Ca breast management (according to NCCN guidelines)

CA BREAST MANAGEMENT

(RECENT GUIDELINES)

BYDR. PIRAH KORAI

fcps-ii traineeg. surgery

cmc larkana

Outlines

• Epidemiology of CA Breast

• Clinical manifestations

• Management according to NCCN guidelines

(Stage-wise)

BREAST CANCER IN THE WORLD

Breast cancer is second only to lung cancer as a cause of cancer deaths

1.15 million new cases

470 000 deaths

Half of the global burden in low- and medium-resourced countries

CLINICAL MANIFESTATIONS

5

Most common: lump or thickening in breast. Often painless

Change in color or appearance of areola

Redness or pitting of skin over the breast, like the skin of an orange

Discharge or bleeding

Change in size or contours of breast

MANAGEMENT

American Joint Committee on Cancer

t< 2 cm,no nodes

t 2 to 5 cm, +/-nodes

matted lymph nodes,variable tumor size

distant metastases

STAGE-WISE MANAGEMENT ( ACCORDING TO NCCN GUIDELINES)

MANAGEMENT OF LCIS

BIOPSY:• FNA• Core Biopsy• Incisional biopsy• Excisional biopsy (Tumor + surgical margins)

ADVISES For RISK REDUCTION:

• Modify life style• Hormonal Therapy: Anti-estrogen• Surgery• Follow-up care

SURGERIES

B/L Simple Mastectomy with reconstruction surgery

Indication:

•Family history of CA Breast•Relatives having mutations in BRCA1 and BRCA2•Ovarian cancer

FOLLOW-UP

•Mammography: every year after age of 50

•CBE: every 6 to 12 months

•Self examination awareness

•Breast MRI

Ductal Carcinoma in situ (DCIS)

13Illustration © Mary K. Bryson

Ductal cancer cells

Normal ductal cell

• Medical history

• Physical examination

• Diagnostic mammography

• Biopsy

• Hormone receptor test

• Genetic counseling

Management

• Lumpectomy alone

• Lumpectomy with radiotherapy (EBRT)– (Breast conserving therapy)

• Total Mastectomy – (with or without breast reconstruction)

• Sentinel lymph node biopsy

BREAST RECONSTRUCTION

BREAST RECONSTRUCTION

• After Lumpectomy– Volume displacement

• After mastectomy– Skin sparing mastectomy– Time for reconstruction

Types of reconstruction

• Implants

• Flaps

• Both

Nipple Replacement

• Remade nipple:– From surrounding tissue– Vulva– Thigh– Other nipple

• fake nipple

Choice between

Breast conserving surgery

/ Breast reconstruction

Breast conserving surgery

–Pros• Skin’s natural look is kept• Quicker healing• Intact sensation so better

psychological satisfaction

–Cons• Asymmetry• Radiation required• May need second surgery

Breast reconstruction

–Pros• Reconstruct whole breast• Less worry about recurrence• Less likely to need radiation

–Cons• Loss of breast• Longer healing• Serious side effects e.g: edema

RISK REDUCTION

Modify life style

Hormonal therapy

Follow-up• Mammography (every 6months)• CBE• Self examination• Breast MRI

STAGE i & STAGE ii

Invasive Lobular Carcinoma (ILC)

27Illustration © Mary K. Bryson

Lobular cancer cells breaking through the wall

WORK-UP• Medical history

• Physical examination

• Blood test: CBC, LFTs

• Imaging: – mammography, – u/s,– MRI,– bone scan,– CT Chest, – Abdominal/pelvic CT scans

• C.A cell tests: – Hormone receptor tests– HER2 receptor test

• Lymph node biopsy

• Genetic counseling

• Fertility counseling

SURGERIES

• Breast conservative surgery: Lumpectomy

• Total mastectomy

(With or without breast reconstruction)

• Surgeries for Lymph node– Sentinel lymph node dissection– Axillary dissection

NEOADJUVANT THERAPY

• Chemotherapy

• Radiotherapy

-In whole breast

-Partial breast

• Hormonal therapy

STAGE iii

• INVESTIGATIONS

• SURGERIES

– BCT: Lumpectomy with radiation

– Total mastectomy (with or without breast reconstruction)

– Lymph nodes dissection

TREATMENT OPTIONS

• Hormonal therapy

• Chemotherapy

• Targeted therapy

HORMONAL THERAPY

• Anti-estrogen: Tamoxifen and Toremifene

• Aromatase inhibitors:

• Hormones: high dose megestrol acetate, flurymesterone, ethinyl estradiol

• Ovarian ablation (through B/L oophrectomy or radiation)

• Ovarian suppression: LNRH agonist e.g: Goserelin, Leuprolide

CHEMOTHERAPY

• Alkylating agents:– carboplatin, cisplatin, cyclophosphamide

• Anthracyclins: – Doxorubicin, epirubicin

• Antimetabolites: – flurouracil, methotraxate, gematabine etc

• Microtubule inhibitors: – Docetexal, emtansine, eribulin, paclitaxel

TARGETED THERAPY

• Trastuzumab and pertuzumab

• Ado-transluzmab

• Lapatinib

• Bevicizumab

• everolimus

SUPPORTIVE TREATMENT

• Bisphosphonates

• Vitamin D

• Calcium etc

QUESTIONS