Breast cancer, brief recap

Investigations and Managementand their role in Breast cancer

CASE STUDY Interactive management discussion

Quiz

BRIEF RECAP!

Pathology Breast Cancer Risk Factors

Epidemiology

Presentation

Most breast cancers are either:

DUCTAL or LOBULAR Carcinoma can be invasive or in situ.

Paget's disease of breast is an infiltrating carcinoma of the nipple epithelium and represents about 1% of all breast cancers.

Inflammatory carcinoma occurs in under 3% all cases with a rapidly growing, sometimes painful mass enlarging the breast and causing the overlying skin to become red and warm. There may be diffuse infiltration of tumour.

It represents almost 1 in 3 of all malignancies in women.

75% of new cases are aged over 50 years.

The death rate from breast cancer is falling. This is probably due to better treatment but mammography may also be detecting cases earlier. In less than 1% of cases there is simultaneous bilateral breast cancer. Breast cancer can occur in men, usually in men aged over 50 years.

Dimpling of the breast skin Breast lump Breast pain Change in the size or shape of the breast Ulceration of the breast skin Involution or inversion of the nipple Nipple discharge or bleeding Axillary lymphadenopathy

ADVANCED OccasionallyFungating mass

Bone pain, Pathological # Jaundice

Triple assessment

Clinical examination A radiological assessment mammography or ultrasound (usually combined) A pathological assessment cytology and/or core biopsy

sensitivity and specificity> 90%

TX means that the tumour size cannot be assessed T1 - The tumour is no more than 2 centimetres (cm) across T2 - The tumour is more than 2 centimetres, but no more than 5 centimetres across T3 - The tumour is bigger than 5 centimetres across T4 Any size tumour involving chest wall or skin ( imflammatory breast cancer also) The N stages (nodes) N0 - No cancer cells found in any nearby nodes N1 MOBILE axillary lymphadenopathy ie not stuck to surrounding tissues N2- Fixed axillary lymph nodes and/or mammary lymph node involvement N3

 Disease that can be fully removed by surgery

T1-3

N0-1

Surgical Treatment

ADJUVANT THERAPY

Pathological assessment and staging to direct adjuvant therapy

Follow up

All patients require complete removal of the 1 tumour: WLE MASTECTOMY WLE= removal of tumour mass with limited margin of uninvolved surrounding tissue (~0.5-1cm). This is now the most commonly performed procedure for early breast cancer. MASTECTOMY = preferred if e.g. patient would prefer, inflammatory carcinoma, large tumour in small breast, multifocal primaries etc.

Breast reconstruction can be offered either at time of primary surgery or later- TRAM flap, lat dorsi flap and implants.

AXILLARY CLEARANCE/DISSECTIONComplete staging of axilla Provides regional control of disease and no need for RT Disadvantages outweigh benefits in the lower risk patients SIDE EFFECTS- painful arm, lymphoedema, sensory loss, debilitating shoulder stiffness AXILLARY SAMPLING At least 4 nodes If surgeon is suspicious, perhaps will remove more Patient with +ve sample may then have axillary clearance, or more commonly RT to the axilla Less morbidity in node negative patients than with a full clearance SENTINEL NODE BIOSPYPatients with unidentified lymphadenopathy Identification and removal of first draining lymph node Injection of blue dye and radio-labelled colloid Any stained node/s removed

 Usually after surgery, unless patient is having

chemotherapy. Some women may not need at all e.g. Mastectomy with very low risk recurrence. Recommended for all women with breast conserving surgery. 5 WEEK course, treatment to the whole breast
AXILLARY RADIOTHERAPY=

SAMPLING maybe CLEARANCE NO Can offer to the SCF if patient lymph node +ve more than 4 nodes

CHEMOTHERAPY BIOLOGICAL THERAPY ENDOCRINE THERAPY

WHO NEEDS ADJUVANT THERAPY?? Women with NODE +VE BREAST CANCER. Take into account tumour grade, node status etc Decision making- clinical judgement NPI NOTTINGHAM PROGNOSTIC INDEX - sum of the tumour size (cm x 0.2) + lymph node stage + histological grade Good prognosis= less than 3.4 Poor= more than 5.4

Greater benefit to younger patients

all women under the age of 70yrs should be considered for

adjuvant chemo.
6 month cycle using a combination of drugs seems to be the

preferred.
E/CMF

Can be given as a Neo-adjuvant

IE HORMONAL AGENTS

Only works if ER +ve!! may be used as the only treatment if comorbidities , ie over 70s Up to 5 yr treatment duration

Tamoxifen stops oestrogen from binding to oestrogen-receptor-positive cancer cells. Aromatase inhibitors Post menopausal oestrogen suppression

Ovarian ablation or suppression Goserelin- a lutenising hormone-releasing hormone agonist (LHRHa). Offer to women who refuse chemotherapy. (Option of choice= chemo + tamoxifen)

HER-2 +ve breast cancer HERCEPTIN (trastuzamab) Inpatient 3 week intervals for 1 yr ASSESS CARDIAC FUNTION BEFOREHAND!! Do not give if

less than LVEF less than 55% 3 monthly echo STOP if LVF drops by 10% and below 50

IE broadly speaking, T4, N2 Median survival exceeds 2 years Staging investigations should include:
CXR, isotope bone scan Liver US or CT scan

15-20% present with metastatic disease PALLIATION IS THE AIM ER +VE longer survival Common sites= lung, pleura, bone, brain CHEMOTHERAPY- MODERATE RESPONSE R adiotherapy- Bone pain, soft tissue disease, and certain metastases BISPHOSPHONATES