Upload
terdsak-rojsurakitti
View
11.335
Download
2
Embed Size (px)
DESCRIPTION
Citation preview
LOGO www.themegallery.com
1
LOGO2
Functionally
part of reproductive system Respond to sexual
stimulation Feed babies
โอ้�วววววววววววววววววววววววววววว
LOGO3
Structure & Anatomy
NippleNipple AreolaAreola Montgomery’s Montgomery’s
tuberclestubercles
LOGO4
Structure & Anatomy
AlveolusAlveolus Milk ductMilk duct Lactiferous ductLactiferous duct Lactiferous sinusLactiferous sinus
LOGO5
Arterial Supply to theBreast
LOGO6
Veins draining the Breast
LOGO7
Lymph Nodes of theBreast
LOGO
8
EvaluationEvaluation
LOGO9
EVALUATION
A. Clinical Manifestation:
B. Physical Examination:
LOGO10
Physical Examination
LOGO11
C. Radiological Examination:1. Mammography (Screening):
• Uses low dose of radiation (0.1 rad)• Complementary study, can not replace biopsy• Microcalcification, architectural dislortion,duct
dilatation, fibronodular density– suggestive of CA• Early detection of an occult CA before
reaching 5 mm.• Recommended Program of Using
Mammography:1. Age 35-40 yr baseline mammography2. Age >40 yr annual mammography3. Age>50 yr mammography q 1-2 yrs depend on doctor
LOGO12
Mammography
รู�ปแสดง malignant microcalcification และ architectural distortion
LOGO13
mammographic findings
การ manage จะแบ่งเป็ น 6 Categories ตาม BIRAD S categories (Breast Imaging Recording And Data
System)
Category 0 . unfinished study : need additional imaging Category 1 . Normal : Suggest routine screening Category 2 . Benign looking : Suggest yearly Screening Category 3 . Probably benign : Suggest diagnostic mammogr
- aphy at 6 12 Month intervals Category 4 . Indeterminate or mild suspicion : Suggest Pathol
ogical tissue diagnosis Category 5 . Suspicious of malignancy : Suggest Pathological
tissue diagnosis
LOGO14
EVALUATION
C. Radiological Examination:2. Computed Tomography or Magnetic Resonant Imaging:
• To expensive• For detection of vertebral metastasis
3. Ultrasonography• No radiation exposure• Can differentiate cystic lesions from solid mass• Can not detect less than 5mm.
4. Interventional Technique:Ductography:
– Inject radio-opaque contrast media into the mammary duct
D. Biopsy: positive result is diagnostic1. Excision biopsy2. Incision biopsy3. Core needle biopsy4. Fine needle biopsy
LOGO
15
BENIGN LESIONS OF THE BENIGN LESIONS OF THE BREASTBREAST
LOGO16
BENIGN LESIONS OF THE BREAST
1.Fibroadenoma: Well circumscribed lesion, movable, smooth,
lobulated, encapsulated, painless, not associated w/ nipple discharge
Size does not regress after menstruation Etiology (?), could also be due to hormonal
imbalance Treatment:
– Excision biopsy (rule out malignancy)
LOGO17
BENIGN LESIONS OF THE BREAST
2. Intra-ductal Papilloma: Proliferation of the ductal epithelium Commonly causes Bloody Nipple Discharge
• Palpable mass – 95% is intra-ductal papilloma
Treatment:• Excision of a palpable mass by biopsy
LOGO18
BENIGN LESIONS OF THE BREAST
3. Phyllodes Tumor• Bulk of the mass is made up of connective tissue, with
mixed areas of gelatinous, edematous areas. Cystic areas are due to necrosis and infarct degenerations
• 80% are benign, usually large bulky lesions • Treatment:
– Excision biopsy:
» Benign – no further treatment, observe
» Malignant – total mastectomy / MRM
LOGO19
BENIGN LESIONS OF THE BREAST
4. Mammary Duct Ectasia (Plasma cell mastitis, Comedomasttitis & Chronic mastitis)
Sub-acute inflammation of the ductal system usually beginning in the subareolar area w/ ductal obstruction
Usually present as a hard mass beneath or near areola w/ either nipple or skin retraction due to increase fibrosis
Appears during or after menopausal period Treatment:
– Excision biopsy
LOGO20
BENIGN LESIONS OF THE BREAST
5. Gynecomastia: Development of female type of breast in male Usually unilateral or bilateral Causes :
a. Hepatic cirrhosis (for elderly alcoholic)
b. Estrogen medication for prostatic CA
c. Tumor producing estrogen/progesterone
Treatment:– tx primary cause– Subcutaneous mastectomy
LOGO
21
Malignant Lesions of the Breast
LOGO22
Malignant Lesions of the Breast
Etiology: - multifactorial
1. Age
2. Age at menarche and menopause
3. Age at first pregnancy
4. HRT (Hormone replacement therapy)
5. Radiation
6. Diet
7. Genetic factor
8. Multiple Primary Neoplasms
LOGO
23
TNM Staging System
LOGO24
TNM Staging System for Breast Carcinoma
Primary Tumor (T)TX – Primary tumor cannot be assessedT0 – No evidence of primary tumorTis – CA in situ (LCIS / DCIS), Paget’s dse of the nipple w/o tumorT1 – 2 cm or less
T1a – 0.5 cm. or lessT1b - > 0.5 cm. to 1 cm.T1c - > 1cm. to 2 cm.
T2 – 2 to 5 cm.T3 - > 5 cm.T4 – any size w/ direct extension to chest wall or skin
T4a – extension to chest wallT4b – edema / ulceration of the skin / satelite
noduleT4c – both T4a and T4bT4d – Inflammatory carcinoma
LOGO25
TNM Staging System for Breast Carcinoma
Regional Lymph Nodes (N)NX – Not assessed (previously removed)
N0 – No regional LN metastasis
N1 – (+) movable ipsilateral axillary LN
N2 – (+) LN fixed to one another
N3 – (+) Ipsilateral INTERNAL MAMMARY LN
Distant Metastasis (M): MX – not assessed M0 – (-) M1 –(+) including metastasis to ipsilateral supraclavicular LN
LOGO26
Metastasis site
Bone - 4960( %)Lung - (15 20%)
Pleura - 1015( %)
Soft tissue - (7 15%)Liver -510( %)
LOGO27
TNM Staging System for Breast Carcinoma
Stage Grouping: 5- year survival rateStage 0 Tis N0 M0 100Stage I T1 N0 M0 100
Stage IIA T0 N1 M0 92T1 N1a M0T2 N0 M0
Stage IIB T2 N1 M0 81T3 N0 M0
Stage IIIA T0 – T2 N2 M0 67 T3 N1-2 M0
Stage IIIB T4 Any N M0 54
Any T N3 M0Stage IV Any T Any N M1 20
LOGO
28
Treatment
LOGO29
Surgical Management
1. Radical Mastectomy (Willi Meyer, Halsted)2. Extended Radical Mastectomy
3. Modified Radical Mastectomy:4. Total mastectomy w/ or w/o radiation:
LOGO30
Surgical Management:5. Subcutaneous Mastectomy:6. Quandrantectomy, axillary, radiotherapy
(QUART)7. Partial Mastectomy and Radiation:
Indications for Conservative Surgery:1. Small breast CA < 4cm
2. Clinically (-) axillary LN
3. Breast volume adequate size to allow uniform dosage of irradiation
4. Radiation therapist experience to avoid damage of retained breast
LOGO31
Chemotherapy: Adjuvant chemotherapy Neoadjuvant chemotherapy (Primary
chemotherapy)Radiation
conserving breast surgery post MRM 2-3 wks of post operative or after finished
Chemotherapy
LOGO32
Hormonal therapy hormonal dependent tumor
• estrogen• growth stimulating factor• epidermal growth factor• growth inhibitory factor
estrogen receptor, progesterone receptor
ชน�ดของการร�กษามะเร�งเต�านมด�วย hormone
1. 1. Ablation:Ablation:• Oophorectomy,
adrenalectomy,hypophysectomy
2. 2. Anti-estrogen:Anti-estrogen:• Tamoxifen – -a non
-steroidal anti estrogeni c.
• Aromasin,Aminogluthethimide
LOGO
34
Therapeutic Approach
LOGO35
Therapeutic Approach for Breast Cancer
Stage 0 Non-infiltrating (In-situ)
Carcinoma of duct and lobules:• Increase diagnosis due to
mammography
1. LOBULAR CARCINOMA in SITU:
• เป็ นพยาธิ�สภาพซึ่"#งเช$#อวาเก�ดที่&# duct lobular apparatus
• การว�น�จฉั�ยสวนใหญ่ เป็ นการพบ่ โดยบ่�งเอ�ญ่ จ"งบ่อกอ,บ่�ต�การณ์.ได�
ยาก• Tx: 1.
Closed observation2.
Hormonal treatment (Tamoxifen/aromatase inhibitor) for 5 years
3. Surgery (bilateral mastectomy) w/ immediate reconstruction
LOGO36
Therapeutic Approach for Breast Cancer
2. Ductal Carcinoma In Situ:
• Absence of invasion of surrounding stroma hence confined w/in the basement membrane
• Treatment: – Total mastectomy– Wide local excision +
Radiotherapy– Wide local excision
alone
LOGO37
Therapeutic Approach for Breast Cancer
Paget’s Disease of the nipple
≈ - 074. % Chronic eczematoid lesion of the nipple Tenderness, itching, burning and intermittent bleeding Tx:
Mammogram เพ$#อหามะเร�งซึ่"#งพบ่รวมก�บ่ Paget ‘ s disease ถ้�าพบ่วาม&มะเร�งอ$#นรวมด�วย ให�ร�กษาตามชน�ดของมะเร�งเต�านมน�1นๆ
หากไมพบ่รอยโรครวมก�บ่มะเร�งชน�ดอ$#นอาจพ�จารณ์าที่4า wide excision หร$อที่4า Simple mastectomy รวมก�บ่ axillary dissection
LOGO38
Therapeutic Approach for Breast Cancer
Breast Cancer in Men: Factors:
a. Klinefelter syndromeb. Estrogen therapyc. Irradiationd. Trauma
Age: 60-70y/o s/sx: breast mass, nipple retraction and/or
discharge, ulceration and pain. Commonly ER positive and well differentiated Prognosis is similar w/ female Treatment:
• MRM + radiation if with ulceration and high grade• Orchiectomy / chemotherapy
LOGO39
Therapeutic Approach for Breast CancerStage I & II
Modified radical mastectomy
(+) LN (-) LN (-) LN Low risk High
risk
Hormonal / observe chemotherapy
chemotherapy
High Risk Patients A. Histologic criteria:B. Rapid growth rateC. Youth of the patientD. Estrogen receptor negative
LOGO40
Therapeutic Approach for Breast Cancer
Advance Breast Cancer (III / IV):
Palliative Mastectomy
(+) Estrogen (-) Estrogen
Chemotherapy/Hormonal/Radiotherapy
Chemotherapy/Radiotherapy
LOGO
41
Thank you