4. Carcinoma of the female breast. (Treatment and follow up) Flashcards
(114 cards)
1
Q
Modalities of treatment of breast cancer
A
I- Surgical
II- Radiotherapy
III- Chemotherapy
IV- Hormonal treatment
V- Immunotherapy
2
Q
Surgical modalities of treatment of breast cancer
A
1- Radical mastectomy: not done now
2- Extended radical mastectomy : not done now
3- Modified Radical mastectomy (MRM)
- Simple mastectomy
- Conservative breast surgery
- Reconstructive breast surgery :
3
Q
Radical mastectomy in surgical modalities of treatment of breast cancer
A
- Alternative name
- Indication
- Procedures
4
Q
Alternative name for Radical mastectomy in surgical modalities of treatment of breast cancer
A
Halsted
5
Q
Indication of Radical mastectomy in surgical modalities of treatment of breast cancer
A
not done now
6
Q
Procedures of Radical mastectomy in surgical modalities of treatment of breast cancer
A
we remove:
1- The whole breast tissue.
2- Pectoralis major & minor muscles ( and interpectoral L.N)
3- All fat, fascia & L.Ns of the axilla
7
Q
Extended radical mastectomy in surgical modalities of treatment of breast cancer
A
- Alternative name
- Indication
- Procedures
8
Q
Alternative name for Extended radical mastectomy in surgical modalities of treatment of breast cancer
A
Urban
9
Q
Indication of Extended radical mastectomy in surgical modalities of treatment of breast cancer
A
not done now
10
Q
Procedures of Extended radical mastectomy in surgical modalities of treatment of breast cancer
A
we remove:
1- The whole breast tissue.
2- Pectoralis major & minor muscles ( and interpectoral L.N)
3- All fat, fascia & L.Ns of the axilla
4- The internal mammary L.N. through removal of the homolateral 1/2 of the sternum & the costal cartilages from 2-5.
11
Q
Procedures of Modified Radical mastectomy (MRM) in surgical modalities of treatment of breast cancer
A
We remove : Whole breast & axilla.
12
Q
Simple mastectomy in surgical modalities of treatment of breast cancer
A
- Procedures
* Indications
13
Q
Procedures of simple mastectomy in surgical modalities of treatment of breast cancer
A
we remove Breast only.
14
Q
Indications of simple mastectomy in surgical modalities of treatment of breast cancer
A
Palliative in stages III & IV caner breast.
15
Q
Conservative breast surgery in surgical modalities of treatment of breast cancer
A
- Procedures
- Indications
- Contraindications
16
Q
Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
either:
1- QUART:
2- TART:
17
Q
QUART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
- QU: Quadrantectomy
- A: Axillary clearance or sampling
- RT: Radiotherapy to the breast
18
Q
TART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
- Lumpectomy with safety margin 2 cm +
- Axillary clearance
- Radiotherapy to the breast
19
Q
Indications of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
Now all females do conservative breast surgery
but in the past, the indications were:
a) Done only in stages I and ll
b) Young age.
c) Small tumour up to 4 cm or up to 5 cm in large breast.
d) Tumour away from nipple & areola.
20
Q
Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
- Absolute
* Relative
21
Q
Absolute Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
A
a) Extensive intraductal (in situ) component.
b) Lobular carcinoma.
c) Grade III tumours.
d) 1st & 2nd trimester of pregnancy.
e) Recurrence after radiotherapy or history of prior radiation to area of treatment.
f) Collagen disease.
22
Q
The reason why Extensive intraductal (in situ) component is considered from the absolute contraindications of Conservative breast surgery
A
as it behaves like multicenteric Known by biopsy
23
Q
The reason why Lobular carcinoma is considered from the absolute contraindications of Conservative breast surgery
A
as it mulicentric
24
Q
the reason why Grade III tumours are considered from the absolute contraindications of Conservative breast surgery
A
as they are undifferentiated
25
the reason why 1st & 2nd trimester of pregnancy. are considered from the absolute contraindications of Conservative breast surgery
Harmful effects of radiotherapy on the fetus
26
the reason why history of prior radiation to area of treatment is considered from the absolute contraindications of Conservative breast surgery
* rule : no radiotherapy on top of previous radiotherapy
| * Due to presence of much fibrosis by previous radiotherapy
27
the reason why Collagen disease is considered from the absolute contraindications of Conservative breast surgery
thin weak Skin of patients with collagen disease can't tolerate radiotherapy
28
Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
a) Large tumour > 5 cm or > 4 cm
b) Small breast (bad cosmetic result).
c) Tumour affecting nipple or areola.
29
The reason why Large tumour > 5 cm or > 4 cm is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
as down staging can be done by 3 courses of chemotherapy
30
The reason why Small breast is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
as Breast reconstruction and augmentation mammoplasty can be done
31
The reason why Tumour affecting nipple or areola is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer
as Nipple & areola reconstruction can be done
32
Reconstructive breast surgery in surgical modalities of treatment of breast cancer
* Components
* Indications
* Bailey and love note
33
Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer
A. Breast reconstruction :
B. Nipple & areola reconstruction :
34
Modalities of Breast reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer
1. Silicone gel implants under the pectoralis major
2. Expandable saline prosthesis.
3. Myocutaneous flaps
35
Procedures of Myocutaneous flaps in Modalities of Breast reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer
a) Transverse rectus abdominis muscle flap (TRAM flap)
| b) Latissimus dorsi muscle flap (LD flap).
36
Modalities of Nipple & areola reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer
1. Prosthetic nipple or partial contralateral nipple graft
| 2. Tattooing is the simplest technique for areola reconstruction.
37
Indications of Reconstructive breast surgery in surgical modalities of treatment of breast cancer
Done only after MRM in stages I & II
38
Bailey and love note on Reconstructive breast surgery in surgical modalities of treatment of breast cancer
To achieve symmetry the opposite breast may require reduction or augmentation mammoplasty
39
Chemotherapy in modalities of treatment of breast cancer
* Indications
* Drug combinations
* Regimens
40
Indications of Chemotherapy in modalities of treatment of breast cancer
It will be of great benefits for hormonal receptors negative
41
Drug combinations in Chemotherapy in modalities of treatment of breast cancer
1. CMF : Combination of Cyclophosphamide, Methotrexate & 5- Fluorouracil.
2. Adriamycin alone.
3. CAF : Combination of Cyclophosphamide, Adriamycin & 5- Fluorouracil
42
Regimens of Chemotherapy in modalities of treatment of breast cancer
* CMF or Adriamycin alone is given in a 6 monthly cycles.
* CAF:
ln 4 monthly cycles when given instead of CMF.
ln 6 monthly cycles in aggressive tumours
43
what is the meaning of 6 monthly cycles
Few days in each month Not the whole month
44
Hormonal treatment in modalities of treatment of breast cancer
* Hormonal receptors
* Management of hormone receptors positive in postmenopausal women
* Management of hormone receptors positive in premenopausal women
45
Hormonal receptors in Hormonal treatment in modalities of treatment of breast cancer
* Estrogen receptors ( ER )
* Progesterone receptors ( PR ).
* Presence of PR indicates there are much estrogen receptors
* No PR positive tumours exist
46
Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
1. Tamoxifen
| 2. Anastrazole & Letrozole ( Femara ).
47
Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
* Mechanism of action
* Significance
* Dose
48
Mechanism of action of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
SERM
Selective Estrogen Receptor Modulator
49
Significance of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
It's the drug of choice
50
The drug of choice in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
Tamoxifen
51
Dose of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
20 mg / day for 5 years
52
Anastrazole and Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
* Mechanism of action
| * Trade name of Letrozole
53
Mechanism of action of Anastrazole and Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
They inhibit aromatase enzyme responsible for conversion of androstenedione produced by the adrenal glands to estrone ( E1 ) in peripheral tissue.
54
Trade name of Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer
Femara
55
Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
1. Tamoxifen :
2. Oopherectomy :
3. Progestins : Medroxyprogesterone acetate & Megestrol acetate
56
Significance of Tamoxifen in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
It's not sufficient to suppress ovarian function.
57
Modalities of Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
a. Surgical.
b. Radiotherapy.
c. Medical
58
Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
* Significance
* Drugs
* Mechanism of action
59
Significance of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
best modality of Oopherectomy as it is reversible
60
Drugs of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
* Zoladex (Goserelin)
or
* Decapeptyl as a monthly S.C injection
61
Mechanism of action of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
LHRH agonists in a continuous manner
62
Progestins in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer
* Medroxyprogesterone acetate
| * Megestrol acetate
63
Immunotherapy in modalities of treatment of breast cancer
* Tissue receptors
| * Drugs
64
Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
* Her-2 receptors
| * P53 receptors
65
Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
* Definition
| * Value
66
Definition of Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
It's an epidermal growth factor protein detected on the cytoplasm of the tumour cells by immunohistochemistry.
67
Value of Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
a. Herceptin : Which is a monoclonal antibody against tumour cells is given.
b. It is an aggressive tumour )> give CAF.
68
Site of Her-1 receptor
present on cancer colon
69
P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
* Definition
| * Value
70
Definition of P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
it is an abnormal protein synthesized by tumour cells and detected in the nucleus of the tumour cells by immunohistochemistry.
71
Value of P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer
It is an aggressive tumour )> give CAF.
72
Drugs in Immunotherapy in modalities of treatment of breast cancer
* Trastuzumab (Herceptin)
* Imatinib
* Bevacizumab (Avastin)
* PARP (Poly ADP-ribosepolymerase) inhibitor
* Rapamycin
73
Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
* Trade name
| * Mechanism of action
74
Trade name of Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
Herceptin
75
Mechanism of action of Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
Blocks HER2/neu receptors which are +ve in 20% of cases
76
Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer
Mechanism of action
Drug combinations
77
Mechanism of action of Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer
* Anti-tyrosine kinase
| * Blocks growth signals transduction.
78
Drug combinations of Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer
When given with Herceptin )> inc. response rate to 80%
79
Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
Trade name
Mechanism of action
80
Trade name of Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
Avastin
81
Mechanism of action of Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer
Anti-VEGF )> anti-angiogenesis
82
Indication of PARP (Poly ADP-ribosepolymerase) inhibitor in Drugs in Immunotherapy in modalities of treatment of breast cancer
Especially in triple negative breast cancer
83
Mechanism of action of Rapamycin in Drugs in Immunotherapy in modalities of treatment of breast cancer
Anti-mTOR
84
Treatment of cancer breast stage by stage
Treatment of stage I cancer breast
Treatment of stage II cancer breast
Treatment of stage III cancer breast
Treatment of stage IV cancer breast
85
Treatment of stage I cancer breast
Modalities
Ways of preserving the axilla
Indications of chemotherapy
86
Modalities of Treatment of stage I cancer breast
A. Modified radical mastectomy OR Conservative breast surgery.
B. Radiotherapy
C. Adjuvant chemotherapy is indicated in selective cases.
D. Further management according to hormonal receptors.
E. Reconstructive breast surgery is recommended after MRM.
87
Radiotherapy in Modalities of Treatment of stage I cancer breast
To the breast & tumour bed after conservative breast surgery
88
Ways of preserving the axilla in Treatment of stage I cancer breast
1. Sentinel node biopsy
| 2. Axillary sampling instead of axillary clearance
89
Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast
Procedures
Results
Disadvantages
90
Procedures of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast
* The sentinel node is localized preoperatively by the injection of patent blue dye and /or radioisotope-labeled albumin near the tumour.
* The marker will pass to the primary node draining the area and will be detected visually or with a handheld gamma camera,
* Sent for frozen section histological analysis.
91
Results of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast
In patients in whom there is no tumour involvement of the sentinel node, it is hoped that further axillary clearance can be avoided
92
Disadvantages of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast
Skip lesions are thought to occur tn 3% of patients
93
Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast
* Levels of axillary L.N
* Procedures
* Disadvantages
94
Levels of axillary L.N in Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast
* level one below pectoralis minor
* level two behind pectoralis minor
* level three above pectoralis minor
95
Procedures of Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast
* Selective removing of level I +/- II axillary L.N
| * Sending them to paraffin section histopathology
96
Disadvantages of Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast
a positive node sample must be followed by axillary irradiation or axillary clearance.
97
Indications of chemotherapy in Treatment of stage I cancer breast
1. Tumour size 1-2 cm. If less than 1 cm )> no micrometastasis occurs
2. Extensive intraductal (in situ) component.
3. Histological grade III tumours.
4. Her-2 or p53 receptors positive.
98
Treatment of stage II cancer breast
A. Modified radical mastectomy Or Conservative breast surgery.
B. Radiotherapy :
C.Adjuvant chemotherapy : CMF or adriamycin or CAF in aggressive tumours
D. Further management according to hormonal receptors.
E. Reconstructive breast surgery is recommended after MRM.
99
Radiotherapy in Treatment of stage II cancer breast
* To breast & tumour bed in conservative breast surgery.
| * To supraclavicular & internal mammary L.N
100
Treatment of stage III cancer breast
A. Palliative simple mastectomy.
B. Radiotherapy
C. Chemotherapy : CMF or adriamycin or CAF in aggressive tumours.
D. Further management according to hormonal receptors
101
Aim of Palliative simple mastectomy in Treatment of stage III cancer breast
Removing the breast which may fungate & facilitates irradiation.
102
Radiotherapy in Treatment of stage III cancer breast
To axilla, supraclavicular & internal mammary L.N.
103
Treatment of stage IV cancer breast
A) as stage III cancer breast
B) Management of metastases.
104
Management of metastases in Treatment of stage IV cancer breast
1) pleural effusion
2) pathological fracture
3) spinal cord compression
4) liver metastases
5) superior vena cava obstruction
105
Management of pleural effusion in Management of metastases in Treatment of stage IV cancer breast
1- Intercostal tube drainage.
2- Usually responds to systemic chemotherapy.
3- If not responding, instillation of cytotoxic bleomycin through the tube is required to induce pleurodesis.
106
Meaning of pleurodesis in Management of pleural effusion in Management of metastases in Treatment of stage IV cancer breast
fibrosis
107
Management of pathological fracture in Management of metastases in Treatment of stage IV cancer breast
* Internal fixation
| * Radiotherapy.
108
Management of spinal cord compression in Management of metastases in Treatment of stage IV cancer breast
Urgent spinal cord decompression with stabilization followed by radiotherapy.
109
Management of liver metastases in Management of metastases in Treatment of stage IV cancer breast
Chemotherapy
110
Management of superior vena cava obstruction in Management of metastases in Treatment of stage IV cancer breast
Radiotherapy is the treatment of choice.
111
Follow up of breast cancer
1- Patients are re-examined every 3 months for the first 2 years
2- Then every 4 months for the next 3 years
3- Patients are re-examined yearly after that.
4- Mammography for the contralateral breast is done every 1 year.
112
First step of breast self examination
* Inspection in front of a mirror to look for any dimpling, puckering or nipple retraction
113
Second step of breast self examination
* Palpate both breasts, axillae, and supra-clavicular regions for the presence of a lump
.
This is done in a systematic manner while showering, by sliding the contralateral hand on the soaped breast.
114
Third step of breast self examination
a repetition of the second while lying down in bed with the arm elevated.
