Transcript Diagnosis and surgical management of breast cancer

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Most commonly diagnosed cancer among women
in Australia.
Lifetime risk of 1 in 9, risk increases with age.
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Each breast contains
15-20 lobes arranged
in a circular fashion.
Each lobe is made up
of lobules with milkproducing glands at
the end.
Cancers develop
through molecular
changes in breast
epithelial cells,
especially of hormonal
receptors.
Histopathology
Carcinoma in situ
 DCIS
› Presentation – mass, pain, nipple discharge.
› MMG – microcalcifications.
› High risk of progression to invasive breast cancer.
 LCIS
› Usually incidental finding without clinical symptoms.
› Originates from terminal breast lobules.
› Marker of increased risk of invasive breast cancer in either
breast.
Invasive breast cancer
 IDC (70-80%)
 ILC (5-10%)
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Age
FHx
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≥1st degree relative
Young age at diagnosis
Ovarian cancer
Male breast cancer
Ashkenazi Jews
Breast disease
› Neoplastic – DCIS, LCIS
› Benign
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Genetic
› BRCA 1/2 mutations
› Other – p53 etc.
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Hormonal
› Endogenous – menstrual, obstetric history
› Exogenous – OCP, HRT
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Presentation
› Asymptomatic – screening
› Symptomatic – breast lump, nipple changes
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Examination
› Breast – lump, skin changes
› Nipple – inversion, discharge
› Axilla – lymphadenopathy
› Metastatic – respiratory, abdominal, bone pain,
neurological
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Mammogram
Asymmetry
› Microcalcifications
› Mass
› Architectural
distortion
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Ultrasound
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MRI
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Screening of
high risk
patients
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Core biopsy – breast lesion
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Histology – IDC, ILC, DCIS, LCIS
Grade
Receptors - ER, PR, Her2
Lymphovascular invasion
Necrosis
FNA – LNs
Triple test = positive if any component is
indeterminate, suspicious or malignant  requires
specialist referral
 99.6% sensitivity
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Staging – TNM
› T – histopathology
› N – SLN biopsy
› M – CT, bone scan (not always indicated for early cancers
due to low risk of metastases)
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Baseline assessment
› Myocardial function – MUGA/echo prior to
chemotherapy/Herceptin
Breast
 Wide local excision ± SLNB/axillary dissection + radiotherapy
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Mastectomy
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Complete excision of breast parenchyma
Indications – multifocal, large tumour size, prior RTx, personal preference
Drains inserted to prevent seroma/haematoma formation
WLE vs. mastectomy
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Clear histological margins with rim of normal breast tissue
Indications – unifocal, <3-4cm
Localisation – carbon/hook-needle
Approach – circumareolar incision for subareolar/central breast lesions, parallel to
Langer’s lines
No difference in metastases or survival between mastectomy vs. WLE + RTx
Higher incidence of local recurrence in WLE (1-2%/year) vs. mastectomy
(0.5%/year).
Breast reconstruction
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Immediate vs. delayed
Implant vs. flaps
Axilla
 Prognosis – axillary LN status is best prognosticator of diseasefree interval and survival. 30% of patients with early cancer
have positive axillary LNs.
 Axillary dissection
› Removal of level 1/2 axillary LNs
› Previously gold standard but high morbidity.
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SLN biopsy
› Minimally invasive procedure designed to stage axilla in patients with
clinically negative nodes.
› Suitable for clinically node negative unifocal tumours <3cm.
› Equivalent accuracy to axillary dissection.
› Technique – inject radioactive tracer and blue dye  1-3 LNs tested
for metastases  intraoperative frozen section  immediate axillary
dissection if positive.
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Adjuvant therapy – with axillary LN involvement RTx improves
disease-free survival and reduces local recurrence.
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DCIS
Resection of primary cancer
Adjuvant radiotherapy
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Post-operative complications
› Seroma
› Wound infection
› Bleeding
› Need for re-excision
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Eradicate local subclinical disease
Indications
› After WLE of DCIS/early breast cancer
› After mastectomy if positive margins, large primary
tumour, ≥4 LNs+
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Side effects
› Early – fatigue, pain, skin changes
› Late – oedema, pain, fibrosis, hyperpigmentation
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Chemotherapy agents
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Alkylating agents, e.g. cyclophosphamide
Anthracyclines, e.g. doxorubicin
Antimetabolites, e.g. 5FU, gemcitabine, methotrexate
Taxanes, e.g. paclitaxel
Vinorelbine
Adjuvant
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Indications
 Locally advanced/metastatic cancer.
 LN- and <0.5cm – not recommended.
 LN- and 0.6-1cm – recommended if high risk factors.
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Regimen
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Combination recommended
Assess tumour responsiveness every 6-12 weeks (2-3 cycles)
If disease control is confirmed, should be continued for 18-24 weeks (6-8 cycles)
Neoadjuvant
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Indications
 Large/locally advanced breast cancer prior to surgery and radiotherapy.
ER +
 Decrease oestrogen's ability to stimulate existing micrometastases or
dormant cancer cells.
 Treatment for 5 years
 Tamoxifen
Pre- and post-menopausal patients
› Side effects – hot flushes, nausea, vomiting, fluid retention
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Aromastase inhibitors
Post-menopausal patients
› Side effects - osteoporosis
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Her2+
 20% of breast cancers are Her2+; more aggressive.
 Trastuzumab (Herceptin)
 Side effects – cardiac toxicity
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Clinical review every 6 months for first 2 years then
annually thereafter.
Mammogram at 6 months then annually
thereafter.
Further investigations as dictated by symptoms.
DEXA scan for patients on aromatase inhibitors.
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Wright, M. (2011). Surgical treatment of breast cancer.
http://emedicine.medscape.com/article/1276001-overview#a1. Accessed Sep 1,
2012.
Swart, R. (2012). Adjuvant therapy for breast cancer.
http://emedicine.medscape.com/article/1946040-overview#a1. Accessed Sep 1,
2012.
Stopeck, A. (2012). Breast cancer.
http://emedicine.medscape.com/article/1947145-overview. Accessed Aug 26,
2012.
NBOCC Recommendations for staging and managing the axilla in early
(operable) breast cancer (2011).
http://guidelines.nbocc.org.au/guidelines/axilla_early/. Accessed Aug 26, 2012.
NBOCC Recommendations for Aromatase inhibitors as adjuvant endocrine
therapy (2006).
http://guidelines.nbocc.org.au/guidelines/adjuvant_endocrine_therapy/.
Accessed Aug 26, 2012.
NBOCC Recommendations for use of sentinel node biopsy (2007).
http://guidelines.nbocc.org.au/guidelines/sentinel_node_biopsy/. Accessed Aug
26, 2012.
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