Presentation on theme: "Breast Cancer. Presentation breast cancer Treatment of breast tumors presentation

Breast cancer (BC) is a malignant tumor of the glandular tissue of the breast 99% of patients are women Every year, about 1 million new cases of breast cancer are recorded in the world, of which about 15 thousand are in Ukraine Every 30 minutes a new case of breast cancer is detected in our country, every hour, one woman dies from it. The duration of normal life of patients with breast cancer when diagnosed in the initial stages and properly treated is over 25 years 12.8% of patients with breast cancer did not live 1 year from the moment of diagnosis

Prevention of breast cancer Primary prevention is the prevention of the disease by studying the etiological factors and risk factors, environmental protection and reducing the effect of carcinogens on the human body, normalization of family life, timely implementation of childbearing function, breastfeeding of the baby, exclusion of marriages with mutual oncological burden Secondary prevention - earlier detection and treatment of precancerous diseases of the mammary glands - various forms of mastopathy, fibroadenomas, other benign tumors and diseases, as well as endocrine system disorders, diseases of the female genital organs, impaired liver function Tertiary prevention - prevention, early diagnosis and treatment of relapses, metastases and metachronous neoplasms

Risk factors for breast cancer Sex, age, constitutional factors: female, age over 60 years, high growth Genetic: blood relatives, patients with breast cancer; burdened family history; carriers of BRCA1 and BRCA2 mutant genes Reproductive: early menarche (before 12 years), late menopause (after 54 years), no pregnancy, late first birth (after 30 years); not breastfeeding; abortions; high x-ray density mammograms Hormonal and metabolic: hyperestrogenism, hyperprolactinemia, hypothyroidism, menstrual disorders, infertility; mastopathy, adnexitis, ovarian cyst, uterine fibroids, endometriosis; obesity in postmenopausal age, diabetes mellitus, liver disease; hormone replacement therapy; use of oral contraceptives for more than 10 years Environmental factors: high socioeconomic status; exposure to ionizing radiation and chemical carcinogens; excess alcohol, fats, calories, animal proteins; lack of vegetables and fruits, dietary fiber

Clinical manifestations of breast cancer: - painless, dense formation in the thickness of the mammary gland - change in the shape and shape of the mammary gland - wrinkling or retraction of the skin of the mammary gland - discomfort or unusual pain in one of the mammary glands - induration or swelling on the nipple, its retraction - spotting from the nipples - an increase in the lymph nodes under the arm on the corresponding side

Diagnosis of breast cancer: Clinical examination (history taking, examination and palpation of the mammary glands and lymphatic drainage tracts) Instrumental methods of research (X-ray mammography, ultrasound and MRI of the mammary glands) Interventional diagnostic methods (TAB, trephine biopsy, excisional biopsy) Morphological method of research (cytological , histological, IHC, therapeutic pathomorphism of breast cancer) Genetic research (BRCA1, BRCA2) Laboratory research methods (oncomarkers, general clinical studies)

Treatment of breast cancer 1. Surgical treatment. – Radical operations: lumpectomy, quadrantectomy, mastectomy – Reconstructive operations: using artificial materials (expander / implant), own tissues (thoracodorsal flap, TRAM flap, etc.)

Plan

Topographic anatomy of the breast

Breast tissue is represented by complex alveolar-tubular glands, collected in small lobules, from which large ones are formed.

lymphatic system

Distinguish the following ways of outflow of lymph from the mammary gland

Breast cancer (BC):

Epidemiology of breast cancer

Incidence of breast cancer

Anterior pituitary gland

Factors contributing to the occurrence of precancerous diseases and breast and breast cancer:

II Endocrine-metabolic factors due to concomitant or previous diseases:

PATHOGENETIC FORMS OF BC

PRECANCER DISEASES CLASSIFICATION OF DISHORMONAL HYPERPLASIAS

When breast and breast cancer occurs, the following hormonal, metabolic and immunological changes often occur:

The group of increased oncological risk for the occurrence of breast cancer includes women who have 5 or more of the above

Histological classification (WHO 2002)

Classification of breast cancer by stages:

The grouping of breast cancer by stage is shown in the table.

Ways of breast cancer metastasis

Clinical picture of breast cancer:

Knotty forms of breast cancer

Mastitis-like form of cancer of the left breast.

Lymphedema of the skin (lemon peel) is a late symptom of the disease. Enlargement or hardening of axillary lymph nodes even

Breast cancer with skin invasion and decay

Breast cancer Metastasis in l/u of Zorgius with decay

Breast Cancer Lemon Peel Symptom

Redness of the skin of the breast. With a malignant tumor of the mammary gland, it indicates the defeat of most of the mammary gland.

Breast cancer Mastitis-like form

Mammary cancer. Tumor decay

Mastitis-like form

Diagnosis of breast cancer

Biopsy of the sentinel lymph node

Differential diagnosis of breast cancer

Choosing a method of treatment for breast cancer

Methods of treatment of breast cancer and principles of their application.

adjuvant chemotherapy

adjuvant hormone therapy

Radiation therapy for breast cancer

Depending on the purpose, radiation therapy for breast cancer is

Irradiated areas during radiotherapy

Types of radiation therapy

Irradiation is carried out in two possible modes

Indications for radiotherapy for breast cancer are

Contraindications for radiotherapy

Ten Key Things to Know About Radiation Therapy

Breast Cancer Immunotherapy

Cancer treatment with CyberKnife

Proton therapy, like many other methods of radiation and radiotherapy, is carried out in cycles and the entire course takes several weeks. In some

Photodynamic therapy for breast cancer

Targeted therapy in the treatment of breast cancer

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In recent decades, in Russia, as in most countries of the world, there has been a steady upward trend in the incidence of the reproductive system, including the mammary gland. Leading positions in the structure of breast diseases are occupied by pathological processes of a benign nature. Among them, the most common are diffuse forms of mastopathy, which affect 50-60% of women. Nodular forms of mastopathy and fibroadenoma, which are considered precancerous diseases and subject to surgical treatment, are less common, accounting for 7.7-20% and 13.1-18% of cases, respectively. Inflammatory nodular processes of the mammary gland are recorded in 1.5% of cases.

slide 3

For 1 woman with breast cancer, there are 40-50 women with dyshormonal pathology of the mammary glands. Etiological disorders that occur in the hormonal and metabolic links of homeostasis and the high frequency of the combination of mastopathy and breast cancer make it possible to classify women with benign dyshormonal diseases of the mammary glands as a risk group for the possible development of oncological pathology in them.

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Issues of prevention, early diagnosis and treatment of benign diseases of the mammary glands by order of the Ministry of Health and Social Development of the Russian Federation No. 808 dated 2.10.2009. “On Approval of the Procedure for the Provision of Obstetric and Gynecological Care”, were included in the scope of the tasks of the obstetric and gynecological service by order of the Ministry of Health and Social Development of the Russian Federation No. 808 dated 2.10.2009. "On Approval of the Procedure for the Provision of Obstetrics and Gynecological Care", subsequently replaced by Order of the Ministry of Health of the Russian Federation No. 572 dated November 1, 2012 "Procedure for the provision of medical care in the field of obstetrics and gynecology (with the exception of the use of assisted reproductive technologies)".

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The provision of specialized medical care, including surgical care, to patients with precancerous diseases of the breast is regulated by the Order of the Ministry of Health of the Russian Federation No. 915n dated November 15, 2012, “On Approval of the Procedure for Providing Medical Care to the Adult Population in the Oncology Profile”.

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According to the Procedures for the provision of medical care, primary health care institutions (healthcare facilities, antenatal clinics) implement the entire range of measures aimed at the prevention and early diagnosis of breast cancer; clarifying diagnosis of the nature of nodular formations of the mammary glands and surgical treatment of patients with benign nodular pathology of the mammary glands are assigned to oncological dispensaries.

Slide 7

The procedure for providing primary specialized health care to women with gynecological diseases provides for: mammography and ultrasound examination of the mammary gland, formation of dispensary observation groups taking into account the detected pathology of the mammary glands, treatment of diffuse forms of mastopathy, referral of women with identified cystic and nodular changes in the mammary glands to an oncological dispensary to verify the diagnosis and treatment.

Slide 8

Examination room of the polyclinic Women's consultation gynecologist mammologist Diffuse mastopathy detected Tumor, nodular mastopathy detected Breast pathology detected District oncologist treatment of diffuse mastopathy benign tumor, nodular mastopathy Breast pathology detected Oncological dispensary Surgical treatment of benign tumors Clarifying diagnosis of the nature of the pathology Treatment of breast cancer Surgical treatment of nodular forms mastopathy observation Treatment FKB polyclinic Doctors reception

Slide 9

Breast cancer occurs 3-5 times more often against the background of benign diseases of the mammary glands and 30-40 times more often with nodular forms of mastopathy with proliferation of the epithelium of the mammary glands. A decisive role in the development of diseases of the mammary glands is assigned to progesterone deficiency conditions, in which an excess of estrogens causes the proliferation of all gland tissues.

Slide 10

The morphological structure of the mammary gland changes under the cyclic influence of estrogen and progesterone. In the follicular phase, under the influence of estrogens, the processes of proliferation of ducts and connective tissue occur. In the luteal phase of the menstrual cycle, under the influence of progesterone, the ducts grow, and a secret begins to accumulate in them. THE LEADING ROLE IN THE APPEARANCE OF FCD IS NOT AS SO MUCH AS AN ABSOLUTE INCREASE IN THE AMOUNT OF ESTROGENS AS MUCH AS A RELATIVE HYPERESTROGENIA ARISING DUE TO A LACK OF PROGESTERONE IN THE II PHASE OF THE MENSTRUAL CYCLE. Etiology of mastopathy Triad of imbalance: hyperestrogenemia, decreased progesterone levels, hyperprolactinemia. Violation in one of the links of the hormonal regulation of the mammary glands is the cause of the development of pathological processes in the mammary glands.

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Hormonal imbalance towards progesterone deficiency causes: morphofunctional restructuring of the mammary glands, accompanied by edema and hypertrophy of the intralobular connective tissue, and excessive proliferation of the epithelium of the ducts, leading to their obstruction, with preserved secretion in the alveoli, leads to an increase in the alveoli and the development of cystic cavities. All conditions caused by a decrease in the level of progesterone against the background of an excess of estrogen levels lead to the development of dyshormonal hyperplasia.

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Prolactin

The reason for the development of dyshormonal hyperplasia of the mammary glands may be an increase in the level of prolactin outside of pregnancy and lactation. The main biological role is the growth and development of the mammary glands, stimulation of lactation. Participates in the process of mammogenesis Provides the growth of epithelial cells In synergy with estradiol and progesterone, activates the processes of physiological proliferation of mammary gland tissues Promotes the differentiation of mammary gland tissues during pregnancy Provides the synthesis of proteins, carbohydrates and milk lipids Stimulates lactation Supports the existence of the corpus luteum and the formation of progesterone in it Participates in regulation of water-salt metabolism. An abnormal increase in prolactin levels can cause anovulation, menstrual irregularities, galactorrhea, and infertility. Primary structure of prolactin 198 amino acids MW 2200

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Causes of hyperprolactinemia

Pathological Diseases of the hypothalamus (tumors, infiltrative diseases, arteriovenous defects, etc.) Diseases of the pituitary gland (prolactinoma, pituitary adenoma, craniosellar cyst, etc.) Primary hypothyroidism Polycystic ovary syndrome Insufficiency of the adrenal cortex Tumors producing estrogens Functional hyperprolactinemia Pharmacological haloperidol, methyldopa, rauwolfia alkaloids, reserpine. Physiological Gestation Breastfeeding (suckling) Exercise (only when anaerobic threshold is reached) Psychological stress Sleep Hypoglycemia

Slide 14

An increase in prolactin levels is accompanied by swelling, engorgement and soreness of the mammary glands, especially in the second phase of the menstrual cycle. In this case, vegetative disorders can be observed: migraine-like headaches, swelling of the limbs, pain and bloating. This symptom complex is called premenstrual syndrome (PMS).

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Breast disease Cyclic Mastodynia Fibrocystic breast Galactorrhea (67%) Menstrual disorders Secondary amenorrhea (60-85%) Oligomenorrhea (27-50%) Polymenorrhea due to corpus luteum insufficiency Anovulatory cycles (70%) Diseases associated with hyperprolactinemia

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Mammalgia

Symptoms: Feeling of pain, tension of the mammary glands Feeling of heaviness in the mammary glands Soreness when touched The main symptom of premenstrual syndrome With fibrocystic mastopathy With hormonal therapy (hormone replacement therapy, oral contraceptives) CAUSES: Hormonal imbalance - estrogens predominate over gestagens, Insufficiency of the corpus luteum phase - little progesterone is formed, increased sensitivity of mammary gland tissues to estrogens, hyperprolactinemia. Characterized by the absence of organic pathohistological changes in the breast tissue

Slide 17

Benign diseases of the mammary glands according to clinical and morphological features are divided into: Diffuse dyshormonal dysplasia (adenosis, fibroadenosis, diffuse fibrocystic mastopathy) - are subject to conservative treatment. Local forms (cysts, fibroadenomas, ductectasias, nodular proliferates) represent diseases with a risk of developing breast cancer and are subject to surgical treatment.

Slide 18

Mastopathy is a disease characterized by a violation of the ratio of epithelial and connective tissue components, a wide range of proliferative and regressive changes in the tissues of the mammary gland. in the breast, worsening shortly before menstruation: Pain that may radiate to the shoulder, shoulder blade, axillary areas Soreness when touched Feelings of enlargement Swelling and engorgement of the mammary glands Discharge from the nipples Palpable lumps * As defined by WHO (1984)

Slide 19

What determines the development of mastopathy - who is at risk?

THE REASONS FOR THE DEVELOPMENT OF MASTOPATHY ARE THE SAME AS FOR BREAST CANCER: Hereditary predisposition (benign and malignant diseases of the mammary glands in blood relatives) Endocrine disorders (for example, diabetes mellitus) Stressful situations Obesity Infertility or lack of pregnancy and childbirth up to 30 years Late first pregnancy and childbirth after age 30 Not breastfeeding or too long a period of feeding (more than 2 years) Early onset of menstruation (before 12 years) and late menopause (after 55 years). The risk group for the development of breast pathology includes women who have 2 or more provoking factors.

Slide 20

Treatment of dishormonal hyperplasia

Should be carried out taking into account: Age Form of the disease The nature of menstrual disorders The presence of concomitant endocrine, gynecological diseases or extragenital pathology In diffuse mastopathy, it is necessary to eliminate the causes that caused hormonal imbalance in the body and restore the functioning of the nervous system.

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Types of treatment

Compensation of the underlying disease Sedatives and adaptogens Diuretics Phytotherapy Homeopathic remedies Vitamin therapy Hormone therapy

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Sedatives.

Novo-Passit - an extract from medicinal plants has a predominantly sedative (calming) effect, guaifenesin has an anti-anxiety effect. Dosage and administration: 5 ml (1 teaspoon) or 1 table. 3 times a day.

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Adaptogens

Ginseng, Eleutherococcus, Schisandra chinensis, flower pollen are a group of substances of plant origin that have a stimulating effect and increase the body's resistance to adverse environmental influences. They contribute to the normalization of metabolic processes, increase the body's resistance to stress, stimulate the synthesis of biostimulants that activate the immune system.

Slide 25

Diuretics

Syndrome of premenstrual tension of the mammary glands - painful engorgement of the mammary glands in the second half of the menstrual cycle. It is caused by a deficiency of progesterone or an excess of prolactin in the tissues of the mammary gland, which leads to swelling of the connective tissue of the gland. In these cases, 7-10 days before menstruation, the following are prescribed: mild diuretics (lingonberry leaves, diuretic tea); or furosemide 10 mg (1/4 tablet); or triampura 1/4 tablet in combination with potassium preparations.

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Modern approaches to the correction of diseases of the female reproductive system Normalizes elevated levels of prolactin Included in the regulatory circle of the hypothalamus-pituitary-ovaries Eliminates the imbalance of sex hormones

Slide 27

Mastodinon

Natural non-hormonal drug for the treatment of moderate forms of mastopathy, mastodynia and PMS Dosage and administration: Inside, with a small amount of liquid, 30 drops or 1 table. 2 times a day (morning and evening) for at least 3 months, without a break during menstruation. Improvement occurs, as a rule, in 4-6 weeks.

Slide 28

Phytotherapy

Cyclodinone (agnucaston) is a preparation containing only prutnyak. It normalizes the level of sex hormones. It has a dopaminergic effect, which causes a decrease in prolactin production. Dosage and administration: 40 drops or 1 tablet 1 time per day (in the morning) for 3 months continuously. Indications: Menstrual disorders associated with insufficiency of the corpus luteum; Mammalgia; premenstrual syndrome. Contraindications: Hypersensitivity, pregnancy, lactation.

Slide 29

Mammoclam. The drug is obtained from kelp. The mechanism of therapeutic action is associated with the content of iodine, omega-3 polyunsaturated fatty acids and chlorophyll. The drug, as a result of the action of iodine of omega-3 polyunsaturated fatty acids and chlorophyll, normalizes the balance of thyroid and sex hormones, normalizes the processes of cell proliferation in the breast tissue. Dosage and administration: 1-2 tablets 2-3 times a day before meals for 1-3 months.

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INDINOL - A preparation based on highly purified indole - 3 - carbinol (found in broccoli). Indole - 3 - carbinol competes with estrogens for binding to receptors, reduces the number of estrogen receptors in target tissues, corrects estrogen metabolism: stimulates the activity of CYP450 1A1,. Dosage and administration: The therapeutic dose is 400 mg (4 capsules) per day for 3-6 months. Prophylactically prescribed 100-200 mg (1-2 capsules) per day with meals for 1-3 months.

Slide 31

Homeopathic preparations

MASTIOL EDAS-127 is a complex (multicomponent) drug that has a wide range of therapeutic effects on the body. The components that make up the drug affect the central and autonomic nervous, vascular systems of the body, and the mammary glands. Dosage and administration: inside without food, 5 drops on a piece of sugar or in a teaspoon of water 3 times a day.

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vitamins

Vitamin A. Reduces the phenomena of epithelial proliferation (antiestrogenic effect), has an antioxidant effect, which determines its oncoprotective effect. Vitamin A contains the following animal products: fish oil, milk fat, butter, cream, cottage cheese, cheese, egg yolk, liver fat. b-carotene (provitamin A) has the highest activity. There is a lot of carotene in mountain ash, apricots, rose hips, black currants, sea buckthorn, yellow pumpkins, watermelons, red peppers, cabbage, spinach, celery, parsley, dill, carrots, sorrel, green onions, green peppers.

Slide 33

Vitamin E. It has antioxidant activity, participates in the processes of tissue metabolism, prevents increased permeability and fragility of capillaries, normalizes reproductive function, inhibits free radical reactions, prevents the formation of peroxides that damage cellular and subcellular membranes; protects vitamin A from oxidation. Natural sources of vitamin E include various oils, wheat germ, cereals, Brussels sprouts and broccoli, leafy greens, spinach, and eggs. The daily requirement for vitamin E for women is 8 IU.

slide 34

Hormonal preparations.

Progestogel - progesterone, the active substance of the drug. In mammary gland tissues, progesterone reduces capillary permeability and the intensity of cyclic edema of the connective tissue stroma, prevents proliferation and mitotic activity of the ductal epithelium. When applied to the skin, it is practically not absorbed into the systemic circulation. How to use: One dose (2.5 g of gel) is applied to the skin of each mammary gland until completely absorbed 1-2 times a day. The course of treatment is up to 3 months.

Slide 35

Local treatment

"Dimexide" in the form of applications is effective in the treatment of festering cysts, non-lactational mastitis in the stage of infiltration. The use of "Dimexide" in a dilution of 1: 3-1: 5 can significantly reduce pain, achieve subsidence of inflammation in 60-70% of patients. Method and doses: Dimexide solution is diluted in a ratio of 1:3 - 1:5, a gauze napkin is wetted with this solution and applied to the pathological area of ​​the mammary gland for 1-1.5 hours 1 time per day. Such applications are made within 5-10 days.

The fundamental difference between nodular mastopathy is the presence of a palpable node or local compaction that differs in characteristics from the rest of the structures being determined. According to morphological manifestations, mastopathy is divided into: a) without proliferation b) with proliferation c) with proliferation and atypia, which ultimately determines the tactics of treatment. Due to the high risk of cancerous proliferation in the node, the treatment of nodular mastopathy is always operative. The nodes formed in the mammary gland are not amenable to conservative treatment and do not resolve.

Slide 40

With the nodular form of mastopathy, women may notice pain in the mammary gland, which may be permanent or manifest itself in certain phases of the menstrual cycle. Basically, a woman feels some discomfort immediately before the onset of menstruation - her breasts increase, swell, become very sensitive, painful. Pain can be felt both at the site of the node, and give to the arm or shoulder blade. After the end of menstruation, the pain decreases or disappears. There may also be discharge from the nipples. They may be clear, yellowish, or bloody. The liquid may come out in large quantities, or in the form of a few drops with strong squeezing. Sometimes it also happens that mastopathy is not accompanied by any of the above symptoms and it can only be detected by chance. Since after surgical treatment of nodular mastopathy, changes in breast tissue due to neuroendocrine disorders persist, subsequently an individual program of examination and treatment of the patient is formed.

Slide 41

TREATMENT OF BREAST FIBROADENOMAS

Fibroadenoma occurs in the form of three histological variants: pericanalicular (51%), intracanalicular (47%) mixed (2%). In 9.3% of cases they are bilateral, in 9.4% they are multiple. The doctor's tactics in the treatment of fibroadenoma are determined by two main properties of fibroadenoma: Fibroadenoma is not amenable to conservative treatment Fibroadenomas are not capable of malignancy (except for leaf-shaped fibroadenoma, which in 10% of cases can degenerate into breast sarcoma) Based on these two facts, indications for surgical treatment of breast fibroadenoma is: Leaf-like structure of fibroadenoma (absolute indication) Large size (over 2 cm), or size causing a cosmetic defect The desire of the patient to remove the tumor Rapid growth of the tumor In other cases, after morphological confirmation of the diagnosis, fibroadenoma can be observed. For the surgical treatment of fibroadenoma, enucleation of the tumor from the paraareolar approach is currently most often used.

Slide 42

LEAF TUMORS OF THE BREAST

A leaf-shaped tumor (foliate fibroadenoma) is formed from an intraductal fibroadenoma and occupies an intermediate position between fibroadenoma and breast sarcoma. There are three types of leaf-shaped tumor: benign leaf-shaped tumor; leaf-shaped tumor borderline; leaf-shaped tumor is malignant. Tumor malignancy occurs in 3-5% of cases. Leaf-shaped tumors occur in all age groups, and the peak incidence occurs during active hormonal periods of life: 11–20 years and 40–50 years. The etiology of leaf-shaped fibroadenomas is unclear. It is believed that the tumor occurs as a result of a violation of the hormonal balance in the body, primarily with a violation of the content of estrogen, as well as with a lack of an estrogen antagonist - progesterone. Lactation and pregnancy are provoking factors. Thyroid diseases, diabetes mellitus, liver diseases are also factors contributing to the disruption of hormonal metabolism and, as a result, the development of leaf-shaped tumors.

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Therapeutic tactics for dishormonal dysplasia of the mammary glands

* If conservative therapy is ineffective in the nodular form of non-proliferative mastopathy - surgical treatment (sectoral resection with urgent histological examination). **When refilling the cyst after the puncture, surgical treatment (sectoral resection with urgent histological examination).

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Breast cancer occurs in 1 out of 10 women.

Mortality due to breast cancer is 19-25% of all malignant neoplasms in women.

Most often found in the left breast.

Most often, the tumor is located in the upper outer quadrant.

1% of all breast cancer cases are male breast cancer.

The greatest risk factors are female gender, family history of breast cancer.

Treatment.

Treatment of breast cancer - combined (surgical, radiation, chemotherapy, hormone therapy).

Surgery.

The operation can be radical or palliative.

In most cases, a modified radical mastectomy is used. Operations with preservation of the mammary gland make it possible to correctly assess the prevalence of the tumor process and improve the cosmetic result: however, not all patients have the possibility of preserving the gland.

Removal of the entire affected mammary gland is necessary due to the multifocal nature of the disease. Approximately 30-35% of patients find precancerous or cancerous lesions in areas adjacent to the affected primary tumor.

Removal of axillary lymph nodes is necessary to determine the damage to the nodes and the stage of the disease.

Operation types:

Lumpectomy (sectoral resection), axillary lymphadenectomy, and postoperative irradiation are used for small tumors (less than 4 cm) and for intraductal carcinomas.

- Simple mastectomy(Maden's operation) includes the removal of the mammary gland with the paranasal space together with the removal of the lymph nodes.

- Modified radical mastectomy(Operation Patty). Remove the skin around the gland, the mammary gland, pectoralis minor, fatty tissue with lymph nodes of the axillary, subclavian and subscapular regions. Uro

- Radical mastectomy according to Halsted. Together with all the tissues mentioned above, the pectoralis major muscle is also removed.

- Major radical mastectomyincludes removal of mediastinal lymph nodes. The operation is indicated for large or medially located tumors with the presence of intrathoracic (parasternal) metastases. High risk of intraoperative mortality.

- Breast reconstruction operations are performed simultaneously with mastectomy or the second stage after complete healing of the primary surgical wound.

Radiation therapy

- Preoperative. After establishing the diagnosis, patients with breast cancer receive a course of preoperative radiation therapy for the mammary gland and the area of ​​regional metastasis.

- Postoperative. Patients who underwent removal of the tumor and axillary lymph nodes and did not undergo a course of preoperative radiation therapy should receive final radiation therapy to the area of ​​the breast and lymph nodes (if metastases are detected in them).

- Obligate postoperative. Breast cancer patients should receive postoperative radiation if any of the following risk factors are present:

the size of the primary tumor is more than 5 cm

metastasis to more than 4 axillary lymph nodes the tumor reaches the resection line, invades the thoracic fascia and/or muscle, or spreads from the lymph nodes to the axillary fat.

Patients at high risk of distant metastasis may receive radiation therapy until completion of adjuvant chemotherapy, or it may be given in conjunction with radiation. Postoperative irradiation of the axilla increases the risk of edema of the upper extremity.

Chemotherapy

Slows down or prevents relapse, improves the survival of patients with metastases in the axillary lymph nodes, as well as in some patients without axillary metastases.

Chemotherapy is most effective in premenopausal patients with axillary lymph node metastases (a 30% reduction in 5-year mortality is observed).

Combination chemotherapy is preferable to monotherapy, especially in the group of patients with metastatic breast cancer. Taking drugs in six courses for six months is the optimal method of treatment in terms of efficiency and duration.

hormone therapy

Ovarian suppression by radiation or oophorectomy has mixed results; in some subgroups of patients, long periods of improvement are noted.

A positive response to hormone therapy is likely under the following conditions:

a long period without metastasis (more than 5 years);

advanced age, the presence of bone metastases;

regional metastases and minimal lung metastases;

histologically confirmed malignancy grades 1 and 2;

long-term remission as a result of previous hormone therapy.

The estrogen antagonist tamoxifen delays relapse, improves survival, and is preferred in postmenopausal patients.

Performed by a student of the medical faculty of group 518 Maltseva O.N.

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Breast cancer is an oncological disease of a malignant nature.

Slide 3: EPIDEMIOLOGY

It ranks first among tumor neoplasms of the female reproductive system. The increase in the incidence of breast cancer over the past 10 years was 29.5%, in women of reproductive age - 25.2% %.

Slide 4: CLASSIFICATION

T - primary tumor. ✧ Tx - not enough data to evaluate the tumor. ✧ Tis (DCIS) ductal carcinoma in situ. ✧ Tis (LCIS) lobular carcinoma in situ. ✧ Tis (Paget) - Paget's (nipple) cancer without signs of a tumor (in the presence of a tumor, the assessment is carried out by its size). ✧ T1mic (microinvasion) - 0.1 cm in greatest dimension. ✧ T1a - tumor from 0.1 cm to 0.5 cm in greatest dimension. ✧ T1b - tumor from 0.5 cm to 1 cm in greatest dimension. ✧ T1c - tumor from 1 cm to 2 cm in greatest dimension. ✧ T2 - tumor from 2 cm to 5 cm in the largest size. ✧ TK - the tumor is more than 5 cm in the largest size. ✧ T4 - Tumor of any size with direct extension to the chest wall1 or skin. Pathological classification: - T4a - germination of the chest wall; - T4b - edema (including "lemon peel") or ulceration of the skin of the breast or satellites in the skin of the gland; - T4c signs listed in paragraphs 4a and 4b; – T4d-inflammatory (edematous) cancer

slide 5 classification

N - regional lymph nodes. ✧ Nx - insufficient data to assess the involvement of regional lymph nodes. ✧ N0 - no signs of regional lymph node metastases. ✧ N1 - metastases in displaced axillary lymph nodes (on the side of the lesion). ✧ N2 - metastases in the axillary lymph nodes on the side of the lesion, soldered together or fixed, or clinically detectable metastases in the intrathoracic lymph nodes in the absence of clinically obvious damage to the axillary lymph nodes. - N2a - metastases in the axillary lymph nodes on the side of the lesion, soldered together or fixed. - N2b - clinically detectable metastases in the intrathoracic lymph nodes in the absence of clinically obvious involvement of the axillary lymph nodes. ✧ N3 - metastases in the subclavian lymph nodes on the side of the lesion, or clinically detectable metastases in the intrathoracic lymph nodes in the presence of a clinically obvious lesion of the axillary lymph nodes, or metastases in the supraclavicular lymph nodes on the side of the lesion (regardless of the condition of the axillary and intrathoracic lymph nodes). - N3a-metastases in the subclavian lymph nodes on the side of the lesion. - N3b-metastases in the intrathoracic lymph nodes in the presence of clinically obvious damage to the axillary lymph nodes. – N3c-metastases in the supraclavicular lymph nodes on the side of the lesion.

slide 6 classification

M - distant metastases. ✧ Mx - insufficient data to determine distant metastases. ✧ M0 - no signs of distant metastases. ✧ M1 - there are distant metastases.

Slide 7: Grouping by stage

Stage T N M Stage 0 Tis N0 M0 Stage I A T1 N0 M0 Stage I B T0, T1 N 1 M0 Stage II A T0 T1 T2 N1 N1 N0 M0 M0 M0 Stage II B T2 T3 N1 N0 M0 M0 Stage IIIA T1 T2 T3 N2 N2 N2 M0 M0 M0 Stage IIIB T4 N0,N1,N2 M0 C Stage III C Any T N3 M0 Stage IV Any T Any N M1

Slide 8: Clinical groups:

Operable breast cancer (0, I, IIA, IIB, IIIA stages); Locally advanced (primarily inoperable) breast cancer (IIIB, IIIC stages); Metastatic breast cancer or recurrence of the disease.

Slide 9: Morphological classification of breast cancer (WHO, 2003)

I. Non-invasive breast cancer. 1. Ductal cancer in situ (intraductal cancer). 2. Lobular cancer in situ. II. Invasive breast cancer. 1. Microinvasive carcinoma. 2. Invasive carcinoma, unspecified. 3. Invasive lobular carcinoma. 4.Tubular carcinoma. 5. Invasive cribriform carcinoma. 6. Medullary carcinoma. 7. Mucinous carcinoma and other tumors with abundant mucinosis. 8. Neuroendocrine cancer. 9. Invasive papillary carcinoma. 10. Invasive micropapillary carcinoma. 11. Apocrine carcinoma. 12. Metaplastic carcinoma. 13. Other rare types of carcinomas.

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Slide 10: ETIOLOGY AND PATHOGENESIS

Breast cancer is a polyetiological disease; in most cases, breast cancer is a hormone-dependent disease caused by an imbalance in the hypothalamic-pituitary-ovarian system. Among all organs of the reproductive system at risk of hormone-dependent hyperplastic processes, the mammary glands suffer most often, being the first to signal neurohumoral homeostasis disorders.

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Slide 11: Risk factors

1. Age 2. Confounded family history 3. Genetic predisposition 4. Disorders in the reproductive system. ✧ Early onset of menstruation (<12 лет) и поздняя менопауза (>55 years) ✧ No childbirth and late age of first birth (> 30 years) ✧ No or short period of breastfeeding. ✧ Menopausal hormone therapy 5. Dyshormonal benign diseases of the mammary glands 6. Increased mammographic density 7. Ionizing radiation 8. Obesity 9. Dietary errors 10. Excessive alcohol consumption 11. History of malignant neoplasms.

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slide 12

Breast cancer is characterized by extreme variability in clinical course: from aggressive to relatively benign, indolent. The period of time from the hypothetical "first" cancer cell to the death of the patient after the tumor reaches a "critical" mass is called the "natural history" of breast cancer growth. The fundamental possibility of metastasis appears already with the onset of angiogenesis in the tumor, when the number of tumor cells exceeds 103, and the tumor diameter is no more than 0.5 mm.

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Slide 13: CLINICAL PICTURE (Nodular cancer)

It occurs most often, representing a round, dense neoplasm with a small- and large-hilly surface, without clear contours, limited mobility. With the localization of the tumor in the deep sections of the mammary gland, as well as in the advanced stage of the disease, the node is fixed to the chest wall. Most often, the tumor node is determined in the upper outer quadrant of the mammary gland. In the case of a central location of the tumor, with its small size, the nipple deviates to the side or its fixation is noted.

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Slide 15: CLINICAL PICTURE (Nodular cancer)

Above the tumor node, pastosity of the skin in a limited area, a symptom of "orange peel" can be detected, which occur either as a result of embolism by tumor cells of deep skin lymphatic vessels, or due to secondary lymphostasis due to metastatic lesions of regional lymph nodes.

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Slide 16: CLINICAL PICTURE (Nodular cancer)

Skin manifestations may also occur: a symptom of umbilization (retraction), Pribram's symptom (when the nipple is pulled, the tumor moves behind it), Koenig's symptom (when pressed with an open palm, the tumor does not disappear), Payr's symptom (the skin over the tumor between the fingers is not collected in a longitudinal, and transverse masonry), Krause's symptom is a thickening of the skin of the areola due to damage by tumor cells of the lymphatic plexus of the subareolar zone.

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Slide 17: umbilical symptom (retraction)

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Slide 18: CLINICAL PICTURE (Diffuse cancer)

Combines edematous-infiltrative, shell-like, erysipelas-like and mastitis-like forms. These forms are characterized by the rapid development of the process both in the organ itself and in the surrounding tissue, extensive lymphogenous and hematogenous metastasis. The edematous-infiltrative form occurs most often in young women. At the same time, the mammary gland is enlarged, its skin is pasty and edematous, hyperemia and a symptom of lemon peel are expressed. It is often difficult to identify a tumor node in the gland tissue. Palpated infiltrate without clear contours, occupying most of the gland. Shell cancer is characterized by tumor infiltration of both the gland tissue itself and the skin covering it. The skin becomes dense, pigmented, poorly displaced. There are many intradermal tumor nodes. The mammary gland is reduced, pulled up, wrinkled. Tumor infiltration compresses the chest in the form of a shell.

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Slide 19

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slide 20: shell cancer

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Slide 21: CLINICAL PICTURE (Diffuse cancer)

Erysipelas-like and mastitis-like forms of cancer have an acute course, are extremely malignant, quickly recur after mastectomies and metastasize rapidly. With an erysipelas-like form, the tumor process in the gland is accompanied by severe hyperemia of the skin with uneven, tongue-shaped edges. An even more rapid course is characterized by mastitis-like cancer, in which the mammary gland is significantly enlarged, tense, dense, and limitedly mobile. Expressed hyperemia and hyperthermia of the skin. The process is often accompanied by a feverish rise in temperature.

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Slide 24: CLINICAL PICTURE

Paget's cancer is a kind of malignant tumor that affects the nipple and areola. According to clinical manifestations, they distinguish: eczema-like (nodular, weeping changes in the areola), psoriasis-like (with the formation of scales and plaques), ulcerative (crater-like ulcer with dense edges) tumor (seals in the subareolar zone) forms. In 50% of patients, the tumor affects only the skin of the nipple, in 40% it is detected against the background of a palpable tumor, in 10% it is only with microscopic examination.

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Slide 25: Paget's cancer

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Slide 26: CLINICAL PICTURE

Metastatic, or occult form of cancer, is characterized by small, sometimes microscopic size and the presence of metastatic lesions of regional lymph nodes. Most often, breast cancer metastasizes to the bones (50–85%), lungs (45–70%), liver (45–60%), and brain (15–25%).

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Slide 27: DIAGNOSIS

Complaints and anamnesis The most common complaints are: the presence of a nodular formation, retraction of a skin area or swelling of the skin, a change in the size or deformation of the shape of the mammary gland, changes in the nipple and areola, the presence of pathological discharge from the nipple (most often hemorrhagic or serous). Pain is not an early sign of breast cancer. When collecting an anamnesis, the nature of complaints, the timing of their appearance, hereditary predisposition to malignant neoplasms are specified, taking into account the period of a woman's life.

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Slide 28: Clinical methods of examination

Inspection and palpation of the mammary glands The optimal time for its use in menstruating women should be considered the 6th or 8th day after the end of menstruation. Non-menstruating women can be examined at any time. Inspection is best done in a standing position, first with the arms lowered, and then with the arms raised behind the head. As a result, the symmetry of the location and shape of the mammary glands, the level of the location of the nipples and the condition of the skin are determined. Palpation determines the location, size, boundaries of the tumor, its surface and consistency, as well as the relationship with surrounding tissues and displacement in relation to them. Palpation is performed with the patient standing, as well as lying on her back and on her side. Palpation examines both the entire mammary gland around the nipple, and sequentially in quadrants and areas up to the submammary fold.

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Slide 30: X-ray mammography

Mammography is the main method for an objective assessment of the state of the mammary glands, allowing timely recognition of changes in the mammary glands in 92–95% of patients. There are direct and indirect signs of cancer. Direct signs include the characteristics of the tumor node and microcalcifications.

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Slide 33: X-ray mammography

Indirect signs of the nodular form of cancer are associated with changes in the skin (local or diffuse thickening, deformation), blood vessels (hypervascularization, expansion of their caliber, the appearance of tortuosity of the veins), surrounding tissues (twisting), retraction of the nipple, the appearance of a cancer path between the tumor node and the skin, and others. .

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slide 34

It is rather difficult to recognize intraductal changes on survey radiographs. In order to expand the diagnostic capabilities of the X-ray method, ductography is proposed - artificial contrasting of the ducts, which allows not only to identify the cause of pathological secretion (parietal growths) with an accuracy of 92–96%, but also to determine the exact localization of the pathological process, which is important for further treatment.

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Slide 36: Ultrasound

With this imaging option, the definition of pathological changes is associated with the presence of a volumetric formation, the density of which exceeds the background density of the surrounding breast tissues, low echogenicity with signs of an infiltrative type of growth. Dopplerography provides clarifying information with traditional ultrasound. In early malignant lesions, these are: high blood flow velocity and atypical Doppler curves due to the formation of arteriovenous shunts.

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Slide 37: Tumor markers

In clinical practice, the following tumor markers are mainly used for breast cancer patients: CA 15-3, mucin-like carcinoma-associated hypertension, cancer embryonic hypertension, which are used to assess the effectiveness of the treatment, as well as in the process of dynamic monitoring of radically treated patients.

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slide 38 genetic testing

To date, it is believed that in 20–50% of cases, hereditary breast cancer is caused by mutations in the BRCA1 and BRCA2 genes. Molecular genetic studies to determine mutations in the BRCA 1 and 2 genes are carried out taking into account one of the factors listed below. 1. Individual history: ✧ breast cancer (up to 50 years); ✧ Ovarian cancer at any age, fallopian tube cancer and primary peritoneal cancer; primary multiple malignant neoplasms. 2. Oncologically aggravated family history: ✧ Breast cancer in blood relatives (including men); ✧ OC in blood relatives; ✧ pancreatic cancer and / or prostate cancer in blood relatives; ✧ Confirmed carriage of BRCA 1.2 mutations in blood relatives.

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Slide 39: Morphological diagnosis

Cytological method: Fine-needle punctate, punctates of regional lymph nodes, discharge from the nipple, scrapings from eroded and ulcerative surfaces of the nipple and skin, fluid from cysts can serve as diagnostic material for cytological examination. The reliability of the cytological diagnostic method, according to different authors, ranges from 42 to 97.5%. Histological method: Is more informative. In order to obtain a small fragment of breast tissue, a biopsy is used using biopsy guns and special needles (gun-needle system), which make it possible to obtain material suitable for cytological and histological studies.

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Slide 41: In the syndrome of palpable nodular formation in the mammary gland, it is recommended:

clinical examination (taking an anamnesis, examination, palpation of the mammary glands and regional zones of lymphatic drainage); panoramic radiography of the mammary glands (in frontal and oblique projections); if necessary, clarification of details - targeted radiography with direct magnification of the x-ray image (when working on analog mammographs), radial ultrasound, doppler sonography, sonoelastography, if necessary, 3D image reconstruction; if cancer is suspected in order to search for metastases - ultrasound of the soft tissues of the axillary regions; trepanobiopsy (less informative fine-needle biopsy) neoplasms, cytological and histological examination of the biopsy, depending on the findings. With breast cancer - immunohistochemical study.

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Slide 42: If breast cancer is detected before the start of treatment, an examination is recommended according to the following scheme:

History taking and physical examination; Complete blood count with leukocyte count and platelet count; Biochemical blood test, (bilirubin, ALT, AST, alkaline phosphatase); Bilateral mammography + ultrasound of the mammary glands and regional zones; according to indications, MRI of the mammary glands; Digital R-graphy of the chest; according to indications - CT / MRI of the chest; Ultrasound of the abdominal cavity and small pelvis, according to indications - CT / MRI of the abdominal cavity and small pelvis with contrast; Bone scintigraphy of the skeleton + radiography of areas of accumulation of the radiopharmaceutical - in patients with locally advanced and metastatic cancer. With breast cancer stages T0–2N0 - performed according to indications (bone pain, increased levels of alkaline phosphatase in the blood serum); Trepanobiopsy of the tumor with pathomorphological examination of the tumor tissue; Determination of estrogen and progesterone receptors, HER-2/ neu and Ki67; Fine-needle aspiration biopsy of the lymph node for suspected metastasis; Fine-needle aspiration biopsy (preferably trephine biopsy) of the primary tumor in the case of "cancer in the cyst"; Evaluation of ovarian function; Genetic DNA analysis of blood (mutation of the BRCA 1, 2 genes) with a burdened hereditary history - the presence of breast cancer in close relatives.

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slide 43: treatment

The tactics of treating patients with breast cancer is based on clinical characteristics (size and location of the primary tumor, the number of metastatic lymph nodes, the degree of involvement of lymph nodes) and the biological characteristics of the tumor (pathomorphological characteristics, including biomarkers and gene expression), and also depends on age, general condition and patient preferences. In the treatment of patients with breast cancer, both loco-regional (surgery, radiation therapy) and systemic methods (hormone therapy, chemotherapy, biotherapy) are used.

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slide 44: surgeon

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Slide 45: The classic radical Halsted-Meyer mastectomy involves the removal in one block of the mammary gland, pectoralis major and minor muscles, axillary-subclavian-subscapular tissue along with lymph nodes

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Slide 46

Functionally sparing mastectomy according to Patey with preservation of the pectoralis major muscle consists in the removal of the mammary gland, pectoralis minor muscle and performing axillary lymph node dissection. With a mastectomy according to Madden, both pectoral muscles are preserved.

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Slide 47

Skin-sparing mastectomy involves the removal of breast tissue and preservation of the skin cover, and in some cases, the juice-areolar complex. This type of mastectomy allows you to minimize the area of ​​scars and preserve the natural contours of the mammary gland for the purpose of its further reconstruction. Organ-preserving operations (tumorectomy, radical resection) consist of a wide excision of the tumor with simultaneous axillary lymph node dissection. In order to reduce the effect of breast tissue resection on the cosmetic result, surgical oncologists use oncoplastic approaches, most often associated with the use of tissue transfer technology. Oncoplastic approaches may lead to improved cosmetic outcomes, especially in patients with large breasts, an unfavorable tumor-to-breast ratio, or cosmetically unfavorable tumor localization in the breast (in the central zone or in the lower hemisphere).

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Slide 49

Reconstruction of the mammary gland involves only the restoration of its aesthetic component. The goals and objectives of the restoration of the mammary gland are to restore the volume of the mammary gland, create an aesthetic form, restore the skin, the nipple-areolar complex, and symmetry. Currently, breast reconstruction with artificial materials (silicone implants), breast reconstruction with own tissues (musculocutaneous flap from the latissimus dorsi muscle, lower abdominal musculoskeletal flap with a base on the rectus abdominis muscle, flap on the free lower epigastric perforator from the lower parts of the abdomen, flap with inclusion of the superior gluteal artery), or a combined reconstruction using both methods. Both immediate and delayed breast reconstruction are possible

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Slide 53

in premenopausal and postmenopausal women with a favorable prognosis, it is recommended to take tamoxifen at a dose of 20 mg/day for 5 years. Ovarian suppression in combination with aromatase inhibitors (letrozole 2.5 mg/day, anastrozole 1 mg/day, exemestane 25 mg/day) can be used to treat patients at high risk of relapse in premenopausal women, as well as contraindications to the appointment of tamoxifen. Ovarian suppression drugs (goserelin 3.6 mg, buserelin 3.75 mg, leuprorelin 3.75 mg) are administered every 28 days for 5 years. Trastuzumab is indicated for patients with overexpression/amplification of the HER2 gene. The standard duration of trastuzumab administration (loading dose - 8 mg/kg, maintenance dose - 6 mg/kg) is 12 months with an interval of 1 time in 3 weeks.

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Slide 54

It is recommended to evaluate the effect of treatment after every 2-3 months of hormone therapy and every 2-3 courses of chemotherapy using data from a general examination, clarification of complaints, blood tests and the results of instrumental examination methods that revealed pathology at the stage of initial diagnosis.

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Slide 55: Follow-up after initial treatment

Follow-up after primary treatment is carried out by oncologists and involves examination and clarification of complaints every 6 months - during the first 3 years, every 12 months - over the next years, including general and biochemical blood tests. Annually, it is recommended to perform bilateral (in case of organ-preserving surgery) or contralateral mammography, R-graphy of the chest organs, ultrasound of the abdominal organs. Particular attention should be paid to long-term adverse effects, in particular osteoporosis, especially in women receiving long-term aromatase inhibitors, as well as those who have reached early menopause as a result of anticancer therapy. This category of patients is indicated for annual densitometry and prophylactic administration of calcium and vitamin D preparations, as well as osteomodifying preparations, according to indications. Women receiving tamoxifen should be examined by a gynecologist at least once every 12 months with ultrasound of the pelvic organs and measurement of endometrial thickness.

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Slide 56: PREDICTION

The prognosis for patients with breast cancer depends on the biological characteristics of the tumor, the general condition of the patient, as well as on the appropriate therapy. The ten-year survival rate for breast cancer exceeds 70% in most European countries. In Russia, the 5-year survival rate of patients with breast cancer was 59.5%. Peaks of recurrence of the disease occur in the 2nd year after diagnosis, but do not exceed 2–5%, starting from the 5th to the 20th years. Patients with lymph node involvement have a higher annual recurrence rate compared to patients without lymph node involvement. In the first few years, the risk of recurrence is higher in patients with estrogen-negative breast cancer, but 5–8 years after diagnosis, the annual recurrence rate decreases more than in estrogen-positive cancer. Recurrence of the disease after more than 20 years from the moment of treatment can occur almost exclusively in hormone-positive breast cancer.

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Slide 57: SCREENING AND PREVENTION

Women of all ages should have monthly breast self-examinations. Starting from the age of 18, every woman should undergo a preventive examination once every 2 years in the examination room of the clinic, which includes examination and palpation of the breast. . For the purpose of early diagnosis of breast diseases, an annual ultrasound of the mammary glands is recommended for women under 35 years of age, further according to indications; x-ray mammography - for patients aged 35–50 years with a frequency of 1 time in 2 years, over 50 years old - annually.

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Last slide of the presentation: Breast cancer: Prevention of breast cancer can be primary, secondary and tertiary

Primary prevention is aimed at eliminating the causative factors that cause the tumor. Depending on risk factors, degree of risk, age, menopausal status, comorbidities, and patient preference, different types of primary prevention can be offered. Secondary prevention is aimed at the diagnosis and treatment of precancerous diseases of the breast, primarily benign dyshormonal dysplasia with atypical proliferation. Tertiary prevention involves the qualitative treatment of primary malignant neoplasms of the breast in order to prevent the development of a recurrence of the disease in the future. The effectiveness of tertiary prevention depends on the effective work of the oncology service.