Powerpoint: Breast Cancer
Powerpoint: Breast Cancer
Powerpoint: Breast Cancer
Epidemiology
Breast cancer is the most prevalent cancer among women and affects
approximately one million women worldwide.
Sex
BC in men is rare (> 1% from all malignant
tumors)
Sex ratio, women / men = 100 : 1
Age
Ageing is the most important RF
RISK FACTORS
Geographical variation
Inherited risk
Up to 10 % of breast cancer in Western
countries is due to an inherited factor.
It is not yet known how many breast cancer
genes there are, but to date, two specific
breast cancer genes have been identified
(BRCA1 and BRCA2).
RISK FACTORS
Previous breast disease
Women with certain benign changes in their breasts -
severe atypical epithelial hyperplasia.
Radiation
Women who received radiation to the chest as a result of
repeated X-rays for tuberculosis, age 10 and 14 years.
Women with Hodgkin's disease who received radiation
therapy to the chest have an excess risk of breast
cancer.
RISK FACTORS
Hormone replacement therapy
Among current users of
hormone replacement therapy (HRT) and
those who have stopped using it one to four
years previously, there is an increased risk of
breast cancer.
This increased risk is very similar to the effect
of a delay in the menopause by one year.
RISK FACTORS
Weight
Being overweight is associated with a doubling of the risk
of breast cancer in postmenopausal women whereas
amongst premenopausal women obesity is associated
with reduced breast cancer incidence.
Alcohol intake
Some studies have shown a link between the amount of
alcohol people drink and the incidence of breast cancer,
but this relationship is not consistent and may be
influenced by dietary factors other than alcohol.
RISK FACTORS
Hormones
Women who take the contraceptive pill are
at a slight increased risk while they take
the Pill and they remain at risk for 10 years
after stopping the drugs.
SYMPTOMS AND SIGNS
Painless lump in the breast
Change in the skin
Dimpling
Fixity
Orange peel
Change in the nipple
Retraction
Eczema- ( Paget’s )
Painless lump in the axilla
INVESTIGATIONS
Mammography
Breast ultrasound
FNAC
Core biopsy
Open biopsy
MRI
CXR
Abdominal ultrasound
Bone scintigraphy
MAMMOGRAPHY
Mammograms are a good way of
identifying abnormalities in the breast.
ABDOMINAL ULTRASOUND
BONE SCINTIGRAPHY
Types of breast cancer
The following stages of breast cancer are known as invasive breast cancer:
Stage 1 The tumour measures less than 2cm. The lymph nodes in the axilla are not
affected and there are no signs that the cancer has spread elsewhere in the body.
Stage 2 The tumour measures between 2 and 5cm. or the lymph nodes in the
axilla are affected, or both. However, there are no signs that the cancer has spread
further.
Stage 3 The tumour is larger than 5cm. and may be attached to surrounding
structures such as the muscle or skin. The lymph nodes are usually affected.
Stage 4 The tumour is of any size, but the lymph nodes are usually affected and
the cancer has spread to other parts of the body. This is metastatic breast cancer.
Tis – Paget,s of the nipple
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T1mic – microinvasion ≤ 0.1 cm.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T1 - ≤ 2 cm.
T1a – > 0.1 cm - 0.5 cm;
T1b –> 0.5 cm - 1 cm;
T1c – > 1 cm - 2 cm.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T2 - > 2 cm - 5 cm
T3 – > 5 cm.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New
York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4a - any size with direct invasion to the chest wall.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas.
New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4b –any size with direct invasion to the skin, orange peel,
skin ulcer, satellite nodule.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging
Atlas. New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4c = T4a + T4b.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer
Staging Atlas. New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4d – inflammatory carcinoma
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas.
New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
pN0 – no lymph node MTS.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New
York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
pN1mi - > 0.2 - 2.0 mm,
pN1c – N1a+N1b
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer,
2006: 219-233.
©American Joint Committee on Cancer.
pN2 – meta 4-9 LN
Hormone receptors
Economic
Work
together.
Treatment overview
Modified radical mastectomy removes all the breast tissue and all
of the lymph nodes in the axilla. It may also be referred to as a total
mastectomy and axillary clearance.
Radical mastectomy removes all the breast tissue and the lymph
nodes in the axilla, together with the muscles behind the breast tissue.
This is only done if the cancer invaded the pectoralis muscles.
Surgical complications
Local pain and tenderness- pain relief with
painkillers
Wound infection
Bleeding wound
Therapeutic goal:
Palliation
Cure- Local recurrence
Initial step:
Systemic therapy or
RTE, after surgical removal of local recurence if possible
LOCALLY ADVANCED BREAST CANCER
ESMO 2008 Recommandations
Radiotherapy
Surgery
HISTORY
no family history of cancers
first period: age 12, last period: may 2002;
pregnancies: 2 (age 28, 31),
abortions: 2
no personal history of relevant diseases/ hospital admissions
DIAGNOSIS
May 2002
Surgery Unit admission/ clinical evaluation:
3.5/4 cm mass in the upper outer quadrant
of the right breast, slightly adherent to skin
associated fixed, matted right axillary
lymph nodes
Fine-needle aspiration biopsy:
malignant cytology
TREATMENT (I)
August 2002
Surgery – quadrantectomy + axillary clearance
Pathology report: invasive ductal carcinoma, pT1
N1a M0 G2 L1 V1
- 1/1 cm tumor, negative resection limits
- 3 out of 10 axillary lymph nodes with large
metastasis
- invasion of the subcutaneous tissue, vascular
emboli, no perineural invasion
Immunehistochemistry report:
ER positive (35%), PR positive (50%)
HER 2 neu negative (1+)
Postoperative treatment
September 2002
Oncology admission/ clinical evaluation:
Biologic work-up – normal
Postoperative thoracic scar – normal aspect
Abdominal ultrasound, chest X-ray – no apparent
secondary lesions
QUESTION 1
January-March 2003
Adjuvant radiation therapy
conventional irradiation, TD 44 Gy/22 fr., tumor bed
+ axillary field
March 2003
Adjuvant hormone therapy
tamoxifen 60 mg/day
2003-2005
3-monthly evaluations (clinical, biologic and imagistic)
no signs of disease progression
February 2005
Clinical evaluation:
progressively worsening
low-back and right leg pain.
July 2005
Bone scan:
Multiple sites of pathologic increased uptake:
skull, vertebral spine, bone pelvis, clavicle,
right humerus, left femur, left tibia
– bone metastases
QUESTION 3
Starts bisphosphonates
pamidronat 60 mg/day I.V., on a monthly basis
Abdominal ultrasound:
Liver – hipoechogenic nodules, segment 6 = 3.4 cm;
segment 8 = 2 cm; segment 2 = 1.8 cm
(metastases)
QUESTION 4
December 2005
Clinical evaluation:
ECOG PS 1, lumbar pain relatively controlled
Liver work-up – normal:
γGT = 33 UI/l
Abdominal ultrasound:
Liver metastases – segment 6 = 2.7 cm, segment 8 = 2.9
cm, segment 2 = 2.0 cm (stable disease)
January 2006
Left femur X-ray:
Median osteoblastic cortical bone lesion
(posttraumatic pathological bone lesion?)
A. Palliative radiotherapy
Abdominal ultrasound:
Liver metastases – segment 6 = 2.8 cm; segment 8 = 1.8 cm;
segment 2 = 1.9 cm (stable disease)
September 2007
Clinical evaluation:
ECOG PS 1, pain controlled
Abdominal ultrasound:
Liver metastases – stable disease
Dorso-lumbar spine X-ray:
Multiple osteoblastic bone lesions (D7-D12, L1-L2, iliac bones,
sacrum)
Left femur X-ray:
Osteosynthesis nail overpasses the femoral head by
approximately 2 cm
March 2008
Clinical evaluation:
pain controlled
Abdominal ultrasound:
Liver – stable disease
Bone X-rays:
stable disease
TREATMENT (present)
Continues 2nd line chemotherapy (capecitabine), 2nd
line hormone therapy (letrozol) and
bisphosphonates (pamidronat), unchanged dosage and
schedule
Continues pain therapy
NSAIDs