1) Breast cancer is a major global health problem, with most cases occurring in developing countries. Ghanaian studies show that patients often present with advanced-stage disease and experience poor outcomes.
2) Early breast cancer is defined as stage 0, 1, or 2 based on tumor size and lymph node involvement. Treatment involves surgery such as breast-conserving therapy or mastectomy, followed by radiation and/or systemic therapies based on tumor biomarkers.
3) Ductal carcinoma in situ (DCIS) is a non-invasive proliferation of malignant cells within breast ducts. Diagnosis is often from mammography screening, and management involves surgery such as lumpectomy plus radiation therapy based on prognostic factors.
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Management of Early Breast Cancer
1. M A N A G E M E N T O F E A R LY B R E A S T
C A
D R . P H I L I P M E N S A H
1
2. BACKGROUND
• Cancer is an important factor in the global burden of disease.
• The estimated number of new cases each year is expected to rise from 10 million in 2002 to 15
million by 2025,with 60% of those cases occurring in developing countries.
• One in 4 deaths is due to cancer
• Estimated new cancer cases: 1,665,540. Estimated deaths: 585,720
2
4. • Very few published data and work on Breast Ca in Ghana
• Clegg-lamptey and Hodasi (june 2007), did ‘A Study On Breast Ca In KBTH:
Assessing The Impact Of Health Education’.
• They found out that;
The majority of the Patient presents in the fifth decade (40 - 49) – 40%
Most women presents with advanced disease (stage 3&4) – 57.6%
Also most patients presents months after symptoms appear
They also identified a high rate of defaults among Patients
4
5. • Work done in CCTH by Prof Debrah et al on Breast Cancer Treatment and Outcomes at
Cape Coast Teaching Hospital, Ghana.
• They concluded:
Ghanaian women frequently present with advanced stage breast cancer and experience
poor outcomes.
Early Breast Cancer (stage 0, 1 & 2 = 21.1%)
Public health initiatives should focus on dispelling harmful beliefs that delay women from
seeking care.
Expansion of the national health care system is needed to support breast cancer screening,
diagnostic tests, and treatment.
5
6. STATISTICS OF SURGERIES DONE FOR
MALIGNANT BREAST DISEASE IN CCTH
FROM JAN 2017 – OCT 2020
BCS
15
29%
MASTECTOMY
37
71%
MALIGNANT BREAST SURGERIES
BCS
MASTECTOMY
6
7. IN GENERAL
• Increasing morbidity but decreasing mortality
• Early detection and effective management
• Multidisciplinary team (MDT) approach
• Tailoring therapy to the individual patients' needs
7
9. • Receives blood from
the medial mammary branches of the anterior perforating branches of the
internal thoracic artery,
the lateral mammary branches of the lateral thoracic artery,
the pectoral branches of the thoracoacromial trunk
the lateral cutaneous branches of the posterior intercostal arteries.
• It Is innervated by the anterior and lateral cutaneous branches of the
second to the sixth intercostal nerves.
9
10. RISK FACTORS FOR BREAST CANCER
1. Early menarche (less than 12 years)
2. Age at full term pregnancy (> 35 years)
3. Late menopause
4. Previous breast ca in one breast
5. Family history of breast ca = worse in first degree relatives
6. Genetics
- BRCA 1 (Ch 17q) associated with ovarian, colorectal and prostate ca
- BRCA 2 (Ch 13q) – tumor suppressor gene (p53)
10
11. • Nulliparity
• Exposure to ionized radiation
• Post-menopausal obesity (increase conversion of steroid hormones to estrogen)
• Diet – fatty foods and alcohol
• Age
• Geographical location – common in the western world
• Hormone replacement therapy
• Gender
• Oral Contraceptive Pills
Protecting factors
1. Breastfeeding for more than 2 years
2. First full term pregnancy less than 21 years
11
12. BAD PROGNOSTIC FACTORS
• More than 4 + axillary lymph nodes
• Age < 35
• ER and PR – Negative
• BRCA 1 & 2 – Positive
• HER2 – Positive
12
13. TUMOR GRADING
• It is the measure of the level of
differentiation
• Grade 1 – 3-5 = well diff
• Grade 2 – 6-7 = moderately diff
• Grade 3 – 8-9 = poorly diff
13
14. CLINICAL STAGING (TNM STAGING)
OF BREAST CA
• T0 No evidence of primary tumor
• Tis Carcinoma in situ
• T1 Tumor ≤20 mm in greatest dimension
• T2 Tumor >20 mm but ≤50 mm in greatest
dimension
• T3 Tumor >50 mm in greatest dimension
• T4 Tumor of any size with direct
extension to the chest wall and/or to the
skin
• N0 no regional node involvement
• N1 metastasis to movable ipsilateral
axillary nodes
• N2 metastasis to fixed ipsilateral
axillary nodes
• N3 metastasis to same side internal
mammary nodes
• M0 No clinical or radiographic
evidence of distant metastases
• M1 Distant detectable metastases
14
16. EARLY BREAST CARCINOMA
• DEFINITION BASED ON TNM STAGING
• AJCC GROUP STAGING OF STAGE 0, 1 & 2
16
17. PATHOLOGICAL CLASSIFICATION OF
BREAST CANCER
• Non-invasive
- DCIS – Ductal Carcinoma In-situ
- ???LCIS – Lobular Carcinoma In-situ
• Invasive
- Infiltrating ductal carcinoma
- Infiltrating lobular carcinoma
- Others
The Invasive Carcinoma can also be classified as
- Special type (ST) – good prognosis – 15%
- No special type (NST) – POOR PROGNOSIS – 85%
17
18. DCIS
• Before the introduction of mammography, most cases of DCIS remained undetected until they
formed a mass.
• Mammography – 10-fold increase in cases of DCIS
• 75% of all Carcinoma In-situ
• DCIS – It is the proliferation of malignant cells that have not breached the ductal basement
membrane and arise from the ductal epithelium in the region of the Terminal Ductal-lobular
Unit.
18
19. CLASSIFICATION OF DCIS
• The classification is based on the differences in the architectural pattern of the cancer cells and
nuclear features
1. Cribiform
2. Comedo
3. Micropapillary
4. Solid
5. Papillary
First 3 types are the commonest
19
20. DCIS CONT’D
• 66 % of DCIS involves only one quadrant
• In 20% of multicentric DCIS, there is a co-existing invasive carcinoma
• If DCIS is left untreated;
- 50% progress to invasive carcinoma, 25% of them within 3-10 years
• DCIS is found at Autopsy in 20% of women older than 45 years
20
21. DIAGNOSIS
• Clinical Presentation
• Before routine Mammogram;
- Palpable Mass
- Nipple Changes – thickening, discharge or Pagets disease
- Incidental finding in benign biopsy specimen
• Currently screening mammogram is more prevalent, most cases are diagnosed when tumor is
clinically occult.
21
22. MAMMOGRAPHY
• Micro-calcification
• Soft tissue density
• Or both
• USG – Helps in axillary lymph node staging
• MRI – very sensitive in assessing DCIS but cost and accessibility makes it less feasible
22
23. BIOPSY
• Core – needle biopsy
• Excisional biopsy can be done in cases where core-needle biopsy
is inconclusive
- it done with the aid of pre-operative wire localization of
mammographic abnormalities
- Aim at margin-negative resection that can serve a definitive
surgery
• Ideally samples are supposed to be radiographed for presence of
mammographic abnormalities to reduced sampling errors
23
24. MANAGEMENT OF DCIS
• Breast conservation therapy is preferred
• NSABP B-06 TRIAL (ENROLLED 1851) - FOUND NO DIFFRERENCE IN THE OVERALL
SURVIVAL RATE AND DISEASE FREE SURVIVAL BCS AND MODIFIED MASTECTOMY
• Indications FOR BCS
- Tumor positive margins
- Patient willingness to do Radiotherapy
- Availability and accessibility of radiotherapy
- Favorable tumor to breast size ratio – help in adequate margins and acceptable cosmesis
24
25. • CONTRA-INDICATIONS FOR BCS
- Mammographic findings of multi-centricity
- Diffuse calcifications which is suggestive of widespread disease
- Large tumor and association with invasive carcinoma
- Patient preference not to conserve the breast
- Tendency for positive margin
- Modified Radical Mastectomy is preferred in such situations
- Has advantage of being able to do breast reconstruction during or right after initial surgery
25
26. VAN NUY’S PROGNOSTIC INDEX
26
• The treatment of DCIS after excision is guided by the VAN NUY’S Prognostic index.
• Patient with low scores may not need further treatment.
• Intermediate and high scores need further loco-regional treatment, including re-
excision, mastectomy or radiotherapy.
• Low score (4 - 6), intermediate score (7 - 9), high score (10 - 12)
Features 1 2 3
Size (mm) < 15 15-40 > 40
Margins(mm) > 10 1 - 10 < 1
Grade and
Necrosis
Low/intermediate
grade, no comedo
necrosis
Low/intermediate
grade, with
comedo necrosis
High grade,
with/without
comedo necrosis
Age (years) >60 40 - 60 < 40
27. SYSTEMIC THERAPY
• Adjuvant Chemotherapy is not given
• Hormonal and targeted therapy is given on the bases of ER/PR status and Her2 status
27
28. LCIS
• Intraepithelial proliferation of the Terminal Ductal-lobular Unit.
• The proliferation do not penetrate the basement membrane
• Cells are slightly larger and paler than those that line the normal acini but lobular architecture
remains intact
• It is multifocal in 30% of cases and bilateral in 30%, nearly always in the same quadrant on
both breast
28
29. LCIS CONT’D
• The current consensus regarding LCIS is, it’s a marker of subsequent development of invasive
cancer rather than a pre-invasive cancerous lesion
• Mostly found in pre-menopausal women
• Not diagnosed in men because male breast do not have terminal lobular unit
29
30. DIAGNOSIS
• LCIS – it is not diagnosed by clinical assessment or mammography (no mammographic
abnormalities)
• Diagnosis pure on incidental findings on breast biopsy specimen
30
31. MANAGEMENT = SURVEILLANCE
• 6 – 12 months clinical examination
• Annual mammography
• Observation for development of invasive cancer (ipsilateral and contralateral breast)
• Risk Reduction With Tamoxifen For Pre-menopausal Women And Raloxifen In Post-
menopausal Women
31
32. INVASIVE CARCINOMA
• stage 0, 1& 2 – early breast ca
• Stage 3 – locally advanced breast ca
• Stage 4 – advanced breast ca
• Debrah et al (CCTH)
32
Stage Frequency %
0 1 0.5
1 5 2.6
2 34 18.0
3 77 40.7
4 72 38.1
Total 189 100%
33. CLASSIFICATION
- Infiltrating ductal carcinoma – 75%
- Infiltrating lobular carcinoma – 5 % TO 10%
- Tubular carcinoma – 2%
- Medullary – 5% - 7%
- Mucinous or Colloid – 3%
The invasive carcinoma can also be classified as
- Special type (ST) – good prognosis – 15%
- No special type (NST) – POOR PROGNOSIS – 85%
33
36. SURGICAL MANAGEMENT FOR INVASIVE
EARLY BREAST CA(T1-3, N0-1, M0)
• BREAST CONSERVATIVE THERAPY
• MODIFIED RADICAL MASTECTOMY
36
37. COMPONENTS OF BREAST
CONSERVATION THERAPY
• Wide local excision
- Curvilinear skin incision
- 1 cm macroscopic free tumor margins
- Remove underlining muscle if involve
- Orient specimen with sutures or clips
- Oncoplastics
• Axillary lymph node dissection
• Radiotherapy to the remainder of the breast
WIDE LOCAL EXCISION
• Lumpectomy
• Segmental mastectomy
• Quadrantectomy
• Tylectomy
• Partial mastectomy
37
38. CONTRAINDICATION FOR
BREAST CONSERVATION
THERAPY
- Patient does not want to conserve breast
- Pregnancy
- Previous radiotherapy to the chest
- Can not afford radiotherapy
- Unfavorable tumor breast ratio
- Multifocal/Multicentric disease
- Unavailability of radiotherapy center's
Consider modified radical mastectomy in this situation
38
39. MODIFIED RADICAL MASTECTOMY
- Removal of the entire breast, nipple and areola
- Axillary lymph node clearance
- Radiotherapy is not a component
39
40. DIFFERENCES
BREAST CONSERVATION
THERAPY
• Radiotherapy is a component
• Markedly reduced local reoccurrence
• Good compliance
• Because of radiotherapy, Breast
reconstruction has to delay
• Can be done for only appropriate
breast to tumor size ratio
MODIFIED RADICAL
MASTECTOMY
• Radiotherapy not a necessity
• Rates of local reoccurrence higher than
in BCT
• Poor compliance
• Breast reconstruction can be
immediate
• Any tumor size
40
41. AXILLARY LYMPH NODE
• Most important prognostic factor (4 or more pathologic positive lymph nodes is associated with
poor prognosis)
• Axillary lymph node dissection
- Pectoralis minor muscle – level 1, 2 & 3
- At least 10 or more lymph nodes should be removed
41
45. ADJUVANT CHEMOTHERAPY
• Indications
- Node positive
- HER 2 +
- Triple negative
• Commonly used chemotherapy regimens.,
CAF REGIMEN( Cyclophosphamide, Adriamycin [Doxorubicin] , 5FluroUracil)
TAXANES – DOCETAXEL, PACLITAXEL
• Started within 6 weeks of surgery
45
46. HORMONAL THERAPY
• Estrogen
• Progesterone
• Tamoxifen - is a selective ER modulator that has antagonistic and weak agonistic effects.
- Thromboembolic disease
• Aromatase inhibitor – A.I.S blocks the conversion of the hormone Androstenedione into
Estrone by inhibition of the aromatase enzyme. Eg Anastrozole, Exemestane, And
Letrozole,
• LHRH Agonist (Goserelin- Zoladex)
• Started after completion of chemotherapy to reduce the side effects
46
47. TARGETED THERAPY
• Her-2 – Human Epidermal Growth Factor - Overexpression
• Trastuzumab Is A Humanized Monoclonal Antibody Developed To Target The Extracellular
Domain Of The Her-2 Receptor.
47
48. MOLECULAR SUBTYPES
LUMINAL A
ER/PR +
HER 2 –
Ki-67 LOW (<14%)
LUMINAL B
HER 2 -
ER/PR +
Ki-67 HIGH
HER 2 +
ER/PR +
ANY Ki-67
HER 2 OVER
EXPRESSION
ER/PR –
HER 2 +
BASAL-LIKE
(TRIPPLE NEGATIVE)
ER/PR –
HER 2 -
NORMAL LIKE
ER/PR +
HER 2 –
KI-67 (V. LOW)
48
49. • Luminal A : Hormonal Therapy
• Luminal B : Hormonal Therapy +/- Anti - HER2
• Her 2 + : Anti - HER 2 + Chemotherapy
• Normal like : Hormonal Therapy
• Triple NEG : Chemotherapy (Commonest Among Africans)
49
50. ONCOPLASTIC SURGERY (BREAST
RECONSTRUCTION)
• The goals of breast reconstruction are
- the restoration of the form and contour of the female breast
- symmetry with the contralateral breast
• Idea improves compliance
- Improve physical and psychology of the patient
• Immediately if no radiotherapy
• 2 years after radiotherapy
• FLAP/TISSUE EXPANDER
50
51. FOLLOW UP
• Recurrence in 2 years
• Intense follow up in the first 2 years
• 6 monthly clinical examinations
• Annual mammography
51
53. ALWAYS REMEMBER
• The Heights By Great Men Reached And Kept Were Not Attained
By Sudden Flight, But They, While Their Companions Slept, Were
Toiling Upward In The Night.
Henry Wadsworth Longfellow
53
54. REFERENCES
• Courtney M. T. et al, (2017) Sabiston Textbook Of Surgery: The Biological Basis Of Modern
Surgical Practice (20th Ed). Elsevier
• Brunicardi F. C. et al, (2015) Schwartz’s Principles Of Surgery (10 ed). McGrew-Hill Education
• Dayananda B. R., (2018) Clinical Surgery Pearls (3rd Ed). Jaypee Brothers Medical
• Archeampong E. Q. et al, (2015), Baja’s Principles And Practice Of Surgery Including Pathology In
The Tropics (5th Ed). Repro India Ltd
• Feig B.W. et al,
54