BREAST CA by Dr Asif Raza

Dr.
M Asif Raza
MBBS, FCPS,FRCS,FACS
Senior Consultant General Surgeon
Dean Academics
RHQ Hospital Skardu
EPIDEMIOLOGY:
• Breast cancer is by far the most frequent cancer among women today.
• In 2023, there were 2 088 849 new cases worldwide representing 11.6% of all new cancers
diagnosed that year.
• In the same period, 626 679 patients died of breast cancer, which was 6.6% of all cancer
related deaths, making it the second most common cause of cancer-related death after lung
cancer.
• In the USA, the incidence and mortality in 2023 were 268 670 and 62 330, respectively
• There is a higher incidence rate in Western nations, but a higher mortality rate in less
developed countries.
• In all age groups, black women are generally diagnosed at a more advanced stage and have
higher mortality rates than other racial/ethnic groups around the world. This can be
explained by intrinsic biological differences in lymph node metastasis, distant metastasis,
and the prevalence of triple-negative (TN) tumors in different racial groups.
TREATMENT-OVERVIEW
• Treatment of breast cancer has changed over the years, both surgically and medically.
• The intention of surgical treatment is to achieve local control, prevent locoregional
recurrence and improve survival.
• The different surgical approaches for treating breast tumors include:
Mastectomy alone or with reconstruction either primary or delayed,
Breast conserving therapy (BCT), with or without the use of oncoplastic techniques .
The extent of axillary surgery is a continuous subject of discussion. The use of sentinel
node diagnostics is standard, with or without subsequent complete axillary dissection.
In selected cases, direct complete axillary dissection is recommended
TNM STAGING
SURGICAL TREATMENT
• Breast-conserving surgery (BCS) and mastectomy with or without immediate
reconstruction are both well-established local managements for early invasive breast
cancer.
• The widespread use of systematic treatments in past decades led to the reduction of
locoregional recurrence rates (LRR) and distant metastasis rates, and the 10-year LRR
of BCS followed by RT was 2–3% for estrogen receptor (ER) positive and human
epidermal growth factor receptor-2 (HER-2) positive breast cancer and 5% for triple-
negative breast cancer (TNBC), which was similar to that after mastectomy in early
breast cancer.
• In addition, patients with BCS+RT had better cosmetic effects and life satisfaction
compared with mastectomy.
• Therefore, BCS following RT is the intended surgical standard of care for most breast
cancers..
• However, the selection of BCS should still be cautious for patients
with :
Diffuse suspicious micro-calcifications

Multicentric cancer
Unable to obtain negative margins
Having contraindications to RT.
• Younger age, lobular carcinoma, and aggressive subtypes, such as
triple-negative and HER2 positive diseases are not contraindications
for BCS.
• For patients with large tumors, neoadjuvant chemotherapy (NAC) can

be chosen to downstage the tumor for BCS
• The management of axillary lymph nodes (ALNs) is decided by the status of ALNs at
diagnosis and the administration of neoadjuvant systemic therapy.
• ALND remains the standard in patients with clinically proven axillary involvement at initial
diagnosis.
• For patients with clinically node-negative (cN0) breast cancer, the management of axillary
is controversial.
• There seemed to be comparable recurrence and survival outcomes between ALND and
sentinel lymph node (SLN) biopsy in the era of contemporary systemic treatments.
• In addition, several prospective trials demonstrated that there was no significance of
recurrence and survival between SLN biopsy alone and SLN biopsy plus RT in patients with
cN0 and one to two SLN involvement.
• Therefore, SLN biopsy might be sufficient for most cN0 patients, and additional axillary
radiation only for selected patients, such as patients with three SLN involvement..
• Stage 0
• Stage 0 cancers are limited to the inside of the milk duct and are non-
invasive (does not invade nearby tissues).
• Ductal carcinoma in situ (DCIS) is a stage 0 breast tumor.
• Lobular carcinoma in situ (LCIS) used to be categorized as stage 0, but
this has been changed because it is not cancer. Still, it does indicate a
higher risk of breast cancer.
• In most cases, a woman with DCIS can choose between breast-
conserving surgery (BCS) and simple mastectomy.
• But sometimes, if DCIS is throughout the breast, a mastectomy might

be a better option.
• There are clinical studies being done to see if observation instead of

surgery might be an option for some women.
• Treatment for stages I to III breast cancer usually includes surgery and
radiation therapy, often with chemo or other drug therapies either before
(neoadjuvant) or after (adjuvant) surgery.
• Stage I: These breast cancers are still relatively small and either have not
spread to the lymph nodes or have only a tiny area of cancer spread in the
sentinel lymph node (the first lymph node to which cancer is likely to spread).
• Stage II: These breast cancers are larger than stage I cancers and/or have
spread to a few nearby lymph nodes.
• Stage III: These tumors are larger or are growing into nearby tissues (the skin
over the breast or the muscle underneath), or they have spread to many
nearby lymph nodes.
• The stage of breast cancer is an important factor in making decisions about treatment.
• Most women with breast cancer in stages I, II, or III are treated with surgery, often followed by
radiation therapy.
• Many women also get some kind of systemic drug therapy (medicine that travels to almost all areas of
the body).
• In general, the more the breast cancer has spread, the more treatment will likely need. But treatment
options are affected by patient’s personal preferences and other information about breast cancer, such
as:
• If the cancer cells have hormone receptors. That is, if the cancer is estrogen receptor (ER)-positive or
progesterone receptor (PR)-positive.
• If the cancer cells have large amounts of the HER2 protein (that is, if the cancer is HER2-positive)
• How fast the cancer is growing (measured by grade or Ki-67)
• Overall health
• If gone through menopause or not
• Surgery is the main treatment for stage I and II breast cancer.
• These cancers can be treated with either breast-conserving surgery (BCS;
sometimes called lumpectomy or partial mastectomy) or mastectomy.
• The nearby lymph nodes will also need to be checked, either with a sentinel
lymph node biopsy (SLNB) or an axillary lymph node dissection (ALND).
• Some women can have breast reconstruction at the same time as the surgery
to remove the cancer. But if she will need radiation therapy after surgery, it is
better to wait to get reconstruction until after the radiation is complete.
• If BCS is done, radiation therapy is usually given after surgery to lower the
chance of the cancer coming back in the breast and to also help people live
longer.
• In a separate group, women who are at least 65 years old may consider
BCS without radiation therapy if ALL of the following are true:
• The tumor was 3 cm (a little more than 1 inch) or less across and it has
been removed completely.
• None of the lymph nodes removed contained cancer.
• The cancer is ER-positive or PR-positive, and hormone therapy will be
given.
• Radiation therapy given to women with these characteristics still lowers
the chance of the cancer coming back, but it has not been shown to
help them live longer.
• If initially diagnosed with stage II breast cancer and were given a
systemic treatment such as chemotherapy or hormone therapy
before surgery, radiation therapy might be recommended if cancer is
found in the lymph nodes during mastectomy.
• A radiation oncologist may talk with patient to see if radiation would
be helpful.
• If chemotherapy is also needed after surgery, the radiation will be
delayed until the chemo is done.
• Stage III, these cancers are treated with neoadjuvant (before surgery)
chemotherapy. For HER2-positive tumors, the targeted drug trastuzumab
is given as well, often along with pertuzumab (Perjeta). This may shrink
the tumor enough for a woman to have breast-conserving surgery (BCS).
If the tumor doesn’t shrink enough, a mastectomy is done.
• Nearby lymph nodes will also need to be checked. A sentinel lymph node
biopsy (SLNB) is often not an option for stage III cancers, so an axillary
lymph node dissection (ALND) is usually done.
• Often, radiation therapy is needed after surgery. If breast reconstruction
is planned, it is usually delayed until after radiation therapy is done. For
some, additional chemo is given after surgery as well.
• Surgery also plays an important role in the management of local-regional
recurrent breast cancer.
• Total mastectomy remains the standard of care for recurrent patients
initially receiving BCS, and salvage mastectomy ± ALND could achieve 85–
95% loco-regional control in this disease.
• Patients suffering chest-wall recurrence after initial mastectomy had a
higher risk of metastasis than those initially treated with BCS.
• In addition, previous studies showed that limited resection was related to a
higher second local recurrence of 60–70%; therefore, the routinely
recommended management for patients initially treated with mastectomy
is wide resection of the recurrent lesions when possible.

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Dr.

Diffuse suspicious micro-calcifications

• For patients with large tumors, neoadjuvant chemotherapy (NAC) can

• But sometimes, if DCIS is throughout the breast, a mastectomy might

• There are clinical studies being done to see if observation instead of

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