BREAST CARCINOMA SEMINAR

1. METASTATIC
BREAST
CARCINOMA
SHAFAQUE MARIAM

2. CONTENTS
 Introduction
 Sites of metastasis
 Treatment approach
 Breast cancer during pregnancy
 Paget’s disease of nipple
 Inflammatory breast carcinoma

3. INTRODUCTION
 Metastasis can be :
limited
extensive disease or visceral crisis
 Mode of spread
haematogenous
lymphatics

4. SITES OF METASTASIS
BONE
 Most common site(70%)
 Vertebrae, femur, pelvis, upper end of
humerus and ribs.
 Spread to vertebra through posterior
intercostal vein and Batson’s venous
plexus.
 Pathological fractures can occur.
 Spinal compression and paraplegia.

5. LUNGS AND PLEURA
 Causes Cannon ball secondaries, effusion,
consolidation and chest wall secondaries.
 Respiratory distress and failure
 HRCT ideal diagnostic tool.
 Signifies terminal event.
 Poor prognosis.

6. LIVER- secondaries present with jaundice,
elevated liver enzymes, abdominal pain, loss of appetite,
nausea, and vomiting
BRAIN- secondaries present with features of
headache, convulsions, vomiting
 Ascites , Krukenberg’s tumours, rectovesical deposits.
 Soft tissue secondaries have better prognosis visceral
ones worst prognosis.

7. TREATMENT APPROACH
Disease with :
1. limited metastases
2. Positive hormone receptors and hormone response
3. Disease free interval ≥ 2 years
Hormonal therapy—if responsive—second line hormonal
therapy if disease progresses

8. Disease with :
1. Extensive metastasis and visceral crisis
2. Negative hormone receptor and no hormone
response.
Chemotherapy –if disease progresses— second-line
chemotherapy

9.  Symptoms per se (e.g. Breathlessness) are not in
themselves an indication for chemotherapy.
 Women with stage IV cancer may develop
anatomically localised problems that will benefit from
individualised surgical or radiation treatment such as
pleural effusion ,pericardial effusion, brain metastasis,
ureteric obstruction, biliary obstruction or pathological
fractures
 Bisphosphonates given additionally in case of bone
metastasis.

10. CHEMOTHERAPY
CYTOTOXIC
First line drugs :
 Methotrexate
 Cyclophosphamide
 Thiotepa
 Vinblastine5-fluorouracil
 Doxorubicin

11. Second and Third line drugs :
 Paclitaxel
 Docitaxel
 Capecitabine
 Capecitabine and docitaxel
 Abraxane
 ixabepilone

12. BIOLOGICAL TARGETED
THERAPY
 Trastuzumab
 Lapatinib

13. ENDOCRINE THERAPIES
Selective estrogen receptor
modulator
 Tamoxifen
 Torimefene
Androgens
 Fluoxymetsterone
Progestins
 Megetrol acetate
 Medroxyprogesterone acetate
High dose estrogens
Aromatase inhibitors
 Letrozole
 Anastrazole
 Exemestane
Steroid antiestrogens
 Fulvestrant
LHRH agonists
 Leuprolide
 Goserelin
Gland ablation
 Ovary
 Pituitary
 adrenals

14. TAMOXIFEN
Hormone receptors are detectable in >90% of ductal and
lobular invasive cancer
Tamoxifen bind to ER in cytosol---blocks estrogen uptake
by breast tissue
Carry over effect
Toxicity—
 Bone pain
 Hot flashes
 Nausea & vomiting

15.  Fluid retention
 Thrombotic events in <3% treated cases
 More incidence of cataract surgery in patients
receiving tamoxifen
 Long term risk of endometrial cancer
In high risk patients who have received adjuvant
tamoxifen therapy for 5 years, an additional
adjuvant therapy with at least 3 years of an
aromatase inhibitor –significant benefit in terms of
disease outcome.

16. GUIDELINES
 Endocrine therapy should be started in all hormone receptor positive
females with metastatic breast cancer
 Hormone therapy may be suitable as a sole therapy in patients with
severe comorbid conditions or very old age
 AI are standard second line agents after tamoxifen
 Recently evidence has emerged which highlights superiority of AI in
first setting too
 In premenopausal females ovarian ablation may be another
alternative. It also allows use of AI in this group.
 Selection of the appropriate initial management depends on—
 Tempo of the disease
 Vital organ involvement
 General condition of the patient
 Socio-economic condition.

17. BREAST CANCER DURING
PREGNANCY

18.  Incidence- 1 in every 3000 pregnant women.
 Axillary lymph node metastasis in 75% of
these cases.
 Average age – 34 years.
 Diagnostic tools—ultrasonography & needle
biopsy. MRI is the investigation of choice.
 Mammography –decreased sensitivity

19.  30% of benign conditions
encountered—galactocele, lobular
hyperplasia, lactating adenoma,
mastitis or abscess.
 On breast cancer diagnosis:
 Complete blood count
 Chest xray with shielding of abdomen
 Liver function tests

20. Treatment
 Usually presentation is in the later stages of the
disease .
 During first and second trimester—modified radical
mastectomy
 Third trimester—lumpectomy with axillary node
dissection and radiation therapy after delivery
 Chemotherapy in second and third trimesters as
neoadjuvant approach
 Hormone treatment contraindicated
 Prognosis same as non pregnant women with breast
cancer.

21. PAGET’S DISEASE OF
NIPPLE
 Approximately 1 to 4 percent of all cases
 The average age at diagnosis is 57 years.
 Characteristic—
Chronic eczematous eruption of the
nipple, which may be subtle but may
progress to an ulcerated weeping lesion.

22.  Usually associated with extensive DCIS or
invasive cancer.
Palpable mass may or may not be present.
On needle biopsy—population of cells that are
identical to underlying DCIS (pagetoid change)
Pathognomic of this caner is the presence of
large pale, vacuolated cells (Paget cells) in the
rete pegs of the epithelium.

23. TREATMENT
 Surgical —
lumpectomy
mastectomy
 Depending on---
extent of involvement of nipple areola complex
presence of DCIS or invasive cancer.

24. INFLAMMATORY BREAST
CARCINOMA(STAGE IIIB)
 <3% of breast cancers
 Most aggressive type.
 Common in lactating women and
pregnancy.
 Mimics mastitis because of it’s short
duration, pain, tenderness and warmth.

25. Characteristics—
Brawny induration ,erythema with a raised edge and
edema (peau d’orange)
 On skin biopsy—permeation of dermal lymph vessels
by cancer cells
 There may be an associated breast mass
More than 75% of these cases present with axillary
lymphadenopathy and distant metastases
 PET & CT SCAN to rule out concurrent metastasis
and recurrence

26. TREATMENT
1
• Anthracycline containing regimen
• HER2/ hormone receptor status
2
• Modified radical mastectomy
3
• Adjuvant chemotherapy
• Chest wall, supraclavicular, internal mammary and
axillary nodes basins--- adjuvant radiation therapy

27. THANK YOU.