BREAST
James
Taclin C. Banez M.D., FPSGS, FPCS
ANATOMY:
Boundaries
Arterial
blood supply
Lymphatic
drainage
EVALUATION
Clinical
Manifestation:
Physical
Examination:
Radiological
Examination:
A positive
result is only suggestive of carcinoma
Mammography
(Screening):
Uses low
dose of radiation (0.1 rad), not proven to escalate breast CA
Complementary
study, can not replace biopsy
(+)
fine stippling of calcium
– suggestive of CA
Early
detection of an occult
CA
before reaching 5 mm.
Indeterminate
mass that presents as a solitary lesion suspicious of a neoplasm
Indeterminate
mass that can not be considered a dominant nodule, especially when multiple
cyst are present
Large, fatty
breast that no nodules were palpated
Follow up
of contra lateral breast after mastectomy
Follow up
examination of breast CA treated with segmental mastectomy and irradiation
Recommended
Program of Using Mammography:
Daily breast
examination after 20y/o
Baseline
mammography 35-40y/o
Annual mammography
> 40 y/o
EVALUATION
Radiological
Examination:
Computed
Tomography or Magnetic Resonant Imaging:
To expensive
For detection
of vertebral metastasis
Ultrasonography
No radiation
exposure
Can differentiate
cystic lesions from solid mass
Can not detect
less than 5mm.
Interventional
Technique:
Ductography:
Inject
radio-opaque contrast media into the mammary duct
Biopsy:
positive result is diagnostic
Excision
biopsy
Incision
biopsy
True-cut
or core biopsy (Vim-Silverman)
Fine needle
biopsy
BENIGN
LESIONS OF THE BREAST
Non-proliferative
lesions:
Chronic
Cystic Mastitis (Fibrocystic
disease, fibroadenosis, Schimmelbuschs’ dse.)
most common
breast lesion (30-40y/o)
Hormonal
imbalance (exact etiology - ?)
Increase
estrogen production – producing exaggerated responses
Some parts
of the breast is hyper-reacting
Manifestations:
Unilateral
/ Bilateral
Rubbery in
consistency, not encapsulated
Size changes
/ can be tender ---> related to menstrual cycle
15% presents
a nipple discharge
(-)
risk factor of carcinoma degeneration
Co-exist
w/ breast carcinoma (mammography
is suggested)
Schmmelbusch
disease: classic
diffuse cystic disease
Bloodgood
cyst: single,
tense, large blue domed cyst
Treatment:
Conservative
for small and not very painful and tender lesions
Danazol
– alleviate mod to severe painful & tender
- synthetic FSH
and LH analog
- Suppresses FSH
and LH
- 100 – 400mg
Surgery
for Bloodgood cyst
BENIGN
LESIONS OF THE BREAST
Fibroadenoma:
Well circumscribed
lesion, movable, smooth, lobulated, encapsulated, painless, not associated
w/ nipple discharge
Etiology
(?), could also be due to hormonal imbalance
Size does
not regress after menstruation
Treatment:
Excision
biopsy (rule out malignancy)
BENIGN
LESIONS OF THE BREAST
Intra-ductal
Papilloma:
Proliferation
of the ductal epithelium; 75% occurs beneath the epithelium
Commonly
causes Bloody
Nipple Discharge
Palpable
mass – 95% is intra-ductal papilloma
Non-palpable
mass – possibility of malignancy is increased: (Ductography)
Paget disease
of the nipple
Adenoma of
the nipple
Deep lying
carcinoma w/ ductal invasion
Treatment:
Excision
of a palpable mass by biopsy
Non-palpable
mass --> do wedge resection of the nipple/areola based on ductographic
result or PE (+) bloody discharge
BENIGN
LESIONS OF THE BREAST
Phyllodes
Tumor
Diagnostic
problem separating it from fibroadenoma and it’s rare variant
that is malignant, sarcoma
Bulk of the
mass is made up of connective tissue, with mixed areas of gelatinous,
edematous areas. Cystic areas are due to necrosis and infarct degenerations
Phyllodes
has greater activity and cellular component than fibroadenoma (3mitoses/hpf);
while malignant component has mitotic figure.
80% are benign,
usually large bulky lesions (tear
drop appearance)
Malignant
component is dependent on:
Number
of mitotic figures/hpf
Vascular
invasion
Lymphatic
invasions
Distant metastasis
Treatment:
Excision
biopsy:
Benign –
no further treatment, observe
Malignant
– total mastectomy / MRM
BENIGN
LESIONS OF THE BREAST
Mammary
Duct Ectasia (Plasma
cell mastitis, Comedomasttitis & Chronic mastitis)
Sub-acute
inflammation of the ductal system usually beginning in the subareolar
area w/ ductal obstruction
Usually present
as a hard mass beneath or near areola w/ either nipple or skin retraction
due to increase fibrosis
Appears during
or after menopausal period w/ hx. Of difficulty of nursing
Histologically,
the duct are dilated and filled w/ debris and fatty material w/ atrophic
epithelium. Sheets of plasma cells in the periductal area.
Treatment:
Excision
biopsy
BENIGN
LESIONS OF THE BREAST
Galactocele:
Cystic or
solid mass w/ or w/o tenderness
Occurs during
or after lactation
Due to obstruction
of a duct distended w/ milk
Treatment:
w/ abscess
---> incision and drain
Solid mass
---> excison biopsy
Fat necrosis:
Present as
a solid mass, usually asymptomatic
w/ or w/o
history of trauma
Treatment:
Excison
biopsy
BENIGN
LESIONS OF THE BREAST
Acute
Mastitis / Abscess:
Bacterial
infection usually during 1st week of lactation
s/sx of inflammation
Treatment:
Proper
hygiene
Cellulitis
----> antibiotis / analgesic
Abscess ---->
incision and drain
BENIGN
LESIONS OF THE BREAST
Gynecomastia:
Development
of female type of breast in male
Usually unilateral,
if bilateral look for systemic causes:
Hepatic
cirrhosis (for elderly alcoholic)
Estrogen
medication for prostatic CA
Tumor producing
estrogen/progesterone
Pituitary
/ Adrenal / Testes
CT scan /
PE
Treatment:
Subcutaneous
mastectomy (if other lesions, producing estrogen/progesterone, present)
Tumor secreting
estrogen ---> tx primary cause
BENIGN
LESIONS OF THE BREAST
Developmental
Abnormality:
Amastia
Polymastia
Athelia
Polythelia
Treatment:
- plastic surgery
Malignant
Lesions of the Breast
One of the
leading cause of death from CA
Etiology:- multifactorial
Sex:male : female ratio (1
: 100)
Age: almost unknown for pre-pubertal
age
20 – 40 y/o steady increase incidence
40 – 50 y/o (menopausal) plateau
> 50 y/o higher incidence
Genetic:
Mother
with carcinoma ---> (2 – 3x) daughter
(+) family
history ----> younger, bilateral
Dietary
influence:
Increase
in developed countries (except) Japan
Increase
in upper class society
Dietary:
Increase in animal fat
Malignant
Lesions of the Breast
Hormonal
Usage:
Oral contraceptive
has adverse effect if taken for prolonged time at early age or when
before the 1st full term pregnancy
No effect
if taken 25 – 39y/o
Slight increase
risk if estrogen usage by peri-menopausal for hormonal replacement
Physical
Stature:
Obesity --->
increase fat cells ----> increase tissue concentration
Malignant
Lesions of the Breast
Multiple
primary neoplasm:
Hx of primary
breast CA ---> 4x fold increase of primary CA
Hx of primary
CA of uterus and ovary ----> 1-1.5 risk
Irradiation:
Multiple
exposure
Had radiotherapy
for breast CA of contralateral breast
Malignant
Lesions of the Breast
Other
factors
1st
pregnancy –
due to estrogen
Long term
nursing
> 36
months
No ovulation
for 9 mos.
Decrease
estrogen
Age of
menopause
Late menopause
(55y/o) higher risk
Infertility
Higher risk
2.0
– 4.0
Normal
parenchyma
Dysplastic
parenchyma
Mammographic parenchymal
patterns
1.1
– 9.0
no
yes
Hx. Of primary
ovarian or endometrial CA
>
4.0
no
yes
Mother or sister
w/ hx. Of breast CA
2.0
– 4.0
no
yes
Hx of breast Ca
1st degree relative
2.0
– 4.0
no
yes
Hx of benign or
cancer in one breast
1.1
– 1.9
thin
heavy
Weight, postmenopausal
women
1.1 -
1.9
late
early
Age at menarchy
1.1 –
1.9
early
late
Age at menopause
1.1 –
1.9
white
black
2.0
– 4.0
Minimal
doses
Large
doses
Radiation to chest
2.0
– 4.0
yes
no
Oophorectomy premenopausally
2.0
– 4.0
<
20 y/o
>
30 y/o
Age of first full-term
pregnancy
1.1 –
1.9
no
yes
Nulliparity
1.1 –
1.9
black
white
Race > 45 years
< 40 years
1.1 –
1.9
rural
urban
Place of residence
1.1 –
1.9
Ever
married
Never
married
Marital status
2.0
– 4.0
low
high
Socioeconomic
status
>4.0
young
old
Age
Relative
risk
Low
risk
High
risk
Risk
factor
Established Risk
factors For Breast cancer in Females:
Malignant
Lesions of the Breast
Natural history
(Schirrhous adenocarcinoma)
Doubling
time (2-9mos)
1 cell --->
30DT/5 yrs ---> 1cm. Mass/20DT ---> increase size & fibrosis
----> dimpling (retraction) ---> invade the lymphatics --->
edema ----> invade regional LN/venous ----> systemic.
Successful
implantation depends on:
Number
of cells
Character
of cell
Host resistance
Histological
Classification of Breast Cancer
Cancers of the
Mammary Gland can be Classified:
Histogenesis
– duct, lobule (acini)
Histologic
Characteristic – adenocarecinoma, epidermoid CA, etc.
Gross
Characteristic – Scirrhous, colloid, medullary, papillary,
tubular
Invasive
Criteria – Infiltrating, in-situ
Non-infiltrating
(In-situ) Carcinoma of duct and lobules:
Increase
diagnosis due to mammography
DCIS : LCIS
(3:1)
LOBULAR
CARCINOMA in SITU:
Considered
as a risk factor
Observed
only in females, premenopousal
No involvement
of the basement membrane
Tx:1. Closed
observation
2.
Hormonal treatment (Tamoxifen/aromatase inhibitor) for 5 years
3.
Surgery (bilateral mastectomy) w/ immediate reconstruction
Histological
Classification of Breast Cancer
Non-infiltrating
(In-situ) Carcinoma of duct and lobules:
Tubular
Carcinoma In Situ:
Absence of
invasion of surrounding stroma hence confined w/in the basement membrane
Type:
PAPILLARY:
Duct epithelium
are thrown into papillae with loss of cohesiveness, loss of cohesiveness,
disorientation of cells with pleomorphism and increase mitotic figure
MICRO-PAPILLARY:
SOLID
CRIBRIFORM
COMEDOCARCINOMA:
Hyperplasia
is more extreme choking the entire duct w/ masses of cells developing
central necrosis of cells
Most aggressive
Treatment:
treated as an early cancer
Histological
Classification of Breast Cancer
Non-infiltrating
(In-situ) Carcinoma of duct and lobules:
25 –
70%
Ipsilateral
5 –
10 yrs
ductal
25 –
35%
Bilateral
15 –
20 yrs
ductal
Subsequent carcinomas:
Incidence
Laterality
Interval to diagnosis
Histology
1 –
2%
1%
Axillary metastasis
10 –
20%
50 –
70%
Bilaterality
40 –
80%
60 –
90%
Multicentricity
2 –
46%
5%
Incidence of Synchronous
Invasive CA
Microcalcification
None
Mammographic signs
Mass,
Pain, Nipple discharge
None
Clinical Signs
5 - 10%
2 - 5%
Incidence
54 –
58
44 -
47
Age
DCIS
LCIS
Histological
Classification of Breast Cancer
Infiltrating
Carcinoma of the Breast:
Paget’s
disease of the nipple (1%):
Primary carcinoma
of mammary duct that invaded the skin
Chronic eczematoid
lesion of the nipple
Tenderness,
itching, burning and intermittent bleeding
Palpable
mass in the subareolar area
PAGET cells:
Characterictic
cells
Large cell
w/ clear cytoplasm and binucleated
80% non-infiltrating
CA
100% 5yr
survival
Histological
Classification of Breast Cancer
Scirrhous
carcinoma: (fibrocarcinoma,
sclerosing CA):
78% (most
common)
Increased
Desmoplastic response to invading CA cells (protective)
Neoplastic
cells are arranged in small clusters or in single rows occupyning a
space between collagen bundles
Originate
in the myoepithelial cells of the mammary duct
Desmoplastic
---> shortend Cooper’s ligament ---> dimpling over the tumor
Medullary
carcinoma:
2-15%
Large round
cancer cells arranged in broad plexiform mass surrounded by lymphocytes
and lymphatic follicles
Soft, bulky
and large tumors w/ necrotic areas
5 year survival
= 85 – 90%
Good prognosis
Histological
Classification of Breast Cancer
Mucinous
(Colloid) carcinoma:
2%
Soft, bulky
w/ ill defined borders
Cancer cells
floats in large mucinous lakes
Cut surface
is glistening, glaring and gelatinous
Tubular
carcinoma
Well differentiated
Ducts lined
by a single layer of well differentiated cancer cells
Absence of
myoepithelial w/ well defined basement membrane
Common in
premenopausal and detected w/ mammography
5 yr survival
---> 100% if the CA contain 90% or more of tubular components
Histological
Classification of Breast Cancer
Papillary
carcinoma:
2 %; present
in 7th decade
Thrown into
papilla w/ well defined fibrovascular stalks and multilayered epithelium
Has the lowest
frequency of axillary nodal involvement; has the best 5 and 10 yrs survival
rates
Even if w/
axillary metastases, it is still indolent and slowly progressive disease
than the common adenocarcinoma
Adenoid
cystic carcinoma:
Indestinguishable from
adenoid cystic carcinoma of the salivary gland
Rare axillary
involvement.
Histological
Classification of Breast Cancer
Carcinoma
of Lobular origin:
10% of breast
CA; LCIS – 3%
Small cell
w/ round nucleus, inconspicuous nucleoli and scant, indistinct cytoplasm.
Arises from
the terminal ducts and acini
Similar to
colloid CA were mucin displaced the nucleus, resembling signet-ring
carcinoma of the GIT.
High propensity
for bilaterality (35-60%), multicentricity (88%) and multifocality
Squamous
Carcinoma:
Metaplasia
w/in the lactiferous duct system
Similar to
epidermoid CA of the skin
Metastasize
thru the lymphatic
Histological
Classification of Breast Cancer
Sarcoma
of the Breast: (Fibrosarcoma,
liposarcom, leiomyosarcoma, malignant fibrous histiocytoma, etc.)
Large,
painless breast mass w/ rapid growth
Mammography
---> false (-)
Grossly:
--> it lacks the cut gabbage surface of phyllodes
Histologically:
Spindle
cell neoplasm that grows expansile and it’s margin either pushes or
infiltrate adjacent structures
It invades
the fat and tend to intervene between the glandular aspect of the breast
parenchyma and expands the lobules and intralobular spaces
Treatment:
--> total mastectomy
Histological
Classification of Breast Cancer
Lymphoma
of the Breast:
Similar to
other malignant lymphoma
Mastectomy
w/ axillary LN sampling
Tx: radiotherapy
/ chemotherapy
Inflammatory
Carcinoma of the Breast
1.5 – 3%
Clinically:
erythema, Peau-d’
orange, skin
ridging w/ or w/o a mass. Skin is warm sometimes scaly and indurated
(cellulitis), nipple retract.
Diagnosis:
biopsy
Histologically:
---> no
predominant histological type.
Subdermal
lymphatic and vascular channels are permeated w/ highly undifferentiated
tumor
Characteristically:
---> absence of PMN and lymphocyte near the tumor
Rapid growth
and majority has (+) cervical LN and distant metastasis
TNM
Staging System for Breast Carcinoma
Primary Tumor (T)
TX – Primary tumor cannot be
assessed
T0 – No evidence of primary tumor
Tis – CA in situ (LCIS / DCIS),
Paget’s dse of the nipple w/o tumor
T1 – 2 cm or less
T1a –
0.5 cm. or less
T1b -
> 0.5 cm. to 1 cm.
T1c -
> 1cm. to 2 cm.
T2 – 2 to 5 cm.
T3 - > 5 cm.
T4 – any
size w/ direct extension to chest wall or skin
T4a
– extension to chest wall
T4b –
edema / ulceration of the skin / satelite nodule
T4c –
both T4a and T4b
T4d
– Inflammatory carcinoma
TNM
Staging System for Breast Carcinoma
Regional Lymph Nodes
(N)
NX – Not assessed (previously
removed)
N0 – No regional LN metastasis
N1 – (+) movable ipsilateral
axillary LN
N2 – (+) LN fixed to one another
N3 – (+) Ipsilateral INTERNAL
MAMMARY LN
Pathological Classification
LN (pN):
pNX – not assessed
pNO – (-)
pN1 – (+) movable ipsilateral
axillary LN
pN1a –
(+) micrometastasis (0.2 cm or less)
pN1b –
any larger than 0.2 cm but less than 2 cm
pN1bi - (+) 1-3 LN
pN1bii - (+) 4 or more LN
pN1biii –
extension of tumor beyond the capsule
pN1biv –
(+) LN > than 2 cm
pN2 – Axillary LN fixed with each
other
pN3 – (+) internal mammary LN
TNM
Staging System for Breast Carcinoma
Distant Metastasis
(M):
MX – not assessed
M0 – (-)
M1 –(+) including metastasis
to ipsilateral supraclavicular LN
Stage Grouping:
Stage
0 TisN0M0
Stage
I T1N0M0
Stage
IIA T0N1M0
T1N1aM0
T2N0M0
Stage
IIBT2N1M0
T3N0M0
Stage
IIIA T0 – T2N2M0
T3 N1-2M0
Stage
IIIBT4
Any NM0
Any TN3M0
Stage
IV Any T
Any NM1
Survival
Rates for patients w/ Breast Cancer Relative to Clinical Stage
-
10
STAGE IV With distant metastases
7 –
80
41
STAGE III Tumor > 5cm in diameter
Tumor any size w/ invasion of skin attached to
chest wall
Nodes in supraclavicular area
Without distant metastases
47 –
74
66
STAGE II Tumors > 5 cm
in diameter
Nodes, if palpable, not fixed
w/o distant metastasis
82 -
94
85
STAGE I Tumor <
2cm in diameter
Nodes, if present, not felt to contain metastases
w/o distant metastases
Range
Survival (%)
Crude
5-yr survival (%)
Clinical staging
(American Joint Committee)
Survival
Rates for patients w/ Breast Cancer Relative to Histologic Stage
21.1
32.0
13.4
> 4 positive axillary
lymph nodes
50.0
62.2
37.5
1 - 3 positive axillary
lymph nodes
34.9
46.5
24.9
Positive axillary
lymph nodes
82.3
78.1
64.9
Negative axillary
lymph nodes
60.3
63.5
45.9
All patients
5-yr
Disease-free survival (%)
Crude
survival (%)
5yr
10yr
Histologic
Staging (NSABP)
Relationship
Between Morphologic Types of Invasive Breast Cancer, Lymph Node Involvement,
and Patient Survival
83
56
17
1
Papillary
73
59
32
3
Colloid
73
58
32
5
Comedo
63
50
44
4
Medullary
50
32
60
9
Lobular
54
38
60
78
Ductal w/ productive
fibrosis
%
Survival
5
yr 10 yr
%
w/ nodal involvement
Frequency
Type
Treatment:
Benign: hormonal, surgery (excision
biopsy), antibiotics
Malignant:
Selection
of patientsa. stage of lesion
b. medical condition of pt
Criteria
of Inoperability / Incurability (Haangensen)
a)
extensive edema of the skin over the breast
b)
satellite nodule in the skin over the breast
c) inflammatory carcinoma of the breast
d)
parasternal tumor nodule
e)
supraclavicular metastasis
f)
edema of the arm
g)
distant metastasis
h)
Any 2 or more of the following locally advances cancer
i. ulceration
of skin
ii. Edema of skin
less 1/3
iii. Solid fixation of
tumor to the chest wall
iv. Axillary LN 2 cm or
more
v. Fixation of axillary
LN to skin and dep structure
Surgical Management:
Radical
Mastectomy
(Willi Meyer, Halsted)
Stage III,
IV
Extended
Radical Mastectomy
Hardley
– 21% of outer quadrant and 44% inner quadrant tumor has (+) internal
mammary nodal involvement.
Wangesteen (Classical RM + Internal mammary
mediastinal
and supraclavicular LN)
Urban (CRM + ipsilateral half of
sternum, part of 2nd to 5th rib
and pleura and internal mammary
LN)
Modified
Radical Mastectomy:
Patey
– preserved pectoralis major
Madden
/ Auchincloss – preserved
both the pectoralis major
and minor
Total
mastectomy w/ or w/o radiation:
Crile – Total mastectomy
Mc Whirter
– Total mastectomy and radiation (Axilla,
supraclavicular and internal
mammary nodes)
Surgical Management:
Subcutaneous
Mastectomy:
Nipple is
retained / for T1s
Quandrantectomy,
axillary, radiotherapy (QUART)
Quadrant
of the breast that has the CA is resected
(quadrant
of breast tissue, skin and superficial pectoralis fascia)
Unacceptable
cosmetic result
Partial
Mastectomy and Radiation:
Lumpectomy,
segmental resection or tylectomy
Histologically
free margin of breast CA (1cm)
Advent of
supervoltage radiotherapy with skin sparing effect
Frozen section
evaluation of margin
To determine
adjuvant chemotherapy adequate sampling of axillary LN (level I), curvilinear
incision should be done
If LN (+)
----> adjuvant chemotherapy
Indications for
Conservative Surgery:
Small breast
CA < 4cm
Clinically
(-) axillary LN
Breast volume
adequate size to allow uniform dosage of irradiation
Radiation
therapist experience to avoid damage of retained breast
Radiotherapy:
Local control
Pre-operative
/ post-operative radiation
Chemotherapy:
CMF, CAF,
CA, AV, doxorubicin
Side effect:
nausea, vomiting, myelosuppression, alopecia, thrombocytopenia, exercise
intolerance
Hormonal Therapy:
Receptor
Assay (ER/PR):
1 gm of
fresh tissue obtained by using cold scalpel and should be determined
w/in 20-30 min.
ER (-) <
10% respond to endocrine ablation or exogenous estrogen
ER (+) > 60%
responds
premenopausal
– 30% (only due to masking effect of endogenous estrogen)
Menopausal
– 60%
PR (+) 15% of premenopausal
benefit from 15%
Hormonal Therapy:
Ablation:
Oophorectomy,
adrenalectomy, hypophysectomy
Replaced
by medical adrenelectomy, etc.
Anti-estrogen:
Tamoxifen – a non-steroidal anti-estrogenic
compound that compete w/ estrogen at receptor site.
Estrogen
receptor assay should be determined; if negative chance of success is
very low
Aromasin
Aminogluthethimide – it interferes with conversion
of androstinedione to estrone and estradiol in the peripheral tissue
and inhibit the conversion of cholesterol to pregnanolone
Hydrocortisone
should be added
Hormonal Therapy:
CT
T + CT
O, T
? T +
CT
ER -
/ PR +
CT
CT
ER -
/ PR -
T
T + CT
O
T--->
T + CT
ER +
/ PR -
T, CT
O, T
T + CT
ER +
/ PR +
Postmenopausal
Premenopausal
Receptor
Status
Therapeutic
Approach for Breast Cancer
Carcinoma
in Situ:
DCIS:
Breast conserving
surgery + radiation therapy w/ or w/o tamoxifen
Total mastectomy
w/ or w/o tamoxifen
Breast-conserving
surgery w/o radiation therapy
Lobular
Carcinoma in Situ:
Observation
after diagnostic biopsy
Tamoxifen
to decrease the incidence of subsequent breast cancer
Study, Tamoxifen
versus raloxifene in high-risk postmenopausal women
Bilateral
prophylactic total mastectomy, w/o axillary dissection
Therapeutic
Approach for Breast Cancer
Stage
I & II
Modified radical mastectomy
(+)
LN(-) LN(-) LN
Low risk High
risk
Hormonal
/observe chemotherapy
chemotherapy
High Risk Patients
(Stage I):
Histologic
criteria:1. Poor cytologic differentiation
2. Lymphatic permeation
3. Blood vessel invasion
4. Poor circumscritption
Rapid growth
rate, by clinical history or thymidine labeling index
Youth of
the patient
Estrogen
receptor negative
Therapeutic
Approach for Breast Cancer
Advance
Breast Cancer (III / IV):
Palliative
Mastectomy
(+)
Estrogen(-) Estrogen
Chemotherapy/Hormonal/Chemotherapy/Radiotherapy
Radiotherapy
Therapeutic
Approach for Breast Cancer
Inflammatory
Breast Carcinoma:
3 – 5%
5 year survival
Main role
of surgery is in the diagnosis
Primary therapy
is chemotherapy and radiotherapy and if possible surgery (mastectomy).
CAF
----- regression ------> extended mastectomy (level I) ---------->
irradiation of axillary and skin flap (30% - 5 yr survival)
Breast
Cancer and Pregnancy/Lactation:
The risk
of aggressive and distant metastasis is profound due to high level of
estrogen and progesterone secreted from the placenta and corpus luteum.
Treat
patient as if she is not pregnant
Lactation
should be suppressed promptly, even if biopsy was benign because milk
from transected lactiferous will drain via the biopsy site
If patient
is undergoing radiotherapy and chemotherapy for breast CA, advice patient
not to get pregnant. ( advice not to use contraceptive pills).
Treatment:
MRM / Segmental
resection + radiation (after delivery)
(+) axillary
---> chemotherapy is delayed on the 2nd trimester (single
agent) 11 – 12% teratogenicity on 1st trimester.
Therapeutic
Approach for Breast Cancer
Breast
Cancer in Men:
Factors:
Klinefelter
syndrome
Estrogen
therapy
Testicular
feminizing syndromes
Irradiation
Trauma
Age: 60-70y/o
s/sx: breast
mass, nipple retraction and/or discharge, ulceration and pain.
Commonly
ER positive and well differentiated
Prognosis
is similar w/ female
Treatment:
MRM + radiation
if with ulceration and high grade
Orchiectomy
/ chemotherapy