1. CANCER BREAST OVERVIEW Dr. Ehab M.Oraby

2. INTRODUCTION  Breast is a modified sweat gland between skin and pectoral fascia.

3. INTRODUCTION  Breast is a modified sweat gland between skin and pectoral fascia.  Origin from mammary ridge; middle part of upper third.

4. 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.

5. RISK FACTORS:  Hormonal:  Estrogen.

6. RISK FACTORS:  Hormonal:  Estrogen.  Cycle numbers “menarche & menopause”  Pregnancy full term.  Lactation 3-4 years.  Obesity.  Exercise.

7. RISK FACTORS:  Hormonal:  Estrogen.  Cycle numbers “menarche & menopause”  Pregnancy full term.  Lactation 3-4 years.  Obesity.  Exercise.  Non-hormonal:

8. 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”.

9. 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)

10. INCIDENCE:  Every female in USA is born with risk 12%

11. INCIDENCE:  Every female in USA is born with risk 12%  At age of 50 years risk is 11%

12. 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%

13. 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:

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. BRCA-II mutation  Characterized by:  Invasive duct carcinoma. BRCA-I mutation:  Characterized by:  Invasive duct carcinoma (??medullary)

20. BRCA-II mutation  Characterized by:  Invasive duct carcinoma.  Well differentiated. BRCA-I mutation:  Characterized by:  Invasive duct carcinoma (??medullary)  Poorly differentiated.

21. 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.

22. 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.

23. 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.

24. NATURAL HISTORY OF CANCER BREAST:  Malignant cell  repeated doubling.

25. NATURAL HISTORY OF CANCER BREAST:  Malignant cell  repeated doubling.   productive fibrosis  ???

26. NATURAL HISTORY OF CANCER BREAST:  Malignant cell  repeated doubling.   productive fibrosis  ???   desmoplastic response  ???  skin retraction.

27. 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. ++

28. 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.

29. 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 ???

30. 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  ???

31. TERMS:  Carcinoma in situ (C.I.S)  malignant cells limited to BM.  ( ductal or lobular).

32. 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.

33. 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”.

34. 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”.

35. 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.

36. LCIS & DCIS  LCIS :  ♂ or ♀ or both??  DCIS :  ♂ or ♀ or both??

37. 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.

38. 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.

39. PATHOLOGICAL TYPES: 3035404550556065707580

40. PATHOLOGICAL TYPES: 3035404550556065707580 NST; axilla 60%

41. PATHOLOGICAL TYPES: 3035404550556065707580 NST; axilla 60% Tubular carcinoma; -ve axilla

42. PATHOLOGICAL TYPES: 3035404550556065707580 Medullary; BRCANST; axilla 60% Tubular carcinoma; -ve axilla

43. PATHOLOGICAL TYPES: 3035404550556065707580 Medullary; BRCANST; axilla 60%Mucinous; bulky soft mass Tubular carcinoma; -ve axilla

44. PATHOLOGICAL TYPES: 3035404550556065707580 Medullary; BRCANST; axilla 60%Mucinous; bulky soft mass Tubular carcinoma; -ve axillaPapillary; small mass< 3cm

45. DIAGNOSIS:  History:

46. DIAGNOSIS:  History:  Mass breast or axillary.

47. DIAGNOSIS:  History:  Mass breast or axillary.  Nipple discharge.

48. DIAGNOSIS:  History:  Mass breast or axillary.  Nipple discharge.  Nipple deformity.

49. DIAGNOSIS:  History:  Mass breast or axillary.  Nipple discharge.  Nipple deformity.  Skin changes.

50. DIAGNOSIS:  History.  Examination:

51. DIAGNOSIS:  History.  Examination:  patient self examination.

52. DIAGNOSIS:  History.  Examination:  Patient self examination.  Doctor examination.

53. DIAGNOSIS:  History.  Examination.  Investigations:

54. DIAGNOSIS:  History.  Examination.  Investigation. Triple assessment:

55. DIAGNOSIS:  History.  Examination.  Investigation. Triple assessment: clinical imaging: u/s & mammography biopsy  FNAC, true-cut, incisional, excisional.

56. MAMMOGRAPHY:  Dose of X-ray is 4 times the ordinary X-ray.

57. MAMMOGRAPHY:  Dose of X-ray is 4 times the ordinary X-ray.  Views:

58. MAMMOGRAPHY:  Dose of X-ray is 4 times the ordinary X-ray.  Views:  Craniocaudal (CC)  medial parts.

59. 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.

60. 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.

61. 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:

62. 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.

63. 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.

64. 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.

65. STAGING:  TNM  Manchester: StageBreastAxillaArm & supraclavicular LN Metastasis IMobile mass----

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

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

68. 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

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

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

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