An Najah National UniversityFaculty of Nursing

Neoplastic disorders

Prepared by: Mr’s Raheegeh Awni05/02/2014

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Breast Cancer

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Breast Cancer• Cancer of the breast is the second leading

cause of cancer deaths in American women.

• One in eight American women will develop breast cancer in her lifetime.

• Mortality rate have declined as a result of earlier detection & improved treatment.

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Symptoms • The most common presenting symptom is a lump or

thickening of the breast.• The lump may feel hard & fixed or soft & spongy.• It may have well-defined or irregular borders.• It may be fixed to the skin, thereby causing dimpling

to occur.• A nipple discharge that is bloody or clear also may be

present.

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• The tumor may become fixed to the deep fascia.

• Extension to the skin may cause retraction and dimpling, whereas ductal involvement may cause nipple retraction.

• Blockage of skin lymphatics may cause lymphedema and thickening of the skin.

Risk factors of Breast Cancer• Age• Previous history of breast cancer• Family history of breast cancer.• Previous history of ( ovarian, endometrial, or thyroid cancer)• Early menarche• Late menopause• Nulliparity or first pregnancy after age of 30• Use of hormonal replacement therapy.• Obesity after menopause• Previous history of benign breast diseases• Race • High socioeconomic status.

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• COMMON BENIGN BREAST DISORDERS

1- FIBROCYSTIC CHANGES

• Are Lesions formerly grouped together under the designation of fibrocystic disease represent a pathologically heterogeneous group of diseases that can be divided into three separate histologic categories: nonproliferative lesions, proliferative lesions (hyperplasia), and atypical hyperplasias.

• Atypical hyperplasia is a condition that's found on a breast biopsy.

• In the breast there are cells that make up the normal glands of the breast itself.

• If those cells increase in number, we call that hyperplasia, which simply means "too many cells."

Characteristics

• Lumpness with or wihout tenderness• Single simple cyst may occur• Symptoms of heaviness and pain one week

before and after mensis• Small multiple cysts

Management

• Depends on the severity o0f the symptoms• Diet change and vit.E Supplement ( It is used

for preventing cancer)• Eliminate consumption of methylxanthines

eg. Colas, coffee, tea, choclate and tobacco• Wearing supportive bra• Applying heat to breasts• OCPs, bromocripitine, tamoxefin

• Bromocriptine (Parlodel) may be used to treat hyperprolactinemia caused by certain types of tumors that produce prolactin, and may shrink these tumors.

• Tamoxifen is an antagonist of the estrogen receptor in breast tissue

• Many women have breast cancer that tests positive for estrogen receptors (ER+). This means that estrogen promotes the growth of the breast cancer cells. Tamoxifen blocks the effects of estrogen on these cells. It is often called an "anti-estrogen."

2- Hyperplasia

• is the most common benign breast disorder and is present in about 50% of women.

• Histologically, the hyperplastic changes may involve any or all of the breast tissues (lobular epithelium, ductal epithelium, and connective tissue).

• When the hyperplastic changes are associated with cellular atypia, there is an increased risk for subsequent malignant transformation.

3- FIBROADENOMA• Fibroadenomas are small, solid, rubbery,

noncancerous, harmless lumps composed of fibrous and glandular tissue.

• Usually single lump present

• Are seen in adolescents• Increase in size in pregnancy and decrease with

aging

• Composed of both fibrous and glandular tissue, the fibroadenoma is the most common benign tumor found in the female breast.

• Clinically these tumors are sharply circumscribed, freely mobile nodules that may occur at any age but are common before the age of 30 years.

• They usually are solitary and generally are removed when they reach 2 to 4 cm in diameter, although giant forms up to 15 cm in diameter occasionally occur and have malignant potential.

management

• Surgical excision• Periodic examination for masses by PHYSICAL

EXAMINATION• BSE• mammography

• Breast cancer

Breast cancer

• s a type of cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk.[1]Cancers originating from ducts are known as ductal carcinomas, while those originating from lobules are known as lobular carcinomas. Breast cancer occurs inhumans and other mammals. While the overwhelming majority of human cases are in women, breast cancer can also occur in men.[2]

• Breast cancer is the second most common cancer in women over the age of 50.

• If breast cancer is diagnosed at an early stage, there is a good chance of a cure.

• In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative. However, treatment can often slow the progress of the cancer.

• A malignant tumour is a lump or growth of tissue made up from cancer cells which continue to multiply.

• Malignant tumours invade into nearby tissues and organs, which can cause damage.

Malignant tumours may also spread to other parts of the body.

• This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body.

• These small groups of cells may then multiply to form secondary tumours (metastases) in one or more parts of the body.

Staging of breast cancer*

• Cancer stage is based on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast.

• AMERICAN JOINT COMMISSION ON CANCER STAGE GROUPINGS

Stage 0

• Stage 0 is used to describe non-invasive breast cancers, such as DCIS and LCIS.

• In stage 0, there is no evidence of cancer cells or non-cancerous abnormal cells breaking out of the part of the breast in which they started, or of getting through to or invading neighboring normal tissue.

Stage I

• Stage I: describes invasive breast cancer (cancer cells are breaking through to or invading neighboring normal tissue) in which:

• the tumor measures up to 2 centimeters, AND • no lymph nodes are involved

Stage II

• Stage II: is divided into subcategories known as IIA and IIB.

• Stage IIA describes invasive breast cancer in which:• no tumor can be found in the breast, but cancer cells

are found in the axillary lymph nodes (the lymph nodes under the arm), OR

• the tumor measures 2 centimeters or less and has spread to the axillary

• Stage IIB: describes invasive breast cancer in which:

• the tumor is larger than 2 but no larger than 5 centimeters and has spread to the axillary lymph nodes, OR

the tumor is larger than 5 centimeters but has not spread to the axillary lymph nodes

Stage III

• Stage III: is divided into subcategories known as IIIA, IIIB, and IIIC.

• Stage IIIA describes invasive breast cancer in which either:• no tumor is found in the breast. Cancer is found in axillary

lymph nodes that are clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone, OR

• the tumor is 5 centimeters or smaller and has spread to axillary lymph nodes that are clumped together or sticking to other structures, OR

• the tumor is larger than 5 centimeters

• Stage IIIB describes invasive breast cancer in which:• the tumor may be any size and has spread to the

chest wall and/or skin of the breast AND • may have spread to axillary lymph nodes that are

clumped together or sticking to other structures, or cancer may have spread to lymph nodes near the breastbone

• Inflammatory breast cancer is considered at least stage IIIB.

• Stage IIIC describes invasive breast cancer in which:

• there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast, AND the cancer has spread

Stage IV

• Stage IV: describes invasive breast cancer in which:• the cancer has spread to other organs of the body -- usually

the lungs, liver, bone, or brain• "Metastatic at presentation" means that the breast cancer

has spread beyond the breast and nearby lymph nodes, even though this is the first diagnosis of breast cancer.

• The reason for this is that the primary breast cancer was not found when it was only inside the breast

• Metastatic cancer is considered stage IV.

• In a retrospective case-control study was conducted to investigate risk factors associated with breast cancer in Jordanian women.

• Result: Significant differences between the cases

and controls, including age of menarche and menopause, use of households’ pesticides, stressful life events, and direct trauma to the breast.

Research Findings

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Logistic regression analysis indicated higher odds ratios breast enlargement, irregular menstruation, use of hair dye, oral contraceptives, and fertility drugs.

(Petro-Nustas W et al. 2002)

BREAST EXAMINATION

• Like the uterus, the breast undergoes regular cyclic changes in response to hormonal stimulation.

• Each month, in rhythm with the cycle of ovulation, the breasts become engorged with fluid in anticipation of pregnancy, and the woman may experience sensations of tenderness, lumpiness, or pain.

• If conception does not occur, the accumulated fluid drains away via the lymphatic network.

• Aftermenopause, adipose breast tissue atrophies and is replaced by connective tissue.

• Elasticity is lost, and the breasts may droop and become pendulous.

• The recurring breast engorgement associated with ovulation ceases.

• If estrogen replacement therapy is used to counteract other symptoms of menopause, breast engorgement may resume.

DIAGNOSIS OF BREAST LESIONS

• Physiologic nodularity and cyclic tenderness caused by the changing hormonal milieu تغيير

الهرمونية must be distinguished from الوسطbenign or malignant pathologic changes.

• Definitive diagnosis of breast neoplasms may be made by open biopsy or by fine-needle aspiration cytology.

• The following strategies may aid in early detection of breast cancer:

1. Regular breast self-examination from midadolescence age.

2. A clinical examination by qualified health care provider.

3. Mammograms: screening & diagnostic mammograms

Diagnosis & Screening

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• Diagnosis of suspicious finding can be confirmed by needle aspiration, a core needle biopsy, or surgical excision.

• U\S can be used to assess a specific area of abnormality.

• Laboratory diagnosis includes CBC, liver enzyme levels, serum calcium, & alkaline phosphatase level.

• Other tests include chest x-ray, CT, bone scan, & MRI

Cont..

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breast self-examination• Monthly (BSE) is the best method for detecting

breast masses early. • A woman who knows the texture and feel of her own

breasts is far more likely to detect changes that develop.

• Thus, it is important for a woman to develop the habit of doing routine BSE as early as possible, preferably as an adolescent.

• Women at high risk for breast cancer are especially encouraged to be attentive to the importance of early detection through routine BSE.

• The effectiveness of BSE is determined by the woman’s

• ability to perform the procedure correctly.• She should do a BSE on a regular monthly basis

about 1 week after each menstrual period, when the breasts are typically not tender

or swollen.• After menopause she should perform BSE on the same day each month (as chosen by the woman).

Clinical breast examination• Conducted by a trained healthcare provider, such as a

physician, nurse practitioner, or nurse-midwife.

• Is an essential element of a routine gynecologic examination.

• Experience in differentiating among benign, suspicious, and worrisome breast changes lets the caregiver

reassure the woman if the findings are normal or move forward with additional diagnostic procedures or referral if the findings are suspicious or worrisome.

MAMMOGRAPHY

• A mammogram is a soft-tissue x-ray of the breast without the injection of a contrast medium.• It can detect lesions in the breast before they can be felt and has gained

wide acceptance as an effective screening tool for breast cancer.• Currently the American Cancer Society recommends that all women age 40 and over have an annual mammogram.• The National Cancer Institute and the American College of Obstetricians and Gynecologists (ACOG) recommend mammograms every 1 to 2 years for women ages 40 to 49 and annually for all women age 50 and older.

Fine-needle aspiration

• is a method of collecting cells from the breast , liver, mouth, neck, lymph nodes, genitals, respiratory tract, or thyroid to look for signs of cancer, infection, or other conditions.

• A doctor inserts a thin needle into a lump and withdraws a sample of cells or fluid. The material is then examined under a microscope.

Management • For the women with early stage (I or II), the

primary treatment can be lumpectomy and modified radical mastectomy.

• Simple mastectomy to remove breast containing the tumor

• Follow up treatment may include radiation, chemotherapy, or hormonal therapy

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• Radical mastectomy: consists of dissection of the entire breast, together with the pectoralis major and minor muscles and the contents of the axilla.

• At present, breast-conserving surgery is increasingly practiced.

Radical mastectomy:

• Radiation Therapy Conservative surgery is almost always performed in conjunction with external radiation to the breast.

• This approach gives equivalent outcomes to radical mastectomy, and functional and cosmetic results are improved.

• Chemotherapy usually consists of anthracycline-based regimens (e.g., 4 cycles of Adriamycin and cyclophosphamide;

• A type of antibiotic that comes from certain types of Streptomyces bacteria. Anthracyclines are used to treat many types of cancer. Anthracyclines damage the DNA in cancer cells, causing them to die.

• AC chemotherapy is a combination chemotherapy treatment used to treat breast cancer.

ADJUVANT THERAPY

• reduces the risk of death by 25%.• Tamoxifen should be continued for 5 years. • An added bonus of Tamoxifen is a 50%

reduction in the risk of cancer in the contralateral breast.

• More recently, aromatase inhibitors such as anastrazole have been shown to be possibly superior to Tamoxifen.

• addition of taxanes(antimitotic agents that inhibit cancer cell growth by stopping cell division) can further improve outcomes.

Facts about Breast Cancer in Palestine

• Breast cancer is the #1 cancer among Palestinian women, accounting for over 30% of all female cancers.

• There is a high mortality rate -- at least 65% -- as women often present at a late stage of disease.

• The mean age of women at diagnosis is about 48, compared to the USA where the average age is 60.

• The Ministry of Health (MOH), various NGO’s and others are working to improve awareness to promote early detection through screening: the breast self-exam, the clinical breast exam performed by a qualified health people.

• Physicians, nurses and technicians are constantly trained and encouraged to promote screening and healthy life styles.

• There are over 20 mammography units in the country.

• Currently the MOH provides free mammograms for women over 40.

PREGNANCY AND BREAST CANCER

• There are massively increased levels of both estrogens and progestins during pregnancy, and some data suggest that higher estrogen levels cause excess cancer later in life, whereas progesterone may be protective (Ward and Bristow, 2002).

• Chorionic gonadotropin and relaxin, may inhibit tumor growth.

• There is intriguing evidence that higher serum levels of alpha-fetoprotein are associated with a decreased

• incidence of breast cancer (Melbye and colleagues, 2000). • Finally, it appears that interruption of pregnancy has no

influence on the course or prognosis of breast cancer.