Transcript الشريحة 1 - MEDtube.net

Breast Cancer
Options Of Treatment
Supervised BY:
Dr. Tamimi
PRESENTED BY:
Dr.Naef Saleh Al haddy
INTRODUCTION
• Breast cancer is the most common sitespecific cancer in women
• It accounts for 26% of all newly diagnosed
cancers in females
• 15% of the cancer-related deaths in women
• Second leading cause of cancer-related
mortality in women
Anatomy of breast
1- position & Extent :2- Breast consist of : nipple.
 Areola.
3- breast divided in to :1) Quadrants :
2) retro areolar area.
3) axillary tail .
Lymphatic System
RISK FACTORS
• Genetic Factors :
(S.B.C) (F.B.C) (H.B.C).
Age:
85 % Of Breast Ca Occurs After The Age Of 40
• Sex:
100 Times More Among Female Than Male
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Ethnicity
Menstrual History
Nulliparity
Personal History Of Breast Ca
Benign Breast Diseases
RISK FACTORS
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Radiation
Oral Contraceptives
Hormonal Replacement Therapy: (H.R.T.)
Breast Feeding
Obesity
Alcohol
Mental health
Insulin-like growth factor
Diet, Exercise, Smoking And Stress
Symptoms
• Hard lump
– 50% of such masses are found in the upper
outer quarter of the breast.
• The nipple may be retracted ,scaly or
discharg
• skin chaneg
• Axillary mass
• Pain
• Systemic manfestaions
Diagnosis of Breast Cancer
• Examination (Inspection ,Palpation).
• Imaging Techniques
Mammography
Ductography
Ultrasonography
Magnetic Resonance Imaging
• Breast Biopsy
Histopathology of Breast Cancer
• Carcinoma in Situ (LCIS, DCIS)
• Paget's disease of the nipple
• Invasive ductal carcinoma
Adenocarcinoma with productive fibrosis (scirrhous,
simplex, NST), 80%
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Medullary carcinoma, 4%
Mucinous, Papillary, Tubular 2%
Invasive lobular carcinoma, 10%
Rare (adenoid cystic, squamous cell, apocrine)
Staging
• clinical stage of breast cancer
• Pathologic stage
@TNM Staging System
@American Joint Committee on
Cancer (AJCC) modification
@Manchester classification
TNM Stage Groupings
Stage 0
Tis
N0
M0
Stage I
T1a
N0
M0
Stage IIA
T0
T1 a
N1
N1
M0
M0
T2
T2
T3
T0
T1a
N0
N1
N0
N2
N2
M0
M0
M0
M0
M0
Stage IIIC
T2
T3
T3
T4
T4
T4
Any T
N2
N1
N2
N0
N1
N2
N3
M0
M0
M0
M0
M0
M0
M0
Stage IV
Any T Any N
Stage IIB
Stage IIIA
Stage IIIB
M1
TREATMENT
OPTIONS
TREATMENT
It depend upon clinical stage of the disease at the
presentation including classical TMN staging
and tumor grade
Consists of :
 Early (Stages I & II )
 Advanced (Stages III & IV).
- Stage III is locally advanced with no distant
metastases.
- Stage IV is advanced with distant metastases.
TREATMENT
• Surgery, radiation or drug theraphy.
• Breast cancer treatment are defined as local
or systemic
Local: Surgery and radiation.
• Surgery is usually the standart initial treatment
Systemic: Drug treatment
Diagnostic Studies for Breast Cancer Patients
Cancer Stage
0 I II III IV
History & physical
Complete blood count, platelet count
Liver function tests and alkaline phosphatase level
Chest radiograph
Bilateral diagnostic mammograms, ultrasound as
indicated
Hormone receptor status
HER-2/neu expression
Bone scana
Abdominal (without or without pelvis) computed
tomographic scan or ultrasound or magnetic resonance
imaging
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Stage 0
• Also called noninvasive carcinoma or carcinoma
in situ.
Lobular carcinoma in situ (LCIS) include
• Observation
• Chemoprevention with tamoxifen, and
• Bilateral total mastectomy
25 to 35% , for invasive breast cancer
a marker of increased risk
Stage 0
Ductal carcinoma in situ
• Mastectomy (>4 cm of disease or disease in
more than one quadrant)
• BCS followed by radiotheraphy.
• Low-grade DCIS of the solid, cribriform, or
papillary subtype that is <0.5 cm in diameter
may be managed by lumpectomy alone
• Use of tamoxifen or other SERMs after
surgery
Stage I and II
• BCT & Radiotherapy
• Modified radical mastectomy
• Adjuvant theraphy
 Chemotheraphy
Hormonal theraphy or both
Tamoxifen therapy is considered for women
with hormone receptor–positive cancers that are
>1 cm.
StageIII (IIIA or IIIB)
• Mastectomy with radiotheraphy and systemic
treatment( chemo, hormonal theraphy or both)
• Neoadjuvat chemotheraphy followed by
surgery + adjuvant chemotheraphy .
• Neoadjuvant chemo for locally advanced ca.
• In selected patients, neoadjuvant chemo _ BCT
Internal Mammary Lymph Nodes
• Systemic chemotherapy and radiation
therapy are indicated in the treatment of
grossly involved internal mammary lymph
nodes.
• women who are at increased risk for occult
involvement(cancers involving the medial
aspect of the breast, axillary lymph node
involvement)
Distant Metastases (Stage IV)
Hormonal therapy for:• hormone receptor–positive cancers
• bone or soft tissue metastases only; and
• limited and asymptomatic visceral metastases
Systemic chemotherapy for:• hormone receptor–negative cancers,
• symptomatic visceral metastases, and
• hormone-refractory metastases
Stage IV
• Surgical treatment for anatomic localized
problems
• Bisphosphonates, bone metastases.
• Surgical resection of the local-regional
disease in women with stage IV breast
cancer
Local-Regional Recurrence
Two groups
• Mastectomy :- surgical resection ,
reconstruction. Chemotherapy and antiestrogen
therapy , and adjuvant radiation therapy .
• BCS :- mastectomy and reconstruction;
Chemotherapy and antiestrogen therapy .
Surgical Techniques in
Breast Cancer Therapy
Excisional Biopsy
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A margin of normal-appearing breast tissue.
Options for local therapy
Excellent scars
Biopsy incision within the boundaries of the
skin excision that may be required as part of
a subsequent mastectomy
• Excisional biopsy with needle localization
Mastectomy and Axillary Dissection
• A skin-sparing mastectomy - removes all
breast tissue, the nipple-areola complex, and
scars from any prior biopsy procedures
• A total (simple) mastectomy , the nippleareola complex, and skin
• An extended simple mastectomy removes
all breast tissue, the nipple-areola complex,
skin, and the level I axillary lymph nodes
Radical mastectomy (Halsted)
• A. Entire breast
• chest wall muscle is
removed.
• and the level I, II, and III
axillary lymph nodes
• LNs in the level 1 (B) and
level 2 (C ), and even
sometimes more distant
lymph node groups (D, E
and F) were also removed.
Modified radical mastectomy (MRM)
• Simple mastectomy, and
the level I & II axillary
LN
• The Patey modification
removes the pectoralis
minor muscle and allows
complete dissection of the
level III axillary lymph
nodes
Breast conserving surgery
• called segmental
mastectomy,
lumpectomy,
partial mastectomy,
wide local excision, and
tylectomy
BCS
• Involves resection of :Primary breast cancer ,
Adjuvant radiation therapy,
Assessment of regional lymph node status
• standard treatment for stage 0, I, or II IDC
• Women with DCIS require only tumor
resection and adjuvant radiation therapy
without assessment of LN
Contraindications
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T4, N2, or M1
Patients who prefer mastectomy
Clinically evident multifocal/multicentric disease
Difficulty in the follow up of the pat.
Collagen vascular disease
Large or central tumors in small breasts
Women with a strong family history of breast cancer
BRCA1 and BRCA2 mutation carriers.
Prior radiation therapy to the breast or chest wall,
Involved surgical margins or unknown margin status after
re-excision,
Sentinel Lymph Node Dissection
• Early breast ca who are clinically LN –ve
• Combination of intraoperative gamma
probe detection of radioactive colloid and
visualization of isosulfan blue dye
Histopathology by:• Touch preparation,
• Frozen-section analysis, or
• GeneSearch assay
CHEMOTHERAPY
Node negative :
Tumor 0.6 -1 cm with a high risk.
Pt. with anther histological type and tumor >3cm
Tumor >1cm +/- hormonal therapy
ER+ve and T1 hormonal therapy
Node positive ;
Post menopausal with ER -ve
Permenopausal with ER+ve +hormonal therapy
Premenopausae with ER –ve.
Neoadjuvant Chemotherapy
• For operable stage IIIA neoadjuvant
chemotherapy followed by surgery ,
followed by adjuvant radiation therapy.
• For inoperable stage IIIA and for stage IIIB.
Adverse prognostic factors
(high risk)
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Blood vessel or lymph vessel invasion,
High nuclear grade,
High histologic grade,
HER-2/neu overexpression, and
Negative hormone receptor status
Neoadjuvant Endocrine Therapy
• Elderly women who were poor candidates
for surgery or chemotherapy
• Has been shown to shrink tumors then BCS
• For women with stage IV breast cancer, an
antiestrogen is the preferred therapy
Adjuvant Endocrine Therapy
• Node-negative
Tumor 1 to 3 cm with ER+ve --- +/chemo
• For node-positive
• Tumor >3 cm
Adjuvant hormone therapy
Antiestrogen Therapy
• Clinical responses in ER+ve >60% & ER–ve <10%
• Tamoxifen therapy is also considered for women
with DCIS with ER+ve
• Tamoxifen therapy usually is discontinued after 5
years
Adjuvant hormone therapy
• In premenopausal woman
– Oophorectomy could control metastatic disease
• Tamoxifen
– Selective estrogen receptor antagonist
– Effective in pre- and post-menopausal
– Effective in adjuvant setting
• Raloxifene
Adjuvant hormone therapy
• Aromatase inhibitor
– Effective in post-menopausal state
– Aromatase, in fat tissue,
• Convert androgen to estrogen
• Main estrogen source in post-menopausal
– Exemestane : Aromasin
– Letrozole: Femara
– Anastrozole: Arimidex
• More effective than Tamoxifen
Ablative Endocrine Therapy
• Oophorectomy in premenopaus with skin or
bony metastases after a disease-free interval
that exceeded 18 months
• Type
– Surgical ablation
– RT ablation
– Medical
• Exogenous estrogens in postmenopaus
Anti–Her-2/Neu Antibody Therapy
Herceptin
• Effective in Her2+ pts
• In patients with tumors that overexpress HER2/neu,response rates appear to be better with
doxorubicin-based adjuvant chemotherapy
• Cardiotoxicity may develop if trastuzumab is
delivered concurrently with doxorubicin-based
chemotherapy.
RADIOTHERAPY
Recommended in :
* After B.C.S
* Stage IIIA or IIIB
* L.N metastasis 4 or more.
* Lymphovascular invasion.
* Positive margins.
Radiation therapy is used for all stages of breast cancer
Adjuvant radiation therapy to the chest wall and
supraclavicular lymph nodes & boost
RADIOTHERAPY
It is now usually given if the tumor was high
grade, large, heavily node positive or if there was
extensive lymphovascular invasion.
Treatment of metastatic dz
• Usual sites:
bone, lung, pleura, soft tissues, and liver
• Incurable
– Goal: live with dz for longest time
• Systemic treatment is mainstay
– Chemotherapy
– Hormone therapy
• Palliative local therapy
– Radiotherapy
– Palliative surgery
Prognosis
• Five-year survival rates for individuals with
breast cancer who receive appropriate
treatment are approximately:
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100% for stage 0
100% for stage I
92% for stage IIA
81% for stage IIB
67% for stage IIIA
54% for stage IIIB
20% for stage IV
Summary
• Breast cancer is the most common site-specific
cancer in women , 85 % After The Age Of 40
• LCIS risk factor, DCIS anatomic precursor
• Treatment depend upon clinical stage of the disease
• BCS Standard treatment for stage 0, I, or II IBC
• Neoadjuvant & Adjuvant Chemotherapy +/hormone therapy +/- Herceptin
• Radiotherapy is used for all stages of breast cancer
• 5 year survival rates more better with New drugs
THANK FOR
YOUR
ATTENTION