CARCINOMA OF THE BREAST for mbbs 600L students
- 1. CARCINOMA OF THE BREAST by Dr Eke
- 2. Carcinoma of the breast • Most common malignancy affecting women in many parts of the world, accounting for 18.4% of female cancers. • 1 in 8 Caucasian women • 1 in 14 blacks in the USA will develop Cancer of the breast in their lifetime. • 1 in 12 in Britain • Incidence is rising and will continue to rise with the rising life expectancy and standard of living. Is rare in Japan and far East. In Africa is becoming common. In the west the mortality is reducing due to early detection and improved adjuvant therapy. • Cause of breast cancer – unknown.
- 3. Predisposing factors 1. Age: Rare before 20yrs 20 – 30 yrs. 2% of cancer Increases from 30 – 80 yrs., then flatten. 2. Sex: Predominantly a female disease. < 0.5% of pts with breast cancer are male. 3. Family History A woman whose 1st degree relative has a CA breast has twice the risk of developing CA breast than one without. Hereditary breast cancer, characterize by early onset, high bilaterality, associated with ovarian, colonic and prostate cancer. A-D, associated genes are BRCA 1, BRCA 2, ATM, P53 PTEN, CHEK2.
- 4. Predisposing factors Cont. 4. Endocrine Factors a. Age of menarche and menopause Early menarche (<12) and late menopause (>55) have greater risk due to prolonged exposure to hormones. b. Age of 1st pregnancy Early Age (<18) is protective late (>30) increases the risk, Nulliparity increases the risk. Breast Feeding, multiparity reduce the risk. c. Oestrogen Hormone replacement therapy increases the risk.
- 5. Risk Late menarche Early Menarche Early Childbirth Late Childbirth Breast Feeding Nulliparity Multiparity 1. Previous breast cancer –increases the risk on the other breast 2. Benign mammary dysplasia(BMD). 3. Ca Corpus Uteri or ovary. 4. Diet & fat: high fat intake increases the risk. 5. Alcohol consumption increases the risk. 6. Smoking increases the risk.
- 6. Pathology Several types but the principal ones are: • Ductal carcinoma insitu – blood stained nipple discharge, calcification on mammography D-3 -10yrs IDC • Lobular carcinoma insitu • Invasive ductal carcinoma – 7-% IDC 40% are multifocal • Invasive lobular carcinoma 10% • Mucinous carcinoma – large 2%ry carcinoma 2% • Adenoid Cystic carcinoma • Inflammatory carcinoma 3% Dev. during pregnancy or lactation • Pagets disease of the nipple 2% • Spread 1. Local invasion 2. Lymphatic spread 3. Blood stream
- 7. Clinical features • Rare before 20. • Painless breast lump most commonly, upper outer quadrant commonest site • Mammography or screen –Detected ones are detected before a mass becomes palpable. • Blood stained nipple discharges – in Ductal carcinoma • Retraction of the nipple • Lymph oedema of the breast or arm (Pagets disease) • Metastasis – pulmonary – cough, dyspnoea
- 8. Clinical features cont. • Axillary adenopathy - Palpable lump in the breast • Bone deposits – bone pains, pathological fracture bony swellings, Paraplegia. • Cerebral metastasis – headache, vomiting, altered consciousness. • Do physical examination of the breast including the contralateral one and all other systems to enable one arrive at a clinical diagnosis.
- 9. Clinical features cont. Differential diagnosis • Fibro – adenoma • BMD (Fibroadenosis) • Galactocele • Lymphoma • Sarcoma • Chronic breast abscess • Traumatic fat necrosis • Duct ectasia
- 10. Staging of Carcinoma of the breast TNM Staging – Devised by International Union against cancer • T – Tumor • N – Regional Lymph nodes (LN) • M – Distant Metastasis • T1 – Tumor size <2cm in greatest diameter • T1a -0.1 -0.5cm • T1b – 0.5-1cm • T1c- 1 -2cm • T2 – Size 2 -5cm • T3 – Size >5cm in greatest diameter
- 11. Staging of Carcinoma of the breast Cont. • T4 – Tumor fixed to chest wall • T4a – Fixed to chest wall • T4b - Skin • T4c – T4a + T4b • T4d – Inflammatory carcinoma • No – No node • N1 – Axillary nodes mobile • N2- Fixed to one another and other structures • N3 – Supra nodes, oedema of arm and IMLN • Mo – No metastasis • Mi – Distant metastasis
- 12. Staging of Carcinoma of the breast Cont’ Manchester Staging (1-4) 1. Tumor in the breast, not involving pectoral or deeper plane. Skin involvement if present, is lesser than the size of the tumour. LN not palpable. 2. Same as (1) above + mobile, discrete ipsilateral axillary Lymph nodes. 3. Tumor fixed to pectoral muscle, or skin involvement more than the tumor size or ipsilateral, matted axillary LN.
- 13. Cont. 4. Tumor • Fixed to chest wall • “Cancer en-curaise” • Skin involvement wider than that of the breast. • Ipsilateral or contralateral supraclavicular LN. • Involvement of opposite breast. • Involvement of opposite axillary LN. • Involvement of bone, lung, liver. • Inflammatory carcinoma. • Early cancer T1N1M0 – TNM. Stages 1 and 2 – Manchester.
- 14. Investigation • To confirm the diagnosis. • To determine the extent of the disease (staging the disease). • Others – to help in further mgt of the disease. Confirming the Diagnosis – Biopsy Types of Biopsy 1. FNAC operator • Disadvantages – operator dependent – False + and –ve result may occur. 2. Tru cut biopsy – using Tru- cut needle Under LA 3. Open biopsy a) Incision biopsy – ulcer, nipple in suspected paget’s disease. b) Excision
- 15. Staging investigation • CXR – secondaries in the chest – Canon - ball metastasis pleural effusion. • Skeletal scintigraphy (Bone scan) using 875r 18f. More sensitive than radiology and picks up small bone metastasis 3-6 month before they become demonstrable by conventional x-ray. • Skeletal survey – Skull, Spine, Pelvis. • Abd ass – liver, Ascites, pelvic metastasis • LFTs e.g. Alkaline phosphatase may be due to metastasis • CT of the brain, liver-looking for metastasis.
- 16. Treatment • The treatment modalities are: 1. Loco-regional therapy. i. Surgery ii. Radiotherapy 2. Systemic therapy. i. Cytotoxic chemotherapy ii. Hormonal therapy 3. Tumour cell specific therapy. 4. Immunotherapy.
- 17. Surgery • Aims of surgery 1. To determine the tumour type and its extent. 2. To eradicate local or regional breast cancer and to improve survival. 3. To prevent local recurrence. 4. To minimize minimal spread. • Operations done are: 1. Wide local Excision +_ or Axillary lymph +_ Radiotherapy. node clearance 2. Total mastectomy +_ Axillary lymph node clearance depending on sentinel mapping.
- 18. Chemotherapy • Cyclical combination therapy is more effective than single drug therapy as the drugs attack the tumour cells in different phases of their growth. • The cycle also ensures that cells which are dormant during one cycle and become active later are attacked during subsequent cycles. • Various combinations i. CMF – Cyclo phosphanide, methotrexate and 5 fluorouracil ii. CAF- Cyclo phosphanide, Adriamylin and 5FU. iii. Taxanes- Pacthitaxel or Docetaxel.
- 19. Chemotherapy continues • Hb, WBC and Platelets checked at the beginning and end of each cycle. Hb > 10/dl WBC Normal Give full dose Platelets Normal WBC 2,500-3,900 Give half dose Platelets 75,000-129,000 WBC < 2500 Don’t give drugs Platelets , 75,000 • Side effects of chemotherapy Nausea, vomiting, diarrhoea,Aloecis. Bone marrow depression, Amenorrhea, skin pigmentation, conjunctivitis.
- 20. Hormonal therapy • Aim: To reduce the level of hormone in the body thereby depriving the tumour of hormones which is essential for its growth. • About 60% of ER+ve and 80% of PR+ve tumours and their metastases respond to hormonal therapy. • Drugs used 1. Anti Oestrogens - Tamoxifen - Raloxifene 2. Selective Aromatase Inhibitors (SAI) - Anastrozole - Progestins • Immunotherapy – Stimulation of Immunological defence mechanism in the treatment of Cancer.