BREAST CANCER

BREAST CANCERBREAST CANCER

The BreastThe Breast

AA ducts ducts BB lobules lobules CC dilated section of duct to dilated section of duct to

hold milkhold milk DD nipple nipple EE fat fat FF pectoralis major muscle pectoralis major muscle GG chest wall/rib cage chest wall/rib cage Enlargement:Enlargement: AA normal duct cells normal duct cells BB basement membrane basement membrane CC lumen (center of duct) lumen (center of duct)

Breast Carcinoma IncidenceBreast Carcinoma Incidence 20% of all cancers in 20% of all cancers in

womenwomen Commonest cause of Commonest cause of

death - 35-55ydeath - 35-55y In UK 1 in 10-12 chancesIn UK 1 in 10-12 chances 1 in 8 women in US1 in 8 women in US Less incidence in AsiaLess incidence in Asia Majority of cancers arise Majority of cancers arise

in the ducts.in the ducts. Very rare before age 25Very rare before age 25

Risk Factors:Risk Factors: Female sex..!, Age, Obesity, high fat Female sex..!, Age, Obesity, high fat

diet diet Maternal relative with breast cancer. Maternal relative with breast cancer. Longer reproductive span. Longer reproductive span. Nulliparity, Oral contraceptivesNulliparity, Oral contraceptives Later age at first pregnancy. Later age at first pregnancy. Atypical epithelial hyperplasia. Atypical epithelial hyperplasia. Previous breast cancer/Endometrial Ca. Previous breast cancer/Endometrial Ca. Geographic factors - countryGeographic factors - country BRCA1 and BRCA2BRCA1 and BRCA2 genes genes

GENDER - All women are

at risk

Age

Family/PersonalHistory

ReproductiveHistory

MenstrualHistoryRace

Genetic Factors

Breast Cancer Risk Breast Cancer Risk FactorsFactors

that cannot be changedthat cannot be changed

Radiation

Treatment withDES

All women are

at risk

Obesity

Breastfeeding

Not having children

Birth ControlPills

AlcoholHormone

ReplacementTherapy

Exercise

All women are

at risk

Obesity

Breastfeeding

Not having children

Birth ControlPills

AlcoholHormone

ReplacementTherapy

Breast Cancer Risk Breast Cancer Risk FactorsFactors

that can be that can be controlledcontrolled

Exercise

Pathology ( WHO Pathology ( WHO classification)classification)

Epithelial (mammary tissueEpithelial (mammary tissue)) Non invasiveNon invasive

DCISDCIS LCISLCIS

InvasiveInvasive Ductal 85 %Ductal 85 % Lobular 9 %Lobular 9 % Mucinous 5 %Mucinous 5 % Papillary < 5 %Papillary < 5 % Medullary < 5 %Medullary < 5 %

Mixed Ct & epithelialMixed Ct & epithelial MiscellaneousMiscellaneous

Paget’s diseasePaget’s disease IBCIBC

Pathology (Foot& Stewart Pathology (Foot& Stewart classification)classification)

Neoplasm of mammary tissue properNeoplasm of mammary tissue proper Neoplasm of lobular epithelium 9- 10 %Neoplasm of lobular epithelium 9- 10 %

LCIS 50 %LCIS 50 % Lobular carcinoma invasive 50 %Lobular carcinoma invasive 50 %

Neoplasm of ductal epithelium 85 %Neoplasm of ductal epithelium 85 % DCISDCIS Ductal carcinoma Invasive ( IDC)Ductal carcinoma Invasive ( IDC)

NOS ( simple type)NOS ( simple type) Special types ( scirrhous, medullary, Special types ( scirrhous, medullary,

mucinous, papillary, cribriform, comedo, mucinous, papillary, cribriform, comedo, tubular, secretory with metaplasia)tubular, secretory with metaplasia)

Unusual presentationsUnusual presentations Paget’s diseasePaget’s disease IBCIBC

Pathology (Foot& Stewart Pathology (Foot& Stewart classification)classification)

Malignant mesenchymal neoplasmMalignant mesenchymal neoplasm SarcomaSarcoma LymphomasLymphomas Myeloid leukemiaMyeloid leukemia

Miscellaneous malignanciesMiscellaneous malignancies Skin Skin

SCCSCC BCCBCC

Skin adenxa ( carcinoma of sweat glands or Skin adenxa ( carcinoma of sweat glands or sebaceous glands)sebaceous glands)

Undifferentiated carcinomaUndifferentiated carcinoma MetastaticMetastatic

Female ( other breast, lung, MM)Female ( other breast, lung, MM) Male (prostate)Male (prostate)

Carcinoma in situCarcinoma in situ

It is a spectrum of pre invasive neoplastic It is a spectrum of pre invasive neoplastic changes in the breast includes;changes in the breast includes;

DCIS 4 % symptomatic 25 % screen DCIS 4 % symptomatic 25 % screen detecteddetected

LCIS <1 % symptomatic 1% screen LCIS <1 % symptomatic 1% screen detecteddetected

Hyper plastic appearance ( ductal or Hyper plastic appearance ( ductal or lobular)lobular)

Ductal Carcinoma in SituDuctal Carcinoma in Situ

It is the group of It is the group of neoplasm arising from neoplasm arising from ductal epithelium & ductal epithelium & confined by basement confined by basement membranemembrane

Ducts expanded by Ducts expanded by large irregular cells large irregular cells with lage irregular with lage irregular nuclei nuclei

Malignant cells are Malignant cells are confined by basement confined by basement membranemembrane

Ductal Carcinoma in Situ Ductal Carcinoma in Situ (classification)(classification)

Comedo DCISComedo DCIS High grade High grade

cytologycytology Extensive Extensive

necrosisnecrosis Branched Branched

calcificationcalcification

Non Comedo Non Comedo DCISDCIS•Low grade Low grade cytologycytology•Lack necrosisLack necrosis•Lack Lack calcificationcalcification

• Cribribriform• Solid• micropapillary

Intermediate histologyIntermediate histology

Ductal Carcinoma in SituDuctal Carcinoma in Situ

Clinical presentationClinical presentation Asymptomatic > 50 % in screening Asymptomatic > 50 % in screening

programs as abnormal mamographic programs as abnormal mamographic findingfinding

Nipple dischargeNipple discharge Paget’s diseasePaget’s disease

Risk of invasive BCRisk of invasive BC is 40 % over 30 y is 40 % over 30 y MulticentricityMulticentricity in 50 % in 50 %

Ductal Carcinoma in SituDuctal Carcinoma in Situ(Diagnosis)(Diagnosis)

Sterotactic Sterotactic CNBCNB U/S guided U/S guided CNBCNB Wire or ink guided Wire or ink guided excisional biopsyexcisional biopsy which which

is a must if;is a must if; Atypical ductal hyperplasiaAtypical ductal hyperplasia Radial scarRadial scar Non specific diagnosisNon specific diagnosis Lack correlation with mammogramLack correlation with mammogram

Wedge biopsyWedge biopsy if paget’s if paget’s

Ductal Carcinoma in SituDuctal Carcinoma in Situ(Treatment)(Treatment)

Depend on Van Nuys Prognostic Index Depend on Van Nuys Prognostic Index which classify patients into 3 groupswhich classify patients into 3 groups

Depending on 3 factorsDepending on 3 factors

3- Surgical free margin

1- Tumor size2- Histological grade

Low riskLow risk Intermediate riskIntermediate risk High riskHigh risk

Wide local excisionWide local excision (BCS)(BCS)

BCS & irradiationBCS & irradiation MastectomyMastectomy SSMSSM

Lobular Carcinoma In SituLobular Carcinoma In Situ It constitute 25 % of CISIt constitute 25 % of CIS The risk of invasive cancer is 20 – 30 % life time The risk of invasive cancer is 20 – 30 % life time

and bilateraland bilateral It is multicentric in 80 %It is multicentric in 80 % Never palpable massNever palpable mass TreatmentTreatment

Follow up byFollow up by C/E every 4 monthsC/E every 4 months Mammography yearlyMammography yearly

Chemoprevention by Tamoxafen or raloxifeneChemoprevention by Tamoxafen or raloxifene Mastectomy which is rarely usedMastectomy which is rarely used

Non Invasive (Carcinoma in Non Invasive (Carcinoma in Situ)Situ)

Feature DCIS LCIS

Incidence 75 % of CIS 25% of CIS Risk of invasive

cancer 30-40 %, mostly in location of DCIS

20 % lifetime, bilateral

Multi-centric 50 % 80 % Palpable Rarely Never

Mammography Mass or microcalcifications

Occult

Invasive Breast CancerInvasive Breast Cancer

Epithelial Invasive BCEpithelial Invasive BC Ductal 85 %Ductal 85 % Lobular 9 %Lobular 9 % Mucinous 5 %Mucinous 5 % Papillary < 5 %Papillary < 5 % Medullary < 5 %Medullary < 5 %

Mixed Ct & epithelialMixed Ct & epithelial MiscellaneousMiscellaneous

Paget’s diseasePaget’s disease IBCIBC

Infiltrating Duct Carcinoma: small Infiltrating Duct Carcinoma: small hard (Atrophic scirrhous)hard (Atrophic scirrhous)

5 %5 % post menopausal with post menopausal with

shriveled breastshriveled breast NEANEA

Small sizeSmall size Irregular in shapeIrregular in shape Very hard in consistencyVery hard in consistency

MPMP ++++ FT++++ FT + islads of malignant + islads of malignant

spheroidal cellsspheroidal cells Infrequant mititic figuresInfrequant mititic figures

Very slowly progress 10 Y Very slowly progress 10 Y Very late metastasesVery late metastases Best prognosisBest prognosis

Infiltrating Duct Carcinoma: Infiltrating Duct Carcinoma: FibrosisFibrosis

(Scirrhous)(Scirrhous) 75 %75 % Middle aged 40 – 60 Middle aged 40 – 60

YY NEANEA

Small sizeSmall size Irregular in shapeIrregular in shape hard in hard in

consistencyconsistency MPMP

+++ FT+++ FT ++ scanty as ++ scanty as

finger like finger like processesprocesses

slowly progress slowly progress late metastaseslate metastases Good prognosisGood prognosis

Medullary Carcinoma: Large softMedullary Carcinoma: Large soft 3- 5 %3- 5 % Well developed breast of Well developed breast of

young womanyoung woman NEANEA

Largr fleshy in sizeLargr fleshy in size Brain like cut section in Brain like cut section in

shapeshape with hge & necrosiswith hge & necrosis Soft in consistencySoft in consistency

MPMP ++ delicate FT++ delicate FT ++ + highly malignant ++ + highly malignant

cellscells Rapidly progress Rapidly progress Moderate metastasesModerate metastases Good prognosisGood prognosis

Rapid increase lead to early Rapid increase lead to early presentationpresentation

Fungate more than infilttrateFungate more than infilttrate Late LN affection dt large cell Late LN affection dt large cell

sizesize

Mucoid or Colloid CarcinomaMucoid or Colloid Carcinoma It form a bulky mass with mucoid It form a bulky mass with mucoid

degeneration & necrosisdegeneration & necrosis It grow slowly & disseminate late & It grow slowly & disseminate late &

may reach huge sizes so have good may reach huge sizes so have good prognosis after surgeryprognosis after surgery

Signet ring shaped cells dt mucoid Signet ring shaped cells dt mucoid materialsmaterials

Lobular CarcinomaLobular Carcinoma It constitute 9 %It constitute 9 % Arise in the Arise in the

terminal lobulesterminal lobules It could take It could take

different different presentation as presentation as ductal carcinomaductal carcinoma

Paget’s DiseasePaget’s Disease It is a chronic It is a chronic

eczematoid malignant eczematoid malignant eruption of the nippleeruption of the nipple

1 % in middle aged and 1 % in middle aged and old womanold woman

EtiologyEtiology Old theory ( skin Old theory ( skin

tumor with secondary tumor with secondary breast massbreast mass

New theory ( tumor in New theory ( tumor in terminal ducts as in terminal ducts as in situ cancer then situ cancer then spreadspread

Outward to nipple Outward to nipple and skinand skin

Inward breast massInward breast mass

Paget’s DiseasePaget’s Disease Hyper plastic changes Hyper plastic changes

in all layers of in all layers of epidermis (epidermal epidermis (epidermal hypertrophy)hypertrophy)

Characteristic paget’s Characteristic paget’s cellscells Large vaculated cellsLarge vaculated cells Deeply stained Deeply stained

eccentric nucleuseccentric nucleus Subdermal round cell Subdermal round cell

infiltrationinfiltration

Paget’s DiseasePaget’s Disease( Clinical picture)( Clinical picture)

Persistent eczema like Persistent eczema like condition that affect old condition that affect old female 50 Y which does female 50 Y which does not respond to topical not respond to topical treatmenttreatment

Unilateral erosion of the Unilateral erosion of the nipple which is red, thick, nipple which is red, thick, scaly & crusted without scaly & crusted without vesicles or itchingvesicles or itching

Serosangious dischargeSerosangious discharge Mass in the breast in 2 Mass in the breast in 2

YearsYears

Paget’sPaget’s

MenopauseMenopause UnilateralUnilateral No vesicles or No vesicles or

itchingitching Sub areolar mass Sub areolar mass

after 2 yearsafter 2 years Not respond to Not respond to

topical treatmenttopical treatment Biopsy paget Biopsy paget

cellscells

EczemaEczema

LactationLactation BilateralBilateral Vesicles and Vesicles and

itchingitching No massNo mass

Respond to Respond to topical treatmenttopical treatment

No paget cellsNo paget cells

Paget’s DiseasePaget’s DiseaseDiagnosisDiagnosis

Mammography is a mustMammography is a must Detect sub clinical massDetect sub clinical mass Detect micro calcificationDetect micro calcification Detect multi centricityDetect multi centricity

Biopsy ( full thickness nipple biopsy)Biopsy ( full thickness nipple biopsy) is is diagnostic where there are 3 different typesdiagnostic where there are 3 different types Paget’s disease with DCIS ( high grade comedo)Paget’s disease with DCIS ( high grade comedo) Paget’s disease with invasive cancer Paget’s disease with invasive cancer

( commonest)( commonest) Paget’s disease confined to epidermis of nipple Paget’s disease confined to epidermis of nipple

& areola ( rarest)& areola ( rarest)

Paget’s DiseasePaget’s Disease( Treatment)( Treatment)

The standard treatment is The standard treatment is mastectomymastectomy Recently BCS is used with Recently BCS is used with segmentectomy of segmentectomy of

nipple & areola & radiotherapynipple & areola & radiotherapyPaget’s disease Paget’s disease with no masswith no massOr with DCISOr with DCIS

SegmentectomSegmentectomy y

Of N & AOf N & A

-Ve marginsVe margins-No No

multicentricmulticentric

+ Ve Ve marginsmargins multicentrimulticentricc

RadiotherapyRadiotherapy MastectoMastectomymy

Paget’s disease Paget’s disease with mass or with mass or with with invasive cancerinvasive cancer

Segmentectomy Segmentectomy Of N & AOf N & A

& Axillary dissection& Axillary dissection


Use of chemotherapy based on 5 Use of chemotherapy based on 5 prognostic indication of prognostic indication of chemotherapychemotherapy

1.1. Age < 35 yearAge < 35 year

2.2. Tumor > 1 cmTumor > 1 cm

3.3. Tumor high gradeTumor high grade

4.4. + ve LN+ ve LN

5.5. - ve ER- ve ER

IBC( Inflammatory breast IBC( Inflammatory breast cancercancer

Very rareVery rare Well developed breast of Well developed breast of

young woman during young woman during pregnancy and lactation pregnancy and lactation should be DD of abscessshould be DD of abscess

NEANEA Diffuse swollen, hot on Diffuse swollen, hot on

palpation ,with dilated palpation ,with dilated veinvein

Soft in consistencySoft in consistency MPMP

+ very little FT+ very little FT ++ + + highly malignant ++ + + highly malignant

anaplastic cells anaplastic cells Rapidly progress Rapidly progress Very early metastasesVery early metastases Bad prognosisBad prognosis

IBC( Inflammatory breast IBC( Inflammatory breast cancercancer

It is very similar to acute breast It is very similar to acute breast abscess with the following abscess with the following differencesdifferences It is a diffuse lesionIt is a diffuse lesion No pyrexiaNo pyrexia LN not tenderLN not tender Progressive in natureProgressive in nature No lecucytosisNo lecucytosis No respond to antibioticNo respond to antibiotic

Spread of Breast Carcinoma:Spread of Breast Carcinoma: Methods of spreadMethods of spread

DirectDirect LymphaticLymphatic BloodBlood Trans- celomicTrans- celomic

Theories of spreadTheories of spread Loco-regional Loco-regional

theorytheory Systemic theorySystemic theory

TNM StagingTNM Staging Tx Tx primary tumor can not be assessedprimary tumor can not be assessed Tis In situ carcinoma & paget’s diseaseTis In situ carcinoma & paget’s disease T0 no palpable massT0 no palpable mass T1 tumor < or = 2 cmT1 tumor < or = 2 cm

T1a < or = 0.5 cm no deep fixation T1a < or = 0.5 cm no deep fixation T2b 0.5 – 1 cm + deep fixationT2b 0.5 – 1 cm + deep fixation T3c 1 – 2 cm + deep fixationT3c 1 – 2 cm + deep fixation

T2 tumor 2 – 5 cmT2 tumor 2 – 5 cm T2a no deep fixationT2a no deep fixation T2b deep fixationT2b deep fixation

T3 tumor 5 – 10 cmT3 tumor 5 – 10 cm T3a no deep fixationT3a no deep fixation T3b deep fixationT3b deep fixation

T4 tumor of any sizeT4 tumor of any size T4a direct chest extensionT4a direct chest extension T4b skin ( Peau d’orange, skin nodule & T4b skin ( Peau d’orange, skin nodule &

ulceration)ulceration) T4c T 4a + T4bT4c T 4a + T4b T4d inflammatory breast cnacerT4d inflammatory breast cnacer

TumorTumor

TNM StagingTNM Staging N N x can not be assessedx can not be assessed N N 0 not palpable LN0 not palpable LN N N 1 palpable homo-lateral axillary LN and mobile1 palpable homo-lateral axillary LN and mobile N N 2 palpable homo-lateral axillary LN and fixed2 palpable homo-lateral axillary LN and fixed N N 3 ipsilateral internal mammary LN3 ipsilateral internal mammary LN

MM XX can not be assessed can not be assessed

M M 0 no known metastases0 no known metastases M M 1 distant metastases including supra-clavicular 1 distant metastases including supra-clavicular

LNLN

NodesNodes

MetastasesMetastases

TNM stagingTNM staging

TT00 TT11 T2T2 T3T3 T4T4

N0N0

N1N1

N2N2

N3N3

Stage I T1 N0 M0Stage I T1 N0 M0

Stage II a T1 N1, T2 N0, T0 Stage II a T1 N1, T2 N0, T0 N1N1

Stage II b T2 N1, T3 N0Stage II b T2 N1, T3 N0

TNM stagingTNM staging

TT00 TT11 T2T2 T3T3 T4T4

N0N0

N1N1

N2N2

N3N3

Stage III a any N2 any T3 except Stage III a any N2 any T3 except T3 N0T3 N0

Stage III b any N3 any T4Stage III b any N3 any T4

Stag

Definition 5-year Surv (%)

7-year Surv (%)

I Tumor 2 cm or less without spread 96 92

II

Tumor 2-5cm with regional lymph node involvement but without distant metastases, OR > 5 cm in diameter without spread

81 71

III

Any size with skin/chest wall fixation, & axillary or internal mammary nodal involvement, without distant metastases

52 39

IV Tumor of any size with or without regional spread but with evidence of distant metastases

18 11

Manchester classificationManchester classification Stage I ( 85%)Stage I ( 85%)

Mobile tumorMobile tumor Free axillaFree axilla Paget’sPaget’s

Stage II ( 66 %)Stage II ( 66 %) Mobile tumorMobile tumor Mobile axillary LNMobile axillary LN

Stage III ( 41 %)Stage III ( 41 %) Tumor fixedTumor fixed LN fixedLN fixed

Stage IV ( 10%)Stage IV ( 10%) Wide disseminationWide dissemination suprac;lavicular LNsuprac;lavicular LN

PrognosisPrognosis Clinical factors

Age Sex Site Stage Grade Pregnancy

Pathological factors Tumor type Grade Axillary LN

Biological factors Receptors ER, Pg R Tumor markers DNA ploidy S phase fraction

Nottingham Prognostic Index Nottingham Prognostic Index (NPI)(NPI) Axillary LN involvementAxillary LN involvement

1 no node1 no node 2 1-3 node2 1-3 node 3 4 or more node3 4 or more node

Grade (1, 2, 3)Grade (1, 2, 3) Tumor size in cm x 0.2Tumor size in cm x 0.2

Prognostic groupPrognostic group NPINPI 10 Y 10 Y survivalsurvival

ExcellentExcellent < or = 2.4< or = 2.4 9494

GoodGood < or = 3.4< or = 3.4 8383

Moderate IModerate I < or = 4.4< or = 4.4 7070

Moderate IIModerate II < or = 5.4< or = 5.4 3131

Poor Poor > 5.4> 5.4 2020

Breast self examination for Breast self examination for early detectionearly detection

Clinical Features: (symptoms)Clinical Features: (symptoms) Main symptomsMain symptoms

LumpLump Discharge ( blood stained)Discharge ( blood stained) Pain ( late)Pain ( late)

Symptoms of spreadSymptoms of spread Direct ( skin, nipple, Areola)Direct ( skin, nipple, Areola) Lymphatic LNLymphatic LN BloodBlood

Lung ( respiratory distress & hemoptsis)Lung ( respiratory distress & hemoptsis) Bone ( aches & patholgical fracture)Bone ( aches & patholgical fracture) Malignant ascitesMalignant ascites Met static nodules any whereMet static nodules any where

Clinical Features: (signs)Clinical Features: (signs)1.1. Breast a wholeBreast a whole

Examination while Examination while sitting ( puckered sitting ( puckered or displacedor displaced

Raising the arms Raising the arms above the head above the head (pulled upward)(pulled upward)

Patient leaning Patient leaning forward ( not forward ( not protrude freely)protrude freely)

Clinical Features: (signs)Clinical Features: (signs)2.2. Nipple changesNipple changes

Recent retraction Recent retraction dt neoplastic fibrosis dt neoplastic fibrosis

& lactiferous ducts & lactiferous ducts invasioninvasion

Should be DD fromShould be DD from Congenital Congenital Chronic Chronic

inflammationinflammation Nipple erosion (should Nipple erosion (should

be DD of eczema)be DD of eczema) Discharge which could Discharge which could

be serous or bloodybe serous or bloody

Clinical Features: (signs)Clinical Features: (signs)3.3. Skin Skin

manifestationsmanifestations1.1. Peau d’ orange dt Peau d’ orange dt

obstruction of skin obstruction of skin lymphaticlymphatic

2.2. Cancerous nodule or Cancerous nodule or satellitessatellites

3.3. Ulceration or fungation Ulceration or fungation dt skin invasiondt skin invasion

Clinical Features: (signs)Clinical Features: (signs)




4.4. Dimpling and Dimpling and puckering dt pull puckering dt pull on cooper on cooper ligamentsligaments

5.5. Dilated veinsDilated veins6.6. Skin lymphoedemaSkin lymphoedema7.7. Tumor fixation to Tumor fixation to

the skinthe skin8.8. Inflammatory signs Inflammatory signs

as in IBCas in IBC9.9. Nipple and areola Nipple and areola

changeschanges


10.10. Cancer en Cancer en cuirassecuirasse

1.1. Atrophic breastAtrophic breast

2.2. HardHard

3.3. PigmentedPigmented

4.4. Fixed to chest wallFixed to chest wall

5.5. Studded with Studded with nodulesnodules

Clinical Features: (signs)Clinical Features: (signs)4.4. Breast lumpBreast lump

Mostly in UOQ in 60 Mostly in UOQ in 60 %%

Irregular in shapeIrregular in shape Hard in consistancyHard in consistancy Ill deined bordersIll deined borders Fixed within the Fixed within the

breast my be fixed to breast my be fixed to skin or chest wallskin or chest wall

5.5. Opposite breastOpposite breast

examined first examined first before the diseased before the diseased one to exclude one to exclude metastasesmetastases

Clinical Features: (signs)Clinical Features: (signs)6- lymph nodes should be examined6- lymph nodes should be examined

Pectoral or anterior group

Central and apical groups

Lateral or brachial groups


Posterior or subscapular group Supraclavicular group


7- general examination 7- general examination Chest Chest effusion, deposites , effusion, deposites ,

mediastinal LNmediastinal LN AbdomenAbdomen ascites, hepatomegally ascites, hepatomegally Pelvis Pelvis by PR and PV by PR and PV

KrukenbergKrukenberg Plummer shelfPlummer shelf

BonesBones tenderness , weakness, tenderness , weakness, deformity and fractures deformity and fractures

Diagnosis:Diagnosis: LaboratoryLaboratory

GeneralGeneral Liver functionLiver function Kidney functionKidney function Cytological examination of nipple dischargeCytological examination of nipple discharge Tumor markersTumor markers

RadiologicalRadiological Plain x rayPlain x ray Breast imagingBreast imaging

MammographyMammography Thermo graphyThermo graphy GalactographyGalactography UltrasoundUltrasound CTCT MRIMRI Light spectroscopyLight spectroscopy

Radioactive isotope scanning of LNRadioactive isotope scanning of LN

Diagnosis:Diagnosis: BiopsyBiopsy

Fine Needle Aspiration BiopsyFine Needle Aspiration Biopsy Core BiopsyCore Biopsy Excision BiopsyExcision Biopsy Frozen sectionFrozen section Drill biopsyDrill biopsy Sentinal node biopsySentinal node biopsy

Immunoperoxidase,Immunoperoxidase, Molecular techniquesMolecular techniques – Gene – Gene

detection.detection.

History of MammographyHistory of Mammography Used in clinical practice Used in clinical practice

since 1927 in diagnosis of since 1927 in diagnosis of breast abnormalities.breast abnormalities.

In the 50’s and 60’s it was In the 50’s and 60’s it was developed to the point that developed to the point that benign and malignant benign and malignant tumors could be tumors could be differentiated.differentiated.

1963-1967 screening 1963-1967 screening program for the detection program for the detection of breast cancer conducted of breast cancer conducted by the Health Insurance by the Health Insurance Plan of New York (60,000 Plan of New York (60,000 women screened).women screened).

1973 Breast Cancer 1973 Breast Cancer Detection Demonstration Detection Demonstration Project (B.C.D.D.P.) – 15 Project (B.C.D.D.P.) – 15 annual screenings of annual screenings of 270,000 women270,000 women..

http://www.thebreastclinic.com/BREAST/IMAGES/mmgs/20_800_348.gif

Low Dose X-raysLow Dose X-rays Electrons originating Electrons originating

at the cathode are at the cathode are accelerated towards accelerated towards the rotating anode.the rotating anode.

Upon contact the Upon contact the kinetic energy of the kinetic energy of the electron is converted electron is converted into x-rays and heat into x-rays and heat (0.5% x-rays)(0.5% x-rays)

Collimator system, Collimator system, composed of lead for composed of lead for complete absorption, complete absorption, focuses the x-ray focuses the x-ray beambeam

X-ray/ Breast InteractionX-ray/ Breast Interaction As with most x-ray images greater contrast As with most x-ray images greater contrast

occurs when there is a large difference in occurs when there is a large difference in attenuation between tissues.attenuation between tissues.

The breast is compressed and the x-ray The breast is compressed and the x-ray beam is applied.beam is applied.

Contrast is best seen between fatty tissue Contrast is best seen between fatty tissue and functional glandular tissue, but contrast and functional glandular tissue, but contrast is poor between glandular tissue and is poor between glandular tissue and cancerous tissues.cancerous tissues.

Thus, in older women, post-menopause, the Thus, in older women, post-menopause, the reduction in functional glandular tissue reduction in functional glandular tissue provides for a distinct contrast between provides for a distinct contrast between cancerous masses and fatty tissues.cancerous masses and fatty tissues.

Two Types of MammogramsTwo Types of Mammograms A screening mammogramA screening mammogram is an x-ray is an x-ray

examination of the breast in a woman who has examination of the breast in a woman who has no breast complaints (asymptomatic). The goal no breast complaints (asymptomatic). The goal of screening mammography is to find cancer of screening mammography is to find cancer when it is still too small to be felt by her doctor when it is still too small to be felt by her doctor or the woman.or the woman.

A screening mammogram usually takes 2 x-ray A screening mammogram usually takes 2 x-ray pictures (views) of each breast.pictures (views) of each breast.

A diagnostic mammogramA diagnostic mammogram is an x-ray is an x-ray examination of the breast in a woman who examination of the breast in a woman who either has a breast complaint (for example, a either has a breast complaint (for example, a breast mass, nipple discharge, etc.) or has had breast mass, nipple discharge, etc.) or has had an abnormality found during a screening an abnormality found during a screening mammogram. During a diagnostic mammogram, mammogram. During a diagnostic mammogram, more pictures will be taken to carefully study the more pictures will be taken to carefully study the breast condition.breast condition.

Two Methods of Two Methods of MammogramsMammograms Ordinary filmOrdinary film

Xero or zeno Xero or zeno mammography mammography over selinium plates over selinium plates

gave different colors gave different colors blue andblue and whitewhite

Mammogram EquipmentMammogram Equipment A mammography unit is a A mammography unit is a

rectangular box that rectangular box that houses a tube in which x-houses a tube in which x-rays are produced. rays are produced. Attached to the unit is a Attached to the unit is a device that holds and device that holds and compresses the breast compresses the breast and positions it so images and positions it so images can be obtained at can be obtained at different angles.different angles.

Modern technique uses a Modern technique uses a special machine special machine exclusively for breast x-exclusively for breast x-rays to produce studies rays to produce studies that are high quality but that are high quality but have a low radiation dose have a low radiation dose (usually about 0.1 to 0.2 (usually about 0.1 to 0.2 rad dose per picture).rad dose per picture).

Mammogram Equipment Cont.Mammogram Equipment Cont.

A mammogram device A mammogram device has special has special accessories that allow accessories that allow only the breast to be only the breast to be exposed to the x-rays.exposed to the x-rays.

x-rays do not x-rays do not penetrate tissue as penetrate tissue as easily as the x-ray easily as the x-ray used for routine chest used for routine chest films or x-rays of the films or x-rays of the arms or legs.arms or legs.

Mammogram ProcedureMammogram Procedure The breast is first placed on a The breast is first placed on a

platform and squeezed between 2 platform and squeezed between 2 platesplates

Breast compression is necessary to: Breast compression is necessary to: 1)1) even out the breast thickness so all even out the breast thickness so all

tissue can be visualizedtissue can be visualized2)2) spread out tissue so small spread out tissue so small

abnormalities won't be obscured by abnormalities won't be obscured by overlying breast tissueoverlying breast tissue

3)3) allow the use of a lower x-ray dose allow the use of a lower x-ray dose since a thinner amount of breast since a thinner amount of breast tissue is being imagedtissue is being imaged

4)4) hold the breast still to eliminate hold the breast still to eliminate blurring of image caused by motionblurring of image caused by motion

5)5) reduce x-ray scatter to increase reduce x-ray scatter to increase sharpness of picture.sharpness of picture.

Indications of MammographyIndications of Mammography

4- Evaluation of contralateral breast

1- Breast with mass2- Breast with discharge

3- Follow up of breast lesions

Follow up is needed in the followingFollow up is needed in the following

Premalignant lesions, papillomatosos,Premalignant lesions, papillomatosos, cystic lesions ,cystic lesions , atypia, lobular neoplasiaatypia, lobular neoplasia

Patient at high risk of Patient at high risk of cancer breastcancer breastPatients with previous BCPatients with previous BC

5 - Screening of BC5 - Screening of BC

6 - breast that is 6 - breast that is difficult to difficult to be examinedbe examined

7 – work up of met static7 – work up of met static Aden carcinomaAden carcinoma

Reading the MammogramReading the Mammogram Best if read by radiologist specializing in mammographyBest if read by radiologist specializing in mammography Important to recognize even the smallest abnormalitiesImportant to recognize even the smallest abnormalities Multiple films and angles are often necessaryMultiple films and angles are often necessary Sometimes two physicians will read the same film for the most Sometimes two physicians will read the same film for the most

thorough assessmentthorough assessment Computer based Computer based digital mammographydigital mammography is used to get maximum is used to get maximum

information from each mammogram takeninformation from each mammogram taken Comparison with older films is also extremely usefulComparison with older films is also extremely useful

Mammography

Average-size lump found by woman practicing occasional breast self-exam (BSE)

Average-size lump found by woman practicing regular breast self-exam (BSE)

Average-size lump found by first mammogram

Average-size lump found by getting regular mammograms

Abnormal Mammographic Abnormal Mammographic findingsfindings

SatelliteSatellite lesionlesion

Micro calcificationsMicro calcifications

LinearLinearbranchingbranching

RoundedRoundedpunctuatepunctuate

CircumscribeCircumscribedd

lesionlesion

Speculated Speculated lesionlesion

Mammographic signs of malignancyMammographic signs of malignancy1.1.Breast lumpBreast lump2.2.Linear or branching micrcalcificationLinear or branching micrcalcification3.3.Skin or nipple thickeningSkin or nipple thickening4.4.Mammary duct distortion or asymmetryMammary duct distortion or asymmetry

UltrasoundUltrasound

It is the intial It is the intial investigation in a investigation in a woman < 35 woman < 35 yeaersyeaers

DD solid and cystic DD solid and cystic lesionslesions

Positive predictive Positive predictive value is 92 % with value is 92 % with palpable masspalpable mass

Sentinel Node BiopsySentinel Node Biopsy An evolving technique An evolving technique

to identify node status to identify node status without formal axillary without formal axillary dissectiondissection

A radioactive tracer A radioactive tracer and/or blue dye is and/or blue dye is identified in the first identified in the first draining nodedraining node

Potentially gives Potentially gives accurate staging with accurate staging with decreased morbiditydecreased morbidity

Sensitivity exceeds Sensitivity exceeds 90% and accuracy 90% and accuracy exceeds 95% for exceeds 95% for experienced surgeonsexperienced surgeons

Breast Cancer TreatmentBreast Cancer Treatment

Treatment of early BC Treatment of early BC ( stage I& II a)( stage I& II a)

Treatment of advanced BCTreatment of advanced BC•(stage II b, III& IV)(stage II b, III& IV)•Metastatic diseaseMetastatic disease•Local recuurenceLocal recuurence

Surgery&Surgery&observationobservation

Surgery& Surgery& Adjuvant therapyAdjuvant therapy

Neoadjuvant chemotherapyNeoadjuvant chemotherapy

Surgery either Mastectomy or BCSSurgery either Mastectomy or BCS

+ or - Radiotherapy+ or - Radiotherapy

+ or - Chemotherapy+ or - Chemotherapy

Treatment of early BCTreatment of early BC Surgery & ObservationSurgery & Observation

IndicationIndication T1 N0T1 N0 ER + veER + ve Patient under willing close observationPatient under willing close observation

SurgerySurgery MRMMRM MRM + breast reconstructionMRM + breast reconstruction

ObservationObservation Monthly C/ EMonthly C/ E Chest x ray, U/S abdomen every 6 monthsChest x ray, U/S abdomen every 6 months

Treatment of early BCTreatment of early BC Surgery & Adjuvant therapySurgery & Adjuvant therapy

Why use of adjuvant therapyWhy use of adjuvant therapy Decrease local recurrence ( Radiotherapy)Decrease local recurrence ( Radiotherapy) Decrease distant metastases as Radiotherapy) Decrease distant metastases as Radiotherapy)

micro metastases are present in 50 % of cases micro metastases are present in 50 % of cases at diagnosis (chemotherapy)at diagnosis (chemotherapy)

Good response to adjuvant therapyGood response to adjuvant therapy Types of adjuvant therapyTypes of adjuvant therapy

RadiotherapyRadiotherapy ChemotherapyChemotherapy Hormonal treatmentHormonal treatment

Breast Cancer TreatmentBreast Cancer Treatment (Surgery)(Surgery) Old operation that lost popularity (Radical Old operation that lost popularity (Radical

Mastectomy) Mastectomy) Remove the whole breast, P Major & minor, Remove the whole breast, P Major & minor,

axillary LN and wide margin of skin & soft tissueaxillary LN and wide margin of skin & soft tissue Its rationale is loco regional theory of spreadIts rationale is loco regional theory of spread

Obsolete operationsObsolete operations Extended Radical Mastectomy ( RM + internal Extended Radical Mastectomy ( RM + internal

mammary LN removal)mammary LN removal)Used with medial lesions, +ve Axillary Ln & M0Used with medial lesions, +ve Axillary Ln & M0

Supra Radical Mastectomy ( RM + clavicle excision Supra Radical Mastectomy ( RM + clavicle excision and supaclavicular LN removal)and supaclavicular LN removal)

Operations that recently gained popularityOperations that recently gained popularity Modified Radical Mastectomy 70 % in USAModified Radical Mastectomy 70 % in USA Simple mastectomy (Total Mastectomy) 70 % in UKSimple mastectomy (Total Mastectomy) 70 % in UK

Breast Conservative proceduresBreast Conservative procedures LumpectomyLumpectomy Partial Mastectomy (Quadrantectomy)Partial Mastectomy (Quadrantectomy) Segmental mastectomySegmental mastectomy TylectomyTylectomy QUART (Quadrantectomy +Axillary clearance + RT)QUART (Quadrantectomy +Axillary clearance + RT)

Conservation Therapy (BCT)Conservation Therapy (BCT)

Indications for Use:Indications for Use:1.1. Tumor Tumor size size

2 cm in small breast2 cm in small breast 4 cm in large breast4 cm in large breast

2.2. Tumor Tumor locationlocation favorable for good aesthetic favorable for good aesthetic result (peripheral location)result (peripheral location)

3.3. Unifocal singleUnifocal single tumor with negative margins tumor with negative margins4.4. Patient’s preferencePatient’s preference for breast conservation for breast conservation5.5. Patient’s inabilityPatient’s inability to tolerate general to tolerate general

anesthesiaanesthesiaAdvantages of Advantages of BCSBCS• Better cosmeticsBetter cosmetics

• Not affect survivalNot affect survival• Not affect local recuurence which if occur not in the chest Not affect local recuurence which if occur not in the chest wall and MRM could be donewall and MRM could be done

Contraindications to Contraindications to ConservationConservation

1.1. Tumor size > 5 cmTumor size > 5 cm2.2. Tumor multi centric (Two or more Tumor multi centric (Two or more

primary tumors in separate quadrants)primary tumors in separate quadrants)3.3. Diffuse tumors ( Diffuse malignant Diffuse tumors ( Diffuse malignant

appearing micro calcifications)appearing micro calcifications)4.4. High grade tumorsHigh grade tumors5.5. Distant metastasesDistant metastases

6.6. Any contraindication to irradiationAny contraindication to irradiation Previous breast irradiationPrevious breast irradiation Pregnancy (unless radiation is Pregnancy (unless radiation is

provided after delivery)provided after delivery) Collagen vascular disease (relative Collagen vascular disease (relative

contraindication)contraindication) Large breast sizeLarge breast size

Standard Axillary DissectionStandard Axillary DissectionMethod Method

Levels I and II axillary Levels I and II axillary dissectiondissection

Aim of axillary surgeryAim of axillary surgery Provides staging Provides staging

informationinformation Provides local control if Provides local control if

node positivenode positive Provide prognostic Provide prognostic

informationinformation No reliable imaging No reliable imaging

techniquetechniqueComplicationsComplications

Wound infectionWound infection Arm lymphoedemaArm lymphoedema Arm morbidityArm morbidity

Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy (SLNB)(SLNB) Surgical Treatment OptionsSurgical Treatment Options

Procedure is still under investigation to Procedure is still under investigation to determine if patients’ survival will not be determine if patients’ survival will not be affected if lymph nodes that may have affected if lymph nodes that may have cancer in them are left behind and cancer in them are left behind and untreateduntreated

Not the standard of care for breast cancer Not the standard of care for breast cancer at this pointat this point

Success rate of about 92 %Success rate of about 92 %

Indications of MRMIndications of MRM Tumor size > 5 cmTumor size > 5 cm Tumor multi centric (Two or more primary Tumor multi centric (Two or more primary

tumors in separate quadrants)tumors in separate quadrants) Diffuse tumors ( Diffuse malignant Diffuse tumors ( Diffuse malignant

appearing micro calcifications)appearing micro calcifications) High grade tumorsHigh grade tumors Distant metastasesDistant metastases

Any contraindication to irradiationAny contraindication to irradiation Previous breast irradiationPrevious breast irradiation Pregnancy (unless radiation is Pregnancy (unless radiation is

provided after delivery)provided after delivery) Collagen vascular disease (relative Collagen vascular disease (relative

contraindication)contraindication) Large breast sizeLarge breast size

Ductal Carcinoma in SituDuctal Carcinoma in Situ(Treatment)(Treatment)

Depend on Van Nuys Prognostic Index Depend on Van Nuys Prognostic Index which classify patients into 3 groupswhich classify patients into 3 groups

Depending on 3 factorsDepending on 3 factors

3- Surgical free margin

1- Tumor size2- Histological grade

Low riskLow risk Intermediate riskIntermediate risk High riskHigh risk

Wide local excisionWide local excision (BCS)(BCS)

BCS & irradiationBCS & irradiation MastectomyMastectomy SSMSSM

Lobular Carcinoma In SituLobular Carcinoma In Situ It constitute 25 % of CISIt constitute 25 % of CIS The risk of invasive cancer is 20 – 30 % life time The risk of invasive cancer is 20 – 30 % life time

and bilateraland bilateral It is multicentric in 80 %It is multicentric in 80 % Never palpable massNever palpable mass TreatmentTreatment

Follow up byFollow up by C/E every 4 monthsC/E every 4 months Mammography yearlyMammography yearly

Chemoprevention by Tamoxafen or raloxifeneChemoprevention by Tamoxafen or raloxifene Mastectomy which is rarely usedMastectomy which is rarely used


The standard treatment is The standard treatment is mastectomymastectomy Recently BCS is used with Recently BCS is used with segmentectomy of segmentectomy of

nipple & areola & radiotherapynipple & areola & radiotherapyPaget’s disease Paget’s disease with no masswith no massOr with DCISOr with DCIS

SegmentectomSegmentectomy y

Of N & AOf N & A

-Ve marginsVe margins-No No

multicentricmulticentric

+ Ve Ve marginsmargins multicentrimulticentricc

RadiotherapyRadiotherapy MastectoMastectomymy

Paget’s disease Paget’s disease with mass or with mass or with with invasive cancerinvasive cancer

Segmentectomy Segmentectomy Of N & AOf N & A

& Axillary dissection& Axillary dissection


Use of chemotherapy based on 5 Use of chemotherapy based on 5 prognostic indication of prognostic indication of chemotherapychemotherapy

1.1. Age < 35 yearAge < 35 year

2.2. Tumor > 1 cmTumor > 1 cm

3.3. Tumor high gradeTumor high grade

4.4. + ve LN+ ve LN

5.5. - ve ER- ve ER

Post-Treatment Post-Treatment Follow-upFollow-up of the of the Patient with Early Stage (I and II) Patient with Early Stage (I and II)

Breast CancerBreast Cancer

Study Year 1-2 Year 3-5 Year > 5

Exam 3-6 mos. 6 mos. 12 mos.

Mammo 6-12 mos. 6-12 mos. 12 mos.

CXR prn prn prn

CT, bonescan

prn prn prn

Infiltrating CancerInfiltrating CancerSurgical treatment OptionsSurgical treatment Options

Breast Conservation Breast Conservation (followed by RT)(followed by RT)

and Axillary Lymph Node Dissectionand Axillary Lymph Node Dissection

Modified Radical Mastectomy Modified Radical Mastectomy (with/without reconstruction(with/without reconstruction))

Long Term Side Effects of Long Term Side Effects of Surgery for Breast CancerSurgery for Breast Cancer

Loss of part or of the whole the Loss of part or of the whole the breast- change of self image and breast- change of self image and sexualitysexuality

Nerve Function Deficits/NeuropathyNerve Function Deficits/Neuropathy LymphedemaLymphedema Motor (Muscle) Function DeficitsMotor (Muscle) Function Deficits PainPain

Breast ReconstructionBreast Reconstruction

Indicated in women undergoing Indicated in women undergoing mastectomy who desire reconstructionmastectomy who desire reconstruction

Radiation after reconstruction may Radiation after reconstruction may produce less desirable resultsproduce less desirable results

Autogenous tissue vs. prosthetic Autogenous tissue vs. prosthetic vs. combinationvs. combination

Immediate vs. delayed- no survival Immediate vs. delayed- no survival differencedifference

Prosthetic Silicon Prosthetic Silicon implantsimplants

Latissmus Dorsi Mycutaneus Latissmus Dorsi Mycutaneus flapflap

TRAM FlapTRAM Flap

TRAM FlapTRAM Flap

Most women with breast cancer may Most women with breast cancer may be treated with breast conservation if be treated with breast conservation if they so desirethey so desire

Most women requiring/choosing Most women requiring/choosing mastectomy may undergo immediate mastectomy may undergo immediate breast reconstructionbreast reconstruction

Optimal treatment involves Optimal treatment involves multimodality therapy provided by multimodality therapy provided by multidisciplinary teamsmultidisciplinary teams

RadiotherapyRadiotherapy Aim toAim to destruction of local micro destruction of local micro

metastases to decrease local recurrencemetastases to decrease local recurrence IndicationsIndications

Radiotherapy to breast areaRadiotherapy to breast area Radiotherapy to AxillaRadiotherapy to Axilla

After all BCSAfter all BCS After mastectomyAfter mastectomy1.1. 4 or more + ve LN4 or more + ve LN

2.2. Extracapsular invasionExtracapsular invasion3.3. + ve or close margin+ ve or close margin

T3 , T4 & pectoral fascia affectionT3 , T4 & pectoral fascia affectionAll ABCAll ABC

Used only if Used only if 1.1. 4 or more + ve 4 or more + ve

Axillary LNAxillary LN2.2. Extra capsular Extra capsular

invasioninvasion

RadiotherapyRadiotherapy When ?When ?

2- 3 weeks after 2- 3 weeks after mastectomymastectomy

Dose Dose 40 – 50 Gy delivered at 15 40 – 50 Gy delivered at 15

– 25 fraction– 25 fraction ComplicationsComplications1.1. T1 N0 it decrease 5 y T1 N0 it decrease 5 y

survivalsurvival2.2. Lymphatic destructionLymphatic destruction3.3. Increase cancer in contra-Increase cancer in contra-

lateral breastlateral breast4.4. Local complicationsLocal complications

Skin burnSkin burn Arm lymph-oedemaArm lymph-oedema Interfere with breast Interfere with breast

reconstructionreconstruction Increase interstitial Increase interstitial

pulmonary fibrosispulmonary fibrosis

Hormonal therapyHormonal therapy Anti-estrogen (Tamoxifen) First lineAnti-estrogen (Tamoxifen) First line

MechanismMechanism Decrease estrogen uptake by tissueDecrease estrogen uptake by tissue Increase TGF inhibitorIncrease TGF inhibitor

AdvantagesAdvantages Decrease annual recurrence by 25 %Decrease annual recurrence by 25 % Decrease annual mortality by 17%Decrease annual mortality by 17% Decrease risk of CB in contra-lateral breast by 40 %Decrease risk of CB in contra-lateral breast by 40 % Benefits observed in pre & post menopausalBenefits observed in pre & post menopausal Great benefit in ER + ve but also in ER – veGreat benefit in ER + ve but also in ER – ve

DoseDose 20 mg/ day for 2- 5 years20 mg/ day for 2- 5 years

Side effectsSide effects Hyper-calcemiaHyper-calcemia Bone painsBone pains Hot flashsHot flashs phlebitisphlebitis

Hormonal therapyHormonal therapy Aromatase Inhibitor Second lineAromatase Inhibitor Second line

It block conversion of androgen to It block conversion of androgen to estrogenestrogen

Progestin Third lineProgestin Third line Megestrol acetate 40 mg 4 times Megestrol acetate 40 mg 4 times

dailydaily LHRH agonistsLHRH agonists

Reversible ovarian suppression in Reversible ovarian suppression in pre-menopausal femalepre-menopausal female

ChemotherapyChemotherapy Aim toAim to

killing of malignant micro-metastases any killing of malignant micro-metastases any where in the bodywhere in the body

Indications Indications 5 major 5 major Age < 35 yearsAge < 35 years Tumor > 1 cmTumor > 1 cm Tumor high gradeTumor high grade ER + veER + ve LN + ve of metastasesLN + ve of metastases

MethodsMethods given 6 cycles post operative in early CBgiven 6 cycles post operative in early CB

ChemotherapyChemotherapyClassic Classic

CMFCMFCMFCMF CACA FACFAC

Cyclo-Cyclo-phosphamidephosphamide

100 100 600 600 600600 400-400-500500

(day 1)(day 1)

MethotrexateMethotrexate 40 40 4040

5 FU5 FU 600 600 600600 400-400-500500

A A ( Doxorubicin)( Doxorubicin)

6060 40-5040-50

Cyclic Cyclic frequencyfrequency

4 weeks4 weeks 3 w3 w 3 w3 w 4 4 weeksweeks

Breast Cancer TreatmentBreast Cancer Treatment

Treatment of early BC Treatment of early BC ( stage I& II a)( stage I& II a)

Treatment of advanced BCTreatment of advanced BC•(stage II b, III& IV)(stage II b, III& IV)•Metastatic diseaseMetastatic disease•Local recuurenceLocal recuurence

Surgery&Surgery&observationobservation

Surgery& Surgery& Adjuvant therapyAdjuvant therapy

Neoadjuvant chemotherapyNeoadjuvant chemotherapy

Surgery either Mastectomy or BCSSurgery either Mastectomy or BCS

+ or - Radiotherapy+ or - Radiotherapy

+ or - Chemotherapy+ or - Chemotherapy

Neo-adjuvant ChemotherapyNeo-adjuvant Chemotherapy AdvantagesAdvantages

1.1. Assessment of tumor responseAssessment of tumor response2.2. 70 % of tumors show clinical response70 % of tumors show clinical response

20- 30 % complete response20- 30 % complete response 80% still have histological evidence of the tumor80% still have histological evidence of the tumor Surgery is required even with complete responseSurgery is required even with complete response

3.3. Increase incidence of BCSIncrease incidence of BCS4.4. Improve cosmetic resultsImprove cosmetic results

DisadvantagesDisadvantages1.1. Delayed local treatmentDelayed local treatment2.2. Loss of prognostic information of LN and tumor Loss of prognostic information of LN and tumor

sizesize3.3. Induction of drug resistanceInduction of drug resistance

Neo-adjuvant ChemotherapyNeo-adjuvant Chemotherapy What to giveWhat to give

CMF CMF VAPVAP CHOPCHOP

When to give When to give 3 months pre-operative3 months pre-operative 9 months post-operative9 months post-operative

SESE BM suppressionBM suppression AlopeciaAlopecia CystitisCystitis Cardio-toxicCardio-toxic Neuro-toxicNeuro-toxic GIT disturbanceGIT disturbance

Treatment of ABCTreatment of ABC

Neo-adjuvant chemotherapyNeo-adjuvant chemotherapy

No responseNo responsePartial responsePartial response

Complete responseComplete response

ChangeChange regimeregimenn

MRMMRM+/- RT+/- RT

+ + ChemoChemo

RT until RT until the tumorthe tumorIs operableIs operable

Stop Stop treattreat

BCS with PALNDBCS with PALNDThen RadioThen RadioThen Chemo for a yearThen Chemo for a year

Radio alone thenRadio alone thenChemo for a yearChemo for a year

Treatment of ABCTreatment of ABC Hormonal treatmentHormonal treatment

used in all patients regardless ageused in all patients regardless age Given continuously until relapse occurGiven continuously until relapse occur

Postoperative chemotherapyPostoperative chemotherapy Life threatening diseaseLife threatening disease

Rapidly growing tumorRapidly growing tumor Liver metastasesLiver metastases Lung metastasesLung metastases

ER – veER – ve Failure of hormonal treatmentFailure of hormonal treatment


RadiotherapyRadiotherapy

If No responseIf No responsePartial responsePartial response

Complete responseComplete response

MRMMRM+/- RT+/- RT

+ + ChemoChemo

RT until RT until the tumorthe tumorIs operableIs operable

BCS with PALNDBCS with PALNDThen RadioThen RadioThen Chemo for a yearThen Chemo for a year

Radio alone thenRadio alone thenChemo for a yearChemo for a year


Palliative RadiotherapyPalliative Radiotherapy Single brain metastasesSingle brain metastases Chest wall recurrenceChest wall recurrence Multiple metastasesMultiple metastases

BoneBone Spinal cordSpinal cord LiverLiver Brachial plexusBrachial plexus

Male BCMale BC 4 quadrant from the 4 quadrant from the

startstart Absent pad of fatAbsent pad of fat Lymphatic spread in Lymphatic spread in

4 directions4 directions Rapid blood spreadRapid blood spread Radical surgery is Radical surgery is

difficult due to lack difficult due to lack of soft tissueof soft tissue

Recently male and Recently male and females are equal females are equal except male with + except male with + ve LNve LN

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BREAST CANCER