cancer breast overview dr. ehab m.oraby. introduction breast is a modified sweat gland between skin...
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CANCER BREAST OVERVIEW
Dr. Ehab M.Oraby
INTRODUCTION
Breast is a modified sweat gland between skin and pectoral fascia.
INTRODUCTION
Breast is a modified sweat gland between skin and pectoral fascia.
Origin from mammary ridge; middle part of upper third.
INTRODUCTION
Breast is a modified sweat gland between skin and pectoral fascia.
Origin from mammary ridge; middle part of upper third.
Boundaries:
Apparently: from 2nd to 6th rib and from lateral sternal border to anterior axillary line.
Actually: from clavicle to below costal margin and from midline to posterior axillary line.
RISK FACTORS:
Hormonal: Estrogen.
RISK FACTORS:
Hormonal: Estrogen.
Cycle numbers “menarche & menopause”
Pregnancy full term.
Lactation 3-4 years.
Obesity.
Exercise.
RISK FACTORS:
Hormonal: Estrogen.
Cycle numbers “menarche & menopause”
Pregnancy full term.
Lactation 3-4 years.
Obesity.
Exercise.
Non-hormonal:
RISK FACTORS:
Hormonal: Estrogen.
Cycle numbers “menarche & menopause”
Pregnancy full term.
Lactation 3-4 years.
Obesity.
Exercise.
Non-hormonal: Radiation:
Ionizing
Mantle radiation (Non-Hodjkin lymphoma”.
RISK FACTORS:
Hormonal:
Estrogen.
Cycle numbers “menarche & menopause”
Pregnancy full term.
Lactation 3-4 years.
Obesity.
Exercise.
Non-hormonal:
Radiation:
Ionizing
Mantle radiation (Non-Hodjkin lymphoma”.
Alcohol.
Fatty diet
Genetic mutations (BRCA-I, BRCA-II)
INCIDENCE:
Every female in USA is born with risk 12%
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics:
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics: BRCA-I mutation risk is 90% to develop cancer breast, 20-40%
cancer ovary.
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics: BRCA-I mutation risk is 90% to develop cancer breast, 20-40%
cancer ovary.
BRCA-II mutation risk is 85% to develop cancer breast.
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics: BRCA-I mutation risk is 90% to develop cancer breast, 20-40%
cancer ovary.
BRCA-II mutation risk is 85% to develop cancer breast.
45% of cancer breast patients is found to be +ve for BRCA-I mutation.
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics: BRCA-I mutation risk is 90% to develop cancer breast, 20-40%
cancer ovary.
BRCA-II mutation risk is 85% to develop cancer breast.
45% of cancer breast patients is found to be +ve for BRCA-I mutation.
80% of cancer ovary patients is found to be +ve for BRCA-I mutation.
INCIDENCE:
Every female in USA is born with risk 12%
At age of 50 years risk is 11%
At age of 70 years risk is 7%
Genetics: BRCA-I mutation risk is 90% to develop cancer breast, 20-40% cancer
ovary.
BRCA-II mutation risk is 85% to develop cancer breast.
45% of cancer breast patients is found to be +ve for BRCA-I mutation.
80% of cancer ovary patients is found to be +ve for BRCA-I mutation.
So; patient presented with cancer ovary high incidence of BRCA mutation high risk of cancer breast.
BRCA-II mutation
Characterized by: Invasive duct carcinoma.
BRCA-I mutation:
Characterized by: Invasive duct carcinoma (??
medullary)
BRCA-II mutation
Characterized by: Invasive duct carcinoma.
Well differentiated.
BRCA-I mutation:
Characterized by: Invasive duct carcinoma (??
medullary)
Poorly differentiated.
BRCA-II mutation
Characterized by: Invasive duct carcinoma.
Well differentiated.
Express hormonal receptors.
BRCA-I mutation:
Characterized by: Invasive duct carcinoma (??
medullary)
Poorly differentiated.
-ve hormonal receptors.
BRCA-II mutation
Characterized by: Invasive duct carcinoma.
Well differentiated.
Express hormonal receptors.
Associated malignancies: Cancer stomach, pancreas,
prostate.
BRCA-I mutation:
Characterized by: Invasive duct carcinoma (??
medullary)
Poorly differentiated.
-ve hormonal receptors.
Asssocited tumor risk: Cancer stomach, pancreas,
prostate.
BRCA-II mutation
Characterized by: Invasive duct carcinoma.
Well differentiated.
Express hormonal receptors.
Associated malignancies: Cancer stomach, pancreas,
prostate.
Cancer G.B., biliary tract and malignant melanoma.
BRCA-I mutation:
Characterized by: Invasive duct carcinoma (??
medullary)
Poorly differentiated.
-ve hormonal receptors.
Asssocited tumor risk: Cancer stomach, pancreas,
prostate.
Cancer cervix, uterus and fallopian tubes.
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
desmoplastic response ??? skin retraction.
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
desmoplastic response ??? skin retraction.
↑tumor size shedding of malignant cells to intercellular space lymphatics L.N. ++
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
desmoplastic response ??? skin retraction.
↑tumor size shedding of malignant cells to intercellular space lymphatics L.N. ++
when cell doubling reach 20th times 3 mm Angiogenic switch “neovascularization” ↑chance of blood spread which is aborted by NK cells and macrophages.
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
desmoplastic response ??? skin retraction.
↑tumor size shedding of malignant cells to intercellular space lymphatics L.N. ++
when cell doubling reach 20th times 3 mm Angiogenic switch “neovascularization” ↑chance of blood spread which is aborted by NK cells and macrophages.
when doubling exceeds 27th times “ 5 mm” successful spread and implantation to ???
NATURAL HISTORY OF CANCER BREAST:
Malignant cell repeated doubling.
productive fibrosis ???
desmoplastic response ??? skin retraction.
↑tumor size shedding of malignant cells to intercellular space lymphatics L.N. ++
when cell doubling reach 20th times 3 mm Angiogenic switch “neovascularization” ↑chance of blood spread which is aborted by NK cells and macrophages.
when doubling exceeds 27th times “ 5 mm” successful spread and implantation to ???
with tumor advancement local infiltration of skin lymphatics and skin itself ???
TERMS:
Carcinoma in situ (C.I.S) malignant cells limited to BM. ( ductal or lobular).
TERMS:
Carcinoma in situ (C.I.S) malignant cells limited to BM. ( ductal or lobular).
Minimal breast cancer C.I.S + invasive carcinoma < 5 mm.
TERMS:
Carcinoma in situ (C.I.S) malignant cells limited to BM. ( ductal or lobular).
Minimal breast cancer C.I.S + invasive carcinoma < 5 mm.
Multicentricity: 2nd tumor in another quadrant “LCIS”.
TERMS:
Carcinoma in situ (C.I.S) malignant cells limited to BM. ( ductal or lobular).
Minimal breast cancer C.I.S + invasive carcinoma < 5 mm.
Multicentricity: 2nd tumor in another quadrant “LCIS”.
Multifocality: 2nd tumor in the same quadrant “DCIS”.
TERMS:
Carcinoma in situ (C.I.S) malignant cells limited to BM. ( ductal or lobular).
Minimal breast cancer C.I.S + invasive carcinoma < 5 mm.
Multicentricity: 2nd tumor in another quadrant “LCIS”.
Multifocality: 2nd tumor in the same quadrant “DCIS”.
Bilaterality: 15% with DCIS.
60-90% with LCIS.
LCIS & DCIS
LCIS: ♂ or ♀ or both??
DCIS: ♂ or ♀ or both??
LCIS & DCIS
LCIS: ♂ or ♀ or both??
It is just a risk factor.
DCIS: ♂ or ♀ or both??
It is considered the anatomic precursor of invasive duct carcinoma.
LCIS & DCIS
LCIS: ♂ or ♀ or both??
It is just a risk factor.
Subsequent invasive cancer ?? Lobular or ductal ??
DCIS: ♂ or ♀ or both??
It is considered the anatomic precursor of invasive duct carcinoma.
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
NST; axilla 60%
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
NST; axilla 60%
Tubular carcinoma; -ve axilla
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
Medullary; BRCA NST; axilla 60%
Tubular carcinoma; -ve axilla
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
Medullary; BRCA NST; axilla 60% Mucinous; bulky soft mass
Tubular carcinoma; -ve axilla
PATHOLOGICAL TYPES:
30 35 40 45 50 55 60 65 70 75 80
Medullary; BRCA NST; axilla 60% Mucinous; bulky soft mass
Tubular carcinoma; -ve axilla Papillary; small mass< 3cm
DIAGNOSIS:
History:
DIAGNOSIS:
History: Mass breast or axillary.
DIAGNOSIS:
History: Mass breast or axillary.
Nipple discharge.
DIAGNOSIS:
History: Mass breast or axillary.
Nipple discharge.
Nipple deformity.
DIAGNOSIS:
History: Mass breast or axillary.
Nipple discharge.
Nipple deformity.
Skin changes.
DIAGNOSIS:
History.
Examination:
DIAGNOSIS:
History.
Examination: patient self examination.
DIAGNOSIS:
History.
Examination: Patient self examination.
Doctor examination.
DIAGNOSIS:
History.
Examination.
Investigations:
DIAGNOSIS:
History.
Examination.
Investigation.
Triple assessment:
DIAGNOSIS:
History.
Examination.
Investigation.
Triple assessment:clinicalimaging: u/s &
mammographybiopsy FNAC, true-cut,
incisional, excisional.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views:
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
Spot compression ± magnification.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
Spot compression ± magnification.
Findings of malignancy:
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
Spot compression ± magnification.
Findings of malignancy: Ill defined, irregular, speculated.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
Spot compression ± magnification.
Findings of malignancy: Ill defined, irregular, speculated.
With microcalcifications linear and branched.
MAMMOGRAPHY:
Dose of X-ray is 4 times the ordinary X-ray.
Views: Craniocaudal (CC)medial parts.
Mediolateral oblique (MLO) upper outer quadrant and axillary tail.
Spot compression ± magnification.
Findings of malignancy: Ill defined, irregular, speculated.
With microcalcifications linear and branched.
± multifocality.
STAGING:
TNM
Manchester:
Stage Breast Axilla Arm & supraclavicular
LN
Metastasis
I Mobile mass
---- ---- ----
STAGING:
TNM
Manchester:
Stage Breast Axilla Arm & supraclavicular
LN
Metastasis
I Mobile mass
---- ---- ----
II Mobile mass
Mobile axilla
----- ------
STAGING:
TNM
Manchester:
Stage Breast Axilla Arm & supraclavicular
LN
Metastasis
I Mobile mass
---- ---- ----
II Mobile mass
Mobile axilla
----- ------
III “locally advanced”
Fixed (skin and/or chest) T4
Fixed axilla ± -------
STAGING:
TNM
Manchester:
Stage Breast Axilla Arm & supraclavicular
LN
Metastasis
I Mobile mass
---- ---- ----
II Mobile mass
Mobile axilla
----- ------
III “locally advanced”
Fixed (skin and/or chest) T4
Fixed axilla ± -------
IV “systemic advanced”
T4 Any axilla ± +ve and/orOpposite breast or axilla
TREATMENT:
Stage Breast Axilla Hormonal Chemotherapy
I-II Lumpectomy + RT +ve dissection-ve sentinel LN ??
If +ve ??
TREATMENT:
Stage Breast Axilla Hormonal Chemotherapy
I-II Lumpectomy + RT +ve dissection-ve sentinel LN ??
If +ve ??
III MRM + RT Dissection If +ve +++++
TREATMENT:
Stage Breast Axilla Hormonal Chemotherapy
I-II Lumpectomy + RT +ve dissection-ve sentinel LN ??
If +ve ??
III MRM + RT Dissection If +ve +++++
IV Neo-adjuvantMRM + RT
Dissection If +ve +++++
Thank you