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Breast cancer

Breast cancer. Reham abdulmonem, MD. Epidemiology. Breast cancer is the most frequently diagnosed cancer in women in United States excluding the skin. A total of 211,300 cases and 39,800 deaths per year. Second leading cause of deaths in women. Worlwide 1 million cases are seen annually.

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Breast cancer

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  1. Breast cancer Reham abdulmonem, MD

  2. Epidemiology Breast cancer is the most frequently diagnosed cancer in women in United States excluding the skin. A total of 211,300 cases and 39,800 deaths per year. Second leading cause of deaths in women. Worlwide 1 million cases are seen annually. Primarily due to increased utilization of screening mammography, breast cancer incidence rates increased rapidly in the 1980s.

  3. Table 1 Ten Most Common Cancers among Saudis, 2004 (All Ages

  4. Anatomy of breast • It extends from 2nd to 6th rib • Covered by pectoralis muscle that is inserted in the acromian process of the scapula

  5. Anatomy • Medial and Lateral Borders of breast tissue typically the sternum & mid axillary line. • Cranial and Caudal borders typically the 2nd anterior rib & 6th anterior rib. • Primary lymphatic drainage is to axillary, internal mammary and SCV nodes.

  6. Anatomy of the Breast • Regional Lymph Nodes: • Axillary • Supraclavicular • Internal mammary

  7. Anatomy LN drainage • 1. Axillary (ipsilateral): • a. Level I (low axilla): lymph nodes lateral to the lateral border of pec minor. • b. Level II (midaxilla): lymph nodes between the medial & lateral borders of pec minor • c. Level III (apical axilla): lymph nodes medial to the medial margin of the pec minor muscle • 2. Internal mammary (ipsilateral): along the edge of the sternum in the endothoracic fascia

  8. Axillary Lymph nodes

  9. Breast cancer • ►Incidence: • The most common cancer among women • Accounts for 30% of all female cancers • Increases with age (> 50 years, 75% in postmenopausal) • ►Risk Factors: • Hereditary:+ve family history in 15% • Tumor suppressor genes(e.g. BRACA-1, BRACA-2) • Hormones:endogenous exposure to estrogen and progesterone • Early menarche, • Late menopause, • Delayed childbirth, and • Postmenopausal obesity

  10. Risk Factors-Age • Age plays a major role in breast cancer risk.In women under 30, breast cancer is extremely uncommon. • The incidence of breast cancer in women aged 35 to 39 was 59 per 100,000; however, in women 55 to 59, the incidence was 296 per 100,000. • Breast cancer increases steeply with age until menopause. After menopause, although the incidence continues to increase, the rate of increase decreases to approximately one-sixth of that seen in the premenopausal period.

  11. Risk Factors-Familial • The majority of women diagnosed with breast cancer do not have a family member with the disease. • Only 5% to 10% have a true hereditary predisposition to breast cancer. • Overall, the risk of developing breast cancer is increased 1.5- to 3.0-fold if a woman has a mother or sister with breast cancer.

  12. Risk Factors-hereditary • The possibility of a mutation in either BRCA1 or BRCA2 should be considered when breast cancer is diagnosed at a young age (i.e., less than 45 to 55), when multiple relatives are affected, when there is a history of other cancers in the family (particularly ovarian cancer), or any combination of these factors. • THESE ARE GENETIC FACTORS

  13. Breast Cancer Pathology • ►Adenocarcinoma: 90% • Ductal: 80% • Lobular: 10% • ►Special types: <10% • Papillary carcinoma • Mucinous carcinoma • Medullary carcinoma • ►Inflammatory carcinoma: 1% • Poorest prognosis

  14. Pathology • OTHERS • DCIS ------in ducts • LCIS--------in lobules

  15. DCIS-clinical presentation • An abnormal mammographic report of clustered microcalcifications is currently the most common presentation of DCIS. • DCIS can also present as a mass or pathologic nipple discharge, or can be identified as an incidental finding in a breast biopsy.

  16. DCIS • Mastectomy is a curative treatment for 98% to 99%.

  17. DCIS-conservative ttt B17 • 818 women were randomized to excision alone or excision plus 5000 cGy of irradiation to the breast. • At 90 months of follow-up,The 8-year incidence of invasive recurrence was significantly reduced from 13.4% to 3.9% by irradiation, and the incidence of recurrent DCIS was also significantly reduced from 13.4% to 8.2%.

  18. DCIS Tamoxifen NSABP-24 • 1804 patients with DCIS treated by lumpectomy and RT were randomized to tamoxifen (20 mg daily) or placebo for 5 years. • Follow-up of 62 months,the risk of ipsilateralrecurrence of any type (invasive or noninvasive) or of new contralateral breast cancers was reduced from 13.0% to 8.8% at 5 years,

  19. LCIS • LCIS is not detectable on macroscopic examination and is always an incidental microscopic finding in breast tissue removed for another reason • 80% to 90% of cases of LCIS occurring in premenopausal women • LCIS is frequently noted to be bilateral., • LCIS is associated with an increased risk for the development of breast carcinoma that is approximately seven to ten times equal in both breasts.

  20. LCIS ttt • management option for the woman with LCIS is careful observation, • The use of tamoxifen in women electing observation only. • Wide surgical excision and histologically negative margins are not needed when careful follow-up is chosen given that LCIS is known to be a multifocal lesion. Similarly, RT has no role in the management of LCIS. assumes.

  21. T classification • The pathologic tumor size for classification (T) is a measurement of only the invasive component. • Microinvasion is the extension of cancer cells beyond the basement membrane into the adjacent tissues with no focus more than 0.1 cm in greatest dimension. • Multiple Simultaneous Ipsilateral Primary Carcinomas,the largest primary carcinoma to classify T.

  22. T staging • T1-------TUMOUR LESS THAN 2CM • T2-------TUMOUR FROM 2-5CM • T3--------TUMOUR MORE THAN 5CM • T4--------TUMOUR INVADES ADJACENT STRUCTURES AS SKIN ,CHEST WALL

  23. Staging I & II

  24. III A , B

  25. III C , IV

  26. pN1a micro <0.2 cm pN1b macro>0.2 cm pN1bi 1-3 LN any>0.2cm,all<2.0cm pN1bii>4LN pN1biii ECE <2 cm pN1biv >2cm pN1mi <0.2cm>0.2mm pN1:1-3 and /or IM ( mic) detected by lymphscintigraphy pN1a 1-3 LN pN1bIM (mic) pN1c both a+b N1

  27. pN2 ipsilateral axillary fixed to one another pN2:4-9 axillary nodes or clinically apparent IM in absence of axillary nodes pN2a 4-9 axillary nodes pN2bclinically apparent IM N2

  28. pN3 ipsilateral internal mammary pN3a:>10 axillary LN or infraclav pN3b Or Clinically apparent IM in the presence of positive axillary nodes pN3b Or >3 axillary LN in the presence of microscopic diseasein IM pN3c Or Ipsilateral Supraclav N3

  29. M---METASTASIS • MO----NO METS • M1-----METS POSITIVE

  30. Prognosis

  31. Breast Cancer Diagnosis • ►Symptoms & Signs: • Breast lump:solitary, unilateral, hard, irregular, nontender • Nipple discharge:bloody and unilateral ( >50 years) • Others: • Local: skin changes • Regional: axillary lymphadenopathy • Distant: metastases • ►Breast Imaging: • Mammography: detects 85% • Ultrasonography: women under 30 year • MRI: if mammography and ultrasound are normal ►Breast Biopsy: FNA cytology or excisional ►Staging Procedures: for invasive breast cancer

  32. Mammography Signs of malignancy: • Clustered microcalcification • Irregular or speculated mass • solid mass with ill-defined borders • enlarging solid mass • development of density when compared with a previous mammogram

  33. A BIOPSY IS MANDATORY FROM A DISCRETE MASS EVEN IF MAMMOGRAPHY IS FREE OR LACK OF GROWTH OVER TIME HOW

  34. DIAGNOSTIC PROCEDURES (A) FNAC: SHOULD BE DONE BEFORE SURGERY SO AS TO HELP THE SURGEON DEFINE THE SURGICAL PROCEDURE. BUT STILL IF NEGATIVE , EXCISION BIOPSY IS MANDATORY

  35. (B)Open biopsy • UNLESS THE LESION IS BIG, EXCISION OF THE WHOLE MASS WITH SAFTEY MARGINS SHOULD BE DONE

  36. (C) IF NO MASSES ARE FELT • A SMALL MASS IS ONLY DETECTED BY MAMMOGRAPHY, THEN WIRE LOCALISATION IS DONE BY RADIOLOGIST AND SOMETIMES INJECTION OF METHYLENE BLUE . • In all cases a follow up mammography should be done after 2 months to be sure that the mass was excised

  37. On the pathological specimenER&PRPloidyHuer2/neCathepsin D

  38. Metastatic work-up • chest x-ray • Abd. And pelvic ultrasound • bone scan if lymph nodes are detected, T3 or sites of severe bone tenderness

  39. Management

  40. SURGERY • Types: • Conservative lumpectomy • quadrantectomy • wide local excision • Modified radical mastectomy • Palliative mastectomy eg.simple mastectomy

  41. Clinical indications mass less than 4 cm age above 35 yrs Absolute contra-indications: multicenteric tumors inadequate safety margins Diffuse micro – calcifications Pregnancy 1st, 2nd trimenster Previous radiotherapy Active SLE,Scleroderma SURGICAL TREATMENTConservative surgeryAxillary dissection + P/O radiation is a must

  42. Breast-reconstructive Technique • Saline implant • Myocutanous flap ( TRAM ) flap or a latissimus dorsi flap.

  43. Surgery-MRM • Involve complete removal of the breast, the underlying pectoral fascia, and some of the axillary nodes.sparing the muscles • The switch to modified radical mastectomy occurred when it became recognized that treatment failure after breast cancer surgery usually is caused by the systemic dissemination of cancer cells before surgery, rather than an inadequate operative procedure.

  44. Definition The first node in the lymphatic basin that recieves primary lymphatic flow. Indications T1-T2 LN –VE No multifocality No prior neoadjuvant cth Tech Tc99. Sulfur colloid, methylene blue ,or both. peritumoral, IMH, PCR St gallen… -ve axillary SNB is now accepted as allowing avoidance of axillary dissection Axillary dissection Sentinel LN

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