Breast Cancer by SOPHIA MWALE - Oncology-unza

BREAST CANCER PRESENTER: SOPHIA MWALE MODERATOR: DR MWANZA OUTLINE Introduction Risk factors Clinical presentation Diagnosis Staging treatment Introduction Breast cancer is a malignant proliferation of epithelial cells lining the ducts and lobules of the breast. Leading cause of cancer death in women worldwide. Second most common cancer in Zambia RISK FACTORS Female gender (F>M) m=1% Increasing age Genes- BRCA – 1 and BRCA-2 Positive family history – breast, cervical, ovarian Reproductive factors – early menarche , late menopause, nulliparity,elderly primigravida birth control pills Alcohol,smoking Obesity - postmenopausal Use hormonal replacement therapy. Clinical presentation Breast mass Change in size and shape Skin changes : erythema, thickening or dimpling of overlying skin, peu d’orange Nipple changes 7Ds : discharge, discolouration,deviated,deppression, duplicated,displacement,destroyed Symptoms of Mets dependent on organ involved Bone – back or leg pain Liver – abdominal pain, jaundice, nausea Lungs - dyspnea , cough Pathology Most breast malignancies arise from epithelial lining and are categorized as carcinomas. The in situ carcinomas are either ductual or lobular The invasive breast carcinomas consist of several histologic subtypes. LCIS is no longer considered a cancer but a risk lesion DUCTAL CARCINOMA IN SITU (DCIS) Malignant proliferation of cells in ducts with no invasion of the basement membrane Often detected as calcification on mammography; DCIS does not usually produce a mass. Mammographic calcifications can also be associated with benign conditions such as fibrocystic changes (especially sclerosing adenosis) and fat necrosis. Biopsy of calcification necessary to distinguish them Histologic subtypes are based on architecture; comedo type is characterized by high-grade cells with necrosis and dystrophic calcification in the center of ducts . Paget disease of the breast is DCIS that extends up the ducts to involve the skin of the nipple Presents as nipple ulceration and erythema Paget disease of the breast is almost always associated with an underlying carcinoma. INVASIVE DUCTAL CARCINOMA Invasive carcinoma that classically forms duct-like structures Most common type of invasive carcinoma in the breast, accounting for > 80% of cases Presents as a mass detected by physical exam or by mammography Advanced tumors may result in dimpling of the skin or retraction of the nipple. Biopsy usually shows duct-like structures in a desmoplastic stroma; special subtypes of invasive ductal carcinoma include Tubular carcinoma-characterized by well-differentiated tubules that lack myoepithelial cells relatively good prognosis Mucinous carcinoma-characterized by carcinoma with abundant extracellular mucin. Medullary carcinoma-characterized by large, high-grade cells growing in sheets with associated lymphocytes and plasma. Relatively good prognosis,Increased incidence in BRCA1 carriers Inflammatory carcinoma-characterized by carcinoma in dermal lymphatics Presents classically as an inflamed, swollen breast (tumor cells block drainage of lymphatics) with no discrete mass; can be mistaken for acute mastitis Poor prognosis LOBULAR CARCINOMA IN SITU (LCIS) Malignant proliferation of cells in lobules with no invasion of the basement membrane LCIS does not produce a mass or calcifications and is usually discovered incidentally on biopsy. Characterized by dyscohesive cells lacking E-cadherin adhesion protein D. Often multifocal and bilateral E. Treatment is tamoxifen (to reduce the risk of subsequent carcinoma) and close follow-up; low risk of progression to invasive carcinoma INVASIVE LOBULAR CARCINOMA Invasive carcinoma that characteristically grows in a single-file pattern cells may exhibit signet-ring morphology. No duct formation due to lack of E-cadherin Diagnosis Tripple assessment Clinical hx + exam imaging mammogram >35y or U/S <35y, bone scan, x-ray for mets – brain,chest,bones, ct III. histology/cytology FNA or core needle Before biopsy – mammography/U/S, Chest radiography After positive biopsy Bone scan indicated for stage 2 and 3 disease CBC ,blood chemistry Other studies *Hormone receptor status (ER, PR) *HER2/neu status *Consider genetic counselling/BRCA testing in selected cases Screening Breast self exam Clinical self exam Mammography Ultrasound Mri Staging International TNM staging Tumor T0- Not palpable Tis- tumour in situ T1 – tumour 2cm, not fixed/tethering T2 – tumour 2-5cm, nipple retraction or tethering T3 – 5-10cm, infiltration or ulceration T4 – Any size invading skin or chest wall (10cm) , ulceration greater than the distance of lump. Node N0 – No palpable ALNs N1 – mobile palpable ALNs N2 –fixed palpable ALN N3 – palpable supraclavicular ALNs Distant metastasis M0 – no distant metastasis M1 – metastasis distant Treatment Treatments exist for every type and stage of breast …