CA Breast by Dr Zakryia

2. CA BREASTCA BREAST
BYBY
DR. ZAKARIYA RASHIDDR. ZAKARIYA RASHID

3. Diagnostic OptionsDiagnostic Options
 CBECBE
 Imaging modalities.Imaging modalities.
 Radiographic.Radiographic.
 Sonographic.Sonographic.
 Magnetic Resonance.Magnetic Resonance.
 Tissue sampling.Tissue sampling.
 For palpable massesFor palpable masses
 `FNAB`FNAB
 Core biopsyCore biopsy
 Excisional biopsyExcisional biopsy
 Incisional biopsy.Incisional biopsy.
 For non palpable massesFor non palpable masses
 Stereotactic core biopsyStereotactic core biopsy
 Vacuum assisted biopsyVacuum assisted biopsy
 Needle localization biopsyNeedle localization biopsy
 Emerging Techniques.Emerging Techniques.

4. DIAGNOSISDIAGNOSIS
 S/S involve three major compartement:S/S involve three major compartement:
 Glandular parenchyma:Glandular parenchyma:
 MassMass
 Asymmetric NodularityAsymmetric Nodularity
 PainPain
 Nipple-Areolar Complex:Nipple-Areolar Complex:
 DischargeDischarge
 RashRash
 Distortion of shapeDistortion of shape
 Breast skin:Breast skin:
 Erythema&EdemaErythema&Edema

5. MammographyMammography
 Screening mammogram:Screening mammogram:
 Annually after 40 yrs.Annually after 40 yrs.
 In pts with known BRCA mutation annually after 25-30yrs.In pts with known BRCA mutation annually after 25-30yrs.
 In pts with strong family history.In pts with strong family history.
 Grading Breast lesion:Grading Breast lesion:
 1=negative1=negative
 2=Benign appearing2=Benign appearing
 3=Probably benign lesion3=Probably benign lesion
 4=Findings suspicious of CA breast biopsy recommended.4=Findings suspicious of CA breast biopsy recommended.
 5=Highly suspicious of malignancy.5=Highly suspicious of malignancy.
 Diagnostic mammogram:Diagnostic mammogram:
 Indicated for:Indicated for:
 a questionable breast massa questionable breast mass
 To see other suspicious lesions& contralateral breast.To see other suspicious lesions& contralateral breast.
 To search for an occult CA breast in pts with metastatic axillary LN.To search for an occult CA breast in pts with metastatic axillary LN.
 To follow the females with CA breast undergoing BCT.To follow the females with CA breast undergoing BCT.
 Mammographic findings suggestive of malignancy are spiculated masses & linearMammographic findings suggestive of malignancy are spiculated masses & linear
microcalcifications & architectural pattern.microcalcifications & architectural pattern.

6. SonographicSonographic
 Differentiate between Solid and cysticDifferentiate between Solid and cystic
 USG guided FNAC from the cyst wallUSG guided FNAC from the cyst wall
 It is performed in relatively younger age group.It is performed in relatively younger age group.

7. Breast BiopsyBreast Biopsy
 For palpable masses :For palpable masses :
 F.N.A.B.F.N.A.B.
 Sensitivity is >90%.Sensitivity is >90%.
 It does not give information about grade & invasion of tumor.It does not give information about grade & invasion of tumor.
 ER & PR can be determined by immunohistochemistry.ER & PR can be determined by immunohistochemistry.
 Core Biopsy Indications include :Core Biopsy Indications include :
 Lack of concordance b/w imaging findings & histology.Lack of concordance b/w imaging findings & histology.
 ADHADH
 Radial scar.Radial scar.
 Excisional Biopsy.Excisional Biopsy.
 Incisional Biopsy.Incisional Biopsy.

8. cont.cont.
 For non palpable masses:For non palpable masses:
 Stereotactic core biopsy:Stereotactic core biopsy:
 Indications.Indications.
 Technique.Technique.
 Contra-indications.Contra-indications.
 Vacuum assisted Biopsy.Vacuum assisted Biopsy.
 NLB>NLB>
 Iodine-125 seed localization biopsy.Iodine-125 seed localization biopsy.

12. Evaluation of other Breast SymptomsEvaluation of other Breast Symptoms
 Breast Pain :Breast Pain :
 Uni-lateral.Uni-lateral.
 Focal.Focal.
 CBECBE
 USG Breast.USG Breast.
 Core tissue Biopsy.Core tissue Biopsy.
 Secondary Mammogram.Secondary Mammogram.
 Nipple Discharge.Nipple Discharge.
 It is usually unilateral, spontaneous & Bloody.It is usually unilateral, spontaneous & Bloody.
 Cytology.Cytology.
 Subareolar Excisional Biopsy is indicated in :Subareolar Excisional Biopsy is indicated in :
 When cytology reveals cellular atypia.When cytology reveals cellular atypia.
 Inrtaductal lesion seen on USG.Inrtaductal lesion seen on USG.
 Persistently discharging single duct.Persistently discharging single duct.

13. BREAST CA ;BREAST CA ;
CELLULAR,BIOCHEMICAL&MOLECULARCELLULAR,BIOCHEMICAL&MOLECULAR
BIOMARKERSBIOMARKERS..
 Breast cancer progression is the result of cumulative effect of successiveBreast cancer progression is the result of cumulative effect of successive
discrete genetic alterations lead to a gradual transition from normal todiscrete genetic alterations lead to a gradual transition from normal to
Premalignant to malignant.Premalignant to malignant.
 BRCA-1&2 .BRCA-1&2 .
 5-10% cases are caused by cancer susceptibility genes.5-10% cases are caused by cancer susceptibility genes.
 56-85% life time risk of developing breast ca.56-85% life time risk of developing breast ca.
 15-45% life time risk of ovarian ca.15-45% life time risk of ovarian ca.
 These are high grade,receptor negative and aneuploid.These are high grade,receptor negative and aneuploid.
 Strategies for prevention of ca breast in BRCA carriers include :Strategies for prevention of ca breast in BRCA carriers include :
 Prophylactic mastectomy & reconstruction.Prophylactic mastectomy & reconstruction.
 Prophylactic oophorectomy and HRT.Prophylactic oophorectomy and HRT.
 Intensive surveillance for breast ca .Intensive surveillance for breast ca .
 Chemoprevention.Chemoprevention.
 Screening mammogram.Screening mammogram.

14. Prognostic & Predictive BiomarkersPrognostic & Predictive Biomarkers
 The biomarkers are biological alterations in tissue thatThe biomarkers are biological alterations in tissue that
occur b/w initiation & cancer developement.occur b/w initiation & cancer developement.
 These are :These are :
 Proliferative changes.Proliferative changes.
 Histologic changes.Histologic changes.
 Genetic alterations.Genetic alterations.
 These include:These include:
 Proliferative markers:PCNA,Ki-67.Proliferative markers:PCNA,Ki-67.
 Apoptic indicators :bcl-2 and bax/bcl-2 ratio.Apoptic indicators :bcl-2 and bax/bcl-2 ratio.
 Angiogenic indicators :VEGF.Angiogenic indicators :VEGF.
 Growth Factor receptors :EGFr,HER-2/neu,p53.Growth Factor receptors :EGFr,HER-2/neu,p53.

15. cont.cont.
 HER-2/neu Receptor:HER-2/neu Receptor:
 HER-2/neu gene amplification carries poor prognosis.HER-2/neu gene amplification carries poor prognosis.
 Anti-HER-2/neu antibodies in combination with Taxanes.Anti-HER-2/neu antibodies in combination with Taxanes.
 Use of adenoviral E1A to suppress HER-2/neu gene transcription.Use of adenoviral E1A to suppress HER-2/neu gene transcription.
 Angiogenic Factors:Angiogenic Factors:
 VEGFVEGF
 Extracellular matrix protein receptors-------integrins.Extracellular matrix protein receptors-------integrins.
 Matrix metalloproteases.Matrix metalloproteases.
 Antiangiogenic Factors:Antiangiogenic Factors:
 Anti VEGF antibody.Anti VEGF antibody.
 VEGF receptor inhibitor.VEGF receptor inhibitor.
 MMP inhibitorsMMP inhibitors
 Antiintegrin antibody.Antiintegrin antibody.
 Vascular targeting agent-------Fixes complement and causes vasculitis.Vascular targeting agent-------Fixes complement and causes vasculitis.

16. Prognostic & Predictive Factors.Prognostic & Predictive Factors.
Tumour Factors.Tumour Factors. Host Factors.Host Factors.
Nodal statusNodal status AgeAge
Tumour sizeTumour size Menopausal statusMenopausal status
Cytologic/nuclear gradeCytologic/nuclear grade Family HistoryFamily History
Vascular invasionVascular invasion Previous breast ca.Previous breast ca.
Pathologic stagePathologic stage ImmunosuppressionImmunosuppression
HR statusHR status NutritionNutrition
DNA contentDNA content Prior chemotherapyPrior chemotherapy
Ext. Intraductal comp.Ext. Intraductal comp. Prior radiotherapyPrior radiotherapy

17. Cont.Cont.
 Nottingham PrognosticNottingham Prognostic
index:index:
 NPI=(Tumour size in cmNPI=(Tumour size in cm
x0.2)+Lymph nodex0.2)+Lymph node
stage(1=no node,2=1-3stage(1=no node,2=1-3
LN positive,3=4 or moreLN positive,3=4 or more
node involved)node involved)
+Grade(1,2 or 3).+Grade(1,2 or 3).
>5.4
2.4-5.4
<2.4

18. Ductal CA in situ.Ductal CA in situ.
 >50% of breast cancers diagnosed with screening mammograph.>50% of breast cancers diagnosed with screening mammograph.
 15-20% of all diagnosed female breast cancers.15-20% of all diagnosed female breast cancers.
 Pathophysiology:Pathophysiology:
 Pre-invasive cancer.Pre-invasive cancer.
 Two broad categories:Two broad categories:
 Comedo Type.:Comedo Type.:
 Necrotic cellular debris within duct.Necrotic cellular debris within duct.
 Numerous mitosis & large pleomorphic nuclei.Numerous mitosis & large pleomorphic nuclei.
 Absence of specific architectural changesAbsence of specific architectural changes
 Denser collection of microcalcification.Denser collection of microcalcification.
 Non-Comedo Type :Non-Comedo Type :
 Lack of central necrosis.Lack of central necrosis.
 Low mitotic rate.Low mitotic rate.
 ER-positive.ER-positive.
 Fewer microcalcification.Fewer microcalcification.
 Low ,medium & high grade.Low ,medium & high grade.

19. Prognostic Index for DCIS.Prognostic Index for DCIS.
ScoreScore 11 22 33
Size(cm)Size(cm) <1.5<1.5 1.5-41.5-4 >4>4
Margins(cm)Margins(cm) >1>1 1-0.11-0.1 <0.1<0.1
HistologyHistology Low withoutLow without
necrosisnecrosis
IntermediateIntermediate
With necrosisWith necrosis
HighHigh
gradegrade

20. DiagnosisDiagnosis
 Screening mammogram:Microcalcification.Screening mammogram:Microcalcification.
 P/C stereotactic core biopsy.P/C stereotactic core biopsy.
 Vaccum assisted aspiration biopsy.Vaccum assisted aspiration biopsy.
 Excisional biopsy:Excisional biopsy:
 1 cm Margins of the excised lesion ,beyond the extent of1 cm Margins of the excised lesion ,beyond the extent of
disease indicated by pre-operative mammography, should bedisease indicated by pre-operative mammography, should be
free of disease.free of disease.
 Excised lesions are marked at six surgical margins & shouldExcised lesions are marked at six surgical margins & should
be send for frozen-section.be send for frozen-section.
 Small titanium clips are used to mark the margins of biopsySmall titanium clips are used to mark the margins of biopsy
cavity for subsequent radiotherapy & is helpful if the re-cavity for subsequent radiotherapy & is helpful if the re-
excisiopn is required.excisiopn is required.
 Re-excision of the lesions with margins within 0.5cm of theRe-excision of the lesions with margins within 0.5cm of the
tumour.tumour.

21. Cont.Cont. Additional treatement.Additional treatement.
 Lesions <0.5cm,favourable histology clear surgicalLesions <0.5cm,favourable histology clear surgical
margins.---------close surveillance.margins.---------close surveillance.
 Lesions b/w 0.5-2.5cm, favourable histology, clear surgicalLesions b/w 0.5-2.5cm, favourable histology, clear surgical
margins.-------post op. radiotherapy.margins.-------post op. radiotherapy.
 Lesions>2.5cmLesions>2.5cm
 Wide excision with 1cm tumour free margins.+Post- op.Wide excision with 1cm tumour free margins.+Post- op.
radiotherapy.radiotherapy.
 Risk factors contributing for consideration of simpleRisk factors contributing for consideration of simple
mastectomy.mastectomy.
 Younger pts.Younger pts.
 Multifocal disease.Multifocal disease.
 Larger lesions relative to breast size.Larger lesions relative to breast size.
 Strong family history.Strong family history.
 Unfavourable histology.Unfavourable histology.

22. Cont.Cont.
 SLND:SLND:
 DCIS >2.5cm withDCIS >2.5cm with
comedo histology.comedo histology.
 Multifocal disease.Multifocal disease.
 Microinvasion.Microinvasion.
 Multicentric disease.Multicentric disease.
 Systemic adjuvantSystemic adjuvant
therapytherapy..

23. Lobular CA in situ.Lobular CA in situ.
 Hormonal Influence.Hormonal Influence.
 Higher frequency of ER-Higher frequency of ER-
positive tumours.positive tumours.
 Diagnosis is purelyDiagnosis is purely
incidental.incidental.
 Pre-malignant condition.Pre-malignant condition.
 Close surveillance.Close surveillance.
 Bilateral mastectomy.Bilateral mastectomy.
 Prophylaxis with Tamoxefin.Prophylaxis with Tamoxefin.
Lobular hyperplasia
Atypical hyperplasia
Lobular ca in situ

24. surgery
Radiotherapy
Systemic therapy

25. Surgical TherapySurgical Therapy
 Breast conservation.Breast conservation.
 Tumours upto 5cm can be managed .Tumours upto 5cm can be managed .
 Local recurrence rate after BCT & radiotherapy is less than 10%.Local recurrence rate after BCT & radiotherapy is less than 10%.
 Pts with recurrence require mastectomy and less often re-excision.Pts with recurrence require mastectomy and less often re-excision.
 Lumpectomy without radiation has higher recurrence but can be avoidedLumpectomy without radiation has higher recurrence but can be avoided
in low risk pts like:in low risk pts like:
 Low grade.Low grade.
 Small size.Small size.
 Adequate resection margins.Adequate resection margins.
 Special histologic Type.Special histologic Type.
 Presence of good prognostic features in Primary cancers.Presence of good prognostic features in Primary cancers.
 Negative SLNB.Negative SLNB.

26. Cont.Cont.
 Contra-indications:Contra-indications:
 Larger tumours in relatively small breast.Larger tumours in relatively small breast.
 Females previously irradiated.Females previously irradiated.
 Multifocal &Multicentric.Multifocal &Multicentric.
 Pregnancy.Pregnancy.
 Collagen vascular disease.Collagen vascular disease.
 Positive resection margins.Positive resection margins.
 Pts with BRCAI & II.Pts with BRCAI & II.

27. Cont.Cont.
 BCT with radiotherapy:BCT with radiotherapy:
 In all cases <45yrs.In all cases <45yrs.
 >45yrs------tumour >1cm.>45yrs------tumour >1cm.
 BCT without radiotherapy:BCT without radiotherapy:
 >45yrs.>45yrs.
 <1cm.<1cm.
 Well differentiated.Well differentiated.
 Tubular,Papillary,Mucinous.Tubular,Papillary,Mucinous.
 Types of BCT :Types of BCT :
 Wide local Excision.Wide local Excision.
 Segmentectomy.Segmentectomy.
 Quadrentectomy.Quadrentectomy.
 Needle localization Excision for impalpable tumour.Needle localization Excision for impalpable tumour.

28. Axillary Surgery.Axillary Surgery.
 Axillary LN status is important prognostic factor for survival.Axillary LN status is important prognostic factor for survival.
 Clinically palpable LN.Clinically palpable LN.
 F.N.A.C. to confirm.F.N.A.C. to confirm.
 Neo-adjuvant chemotherapy.Neo-adjuvant chemotherapy.
 Axillary clearance-upto level III.Axillary clearance-upto level III.
 Complications.Complications.
 Post op. radiotherapy .Post op. radiotherapy .
 Clinically negative LN.Clinically negative LN.
 No axillary evaluation is required in pts with low risk for axillaryNo axillary evaluation is required in pts with low risk for axillary
metastasis(<5%) which includes tumours <1cm,tubular,mucinous &metastasis(<5%) which includes tumours <1cm,tubular,mucinous &
papillary variety and elderly females with small cancer.papillary variety and elderly females with small cancer.
 In all other pts with invasive carcinoma:SLNB & ALNS.In all other pts with invasive carcinoma:SLNB & ALNS.

29. Cont.Cont.
 SLNB:SLNB:
 Indications:Indications:
 Early invasive & node negative.Early invasive & node negative.
 Procedure.Procedure.
 Complications.Complications.
 Contra-Indications.Contra-Indications.
 Pre-operative chemotherapy & radiotherapy.Pre-operative chemotherapy & radiotherapy.

30. EVALUATION OF LYMPHEVALUATION OF LYMPH
NODESNODES

31. Adjuvant Systemic TherapyAdjuvant Systemic Therapy
 Pts. are at risk of developing either local or distant metastasis.Pts. are at risk of developing either local or distant metastasis.
 Risk is assessed from different prognostic factors:Risk is assessed from different prognostic factors:
 Size.Size.
 LN status.LN status.
 Estrogen Receptor status.Estrogen Receptor status.
 Grade.Grade.
 Lymphovascular invasion.Lymphovascular invasion.
 Aim is to eliminate micrometastasis,thus reducing the risk ofAim is to eliminate micrometastasis,thus reducing the risk of
recurrence & metastasis.recurrence & metastasis.
 Treatement can be given in the form of:Treatement can be given in the form of:
 Adjuvant.Adjuvant.
 Neo-adjuvant.Neo-adjuvant.

32. Currently available treatement optionsCurrently available treatement options..
 ChemotherapyChemotherapy
 Hormone therapyHormone therapy
 Biological TherapyBiological Therapy

33. Cont.Cont.
 Decision is based on:Decision is based on:
 Disease related factors:Disease related factors:
 Tumour size.Tumour size.
 LN status.LN status.
 Lymphovascu;ar invasion.Lymphovascu;ar invasion.
 Receptor status.Receptor status.
 Grade.Grade.
 Pt related factors:Pt related factors:
 AgeAge
 Menopause.Menopause.
 Fitness.Fitness.

34. ChemotherapyChemotherapy
 Benefit is independent of nodal & menopausal status.Benefit is independent of nodal & menopausal status.
 Absolute improvement is more for node positive pt.Absolute improvement is more for node positive pt.
 Benefit is less for pts >70yrs.Benefit is less for pts >70yrs.
 Combinations used:Combinations used:
 CMF.CMF.
 MF.MF.
 CAF.CAF.
 AC-----TAC-----T
 Adverse effects.Adverse effects.
 G.I. disturbance.G.I. disturbance.
 Alopecia.Alopecia.
 Hematological suppression.Hematological suppression.
 Fertility and ovarian function is affected >40yrs in Cyclophosphamide containingFertility and ovarian function is affected >40yrs in Cyclophosphamide containing
regimens.regimens.
 Induction of second cancers(hematological).Induction of second cancers(hematological).
 Cardiac ToxicityCardiac Toxicity

35. EndocrineEndocrine
TherapyTherapy

36. Drugs Targeting Estrogen and It’sDrugs Targeting Estrogen and It’s
Receptor in Breast CancerReceptor in Breast Cancer
EstrogenEstrogen
CellCell
GrowthGrowth
andand
DivisionDivision
Estrogen
Receptor
SERMS (tamoxifen,SERMS (tamoxifen,
raloxifene), SERDSraloxifene), SERDS
(fulvstrant)(fulvstrant)
AromataseAromatase
inhibitors, ovarianinhibitors, ovarian
suppressionsuppression

37. Hormonal TherapyHormonal Therapy
 Tamoxefin.Tamoxefin.
 Beneficial in pts with ER+ve irrespective ofBeneficial in pts with ER+ve irrespective of
 Age.Age.
 LN status.LN status.
 Menopausal.Menopausal.
 For older pts adding CT is not helpful due to additionalFor older pts adding CT is not helpful due to additional
toxicity.toxicity.
 Adverse effects:Adverse effects:
 Vasomotor Symptoms.Vasomotor Symptoms.
 Decrease cholesterol.Decrease cholesterol.
 Increase thrombosis.Increase thrombosis.
 Bone loss in pre-menopausal pts.Bone loss in pre-menopausal pts.
 Bone protecting in post-menopausal pts.Bone protecting in post-menopausal pts.

38. Cont.Cont.
 Ovarian ablation.Ovarian ablation.
 In pre-menopausal pts.In pre-menopausal pts.
 Benefit is independent of nodal status.Benefit is independent of nodal status.
 Methods :Methods :
 Surgery.Surgery.
 Radiation.Radiation.
 LHRH agonists.LHRH agonists.
 It exists as an alternative to CT or as optimal endocrineIt exists as an alternative to CT or as optimal endocrine
therapy.therapy.
 Treatement by LHRH agonist (Goserelin) in S/C depotsTreatement by LHRH agonist (Goserelin) in S/C depots
monthly.monthly.
 Treatement is reversible with preservation of fertility.Treatement is reversible with preservation of fertility.
 Menopausal symptoms.Menopausal symptoms.

39. Cont.Cont.
 Aromatase inhibitor:(Anastrozole)Aromatase inhibitor:(Anastrozole)
 Beneficial in post-menopausal females.Beneficial in post-menopausal females.
 It inhibits the conversion of adrenal androgens into estradiolIt inhibits the conversion of adrenal androgens into estradiol
and estrone.and estrone.
 Less severe side-effects.Less severe side-effects.
 Increase risk of fractures due to effect in bone mineralIncrease risk of fractures due to effect in bone mineral
density.density.
 Alternative first line therapy where potential risk forAlternative first line therapy where potential risk for
Tamoxefin is present.Tamoxefin is present.
 Switching to aromatase inhibitor after 2-3 yr use ofSwitching to aromatase inhibitor after 2-3 yr use of
Tamoxefin.Tamoxefin.

40. Aromatase InhibitorsAromatase Inhibitors
Adrenal HormonesAdrenal Hormones
CortisolCortisol AndrostenedioneAndrostenedione AldosteroneAldosterone
EstradiolEstradiol
TestosteroneTestosteroneEstroneEstrone
Aromatase inhibitors blockAromatase inhibitors block
post-menopausal estrogenpost-menopausal estrogen
productionproduction
Anastrozole (Arimidex)Anastrozole (Arimidex)
Letrozole (Femara)Letrozole (Femara)
Exemestane (Aromasin)Exemestane (Aromasin)

41. Biological TherapyBiological Therapy
 Target the factors which allow the cancer cells toTarget the factors which allow the cancer cells to
grow and survive and spreadgrow and survive and spread
 . Adjuvant therapy containing Doxorubicin is. Adjuvant therapy containing Doxorubicin is
effective.effective.
 Anti-HER-2/neu antibodies in combination withAnti-HER-2/neu antibodies in combination with
Taxanes.Taxanes.
 Use of adenoviral E1A to suppress HER-2/neuUse of adenoviral E1A to suppress HER-2/neu
gene transcriptiongene transcription

42. The HER Family ofThe HER Family of
ReceptorsReceptors
HER1
EGFR
HER2 HER3
HER4
Tumor CellTumor Cell
•Trastuzumab (Herceptin)Trastuzumab (Herceptin)
•Pertuzumab (Omnitarg)Pertuzumab (Omnitarg)
•LapatinibLapatinib
•Erlotinib (Tarceva)Erlotinib (Tarceva)
•Gefitinib (Iressa)Gefitinib (Iressa)
•Cetuximab (Erbitux)Cetuximab (Erbitux)

43. Drugs Targeting HER-2 in Breast CancerDrugs Targeting HER-2 in Breast Cancer
HER-2
nucleus
cancer cell
cell division
Trastuzumab (Herceptin)
Anti-HER-2 Antibody (IV)
HER-2 Oncogene: overexpressed inHER-2 Oncogene: overexpressed in
20-25% of breast cancers20-25% of breast cancers
Lapatinib (Tykerb)
Dual HER-1/HER-2 (oral)
Tyrosine Kinase Inhibitor

45. Multidisciplinary Cancer Breast Management
Natural History of DiseaseNatural History of Disease
• • Most cases of stage III breast cancer were onceMost cases of stage III breast cancer were once
stage I breast cancerstage I breast cancer
•• In poor countries, more than half of patients haveIn poor countries, more than half of patients have
locally advanced or metastatic disease at the time oflocally advanced or metastatic disease at the time of
diagnosisdiagnosis
–– Lack of educationLack of education
–– Lack of screeningLack of screening

46. Multidisciplinary Cancer Breast Management
Clinical Presentation ofClinical Presentation of
Stage III Breast CancerStage III Breast Cancer
Peau d’orange Large mass, edema, and erythema

47. Multidisciplinary Cancer Breast Management
Clinical Presentation of Stage III, Locally
Advanced (Inoperable) Disease
Large primary breast cancer Locally advanced breast cancer

48. Multidisciplinary Cancer Breast Management
Stage Classifications for Locally
Advanced Breast Cancer
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0

49. Multidisciplinary Cancer Breast Management
Stage Classifications for Locally
Advanced Breast Cancer (cont.)
Stage IIIB T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1

50. Locally Advanced CarcinomaLocally Advanced Carcinoma
 Stage lll and Inflammatory breast Carcinoma.Stage lll and Inflammatory breast Carcinoma.
 Combination CT (CAF)has dramatic regressionCombination CT (CAF)has dramatic regression
of breast lesion in 65-70% percent of cases.of breast lesion in 65-70% percent of cases.
 With induction responses following 2-6 drugWith induction responses following 2-6 drug
cycles an extended simple mastectomy with levelcycles an extended simple mastectomy with level
l nodal dissection should be done.l nodal dissection should be done.
 Peripheral lymphatics,skin flaps and central andPeripheral lymphatics,skin flaps and central and
apical LN group are treated with comprehensiveapical LN group are treated with comprehensive
radiation therapy.radiation therapy.

51. Cont.Cont.
 Multimodal approach in stage lll decreases theMultimodal approach in stage lll decreases the
chest wall recurrence to 4-10%.chest wall recurrence to 4-10%.
 And improve the 5 year survival to 45 %.And improve the 5 year survival to 45 %.
 ,and 10 year survival to 28 %.,and 10 year survival to 28 %.

52. Multidisciplinary Cancer Breast Management
Neoadjuvant Chemotherapy
•Concept developed concurrently with adjuvant
chemotherapy in the 1970s
•Treatment for locally advanced breast cancer
(stage III disease)
•Allows for immediate assessment of tumor response
•Allows for the evaluation of new and novel agents

53. Multidisciplinary Cancer Breast Management
Neoadjuvant Chemotherapy (cont.)
•Goals:
– Decrease tumor size
– Minimize surgery
– Establish tumor sensitivity
•Appropriate treatments:
– Chemotherapy
– Tamoxifen or aromatase inhibitors
– Radiation therapy

54. Multidisciplinary Cancer Breast Management
Clinical Rationale for Preoperative Chemotherapy:
•Excellent response rates for locally advanced breast cancer
• Efficacy of adjuvant chemotherapy for node- negative
breast cancer
• Equivalent survival for breast-conserving surgery and
mastectomy

55. Multidisciplinary Cancer Breast Management
Advantages of
Neoadjuvant Chemotherapy
•Increased rate of breast-conserving surgery
•Earlier treatment of micrometastases
•Treatment serves as in vivo chemosensitivity assay
•Improved rates of local control and disease-free survival

56. Multidisciplinary Cancer Breast Management
Factors Influencing Decision to Use
Neoadjuvant Chemotherapy in Operable Breast
Cancer
•Does the patient need adjuvant chemotherapy based
on information known prior to surgery?
•Would neoadjuvant chemotherapy potentially alter
the extent of resection?
•Does the patient desire breast preservation?
•Would treatment benefit from knowledge of in vivo
chemosensitivity?

57. Multidisciplinary Cancer Breast Management
Radiation Therapy after Mastectomy
According to Consensus Statement developed by
American Society for Therapeutic Radiology and
Oncology (ASTRO)
•Radiation therapy should be part of the treatment for stage
III breast cancers and for disease that involves four or more lymph
nodes
•At a minimum, the chest wall and the supraclavicular fossa should
be treated with doses of at least 50 Gy

59. Oncoplastic Breast Surgery(OBS)Oncoplastic Breast Surgery(OBS)
 It includes all approaches of plastic and Re-It includes all approaches of plastic and Re-
constructive surgery aimed at achieving tumourconstructive surgery aimed at achieving tumour
resection with satisfactory margins inresection with satisfactory margins in
conservative treatement.conservative treatement.
 It attempted to minimize potential deformitiesIt attempted to minimize potential deformities
and to obtain best possible cosmeticand to obtain best possible cosmetic
results,without compromising resection marginsresults,without compromising resection margins

60. ClassificationClassification
 Post-mastectomy breast re-constructionPost-mastectomy breast re-construction
 ImmediateImmediate
 DelayedDelayed
 Conservative Post surgery Breast Re-Conservative Post surgery Breast Re-
constructionconstruction
 ImmediateImmediate
 DelayedDelayed
 Re-construction of chest wall and soft tissueRe-construction of chest wall and soft tissue
deformities after surgical treatement of LABCdeformities after surgical treatement of LABC
and extensive local recurrence.and extensive local recurrence.