Dealing with metastatic breast cancer
◼️The above is a radioisotope scan showing multiple metastasis (white arrows).
◼️Metastatic breast cancer is inoperable, the primary treatment is palliation to deal with the symptoms.
◼️Usually the first line therapy is hormonal therapy due to its less side effects, it is particularly useful for bony metastasis, the unfortunate reality is that only 30% are hormone sensitive, and even those which are responsive, they with time become resistant, the use of a different hormonal agent with such event may however produce half of the original response.
◼️The first line for Postmenopausal women is now anastrazole or some other 3rd generation aromatase inhibitor.
◼️Chemotherapy especially for rapidly growing visceral metastasis and young women may be considered.
◼️Local radiotherapy may prove useful for some cases for painful bony deposits, also internal fixation for pathological fractures is considered.
#Breast
◼️The above is a radioisotope scan showing multiple metastasis (white arrows).
◼️Metastatic breast cancer is inoperable, the primary treatment is palliation to deal with the symptoms.
◼️Usually the first line therapy is hormonal therapy due to its less side effects, it is particularly useful for bony metastasis, the unfortunate reality is that only 30% are hormone sensitive, and even those which are responsive, they with time become resistant, the use of a different hormonal agent with such event may however produce half of the original response.
◼️The first line for Postmenopausal women is now anastrazole or some other 3rd generation aromatase inhibitor.
◼️Chemotherapy especially for rapidly growing visceral metastasis and young women may be considered.
◼️Local radiotherapy may prove useful for some cases for painful bony deposits, also internal fixation for pathological fractures is considered.
#Breast
Notes to keep in mind when dealing with breast cancer
◼️Sadly, breast cancer has a very dark side to it,, even small tumors may have already sent distant micrometastases which cannot be detected by conventional means.
◼️Months or years later from the day when it was treated, these micrometastases appear again sometimes in multiple sites.
◼️Therefore, the outcome of treatment is predetermined by the presence or absence of micrometastases, to add to this dark side of breast cancer, sometimes these micrometastases remain dormant for very long time, and then suddently they decide to appear like a dead man from the grave (check above) 😕💔
◼️This is why the presence of axillary metastasis is a reflection of the evilness of the tumor and its metastatic potential, and this is why axillary dissection is mainly done to know the prognosis and NOT to improve survival, and also this is the reason why chemotherapy is indicated strongly in women with node positive disease
#Breast
◼️Sadly, breast cancer has a very dark side to it,, even small tumors may have already sent distant micrometastases which cannot be detected by conventional means.
◼️Months or years later from the day when it was treated, these micrometastases appear again sometimes in multiple sites.
◼️Therefore, the outcome of treatment is predetermined by the presence or absence of micrometastases, to add to this dark side of breast cancer, sometimes these micrometastases remain dormant for very long time, and then suddently they decide to appear like a dead man from the grave (check above) 😕💔
◼️This is why the presence of axillary metastasis is a reflection of the evilness of the tumor and its metastatic potential, and this is why axillary dissection is mainly done to know the prognosis and NOT to improve survival, and also this is the reason why chemotherapy is indicated strongly in women with node positive disease
#Breast
Genetic predisposition to breast cancer
BRCA1 = chromosome 17q predispose to breast cancer, ovarian cancer and to lesser extent prostate and colorectal cancer.
BRCA2 = chromosome 13 q, linked strongly with male breast cancer.
P53 = autosomal dominant, causes what so called Li Fraumeni syndrome which is the life of cancer at its fullest (rhabdomyosarcoma, breast cancer, leukemia, brain tumors, adrenal tumors and others)
N.B prophylactic mastectomy in these cases do not completely eliminate the risk of cancer, however it reduce it considerably, in general the risk of having BRCA genes is considered to be 30-50%.
#Breast
BRCA1 = chromosome 17q predispose to breast cancer, ovarian cancer and to lesser extent prostate and colorectal cancer.
BRCA2 = chromosome 13 q, linked strongly with male breast cancer.
P53 = autosomal dominant, causes what so called Li Fraumeni syndrome which is the life of cancer at its fullest (rhabdomyosarcoma, breast cancer, leukemia, brain tumors, adrenal tumors and others)
N.B prophylactic mastectomy in these cases do not completely eliminate the risk of cancer, however it reduce it considerably, in general the risk of having BRCA genes is considered to be 30-50%.
#Breast
Tip
Li Fraumeni = SBLA syndrome
S = sarcoma (rhabdomyosarcoma).
B= Breast cancer/Brain cancer (glioblastoma usually).
L= Leukemia/Lymphoma.
A= Adrenocortical carcinoma.
#Breast
Li Fraumeni = SBLA syndrome
S = sarcoma (rhabdomyosarcoma).
B= Breast cancer/Brain cancer (glioblastoma usually).
L= Leukemia/Lymphoma.
A= Adrenocortical carcinoma.
#Breast
Hormonal therapy in breast cancer
◼️Some breast tumors are positive for estrogen and progesterone receptors, these hormones has a promoting effect on the tumor in that they increase its growth.
◼️The idea of hormonal therapy is to alleviate the effect of estrogen on the tumor which can be done by either blockage of the receptors, or reduction of endogenous estrogen production.
◼️Tamoxifen is the most widely used drug, it selectively blocks estrogen receptors, the dose used is 20 mg daily for 5 years (studies has shown that this is better than 2 years).
◼️LHRH agonists, produces reversible ovarian suppression which has equal effect as ovarian ablation by surgery or radiation, this will block ovarian estrogen production in premenopausal women.
◼️Aromatase enzyme inhibitors (e.g anastrazole) blocks the enzyme aromatase which converts androgens into estradiol, it is suitable for Postmenopausal women, and also it is being studied for prevention of breast cancer.
#Breast
◼️Some breast tumors are positive for estrogen and progesterone receptors, these hormones has a promoting effect on the tumor in that they increase its growth.
◼️The idea of hormonal therapy is to alleviate the effect of estrogen on the tumor which can be done by either blockage of the receptors, or reduction of endogenous estrogen production.
◼️Tamoxifen is the most widely used drug, it selectively blocks estrogen receptors, the dose used is 20 mg daily for 5 years (studies has shown that this is better than 2 years).
◼️LHRH agonists, produces reversible ovarian suppression which has equal effect as ovarian ablation by surgery or radiation, this will block ovarian estrogen production in premenopausal women.
◼️Aromatase enzyme inhibitors (e.g anastrazole) blocks the enzyme aromatase which converts androgens into estradiol, it is suitable for Postmenopausal women, and also it is being studied for prevention of breast cancer.
#Breast
Radiotherapy for breast cancer
◼️In cases of conservative breast surgery, radiotherapy is necessary, because if conservative breast surgery is done alone, it leads to unacceptable recurrence rate.
◼️The use of radiotherapy following mastectomy has been largely abandoned, except if there was a locally advanced disease with infileration of chest wall, or the tumor was high grade on histology, or if there is heavy nodal disease.
◼️Axillary radiotherapy should not be combined with axillary dissection because of high risk of arm lymphedema.
#Breast
◼️In cases of conservative breast surgery, radiotherapy is necessary, because if conservative breast surgery is done alone, it leads to unacceptable recurrence rate.
◼️The use of radiotherapy following mastectomy has been largely abandoned, except if there was a locally advanced disease with infileration of chest wall, or the tumor was high grade on histology, or if there is heavy nodal disease.
◼️Axillary radiotherapy should not be combined with axillary dissection because of high risk of arm lymphedema.
#Breast
Sentinel lymph node biopsy
◼️Sentinel lymph node is the first node that drain the tumor-bearing area in the breast.
◼️The technique involves injection of patent blue dye or/and radioisotope labelled albumin at the site of the tumor.
◼️The injected material will pass to the first node draining the tumor (sentinel).
◼️The dye can be visualized, or if radioisotope labelled albumin is used, it can be detected using gamma camera.
◼️When the node is identified, it is biopsied and sent for frozen section or more commonly definitive histology, because sometimes subcapsular micrometases in the node can be missed on frozen sections.
◼️If the sentinel lymph node biopsy is negative for metastasis, axillary dissection can then be avoided, because skip lesions (metastasis occuring distal to the sentinel lymph node) is present in less than 3% of all patients.
#Breast
◼️Sentinel lymph node is the first node that drain the tumor-bearing area in the breast.
◼️The technique involves injection of patent blue dye or/and radioisotope labelled albumin at the site of the tumor.
◼️The injected material will pass to the first node draining the tumor (sentinel).
◼️The dye can be visualized, or if radioisotope labelled albumin is used, it can be detected using gamma camera.
◼️When the node is identified, it is biopsied and sent for frozen section or more commonly definitive histology, because sometimes subcapsular micrometases in the node can be missed on frozen sections.
◼️If the sentinel lymph node biopsy is negative for metastasis, axillary dissection can then be avoided, because skip lesions (metastasis occuring distal to the sentinel lymph node) is present in less than 3% of all patients.
#Breast
Strange phenomenon of mirror image in invasive lobular carcinoma... The cancer tends to occur at exactly the same quadrant as the contralateral breast, sometimes prophylactic quadrantectomy on the other appearantly healthy side may be done
#Breast
#Breast
Bloody nipple discharge
◼️The primary goal is to exclude breast carcinoma (the dark shadow of carcinoma seems to follow every single breast disease).
◼️Bloody discharge may occur from a single duct or from multiple duct.
◼️Single duct bloody discharge may occur from intraductal papilloma, carcinoma or from duct ectasia.
◼️Bloody discharge from multiple ducts can also signify carcinoma, duct ectasia or even fibrocystic disease (which is not really a disease, its called now with the updated name abberration of normal development and involution for short ANDI).
◼️CAREFUL palpation of the breast and axillary lymph nodes is essential to detect underlying mass.
◼️Mammography may be done to detect subclinical mass.
◼️The discharge may be sent for cytology, but if negative, this do not exclude carcinoma.
#Breast
◼️The primary goal is to exclude breast carcinoma (the dark shadow of carcinoma seems to follow every single breast disease).
◼️Bloody discharge may occur from a single duct or from multiple duct.
◼️Single duct bloody discharge may occur from intraductal papilloma, carcinoma or from duct ectasia.
◼️Bloody discharge from multiple ducts can also signify carcinoma, duct ectasia or even fibrocystic disease (which is not really a disease, its called now with the updated name abberration of normal development and involution for short ANDI).
◼️CAREFUL palpation of the breast and axillary lymph nodes is essential to detect underlying mass.
◼️Mammography may be done to detect subclinical mass.
◼️The discharge may be sent for cytology, but if negative, this do not exclude carcinoma.
#Breast
Nomenclature
◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.
◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.
◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.
◼️Quadrantectomy = removal of the segment containing the tumor.
◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.
#Breast
◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.
◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.
◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.
◼️Quadrantectomy = removal of the segment containing the tumor.
◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.
#Breast
Note
Radical Halsted mastectomy which involved removal of the breast, pectoralis major and minor muscles, and axillary lymph nodes is no longer indicated because it causes significant morbidity with no survival benefit.
#Breast
Radical Halsted mastectomy which involved removal of the breast, pectoralis major and minor muscles, and axillary lymph nodes is no longer indicated because it causes significant morbidity with no survival benefit.
#Breast
Indications for mastectomy
Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:
◼️Large tumor in relation to the size of the breast (small breast).
◼️Central tumor beneath or involving the nipple.
◼️Multifocal especially seen in lobular carcinoma.
◼️Local recurrence.
◼️Patient preference.
#Breast
Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:
◼️Large tumor in relation to the size of the breast (small breast).
◼️Central tumor beneath or involving the nipple.
◼️Multifocal especially seen in lobular carcinoma.
◼️Local recurrence.
◼️Patient preference.
#Breast
Lymphangiosarcoma (stewart treves syndrome) following longstanding lymphedema is a rare complication that occur years after the original treatment, it presents with multiple subcutaneous nodules in the upper arm (see image above), it has poor prognosis although some patients responds to cytotoxic drugs and radiotherapy, some patients may need interscapulothoracic amputation.
#Breast
#Breast
Carcinoma en cuirasse
◼️It is an infileration of the chest skin by cancer that became likened to a coat.
◼️It is a rare form of cutaneous involvement by breast cancer, it is usually a form of local recurrence following mastectomy, and usually seen following the distribution of chest wall irradiation.
◼️Prognosis is poor
#Breast
◼️It is an infileration of the chest skin by cancer that became likened to a coat.
◼️It is a rare form of cutaneous involvement by breast cancer, it is usually a form of local recurrence following mastectomy, and usually seen following the distribution of chest wall irradiation.
◼️Prognosis is poor
#Breast
Peau d' orange
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
Causes of nipple retraction
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
How does eczema differ from paget disease clinically?
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
Operative note
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
Note
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Examples of tumors presenting with signs and symptoms of acute inflammation
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
Interesting rare case of a male inflammatory breast carcinoma, these are highly malignant tumors with undifferentiated histology, they appear as redness, warmth, and cutaneous edema of the breast, BECAREFUL, it mimics breast abscess,, histology is required for diagnosis.
#Breast
#Breast