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Diagnosis and Surgical M anagement of Breast C ancer

Diagnosis and Surgical M anagement of Breast C ancer. Vivien Li Intern. Introduction. Most commonly diagnosed cancer among women in Australia. Lifetime risk of 1 in 9, risk increases with age. Anatomy & Pathophysiology. Each breast contains 15-20 lobes arranged in a circular fashion.

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Diagnosis and Surgical M anagement of Breast C ancer

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  1. Diagnosis and Surgical Management of Breast Cancer Vivien Li Intern

  2. Introduction • Most commonly diagnosed cancer among women in Australia. • Lifetime risk of 1 in 9, risk increases with age.

  3. Anatomy & Pathophysiology • Each breast contains 15-20 lobes arranged in a circular fashion. • Each lobe is made up of lobules with milk-producing glands at the end. • Cancers develop through molecular changes in breast epithelial cells, especially of hormonal receptors.

  4. 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%)

  5. Risk factors • Age • FHx • ≥1st degree relative • Young age at diagnosis • Ovarian cancer • Male breast cancer • Ashkenazi Jews • Breast disease • Neoplastic – DCIS, LCIS • Benign • Genetic • BRCA 1/2 mutations • Other – p53 etc. • Hormonal • Endogenous – menstrual, obstetric history • Exogenous – OCP, HRT

  6. Diagnosis (1) – History & Exam • Presentation • Asymptomatic – screening • Symptomatic – breast lump, nipple changes • Examination • Breast – lump, skin changes • Nipple – inversion, discharge • Axilla – lymphadenopathy • Metastatic – respiratory, abdominal, bone pain, neurological

  7. Diagnosis (2) – Imaging • Mammogram • Asymmetry • Micro-calcifications • Mass • Architectural distortion • Ultrasound • MRI • Screening of high risk patients

  8. Diagnosis (3) - Biopsy • Core biopsy – breast lesion • 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

  9. Investigation of a new breast symptom http://canceraustralia.nbocc.org.au/view-document-details/ibs-the-investigation-of-a-new-breast-symptom-guide-for-gps

  10. Workup • Staging – TNM • T – histopathology • N – SLN biopsy • M – CT, bone scan (not always indicated for early cancers due to low risk of metastases) • Baseline assessment • Myocardial function – MUGA/echo prior to chemotherapy/Herceptin

  11. Management – Surgery Breast • Wide local excision ± SLNB/axillary dissection + radiotherapy • 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 • Mastectomy • Complete excision of breast parenchyma • Indications – multifocal, large tumour size, prior RTx, personal preference • Drains inserted to prevent seroma/haematoma formation • WLE vs. mastectomy • 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 • Immediate vs. delayed • Implant vs. flaps

  12. Management – Surgery Axilla • Prognosis – axillary LN status is best prognosticator of disease-free 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. • SLN biopsy • Minimally invasive procedure designed to stage axilla in patients with clinically negative nodes. • Suitable for clinically node negative unifocaltumours <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. • Adjuvant therapy – with axillary LN involvement RTx improves disease-free survival and reduces local recurrence.

  13. Management – Surgery • DCIS • Resection of primary cancer • Adjuvant radiotherapy

  14. Management – Surgery • Post-operative complications • Seroma • Wound infection • Bleeding • Need for re-excision

  15. Management – Radiotherapy • Eradicate local subclinical disease • Indications • After WLE of DCIS/early breast cancer • After mastectomy if positive margins, large primary tumour, ≥4 LNs+ • Side effects • Early – fatigue, pain, skin changes • Late – oedema, pain, fibrosis, hyperpigmentation

  16. Management – Chemotherapy • Chemotherapy agents • Alkylating agents, e.g. cyclophosphamide • Anthracyclines, e.g. doxorubicin • Antimetabolites, e.g. 5FU, gemcitabine, methotrexate • Taxanes, e.g. paclitaxel • Vinorelbine • Adjuvant • Indications • Locally advanced/metastatic cancer. • LN- and <0.5cm – not recommended. • LN- and 0.6-1cm – recommended if high risk factors. • Regimen • 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 • Indications • Large/locally advanced breast cancer prior to surgery and radiotherapy.

  17. Management – Hormonal therapy 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 • Aromastase inhibitors • Post-menopausal patients • Side effects - osteoporosis Her2+ • 20% of breast cancers are Her2+; more aggressive. • Trastuzumab (Herceptin) • Side effects – cardiac toxicity

  18. Follow up • 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.

  19. References • 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. • Uptodate

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