Friday 28 September 2012

Breast cancer management

Breast cancer (Kills people, also most common cancer)
  • Types
    • Ductal Carcinoma In Situ (DCIS)
    • Lobular Carcinoma In Situ (LCIS)
    • Invasive Ductal Carcinoma (IDC)
    • Invasive Lobular Carcinoma (ILC)
    • Other types
      • Paget's disease of the nipple
      • Phyllodes tumours of the breast
  • Metastasis
    • Bone
    • Liver
    • Lung
  • Classify
    • Oestrogen receptor positive
      • Mainly older women
      • HORMONE
    • Oestrogen receptor negative
      • Mainly younger women
      • CHEMOTHERAPY
  • www.predict.nhs.uk


MANAGEMENT


SURGERY
  • WIDE LOCAL EXCISION (WLE)
    • Done mainly for focal disease
    • Followed by sentinel node biopsy (methylene blue)
    • If sentinel node is positive, then axillary lymph node excision can be done
      • Lymphoedema (20% risk)
      • Brachial plexus injury
      • Long thoracic nerve injury

  • MASTECTOMY
    • Done mainly for multifocal disease


MEDICAL (USUALLY ALWAYS USED AS AN ADJUNCT TO SURGERY) (HELPS PREVENT RECURRENCE)
  • Oestrogen receptor positive
    • Tamoxifen
      • Oestrogen receptor antagonist
      • Increases risk of endometrial cancer
    • Letrozole (node positive?), Anastrozole (node negative?), Exemestane (metastases?)
      • Aromatase inhibitor (stops production of oestrogen)
      • Follow up with bone scan, and give Ca2+/Vit D to counter the effects of osteoporosis (Decreasing what little oestrogen is left) 
    • Zoladex (Goserelin Acetate)
      • Gonadotropin releasing hormone superagonist (GnRH agonist)
      • Increases oestrogen and testosterone production in a non-pulsatile fashion such that production decrease
      • Eventual decrease in oestrogen and testosterone
      • Useful for prostate cancer, breast cancer, and precocious puberty
    • Chemotherapy

  • Oestrogen receptor negative
    • Chemotherapy (Bolded is a sample combination - FEC)
      • 5-fluorouracil
      • Epirubicin
      • Cyclophosphamide
      • Doxorubicin
      • Methotrexate
      • Docetaxel
    • Zoladex?

  • HER2/neu receptor positive
    • Trastuzumab
      • Monoclonal antibody
      • Arrest in cell stage G1 after treatment

RADIOTHERAPY (SOMETIMES USED AS AN ADJUNCT TO BOTH CHEMOTHERAPY and SURGERY) (HELPS PREVENT RECURRENCE)
  • Targeted versus not targeted - 'radiotherapy equivalent of mastectomy'
  • Has to be first simulated and planned
  • Treatment is then given after planning
  • HAS BEEN SHOWN TO IMPROVE ALL SUCCESS RATES
  • Not used so much after mastectomy, since even though there is still an improvement, because with mastectomy the % recurrence is so small anyway (given the chemotherapy that would inevitably be given)

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