Approach to Breast Cancer Management

for mastectomy, preop psychological preparation of patients and her family is important to accept it. after surgery, if no reconstruction, prosthetic breast incorporated into cup is important.

Fischer's 

young, poor diff more likely have distal micromets on diagnosis which may reccurence. (fisher's theory- curative tx should be effective against disseminated ds by evidence 30% node negative patients relapse with distal mets)

Halsted's

cancer in old patient low mets potential diagnosed with tumour before mets (Halsted's theory- cancer spread fr focal lesion to regional nodes to bloodstream to harmatogenous mets)

10 yrs overall survivor- 74%, 20 yrs- 64% (lead-time-bias?, >improve adjuvant tx act on mets and primary)

Regional LN:

1. axillary
2. supraclavicular
3. internal mammary

Disseminated:

1. Brain: headache, epilepsy, ataxia, paresis, paraesthesia
2. Lung: usu asymp
3. pleural: effusion, SOB
4. liver: hepatomegaly, mass, jaundice, ascites
5. long bones: (skull, vetebrae, ribs, pelvis) pain, patho frac, spinal cord compression

Ix: 

tripple assessment:

clinical (history and PE)

radiological (<45yo-u/s or >45yo-mammography)

- mammagraphy (CA sensitivity 88% in old age)

2 plane cranial-caudal (CC), mediolateral oblique (MLO)

4 things to look (mass lesion, microcalcification, archetectual distortion, asymmetry)

CA feature is spiculated irregular border microcalcification (finer linear or granular)

DCIS- fine branching microcalcification

Benign feature is coarser hyperdense area with well-define margin

- u/s (CA sensitivity 85%, cyst 100%)

CA feature is irregular margin of hypoechoeic with acustic shadow, no posterior enhancement

benign tumour is hypoechoeic mass with regular margin, no posterior enhancement

cyst is most hypoechoeic with well circumscribe border with posterior enhancement

histological FNAC(95%) and core biopsy (98%)

FNAC eventually need core biopsy, if the tumour is big enough, straight core biopsy

Staging (treatment management, prognosis)

micromets cannot be detected inany reliable methods, if axillary LN affected= strongest predictor for micro mets-bone, liver, lung

contrasted CT TAP might be high to suprascapular region for LN

CXR

radioisotope bone scan

liver u/s

u/s abd

FBC

LFT 

ca153, CEA for monitoring treatment

oestrogen receptor after excise the tumour for hormonal treatment effectiveness 

Tis- in-situ (DCIS,LCIS, Paget's ds)

T1- <2cm

T2- 2-5cm

T3- >5cm

T4- any size with skin or chest wall invasion

N1-  movable ipsilat axillary LN

N2- fix ipsilat axillary LN

N3- ipsilat internal mammary nodes

M1- mets

Treatment:

Loco-regional treatment (control ds within breast and underlying chest wall)

1) surgery (mastectomy or conservative surgery)

2) radiotherapy

3) surgery+ radiotherapy

4) Breast conservative surgery:

(conservative surg done in single lesion, <3cm, 2cm away from nipple, low histo grade, no extensive in-situ, no extensive nodal involve)

5) lumpectomy, clear 1cm margin (risk of +ve resection margin)

6) wide local excision, clear 2-3cm macroscopic margin

7) quadrandectomy

Mastectomy (preserve pec mj and min) curative (wide spread DCIS) or paliative (local advances)

+/- reconstruction prosthetic or patient's tissue (transverse abdominis flap or latissimus dorsi flap)

pec minor remove for axillary LN clearence.

immediate breast reconstruction can be done via skin sparing mastectomy. breast remove via periaureolar biopsy and reconstruct via prosthetic material or tranverse rectus abdominis myocutaneous flap or lattisimus dorsi flap

breast reconstruction is greater ops and have greater morbidity. no effect on ca clearence.

Axillary Clearence

axillary nodal status= best prognostic factor. depends of the pec minor

some have skip mets

level:

1. below lower margin of pec minor
2. level of the muscle
3. above the muscle

LN sampling= excise at least 4 LN fr axillary tail/ level 1> level 2= at least 10 nodes removed> level 3 node clearence- will cause lymphoedema, pain, paraesthesia restrict shoulder mobility

if contain tumour cell, complete dissection and irradiation of axilla.

sentinel nodes biopsy (use dye to detect cancer nodes, more sensitive)

Radiotherapy:

improve loco regional control after breast conserving surg

reduce recurrence- 60%

reduce distal mets- 5%

improve survival- 10%

also give to poor differentiated with lymphovascular invasion >=4 nodes

if large tumour small local margin- give booster dose

Adjuvant systemic treatment:

when tere is occult metastasis spread which has micrometastasis, cannot be detected

Chemotherapy:

recomended in premenopause, young, with LN spread but without mets.

induce ovarian ablation

benefit to premenopausal women and under 50 yo (reduce 35%mortality  in 10 yrs)

age, menopause status, hormone receptor status.

SE: alopecia, nausea, vomiting, mucositis, neutropenia

long term: premature ovarian failure then early menopause, cardiomyopathy (anthracycline)

For your interest:
                              CMF (cyclo, metotraxate, 5-fluorouracil)

                              doxyrubicin (anthracycline)- Ab prvnt cell division

                              mets>50%:

                              taxanes- promote microtubule lead to cell death

Hormonal therapy :

ovarian ablation (LHRH analog or oophorectomy)

tamoxifen (selective action- preserve bone density and favour lipid profile)

block ER

thromembolism, endometrial ca, visual disturbance

aromatase inhibitor

inhibit syn of oestrogen in adipose tissue

Biological:

Herceptin- human monoclonal Ab to HER/neu (cerbB2) transmembrane receptor

35% response in mets, 50% reduce recurrence rate.

benifit in tumour with ER

greatest benifit in postmenopause  women (reduce mortality 30% in 10 yrs)

similar benifit in premenopause- can cause oestrogen withdrawal

normally clinically early ds can treat with curative intent but some have micromets which can progress to clinical mets

metastasis- paliative treatment

local advance:

chest wall- carcinoma en cuirasse

histological diag then neoadjuvant chemo to downgrade then operate

radio for skin, breast, chest, LN

Poor diff in young >spread to visceral organ

pul mets -pleural eff -->pleurodesis (obliterate pleural cavity by tetracyclin and bleomycin OR pleurodectomy)

liver mets --> ascites --> fulminant liver mets

Limphangitis carcinomatosa --> skin and lung

well diff, +ve ER, post menopause: >bone mets --> patho frac

lobular ca > skin, GIT mets

F/up

15% life time recurrence in other breast

>lobular ca

breast ca can occur at same time in multiple foci

f/up clinically + memography 3-5 yrs

prognosis:

50% "personal cure"

micromets can remain dormant for 35 yrs

Nottingham prognostic index : 0.2X size + histo grade + LN statue (node -ve=1, 1-3 +ve=2, 4 +ve=3)