34 Breast - Breast Cancer

  1. Risk factors for breast cancer? [TU 2072]
    • Risk Factors That Cannot be Modified
    • Increasing age
    • Female sex
    • Menstrual factors
    • Early age at menarche (onset of menses before age 12 yr)
    • Older age at menopause (onset beyond age 55 yr)
    • Nulliparity
    • Family history of breast cancer
    • Genetic predisposition (BRCA1 and BRCA2 mutation carriers)
    • Personal history of breast cancer
    • Race, ethnicity (white women have increased risk compared with women ofother races)
    • History of radiation exposure

    • Risk Factors That Can Be Modified
    • Reproductive factors
    • Age at first live birth (full-term pregnancy after age 30 yr)
    • Parity
    • Lack of breastfeeding
    • Obesity
    • Alcohol consumption
    • Tobacco smoking
    • Use of hormone replacement therapy
    • Decreased physical activity
    • Shift work (night shifts)

    • Histologic Risk Factors
    • Proliferative breast disease
    • Atypical ductal hyperplasia
    • Atypical lobular hyperplasia
    • Lobular carcinoma in situ
  2. Classification of primary breast cancer?
    • Noninvasive Epithelial Cancers
    • Lobular carcinoma in situ - classic and pleomorphic
    • Ductal carcinoma in situ or intraductal carcinoma 
    • - comedo - large cell: more aggressive form
    • - non-comedo (cribriform, micropapillary, papillary and solid) - small cell: less aggressive 

    • Invasive Epithelial Cancers (Percentage of Total)
    • Invasive lobular carcinoma (10%)
    • Invasive ductal carcinoma
    • • Invasive ductal carcinoma, not otherwise specified (50%-70%)
    • • Tubular carcinoma (2%-3%)
    • • Mucinous or colloid carcinoma (2%-3%)
    • • Medullary carcinoma (5%)
    • • Invasive cribriform carcinoma (1%-3%)
    • • Invasive papillary carcinoma (1%-2%)
    • • Adenoid cystic carcinoma (1%)
    • • Metaplastic carcinoma (1%)

    [@ M3I3TA]

    • Mixed Connective and Epithelial Tumors
    • Phyllodes tumors, benign and malignant
    • Carcinosarcoma
    • Angiosarcoma
    • Adenocarcinoma.
  3. What is invasive and non-invasive breast cancer?
    Non-invasive – Basement membrane layer is maintained.  Carcinoma in situ of the breast represents a heterogeneous group of neoplastic lesions confined to the breast ducts (DCIS) and lobules (LCIS) with no evidence of invasion into the surrounding stroma on routine light microscopic examination. 

    Invasive – Penetration of basement membrane by malignant cells invading the stroma.
  4. Inflammatory breast carcinoma?
    • Diffuse tumor involvement of the dermal lymphatic channels within the breast and overlying skin, often without an underlying tumor mass.
    • Inflammatory breast cancer manifests clinically as erythema, edema, and warmth of the breast as a result of lymphatic obstruction.
    • Most patients with inflammatory breast cancer donot have a defined mass in the breast and usually the whole breast is enlarged.
    • This lesion is often confused with breast abscess. However, the differentiating features are absence of fever and presence of skin changes like peau d’orange.
    • There may be no abnormality on mammography beyond skin thickening.
    • The prognosis of this type of carcinoma is uniformly poor.
  5. Peu d orange
    Localized edema due to disruption of lymphatic drainage. 

    Peau d’orange may also be demonstrated by squeezing a segment of skin over the breast which will show the lymphedema in the skin with prominent hair follicles in between.
  6. Molecular subtypes of breast cancer?
    Four major molecular subtypes:

    • Luminal A
    • Luminal B
    • Triple negative/basal-like
    • HER2 type

    Luminal A and B subtypes are both estrogen-receptor-positive (ER+) and low-grade, with luminal A tumors growing very slowly and luminal B tumors growing more quickly. Luminal A tumors have the best prognosis.
  7. Triple negative breast cancer?
    • Lack expression of ER, PR and Her-2
    • Some overlap with Basal like breast cancer.
    • It is more aggressive- no targeted treatment in these cancers
  8. Modalities of breast imaging?
    • Mammography
    • Mediolateral Oblique and craniocaudal view 
    • Sensitivity depends on breast density 
    • increased age - increased fat tissue - fat absorbs relatively little radiation and provides a contrasting background that favors detection of small lesion 
    • American cancer society recommendation - annual screening for women >40 years, this practice should continue as long the woman is in good health 

    • USG 
    • to determine if the lesion detected by mammogram is cystic or solid 
    • to determine lesions in dense breast 
    • Not useful as breast cancer screening tool 

    • MRI 
    • for identifying the primary tumor in the breast in patients who present with axillary lymph node metastases without mammographic evidence of a primary breast tumor (unknown primary tumor)
    • patients with Paget disease of the nipple without radiographic evidence of a primary tumor
    • assessing the extent of the primary tumor,particularly in young women with dense breast tissue; for evaluating for the presence of multifocal or multicentric cancer
  9. What is ductography?
    • It is a contrast study for evaluation of patient with nipple discharge. The duct opening is gently dilated and a fine cannula is passed into the duct. About 0.1–0.2 ml of dilute contrast medium is injected into the duct and craniocaudal and mediolateral views are taken
    • „ Intraductal papilloma may be seen as a filling defect within the duct
    • „ Intraductal carcinoma may appear an irregular filling defect within the duct.
  10. Triple test score
    • The triple test score (TTS) is a diagnostic tool for examining potentially cancerous breasts.  
    • Scoring includes using the procedures of physical examination, mammography and needle biopsy

    • To obtain the triple test score, a number from 1 through 3 is assigned to each one of the procedures.
    • A score of 1 is assigned to a benign test result, 2 applies to a suspicious test result, and 3 applies to a malignant result.
    • The sum of the scores of all three procedures is the triple test score.
    • A score of 3 to 4 is most likely benign, whereas a score of greater than 6 is possibly malignant
  11. Short note on CA 15.3. [TU 2070/6]
    • CA 15-3 (also known as MUC1) is the most widely used serum marker in breast cancer.
    • MUC1 is a large transmembrane glycoprotein which is frequently overexpressed and aberrantly glycosylated in cancer.
    • Physiologically, MUC1 appears to play a role in cell adhesion and the high levels present in cancer may be causally involved in metastasis.
    • At present the main uses of CA 15-3 are in preclinically detecting recurrent breast cancer and monitoring the treatment of patients with advanced breast cancer.
    • Elevated CA15-3, in conjunction with alkaline phosphatase (ALP), was found to be associated with an increased chance of early recurrence in breast cancer.Both CA 15-3 and CA 27-29 may be elevated in patients with benign ovarian cysts, benign breast disease, and benign liver disease.
    • Elevations may also be seen in cirrhosis, sarcoidosis and lupus
  12. BIRADS?
    • Breast Imaging Reporting and Data System
    • To catagorize the degree of suspicious of malignancy for mammographic abnormality 
    • Bening lesions - BIRADS 0-3 
    • Malignant lesions - BIRADS 4-6 

    • 0 - Incomplete assessment—need additional imaginge valuation or prior mammograms for comparison
    • 1 Negative—nothing to comment on; usually recommendannual screening
    • 2 Benign finding—usually recommend annual screening
    • 3 Probably benign finding (<2% malignant)—initial short-interval follow-up suggested
    • 4 Suspicious abnormality (2%-95% malignant)—biopsy should be considered
    • 5 Highly suggestive of malignancy (>95% malignant)—appropriate action should be taken
    • 6 Known biopsy—proven malignancy
  13. Growth pattern of invasive ductal and lobular carcinoma?
    Invasive ductal cancer tends to grow as a cohesive mass; it appears as discrete abnormalities on mammograms and is often palpable as a discrete lump in the breast smaller than lobular cancers. Invasive lobular cancer tends to permeate the breast in a single-file nature, which explains why it remains clinically occult and often escapes detection on mammography or physical examination until the disease is extensive
  14. Mammographic finding of DCIS?
    • Clustered Pleomorphic microcalcifications 
    • - Linear calcifications - comedo-type
    • - Fine, granular calcifications - low grade non-comedo

    [craniocaudal and a mediolateral views are essential in mammography]
  15. Reason for calcification in breast cancer?
    • As the cells inside the ductal membrane grow, they have a tendency to undergo central necrosis, perhaps because the blood supply to these cells is located outside the basement membrane. The necrotic debris in the center of the duct undergoes coagulation and finally calcifies, leading to the tiny, pleomorphic, and frequently linear forms of microcalcifications seen on mammograms.
    • In some patients, an entire ductal tree may be involved in the malignancy, and the mammogram shows typical calcifications from the nipple extending posteriorly into the interior of the breast (termed segmental calcifications).
  16. Methods of breast biopsy?
    • a) FNAC - Use 22G needle, tissue immediately fixed with 95% ethyl alcohol
    • - Does not differentiate between non-invasive from invasive lesion if malignant cells are identified (core needle biopsy is needed if malignant cells are identified).
    • - Hormone receptor study is not possible in FNAC specimen.
    • Uses – evaluation of second suspicious lesion in ipsilateral breast with known malignancy, evaluation of regional LN for suspected metastasis

    b) Core needle biopsy – method of choice, done under mammogram (stereotactic), USG or MRI guidance, Obtain histological subtype, grade and receptor

    c) Excisional biopsy – required only if core needle biopsy is unconclusive, eg speculated mass on imaging and normal breast tissue on core needle biopsy
  17. Indication of image localized surgical excision of non palpable breast lesions?
    If diagnosis is not concordant with imaging finding or there is ADH in the field of microcalfications, that may present DCIS. 

    • Methods of localization -
    • - Localizing wire
    • - 4.5 mm I125 radioactive seed placed in breast tissue
  18. TNM staging of breast cancer? [TU 63]

    Describe pathological TNM classification of breast cancer. [TU 2063/12]
    • T1 - <2cm
    • T2 – 2-5 cm
    • T3 - >5cm
    • T4 – any size with direct extension to chest wall or skin
    • T4a – Extension to chest wall, not including only pectoralis muscle adhesion or invasion
    • T4b – ulceration, satellite nodule or edema of the skin
    • T4c – Both
    • T4d – inflammatory carcinoma

    • Pathological Nodal Classification
    • N1 – 1-3 axillary nodes, internal mammary nodes detected by sentinel biopsy, not clinically detected
    • N1mi – Micrometastasis (<2mm)
    • N1a - >2mm
    • N2 – 4-9 axillary nodes, or clinically detected internal mammary nodes
    • N3 - ≥10 axillary nodes, or level III nodes

    • Clinical Nodal classification 
    • N1
    • - movable ipsilateral level I, II axillary lymph node(s)

    • N2
    • - Ipsilateral I, II axillary nodes that are fixed or matted
    • - Clinically detected ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases

    • N3
    • - clinically detected ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases
    • - ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II  lymph node
    • - metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement
  19. Stages of breast cancer?
    • IA - T1 N0 M0
    • IB - T0 N1mi M0, T1 N1mi M0
    • IIA - T0 N1 M0, T1 N1 M0, T2 N0 M0
    • IIB - T2 N1 M0, T3 N0 M0
    • IIIA - T0 N2 M0, T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N2 M0
    • IIIB - T4 N0 M0, T4 N1 M0, T4 N2 M0
    • IIIC - Any T N3 M0
    • IV - Any T Any N M1

    • For the treatment purpose, breast cancer can be divided into 
    • ● Early stage – Clinical stage I, IIA, or a subset of stage IIB disease (T2N1).
    • ● Locally advanced – Clinical stage IIB disease (T3N0), IIIA to IIIC disease.
    • ● Metastatic disease - Clinical stage IV

    [NCCN 2016 - does not include T3N0 in locally advanced] 
  20. What is the implication of serratus anterior fixity of the lump?
    • Serratus anterior fixity of a lump denotes chest wall fixity, i.e. T4a.
    • Pectoral muscle fixity does not alter T staging.
  21. What is locally advanced breast cancer?
    • Large primary tumors (>5 cm)
    • Involving the chest wall,skin involvement, ulceration or satellite skin nodules
    • Inflammatory carcinoma
    • Bulky or fixed axillary nodes
    • Clinically apparent internal mammary or supraclavicular nodal involvement(stages IIB, IIIA, and IIIB disease).
  22. The most common sites of distant metastases from breast cancer?
    • „ Bones: 50–65%
    • „ Lung: 15–20%
    • „ Pleura: 10–15%
  23. Risk assessment for hereditary breast cancer?
    Assessment of risk for hereditary breast cancer (eg, BRCA1/BRCA2) is made following a diagnosis of invasive breast cancer and DCIS. If the patient is at high risk (greater than 10 percent chance) for carrying a deleterious mutation as determined by published risk assessment tools, or wishes to undergo genetic testing for personal interest, a referral for genetic counseling is appropriate, particularly those with a family history of ovarian cancer. 

    • Risk assessment models in breast carcinoma
    • 1. Gail model 
    • 2. Hereditary and family models 
    • a) Claus model - based on first and second degree relatives with breast cancer at their age of diagnosis 
    • b) Couch model - uses mutation in BRCA gene
  24. Gail Model?
    Used to estimate the relative risk of breast cancer development . It uses Age at menarche, Age at first live birth, No of breast biopsy specimen, H/o of atypical hyperplasia, No of first degree of relative with breast carcinoma

    • This model does not use BRCA1 and BRCA 2 mutation 
    • Should not be used for DCIS or LCIS 
    • Does not make adjustment for first degree and premenopausal or bilateral breast cancer 
    • Increased risk in breast cancer is defined if a 5 year calculated risk is 1.7% or higher
  25. BRCA1 and BRCA2
    • Both are tumor suppressor genes
    • BRCA1 – 17q
    • BRCA2 – 13q
  26. Treatment of BRCA gene mutation?
    • Prophylactic surgery
    • Chemoprevention is not effective
    • MRI - who prefer intensive screening
  27. Recommendations for high risk cases for breast cancer?
    • Close surveillence 
    • Chemoprevention 
    • Prophylactic mastectomy with salpingo-oopherectomy
  28. Close Surveillance guidelines in high risk cases
    • Monthly breast self examination beginning at age 18 to 20 years
    • Semiannual clinical breast examination beginning at age 25 years
    • Annual mammography beginning at age 25 years or 10 years before the earliest age at onset of breast cancer in a family member.
    • For women with a strong family history of early-onset breast and ovarian cancer who have not undergone genetic counseling, genetic counseling is offered; this includes a discussion of genetic testing for BRCA1 and BRCA2 mutations
  29. Planning treatment of breast cancer?
    • Core needle biopsy of a palpable or image-detected lesion is the preferred approach for diagnosis.
    • Computed tomography scans, bone scans, and other imaging studies are generally reserved for patients with abnormalities on blood chemistry tests or chest radiographs and for patients with locally advanced or inflammatory breast cancer.
    • In the absence of metastatic disease, the first intervention forpatients with early-stage breast cancer is surgery for excision ofthe tumor and surgical staging of the regional lymph nodes
    • Patients with locally advanced and inflammatory breast cancers should receive systemic therapy before surgery
    • Patients with a known BRCA mutation are generally counseled toward bilateral mastectomy for treatment of the index breast and reduction of the risk of contralateral breast cancer. 

    • For patients with T1N0 or T2N0 breast cancer, mastectomy and SLND provide effective local control, and radiation therapy is not required.
    • In contrast, patients with stage III breast cancer have high rates of locoregional recurrence after treatment with a modified radical mastectomy and adjuvant or neoadjuvant chemotherapy. Postmastectomy radiationtherapy can significantly improve the outcome of patients whowould be expected to have a 20% to 40% risk of locoregional recurrence without radiation therapy.
  30. Management of lobular carcinoma in situ?
    • Observation 
    • Chemoprevention - with tamoxifen/Raloxifen 
    • Bilateral mastectomy
  31. How to manage a case of DCIS? [TU 2072]

    Treatment approach of DCIS?
    • Surgery -
    • 1. Breast-conserving therapy (BCT).
    • 2. Mastectomy 

    A sentinel lymph node biopsy in high risk cases (ie, those who do not meet criteria for BCT)

    • Adjuvant therapy -
    • - Radiation therapy in high risk cases.
    • - Chemotherapy plays no role
    • - Endocrine therapy in BCT or unilateral mastectomy;
    • a. ER/PR positive – endocrine therapy for 5 years  
    • b. ER/PR negative – adjuvant tamoxifen to prevent a new ER-/PR-positive contralateral or ipsilateral breast cancer.
    • - No role for adjuvant endocrine therapy in bilateral mastectomy. 

    Posttreatment surveillance consists of regular history and physical examination and mammography (if applicable), without routine utilization of laboratory tests, tumor markers, or other imaging.
  32. What is Van Nuys Prognostic Index?
    The VNPI is an attempt to objectively determine the aggressiveness of DCIS in terms of the likelihood of ‘local recurrence’ following ‘breast conserving’ surgeries. 

    • 4, 5 or 6 - excision only
    • 7, 8, or 9- Radiation therapy or reexcision if margin width <10 mm and cosmetically feasible
    • 10, 11, or 12 -  mastectomy

    Image Upload 1
  33. Discuss the indication and contraindication in breast conservative surgery for breast cancer. Discuss the minimal invasive surgical technique in breast cancer surgery. [TU 2057,59]

    Discuss the limitation of breast conserving surgery for breast cancer. [TU 2063/2, 63/2]

    Discuss the recent development in minimally invasive techniques in breast cancer surgery. [TU 2057] 

    Breast conserving surgery?
    • Breast conserving therapy (BCT) refers to breast conserving surgery (BCS), followed by moderate-dose radiation therapy (RT) to eradicate any microscopic residual disease.
    • The goals of BCT are to provide the survival equivalent of mastectomy, a cosmetically acceptable breast, and a low rate of recurrence in the treated breast.

    • BCT consists of lumpectomy, wide excision, partial mastectomy or quadrantectomy followed in most cases by adjuvant radiation. 
    • When DCIS is present on a core biopsy, needle or wire localization under mammographic guidance prior to BCT may ensure complete resection.
    • SLNB is not indicated for most patients undergoing BCT for DCIS. Omitting SLNB at the time of breast-conserving surgery for DCIS decreases perioperative morbidity. 
    • Negative Margin width - 10mm
    • As in the treatment of invasive breast cancer, the standard of care for patients undergoing BCT is to deliver adjuvant whole-breast RT . Conventionally dosed WBRT is delivered to the entire breast in 1.8 to 2 Gy daily fractions over 4.5 to 5 weeks to a total dose of 45 to 50 Gy
  34. Discuss the indications and contraindications of breast conservation surgery in breast cancer. [TU 2064/12] What is breast conserving surgery (BCS)?  What are the indications and limitations of BCS? [TU 2064/5] 

    Enlist the indications and contraindications of conservative surgery in breast cancer. [TU 2057,62]
    A. Patient factor -

    1) Age - Although young age, have been associated with an increased risk for local failure after BCT or after mastectomy; young age alone should not preclude breast conservation 

    2) Family History - A family history of breast cancer is not a contraindication to breast conservation

    3) BRCA gene mutations - is the contraindication for BCS. 

    4) Preexisting collagen vascular disease -  Patient with a history of autoimmune diseases such as scleroderma, systemic or discoid lupus, and dermatomyositis may have increased sensitivity to radiation resulting in abnormal fibrosis which may compromise the cosmetic outcome. 

    5) Pregnancy - Radiation therapy during pregnancy is known to increase the risk of birth defects, so it is not recommended for pregnant women with breast cancer. 

    B. Tumor factor

    1) Tumor Size - Patients with tumors up to 4 cm. in diameter are good candidates for BCS. However, the ratio of tumor size / breast volume seems to have a greater impact on the decision to proceed for BCS. 

    2) Tumor Location - Multicentricity (ie, 2 separate cancers in different quadrants of the same breast) is an important Contraindication to BCS. Multifocal disease is not necessarily a contraindication to BCT. 

    3) Tumor Histology - persistently positive surgical margins after reexcision and diffusely positive pathological margins are the contraindications for BCS. 

    4) Tumor Grade - Most studies indicate that histologic grade is not predictive of recurrence 

    5) Involvement of axillary lymph nodes - The presence of clinically suspicious and mobile axillary lymph nodes or microscopic tumor involvement in axillary nodes should not prevent patients from being candidates for breast conservation surgery (BCS). 

    C. Radiological factor - Diffuse suspicious or malignant appearing microcalcifications is the contraindication  for BCS.
  35. What is multifocal and multicentric breast cancer?
    A multicentric breast cancer is a term given to a breast cancer where there are two or more breast cancers separated by normal breast tissue (often taken as 5 cm of separation).

    Multifocal breast cancer refers to two or more individual breast cancers diagnosed at the same time within the same quadrant of the same breast. 

    Image Upload 2
  36. What is SLND?

    Sentinel lymph node biopsy of breast cancer. [TU 2069/1, 66/1, 64/5, 61/5]
    • ● The status of the axillary lymph nodes remains one of the most important prognostic factors in women with early stage breast cancer. Histologic examination of excised lymph nodes is the most accurate method for assessing spread of disease to these nodes.
    • ●Lymphatic mapping is based upon the concept that one or more nodes are the first to be involved with metastatic disease within a given lymph node basin. If these sentinel lymph nodes are not involved, the entire basin should be free of tumor.
    • ● For clinically node negative patients, sentinel lymph node biopsy offers a less morbid staging procedure than full axillary lymph node dissection for selected patients with early breast cancer.
    • ●Patients with clinically palpable axillary nodes should have a fine needle aspirate or core biopsy of these first. If the needle biopsy is positive, the patient should have a full ALND. If the needle biopsy is negative, sentinel lymph node biopsy (SLNB) should be performed.
    • Image Upload 3

    • Benefits of SLND over ALND - 
    • Performed as an outpatient procedure
    • Does not require a drain
    • More rapid return to full mobility
    • Long-term morbidity, including lymphedema, numbness, andchronic pain, is greatly reduced.
    • At least 10 lymph nodes have to be removed from level I and level II axillary nodes for proper sampling.

    • Contraindicatios of  SLNB - 
    • 1. Clinically involved axilla - If axillary lymph node is clinically palpable then sentinel lymph node biopsy may be fallacious. This may be due to a change in the lymphatic flow as a result of replacement of the sentinel node with metastatic deposit. The radioactive colloid or blue dye bypasses the sentinel node and move on to a non-sentinel lymph node.
    • 2. Multifocal tumors are likely to involve more than one lymphatic trunk from the mammary gland to the axillary node which may give rise to a false negative result.

    Note - SLNB is also practiced in Carcinoma of penis and Malignant melanoma.
  37. What is clinical significance of SLNB in management of early breast cancer. [TU 2065/5] 

    Describe the steps of sentinel lymph node biopsy in care of breast cancer. [TU 2062/5]
    • Lymphatic mapping  using - a combination of 99mTc-labeled sulfur colloid and a vital blue dye, isosulfan blue (Lymphazurin), or with a single agent. 
    • 2.5 mCi of 99mTc-labeled sulfur colloid injected on the day before surgery for preoperative lymphoscintigraphy
    • In the operating suite, 3 to 5 mL of blue dye is injected peritumorally,and the injection site is massaged to facilitate passage of the dye through the lymphatics.
    • A hand-held gamma probe isused to localize transcutaneously the area of increased radioactivity;this helps to guide placement of the incision for the sentinel node procedure.
    • After the incision is made, an area of increased radioactivity is localized with the hand-held gamma probe, and the surgeon visualizes blue lymphatic channels leading to the sentinel node.
    • Dissection is performed to avoid prematurely disrupting the afferent lymphatics.
    • If a blue-stained lymphatic channel or a specific area of radioactivity (“hot spot”) cannot be identified, the primary tumor can be resected to remove the site of injection, decreasing the background shine-through radioactivity.
    • The sentinel node may be identified and removed, after which the nodal basin is checked again to confirm that the level of radioactivity has decreased.
    • If the level of radioactivity remains high, additional sentinel nodes may remain in the nodal basin,and additional dissection should be completed to remove all sentinel nodes.

    Note - Electrocautery should not be used while cutting near the tumor as it may invalidate ER/PR activity
  38. Office secretary with firm mobile lump 3 cm in upper outer quadrant of breast. Describe the steps of its management. [TU 2059]

    Discuss the current controversies in the management of stage I carcinoma of breast (early stage). [TU 2056] 

    Treatment of Early-stage breast cancer?

    Outline the treatment plan for T2N1M0 breast carcinoma. [TU 2060/12]

    Discuss various modalities of operative management in a case of 4 cm mobile breast carcinoma located in the upper outer quadrant of right breast in female aged 48 years. [TU 2067/12]
    30 years old female, office secretory presents with a firm, mobile 3cm lump in the upper and outer quadrant of left breast. Describe the steps of its management. [TU 2059]
    How will you treat a patient of breast carcinoma with positive estrogen receptor? [TU 2059]
    The surgical options include breast-conserving therapy (breast-conserving surgery plus radiation therapy or mastectomy (with or without RT).

    • Surgical approach to the regional nodes - depends on the clinical status of the axilla
    • - For patients presenting with clinically suspicious axillary nodes, a preoperative work-up including ultrasound plus lymph node biopsy can help to determine the best surgical approach. If the lymph node biopsy is positive, an axillary node dissection should be performed. If the lymph node biopsy is negative, a sentinel lymph node biopsy (SLNB) at the time of surgery should be performed.
    • - Patients who present with a clinically negative axilla do not require a preoperative work-up. These patients should undergo an SLNB at the time of definitive breast surgery. Patients who have <3 pathologically involved sentinel nodes by SLNB do not require an axillary node dissection. (Z0011 Trial) Whether or not patients with ≥3 pathologically involved sentinel nodes involved should undergo an axillary node dissection is best determined on an individualized basis, taking into account all other tumor risk factors and the patient’s performance status and comorbidities.

    • Adjuvant treatment 
    • 1. ER/PR -positive breast cancer  - adjuvant endocrine therapy. 
    • 2. Patients with HER2-positive breast cancer - HER2-directed therapy.
    • 3. Indications of chemotherapy 
    • a.  Node positive breast cancer 
    • b.  >1 cm mass 
    • c.  Node negative, >0.5 cm with following adverse prognostic features - lymphovascular invasion, high nuclear grade, high histological grade, Her-2 positive, hormone receptor negative

    NSABP-32 trial - Clinically node-negative breast cancer were randomly assigned to undergo SLND plus ALND or SLND with ALND only if the sentinel node was positive. SLND alone without further ALND is appropriate for patients with clinically negative lymph nodes.
  39. What do you mean by locally advanced breast cancer ? Describe the principle of its treatment. [TU 2072]
    What is locally advanced breast cancer? Discuss the management of inflammatory breast cancer. [TU 2073]

    Treatment of Locally advanced breast cancer?
    • Preoperative management -
    • - Neoadjuvant systemic therapy rather than proceeding with primary surgery.
    • - These patients are usually not candidates for breast conservation at their initial presentation.
    • - Neoadjuvant treatment improves the rate of breast conservation without compromising survival outcomes.
    • - Use chemotherapy in the neoadjuvant setting rather than endocrine therapy.
    • -  A HER2-directed agent should be added to the chemotherapy regimen for tumors that are HER2-positive.
    • - ER-positive breast cancer, in whom surgery is not an option - primary hormonal treatment  without surgery

    • Operative procedure 
    • - MRM 

    • Adjuvant treatment -
    • - All patients who undergo BCS should undergo adjuvant RT
    • - Patients treated by a mastectomy should receive postmastectomy RT. The administration of adjuvant RT should be based upon the original pretreatment stage, regardless of the pathologic response to neoadjuvant therapy.
    • For patients who received neoadjuvant chemotherapy:
    • 1. ER/PR-positive - adjuvant endocrine therapy.
    • 2. Patients with HER2-positive breast cancer - trastuzumab for one year

    ER/PR- negative - should not receive further treatment provided they completed the planned neoadjuvant chemotherapy regimen. These patients should begin posttreatment surveillance. Patients with hormone receptor-negative breast cancer who did not complete planned neoadjuvant treatment prior to surgery are candidates for further chemotherapy in the postoperative (or adjuvant) setting.
  40. Chemotherapy regimen in breast cancer?
    • Regimens for HER2-negative breast cancer
    • 1. FEC Regimen:
    • Drugs - 5-fluorouracil (500 mg/m2 IV), epirubicin (100 mg/m2 IV) and cyclophosphamide (500 mg/m2 IV) 
    • All drugs are given in day 1. 
    • Cycle length: 21 days.
    • Duration of therapy: 6 to 8 cycles

    • 2. FEC followed by weekly docetaxel
    • Cycle 1-3 - FEC 
    • Cycle 4-6 - Docetaxel (100 mg/m2 IV)

    • 3. CMf (cyclophosphamide /methotrexate/5—fluorouracil) as  a monthly cycle for six cycle - 
    • • Cyclophosphamide: 500 mg/sq meter of body surface area
    • • Methotrexate: 10 mg/sq meter
    • • 5-Fluorouracil: 500 mg/sq meter.
    • These are administered every 21 days for a total of six cycles

    FEC  has been claimed to be superior to CMF.

    • Regimens for HER2-positive breast cancer
    • 1. Neoadjuvant docetaxel, pertuzumab and trastuzumab followed by adjuvant FEC plus trastuzumab. [@ DPT] 
    • Cycle length: Every 21 days.
    • Duration of therapy:
    • - Prior to surgery (neoadjuvant portion of treatment), administer four cycles of docetaxel, trastuzumab, and pertuzumabΔ.
    • - Following surgery, adjuvant treatment consists of three 21-day cycles of FEC plus trastuzumab followed by trastuzumab alone to complete a total of 51 weeks of trastuzumab.
  41. Indication of post mastectomy radiation?
    For patients with T1N0 or T2N0 breast cancer, mastectomy and SLND provide effective local control, and radiation therapy is not required

    Only for selected patients with stage II disease- extracapsular extension, lymphovascular invasion,age 40 years or younger, close surgical margins, or a nodal positivity ratio (ratio of positive nodes to total nodes examined) of 20% or greater and patients who have undergone less than a standard level I or II axillary dissection.

    All stage III breast cancer require radiation therapy
  42. Management of metastatic breast cancer?
    • The aims of treatment
    • „ To provide palliation
    • „ Symptomatic relief
    • „ Relief of symptom due to growth in the breast which may be fungated.
Card Set
34 Breast - Breast Cancer