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    Investigations & Staging of Breast Carcinoma Gowsik

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    Gowsik Darshan (GD)
    The document discusses investigations and staging for breast carcinoma. Key investigations include triple assessment with clinical examination, radiological imaging like mammography and ultrasound, and pathological assessment with FNAC and biopsy. Staging involves assessing the tumor size, lymph node involvement, and presence of distant metastases using imaging tests and is categorized by TNM staging. The document also describes early breast carcinoma treatment aiming for cure while conserving breast form and preventing recurrence.

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    Investigations & Staging of Breast Carcinoma Gowsik

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    Gowsik Darshan (GD)
    27 views25 pages
    The document discusses investigations and staging for breast carcinoma. Key investigations include triple assessment with clinical examination, radiological imaging like mammography and ultrasound, and pathological assessment with FNAC and biopsy. Staging involves assessing the tumor size, lymph node involvement, and presence of distant metastases using imaging tests and is categorized by TNM staging. The document also describes early breast carcinoma treatment aiming for cure while conserving breast form and preventing recurrence.

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    The document discusses investigations and staging for breast carcinoma. Key investigations include triple assessment with clinical examination, radiological imaging like mammography and ultrasound, and pathological assessment with FNAC and biopsy. Staging involves assessing the tumor size, lymph node involvement, and presence of distant metastases using imaging tests and is categorized by TNM staging. The document also describes early breast carcinoma treatment aiming for cure while conserving breast form and preventing recurrence.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    27 views25 pages

    Investigations & Staging of Breast Carcinoma Gowsik

    Uploaded by

    Gowsik Darshan (GD)
    The document discusses investigations and staging for breast carcinoma. Key investigations include triple assessment with clinical examination, radiological imaging like mammography and ultrasound, and pathological assessment with FNAC and biopsy. Staging involves assessing the tumor size, lymph node involvement, and presence of distant metastases using imaging tests and is categorized by TNM staging. The document also describes early breast carcinoma treatment aiming for cure while conserving breast form and preventing recurrence.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    of 25

    INVESTIGATIONS

    & STAGING OF
    BREAST CARCINOMA
    z

    ROLL NO. 35
    z INVESTIGATIONS

    Purpose of doing investigations:-


     To screen for disease
     To diagnose the disease
     For staging the disease
     For the selection of appropriate treatment
    z
    TRIPLE ASSESSMENT

    Clinical Radiological Pathological

    History USG FNAC

    examination Core needle biopsy


    Mammogram

    Excision biopsy
    MRI

    Confident diagnosis
    in 99.9% cases
    TO CONFIRM THE DIAGNOSIS:-
    z
    • Ultrasonogram
    • Mammogram
    • FNAC
    • Core needle biopsy
    • Excision biopsy

    TO STAGE THE DISEASE:-


    • X-Ray / CT Chest
    • CT Abdomen
    • Skeletal Survey / bone scan
    • CT brain – if symptomatic

    ROUTINE INVESTIGATIONS:-
    • Blood - complete blood count
    - serum urea, creatinine
    - blood glucose, blood grouping
    - serology(HIV, HCV, HbsAg)
    - LFT
    • Urine - Albumin, sugar
    MAMMOGRAPHY
    z
     It is radiograph of breast tissue taken by placing it in direct contact with
    ultrasensitive film exposing it to low voltage high temperature X-rays
     Mammography is preferred in older patients(usually >40 years) since
    they have decreased glandular tissue
     Radiation exposure – 0.1 Gy
     2 views are taken – Mediolateral oblique and Craniocaudal views
    z

    Normal mammogram mediolateral oblique(a) and craniocaudal(b) views


    Mammogram findings in Breast cancer:-
    z

    Irregular spiculated mass with increased density

    Fine pleomorphic
    Microcalcifications
    <0.5 mm

    Architectural distortion

     In advanced lesions, ancillary signs of malignancy such as


    lymphadenopathy, breast oedema, skin or areolar thickening or
    retraction may be seen
    z ULTRASONOGRAPHY

     Primary imaging modality for young women(<40 years) with dense breast
    tissue

     Advantage of USG over mammogram is that it is non-invasive and does not


    disturb the architecture of breast

     Can differentiate between solid and cystic lesions

     FNAC can be done under Ultrasound guidance

     Can be done during pregnancy and early lactation

     Ultrasound of axilla can be done to assess axilla


    Breastz Carcinoma findings in Ultrasonography:-

    • Solid,
    • Irregular shaped,
    • hypoechoic,
    • Taller than wide
    • Angular irregular margins
    • Irregular posterior shadowing
    Breast
    z Imaging Reporting and Database System (BI-RADS):-

     to achieve uniformity and objectivity in the interpretation and reporting of mammograms


    and ultrasound

    CATEGORY Assessment Probability of malignancy Follow up


    0 incomplete Not applicable Further imaging studies
    Routine annual screening
    1 negative 0%
    mammography (over age 40)
    Routine annual screening
    2 Benign finding 0%
    mammography (over age 40)
    3 Prabably benign 0% to 2% Short term follow up for 6 months
    Highly suspicious of
    4 2% to 95% Biopsy
    malignancy
    Highly suggestive of
    5 More than 95% Biopsy
    malignancy
    Biopsy proven
    6 100% Treat for malignancy
    malignancy
    MAGNETIC RESONANCE IMAGING
    z
    It is useful in,
    • Screening in high risk young females

    • To differentiate scar from recurrence

    • In women with dense breast or discordant or equivocal


    findings in mammogram/ultrasound

    • To assess multifocal and multicentric lesions

    • In women with breast implants

    • Axillary node without clinically palpable lump

    • Most sensitive for DCIS


    Fine Needle
    z Aspiration Cytology:-
    • It is done with 23-24 Gauge needle
    • it is fast and easy to perform
    • It can differentiate between malignant & benign
    lesions

    Core Needle Biopsy:-


    • It is the best confirmatory investigation
    • It is done with 14-18 Gauge needle
    Difference
    z between FNAC and Core needle biopsy:-

    FNAC Core Needle Biopsy


    Material obtained Cell Tissue
    Sensitivity & specificity Less compared to core Very less false negative
    needle biopsy rate
    Grade & Type of Cannot be identified Can be identified
    carcinoma
    ER,PR,Her2neu status Cannot be assessed Can be assessed
    Invasive/non invasive Cannot be differentiated Can be differentiated
    Chance of iatrogenic Not possible possible
    hematogenous spread
    Anesthesia Not required Local anesthesia required
    Tissue processing time less more
    Cost less more
    Difficulty of procedure less more
    z
    Investigations for staging:-

    • X-Ray/ CT chest – Pleural effusion, mediastinal nodes, intercostal


    muscle involvement, rib involvement
    • Skeletal survey/ Bone scan – Osteolytic lesions in ribs, pelvis, spine
    • CT Chest – Mediastinal nodes
    • USG Abdomen – liver secondaries,
    – krukenberg’s tumour,
    – malignant ascites
    TNM STAGING
    z
    Tumour (T) Criteria
    TX Primary tumor cannot be assessed
    T0 No evidence of primary tumour
    Tis(DCIS) Ductal carcinoma in situ*
    Tis(Paget’s) Paget’s disease not associated with invasive carcinoma or DCIS
    T1mi ≤1 mm in greatest dimension
    T1
    T1a >1 mm but ≤5 mm in greatest dimension
    (≤20 mm in greatest T1b >5 mm but ≤10 mm in greatest dimension
    dimension)
    T1c >10 mm but ≤20 mm in greatest dimension
    T2 >20 mm but ≤50 mm in greatest dimension
    T3 >50 mm in greatest dimension

    T4 T4a Extension to the chest wall


    (Tumour of any size with T4b Skin involvement
    direct extension to the
    chest wall and/or to the T4c Both chest wall and skin involvement
    skin) T4d Inflammatory carcinoma (>1/3rd of surface)

     Chest wall - Ribs, Intercostal muscles, Serratus anterior


     Skin changes – ulceration, peau d’ orange, satellite nodules*
     Inflammatory changes – brawny induration, erythema with raised edge & peau d’ orange
    Cn category Criteria

    cNx z cannot be assessed

    cN0 No regional node metastasis

    cN1 Mobile ipsilateral axillary nodes


    cN1
    cN1mi Micrometastasis(each less than 2 mm)
    cN2a Fixed ipsilateral axillary nodes
    cN2
    cN2b Ipsilateral internal mammary without axillary node involvement
    cN3a Ipsilateral infraclavicular nodes
    cN3 cN3b Ipsilateral internal mammary and axillary nodes
    cN3c Ipsilateral supraclavicular nodes

    M category Criteria

    cM0 No metastasis

    cM1 Metastasis present

    c – clinical staging
    p – pathological staging
    y – post radiation or neoadjuvant therapy - Prefixes used in TNM staging
    r – staging at time of retreatment
    m – multiple synchronous tumours
    z
    STAGE GROUPS

    Early breast carcinoma

    Locally advanced breast carcinoma

    Metastatic carcinoma
    z
    EARLY BREAST CARCINOMA
    It includes Stage I, II A & II B of Breast carcinoma

    Aims of treatment:-
    • To achieve possible cure
    • Control of local disease in breast & axilla
    • Conserving breast form & function
    • Prevention of distant metastasis
    • Prevention of local recurrence

    Treatment strategy:-
    • Breast conservation therapy (Breast conservation surgery + Radiotherapy)
    • In case of no clinically palpable node, Sentinal node biopsy is done
    preoperatively or perioperatively
    • Axillary dissection is done if nodes are clinically palpable or SLNB is positive
    LOCALLY
    z
    ADVANCED BREAST CARCINOMA
    Stage IIIA, IIIB & IIIC of Breast carcinoma

    It includes,
    • Large primary tumour (>5 cm)
    • Locally inoperable tumour (adherent to chest wall)
    • Skin involvement
    • Inflammatory carcinoma
    • Fixed axillary or opposite axillary nodes
    • Ipsilateral internal mammary or supraclavicular node
    • Bilateral carcinoma
    Clinical
    z presentation:-

    • Peau de orange Skin ulceration Inflammatory carcinoma

    Satellite nodules
    z

    Treatment of locally advanced breast carcinoma:-

    Initial neoadjuvant chemotherapy

    Response to chemotherapy is assessed (4 types of response)

    Nonresponders are treated by Radiotherapy

    Responders are treated with MRM/Total mastectomy or


    sometimes BCS
    z METASTATIC CARCINOMA

    Modes of spread:-
    • Lymphatic spread
    • Haematogenous spread
    • Transcoelomic spread

    Sites of metastasis:-
    • Bone
    • Lungs & pleura
    • Liver
    • Brain
    • Adrenals & ovary
    z
    SITES OF METASTASIS

    A. BONE (most common) - 70%


     Lumbar vertebrae, femur, ends of long bones,
    thoracic vertebrae, ribs, skull
     Spread to vertebra is through posterior
    intercostal vein and batson’s venous plexus
     They are osteolytic lesion with pathological
    fracture
     Presents with painful, tender, hard, non-
    mobile swelling
     70% of bone secondaries in a women is due
    to Ca breast
    z
    B. LIVER - either through blood or lymphatics – Liver
    secondaries
    C. LUNGS & PLEURA – malignant pleural effusion,
    consolidation, cannon ball secondaries & chest wall
    secondaries
    D. BRAIN – present with headache, vomiting, convulsions
    E. OVARIES – Krukenberg’s tumour (transcoelomic spread)
    F. CONTROLATERAL AXILLARY NODE – when present in
    the absence of contralateral primary, it is considered as
    metastatic disease
    z

    Thank You

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