Incidence Lifetime risk of developing of breast cancer

Incidence • Lifetime risk of developing of breast cancer in the U. S. is 12. 15% or 1 in 8 women • Women greater than 65 years of age have a six times greater risk of diagnosis • If rate remains unchanged an estimated 80 million women will be diagnosed with breast cancer by the year 2050, Increase of 72 % Ravert & Huffaker, 2010

New Case of Breast cancer patient in Ramathibodi Hospital

Pathology of Breast Cancer. 1 Ductal carcinoma In situ (DCIS( Invasiveductal carcinoma : found 70 % 80 -%. 2 Lobular In situ ( LCIS) Inflitrating lobular carcinoma. 3 Nipple Paget’ disease with intraductal carcinoma Paget’ disease with invasiveductal carcinoma. 4 Other Undifferentiated carcinoma

Phyllodes Tumor

Paget disease

Staging of breast cancer Stage 0 Tis N 0 M 0 Stage IIIA T 0 N 2 M 0 Stage IA T 1 N 0 M 0 T 1 N 2 M 0 Stage IB T 0 N 1 mi M 0 T 2 N 2 M 0 T 1 N 1 mi M 0 T 3 N 1 M 0 Stage IIA T 0 N 1 M 0 T 3 N 2 M 0 T 1 N 1 M 0 Stage IIIB T 4 N 0 M 0 T 2 N 0 M 0 T 4 N 1 M 0 Stage IIB T 2 N 1 M 0 T 4 N 2 M 0 T 3 N 0 M 0 Stage IIIC Any T Stage IV N 3 ระยะลกลาม M 0 Any T Any N M 1 ระยะแพรกระจ

Biological Tumor Marker in Breast cancer Hormonal Treatment ER: Estrogen Receptor(%) Pg. R: Progesterone Receptor(%) Her 2 / Neu (1+, 2+, 3+) KI 67 (%)

Molecular Subtypes of Breast Cancer 1. Luminal A : ER receptorและหรอ Pg. R receptor Positive, Her-2 Neg , KI 67 <14% , KI 67 intermediate (14% to 19%)และ Pg. R receptor Positive >20% 2. Luminal B : ER receptorและหรอ Pg. R receptor Positive , Her-2 Neg, KI 67 >14%, . 3 Luminal / Her 2: ER receptorและหรอ Pg. R receptor positive, Her-2 Positive 4. Her 2 enriched: ER receptorและPg. R receptor Neg, Her-2 Positive 5. Basal-like : ER receptor, Pg. R receptor และHer-2 Neg, และEGFR และหรอ cytokertin 5/6 Positive 6. Triple Negative non basal: ER receptor, Pg. R receptor และHer-2 Neg

Biological Tumor Marker in Breast cancer Hormonal Treatment Her 2 / Neu (1+, 2+, 3+) สงยอม FISH (Fluorescence in situ hybrization) การเปนผลบวก HER-2 gene copies to chromosome 17 centromeres > 2. 2 จะรกษาเสรมดวย Trastuzumab

Frequency of Site –specific Metatasis Sub type Luminal A Luminal B Luminal / Her 2 enriched Basal-like Triple Negative non basal Brain 7. 6% 10. 8% 15. 4% 28. 7% 25. 2% 22. 0% Liver 28. 6% 32. 0% 44. 4% 45. 6% 21. 4% 32. 1% Lung 23. 8% 30. 4% 36. 8% 47. 1% 42. 8% 35. 8% Bone 66. 6% 71. 4% 65. 0% 59. 6% 39. 0% 43. 1% 2010, American Society of Clinical Oncology

Bone Metastatic ø Incidence 30 -40% Frist metastasis ใน Breast cancer Metastases in advanced breast cancer patients >80% 21

Bone Metastatic Osteoblastic activity : Bone formation Osteoclastic activity : Bone absorption Mechanism of bone destruction Osteoclastogenic factors increase activity of osteoclasts Bone metastatic Tumor cell secrete osteolytic factors - Parathyroid hormone related peptide - Interleukin 1, 6 - TNF 22

Bone Metastatic Diagnosis FPlain film FBone scan FMRI 23

Bone Metastatic • Common sites of bone metastases • Spine; thoracic, lumbar • Pelvis • Ribs • Skull • Proximal limbs 24

Bone Metastatic Skeletal-related events : SRE Bone pain Pathological Facture Bone metastasis Spinal cord compression Hypercalcemia

Bone Metastatic การรกษา ยาแกปวด NSAID , Opioid F ใหยา bisphonates F ใหยาตาน Hormone ใหยา chemotherapy ฉายรงส 27

Bisphonate Pamidronate disodium (Aredia) Zoledronic acid (Zometa) Mechanism of action: Inhibits bone resorption. Inhibits tumor- related osteoclast activity in bone , promotes apoptosis of osteoclast, and blocks dissolution of minerals (hydroxyapatite) in bone. Inhibits the release of calcium from bones

กอนใหยา ประเมน : Oral hygiene : ปญหาชองปาก (ฟนผปวดฟน ) สงใหตรวจฟนกบ ทนตแพทย : BUN & Cr Creatinine clearance > 60 ml/min CLcr : Creatinine Clearance (ml/min) = (140 – age) x (Wt in kg) x (0. 85 if female) / (72 x Scr : mg/dl) Hydrate : drink water 500 cc before and after

Drug Administration Pamidronate : Aredia 60 -90 Mg IVdrip at least 2 -4 hrs Add IV 0. 9%NSS, 5%D/W 500 -1000 cc. Zoledronic acid : Zometa 4 Mg IV drip at least 15 -30 minutes Add IV 0. 9%NSS, 5%D/W 100 cc After add IV ; Keep in 2 -8 0 c , use in 24 hrs. Every 3 months Do not add IV solution that add calcium : LR

Bone Metastatic อาการขางเคยง ยา Bisphonate Fever Headache Flu-like symptoms of chill Bone pain/arthralgias/ myalgias Nasea / vomiting constipation Rash Osteonecrosis of the Jaw หามใหในผหญง Pregnancy 32

Hypercalcemia Occurs in 10 -20% of cancer patient Hypercalcemia is an elevation in the calcium level Serum calcium (8. 5 -10. 5 mg / dl) • The degree of hypercalcemia Mild: 10. 5 -11. 9 mg/dl Moderate: calcium 12 -14 mg/dl Severe: calcium > 14 mg/dl

Hypercalcemia Tumors that secrete a osteolytic substance that results in bone resorption of CA++; such as; PTHr. P by solid tumor, OAFs by multiple myeloma, Calcitrol by lymphoma, IL-1, TNFs

Form of body calcium F 99% stored in bone ; combined with phosphate to form organic compound that contributes to bone rigidity F Only 1% is in serum Non –ionized, inactive - 45% is bound to proteins ; albumin, globulin - 10% form complexes with the anions; bicarbonate, phosphate Free ionized calcium, active - 45% is active free ionized

Serum calcium F Corrected Calcium = Measured Calcium (mg/dl) + (4 -Serum Albumin g/dl ) x 0. 8 Example Lab Ca level 10. 5 mg/dl, Alb level 2. 0 g/dl Corrected Ca = 10. 5+ (4 -2)x 0. 8 10. 5+1. 6 12. 1 mg/dl

การรกษา Saline Hydration infusion of 4 -6 liters of NSS per day at least 48 hrs loop diuretics -Furosemide ; blocks calcium resorption in the loop of Henle Medication: inhibit bone resorption - Bisphonate , Mithramycin , Calcitonin, Corticosteroid Dialysis

การพยาบาล ผปวย Bone metastasis Prevention problem ประเมนความเสยง - health education early detection & early treatment ควบคมอาการปวด : -. ใหยาแกปวด ตามแผนการรกษาอยางเพยงพอ - Nonphamacologic intervention คงไว optimal level of mobility, range of Motion, strength: - ใชวธ passive & active exercise

Lung Metastatic การวนจฉย Chest X-ray C-T scan Biopsy

การรกษา ใหยาเคมบำบด F ฉายรงส Thoracentesis -Large volumes of fluid can be slowly remove & not exceed 1500 ml to avoid re-expansion; pulmonary edema, hypotension Chest tube

การพยาบาล ผปวย Lung Metastasis F ประเมนการหายใจ & oxygenation -monitor vital signs & pulse oximetry สอนเทคนคการหายใจเพอใหได ventilation maximize -help patient in to a position that maximizes ventilation ; high fowler‘s position - encourage energy conservation; rest , deep breathing , purse-lip breathing

การพยาบาล (ตอ ( Effective care a chest tube Prevent complication; pneumothorax Patient educations Psychological , Emotional support: reduce anxiety - nonpharmacological approaches; relaxation exercises, meditation

Liver Metastatic F Incidence ranges from 50% in multiple organ sites of metastatic breast cancer F Incidence less than 5% of breast cancer patients spread to the liver only

การพยาบาล Focus on supporting patient F ประเมนอาการปวด dull and aching pain F ประเมนการหายใจ : increased abdominal pressure F อาการคลนไส อาเจยน Psychological , Emotional support : reduce anxiety

Brain Metastatic -Incidence -ER Negative -Her 2 / neu positive 51

Brain Metastatic การวนจฉย : ใชการวนจฉยจากการตรวจรางกาย การซกประวต รวมกบการ Scanning - CT scan (Computerized Tomography) - MRI (Magnetic resonance imaging) - PET (Positron emission tomography)/PET CT scan 52

Brain Metastatic การรกษา (ตอ ) : - การฉายรงสคลมทวศรษะ ( whole brain radiation) - การฉายรงส Gamma Knife Stereotactic Radio Surgery 57

Case study ผปวยหญงคอาย 39 ป Know case advanced ca Lt breast post Neoadjuvant AC x 6 Cycle post Salvage Lt mastectomy ผลPatho IDC Gr 2 , T 9 x 7 x 3. 5 cm ER neg PR neg Her 2 neg Ki 67 30% หลงผาตด cycle 3 weeks Plan ให ยา paclitaxel 80 Mg/m 2 every week x 12 * ชวงใหคำแนะนำสงเกตเหนผปวย มปญหาการเซนตชอ * รายงานแพทย ทำ CT brain – ม Brain Metastasis multifocal mass * Admit Consult Neuro surg & RT * Dexamethasone 5 mg iv Q 6 Hr 58

Arm lymphedema Ipsilateral arm lymphedema develops in 10% - 35% of patients who undergo axillary dissection and/or nodal radiation Mehra golshan, 2005

การรกษา The goal of treatment are: - to control swelling, - relieve symptoms, - prevent the swelling from worsening over time. - การผาตด

Manual lymphatic drainage

gental massage

Bandage & Pressure garment

Be careful Animal bite