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Breast ca

  1. 1. BREAST CANCERBREAST CANCER Mizan Kidanu March,18/2013
  2. 2. OUTLINEOUTLINE Introduction Epidemiology Risk factors Classification Diagnosis Treatment Prognosis
  3. 3. INTRODUCTIONINTRODUCTION • Two ventral bands of thickened ectoderm (mammary ridges, milk lines) • These ridges disappear after a short time, except small portions that persist in the pectoral region • when normal regression fails accessory breasts (polymastia) or accessory nipples (polythelia) may occur
  4. 4. ANATOMYANATOMY Location  2nd to 6th rib  lateral border of sternum to anterior axillary line  lies on pec. major and seratus anterior Contains:  Fat, glandular tissue, suspensory ligament
  5. 5. • Blood supply internal mammary axillary artery intercoastal arteries • Venous drainage axillary vein internal thoracic vein lateral thoracic vein intercoastal vein •Lymphatic drainage axillary LNs ~85% internal mammary LNs
  6. 6. •Axillary LNs receive approximately 85% of the drainage grouped into: lateral anterior posterior central apical interpectoral
  7. 7. Axillary LNs  with respect to pectoralis minor muscle they are grouped into: Level-I Level-II Level-III
  8. 8. EPIDEMIOLOGYEPIDEMIOLOGY Is the most common female cancer (26%) 2nd common cause of cancer death in women Main cause of death in women ages 40-59 yrs Mortality rates have declined since the use of screening mammography and improvements of adjuvant therapies Invasive ductal ca is the commonest type
  9. 9. Relative distributionsRelative distributions  Upper outer quadrant ~ 60%  Upper inner quadrant ~12%  Lower outer quadrant ~ 10%  Lower inner quadrant ~ 6%  Central quadrant ~ 12% 60% 12% 6%10% 12%
  10. 10. RISK FACTORSRISK FACTORS  Sex - >99% occur in females  Early menarche, late menopause, nulliparity, older age at first live birth  Age - is rare below 20 yeas of age  Radiaton exposure  Family Hx of breast CA  Genetic factors … BRCA-1 or BRCA-2  Prior breast cancer  Obesity  Dietary factors  Smoking & increased alcohol consumption  Hormone replacement therapy & OCP
  11. 11. CLASSIFICATIONCLASSIFICATION Carcinoma in situ, CISCarcinoma in situ, CIS  Ductal carcinoma in situ(DIS)Ductal carcinoma in situ(DIS)  Lobular Carcinoma in situ(LIS)Lobular Carcinoma in situ(LIS) Invasive carcinomaInvasive carcinoma  DuctalDuctal scirrhous carcinoma medullary mucinous (colloid) papillary tubular  LobularLobular  Paget’s disease of the nipple
  12. 12. Carcinoma in-situCarcinoma in-situ  Malignant cells in the duct system or lobules but no invasion of the basement membrane  Since the use of screening mammography there is a 14-fold increase in the incidence  Multicentricity - refers to the occurrence of a 2nd breast cancer outside the breast quadrant of the primary cancer (or at least 4 cm away)  Multifocality - refers to the occurrence of a 2nd cancer within the same breast quadrant as the primary cancer (or within 4 cm of it)
  13. 13. LCIS marker of increased risk for invasive breast carcinoma, not anatomic precursor bilateral in 50-70% develops only in the female breast multicentric in 60-90% DCIS anatomic precursor of invasive ductal carcinoma multicentricity for DCIS is 40-80% bilateral in 10-20%
  14. 14. CLINICAL FEATURESCLINICAL FEATURES Lump hard, painless swelling Change in the skin puckering Peau d’orange skin ulceration skin nodules Nipple changes distortion, inversion discharge eczema (paget’s disease) Metastatic disease regional LNs distant sites
  15. 15. SPREAD OF BREAST CANCERSPREAD OF BREAST CANCER Local spread with in the breast involves the skin & fascia chest wall and other portions of the breast Regional spread of breast cancer axillary LNs internal mammary LNs Supraclavicular LNs Hematogenous (distant) spread in order of frequency, are bone, lung, pleura, soft tissues, and liver.
  16. 16. Axillary nodal metastasesAxillary nodal metastases Common site of spread (45% at presentation) Spread depends on the primary tumor (size) Clinical assessment is unreliable Axillary nodal spread Vs prognosis number of nodes affected level of nodal disease
  17. 17. DIAGNOSISDIAGNOSIS History duration of illness associated symptoms (pain, headache, cough, nipple discharge) age at menarche and menstruation status (pre or postmenopausal) age at first delivery family history of breast cancer,….
  18. 18. Physical examination Inspection arms by her side or straight up in the air hands on her hips arms extended forward in a sitting position leaning forward to accentuate any skin retraction symmetry, size, and shape, peau d'orange, nipple or skin retraction or erythema
  19. 19.  Palpation supine position examine all quadrants examine with the palmar aspects of the fingers avoiding a grasping or pinching motion assesses all three levels of axillary lymphadenopathy location, size, consistency, shape, mobility, fixation,...
  20. 20. InvestigationsInvestigations CBC, Blood group & Rh, FNAC, core needle biopsy, Mammography, breast u/s, MRI, ductography ER/PR status determination Metastasis - LFT, CXR, CT, MRI, abd u/s,….
  21. 21. Characterstics of malignant lesions in mammography: architectural distortion solid mass with or without stellate features microcalcifications stippled calcifications asymmetric thickening of breast tissues nipple retraction
  22. 22. Triple AssessmentTriple Assessment Any patient with a breast lump or other symptoms suspicious of carcinoma, the Dx should be made by a combination of: 1. Clinical assessment 2. Radiological imaging and 3. Tissue sample (cytological or histological) Positive predictive value is 99.9%
  23. 23. TNM StagingTNM Staging Primary tumor (T) Tx: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: carcinoma in situ T1 : ≤2 cm in greatest dimension T2: >2 cm but not >5 cm in greatest dimension T3: >5 cm in greatest dimension T4: any size with direct extension to (a) chest wall or (b) skin
  24. 24. Regional lymph nodesRegional lymph nodes N0: no regional LN involvement N1: moveable ipsilateral axillary LAP N2: Ipsilateral axillary LNs fixed or matted; Ipsilateral internal mammary LN in the absence of axillary LN involvement N3: Ipsilateral infraclavicular LAP; Ipsilateral axillary & internal mammary; Ipsilateral supraclavicular M0: No distal metastases M1: Distal metastases Distal metastasesDistal metastases
  25. 25. Stage groupingStage grouping Stage 0: TisN0M0 Stage I: T1N0M0 Stage IIA: T0N1M0; T1N1M0; T2N0M0 Stage IIB: T2N1M0; T3N0M0 Stage IIIA: T0N2M0; T1N2M0; T2N2M0; T3N1M0 Stage IIIB: T4anyNM0 Stage IIIC: AnyTN3M0 Stage IV: AnyT AnyNM1
  26. 26. MANAGEMENT OF BREAST CANCERMANAGEMENT OF BREAST CANCER Multidisciplinary Surgeons Radiotherapists Oncologists Pathologists Other professionals councellors breast care nurses
  27. 27. Treatment for breast ca entails:  Local control surgery & radiotherapy  Systemic control hormone & chemotherapy
  28. 28. SURGERYSURGERY 1-Wide local excision (lumpectomy) 2-Total (simple) mastectomy  removes all breast tissue, nipple areola complex, and skin 3-Modified Radical Mastectomy (MRM)  preserves pectoralis major and minor muscles, allowing removal of level I & II but not level III axillary 4-Radical mastectomy  removes all breast tissue, skin, nipple areola complex, pectoralis major and minor muscles, and level I, II, & III axillary LNs
  29. 29. Factors affecting type of treatmentFactors affecting type of treatment Lymph node status  +ve node: needs adjuvant treatment Size and extent of tumor  large tumors recur more often Histology  CIS: no adjuvant treatment Hormone receptors status Age and/or menopausal status
  30. 30. Treatment of early breast cancerTreatment of early breast cancer ((Stage I & IIStage I & II)) Breast conservation - resection of the primary breast ca with a normal margin, adjuvant radiation therapy, and assessment of regional lymph node status Mastectomy with sentinel lymph node and/or axillary LN dissection
  31. 31. Breast conserving surgeryBreast conserving surgery Excision of the tumor with a rim of normal tissue lumpectomy segmental mastectomy partial mastectomy quadrantectomy
  32. 32. Contraindications for breast conserving operations(BCS) tumor >4cm multicentricity centrally located tumors poor tumor differentiation node positive disease positive margin after re-excision Hx of previous radiotherapy pregnancy
  33. 33. HORMONAL THERAPYHORMONAL THERAPY Immunoassays & immunohistochemical methods are employed to measure levels of ER Patients with significant increase in ER respond favourably to endocrine therapy E.g: Tamoxifen therapy
  34. 34. CHEMOTHERAPYCHEMOTHERAPY Adjuvant chemotherapy for early invasive breast ca is indicated in all patients with: node-positive cancers tumor >1 cm node-negative cancers of >0.5 cm with adverse prognostic features (blood vessel or lymph vessel invasion, high histologic grade, HER-2/neu overexpression, and negative hormone receptor status)
  35. 35. Locally advanced breast cancerLocally advanced breast cancer (( Stage-IIIStage-III))  Neoadjuvant chemotherapy  Usually a modified radical mastectomy (MRM)  Followed by adjuvant radiation therapy
  36. 36. Breast ca with distant metastasisBreast ca with distant metastasis ((Stage IVStage IV)) Aim of management  provide palliation  symptomatic relief Treatment  combination chemotherapy  toilet mastectomy  radiotherapy  Tamoxifen therapy in ER positive
  37. 37. COMPLICATIONS OF MASTECTOMYCOMPLICATIONS OF MASTECTOMY Seromas - the most common Wound infections Hemorrhage Lymphedema - increased risk in:  extensive ALND  the delivery of radiation therapy  the presence of pathologic lymph nodes  obesity Nerve injury
  38. 38. FOLLOW UPFOLLOW UP Assess local recurrence, especially in BCT Assess the contralateral breast Detect psychiatric morbidity Allow provision of prosthesis Early detection & treatment of metastatic disease
  39. 39. PROGNOSIS OF BREAST CAPROGNOSIS OF BREAST CA 5-year survival rate Stage 5yr survival I 100% IIa 92% IIb 81% IIIa 67% IIIb 54% IV 18%