN probe is reapplied tosite and radioactivity measured for
confirmation
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PIT FALLS IN SENTINEL NODE DISSECTION? 6% FALSE NEGATIVE
? SKIP PHENOMENON & CHANGED FLOW
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DIRECTION? INFILTRATION BY CARCINOMA
? FATTY DEGENERATION
? UPPER OUTER QUADRANT -CLOSE
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PROXIMITY TO SENTINEL NODE. SHINE
THROUGH PHENOMENON-Breast to be
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retracted when probingSpecial problems
SPECIAL PROBLEMS IN BREAST
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CANCER ? PAGETS DISEASERare before 30 years, peak between 50
& 60
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Can occur in the male
Erythematous exudative or scaly lesion
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appears first on the nipple spreads toareola
Does not involve surrounding skin
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Nipple retraction & nipple pigmentation &
mass
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D D for Pagets diseaseChronic Eczema
Malignant melanoma
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Syphilitic chancre
Bowens disease
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Mammary ductectasiaMammography
Mass , sub areolar micro calcification
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or only thickening of nipple areolacomplex
Biopsy
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Full thickness nipple biopsy or
exfoliative scrape cytology
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PAGETS TREATMENT1) with palpable mass-
segmentectomy with 1.5 cm margin
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with ALND with PO-RT
2)if resection margins positive or muticentric or
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solid or comedo type or high grade withnecrosis
completion mastectomy is done
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Pagets without palpable massBiopsy of nipple areola complex positive
first step: On mammo no occult mass.no
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microcalcification--do segmentectomy of nipple
areola complex +RT without axil ary dissection
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Mammography + veStereotactic needle localisation of occult mass
or microcalcification with frozen section biopsy
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and proceed
Tamoxifen
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BREAST CANCER IN PREGNANCY&LACTATION
DELAY IN DIAGNOSIS
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1) firm ,nodular &hypertrophied breast
2) small tumours can be missed
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3) present at advanced stage4) high proportion of ER-ve
5) bad prognosis
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BREAST CANCER IN PREGNANCYMammography
FALSE NEGATIVE rate is high
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due to high radiographic density of
pregnant breast
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BREAST CANCER IN PREGNANCYAlkaline phosphatase is elevated in
pregnancy
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Chest X-ray is al owed with proper
shielding
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Bone scanA) Stage 1 & 2-Bone mets uncommon
scan not done
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B)Stage 3 Especial y with bone pain
Bone scan done in later stages of
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pregnancy or after pregnancyBREAST CANCER IN PREGNANCY
Treatment
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Modified Radical Mastectomy is thechoice irrespective of the trimester
In the first & second trimester breast
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conservation with radiotherapy should not
be
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done due to radiation induced anomaliesin foetus
Study questions
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? A 57-year-old woman undergoes core-needle biopsy of a breast mass.The pathologic diagnosis is infiltrating ductal carcinoma of the breast.
? How wil you stage this cancer?
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? What are the important prognostic factors?A 49-year-old woman presents with a breast mass. You are examining the
affected breast.
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How would the fol owing clinical findings affect the woman'sprognosis?
1. Red edematous breast with an underlying mass
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2. Edema of the skin overlying the mass
3. Puckering of the skin overlying the mass
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4. Retraction of the nipple5. A 1.5-cm mass fi xed to the deeper tissues
6. A lymph node palpable in the supraclavicular area
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7. A hard, fi xed lymph node in the ipsilateral axil a
8. Arm edema
? A 60-year-old woman has breast cancer and undergoes preliminary
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staging. The lesion is 1.5 cm in diameter, and no axillary nodes are
palpable. A metastatic workup is negative.
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? What stage is this woman's cancer?? What are this woman's surgical options, both for sampling the
lymph nodes and treating the primary tumor?
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? A 38-year-old woman is scheduled for a mastectomy and sentinelnode biopsy. She is concerned about her appearance and would like
to know her options for breast reconstruction.
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? What options should you offer?
? A 38-year-old woman presents with a 3-month history of a progressively
enlarging breast mass. At the time she sees you, she has a 6- 7-cm fi xed
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mass, with erythema and edema on the upper, outer aspect of her right
breast. Clinical y, her axil a is positive with enlarged, firm lymph nodes.
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? What is the suspected diagnosis?? What histologic features are typical of this condition?
? The surgeon confirms the physical findings and obtains a punch biopsy of
the mass. Pathology reveals inflammatory carcinoma. Estrogen and
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progesterone receptors are negative.
? What is the recommended treatment?
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? A 55-year-old woman has a modified radical mastectomy for a stage IIcarcinoma of the breast.
? A smal , 0.5-cm nodule in the suture line 5 years after surgery.
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? A mammographic abnormality in the opposite breast? Elevated liver function studies
? A fracture of the femur