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Breast Anatomy please review

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1 Breast Anatomy please review

2 Macroscopic anatomy Conventional partition 4 quadrants Areola
Axillary part Inframamary fold

3 Functional structure of the breast
Please review physiology

4 3 ESENTIAL COMPONENTS Glandular tissue Connective tissue Fatty tissue
Their proportions varies significantly with Age Nutrition status Pregnancy/Post-partum/Lactation

5 Microscopic structure
1.Glandular tissue Produces milk as final product 15-20 lobules completely separated, with radial disposition around the nipple Galactofore ducts – nipple (small dilated area in the areola, opening in the nipple)

6 Microscopic structure
2 Conective tissue Creates structure/ support Included are the suspensory ligaments Connects the breast to the skin and fascia of the pectoralis major

7 Microscopic structure
3 Fatty tissue Participates to the structure of the breast Anterior, posterior and within the lobules Varies according to diet and can produce major variations in the volume of the breast

8 Areola Specialized skin adapted for lactation Nipple in the middle
Sebaceous glands visible on the surface (Montgomery) Contains smooth muscles which participate in milk evacuation during lactation Highly innervated area

9 Male breast Rudimentary, areola and nipple
Glandular tissue + fatty tissue are – most often- rudimentary or absent. Normal <2cm

10 Breast development Significant changes in volume and shape according to Age Physiologic status In adolescence structure becomes nodular and the volume and structure changes during menstrual cycle.

11 Aging Volume diminishes
Changes in structural proportions – glandular tissue diminishes and is replaced by fat Changes in position due to loss in the elasticity of suspensor structures Loss of axillary hair Sclerosing of ducts

12 Blood vessels and lymphatics
Please review anatomy

13 Axilary lymph nodes Please review anatomy

14 Congenital malformations
Breast develops from the mammary folds (ectodermic epithelium) on a virtual line (axilla – inguinal ligament) On this line mammary buds develop and regress spontaneously At birth – breast is fully developed and may produce milk under maternal hormonal influence (first days crises)

15 Congenital anomalies – number and position

16 Amastia One of the mammary bud lack of development

17 Polymastia Frequent malformations
More gland with incomplete development On the axillary line Mammary ectopy Supranumerary breast may have complete structure and milk secretion May generate diseases like a normal gland

18 Ately - Politely Congenital absence of the nipple
Breast can be normal in structure Lactation is impossible More nipples with or without areola With or without breast tissue

19 Abnormal positions of the nipple
Difficulties during breast feeding Major confusion = retraction of the nipple characteristic of breast cancer

20 Abnormalities in shape and volume

21 Atrophy Hipertrofia mamara Surgical cure Dystrophy
Trauma (including surgical) Congenital – associated with atrophy of pectoralis major Infections After radiation Hipertrofia mamara Uni/bilateral Excessive growth? In Endocrine pathology Obesity Surgical cure Esthetic reason Psychological reason

22 Surgical correction for esthetic reasons Asymmetry
Hypotrophy Reversed form hypertrophy Uni/bilateral Mycromasty Surgical correction for esthetic reasons Asymmetry Major difference between left and right breast Esthetic and psychological problems Easy to solve: surgical reduction or breast implant Gynecomasty Normal/pathologic not mathematical limit Uni/bilateral Primary gonadal dysfunction or secundary endocrine imbalance Adolescent?! ~ normal Surgical removal

23 Trauma of the breast Breast contusion
Acute compression on the costal grid During lactation lesions are more complex: Large galactofore ducts may break Increases risk of infection Steatonecrosis of fat tissue Residual lesion after contusion Aseptic necrosis of fat tissue – fat liquefy – pseudocysts form and finally = fibrotic scar Clinical examination: hard nodule, not well delimited – frequent confused with malignancies RESECTION BIOPSY

24 Traumatic lesions of the breast
Wounds Most frequently stab wounds (precordial area) In non-lactating breast – no special problem Lactating breast Wound involving galactofore ducts – high risk of infection Intra-glandular dissemination via ducts Fistula – require the mother to stop lactation

25 Inflammatory lesions

26 Major forms According to type of tissue Types
Mastitis: primary infection of glandular structures Paramastitis (perimastitis) inflammation of connective tissue surrouding glandular structures Types Acute Chronic

27 Mastitis Ethology Almost exclusively during lactation, usually in the first 2-3 weeks More frequently after the first child and in women with neglect in the care of the breast (local contamination in all cases) Bacteria penetrate through small lesions produced in the area of the areola and affect-later on- structures in surrounding tissues

28 Mastitis – stages of development
GALACTOFORITIS Isolated infection of galactofore ducts (one or more then one lobules) PRESENTATION: Increase in the volume of the breast Pain, both spontaneous and on mombilization. Accentuated during breast feeding Pressure on the nipple: milk + puss through one orifice: differential diagnosis BUDIN sign Non significant general signs of inflammation- fever 38 No axillary lymph nodes enlargements at this stage EVOLUTION: - breast feeding should stop (ATB) + breast emptying. - potentially reversible after antibiotics and anti-inflammatory drugs - may progress to abscess formation

Suppurative inflammation progresses in connective tissue outside glandular mass CLINICAL PRESENTATION: Accentuated local signs + general signs of inflammation Breast is extremely painful Deformation of the breast: globally enlarged but also not regular shape (small abscesses are more prominent in contour) Budin sign = present Venous stasis – visible veins on the surface of the breast Lymphangitis but no inflammatory lymph node enlargements

30 Mastitis BREAST ABSCESS Treatment: ATB + surgical drainage
Recurrent infection : more then one lobule infected in different evolution stages – serial abscess formation Possible diffusion of infection in the fatty tissues surrounding the breast PARAMASTITIS BREAST FLEGMONOUS INFECTION

31 Paramastitis Inflammation of the fatty tissue of the breast by inoculation Direct Complication of mastitis Forms: Areolas abscess Subcutaneous abscess Retro-mammary abscess

32 Areolas abscess Acute inflammation of glands on the surface of the areola CLINICAL PRESENTATION: Small tumor in the area of the areola Very thin skin – tendency to evacuate spontaneously Lactation should be discontinued

33 Subcutaneous abscess Develops subcutaneous Associates lymphangitis
Easy to observe collection, superficial, is drained or spontaneous fistulisation

34 Retro-mammary abscess
Inflammation of the fat in the back of the breast Ethiology: mastitis developed in a lobule situated deep in the breast Well developed inflammation signs SPECIFIC: the breast appears as pushed forward due to inflammation behind Floating sensation Very painful when mobilized


36 Forms Hard (wood-like) chronic mastitis (evolution of an acute mastitis) Galactocele Tuberculosis history of Sifilis medicine

37 Hard (wood-like) mastitis
Evolution of an acute form Tendency to develop very slowly New findings Hard nodules Orange-skin appearance (adherence to skin) Permanent retraction of the nipple Lymph node enlargements Confusion with breast cancer

38 Galactocele Particular form of chronic mastitis developing during lactation Pseudocyst- cavity of the abscess communicates with one or more large ducts. Contains milk or milky secretion Pressure on the nipple – secretion containg puss and milk

39 Galactocele Exploration ASYMETRIC breast enlargement
”tumor” with a regular surface Fluctuence Painless Deformable Thumb print No inflammatory signs Secretion contains milk + puss

40 Dystrophic lesions 1. Fibrocystic disease 2. Solitary cyst

41 Fibrocystic disease (Reclus)
Most frequent disease of the breast Hormonal influence (most frequent year and unlikely during menopause) Determined factor: estrogen or an imbalance between estrogen and progesteron

42 Microscopic lesions Typical epithelial lesions are encountered also in the normal breast but have been classified as pathological Typical lesions: Cysts (macro and microscopical) Papilomatosis Adenosis Fibrosis Epithelial duct hyperplasis

43 Clinical presentation
Numerous “tumors” uni-/bilateral with no or few symptoms = PAIN is the most important one and points for explorartion of the breast Nipple discharge Symptoms vary during cycle, aggravates premenstrual, nodules change in shape and size and may also disappear.

44 Differential diagnosis
Pain breast Variations in symptoms cancer Mammography may help (not beneficial in very young women – breast structure too dense to allow for a good evaluation) Ultrasound + Doppler is probably the best method of evaluation Guided biopsy in cases with doubtful lesions

45 Treatment Surgical biopsy if any doubt
Limited excision under local or general anaestesia Punction for decompression of large cysts (+cytology) FOLLOW UP

46 Prognostic Alternating periods of rest and exacerbation of symptoms
Auto-examination of the breast and seek medical advise if changes develop Risk of cancer is minimally increased only in patients with epithelial dysplasia

47 Solitary cyst Dystrophic lesion in young women 30-40 years
Large cystic TUMOR with no signs of maligancy. Malignant characteristics would be apparent in such a size. CYST (hard, very hard, well circumscribed) US: liquid content Treatment : punction to evacuate and clinical follow-up


49 Definitions Breast cancer is a growth of abnormal cells usually within the ducts (which carry the milk to the nipple) or lobules (glands for milk production) of the breast. In more advanced stages of the disease, these out-of-control cells invade nearby tissues or travel throughout the body to other tissues or organs

50 How does breast cancer develop?
1. Normal ducts 2.  Intraductal Hyperplasia 3.  Atypical Ductal Hyperplasia 4.  Ductal Carcinoma In Situ 5.  Invasive Ductal Cancer

51 Epidemiology Incidence and prevalence
Each year the disease is diagnosed in over one million women worldwide and is the cause of death in over 400,000 women, second leading cause of death in women Breast cancer can occur in men, although the incidence is much lower, amounting to around 1% of all breast cancers.

52 Risk factors Age; Nearly 80% of all newly diagnosed invasive breast cancer cases occur in women aged 50 and older and is less common in premenopausal women. Family history of breast cancer. Paget´s disease accounts for 1% of all breast CA, is associated with an infiltrating, and intraductal carcinoma.

53 Mutations in these genes are associated with a lifetime
Genetic factors; some cancers have a genetic component and can be inherited. It is estimated that between 5 and 10% of breast cancer can be attributed to one of two predisposing genes: BRCA1 on chromosome 17. BRCA2 on chromosome 13. Mutations in these genes are associated with a lifetime

54 BRCA Mutations

55 Risk factors Hormone factors:
Early menarche women who started their period before 12 years of age. Late menopause women who go through menopause after age 55 Pregnancy history: women who have their first child after the age of 30 or who have had fewer pregnancies or no pregnancies. Breast density: women with less fatty, denser breasts, which are normally older women, have an increased chance of breast cancer. Obesity after menopause women who were overweight based on a body mass index (BMI) greater than 25 are 1 to 2 times more likely to die from breast cancer than women with a normal BMI.

56 Risk factors Ionizing radiation; In 2005, the National Toxicology Program classified X radiation and gamma radiation as known human carcinogens. Compelling scientific evidence points to some of the 100,000 synthetic chemicals in use today as contributing to the development of breast cancer, either by altering hormone function or gene expression.

57 Risk factors There is broad agreement that exposure over time to estrogens in the body increases the risk of breast cancer. Hormone replacement therapy (HRT) and hormones in oral contraceptives increase this risk – limited increase with oral contraceptives

58 Risk factors Breast disease Atpyical Hyperplasia
Intraductal carcinoma in situ Intralobular carcinoma in situ Diet Fat Alcohol

59 Pathology

60 Types of breast cancer In situ Invasive Intraductal (DCIS)
Intralobular (LCIS) Invasive Infiltrating ductal carcinoma Tubular carcinoma Medullary carcinoma Mucinous carcinoma There are 2 primary classifications of in situ breast cancer. These are ductal carcinoma in situ and lobular carcinoma in situ. Ductal carcinoma or non-infiltrating or intraductal carcinoma is malignant epithelial cells confined to the mammary ducts with no evidence of invasion of the basement membranes. In the past, DCIS was treated with mastectomy, which resulted in cure for 98% of patients. Screening programs have increased the diagnosis of DCIS. With more women being diagnosed with DCIS, breast-conserving therapy is more desirable. This has become a most controversial area in the treatment of breast cancer. Lobular ductal carcinoma in situ is not detectable clinically or by mammography. It is considered a risk factor for breast cancer, but not a precursor. The general approach is for careful observation. Bilateral prophylactic mastectomy has been used to treat LDIS. The categories of invasive carcinoma are infiltrating ductal carcinoma (75%), tubular carcinoma, modularly carcinoma, and mucinous carcinoma.

61 In Situ Breast Cancer In Situ Breast Cancer remains within the ducts or lobules of the breasts. This type of cancer is only detected by mammograms – not by a physical examination. If the cancer is in the duct it is called Ductal Carcinoma in situ. If the cancer is in the lobule of the breast, it is called Lobular Carcinoma in situ. This type of cancer is most common among pre-menopausal women. There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other.

62 Infiltrating Breast Cancer
Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule. This type of cancer forms a lump that can eventually be felt by a physical examination. Breast cancer cells cross the lining of the milk duct or lobule, and begin to invade adjacent tissues. This type of cancer is called "infiltrating cancer." In this picture, you can see the breast cancer cells invading the milk duct.

63 More on Infiltrating Breast Cancer
Infiltrating cancer of the duct Called “Infiltrating Ductal Carcinoma” It is the most common type of breast cancer. Cancer cells that are invading the fatty tissue around the duct, they stimulate the growth of non-cancerous scar like tissue that surrounds the cancer making it easier to spot. Infiltrating cancer of the lobules Called “Infiltrating Lobular Carcinoma” Occurs when cells stream out in a single file into the surrounding breast tissue. This type of cancer is harder to detect on a mammogram because there is no fibrous growth.

64 Other Types of Breast Cancer
Cystosarcoma Phyllodes Inflammatory Cancer Accounts for less than one percent of all breast cancers and looks as though the breast is infected. Breast Cancer During Pregnancy Paget’s Disease

65 TNM Criteria T = Primary Tumor N = Regional Lymph nodes
Tis = carcinoma in situ T1 = less than 2 cm in diameter T2 = between 2 and 5 cm in diameter T3 = more than 5 cm in diameter T4 = any size, but extends to the skin or chest wall N = Regional Lymph nodes N0 = no regional node involvement N1 = metastasis to movable same side axillary nodes N2 = metastasis to fixed same side axillary nodes N3 = metastasis to same side internal mammary nodes M = Distant Metastasis M0 = no distant metastasis M1 = distant metastasis

66 Stage 1 Tumor < 2.0 cm in greatest dimension
No nodal involvement (N0) No metastases (M0) Stage 1 breast cancer involves primarily small tumors (less than or equal to 2 cm) with no known lymph node involvement and no metastases to other organs. About 40 to 50% or women present at this stage. 30% will relapse following local regional treatment.

67 Stage II Tumor > 2.0 < 5 cm or
Ipsilateral axillary lymph node (N1) No Metastasis (M0) In general, stage 2 breast cancers are characterized by either slightly larger primary tumor than stage 1 (between 2 and 5 cm) or if there is lymph node involvement. About 70% of stage II patients will relapse following treatment.

68 Stage III Tumor > 5 cm (T3)
or ipsilateral axillary lymph nodes fixed to each other or other structures (N2) involvement of ipsilateral internal mammary nodes (N3) Inflammatory carcinoma (T4d) In general, stage III consists of large tumors (greater than 5 cm) with signs of inflammatory breast cancer. Also if ipsilateral nodes are involved where the tumor has caused the node to be fixed to another node or to other structures it is designated stage 3. Also metastasis to ipsilateral internal mammary lymph nodes gets a designation of stage 3.

69 Stage IV (Metastatic breast cancer)
Any T Any N Metastasis (M1) Stage 4 means any metastatic breast cancer no matter what size the tumor or if there is nodal involvement or not. If it is metastatic, it is stage 4. In general, stage 4 is not considered curable. The goals are to increase the quality of life and extend survival time.

70 Screening and Symptoms
Breast Cancer: Symptoms and Screening


72 Clinical examination Performed by doctor or trained nurse practitioner
Annually for women over 40 At least every 3 years for women between 20 and 40 More frequent examination for high risk patients Let’s begin by looking at the clinical exam. Clinical breast exams are recommended annually for women over 40 and at least every 3 years for women between 20 and 40. It should be performed by a physician or a trained nurse practitioner. If the woman has a high risk of breast cancer, her physician may recommend frequent examination. Clinical breast exam has been shown to decrease breast cancer mortality.

73 Mammography X-ray of the breast
Has been shown to save lives in patients 50-69 Data mixed on usefulness for patients 40-49 Normal mammogram does not rule out possibility of cancer completely Mammography is the next method of breast cancer screening. It is an x-ray of the breast but uses the lowest radiation doses. It is the mainstay of breast cancer detection with an 85 to 90% diagnostic accuracy rate which is very high and can detect breast cancers the size of a freckle. However, a normal mammogram does not rule out the possibility of cancer completely. On the other hand, screening mammography has been shown to save lives. This is especially true in women over 50, where routine mammogram leads to a 25 to 30% decrease in breast cancer mortality.

74 Mammography American Cancer Society recommends: Women (asymptomatic) 40 years of age and older should have a mammogram every year. The American cancer society recommends that asymptomatic women 40 years of age and older should have a mammogram every year.

75 Thermograph Thermograph is one of the newest ways to detect breast cancer. Thermograph is a thermal image of the breast tissue. It can also detect cancer before the traditional mammogram can.

76 Breast Self Examination
Opportunity for woman to become familiar with her breasts Monthly exam of the breasts and underarm area May discover any changes early Begin at age 20, continue monthly Monthly breast self-exam or BSE is monthly examination of the breasts and underarm area by the patient where she is looking and feeling for changes. It is an opportunity for the patient to become familiar with her breasts so if there is a change, she’ll be able to detect it more quickly. Breast self-exam should begin at the age of 20 and continue monthly. In, November 2002, the United States Preventative Services Task Force found that evidence is insufficient to recommend teaching BSE. They found fair evidence that BSE caused false-positive results which increased costs to the health care system. Because there have not been any good studies done to decide the benefit/risk ratio of BSE, this group dropped BSE from its recommendations. Many doctors still teach BSE during clinical breast exams and feel there is benefit to a woman being familiar her own body. More studies need to be done.

77 When to do BSE Menstruating women- 5 to 7 days after the beginning of
their period Menopausal women - same date each month Pregnant women – Takes about 20 minutes Perform BSE at least once a month Examine all breast tissue Despite the controversy, because some women will still want to utilize BSE, the guidelines are included in this presentation. Premenopausal women should perform BSE five to seven days following the start of menstruation. Postmenopausal women and pregnant women should mark their calendar and perform BSE the same day each month. BSE usually takes around 20 minutes and it is important that all breast tissue be examined during the self-exam. Although there have been no studies, which demonstrate a survival advantage to performing monthly BSE, it remains a cornerstone of the recommendation for early breast cancer detection by the ACS and NCI.

78 Why don’t more women practice BSE?
Fear Embarrassment Youth Lack of knowledge Too busy, forgetfulness Why don’t more women practice BSE? Some fear finding a lump or cancer. Some are embarrassed or have difficulty touching oneself. There are taboos in some cultures about touching one’s own body. Many women think they are too young- I will worry later about cancer. Life-saving health habits formed early become a routine part of daily life and pay off later. This is why more emphasis is being place on reaching teenagers. Another big reason for not performing self-exams is a lack of knowledge of how to perform BSE, lack of confidence. Women say they are too busy or cite forgetfulness. These reasons may also be linked to fear. Since most women or their partners find breast changes, BSE can be a life saver.

79 Abnormal signs and symptoms
So, lets look at abnormal signs and symptoms. Breast tumors can produce puckering, dimpling, or retractions by disrupting underlying structures. Also, if a tumor is blocking the lymphatic drainage, the pores of the breast skin may become more prominent. This results in an orange peel appearance. In breast self-exam, the nipple should always be squeezed to check for discharge. Any new discharge should be reported to the physician. A milky or clear discharge can be a normal finding in women anytime following childbirth. Greenish discharges are often a sign of mastitis and infection. A bloody discharge is strongly suggestive of breast cancer and should be reported immediately. Any new thickening of the skin or lump or “knot” in the breast should be reported to a physician. It is normal for an adult breast to feel granular, nodular, or lumpy especially premenstrually. However, any new mass or enlargement of an existing mass should be reported to a physician. Breast cancers tend to be hard, with no clear borders and immobile ( attached to skin or underlying structures). A retracted or inverted nipple can be normal and in itself is not a problem. However the recent inversion of a nipple could be a sign of breast cancer. Puckering Dimpling Retraction Nipple discharge Thickening of skin or lump or “knot” Retracted nipple

80 Abnormal signs and symptoms
A recent change in breast size, especially unilaterally can be of concern if not related to a normal physiological change. Breast pain or tenderness during the menstrual period is normal. However, prolonged tenderness may be a sign of breast cancer. It is important to note that most malignant breast lesions are not painful. Inflammatory signs of cancer can be rash or edema. A change in the direction the nipple is pointing may also be a sign of breast cancer. Scaling on nipples can also indicate a problem. Scaling around both nipples could be due to allergy to soap or powder but scaling around one nipple often indicates an abnormality. And then finally a sore on the breast that does not heal should be examined by a physician. Change in breast size Pain or tenderness Redness Change in nipple position Scaling around nipples Sore on breast that does not heal

81 Common Symptoms A change in how the breast or nipple feels
Lump or thickening in or near the breast or in the underarm area Nipple tenderness A change in how the breast or nipple looks Change in the size or shape of the breast Nipple turned inward into the breast Change in the skin of the breast (“orange” skin, scaly, red, or swollen) Nipple discharge (fluid)

82 How is Breast Cancer Diagnosed?
Screening and/or diagnostic mammography Ultrasound MRI scan Biopsy is necessary to confirm a diagnosis Blood tests are often used to determine if the cancer has spread outside the breast Additional tests may be used to determine stage

83 Methods of Detection Clinical exam by MD or nurse Mammography
Monthly breast self-exam (BSE) Methods of Detection There are 3 main screening methods for breast cancer. These are clinical exam by a physician or nurse, mammography, and monthly breast self exam.

84 Diagnostic alternatives
Screening – abnormal image requiring histology Nodule: discovered during BSE requires clinical examination + immaging + histology Nodule discovered during clinical examination (same) LARGE tumor with clinical characteristics of breast cancer – diagnostic obvious, BUT immaging and histology compulsory

85 Conventionell Mammography Screening
A mammogram is an x-ray of the breast, may find tumors that are too small to feel. May find ductal carcinoma in situ, abnormal cells in the lining of a breast duct, which may become invasive cancer in some women. 85 85 85

86 Mammogram Main radiographic examination for breast cancer detection
Breast cancer Lesions can be either: Microcalcifications Nodules : typically irregular lesion There could be false negative or false positive

87 Ultrasound May be used along with a mammogram to evaluate breast abnormalities. Performed by a radiologist Allows images from almost any orientation Excellent at imaging cysts Helps for a guided biopsy or FNA Explores a suspicious lymph node. Limits: lacks the detail of conventional mammography Unable to image microcalcifications -> not approved as a screening tool for breast cancer diagnosis

88 Ultrasonography- Diagnosis
Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tissue in women with nonspecific thichening Doppler effect 88 88 88

89 Biopsy- Diagosis If the clinical breast exam, mammogram or ultrasound shows an area of possible concern, a biopsy is usually the next step. A biopsy is the removal of cells or tissues of concern so that they can be viewed under a microscope and further tested by a pathologist. 89 89 89

90 Needle Aspiration Needle aspiration  Cytology
Nature of cells: cancerous or not Advantages: rapid, minimal discomfort, no incision complicating local therapy, immediate results Limits: no difference between in situ from and invasive cancer, false-negative

91 Biopsy Biopsy « tru-cut », mamotome  Histology
DIAGNOSIS Biopsy Biopsy « tru-cut », mamotome  Histology Advantages: rapid, minimal to moderate discomfort, no surgical incision, guided by ultrasound Limits: false-negative, sampling error with larger lesions L ’aspiration à l ’aiguille fine réalise une « cytoponction », éventuellement radioguidée. Cette technique est la plus utilisée, simple, indolore, elle permet de ramener du matériel de qualité pour l ’immuno-histochimie ( 5 % de faux négatifs ). L ’association de la clinique à la radiologie et à la cytoponction procure une fiabilité de 99 %. La biopsie au trocart de type « tru-cut » représente un geste plus lourd avec un risque d ’hématome et le matériel obtenu n ’est pas toujours satisfaisant pour l ’immuno-histochimie. Une biopsie-excision chirurgicale, radio-guidée ou non, pourra être effectuée en fonction de la présence ou non de lésion clinique. Dans tous les cas un diagnostic histologique préalable est nécessaire à une chimiothérapie ou à une radiothérapie première.

92 Chest x-ray To determine if the breast cancer has spread to the lungs.
92 92

93 Bone Scan A common place for breast cancer to spread is to the bones.
A bone scan is often done to assure there is no detectable metastasis to the bones. 93 93

94 positron emission mammography (a PEM scan)
The PEM system’s camera and detectors are closer to the area affected with cancer, which produces a very sharp, detailed image of tumors and cancerous tissue. With PEM, cancers can be seen as small as 1.5 – 2mm, about the width of a grain of rice 94 94 94

95 (MRI) To Improve Breast Cancer Detection
Magnetic Resonance Imaging Technology (MRI) To Improve Breast Cancer Detection MRI combines the use of powerful magnets and radio wave pulses. Used to detect breast cancer in some women at higher risk MRI can also be used before surgery to identify areas of the breast affected by the tumor. 95 95 95

96 Prevention No intervention can completely prevent cancer; there are ways to reduce risk Prophylactic mastectomy (preventive removal of breasts) and prophylactic oophorectomy (preventive removal of ovaries) for women at high risk Chemoprevention (drugs that lower breast cancer risk) with tamoxifen (Nolvadex) or raloxifene (Evista) Risk assessment tools can help those without strong family history discover risk of developing breast cancer

97 How is Breast Cancer Treated?
Treatment depends on stage of cancer More than one treatment may be used Surgery Radiation therapy Chemotherapy Hormone therapy Targeted therapy

98 Factors Considered in Treatment Decisions
The stage and grade (how different cancer cells look from healthy cells) of the tumor The tumor’s hormone receptor status (estrogen receptor [ER], progesterone receptor [PR]) and human epidermal growth factor receptor-2 (HER2) status Genetic description of the tumor The presence of known mutations to breast cancer genes The woman’s menopausal status, age, and general health

99 Cancer Treatment: Surgery
Generally, surgery to remove the tumor followed by radiation therapy is initial treatment For invasive cancer, lymph nodes are removed and evaluated More invasive surgery (such as mastectomy) is not always better; discuss with your doctor Breast reconstruction (plastic surgery) is an option after mastectomy

100 Principles of Surgery Early Breast Cancer Targets: breast and nodes
Objectives: to remove the tumor, to get histologic data  Curative treatment Advanced and metastatic breast cancer Target: assessible mass Objectives: to reduce tumor volume, to remove one isolated metastasis (pulmonary or liver), to treat complications of the disease (spinal compressions…)  Palliative treatment

101 Partial Mastectomy (Lumpectomy)
Contraindications A. Previous history of Radiation Therapy B. More than one cancer in same breast C. Large tumor, small breast, cosmetic deformity D. Nipple involvement

102 Surgery Terms Excisional Biopsy vs. Lumpectomy
Partial Mastectomy vs. Lumpectomy Incisional Biopsy

103 Mastectomy Difference between Total (simple) Mastectomy
Modified Radical Mastectomy

104 Skin Sparing Mastectomy
Skin sparing mastectomy preserves the majority of the breast skin and the inframammary fold The entire nipple and areola are removed

105 Is Radical Mastectomy still in use? What is it?

106 Subcutaneous Mastectomy
Is Subcutaneous Mastectomy a cancer operation? How does it differ from Total Mastectomy?

107 Sentinel Node Biopsy Major advance Almost no risk of lymphedema
Blue dye Nuclear medicine

108 Sentinel Lymph Node Biopsy
Quickly becoming the gold standard May be as accurate or more accurate than ALN dissection while limiting the complications and costs Involves injection off Technitium-99 sulfur colloid and or 1% isosulfan blue dye

109 Histological information after surgery of early breast cancer
Type of tumor: invasive or in situ, adenocarcinoma or others, ductal or lobular,… Definitive size Histopronosis grade (SBR) Vascular and lymphnode embols Margins +++ Hormonal receptors HER2 status (IHC and/or FISH)

110 Tissue expander Latissimus dorsi TRAM
Reconstruction Tissue expander Latissimus dorsi TRAM

111 Reconstruction: Tissue expander
Encapsulated silicone implant reconstruction corrected with tissue expansion. The capsule is first excised, and the tissue expander is used to create an oversized pocket for the implant.

112 Reconstruction: Latissimus Dorsi
following autogenous latissimus reconstruction w/o implant. Opposite breast reduction mammoplasty required for symmetry.

113 Reconstruction: TRAM following left free TRAM reconstruction. Skin replacement included all skin between scar & inframammary fold. Nipple reconstruction, opposite mastopexy done at separate procedure.

114 Breast Reconstruction in the Skin Sparing Mastectomy
TRAM flap Latissimus flap Implant/Expander Silicone is preferred and is available on study protocol Tram flap with nipple reconstruction and tatooing

115 Cancer Treatment: Adjuvant Therapy
Treatment given in addition to surgery to reduce the risk of recurrence May include radiation therapy, chemotherapy, targeted therapy, and hormone therapy

116 Cancer Treatment: Radiation Therapy
The use of high-energy x-rays to destroy cancer cells Usually used to treat breast cancer after surgery External-beam: outside the body Internal: uses implants inside the body More precise ways to direct radiation to the tumor and shorter treatment courses are being studied in clinical trials Side effects may include fatigue, swelling, and skin changes

117 Radiotherapy principles
TREATMENT Radiotherapy principles Objectives Eradicate residual disease thus reduce local recurrence Increase DFS (disease free survival) and OS (overall survival) Radiation therapy warranted after breast-conservative surgery Sometimes indicated after mastectomy

118 Systemic treatment: principles
Systemic treatment is recommended under certain circumstances based on prognostic factors and guidelines Treatment objectives: Reduce the distant metastasis Increase Time to progression (TTP), Prolong overall survival In all cases of LABC or MBC Principles: Chemotherapy Endocrine therapy Targeted therapies

119 Cancer Treatment: Chemotherapy
Use of drugs to kill cancer cells May be given before surgery to shrink a large tumor (neoadjuvant chemotherapy) or after surgery to reduce the risk of recurrence (adjuvant chemotherapy) A combination of medications is often used

120 Cancer Treatment: Hormone Therapy
Used to lower risk of recurrence for cancers that test positive for ER and/or PR Tamoxifen is a common hormone therapy effective in many premenopausal and postmenopausal women Aromatase inhibitors (AIs) are also used alone or following tamoxifen use as treatment for postmenopausal women, including anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin) Tamoxifen and AIs also used for metastatic cancer; fulvestrant (Faslodex) is another option

121 Targeting the Estrogen Pathway Block receptor SERM (selective estrogen receptor modulators) Tamoxifen treatment Raloxifene prevention Decrease ligand Aromatase inhibitors Oopherectomy GnRH analogs Targeting the estrogen pathway is appealing from both treatment and prevention approaches to breast cancer since estrogen is a well recognized growth factor for the majority of breast cancers. In the prevention setting the two leading ways that the estrogen pathway has been targeted is with drugs that work at the receptor, the SERMS tam and raloxifene or agents that interfere with estrogen synthesis by targeting the aromatase enzyme and decreasing the ligand, like the AIs. the estrogen receptor is preferentially expressed in breast as well as a number of other tissues. Tamoxifen (shown here) disrupts the estrogen pathway by binding to the nuclear ER thereby preventing circulating estrogen from binding. 121

122 Cancer Treatment: Targeted Therapy
Treatment that targets genes, proteins, or tumor cell environment that helps cancer grow and survive HER2-targeted therapy: trastuzumab (Herceptin) for HER2-positive breast cancer either with or after adjuvant chemotherapy; lapatinib (Tykerb) plus capecitabine (Xeloda) for advanced or metastatic cancer Anti-angiogenic therapy (blocks blood vessels): bevacizumab (Avastin) for metastatic or recurrent breast cancer Drugs that block bone destruction (bisphosphonates)

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