医学精品课件：05.breast cancer-2017在校.pptx

1、Breast CancernEpidemiology and risk factorsnDignosisnPrognstic factorsnTreatmentsEpidemiology and risk factorsEpidemiologynThe most common invasive cancer in women.nComprises 22.9%of invasive cancers in women,16%of all female cancers.nThe number of cases worldwide has significantly increased since t

2、he 1970s.The incidence of breast cancer varies greatly around the world.2015Epidemiology In China,the economic developed cities have higher morbidity of breast cancerIncidence 2009 in china Breast cancer also occurs in males.Incidences approximately 100 times less.Same statistical survival rates as

3、women.Risk factorsnGenderbeing a womanThe lifetime risk in men and in women 0.11%vs 13%Risk factorsnAge:the chance of getting breast cancer increases with age.nEstimated risk of developing breast cancer by age,females,UK,2008Risk factorsRisk factorsnFamily history nGenetics Carriers of alterations i

4、n either of two familial breast cancer genes BRCA1 or BRCA2 up to an 80%risk of being diagnosed with breast cancerRisk factorsnBreast diseasenAtpyical HyperplasianIntraductal carcinoma in situnIntralobular carcinoma in situnA previous diagnosis of breast cancer nRadiation exposure The effect is stro

5、ngly related to age at exposurenEndogenous and exogenous hormones-Early age at menarche-Late menopause-Nulliparity-First birth after the age of 35 -Oral Contraceptives(OCs)-Hormonal replacement therapy(HRT)-Breastfeeding:reduce riskRisk factorsnLifestyle factors nRacePATHOLOGYPathologyThe 2012 World

6、 Health Organization(WHO)classification of tumors of the breast recommends the following pathological types:PathologynNoninvasive lesions Lobular neoplasia Lobular carcinoma in situ Intraductal proliferative lesions Usual ductal hyperplasia Ductal carcinoma in situ Intraductal papillary neoplasmsPap

7、illoma Intraductal papillary carcinoma Nipple adenoma Pagets disease of the nipple Microinvasive carcinomaPathologyDiagnosisSigns and SymptomsMost common:lump or thickening in breast.Often painlessChange in color or appearance of areolaRedness or pitting of skin over the breast,like the skin of an o

8、rangeDischarge or bleedingChange in size or contours of breastDiagnosisMetastasis lymphatic Lymph Node Areas Adjacent to Breast AreaA Pectoralis major muscleB Axillary lymph nodes:levels IC Axillary lymph nodes:levels IID Axillary lymph nodes:levels IIIE Supraclavicular lymph nodesF Internal mammary

9、 lymph nodesDiagnosisnDistance metastasis：bones，lung，brain，liver,soft tissue and adrenal glands，etcs。DiagnosisDiagnosisDiagnosisDiagnosisTwo of the most important mammographic indicators of breat cancersnMasses Malignant masses have a more spiculated appearanceDiagnosisnMicrocalcifications:Tiny flec

10、ks of calcium like grains of salt in the soft tissue of the breast.DiagnosisDiagnosisDiagnosisnBiopsy-Fine-needle aspiration cytology(FNAS)The sensitivity in diagnosing malignancy has been reported to be 90%to 95%,with almost no false-positive results.-Ultrasound or stereotactic core biopsy.-Mammoto

11、me -Excisional biopsy StagingTNM System(2010)nT:tumor Tx means that the tumor size cannot be assessed T0:No available of primary tumors Tis:Carcinoma in situ Tis（DCIS）:ductal carcinoma in situ Tis（LCIS）:lobular carcinoma in situ Tis（Paget）:Pagets disease of the nipple NOT associated with invasive ca

12、rcinoma and/or carcinoma in situ(DCIS and/or LCIS)in the underlying breast parenchyma.StagingnT1 Tumor 20 mm in greatest dimensionT1mic Tumor 1 mm in greatest dimension T1a Tumor 1 mm but 5 mm in greatest dimension.T1b Tumor 5 mm but 10 mm in greatest dimension T1c Tumor 10 mm but 20 mm in greatest

13、dimension StagingnT2 Tumor 20 mm but 50 mm in greatest dimensionn T3 Tumor 50 mm in greatest dimension StagingnT4 Tumor of any size with direct extension to the chest wall and/or to the skin(ulceration or skin nodules)T4a Extension to the chest wall,not including only pectoralis muscle adherence/inv

14、asion StagingT4b Ulceration and/or ipsilateral satellite nodules and/or edema(including peau dorange)of the skin,which do not meet the criteria for inflammatory carcinoma T4c Both T4a and T4b T4d Inflammatory carcinomaStagingnN:regional lymph nodes nClinical nNx Regional lymph nodes cannot be assess

15、ed(e.g.,previously removed).nN0 No regional lymph node metastases.nN1 Metastases to movable ipsilateral level I,II axillary lymph node(s).StagingnN2 Metastases in ipsilateral level I,II axillary lymph nodes that are clinically fixed or matted;or in clinically detected ipsilateral internal mammary no

16、des in the absence of clinically evident axillary lymph node metastases.StagingnN3 Metastases in ipsilateral infraclavicular(level III axillary)lymph node(s)with or without level I,II axillary lymph node involvement;or in clinically detected ipsilateral internal mammary lymph node(s)with clinically

17、evident level I,II axillary lymph node metastases;or metastases in ipsilateral supraclavicular lymph node(s)with or without axillary or internal mammary lymph node involvement.StagingnPathologic (PN)n pNx Regional lymph nodes cannot be assessed(for example,previously removed,or not removed for patho

18、logic study)n pN0 No regional lymph node metastasis identified histologically StagingnpN1 Micrometastases;or metastases in 13 axillary lymph nodes;and/or in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detectedStagingnpN2 Metastases in 49 axillary

19、lymph nodes;or in clinically detected internal mammary lymph nodes in the absence of axillary lymph node metastases StagingnpN3 Metastases in 10 or more axillary lymph nodes;or in infraclavicular(level III axillary)lymph nodes;or in clinically detected ipsilateral internal mammary lymph nodes in the

20、 presence of one or more positive level I,II axillary lymph nodes;or in more than three axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected;or in ipsilateral supraclavicular lymph nodes.St

21、agingnMnM0 No clinical or radiographic evidence of distant metastases.nM1 Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven 0.2 mm.STAGETNMT1N0M0T0-1M0T0-1T2N1N0M0M0T2T3N1N0M0M0T0-2T3N2N1-2M0M0T4N0-2M0N3M0M1Prognosis Factors PROGNOSIS

22、 FACTORSnAge：women younger than 40 years have a poorer prognosis than post-menopausal women.The stage:has a greater effect on the prognosis than the other considerations.The higher the stage at diagnosis,the poorer the prognosis.nBreast cancer grade:The Nottingham modification of the Scarff-Bloom-Ri

23、chardson grading system grades breast carcinomas by adding up scores for tubule formation nuclear pleomorphism mitotic count each of which is given 1 to 3 points.3-5:Grade 1 tumor(well-differentiated).21%Best prognosis6-7:Grade 2 tumor(moderately differentiated).50%Medium prognosis.8-9 Grade 3 tumor

24、(poorly differentiated).29%Worst prognosis.nThe presence of estrogen and progesterone receptors(ER and PR)in the cancer cell is important in guiding treatment.n The HER2/neu(ERBB2)oncogene amplified and/or overexpressed in approximately 20%of breast cancers,a strong prognostic factor for relapse and

25、 poor overall survival,particularly in node-positive patients.TREATMENTSnMASTECOMY:complete surgical resection of the breast tissue.nTypes of mastectomy include radical mastectomymodified radical mastectomysimple mastectomyskin-sparing mastectomynipple-areolar sparing mastectomy.nBreast-conserving s

26、urgery（BCS）is an operation to remove the cancer and some normal tissue around it.lumpectomy,partial mastectomy,segmental mastectomy,quadrantectomy,or breast-sparing surgery.nContraindications to BCS.Multicentric disease in separate quadrants of the breast.Diffuse malignant microcalcifications on mam

27、mography.A history of prior therapeutic RT.Pregnancy in the first two trimester.Persistently positive resection margins after multiple attempts at reexcision.RADIOTHERAPYRADOITHERAPYPostmastectomy radiation therapy(PMRT)Radiotherapy Postmastectomy radiation therapy(PMRT)PMRT has two potential benefi

28、ts:decrease about 20%of local-regional recurrence.increase in long-term breast cancer-specific and overall survivals(3%-5%of 15-20 years OS).Whole breast radiation therapy(WBRT)after BCS The results of meta-analysis showed that WBRT resulted in:A nearly 50%reduction in the 10-year risk of any first

29、recurrence compared with BCS alone(19%vs 35%).A reduction in the 15-year risk of breast cancer death(21%vs 25%).WBRT is recommended for patients after BCS.TECHNIQUEThe patient is immobilized supine to ensure movements are minimized.Radiopaque catheters are applied to the patient to delineate the bor

30、ders of the treatment fields,any scars,and match line junctions.Large breasts the planned position can be done lateral or prone.Tangential fields:for breast or chest wall Superior:suprasternal notch Inferior:1-2 cm inferior of the inframammary fold Medial:anatomical midline Lateral:midaxillary line

31、Anterior:about 1cm anterior of breast,to ensure coverage during normal breathing Posterior:to cover chest wall,with a maximum lung depth of 2cmSupraclavicular field matched to the tangential fields of the breast to prevent any overdose to the junction of the fields.Shielding is used to shield the sh

32、oulder joint and the apex of the lung.angle this field 10 degrees laterally so that divergence does not enter the cervical spine.BordersMedial:1cm ipsilateral to anatomical midline(to avoid the oesophagus)Inferior:to match breast tangentialsSuperior:to cover the thyroid cartilage,Lateral：extends to

33、the coracoid process（only include the supraclavicular and infraclavicular nodes）extends to the mid humeral head （include the full axilla）Posterior axillary boost(PAB)If coverage of deep nodes lymph node levels is desired or dose coverage for supraclavicular field provides inadequate coverage due to

34、axillary node seperation,then a PAB may be prescribed to provide optimal dose distribution.BordersMedial:1.5-2.0 cm of lungLateral:Lateral posterior axillary foldInferior:to match breast tangential fieldsSuperior:splits claviclenPrescriptionAnterior SCV field and the posterior PAB field overlap vari

35、es from patient to patient.Dose is prescribed such that the combined dose distribution is optimal and provides coverage of nodal volumes.IMNsseparates from tangential fields：Medial:anatomical midline Lateral:5cm to midline Superior to inferior:the first three interspaces.Combination of electron and

36、photon beamsnIMNs within tangential fields：3DCRT and IMRTPatient immobilization Imaging CT scan of the treatment area is obtained while patient remains in the treatment position,to allow for precise target delineation.Delineation of the target volumes：clinicians use the imaging studies to contour th

37、e target volumes,as well as normal tissues(heart,lung,etcs.)Dose and schedule definition the dose for target volumes and normal tissues:CTV，PTV lung(V205cmClear margin 1mmFields of irradiation includes:the chest wall(node negative)+the regional nodes(supraclavicular and infraclavicular nodes).IMNs(i

38、nternal mammary nodes)RT is controversial.Axilla fossa RT is for patients with positive sentinel nodes without axillary dissection Dose rescription whole breast/chest wall and the regional nodes 1.8-2.0 Gy/fractions over 5-5.5 weeks (total dose,45-50 Gy)boost:10-15Gy(BCS)4-6MV PhotonInterval of radi

39、ation and surgeryFor patients who have been recommended to receive adjuvant chemotherapy,RT is generally administered following the completion of chemotherapy.Complications of RTnSkin and soft tissue complicationsAcute radiation dermatitis erythema,edema,pigment changes,and dry or moist desquamation

40、 Radiation-induced fibrosis of the skin and subcutaneous tissue is the most common complication in postoperative RT.The risk of radiation fibrosis after conventional RT for breast cancer is low.nLymphedema Rates of lymphedema are highest in women who undergo mastectomy with axillary lymph node disse

41、ction followed by chest wall and axillary RT.nRadiation pneumonitis presents as a persistent dry cough or shortness of breathwith modern RT techniques it is a rare event.nCardiovascular morbidity Symptoms of early congestive heart failure should prompt a cardiac evaluation.Increase the risk of ische

42、mic heart disease,myocardial infarction Take home messageRisk factors of breast cancer(protective factors)Most common nonivasive and invasive pathological types of breast tumorsPrognosric factorsIndications for PMRT,technique for breast or chest wall radiation,and the fields for PMRTComplications of RT