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 2 nd to 6 th 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 20 th 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 20 th times  3 mm  Angiogenic switch “neovascularization”  ↑chance of blood spread which is aborted by NK cells and macrophages.   when doubling exceeds 27 th 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 20 th times  3 mm  Angiogenic switch “neovascularization”  ↑chance of blood spread which is aborted by NK cells and macrophages.   when doubling exceeds 27 th 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: 2 nd 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: 2 nd tumor in another quadrant “LCIS”.  Multifocality : 2 nd 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: 2 nd tumor in another quadrant “LCIS”.  Multifocality: 2 nd 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:

PATHOLOGICAL TYPES: NST; axilla 60%

PATHOLOGICAL TYPES: NST; axilla 60% Tubular carcinoma; -ve axilla

PATHOLOGICAL TYPES: Medullary; BRCANST; axilla 60% Tubular carcinoma; -ve axilla

PATHOLOGICAL TYPES: Medullary; BRCANST; axilla 60%Mucinous; bulky soft mass Tubular carcinoma; -ve axilla

PATHOLOGICAL TYPES: Medullary; BRCANST; axilla 60%Mucinous; bulky soft mass Tubular carcinoma; -ve axillaPapillary; 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: clinical imaging: u/s & mammography biopsy  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: StageBreastAxillaArm & supraclavicular LN Metastasis IMobile mass----

STAGING:  TNM  Manchester: StageBreastAxillaArm & supraclavicular LN Metastasis IMobile mass---- IIMobile massMobile axilla

STAGING:  TNM  Manchester: StageBreastAxillaArm & supraclavicular LN Metastasis IMobile mass---- IIMobile massMobile axilla III “locally advanced” Fixed (skin and/or chest) T4 Fixed axilla±

STAGING:  TNM  Manchester: StageBreastAxillaArm & supraclavicular LN Metastasis IMobile mass---- IIMobile massMobile axilla III “locally advanced” Fixed (skin and/or chest) T4 Fixed axilla± IV “systemic advanced” T4Any axilla±+ve and/or Opposite breast or axilla

TREATMENT: StageBreastAxilla HormonalChemotherapy I-IILumpectomy + RT+ve  dissection -ve  sentinel LN ?? If +ve??

TREATMENT: StageBreastAxilla HormonalChemotherapy I-IILumpectomy + RT+ve  dissection -ve  sentinel LN ?? If +ve?? IIIMRM + RTDissectionIf +ve +++++

TREATMENT: StageBreastAxilla HormonalChemotherapy I-IILumpectomy + RT+ve  dissection -ve  sentinel LN ?? If +ve?? IIIMRM + RTDissectionIf +ve IVNeo-adjuvant MRM + RT DissectionIf +ve+++++