Download MBBS Surgery Presentations 10 Breast Cancer Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 10 Breast Cancer PPT-Powerpoint Presentations and lecture notes

BREAST CANCER

EPIDEMIOLOGY
? Collectively, US, India and China account for almost one third of

the global breast cancer burden.

? India has a long way to go!
? See the images below and listen to the discussion and you wil

understand why.

?

? Why is the mortality so high?

? more patients turn up in later stages.

? What are the reasons for late presentations?

? lack of awareness,

? shyness on part of patients,

? social stigma,

? ignorance of doctors

So what do we learn today?

WHO prediction for breast cancer in India

? For the years 2015, there will be an estimated 1,55,000 new cases of

breast cancer and about 76000 women in India are expected to die of

the disease. The gap only seems to be widening, which means, we

need to work aggressively on early detection.
RISK FACTORS

? Three main groups:
? Major
? Intermediate and
? Minor
Major risk factors

? Gender
v100 times more common in women than in men.
? Age
vVery rare before the age of 20 and rare below 30 years.
vThe incidence of breast cancer doubles every 10 years until the

menopause.

? Previous breast cancer
? Family history and genetic predisposition

Intermediate risk factors

? Diet and alcohol intake
? Endocrine factors
?Increased duration of exposure to endogenous estrogens.
?Early age of menarche (age< 12), late age of menopause (>

55), and late age at first pregnancy (> 30),nulliparity,HRT,OCPs.

?Lifetime number of menstrual cycles.
? Irradiation
Minor and controversial risk factors

? Body size
? Stress

Genetics of breast cancer
BRCA 1
BRCA 2
? BRCA-1 is located on chromosome 17q.
? BRCA-1?associated breast cancers are invasive ductal carcinomas, are

poorly differentiated, and are hormone receptor?negative.

? BRCA-2 is located on chromosome 13q .
? BRCA-2?associated breast cancers are invasive ductal carcinomas, are

well differentiated and express hormone receptors.

PATHOLOGY
Why?

? 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;

most are based on whether the tumour is invasive or non-invasive

and whether it is derived from the duct system or the lobule.

Ductal carcinoma of the breast

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

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

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

have any lump or other symptom then. In that mammogram, there was a small

area of stippled microcalcification, which was very suspicious (Stippled

microcalcifications are pathognomonic for cancer) . The radiologist had also

mentioned 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

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

placed her in stage 3A. So please understand here, the gynecologist advised the

mammogram, 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

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

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

examination, breasts were normal, except for slightly engorged. Again here, her

family doctor had advised her mammography (I wouldn't have advised her

mammography, if at all needed, I would have gone for an ultrasound of the breast

first). 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

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

other had given some non specific medications. Al the doctor did was to

reassure 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

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

symptoms, and that over a period of time, it wil all settle. Gave her some

symptomatic medications and some vitamin supplements and believe me, after

three months, she was almost settled of symptoms and was very happy. Not that

medications worked or something, but it was the re assurance that worked.
CLINICAL FEATURES

? A lump
? Changes in the skin may be the sole presenting symptom.
? Puckering .
? Peu d'orange .
? Ulceration .
? Nipple distortion and inversion .
? A unifocal or bloodstained nipple discharge.
Diagnosis

? Fine-needle aspiration cytology
? Core biopsy
? Mammography

TNM definitions
Primary Tumour

? Tx ? Primary tumour cannot be assessed

? To ? No evidence of primary tumor

? Tis ? Carcinoma in situ

? T1 ? Tumor 2 cm or less

? T2 ? 2 ? 5 cm tumor

? T3 ? Tumor 5 cm and above

? T4 ? Extn. to chest wal / skin
Regional lymph node involvement - clinical

NX ? Regional lymph nodes cannot be

assessed.

No ? No regional lymph nodes.

N1 ? Movable ipsilateral axil ary nodes.

N2 ? Fixed ipsilateral axil ary nodes.s

N3 ? Ipsilateral internal mammary nodes

Regional lymph node involvement -

pathological

? pNX ? Regional lymph nodes cannot be assessed.

? pNo ? No regional lymph node metastasis.

? pN1 ? Movable ipsilateral axil ary node metastasis.

? pN1a ? Micrometastases (< 0.2 cm )

? pN1b ? Metastases ( > 0.2 cm )

? i) 1 ? 3 nodes

? i ) 4 or more nodes

? i i) extending beyond the capsule (< 2 cm)

? iv)Metastases to nodes ( > 2 cm )

? pN2 - Fixed ipsilateral axil ary nodes

? pN3 ? Ipsilateral internal mammary nodes
Distant Metastases

? Mx ? Distant metastases cannot be assessed.
? Mo ? No distant metastases.

? M1 ? Distant metastases ( ipsilateral

supraclavicular lymph nodes )

AJCC / UICC Stage grouping

? St 0 - Tis

No

Mo

? St 1 ? T1

No

Mo

? St 2a

To

N1

Mo

T1 N1

Mo

T2

No

Mo

? St 2b

T2

N1

Mo

T3

No

Mo
AJCC / UICC Stage grouping
? St 3a

To N2 Mo

T1 N2 Mo

T2 N2 Mo

T3 N1 Mo

T3 N2 Mo

? St 3b

T4 any N Mo

any T N3 Mo

? St 4

any T any N M1



STAGING

? The Manchester system (1940)
? Stage I. Tumour confined to breast. Any skin involvement covers an

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

fixation in an area greater than the size of the tumour or because of

ulceration. Tumour fixity underlying fascia.

? Stage IV. Fixed axillary nodes, supraclavicular nodal involvement,

satellite nodules or distant metastases.
MANAGEMENT

Management of non-invasive

breast cancer
Stage 0
LCIS

? Because LCIS is considered a marker for increased risk rather than an

inevitable precursor of invasive disease, the current treatment of LCIS

is observation with or without tamoxifen.

? The goal of treatment is to prevent or detect at an early stage the

invasive cancer.

? 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.

The use of tamoxifen as a risk-reduction strategy should be

considered in women with a diagnosis of LCIS.

DCIS

? Women with DCIS and evidence of widespread disease (two or more

quadrants) require mastectomy.

? For women with limited disease, lumpectomy and radiation therapy

are recommended.

? Low-grade DCIS of the solid, cribriform, or papillary subtype, which is

less than 0.5 cm in diameter, may be managed by lumpectomy alone.

? Adjuvant tamoxifen therapy is considered for all DCIS patients.
? Simple mastectomy
? 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

Early Invasive Breast Cancer
Stage I, IIa, or IIb
T1?3, N0?1 tumors.
? Treatment of the breast and axilla
? Pathological staging to direct adjuvant therapy
? Adjuvant therapy--endocrine, chemotherapy, radiotherapy
? Follow-up

Breast surgery

? Quadrantectomy removes the primary cancer with a margin of 2.0

cm of normal breast tissue.

? Lumpectomy is the removal of the tumour mass with a limited

portion of normal tissue (1 cm).

? MRM
INDICATIONS OF BCS

? T1,T2lesions, N0/N1,M0 disease.
? Tumor>4cm in a large breast.
? Single clinical and mammographic lesion.
? Patient should be willing tomaccept the chances of recurrence.

CONTRA INDICATIONS OF BCS

? T4,N2 Lesions
? Patients choice
? Multifocal/Multicentric disease
? Tumor size high as compared to breast size.
? Extensive calcification on mammography
? Pregnancy
? Persistent positive margins
? Patient's contraindication to radiotherapy.
Treatment of the axil a

? Surgery
? --sentinel node biopsy:
? --removal of first node which contains secondary deposit
? --use either blue dye or 99MTc colloid
? --negative sentinel node avoids clearance

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
Adjuvant endocrine therapy

? 60% of breast cancers are oestrogen receptor positive
? Ovarian ablation
? Side-effects of tamoxifen--menopausal symptoms
? --endometrial cancer, 4-fold increase in risk
? LHRH agonists

Adjuvant chemotherapy

? CMF (cyclophosphamide, methotrexate, 5FU)
? Anthracycline regimes may be better
? Taxanes based regimes
Management of local y advanced

breast cancer
Stage II a or II b

? The probability of metastatic disease is high (>70%).
? A combination of neoadjuvant chemotherapy, surgery and

radiotherapy is commonly used.
Management of metastatic

breast cancer
? 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
? Combination of endocrine therapy, chemotherapy, radiotherapy and

symptomatic tt is given.

SENTINAL LYMPH NODE BIOPSY
SENTINEL NODE CONCEPT

Based on the hypothesis lymph flow is orderly,

predictable & tumor cells spread sequentially

Sentinel node is the first node encountered by

the tumour cells

The sentinel node is in the direct pathway of

the primary tumour

Advantages of sentinel node biopsy

? Minimally Invasive
? Low Cost
? low morbidity
? Nodal metastasis outside axil a detected
? obviates the need for ALND without compromising staging &

local control
Disadvantages of Sentinel node Biopsy

? 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

same side

Technique

Blue dye isosulfan blue (or)

technitium labelled colloidal albumin with

gamma camera and probe can be used
Sub dermal injection

A single dose of 0.2 ml of the dye is

injected at the tumour site sub-dermally

one day prior to surgery

Peri tumour injection

Dye injected at four sites.

Larger volumes are given

Removal of dye or tracer is slower due to

scanty lymph supply of breast

parenchyma

imaged 1 to 2 hrs after injection

SENTINEL LYMPH NODE DISSECTION

WITH DYE TECHNIQUE

Blue lymphatics leading to SLN are traced

Discolouration of breast and blue urine
ISOTOPE TECHNIQUE

Probe guided surgery is superior

Useful for intra-operative localisation

After removal of SLN probe is reapplied to

site and radioactivity measured for

confirmation
PIT FALLS IN SENTINEL NODE DISSECTION

? 6% FALSE NEGATIVE
? SKIP PHENOMENON & CHANGED FLOW

DIRECTION

? INFILTRATION BY CARCINOMA
? FATTY DEGENERATION
? UPPER OUTER QUADRANT -CLOSE

PROXIMITY TO SENTINEL NODE. SHINE

THROUGH PHENOMENON-Breast to be

retracted when probing

Special problems
SPECIAL PROBLEMS IN BREAST

CANCER ? PAGETS DISEASE

Rare before 30 years, peak between 50

& 60

Can occur in the male

Erythematous exudative or scaly lesion

appears first on the nipple spreads to

areola

Does not involve surrounding skin

Nipple retraction & nipple pigmentation &

mass

D D for Pagets disease

Chronic Eczema

Malignant melanoma

Syphilitic chancre

Bowens disease

Mammary ductectasia
Mammography

Mass , sub areolar micro calcification

or only thickening of nipple areola

complex

Biopsy

Full thickness nipple biopsy or

exfoliative scrape cytology

PAGETS TREATMENT

1) with palpable mass-

segmentectomy with 1.5 cm margin

with ALND with PO-RT

2)if resection margins positive or muticentric or

solid or comedo type or high grade with

necrosis

completion mastectomy is done
Pagets without palpable mass

Biopsy of nipple areola complex positive

first step: On mammo no occult mass.no

microcalcification--do segmentectomy of nipple

areola complex +RT without axil ary dissection

Mammography + ve

Stereotactic needle localisation of occult mass

or microcalcification with frozen section biopsy

and proceed

Tamoxifen

BREAST CANCER IN PREGNANCY&

LACTATION

DELAY IN DIAGNOSIS

1) firm ,nodular &hypertrophied breast

2) small tumours can be missed

3) present at advanced stage

4) high proportion of ER-ve

5) bad prognosis
BREAST CANCER IN PREGNANCY

Mammography

FALSE NEGATIVE rate is high

due to high radiographic density of

pregnant breast

BREAST CANCER IN PREGNANCY

Alkaline phosphatase is elevated in

pregnancy

Chest X-ray is al owed with proper

shielding

Bone scan

A) Stage 1 & 2-Bone mets uncommon

scan not done

B)Stage 3 Especial y with bone pain

Bone scan done in later stages of

pregnancy or after pregnancy
BREAST CANCER IN PREGNANCY

Treatment

Modified Radical Mastectomy is the

choice irrespective of the trimester

In the first & second trimester breast

conservation with radiotherapy should not

be

done due to radiation induced anomalies

in foetus

Study questions
? 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?
? What are the important prognostic factors?

A 49-year-old woman presents with a breast mass. You are examining the

affected breast.
How would the fol owing clinical findings affect the woman's

prognosis?

1. Red edematous breast with an underlying mass

2. Edema of the skin overlying the mass

3. Puckering of the skin overlying the mass

4. Retraction of the nipple

5. A 1.5-cm mass fi xed to the deeper tissues

6. A lymph node palpable in the supraclavicular area

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

staging. The lesion is 1.5 cm in diameter, and no axillary nodes are

palpable. A metastatic workup is negative.

? 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?

? A 38-year-old woman is scheduled for a mastectomy and sentinel

node biopsy. She is concerned about her appearance and would like

to know her options for breast reconstruction.

? 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

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.

? 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

progesterone receptors are negative.

? What is the recommended treatment?

? A 55-year-old woman has a modified radical mastectomy for a stage II

carcinoma of the breast.

? A smal , 0.5-cm nodule in the suture line 5 years after surgery.
? A mammographic abnormality in the opposite breast
? Elevated liver function studies
? A fracture of the femur