BREAST CANCER: EXPERIENCE IN UBTH DR IROWA O.O. DEPT OF SURGERY UBTH ( PRESENTATION AT MDT)

OUTLINE INTRODUCTION CLINICAL PRESENTATION OF BBREAST CANCER INVESTIGATIONS STAGING TREATMENT PLAN/SCHEDULE CASE SUMMARIES LIMITATIONS/CHALLENGES CONCLUSION

INTRODUCTION Breast cancer is the commonest malignancy among women worldwide It constitute 25% of all female cancers Usually affects women in their 5th decade of life 1.7Millon diagnosed in 2012;53% in the developing world and more than half a Million deaths. In Nigeria— the commonest malignancy in Ibadan and Benin About 77% present with late stage disease

CLINICAL PRESENTATION OF BREAST CANCER A lump in the breast Swelling in the axilla Breast ulcer/Sore Pain in the breast Cough/Chest pain/Difficulty in breathing Bone pain Scalp swelling Headaches/seizures Abdominal swelling Yellowness of the eyes Etc

INVESTIGATIONS Breast USS Mammography Breast Biopsy Histology, Grade, IHC (ER,PR, Her2, Ki67) CXR LFT CT Scan –TAP, Brain Skeletal Survey/ Bone Scan MRI PET Scan

STAGING TNM Classification/Staging –Anatomic in nature Based on the above there is the Early and Late disease Early disease—confined to the breast/ axilla Late disease –Beyond the breast; skin , axilla and distant sites BIOLOGIC STAGING (Gene expression profiling)– Focuses on the behavior of the caner cells

TREATMENT PLAN/ SCHEDULE Neoadjuvant Chemotherapy Surgery (Mastectomy) Adjuvant Chemotherapy Radiation Therapy Hormonal Therapy / Targeted Therapy

Case Summary 1 There were no symptoms suggestive of distant spread I.J a 54yr old woman presented with a painless lump which she noticed 3months ago. She has 6 children and 8 years postmenopausal. No prior breast lesion/biopsy No family history of breast cancer/other cancers She does not smoke or drink alcohol There were no symptoms suggestive of distant spread She is hypertensive and well controlled with medication

Case Summary 1 She presented to the SOPD based on a referral from GPC On Examination—A middle aged woman, afebrile, not pale anicteric, no peripheral oedema. Breast: A mass in the inner upper quadrant of the left breast, no tenderness/differential warmth.Not attached to the skin or fixed to the chest wall.The mass measures 2cm by 3cm. The left axillary lymph nodes were discrete (mainly Anterior group) with the largest measuring 1cm by 1cm Systemic examination were normal

Case Summary 1 Mammography—BIRADS 4, Right breast normal Incisional biopsy –Invasive ductal carcinoma, ER and PR positive. Her2 negative CXR, LFT, ABD USS were normal TNM classification/Staging– T2N1Mo (stage 2) She had Left modified radical mastectomy and subsequent adjuvant chemotherapy She completed a 5 year course of Letrozole She 8 years pos t therapy; alive and well

Case Summary 2 O.D, a 44yr old foodstuff seller who lives in Benin, a christian and Bini. Presented with an 8months history of right breast lump noticed during SBE and has increased in size since noticed. There was yellowish nipple discharge but no sores in the breast. She developed pain in the right axilla 1 month before presentation

Case Summary She is Para 2,menarche at 15yrs and LMP1/1/16. No previous breast lump. No family history of breast cancer or other malignancies. No previous gynae/colonic surgeries. No use of OCP. She does not smoke or drink alcohol No symptoms suggestive of metastasis at presentation

Case Summary She had presented in CDC 7months earlier with a month history right breast lump and a breast USS done revealed features of mitotic lesion but she defaulted on the ground of financial difficulty. She was referred to SOPD when she represented in CDC. Examination revealed a middle aged woman , afebrile , not pale, anicteric, not dehydrated

Case Summary Breast examination revealed a mass occupying the right breast, no differential warmth, non tender, hard with skin attachment, not fixed to the chest wall and measures 18×14cm.The right axillary lymph nodes were matted. The left breast was normal. Systemic examination were normal. A provisional diagnosis of mitotic disease of the right breast was made.

Case Summary Mammography done(21/1/16) revealed features of right breast cancer. BIRADS 5. The left breast was normal. (1 week after 1st visit) Incisional biopsy was done on the 25/1/16 and histology report received on the 25/2/16 –Invasive ductal carcinoma.Nottingham grade III. IHC to follow. The breast ulcerated following incisional biopsy and wound dressings/antibiotic commenced.

Case Summary Chest X-ray, Abdominal USS and LFT were normal. A diagnosis of invasive ductal carcinoma of the right breast was made - T4bN2M0 She commenced neoadjuvant chemotherapy after a delay of 3weeks due to financial constraints. She has had 2cycles of FEC regimen(based on financial difficulty).

Case Summary Review 1 week ago in SOPD revealed development of skin nodules along with the previous ulceration in the right breast with ipsilateral supraclavicular nodes. The left breast now has a mass in the upper outer quadrant-4×5cm in diam,peau d’orange,matted left axillary lymph nodes and supraclavicular lymph nodes .

Case Summary A new diagnosis of bilateral breast cancer/Tumour progression and non response to chemotherapy was made. She has been counseled on the need to change chemotherapy to taxen based regimen. Awaiting restaging of the disease.

Case summary

INVESTIGATIONS Mammography : BIRADS 5 Incisional Biopsy /Histology : Invasive ductal carcinoma CXR/ABD USS :normal FBC, LFT, E/U+Cr :normal

DIAGNOSIS INVASIVE DUCTAL CARCINOMA OF THE RIGHT BREAST (T4bN2MO)

TREATMENT THUS FAR Two(2) cycles of Cyclophoshamide ,5 FU and Epirubicin regimen and then defaulted. She presented 3months after with difficulty with breathing due to lung metastsis She had a cycle of Taxen based regimen with some response but never presented back to hospital following discharge

LIMITATIONS/CHALLENGES Late presentation Financial difficulty Rapidly progressive disease

SOLUTIONS/PROPOSITIONS

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