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