Breast Cancer

Presented by: Ola Nemri

Most

common cancer in females.

The

crude incidence rate for female breast cancer was 30.2/100,000. F:M = 95:1

Pathology
Breast CA

Ductal 85%

Lobular 15%

DCIS

invasive

LCIS

invasive

Carcinoma in situ LCIS,DCIS

Pre-invasive cancer, that hasnt breached the BM. Now accounts for over 20% of cancer detected by screening in the UK. May be cured with surgery, without the need for radiotherapy.

Invasive cancer will go on to develop in at least 20% of the cases. Lobular carcinoma tends to be multifocal in the same breast, and bilateral.

Inflammatory carcinoma:
Rare. Highly

aggressive. Presents as painful, swollen breast, which is warm with cutaneous edema, because of blockdge of the subdermal lymphatics with carcinoma cells. DDx with breast abcess. Dx by biopsy Treat with aggressive chemo and radiotherapy, and salvage surgery.

Pagets disease of the nipple

A superficial

manifestation of an underlying Breast

CA. Presents as an eczema-like condition of the nipple and the areola, which slowly erodes. An underlying carcinoma will sooner or later become clinically evident. Dx by biopsy, paget cells in epidermis. DDx with nipple eczema.**

Clinical presentation An approach to Breast cancer

Risk Factors
Age: The risk increases with increasing age, rare below the age of 20Y. Genetic factors: Familial like P53, BRCA-1, and BRCA-2. Non-Familial like C-erb. Hormonal: Late age of 1st pregnancy**. Nulliparity. Early menarche, late menopause. Obesity. Long term exposure to HRT. Gynecological CA.

Diet: Obesity and alcohol. Geographic location; more common in the western world. Pre-existing condition: Cancer in the contralateral breast. Exposure to radiation (hodgkin).

Approach to Breast cancer

Triple assessment 1- Detailed history and physical examination. 2- Diagnostic imaging by Mammography and/or Ultrasound scanning. 3- Cytology or Histology.

Triple assessment/History

Age. Symptoms
Breast Mass Hx of a mass. Skin changes: Ulceration, nipple changes. Bloody Nipple Discharge. The breast may become harder, or change in shape. Pain or Pricking sensation. Arm swelling, or axillary lump. Symptoms of Mets. (backache, pathological fx, Cough, Headache, Abdominal pain)
Painless

Parity, and age at 1st pregnancy. Menstrual pattern and relation to complaint. Family history. Risk factors.

Triple assessment/Exam

Breast examination

Inspection: Nipple changes (Retraction, Destruction, discharge, eczema) ,skin tethering or dimpling ,skin ulceration, Peau dorange , dilated veins . Palpation: Size and site(UOQ in 60%),surface, consistence, Fixation to the skin or underlying muscle Dont forget the axillary tale and the contralateral breast.**

Axillary LN. General examination of the chest and abdomen.

***

Triple assessment/Imaging
-Mammography:
Screening Diagnostic Follow up patients for recurrence.

The

sensitivity of the mammogram is in the 90% range. Cancers missed by mammography are in the range of 10-30%. The Sensitivity increases with age. Signs of malignancy: :
Area of increased density. MicroCalcification. Distortion of the parenchyma . Speculated mass.

Triple assessment/Imaging
2-Ultrasound Useful in young woman. Can determine whether a lesion is solid or cystic. Can define the size, contour, or internal texture of the lesion. 3- MRI: Useful to differentiate between scar and recurrence , Imaging for women with implants, Evaluate patients with axillary metastases or chest wall involvement.

Triple assessment/Cytology & Histology

Fine-Needle aspiration Cytology Reliable, least invasive, Accurate, Sensitivity > 90%. It differentiates between benign and malignant cells, cells shape and size, and nuclei.. Disadvantage: false ve may occur, invasive cancer cant be distinguished from CIS. Core Biopsy Distinguish between invasive and non invasive cancer "histology" Provide information of tumor grade and receptors ER,PR. Excisional biopsy, usually for benign conditions.

Tumor Biomarker

Hormone receptors: oEstrogen receptors. oProgesterone receptors.

Good prognostic factor

C-erbB2
factor

(growth factor receptor)

bad prognostic

The spread of Breast CA

Local spread: Other portions of the breast. Skin, Pectoral muscle and Chest wall. Lymphatic metastasis : Axillary LN. Internal mammary chain of LN.(post 1/3) Supraclavicular LN. Contralateral LN.
Notes: The involvement of LN is not just a chronological event, but rather marker for metastatic potential of the cancer (micrometastasis).

Spread by blood stream: Bone, (lumber, femur, thoracic, rib, skull) osteolytic lesion. liver, lung, brain,skin, adrenal glands, ovaries.

Staging of Breast CA

Careful

clinical examination. Chest X-ray. Chest /Abdomen CT. Isotope bone scan.

TNM Staging
T N
T1 <= 2cm , no fixation or tethering. T2 2-5cm with tethering or nipple retraction. T3 5-10cm with infiltration, ulceration, peau dorange or deep fixation. T4 >10cm. Any tumor with infiltration or ulceration larger than its diameter.

N0no palpable axillary nods. N1 mobile palpable axillary nods. N2 fixed axillary nods. N3 palpable supraclavicular nods, arm oedema.

M0 no evidance of distant mets. M1 distant mets.

Treatment of Breast CA

Basic principles:
Reduce

the chance of local recurrence. Reduce the risk of metastatic spread.

S1, S2(early) surgery , radiotherapy.

systemic therapy if bad Px or +ve LN. Aim to cure S3, S4(late) systemic therapy, small role for surgery. palliative

Surgery

Indication for mastectomy:

Large tumor. 2. Central tumor beneath or involving the nipple. 3. Multifocal disease. 4. Local recurrence. 5. Patient preference.
1.

Types of surgery
Radical

Halsted mastectomy. Modified radical mastectomy(patey): Includes: *the whole breast.

*large portion of the skin overlying the tumor with the nipple. *all of the fat, fascia and LN of the axilla.

 Conservative

breast cancer surgery(wide local

excision):
Remove the tumor +safety margin at least 1cm.
Quadrantectomy :

Remove the entire segment that contains the tumor.

Axillary

LN in conservative surgery,..sentinel node Bx, sampling, remove the nods behind and lateral to the PM, or full dissection through a separate incision.

Axillary

surgery is for staging, treat the axilla and prognosis. surgery shouldnt be combined with radiotherapy to the axilla, it increases tha morbidity.

Axillarry

High

rate of local recurrence in conservative surgery**, young pt, and high grade tumors.

Complications of mastectomy
General

vs. local /Immediate vs. late.

Seroma: accumulation of serous/lymphatic fluid underneath the breast flaps and in the axilla. Hematoma. Intercostal brachial nerves are usually divided, may result in numbness in the upper arm and under the arm of the surgical site. . Lymphedema, R/O recurrence. Psychological.

Radiotherapy

Indicated in pt whom the risk of local recurrence is high. Large tumor , large number of +ve nods, extensive lymphovascular invasion.

Systemic therapy ,for micrometastasis

A.

Chemotherapy

1. Adjuvant chemotherapy:
After locoregional surgery.
2.

Neoadjuvant chemotherapy:

Before surgery in a locally advanced carcinoma, aiming to reduce the size of the tumor to get a more conservative surgery.

Commonly used agents

Cyclophosphamide hemorhegic cystitis.
Methotrexate. 5-flurouracil. Doxorubicin. cardiotoxic.
Herceptin (Trastuzamab) humanized monoclonal antibody directed against HER2, is active against tumors containing C-erb GF receptor.

B. Hormonal therapy:
In estrogen and progesterone receptor +ve tumors. Used to reduce the rate of recurrence and tumor in the contralateral breast.

Tamoxifen LHRH agonist, ovarian suppression in premenopausal. Oral Aromatase inhibitor (anastrazole)for postmenopausal pt.

Follow up of Breast CA
Yearly or 2-yearly mammography of the treated and contralateral breast. CXR, CBC, LFT.

Screening for Breast CA

Familial breast cancer..

The Male Breast

Gynecomastia
o o o o o

Idiopathic, uni/bi, at puberty. Hormonal , adrenal and pituitary disease, paraneoplastic lung ca, steroid therapy. Liver disease, failure to metabolize estrogen. Drugs, digitalis, spironolactone, cimetidine. Klinefelter syndrome. in a healthy pt is reassurance, if not, mastectomy.

Treatment

Carcinoma of the male breast

Less than 0.5% of all cases. Known predisposing factors are gynecomastia and excess exogenous and endogenous estrogen. Treatment as in female.

Thank you.