tx ca mama

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DEVELOPMENT OF BREAST On each side of the ventral surface of young embryos, a

thickened band of ectoderm develops(the milk ridge).

It extends obliquely from axilla to inguinal region.

In human, the whole of these ridge atrophies, excepting only

small portion in each pectoral region from which breastarises.

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CONGENITAL ANOMALY OFBREAST Amastia bilateral absence of breast tissue ! nipple. "hen

breast tissue is absent unilaterally, the pectoral muscle is often

absent.(#)

Polymastia more than one breast in one or both sides.($)

Polythelia supranumerary nipples are situated irregularlyover the breast ! not on milk ridge.(%)

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3

EVALUATIONA. Clinical Manifestation:

B. Physical Examination:

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IMAGENES

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La consulta médica luego

de los 40 años debe efectuarse

anualmente

Lo ideal es detectar el cáncer antes que

se palpe.

La Mamografía es el único método porexcelencia para la detección del cáncer

de mama.

onlle!a una mínima preparación " se

reali#a

en pocos minutos.

RELEVANCIA DE LA MAMOGRA!A

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Indicaciones de

mamografa• Control anual a partir de los 40 años• Con antecedentes amiliares apartir de los

35 años o 10 años antes del amiliar más joven• Paciente de cualquier edad con diagnstico

de cáncer de mama• Paciente de cualquier edad con enermedad

metastásica demostrada sin tumor primario!• Previo a cualquier intervencion quirurgica

mamaria• "urante la terapia #ormonal con

periodicidad anual• $n el varn para dierenciar ginecomastia%

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$cografa mamaria• $s un estudio complementario!• &o es m'todo de screening!• (til en premenopausicas) em*ara+adas) en

lactancia• "iag!di!de lesiones qu,sticas%slidas• -amas densas• $valuacin de prtesis• Procesos in.amatorios

• /u,a de procedimientos intervencionistas• Primera evaluacin de mujeres de 30%35años!

• esiones ailares 2adenopat,as!• Complemento de lesin palpa*le

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esonancia magnetica

nuclear• $valuar la etensin de la enermedadpreoperatoria!

• Prtesis• Carcinoma oculto por imágenes

#a*ituales• -ama operada%irradiada•

-onitoreo pos tratamiento!• ospec#a de enermedad metastásica!• Paciente de alto riesgo 2*cra1%!

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ignos -amográfcos

• &dulo 6 -asa• -icrocalcifcaciones

• "eormidad del par'nquima• 7simetr,a• esin $spiculada

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Carcinoma ductal infiltrante

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Calcifcaciones

• Beni"nas Mali"nas• edondas Irregulares• "ispersas 7grupadas• 8ilaterales 9nilaterales• /randes -u: pequeñas

mic#ocalci$caciones

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;alla+gos $cográfcosen Cáncer de -ama

• 8ordes irregulares) redondeados• $structura interna #eterog'nea)

irregular• om*ra ac

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3! P>C$"I-I$&?>I&?$@$&CI>&I?7

• Punciones cito#istolgicas *ajocontrol $C>/ABIC> o

$?$$>?AIC> DE

• -arcaje prequirurgico de lesiones nopalpa*les= – 8I>PI7 "II/I"7 C>& 7P>&

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F adiolog,a C;7 30

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Carcinoma ductal infiltrante

Classification

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85% of ca arises in ducts, thus ductal ca is most common variant

Most frequently upper outer quadrant is involved lobular ca occur in up to 15% of cases

Breast cancers are divided in to…

!"# $!"#

uctal

$obular

Medullary

!olloid

ubular

"nflammatory !a

&a'et(s isease

Classification

o n I n v a s i v e ( I N S I T U )

2 - I n v a s i v e

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Diagnosis should be made by combination of 1)clinical assessments*)radiolo'ical ima'in'

+)cytolo'ical or thru histolo'ical analysis

D AG OS S

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BREAST CANCER STAGINGACCORDING TO TNM CLASSIFICATION

Stage 0 Tis N o M o

Tis & carcinoma in situ

N o& no reginal lymph

node metastasis

M o& no distant metastasis

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BREAST CANCER STAGINGACCORDING TO TNM CLASSIFICATION

'tage $ $ o * o

$ & tumor %cm or less

in greatest dimension

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'tage %a

To N! Mo $& metastasisto ipsilateral

ax. odes

T! N! Mo mobile

T" N o Mo %& tumor+%cm but -cm in

greatest

dimention

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'tage %b

% $ *o

# o *o #& tumor sie

+ -cm in

greatest

dimention

Stage #a N"a $met to i%silat a&illa'y N",$ met to i%silat i(t mamma'y

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(o)e * +i&e) o' matte) (o)e i( a,se(-e o+ a&. (o)e

o % * o

$ % *o

% % *o

# $ *o

# % *o

Stage #, T/a$ e&te(sio( T/,$ T/-$ ,oth T/a T/)$

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to -hest all e)ema1Pea2)3O'a(ge4*

5 T/, i(+lammato'y-a'-i(oma

/ o *o

/ $ *o

/ % *o

/ % *o

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Stage # - N#a$ met toi%silati(+'a-la6i-2la' LN

N#,$ i%silatI(te'(al mamma'y5 a&illa'y LN

N#-$ i%silats2%'a-la6i-2la' LN

0ny

#

*o

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'tage / 0ny any 1 *$

*$& distant metastasis

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Silverstein, The Breast Journal 4:324, 1998

Positive aillar: l:mp# node versus ? stage

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$%&L&'(L

#-$-.$ $ / $umber vertebrate

0 / 0emur

/ vertebrae

2/ 2"B#

#/ #3ull

Metastasis may

occur in liver,lun's 4brain

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45

ET Scan

PET scan Normal

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4G

ET Scan

PET scan

abnormal

PET in woman with breast CA

that has spread to bone

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Name

umor sie, e6tent 72e'ional lymph node involvement 79

Metastasis 7M:istolo'y) type;rade!hromatinumor necrosisMitotic counts9. ploidyhymidine labelin' inde6

#/phase< flo= cytometryi/>? antibody

&rofileratin' cell nuclear anti'en

&!9.

.n'io'enesis

&eritumoral lymphatic vessel invasion

Literature

support

@

@

@

@

@

@

@

@

A

@

@A

@

@

@

!OGNOSTIC "ACTO!S

Anatomic and cellular pro#nostic factors

roperties

&atholo'ic more reliable than clinical

&atholo'ic more reliable than clinical

2adio'raphic tests acceptable

Most breast cancer is ductal

&roblems =ith uniformity of criteria

9uclear morpholo'y

!ell de'eneration and death

!ell activity, fi6ative problems, only M/phase cells

!onflictin' results

!ell proliferation, thymidine a 9. precursor, thymidine

analo'ue 5/bromodeo6yuridine also used, predicts

recurrence

!ell proliferation, no standardied cutoff point2eco'nies nuclear anti'en e6pressed only in

proliferatin' cells

!ell cycle/dependent protein that accumulates in the

nucleus of replicatin' cells durin' #/phase, conflictin'

results

2elated to tumor an'io'enesis factors

#i'nificant for relapse/free survival but not overall

survival

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"actores Tumorales

!ompromiso 'an'lionar amao umoral;rado :istolo'ico y nuclear"nvasion $infatica y vascular

-6presion her * neu2eceptores hormonales 7-2C&2

"actores del $uesped

-dad-stado Menopausico:istoria 0amiliar -nfermedad neoplasica previa"mmunosupresion

2espuesta inflamatoria9utricionDuimioterapia previa2adioterapia previa

"ACTO!ES !ONOSTICOS

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$arlier stage % *etter survival

%ta"e

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50

Sur%i%al !ates for patients &' (reast Cancer

!elati%e to $istolo#ic Sta#e

&istolo"ic %ta"in"'N%ABP(

C#)*es)#+i+al ',(-y# /y#

-0y#Disease0f#ees)#+i+al ',(

All 1atients G3!5 45!H G0!3

Ne"ati+e axilla#y lym1h no*es J!1 G4!H J!3

Positi+e axilla#y lym1h no*es 4G!5 4!H 34!H

0 2 1ositi+e axilla#y lym1hno*es

G! 3!5 50!0

3 4 1ositi+e axilla#y lym1hno*es

3!0 13!4 1!1

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T!ATAMIENTO

Clasificacion de ries#o

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Inte#me*iate Ris5

&i"h Ris5

Lo6 Ris5

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o reduce the chance of local recurrence

o reduce the ris3 of metastatic spread

Surgery Radiotherapy

Aduvant syste!i" therapy

M()(*&M&)'

i c p r i n c i p l e s o f t r e a t m e n t

AT" ! N T " O D A # I T I ! S

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Locore#ional

Ciru#)a

!adioterapia

Sistmico

*uimioterapia

$ormonoterapia

A.C Monoclonales

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55

T+erapeutic Approac+ for (reast Cancer

A. Ca#cinoma in %it):. DCI%:a! 8reast conserving surger: K radiation t#erap: L6 or L6o

tamoien

*! ?otal mastectom: L6 or L6o tamoien

c! 8reast%conserving surger: L6o radiation t#erap:

7. Lo8)la# Ca#cinoma in %it):a! >*servation ater diagnostic *iops:

*! ?amoien to decrease t#e incidence o su*sequent *reastcancer

c! tud:) ?amoien versus raloiene in #ig#%risMpostmenopausal Lomen

d! 8ilateral prop#:lactic total mastectom:) L6o aillar:dissection


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5G

T+erapeutic Approac+ for (reast Cancer B. %ta"e I 9 II. -odifed radical mastectom:

.

. DKE & D%E & D%E &

. oL risM ;ig# risM

.

. ;ormonal 6 o*serve c#emot#erap:

. c#emot#erap:

. &i"h Ris5 Patients '%ta"e I(:

7! ;istologic criteria= 1! Poor c:tologic diNerentiation) ! :mp#atic

permeation) 3! 8lood vessel invasion) 4! Poor circumscritption8! apid groLt# rate) *: clinical #istor: or t#:midine la*eling inde

C! Oout# o t#e patient

"! $strogen receptor negative

T+ i A + f ( C

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5


2. A*+ance B#east Cance# 'III IV(:

. Palliative -astectom:

. DKE $strogen D%E $strogen

. C#emot#erap:6;ormonal6 adiot#erap:C#emot#erap:6adiot#erap:

.

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SIT7ATION

he breast lies in the superficial fascia of the pectoral region.

foramen of langer

0 small extension called the axillary tail(of 'pence) pierces the deep fascia and

lies in the axilla

In some normal sub2ects it can be palpable or seen premanstrually or during

lactation.

0 well developed axillary tail sometimes mistaken for mass of enlarge lymph

nodes.

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DEEP RELATIONS OF T9E

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DEEP RELATIONS OF T9EBREAST he breast lies on the deep fascia (pectoral

fascia) covering the pectoralis ma2or.

pectoral fascia

pectoralis

ma2or


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DEEP RELATIONS OF T9EBREAST 'till deeper there are parts of four muscles,

namely pectoralis ma2or, the serratus anterior,

latissimus dorsi and external oblique muscle.

pectoralis ma2or

'erratus

anterior

latissimus dorsi external oblique


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DEEP RELATIONS OF T9EBREAST 7ocated deep to pectoralis muscle, the pectoralis minor muscle is

enclosed in clavipectoral fascia.

clavipectoral fascia

pecroralis minor

axillary fascia

clavipectoral fascia extends laterally to fuse with axillary fascia


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DEEP RELATIONS OF T9EBREAST

8reast is separated from pectoralis fascia by loose areolar tissue(retromammary space).

It is thin layer of loose areolar tissue that contains lymphatics ! small vessels.

retromammary pectorali

space minor

clavipectoral

fascia

axillary fascia

8ecause of this loose tissue the normal breast can be moved freely over the pectoralis

ma2or

S2'gi-al im%o'te(-e during removal of breast the breast is separeted from pectoral musclein plane of retromammary space.

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STR7CT7RE OF T9E BREAST 'tructure of the breast can be studied under following heading skin,

parenchyma, ! stroma.

'kin

6 nipple !

6 areola

/th I9 space

ipple erectile structure, covered with thick pigmented skin(which increases

during pregnancy)

It contains smooth muscle fiber arranged concentrically ! longitudinally.

ear its apex lies orifices of lactiferous ducts.

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A'eola epithelium of areola containsnumerous modified sweat glands and

sebacious glands.

hese glands enlarge during

pregnancy(:lands of *ontogomery).

It contains involuntary muscles arranged in

concentric rings as well as radially in

subcutaneous tissue.

ARC9ITECT7RE OF T9E

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ARC9ITECT7RE OF T9EPARENC9YMA ;arenchyma consist of $< to $

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=ifferent portions of duct system are

associated with different diseases.

7arge duct6 duct papilloma

duct ectasia

'maller duct6(during development of breast)

6 fibroadenoma

6(during involution of breast)

6 cyst formation

6 sclerosing adenosis

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T9E STROMA It forms the supporting framework of the gland. It is partly fibrous !

partly fatty

>ibrous part ?7igament of 9ooper@6hollow conical pro2ection of

fibrous tissue filled with breast tissue, the apices of cones firmly

attached to superficial fascia ! to the skin.

It anchor the skin ! gland to the pectoral fascia.

>atty stroma forms the main bulk of the gland. It is distributed all over

the breast, except beneath the areola ! nipple.

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T9E STROMA

In cancer of the breast, the malignant cells mayinvade these ligaments ! consequent contraction

of these strands may cause dimpling of the skin.

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T9E STROMA

If the underlying growth attached to the skin, it cannot be

pinched up from the lump

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T9E STROMAIf cancer cells grow along the ligament of cooper binding

the breast to the pectoral fascia breast fixed to

pectoralis ma2or

It cannot then moved in the long axis of the muscle.

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T9E STROMAIf cancer cells grow along the ligament of cooper binding

the breast to the pectoral fascia breast fixed to

pectoralis ma2or

It cannot then moved in the long axis of the muscle.

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BLOOD S7PPLY

internal thoracic art.(br. of

subclavian art)

axillary supirior thoracic artery

artery acromiothoracic artery

lateral thoracic artery

branches from intercostal artery

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Ve(o2s )'ai(age the superficial veins radiate from breast ! arecharacteried by their proximity to skin.

hey are accompanied by lymphatics ! drain to axillary, internal mammary !

intercostal vessels.

;hlebitis of one of these superficial veins feel like a cord immediately beneath

the skin. he condition produces no discoloration ! may be tensed like

bowstring by putting traction on it (*ondorAs disease). erve supply the secreting tissue is supplied by sympathetic nerves(%nd64th

intercostal nerves). he overlying skin is supplied by the ant ! lat branches

of /th, -th ! 4th intercostal nerves.

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A8ILLARY LYMP9 NODES he breast drains mainly to the axillary nodes, of which there are - sets

axillary vein

apical axillary nodes

lat ax.nodes

pectoralis minor

interpectoral nodes(Botters)

anterior axillary nodes

post ax.nodeslat thoracic v.

central axilary nodes

subscapular vein internal mammary chain

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A8ILLARY LYMP9 NODES A(te'io' set

situation6 along the lateral thoracic vein under anterior axillary fold. hey lie manly

on #rd r

he axillary tail of 'pence is in close contact with these nodes ! therefore , cancer

involving this process may be misdiagnosed as enlarged node with an apparentlyhealthy breast.

0nterior axillary nodes may be involved, by continuity of the tissue

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0CI770BD LYMP9 NODESCe(t'al set

'ituation6 in the fat of upper part of axilla.

Intercostobrachial nerve passes outwards amongst these nodes

Intercostobrachial nerve

Enlargement of these nodes(in cancer) by pressure on the nerve, cause

pain in the distribution of the nerve along the inner border of the arm.

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0CI770BD LYMP9 NODES 0pical set(infraclavicular nodes)

situation6 bounded below by $st intercostal space, behind by axillary vein, in front by

the costocoracoid membrane.

hey are of great importance because they receive one vessel directly from upper part

of the breast ! ultimately most of the lymph from the breast

0 single trunk leaves the apical group on each side of the subclavian trunk, ! enters the

2unction of 2ugular ! subclavian vein

or may 2oin the thoracic duct on the left.

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A8ILLARY LYMP9 NODES LEVELS

7evel $ lateral to lateral border of pectoralis minor

7evel #(apical groups)

7evel % (central groups)

7evel $

(lateral groups)

7evel % central axillary nodes located under pectoralis minor muscle.

7evel # subclavicular nodes medial to pectoralis minor muscle. It is difficult

to visualised ! remove unless pectoralis muscles are sacrifised or divided.

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T9E A8ILLARY FASCIAL :TENT30xillary lymph nodes are enclosed by layers of fascia which

resembles tent lying on its side

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T9E A8ILLARY FASCIAL :TENT30xillary lymph nodes are enclosed by layers of fascia which resembles tent lying on its side0nterior wall pectoralis minor ! clavipectoral fascia

;osterior wall subscapularis muscle lying on the scapula

*edial wall deep fascia covering chest wall, upper ribs, intercostal ! serratus ant muscle.

surgical importance

n. to serratus ant.

lies here

0pex points upwards !

medially where layers of

fascia comes into contact

with

each other.8ase points downwards ! laterally ! it is

open

'urgical importance 8lock dissection

of axillary lymph nodes should excise the

FtentAintact

LYMP9ATIC DRAINAGE OF T9;E

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LYMP9ATIC DRAINAGE OF T9;EBREAST Lym%hati- o+ the o6e'lyi(g s

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LYMP9ATIC DRAINAGE OF T9;EBREAST

7ymphatics of the parenchyma of the breast

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S7RGERY FOR BREAST CANCER Extended simple mastectomy

removal of all breast tissue, nipple areola

complex, ! skin 1 level $ axillary

lymph node

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S7RGERY FOR BREAST CANCER

*odified radical mastectomy


complex, ! skin 1 level $ ! level %

axillary lymph nodes.

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S7RGERY FOR BREAST CANCER

*odified radical mastectomy


complex, ! skin 1 level $ ! level %

axillary lymph nodes.

7 ill & d "i ti

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7illar: &ode "issection

• ?:picall: evels I andII

• 10 2 30 l:mp# nodes

removed• 15%0 incidence ol:mp#edema

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ti l d *i

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entinel node *iops:

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S#R$%&A' TR(AT)(*T

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Two Aspects of surgery

Mastectom, Conser%ati%e -reast sur#er,

INDICATIONS $ar'e tumor related to sie of the breast

!entral tumor beneath the areola or involvin' nipple

Multi focal disease $ocal recurrence

&atients preference

S#R$%&A' TR(AT)(*T

$ " a s t e c t o m %

Conservative breast surgery

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#mall tumor related to the sie of breast .vailability of radiotherapy facility

&atient preference

"nvolves removal of lump or tumor =ith rim of 1cm normal

breast tissue Ter! lu!pe"to!y is reserved +or operation in hi"h -enign tu!our ise."ised and large a!ount o+ nor!al -reast is not rese"ted

2emovin' the entire se'ment of the breast =hich contain thetumor

2adiotherapy to the remainin' breast tissue /uadrante"to!y, a.illary disse"tion 0 radiotherapy is non as

/#ART

D ! # O ' A # ! ' I S I O N

) * a + r a n t e c t o m %

Indications for Conser%ati%e

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E5

Indications for Conser%ati%e

Sur#er,

1 #mall breast !. F Gcm* !linically 7/ a6illary $9

+ Breast volume adequate sie to allo=

uniform dosa'e of irradiationG 2adiation therapist e6perience to avoid

dama'e of retained breast

-. %)8c)taneo)s Mastectomy:

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HG

&ipple is retained 6 or ?1s

;.

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H

umpectom:) segmental resection ort:lectom:

;istologicall: ree margin o *reast C7 D1cmE 7dvent o supervoltage radiot#erap: Lit# sMin

sparing eNect Bro+en section evaluation o margin

?o determine adjuvant c#emot#erap:adequate sampling o aillar: & Dlevel IE)curvilinear incision s#ould *e done I & DKE %%%%R adjuvant c#emot#erap:

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' A # " A S T ! ' T O " , ( A # S T

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"t includes -6cision of =hole breast

.ll a6illary lymph nodes .ll fat and fascia of the anterior chest =all

-6cision of pectoralis maHor and minor muscles

)ore "o!!only per+or!ed

(."ised )ass is "o!posed o+

Ihole breast

$ar'e portion of s3in overlies the tumor and nipple .ll fat, fascia, and lymph nodes of a6illa &ectoralis minor muscle divided or retracted Iith preservin' of a6illary vein, nerve to serratus anterior 4

lattissimus dorsi

(

+ r a + i c a l ( / a t e % m a s t e c t o

Sur#ical Mana#ement

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1AA

/. Modified !adicalMastectom,0. ate, – preserved

pectoralis maHor 1. Madden ' Auc+incloss –

preserved both thepectoralis maHor andminor

2. Total mastectom, &' or&'o radiation0. Crile – otal mastectomy1. Mc 3+irter – otal

mastectomy and radiation7.6illa,

. supraclavicular andinternal mammary nodes

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a+iot2erap%

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INDICATION

A+ter !aste"to!y igh grade tu!our 'arge nodal involve!ent )ulti+o"al disease (.tensive ly!phovas"ular invasion

AIM:

To delay the relapse To prolong the survival

Indications: 'y!ph node positive o!en oor prognosis or!onal re"eptor positive o!en ld patient

0U1ANT S,ST!"I' T-!A/,

a+iot2erap%

Ra*iothe#a1y:

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10G

1y ocal control

Pre%operative 6 post%operative radiation

Breast irradiation positioning Acute effects ofbreast irradiation

-6ternal Beam herapy

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10

-6ternal Beam herapy

(rac+,t+erap,

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10J

(rac+,t+erap,

-O"ONA# T-!A/,

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Ta!o.i+en is idely used hor!onal treat!ent

%+ pat is pre!enopausal get -ene+it +ro! 2o!g daily o+ ta!o.i+en

*e aro!atase inhi-itors i5e5anastro6ole,letro6ole et" are used i+ pat is post !enopausal

%t redu"es ris o+ "an"er in "ontra lateral -reast

ther hor!onal agents are -eing developed i5e5 'R

The ai! o+ this R. is to shrin tu!or to ena-le -reast preservingsurgery5

7 !onths "y"les o+ "y"lophospha!ide, !ethotre.ate and #

a"hieve 2; redu"tion in ris o+ relapse &he!otherapy !ay -e "onsidered in node

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C-B) C7B) C7) 7@) dooru*icin

ide eNect= nausea) vomiting) m:elosuppression)alopecia) t#rom*oc:topenia) eercise intolerance

&o#monal ?he#a1y: eceptor 7ssa: D$6PE=

1 gm o res# tissue o*tained *: using cold scalpel and s#ould *edetermined L6in 0%30 min!

$ D%E S 10 respond to endocrine a*lation or eogenousestrogen

$ DKE R G0 responds premenopausal 2 30 Donl: due to masMing eNect o endogenous

estrogenE -enopausal 2 G0

P DKE 15 o premenopausal *eneft rom 15

&o#monal ?he#a1y:

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&o#monal ?he#a1y:7. Anti0est#o"en:

a. ?amoxifen 2 a non%steroidal anti%estrogenic compound t#at compete L6estrogen at receptor site!

$strogen receptor assa: s#ould *edeterminedT i negative c#ance osuccess is ver: loL

NEOAD;7VANT SYSTEMIC T9ERAPY

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FOR OPERABLE BREAST CANCER

0dministration of systemic chemotherapy or hormonaltherapy result in reduction of tumor sie in -< to H

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OF ADVANCED BREAST CANCER

C M F 'egime( 9 G cyclophosphamide

* G methotrexate

> G - flurouracil FAC 'egime(

> G - flurouracil

0 G adriamycin(doxorubicin)

9 G cyclophosphamide

AC 'egime(

0 G adriamycin

9 6 cyclophosphamide

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NE=ER AGENTS

rastuumab is a humanied murine(5erceptin) monoclonal antibody raised

against erb 8%, 5EB %

surface receptor

7aptinib a dual inhibitor of both

6 E:>B

6 5EB %

ENDOCRINE> AGENTS 7SED IN TREATMENTOF BREAST CANCER

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OF BREAST CANCERClass Commo( e&am%les Cli(i-al 2se

'elective estrogen

receptormodulator('EB*')

amoxifen,

Baloxifen,oremifen

0d2uvant therapy for

metasttic disease

0romataseinhibitors(0Is)

0nastraole7etrooleExemestane

0d2uvant therapy formetasttic disease

;ure antiestrogen7utiniing hormone6releasinghormone(75B5)

>luvistrant:oserelin7euprolide

6%nd

line therapy formetastatic disease60d2uvant therapyfor metasttic disease

;rogestational

agents

*egestrol %nd line therapy for

metastatic disease

0ndrogens >luoxymesterone #rd line therapy formetastatic disease

5igh dose estrogens =iethylstilbestrol #rd line therapy for

metastatic disease

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tx ca mama

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