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Breast Cancer Seminar

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by

Pakorn Kerdsinchai

on 12 June 2014

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Transcript of Breast Cancer Seminar

Stages of Breast Cancer
Case 1

A 40-year old Thai female presenting with a

3-cm
right breast mass, firm consistency, movable, upper outer quadrant location,

Axillary lymph node negative
.
- Core needle biopsy shows : invasive ductal carcinoma, ER – negative, PR – positive, Her-2 – negative
- CXR & Liver Ultrasound reveal unremarkable studies.


Case find the appropriate answers of the following :
WHAT IS INVASIVE DUCTAL CARCINOMA?
The abnormal cancer cells that began forming in the milk ducts have spread beyond the ducts into other parts of the breast tissue. can also spread to other parts of the body.

infiltrative ductal carcinoma

70- 80% of all breast cancer diagnoses.

. If the patient received the breast conserving surgery and the pathology report showed the adequate surgical margin with negative lymph nodes 0/12, what should we do for this patient ?
stage
is based on four characteristics:
- the size of the cancer
- whether the cancer is invasive or non-invasive
- whether cancer is in the lymph nodes
- whether the cancer has spread to other parts of the body beyond the breast

. If the patient got the MRM (modified radical mastectomy) and the pathology report demonstrated the adequate surgical margin with positive lymph nodes 4/12, should we give her further treatment?
. Options of the treatment for this patient in details.
Breast Cancer Seminar
case 1

a.)

Options of the treatment for this patient in details.
b.)

If the patient received the breast conserving surgery and the pathology report showed the adequate surgical margin with negative lymph nodes 0/12, what should we do for this patient?
c.)

If the patient got the MRM (modified radical mastectomy) and the pathology report demonstrated the adequate surgical margin with positive lymph nodes 4/12, should we give her further treatment?
d.)
Does this woman need the adjuvant systemic treatment? Please explain.

Stage 0
non-invasive
breast cancers, such as DCIS (ductal carcinoma in situ). no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or getting through to or invading neighboring normal tissue.

Stage I
* invading cancer cells can't measure more than 1 millimeter.
Stage IA :

- the tumor measures up to
2 centimeters
AND
- the cancer has not spread outside the breast; no lymph nodes are involved

Stage IB :

- there is no tumor in the breast; instead, small groups of cancer cells – larger than 0.2 millimeter but not larger than 2 millimeters – are
found in the lymph nodes

- there is a tumor in the breast that is no larger than 2 centimeters, and there are small groups of cancer cells – larger than 0.2 millimeter but
not larger than 2 millimeters
– in the lymph nodes

Stage II
Stage IIA :

- no tumor can be found in the breast, but cancer (larger than 2 millimeters) is found
in 1 to 3 axillary lymph nodes
(the lymph nodes under the arm) or in the lymph nodes near the breast bone (found during a sentinel node biopsy) OR
- the tumor measures 2 centimeters or smaller and has
spread to the axillary lymph nodes

-
the tumor is larger than 2 centimeters but not larger than 5 centimeters and has not spread to the axillary lymph nodes

Stage IIB :
- the tumor is larger than 2 centimeters but no larger than 5 centimeters; small groups of breast cancer cells -- larger than 0.2 millimeter but not larger than 2 millimeters --
are found in the lymph nodes
- the tumor is larger than 2 centimeters but no larger than 5 centimeters; cancer has
spread to 1 to 3 axillary lymph nodes
or to lymph nodes near the breastbone (found during a sentinel node biopsy)
- the tumor is
larger than 5 centimeters
but has not spread to the axillary lymph nodes


Stage III
Stage IIIA :
- no tumor is found in the breast or the tumor may be any size; cancer is
found in 4 to 9 axillary lymph nodes
or in the lymph nodes near the breastbone (found during imaging tests or a physical exam) OR
- the tumor is
larger than 5 centimeters
; small groups of breast cancer cells (larger than 0.2 millimeter but not larger than 2 millimeters) are found in the lymph nodes OR
- the tumor is
larger than 5 centimeters
; cancer has spread to 1 to 3 axillary lymph nodes or to the lymph nodes near the breastbone (found during a sentinel lymph node biopsy)

Stage IIIB :
- the tumor may be any size and has
spread
to the chest wall and/or skin of the breast and caused swelling or an ulcer AND
- may have spread to
up to 9 axillary lymph nodes
OR
- may have spread to lymph nodes near the breastbone
Inflammatory breast cancer is considered at least stage IIIB:
-
reddening
of the breast skin
- the breast feels
warm
and may be
swollen
- cancer cells have
spread
to the lymph nodes and may be found in the skin


Stage IIIC :
- there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast AND
- the cancer has spread to 10 or more axillary lymph nodes OR
- the cancer has spread to lymph nodes above or below the collarbone OR
- the cancer has spread to axillary lymph nodes or to lymph nodes near the breastbone


Stage IV
invasive : spread beyond the breast and nearby lymph nodes to other organs of the body.
such as the lungs, distant lymph nodes, skin, bones, liver, or brain.


advanced
” and “
metastatic


Stage : IIA
Treatment to the Breast
Treatment to the Lymph Nodes
total mastectomy
lumpectomy plus radiation
"Simple" or "total" Mastectomy
- The surgeon removes the entire breast.
- The surgeon does not perform axillary lymph node dissection(removal of lymph nodes in the underarm area). Sometimes, however, lymph nodes are occasionally removed because they happen to be located within the breast tissue taken during surgery.
- No muscles are removed from beneath the breast.


removal of the breast tumor (the "lump") and some of the normal tissue that surrounds it.
“breast-conserving” or "breast preservation" surgery
biopsy, lumpectomy, partial mastectomy, re-excision, quadrantectomy, or wedge resection
removes only the tumor (the “lump”) and some of the normal tissue that surrounds it. Sometimes, axillary (underarm) lymph nodes are removed for examination.

Lumpectomy
Radiation
Radiation Therapy / Radiotherapy
- highly targeted and highly effective
- reduce the risk of breast cancer recurrence about 70%
- relatively easy to tolerate and its side effects are limited to the treated area.

How Radiation Works
Ways to deliver radiation  to the tissues to be treated
- high-energy beam damage cancer cells (damage a cell’s DNA)
- radiation damages can damage both normal cells and cancer cells.
- Cancer cells are busy growing and multiplying —> slowed or stopped by radiation.
- Cancer cells are less organized than healthy cells
—> harder to repair the damage done by radiation —> more easily destroyed

- radiation affects cancer cells more than normal cells.
1 ) a machine called a linear accelerator : delivers radiation from outside the body

2 ) pellets, or seeds, of material that give off radiation beams from inside the body

* Tissues to be treated might include the breast area, lymph nodes, or another part of the body.

Why Lumpectomy Plus Radiation
- reduce the risk of recurrence after surgery
- Research : patients with radiation after lumpectomy are more likely to live longer, and remain cancer-free longer, than those who don't get radiation.
- In one large study, women who didn't get radiation after lumpectomy were shown to have a 60% greater risk of the cancer coming back in the same breast. Other research has shown that even women with very small cancers (1 centimeter or smaller) benefit from radiation after lumpectomy.

The recurrence can still happen with lumpectomy plus radiation. In the studies mentioned above, 14% of the women in one study and 9% of the women in the other study who had lumpectomy plus radiation had a recurrence in the same breast.

- axillary lymph node removal by traditional approach
- sentinel approach /sentinel lymph node dissection (preferred approach for people without enlarged nodes) +possible radiation to supraclavicular and/or internal mammary lymph nodes

Sentinel Lymph Node Dissection
the sentinel lymph node is the first node "standing guard" for your breast.
very first lymph node that filters fluid draining away from the breast cancer.
If cancer cells are breaking away from the tumor and traveling away from your breast via the lymph system, the sentinel lymph node is more likely than other lymph nodes to contain cancer.


The idea behind sentinel node dissection
Instead of removing ten or more lymph nodes ,remove only the one node that is most likely to have it. If this node is clean, chances are the other nodes have not been affected. In reality, the surgeon usually removes a cluster of two or three nodes—the sentinel node and those closest to it.

Chemotherapy
Chemotherapy weakens and destroys cancer cells at the original tumor site and throughout the body.
destroying the cells or stopping them from dividing.



Chemotherapy for early-stage disease
- Early-stage breast cancer generally means cancer that is classified as:
- stage 0
- stage I
- stages IIA and IIB
- some stage III

Chemotherapy is used to treat:
- early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back
- advanced-stage breast cancer to destroy or damage the cancer cells as much as possible
- In some cases, chemotherapy is given before surgery to shrink the cancer.

A
Hormonal Therapy
Hormonal therapy
IS NOT
hormone replacement therapy (HRT).

Treat hormone-receptor-positive breast cancers in two ways:
by lowering the amount of the hormone progesterone in the body
by blocking the action of progesterone on breast cancer cells 


reduce the risk of early-stage hormone-receptor-positive breast cancers coming back (recurring) after surgery

B

Radiation Therapy after breast conserving surgery (lumpectomy)
remains an acceptable standard of care
* In patients with clinically negative axillae who do not undergo axillary dissection, radiation therapy to the supraclavicular and axillary regions at the time of breast irradiation results in a high rate (>95%) of regional nodal control with minimal morbidity

Radiation Therapy after Breast-Conserving Surgery Improves Survival
- Radiation therapy after breast-conserving surgery substantially reduces the risk of cancer recurring in the breast and moderately reduces the risk of death from the disease, according to updated results from a meta-analysis by the Early Breast Cancer Trialists' Collaborative Group.
- The results, published online October 19, 2011 in The Lancet, are based on data from nearly 11,000 women who participated in 17 randomized trials that compared breast-conserving surgery with and without radiation therapy. Radiation therapy may help prevent breast cancer from recurring or spreading to other parts of the body by eliminating microscopic disease that remains in the breast after surgery.
- Overall, the authors reported, radiation therapy was associated with a
16 percent drop in the absolute risk of breast cancer recurring
in the first decade (from 35 percent to 19 percent); it was also associated with a
4 percent drop in the absolute risk of dying
from breast cancer in the first 15 years after surgery (from 25 percent to 21 percent).
- The success of radiation in reducing the recurrence of breast cancer depended on which biological subtype of the disease a woman had, the study found.
Patients with estrogen receptor-positive tumors benefited more
than women with estrogen receptor-negative and triple-negative disease.

http://www.cancer.gov/clinicaltrials/results/summary/2011/EBCTCG1211

- begins 2-4 weeks after surgery
- The dose of radiation delivered to the entire breast is between 4,500 and 5,000 cGy
- A booster dose of 1,500 cGy is delivered to the tumor site
- Treatment is given for 5 days per week during a period of 6 weeks
- Side effects can include fatigue, burns, and skin thickening

Follow-Up Care of long term survivors
*The vast majority of relapse, both regional and distant, occur within the first 3 years.
Physical examination
should be performed
- every 3-6months for the first three years
- every 6 months in years four and five.
- After five years, annual physical examinations provide adequate follow-up
Mammography
is important for the early recognition of recurrence.
- approximately six months after tumor excision and the completion of all treatments
- should then be done at least annually.
Chest x-ray
Routine chest radiograms detect 2.3-19.5 % of recurrences in asymptomatic patients and may be indicated on an annual basis.
- Other imaging studies may be necessary in symptomatic patients

C
- Chemotherapy and radiation
therapy after mastectomy
- The risk of locoregional failure remains significantly high enough to consider postmastectomy radiation therapy in patient with
- positive postmastectomy margins
- primary tumor >5cm
-
involvement of 4 or more lymph nodes at the time of mastectomy

- Clinical practice guidelines recently developed by the American Society of Clinical Oncology (ASCO) support the routine use of postmastectomy radiation therapy for woman with stage 3 or T3 diseases or who have 4 or more involve axillary lymph nodes.

Radiation dose and protocal
- 4500 – 5000 cGy should be sufficient to control subclinical microscopic disease
- In patient who have undergone axillary lymph node dissection, even in those with multiple positive nodes, treatment of the axilla dose not appear to be necessary
- Treatment of the suprclavicular and/or internal mammary chain should employ tecniques and field arrangements that
minimize overlap between adjacent fields
and decrease the dose to underlying cardiac and pulmonary structure

. Does this woman need the adjuvant systemic treatment? Please explain.
D
endocrine therapy
- Tamoxifen
- Aromatase inhibitors (Ais)

Adjuvant treatment of breast cancer is designed to
treat micrometastatic disease
(ie, breast cancer cells that have escaped the breast and regional lymph nodes but which have not yet had an established identifiable metastasis). Adjuvant treatment for breast cancer involves radiation therapy and systemic therapy (including a variety of chemotherapeutic, hormonal and biologic agents).

If breast cancer cells have progesterone receptors, the cancer is called
PgR-positive breast cancer
. About 75 to 80 percent of breast cancers are ER- and/or PgR-positive.
Low-grade cancers
are even more likely to be ER- and/or PgR-positive

- Our patient is in the group of Early stage breast cancer Because the lesion is still in breast and lesion is not metastasis to skin or lymphnode in other areas.
- Patient is separated in to 3 groups by using Predictive markers that is Hormone receptor status and HER2 status
- Found that ER – negative,
PR – positive
,
Her-2 – negative so patient classify as
Hormone receptor positive breast cancer group
.
-
So the treatment is endocrine therapy

Adjuvant Endocrine Therapy, ER/PR+ Localized Disease
Selection of agents depends on menopausal status and concern about side-effect profile

Tamoxifen
- reduce the risk of recurrence by about 40% and the risk of death by about 30%
- effective in both premenopausal and postmenopausal women
- may be used either alone or after chemotherapy

Adverse Effect : Acute toxicities of tamoxifen include hot flushes and gynecologic symptoms; long-term toxicities are thrombosis and uterine cancer

Aromatase inhibitors

- effective for postmenopausal women
- reducing the risk of recurrence by approximately 20% compared with tamoxifen
- Adverse Effect :Acute toxicities of AIs include arthralgias, hot flushes, and gynecologic symptoms; osteoporosis is a long-term adverse effect

Premenopausal patients

- Tamoxifen 20 mg PO daily for 5y 

or

- Tamoxifen 20 mg PO daily for 2-5y, followed by an AI for a total of up to 10y
(used for patients who are premenopausal at diagnosis and become postmenopausal during therapy)


Postmenopausal patients

- Tamoxifen 20 mg PO daily for 5y 

or

- AIs for 5y, either alone or sequentially after 2-5y of tamoxifen

Risk evaluation of giving Chemotherapy
THANK YOU
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