Breast Cancer Surgery II PDF

SURGERY II BREAST CANCER Dr.MAYMONA CHOUDRY August 22,2024 EPIDEMIOLOGY o it predicts the cumulative risk of breast Most common...

SURGERY II BREAST CANCER Dr.MAYMONA CHOUDRY August 22,2024 EPIDEMIOLOGY o it predicts the cumulative risk of breast Most common cancer in the Philippines cancer according to decade of life 3 for every 100 Filipina (PSA and DOH) o 5-year risk and lifetime risk 197 countries – highest prevalence Female:Male (1000x) Males: 1:1000 85% no family history 2022 – 33.079 cases (WHO) Average lifetime risk: 12% o 50 years old: 11% o 70 years old: 7% The most common site-specific cancer in women Leading cause of death from cancer for women age 20-59 years Higher rates occur in westernized countries due to changes in reproductive patterns, increased screening, dietary changes, and decreased activity Incidence increases rapidly during the 4th-5th decade of life RISK FACTORS Estrogen exposure is directly proportional to breast cancer Hormonal vs. non-hormonal factor Hormonal Risk Factors Early menarche Nulliparity Late menopause Obesity Protective Factors Moderate levels of exercise Longer lactation period Full term pregnancy Radiation exposure o Young women who receive mantle radiation therapy for Hodgkin’s lymphoma have a breast cancer risk that is 75 times greater than that of age- matched control subjects Alcohol consumption à increase levels of estradiol Long-term consumption of food with high fat content à contributes to an increased risk of breast cancer by increasing serum estrogen level RISK ASSESSMENT MODEL Gail Model o Most frequently used in the US o incorporates: § age Claus Model § age at menarche o Cancer and Steroid Hormone Study § age at first live birth o Prevalence of high penetrance breast § number of breast biopsy cancer susceptibility genes specimens o VS Gail Model: incorporates more § history of atypical hyperplasia information about family history but § number of 1st degree relatives excludes other risk factors. with breast cancer o Provides individual estimates of breast cancer risk according to decade of life MAT-MAT 50 years old BRCAPRO Model o Mendelian model o Calculates the probability that an individual is a carrier of a mutation in one of the breast cancer susceptibility genes based on their family history of breast and ovarian cancer o Requires input of all family history information regarding breast and ovarian cancer Tyrer-Cuzick Model o Attempts to utilize both family history information and individual risk Chemoprevention information o Tamoxifen – SERM o Uses the family history to calculate the § 1st drug to reduce incidence of probability that an individual carries a breast in healthy women mutation in one of the breast cancer § Recommended only for: susceptibility genes, and then the risk is women who have a Gail adjusted based on personal risk factors, relative risk of 1.66% or including age at menarche, parity, age at higher; first live birth, age at menopause, history women who are age 35 of atypical hyperplasia or LCIS, height, and to 59; body mass index women over the age of 60; or women with a diagnosis of LCIS or atypical ductal or lobular hyperplasia § DVT: 1.6x § Pulmonary embolism: 3x § Endometrial cancer: 2.5x § Cataract surgery: 2x most likely Tamoxifen vs. Raloxifene Tamoxifen Raloxifene Ability to reduce = = cancer risk Adverse event + profile 76% efficacy of tamoxifen MAT-MAT 90% § Invasive ductal carcinomas – Effects on long-term QOL: poorly quantified poorly differentiated Women with an estimated lifetime risk of 40% § Hormone receptor negative o Prophylactic mastectomy added 3 years § Triple receptor negative of life o Profile: Women with an estimated lifetime risk of 85% § Early age of onset o Prophylactic mastectomy added >5 years § Higher prevalence of bilateral Risk reducing mastectomy is highly effective at breast cancer preventing breast cancer in both BRCA1 & BRCA2 § (+) ovarian cancer possibly colon mutation carriers and prostate cancers BRCA 2 o Autosomal dominant with high penetrance BRCA MUTATIONS o BRCA 2 mutation carriers: 5% of breast cancer § Lifetime breast cancer risk: 85% Autosomal dominant with varying penetrance § Lifetime ovarian cancer risk: 20% Germline mutations in BRCA1 o Men with BRCA 2 mutations: o 45% hereditary breast cancers § Estimated breast cancer risk is o At least 80% hereditary ovarian cancers 6% Female mutation carriers § 100-fold increase o Lifetime breast cancer risk: 85% o Associated breast cancers: o Lifetime ovarian cancer risk: 40% § Invasive ductal carcinomas – well differentiated § Express hormone receptors o Profile: § Early age of onset § Bilateral breast cancer § (+) ovarian, colon, prostate, pancreatic, gallbladder, bile duct, stomach cancers, and melanoma IDENTIFICATION OF BRCA MUTATION CARRIERS Obtaining a complete, multigenerational family history MAT-MAT 1st- or 2nd-degree relatives with PRIMARY BREAST CANCER breast cancer at any age >80% breast cancers: productive fibrosis that o Patient or relative with bilateral breast involves the epithelial and stromal tissues cancer With growth of the cancer and invasion of the o Male breast cancer in a relative at any age surrounding breast tissues, the accompanying CANCER PREVENTION FOR BRCA MUTATION CARRIERS desmoplastic response entraps and shortens Risk management strategies: Cooper’s suspensory ligaments à skin retraction o Risk reducing mastectomy and Peau d’orange à develops when the drainage of reconstruction the lymph fluid from the skin is disrupted o Risk reducing salphingo-oophorectomy Disease-free and overall survival correlates: o Intensive surveillance for breast and o Size of primary breast cancer ovarian cancer Close association o Chemoprevention o Cancer size and axillary LN involvement Screening: Breast cancer recurrence o Clinical breast examination every 6 Local-regional 20% months Distant >60% o Mammography every 12 months Local-regional + distant 20% beginning at the age of 25 years MRI: HISTOPATHOLOGY OF BREAST CANCER o ASCO recommendations CARCINOMA IN SITU § MRI in women with 20-25% Absence of invasion of cells into the surrounding greater lifetime risk of stroma and their confinement within natural developing breast cancer (mainly ductal and alveolar boundaries based on family history) Multicentricity à refers to the occurrence of a § Women with a known BRCA1 or second breast cancer outside the breast quadrant BRCA2 mutation of the primary cancer (or at least 4cm away) § Those who have a first-degree o Occurs in 60 to 90% of women with LCIS relative with a BRCA1 or BRCA2 o 40 to 80% in DCIS mutation and not had a genetic Multifocality à refers to the occurrence of a testing themselves second cancer within the same breast quadrant as § Women who were treated with the primary cancer (or within 4cm of it) radiation therapy to the chest LCIS à bilaterally in 50% to 70% of cases between the ages of 10 and 30 DCIS à bilaterally in 10% to 20% of cases years § Those who have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba MAT-MAT