includes graphs and pictures with latest advances in the management

2. Dr Sriram
Dr Dinesh
Dr Pareekshith
Department of GENERAL SURGERY
MMCH AND RESEARCH
CENTER,CALICUT
MENTOR: Dr. C. M. Lakshminarayanan
Professor & HOD

3.  Incidence
 Risk factors
 Etiopathogenesis
 Clinical features
 Management
 Recent advancements

8.  Breast cancer is SECOND most common cancers
affecting females.
 It is the 2nd most common cause of death due to
cancer in women after Lung cancer.
 one in 100 Indian females is likely to develop breast
cancer during her lifetime.

10. Age
Gender
Race
Country of birth
Family History
Genetic Risks
Personal History
Certain types of
benign breast
disesase
Menstrual History
Reproductive History
Oral Contraceptives
Hormone Replacement
Alcohol
Diet
Obesity
Ionising radiation
Nonmodifiable Risks Modifiable Risks

11.  Age
Increases with age.
Mostly common in middle age group
Gender
average risk for women in life time-12.2%
More common in women than men (150:1)


12. Country of birth
More common in West
Sporadic breast cancer 65-75%
Familial breast cancer 20-30%
Hereditary breast cancer 5-10%

13. Family History
 1st degree relatives of patient-> risk increased by
2 or 3 fold
Risk is much higher if
-B/L carcinoma
-Early onset 50% risk
-Multiple members
Family history of ovarian cancer

14. BRCA 1 BRCA 2
Long arm of chromosome 17 Long arm of chromosome 13
40% of familial breast CA 20-30% familial breast CA
45% of lifetime risk for ovarian CA. 30% of ovarian CA
High grade Low grade
Hormone receptor negative Positive
Unfavourable prognosis. Favourable prognosis.
Genetic factors

15.  SYNDROMES ASSOCIATED WITH
BREAST CANCER:
SYNDROME GENE MUTATION
- Li-Fraumeni syndrome P53
- Cowden’s syndrome PTEN
- Muir syndrome MSH2 / MLH1
- Ataxia telengiectasia ATM
-Putz-jeghrs syndrome STK11/LKB1

16. Personal History of Previous Cancer
 3- to 4-fold increased risk
 Contralateral breast
 Ovary
 Endometrium
 Certain Types of Benign breast diseases
Type Relative risk
Non proliferative disease 1
Proliferative without atypia 1.3-1.9
Proliferative with atypia 3.7-4.2
Ductal involvement by cells of atypical ductal
hyperplasia
>7

17.  Menarche < age 12 increases risk
 Menopause > age 55 increases risk
 1st child after age 30 or nulliparous
 Prolonged combined estrogen & progesterone
replacement therapy
 OCP’S- ???
 BILATERAL OOPHORECTOMY BEFORE THE AGE OF 40
YEARS IS PROTECTIVE AGAINST BREAST CANCER.

19.  Diet
 Alcohol
 High fat diet
 Irradiation
 Risk factors for young women
 Hodgkin lymphoma and fluoroscopic tests
 Obesity
 Androstenodione Estrone
 Radial scar
Adipose tissue

20.  BREAST FEEDING IS PROTECTIVE
 SMOKING AND OCP ARE NOT PROVED TO BE
RISK FACTOR FOR CARCINOMA BREAST

21. GAIL MODEL
Computer model available that can calculate an
individual woman’s 5-yr risk of breast cancer
Developed by the National Cancer Institute
Utilizes a series of questions to calculate risk based on
nonmodifiable & modifiable factors
Administered by a health care professional

24.  Histopathology
Cancer cells are
divided
Invading
through
basement
membrane
Invasive
carcinoma
No
Carcinoma in
situ

25. Classification of
breast cancer
In situ
(15-30%)
Ductal
carcinima
insitu (80%)
Lobular
carcinoma
insitu
(20%)
Invasive
(70-85%)
Invasive ductal
carcinoma
with
productive
fibrosis (80%)
Invasive
lobular
carcinoma
(10%)
Mucinous
(colloid)
(2.4%)
Tubular
(1.5%) Medullary
(1.2%)
Papillary
(1%)

27. Subtype ER Her- 2 -Neu Ki67
Luminal A +ve -ve Low
Luminal B +ve +ve High
Her-2-Neu over
expression group
-ve +ve High
Basal cell like ER and PR -ve -ve High
Claudin-Low -ve -ve High

31.  HISTORY AND PHYSICAL EXAMINATION
 RADIOLOGICAL ASSESSMENT
 PATHOLOGICAL ASSESSMENT

32.  MAMMOGRAPHY
 ULTRASONOGRAPHY
 MAGNETIC RESONANCE IMAGING

34.  To distinguish scar from recurrence in women
who have had previous breast conservation
therapy for cancer
 To assess multifocality and multicentricity in
lobular cancer and to assess the extent of
high-grade ductal carcinoma in situ (DCIS). It
is less useful in low-grade DCIS;
 It is the best imaging modality for the
breasts of women with implants;
 As A screening tool in high-risk women
(because of family history

35.  FINE NEEDLE ASPIRATION BIOPSY
 CORE NEEDLE BIOPSY
 EXCISIONAL BIOPSY

36.  LFT
 USG abdomen and pelvis.
 Biopsy of metastatic lesion – very important (
biomarkers may differ in primary and
secondary deposits)
 Pleural fluid analysis, Ascitic fluid analysis.
 CT CHEST & ABDOMEN.
 MRI/ PET CT
 Whole body scan.

40.  CHEST XRAY
 „ECG
 „Blood for hemoglobin, total leukocyte count
(TLC), differential leukocyte count (DLC)
and
 Erythrocyte sedimentation rate (ESR)
 „Blood for sugar, urea and creatinine.
 Blood grouping and typing

43.  1. BCS + SLN biopsy +RT
 2. MRM
WITH ADJUVANT
SYSTEMIC
THERAPY

44. • NEAOADJUVANT CHEMOTHERAPY
• BCS/MRM
• RADIOTHERAPY

45. Primary goal of therapy
 Improvement and maintenance of Quality of life
 Prolongation of survival

46.  Main stay of treatment is AGGRESSIVE
CHEMOTHERAPY
 More useful in hormone negative tumours.
 Hormone positive tumours not responding to
ET
 Patients with symptomatic visceral
metastasis.

47.  BONE METASTASIS
 Rx – Bisphosphonates IV (Zolendronic acid-
4mg,Pamidronate-90mg) RT
 Internal fixation, spinal decompression,
laminectomy.
 ORAL Calcium and Vitamin D3
supplements

48.  Brain mets
Localised Surgery
Steroid followed by RT
 Spine
Steroid with decompression and
stabilization
 Malignant Ascites
Symptomatic > diuretics,
Paracentesis
Peritoneo venous shunts

49.  Limited role
 Radiotherapy

52. BIOMARKERS
RECEPTORS
PATHOLOGY
IMAGING MODALITIES
CLASSIFICATIONS
SURGICAL APPROACH
CHEMOTHERAPY

53.  BC1, BC2, BC3
 BC3 posses highest individual diagnostic
power
 CA15-3, CA27-79, KK-LC-1,
 KK-LC-1[kita-Kyushu lung antigen-1]
expressed in triple negative breast
cancer

54.  IGF-1, E-Cadherin , PTEN
 Loss of E Cadherin is hallmark of invasive
lobular carcinoma

55.  LIQUID BIOPSY
 RADIOACTIVE SEED LOCALIZATION- I125
 STEREOTACTIC MAMMOGRAPHIC CORE
NEEDLE BIOPSY
 NEEDLE LOCALIZED BIOPSY UNDER
MAMMOGRAPHY
 VACUUM ASSISTED BIOPSY
 MRI GUIDED CORE NEEDLE BIOPSY

56.  Xero mammography- dense breasts
 PET/CT
 PET/MRI
 Breast ductal endoscopy
 Diffusion Weighted Imaging with ADC
 Thermography

57.  MRI is superior to mammography in
detecting cancer in patients receiving HRT
and young females
 One view breast tomosynthesis- least
radiation dose

58.  Based on genomic hybridization
 Cluster A- poor prognosis
 Cluster B- good prognosis

59.  ILC BASED ON RECEPTOR STATUS

61.  Skin sparing mastectomy/ key hole
mastectomy
 Nipple sparing mastectomy
 Oncoplasty

63.  NEWLY APPROVED DRUGS
 Ixabepilone - Anthracycline and taxane
resistant cases
 Lapatinib - Second line HER2new therapy
 Sunitinib - Refractory metastatic breast
cancers
 Bevacizumab – monoclonal antibody against
VEGF

64.  Nelipepimut-S :- Investigating as vaccine
to prevent clinical recurrence in high risk
patients
 Pembrolizumab- monoclonal IgG4
antibody
 Fulvestrant – ER degrader