1. Breast Cancer Options Of Treatment Supervised BY: Dr. Tamimi PRESENTED BY: Dr.Naef Saleh Al haddy

2. INTRODUCTION Breast cancer is the most common site- specific cancer in women It accounts for 26% of all newly diagnosed cancers in females 15% of the cancer-related deaths in women Second leading cause of cancer-related mortality in women

3. Anatomy of breast 1- position & Extent :- 2- Breast consist of :- nipple. Areola. 3- breast divided in to :- 1) Quadrants : 2) retro areolar area. 3) axillary tail.

4. Lymphatic System

5. RISK FACTORS Genetic Factors : (S.B.C) (F.B.C) (H.B.C). Age : 85 % Of Breast Ca Occurs After The Age Of 40 Sex: 100 Times More Among Female Than Male Ethnicity Menstrual History Nulliparity Personal History Of Breast Ca Benign Breast Diseases

6. RISK FACTORS Radiation Oral Contraceptives Hormonal Replacement Therapy: (H.R.T.) Breast Feeding Obesity Alcohol Mental health Insulin-like growth factor Diet, Exercise, Smoking And Stress

7. Symptoms Hard lump –50% of such masses are found in the upper outer quarter of the breast. The nipple may be retracted,scaly or discharg skin chaneg Axillary mass Pain Systemic manfestaions

8. Diagnosis of Breast Cancer Examination (Inspection,Palpation). Imaging Techniques Mammography Ductography Ultrasonography Magnetic Resonance Imaging Breast Biopsy

9. Histopathology of Breast Cancer Carcinoma in Situ ( LCIS, DCIS) Paget's disease of the nipple Invasive ductal carcinoma Adenocarcinoma with productive fibrosis (scirrhous, simplex, NST), 80% Medullary carcinoma, 4% Mucinous, Papillary, Tubular 2% Invasive lobular carcinoma, 10% Rare (adenoid cystic, squamous cell, apocrine)

10. Staging clinical stage of breast cancer Pathologic stage @TNM Staging System @American Joint Committee on Cancer (AJCC) modification @Manchester classification

11. Stage 0 TisN0M0 Stage I T1 a N0M0 Stage IIA T0N1M0 T1 a N1M0 T2N0M0 Stage IIB T2N1M0 T3N0M0 Stage IIIA T0N2M0 T1 a N2M0 T2N2M0 T3N1M0 T3N2M0 Stage IIIB T4N0M0 T4N1M0 T4N2M0 Stage IIIC Any TN3M0 Stage IV Any TAny NM1 TNM Stage Groupings

12. TREATMENT OPTIONS

13. TREATMENT It depend upon clinical stage of the disease at the presentation including classical TMN staging and tumor grade Consists of : EE arly (Stages I & II ) AA dvanced (Stages III & IV). - Stage III is locally advanced with no distant metastases. - Stage IV is advanced with distant metastases.

14. TREATMENT Surgery, radiation or drug theraphy. Breast cancer treatment are defined as local or systemic Local: Surgery and radiation. Surgery is usually the standart initial treatment Systemic: Drug treatment

15. Cancer Stage 0IIIIIIIV History & physicalXXXXX Complete blood count, platelet count XXXX Liver function tests and alkaline phosphatase level XXXX Chest radiograph XXXX Bilateral diagnostic mammograms, ultrasound as indicated XXXXX Hormone receptor status XXXX HER-2/neu expression XXXX Bone scan a XXX Abdominal (without or without pelvis) computed tomographic scan or ultrasound or magnetic resonance imaging XX X Diagnostic Studies for Breast Cancer Patients

16. Stage 0 Also called noninvasive carcinoma or carcinoma in situ. Lobular carcinoma in situ (LCIS) include Observation Chemoprevention with tamoxifen, and Bilateral total mastectomy 25 to 35%, for invasive breast cancer a marker of increased risk

17. Stage 0 Ductal carcinoma in situ Mastectomy (>4 cm of disease or disease in more than one quadrant) BCS followed by radiotheraphy. Low-grade DCIS of the solid, cribriform, or papillary subtype that is <0.5 cm in diameter may be managed by lumpectomy alone Use of tamoxifen or other SERMs after surgery

18. Stage I and II BCT & Radiotherapy Modified radical mastectomy Adjuvant theraphy Chemotheraphy Hormonal theraphy or both Tamoxifen therapy is considered for women with hormone receptor–positive cancers that are >1 cm.

19. (IIIA or IIIB) StageIII Mastectomy with radiotheraphy and systemic treatment( chemo, hormonal theraphy or both) Neoadjuvat chemotheraphy followed by surgery + adjuvant chemotheraphy. Neoadjuvant chemo for locally advanced ca. In selected patients, neoadjuvant chemo _ BCT

20. Internal Mammary Lymph Nodes Systemic chemotherapy and radiation therapy are indicated in the treatment of grossly involved internal mammary lymph nodes. women who are at increased risk for occult involvement(cancers involving the medial aspect of the breast, axillary lymph node involvement)

21. Distant Metastases (Stage IV) Hormonal therapy for:- hormone receptor–positive cancers bone or soft tissue metastases only; and limited and asymptomatic visceral metastases Systemic chemotherapy for:- hormone receptor–negative cancers, symptomatic visceral metastases, and hormone-refractory metastases

22. Stage IV Surgical treatment for anatomic localized problems Bisphosphonates, bone metastases. Surgical resection of the local-regional disease in women with stage IV breast cancer

23. Local-Regional Recurrence Two groups Mastectomy :- surgical resection, reconstruction. Chemotherapy and antiestrogen therapy, and adjuvant radiation therapy. BCS :- mastectomy and reconstruction; Chemotherapy and antiestrogen therapy.

24. Surgical Techniques in Breast Cancer Therapy

25. Excisional Biopsy A margin of normal-appearing breast tissue. Options for local therapy Excellent scars Biopsy incision within the boundaries of the skin excision that may be required as part of a subsequent mastectomy Excisional biopsy with needle localization

26. Mastectomy and Axillary Dissection A skin-sparing mastectomy - removes all breast tissue, the nipple-areola complex, and scars from any prior biopsy procedures A total (simple) mastectomy, the nipple- areola complex, and skin An extended simple mastectomy removes all breast tissue, the nipple-areola complex, skin, and the level I axillary lymph nodes

27. Radical mastectomy (Halsted) A. Entire breast chest wall muscle is removed. and the level I, II, and III axillary lymph nodes LNs in the level 1 (B) and level 2 (C ), and even sometimes more distant lymph node groups (D, E and F) were also removed.

28. Modified radical mastectomy (MRM) Simple mastectomy, and the level I & II axillary LN The Patey modification removes the pectoralis minor muscle and allows complete dissection of the level III axillary lymph nodes

29. Breast conserving surgery called segmental mastectomy, lumpectomy, partial mastectomy, wide local excision, and tylectomy

30. BCS Involves resection of :- Primary breast cancer, Adjuvant radiation therapy, Assessment of regional lymph node status standard treatment for stage 0, I, or II IDC Women with DCIS require only tumor resection and adjuvant radiation therapy without assessment of LN

31. Contraindications T4, N2, or M1 Patients who prefer mastectomy Clinically evident multifocal/multicentric disease Difficulty in the follow up of the pat. Collagen vascular disease Large or central tumors in small breasts Women with a strong family history of breast cancer BRCA1 and BRCA2 mutation carriers. Prior radiation therapy to the breast or chest wall, Involved surgical margins or unknown margin status after re-excision,

32. Sentinel Lymph Node Dissection Early breast ca who are clinically LN –ve Combination of intraoperative gamma probe detection of radioactive colloid and visualization of isosulfan blue dye Histopathology by:- Touch preparation, Frozen-section analysis, or GeneSearch assay

33. CHEMOTHERAPY Node negative : Tumor 0.6 -1 cm with a high risk. Pt. with anther histological type and tumor >3cm Tumor >1cm +/- hormonal therapy ER+ve and T1 hormonal therapy Node positive ; Post menopausal with ER -ve Permenopausal with ER+ve +hormonal therapy Premenopausae with ER –ve.

34. Neoadjuvant Chemotherapy For operable stage IIIA neoadjuvant chemotherapy followed by surgery, followed by adjuvant radiation therapy. For inoperable stage IIIA and for stage IIIB.

35. Adverse prognostic factors (high risk) Blood vessel or lymph vessel invasion, High nuclear grade, High histologic grade, HER-2/neu overexpression, and Negative hormone receptor status

36. Neoadjuvant Endocrine Therapy Elderly women who were poor candidates for surgery or chemotherapy Has been shown to shrink tumors then BCS For women with stage IV breast cancer, an antiestrogen is the preferred therapy

37. Adjuvant Endocrine Therapy Node-negative Tumor 1 to 3 cm with ER+ve --- +/- chemo For node-positive Tumor >3 cm

38. Adjuvant hormone therapy Antiestrogen Therapy Clinical responses in ER+ve >60% & ER–ve <10% Tamoxifen therapy is also considered for women with DCIS with ER+ve Tamoxifen therapy usually is discontinued after 5 years

39. Adjuvant hormone therapy In premenopausal woman –Oophorectomy could control metastatic disease Tamoxifen –Selective estrogen receptor antagonist –Effective in pre- and post-menopausal –Effective in adjuvant setting Raloxifene

40. Adjuvant hormone therapy Aromatase inhibitor –Effective in post-menopausal state –Aromatase, in fat tissue, Convert androgen to estrogen Main estrogen source in post-menopausal –Exemestane : Aromasin –Letrozole: Femara –Anastrozole: Arimidex More effective than Tamoxifen

41. Ablative Endocrine Therapy Oophorectomy in premenopaus with skin or bony metastases after a disease-free interval that exceeded 18 months Type –Surgical ablation –RT ablation –Medical Exogenous estrogens in postmenopaus

42. Anti–Her-2/Neu Antibody Therapy Herceptin Effective in Her2+ pts In patients with tumors that overexpress HER- 2/neu,response rates appear to be better with doxorubicin-based adjuvant chemotherapy Cardiotoxicity may develop if trastuzumab is delivered concurrently with doxorubicin-based chemotherapy.

43. RADIOTHERAPY Recommended in : * After B.C.S * Stage IIIA or IIIB * L.N metastasis 4 or more. * Lymphovascular invasion. * Positive margins. Radiation therapy is used for all stages of breast cancer Adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes & boost

44. RADIOTHERAPY It is now usually given if the tumor was high grade, large, heavily node positive or if there was extensive lymphovascular invasion.

45. Treatment of metastatic dz Usual sites: bone, lung, pleura, soft tissues, and liver Incurable –Goal: live with dz for longest time Systemic treatment is mainstay –Chemotherapy –Hormone therapy Palliative local therapy –Radiotherapy –Palliative surgery

46. Prognosis Five-year survival rates for individuals with breast cancer who receive appropriate treatment are approximately: 100% for stage 0 100% for stage I 92% for stage IIA 81% for stage IIB 67% for stage IIIA 54% for stage IIIB 20% for stage IV

47. Summary Breast cancer is the most common site-specific cancer in women, 85 % After The Age Of 40 LCIS risk factor, DCIS anatomic precursor Treatment depend upon clinical stage of the disease BCS Standard treatment for stage 0, I, or II IBC Neoadjuvant & Adjuvant Chemotherapy +/- hormone therapy +/- Herceptin Radiotherapy is used for all stages of breast cancer 5 year survival rates more better with New drugs

48. THANK FOR YOUR ATTENTION