4. Carcinoma of the female breast. (Treatment and follow up) Flashcards Preview

Surgery.(General 2).Breast > 4. Carcinoma of the female breast. (Treatment and follow up) > Flashcards

Flashcards in 4. Carcinoma of the female breast. (Treatment and follow up) Deck (114):
1

Modalities of treatment of breast cancer

I- Surgical

II- Radiotherapy

III- Chemotherapy

IV- Hormonal treatment

V- Immunotherapy

2

Surgical modalities of treatment of breast cancer

1- Radical mastectomy: not done now

2- Extended radical mastectomy : not done now

3- Modified Radical mastectomy (MRM)

4. Simple mastectomy

5. Conservative breast surgery

6. Reconstructive breast surgery :

3

Radical mastectomy in surgical modalities of treatment of breast cancer

* Alternative name

* Indication

* Procedures

4

Alternative name for Radical mastectomy in surgical modalities of treatment of breast cancer

Halsted

5

Indication of Radical mastectomy in surgical modalities of treatment of breast cancer

not done now

6

Procedures of Radical mastectomy in surgical modalities of treatment of breast cancer

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

Extended radical mastectomy in surgical modalities of treatment of breast cancer

* Alternative name

* Indication

* Procedures

8

Alternative name for Extended radical mastectomy in surgical modalities of treatment of breast cancer

Urban

9

Indication of Extended radical mastectomy in surgical modalities of treatment of breast cancer

not done now

10

Procedures of Extended radical mastectomy in surgical modalities of treatment of breast cancer

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

Procedures of Modified Radical mastectomy (MRM) in surgical modalities of treatment of breast cancer

We remove : Whole breast & axilla.

12

Simple mastectomy in surgical modalities of treatment of breast cancer

* Procedures

* Indications

13

Procedures of simple mastectomy in surgical modalities of treatment of breast cancer

we remove Breast only.

14

Indications of simple mastectomy in surgical modalities of treatment of breast cancer

Palliative in stages III & IV caner breast.

15

Conservative breast surgery in surgical modalities of treatment of breast cancer

* Procedures

* Indications

* Contraindications

16

Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

either:

1- QUART:

2- TART:

17

QUART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

* QU: Quadrantectomy

* A: Axillary clearance or sampling

* RT: Radiotherapy to the breast

18

TART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

* Lumpectomy with safety margin 2 cm +

* Axillary clearance

* Radiotherapy to the breast

19

Indications of Conservative breast surgery in surgical modalities of treatment of breast cancer

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

Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

* Absolute

* Relative

21

Absolute Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

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

The reason why Extensive intraductal (in situ) component is considered from the absolute contraindications of Conservative breast surgery

as it behaves like multicenteric Known by biopsy

23

The reason why Lobular carcinoma is considered from the absolute contraindications of Conservative breast surgery

as it mulicentric

24

the reason why Grade III tumours are considered from the absolute contraindications of Conservative breast surgery

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.