資料講稿腫瘤學(xué)breast cancer

1、Breast Cancer Email: Cancer Center of Guangzhou Medical University Qiu Ni 1 Anatomy of Breast On the anterior chest wall Extends from the 2nd rib above to the 6th or 7th rib below Medial extension is to the sternum, and the lateral border extends to the mid-axillary line The posterior surface of the

2、 gland rests upon the fascia of the pectoralis major and serratus anterior muscle n The breast is comprised of three major structures: skin(nipple-areola complex with adnexal structure), subcutaneous tissue (adipose and fibrous connective tissue),and mammary parenchyma Vasculature of Breast Internal

3、 mammary artery Lateral thoracic and pectoral arteries Lateral branches of the posterior intercostal arteries Lymphatic Drainage Unidirectional, from the superficial to the deep lymphatic plexus The main route of drainage of the breast, greater than 75 %, is through the axillary lymph node groups. T

4、he axillary lymph node groups are divided according to their lateral and medial relationship to the pectoralis minor muscle into levels IIII. 2 Breast Cancer Epidemiology Etiology Clinical symptom Diagnosis Medical Therapy Genetic Prolonged estrogen exposure obesity History Age Radiation exposure .

5、Etiology Genetic About 5% of women with breast cancer carry a mutation in one of the 2 known breast cancer genes, BRCA1 or BRCA2. If relatives of such a woman also carry the gene, they have a 50 to 85% lifetime risk of developing breast cancer. Men who carry a BRCA2 mutation also have an increased r

6、isk of developing breast cancer. Women with BRCA1 mutations also have a 20 to 40% lifetime risk of developing ovarian cancer; risk among women with BRCA2 mutations is increased less. Family history of breast cancer in a 1st-degree relative (mother, sister, daughter) doubles or triples risk of develo

7、ping the cancer When 2 1st-degree relatives have breast cancer, risk may be 5 to 6 times higher History of in situ or invasive breast cancer (0.5-1% per year) Atypical ductal or lobular hyperplasia increases risk of breast cancer 4- to 5-fold; risk increases to about 10-fold in patients who also hav

8、e a family history of invasive breast cancer in a 1st-degree relative History Prolonged estrogen exposure Early menarche(50 years) Women who have a 1st pregnancy after age 30 , nulliparous Women who began to use contraceptives before age 20 Older younger ; Peak at 45-55 and 65 years Age Other Obese

9、postmenopausal women Exposure to radiation therapy before age 30 Symptoms and signs Diagnosis 1 2 3 4 Medical history Physical examination MRI/CT/PET Nipple discharge examination Ductogram Mammogram Ultrasound Biopsy Medical history Personal and family medical history Physical exam Lump: Location, t

10、exture, size, relationship to the skin and chest muscle Nipple: pain, retraction, discharge Lymph nodes: under the armpit and above the collarbones; swelling or firmness Skin: irritation, redness, itching or scaliness Mammogram Abnormalities Masses Size, Sharp and Edge Spiculated ill-defined Circums

11、cribed Calcifications alone or in clusters macrocalcification microcalcification Ultrasound An imaging method using high frequency sound waves No radiation exposure occurs The only way to tell if a fluid-filled cyst is present Magnetic resonance imaging (MRI) uUsing magnetic fields, not radiation uH

12、igher sensitivity and more accurate for breast cancer detection Nipple Discharge Exam Collected fluid for pathological exam n Ductogram n Green n Yellow n Milky n Clear n Red or Red -brown Biopsy The only way to tell if cancer or benign breast tumor is present There are four types of biopsy used to

13、check for breast cancer: Excisional biopsy: The removal of an entire lump of tissue. Incisional biopsy: The removal of part of a lump of tissue. Core needle biopsy: The removal of tissue using a wide needle. Fine needle aspiration biopsy: The removal of tissue using a thin needle. Antidiastole of br

14、east cancer Fibroadenoma Most common in young women in 2030s Made up of both glandular breast tissue and stromal (fibroconnective) Removal if fibroadenomas continue to grow Sometimes new fibroadenomas will grow after one is removed. Fibrocystic breast diesease A common noncancerous breast condition

15、in women in 3040s Changes in size throughout the menstrual cycle, and are the result of monthly hormonal changes It may be hard to tell the difference between a cyst and a solid mass In most cases, treatment is not needed for fibrocystic breast changes. Removing fluid through fine-needle aspiration

16、may help relieve symptoms of pain or pressure. Intraductal Papilloma Wartlike growths of gland tissue and fibrovascular tissue involve the large ducts near the nipple, resulting in a bloody nipple discharge Found in small ducts in the areas of the breast further from the nipple, there will be severa

17、l growths and have epithelial hyperplasia Often remove the papilloma and a part of the duct it is found in, through an incision at the edge of the areola Breast Cancer TNM stage and histology TNM definitions T: tumor size; N: lymph node status; M: distant metastases Stage 0Stage IStage IIStage IIISt

18、age IV Carcinoma in situ- Early form Survival rate almost at 100% Tis Localized Survival rate at 98% Early locally advanced Survival rate at 88% Late locally advanced Survival rate at 52% T4 IIIB N3 IIIC Metastasized Survival rate at 16% M1 Stage 0 Histopathology Pre-invasion In situ Ductal carcinom

19、a Lobular carcinoma Paget s Disease in nipple 3050% develops invasion ductal carcinoma over a 10 year period 10%37% develops invasion carcinoma Ductal carcinoma Lobular carcinoma Inflammatory carcinoma Invasion 55%65% 10%15% 15% Management Surgery Radiation Chemotherapy Hormone-blocking therapy Mono

20、clonal antibodies Treatment of complications Follow-up Surgery Lumpectomy, also known as breast-conserving surgery, is the removal of only the tumor and a small amount of surrounding tissue. Mastectomy is the removal of all of the breast tissue. Mastectomy is more refined and less intrusive than it

21、used to be because in most cases, the muscles under the breast are no longer removed. Lymph node removal, or axillary lymph node dissection, can take place during lumpectomy and mastectomy if the biopsy shows that breast cancer has spread outside the milk duct. Some people qualify for the less-invas

22、ive sentinel lymph node dissection. Radiation Therapy Called radiotherapy is a highly targeted and highly effective way to destroy cancer cells in the breast that may stick around after surgery. Despite what many people fear, radiation therapy is relatively easy to tolerate and its side effects are

23、limited to the treated area. n External Radiation is the most common type of radiation, typically given after lumpectomy and sometimes, mastectomy. n Internal Radiation is a less common method of giving radiation. It is being studied for use after lumpectomy. n Intraoperative Radiation (IORT) is giv

24、en during lumpectomy surgery after the cancer has been removed. Type of Radiation Therapy External radiation p This form of radiation is given on an outpatient basis 5 days a week, over 5 to 7 weeks, depending on the particular situation. p Radiation to the breast is delivered from 2 different treat

25、ment fields. The 2 fields come from opposite directions and face each other: p If the adjacent lymph nodes are also being treated, additional treatment fields may be added. One starts from the side of the breast and faces the middle of the chest (where the breastbone is). One starts in the middle of

26、 the chest and faces the side. Chemotherapy Treatment p Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body, including cells at the original cancer site and any cancer cells that may have spread to another part of the body. Chemotherapy, often shortened to just chemo,

27、 is a systemic therapy, which means it affects the whole body by going through the bloodstream. p 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 bre

28、ast cancer to destroy or damage the cancer cells as much as possible In some cases, chemotherapy is given before surgery to shrink the cancer. Its called neoadjuvant chemotherapy chemotherapy medicines are given in combination, which means you get two or three different medicines at the same time. T

29、hese combinations are known as chemotherapy regimens. In early-stage breast cancer, standard chemotherapy regimens lower the risk of the cancer coming back. In advanced breast cancer, chemotherapy regimens make the cancer shrink or disappear in about 30-60% of people treated. Standard chemotherapy r

30、egimens include: AT: Adriamycin and Taxotere AC T: Adriamycin and Cytoxan, with or without Taxol or Taxotere TAC: Taxotere, Adriamycin, and Cytoxan CMF: Cytoxan, methotrexate, and fluorouracil CEF: Cytoxan, Ellence, and fluorouracil FAC: fluorouracil, Adriamycin, and Cytoxan CAF: Cytoxan, Adriamycin

31、, and fluorouracil (The FAC and CAF regimens use the same medicines but use different doses and frequencies) GET: Gemzar, Ellence, and Taxol Hormonal therapy n Hormonal therapy medicines are whole-body (systemic) treatment for hormone-receptor-positive breast cancers. n Hormone receptors are like ea

32、rs on breast cells that listen to signals from hormones. These signals turn on growth in cells that have receptors. n A cancer has receptors for either estrogen or progesterone, its considered hormone-receptor-positive. n There are three different types of hormonal therapy medicines: aromatase inhib

33、itors: Arimidex (chemical name: anastrozole) Aromasin (chemical name: exemestane) Femara (chemical name: letrozole) SERMs (selective estrogen receptor modulators): Tamoxifen Evista (chemical name: raloxifene) Fareston (chemical name: toremifene) ERDs (estrogen receptor downregulators): Faslodex (che

34、mical name: fulvestrant) Targeted Cancer Therapies This kind of treatment is target specific characteristics of cancer cells, such as a protein that allows the cancer cells to grow in a rapid or abnormal way. Targeted therapies are generally less likely than chemotherapy to harm normal, healthy cell

35、s. Some targeted therapies are antibodies that work like the antibodies made naturally by our immune systems. These types of targeted therapies are sometimes called immune targeted therapies. Herceptin (trastuzumab) ; Perjeta (pertuzumab) ; Tykerb (lapatinib) Works against HER2-positive breast cance

36、rs by blocking the ability of the cancer cells to receive chemical signals that tell the cells to grow Treatment by stage StagePrimary Treatment options Adjuvant Systemic Therapy 0 (in situ)BCS+ radiotherapy BCS alone if margins 1cm and low nuclear grade Mastectomy SLNB None IBCS+ axillary node dissection + radiotherapy Mastectomy+axillary node dissection/SLNB May not be needed; discuss risks/benefits of chemotherapy an