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Breast cancer

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Breast cancer

  2. 2. CANCER: a disease that is characterized by uncontrolled cell growth in an organ, the site the cells originate from. BREAST CANCER: begins in the breast tissue and may start in the duct or lobe of the breast. When the “controls” in breast cells are not working properly, they divide continually and a lump or tumor is formed.
  3. 3. incidence Account 20% of female cancer death Age : most common above 50yrs but may come any age Site: commonest in upper outer quadrant 60% Sex : female>male {99:1} Race : white>black Synchronus lesion : 1% Metachronus lesion :5%
  4. 4. Risk factors GENETICS BRCA1 BRCA2 Li-fraumeni syndrom Cowden disease Peutz-jeghers syndrom Family history 1st degree relative Risk if occurred premonopausal or bilateral or affect 2 or more 1st D Hormonal factors Early menarche Late menopause Null parity Non lactating Long term CCP &HORMONAL REPLASMENT Precancerous lesions Duct papilloma a( 2 times) Epithelial hyperplasia ( 2-5 ) Carcinoma in situ (5-10) Dietary & environmental factors Alcohol obesity Radiation exposure previous breast cancer
  5. 5. W.H.O. Classification of Carcinoma of the Breast Noninvasive carcinoma Ductal carcinoma in situ Lobular carcinoma in situ Paget's disease of the nipple (without mass) Invasive carcinoma Invasive ductal carcinoma -- 80% Invasive lobular carcinoma – 10% Mucinous carcinoma -- 2% Medullary carcinoma – 5% Papillary carcinoma -- 1% Tubular carcinoma – 1% Adenoid cystic carcinoma Secretory (juvenile) carcinoma Apocrine carcinoma Carcinoma with metaplasia (metaplastic carcinoma) Inflammatory carcinoma Pathology of breast cancer (foot & stewart calssifiction)
  6. 6. Carcinoma in situ ( doesn't penetrate the basement membrane) Ductal carcinoma in situ -originat from terminal duct lobular units -CP: mass .pain . discharge -ipsilateral -common(25-70%) Lobular carcinoma in situ -no clinical sign -no microcalcifictions by mammogram -bilateral -less(25-35) pajet disease -AFFecting nipple and areola -Eczema like condition -female>40 -1-2%of breast cancer
  7. 7. DCIS TYPES Papillary Subtype Cribiform Subtype Solid Subtype Comedo Subtype More malignant than non-comedo subtypes (40% progress to invasive type)
  8. 8. Ductal cancer cells Normal ductal cell
  9. 9. Paget’ s disease of the nipple  *Eczema like condition of the nipple & areola  *± Breast mass behind the areolaHyperplasia of all layers of the epidermis → thickening of epidermis followed by ulceration of the skin.  *Paget's cell (large, clear cytoplasm, small dark nuclei with apparent nucleoli) in the deep layer of the epidermis.  Round & plasma cell infiltration of the dermis  Staging:  without mass → Stage 0 (carcinoma insitu)  with mass → according to mass size  Prognosis: Good due to: 1. Early diagnosis 2. Slow rate of growth
  10. 10. Invasive Breast Carcinoma 1-Infiltrating Ductal Carcinoma (IDC) -75 % of all breast cancer -Histologically, the tumor cells are arranged in groups, cords and gland-like structures. Scirrhous carcinoma; Hard in consistency - - Cut section: gritty sensation , Retract below the cut surfaces 2- Infiltrating Lobular Carcinoma -5-10% of breast cancer -have abundant fibrous stroma, so that macroscopically they are always scirrhous. - the cells are small and uniform and are dispersed singly, or in columns one cell wide (Indian files) in a dense stroma. Lobular cancer cells breaking through the wall Ductal cancer cells breaking through the wall
  11. 11. 3- MEDALLARY CARCINOMA -LARGE –SOFT - WELL CIRCUMSCRIB 4-MUSINOUS CARSINOMA -BULKY &SOFT 5-TUBULAR CARCINOMA -Diagnosed only when more than 75%of the tumor is tubular formation 6-papillary carcinoma -presence of papillae 7-mastitis carcinomatosis -most malignant form - during pregnancy & lactation
  12. 12. Spread 1- Direct (Local) into skin and muscle 2- Via lymphatics • Axillary nodes (75%) • Internal mammary nodes (20%) • Post intercostal L.N. (5%) 3- Via bloodstream to lungs, bone, liver and brain Bones metastasis:  -May appear before lung  -Lumbar vertebrae > femur > thoracic vertebra > skull  -usually osteolytic → pathological fracture 4-Transperitoneal (Transcoelomic) spread:-  Malignant ascitis  Ovaries: Krukenberg's tumor  bilateral  premenepausal  Douglas pouch: Rectal shelf of Plummer Cancer cells invade lymph duct Cancer cells invade blood vessel
  13. 13. Diagnosis of Breast Cancer Clinical Examination Radiology • Mammography → > 35y • US → < 35y Pathology (Biopsy) • FNAC • Core (Tru-cut) Biopsy
  14. 14. 1. Painless lump 2. Pain 3. Nipple discharge 4. Paget's disease of the nipple 5. Mastitis carcinomatosa (inflammatory carcinoma) 6. Skin manifestations of breast cancer 7. Metastatic presentation (if this is the only presentation → occult presentation)  Regional axillary or supraclavicular L.N  Distant metastasis  May be the 1st complaint 8. Asymptomatic: discovered accidentally during screening programs Clinical Presentation
  15. 15. 1- Painless lump:  discovered accidentally by the patient (e.g. during bathing) or by physician during screening programs  on examination → usually:  not tender  irregular shape and surface  ill defined edge or well-circumscribed edge, due to difference in consistency between hard mass & the soft breast.  hard consistency freely mobile (at early stages), but become fixed either to overlying skin or underlying tissues (in late stages) 2- Pain:  due to infiltration of nerves, infection  with mastitis carcinomatosa 3- Nipple discharge:  Bloody in → duct carcinoma  Past like in → comedo carcinoma  Necrotic discharge → in degenerating carcinoma
  16. 16. 4- Paget's disease of the nipple:  Crusty, flaking lesion  Gradual onset over months or years  Associated with underlying breast malignancy  Diagnosis confirmed by needle or wedge biopsy  Mammography is mandatory 5- Mastitis Carcinomatosa (Inflammatory Carcinoma):  Usually in pregnant & lactating  Breast is painful  Skin → erythematous, warm & edematous 6- Skin manifestation of breast cancer:  Due to Cooper’s ligament infiltration:  1) Dimpling 2) Tethering 3) Puckering  Due to direct skin infiltration:  4) Skin fixation 5) Ulceration 6) Fungation 7) Nipple retraction  8) Paget's disease of nipple  Due to lymphatic involvement:  9) Peau d’orange (Pitted edema) 10) Satellite nodules  Due to venous involvement:  11) Dilated veins
  17. 17. 2- Radiology 1- Mammography Def: low voltage compression X-ray taken in 2 directions (craniocaudal—mediolateral) Indication: - female>35 - Doubtful mass - Nipple discharge - - -paget`s disease - Fllow up ACCURACY: 90% 2-Xeroradiogeaphy As mammography but image recevied on selenium plate -more accurate & easier reading 3-Ductography : to identify filling defect in the duct 4-ultrasonography -female<35 -differentiat cystic from solid 5-MRI -differentiate () fibrosis &recurrence
  18. 18. Carcinoma -ill-defined margins, low-level -heterogeneous internal echoes Solid benign mass Cyst -absence of internal echoes (anechoic interior), -clearly defined posterior wall, and enhancement of distal echoes
  19. 19. III- Biopsy FNAC (Fine Needle Aspiration) •Can be done for non-palpable masses. •FNAC takes individual cells Does not show architecture C0 No epithelial cells C1 Inadequate C2 Benign C3 Atypia C4 Suspicious C5 Malignant
  20. 20. Used for • T≥ 3 cm • operable cases candidate for mastectomy Tru-cut (Core Biopsy) Needle B1 Normal tissue / unsatisfactory B2 Benign B3 Lesion uncertain malignant potential B4 Suspicion of malignancy B5a In situ malignancy B5b Invasive malignancy
  21. 21. IV-INVISTIGATION FOR METASTASES LUNG : X-ray & CT LIVER : liver function test –U/S-CT BONE : bone survey &scan BRAIN:CT
  22. 22. T.N.M. Staging T (Tumor size): Tx → Primary tumor can not be assessed & not palpable clinically (previous excision biopsy or unplanned resection) T0 → No evidence of primary tumor Tis → Carcinoma in situ T1 → < 2cm (in greatest dimension) Tmic → microinvasion ≤ 1mm T1a → ≤ 0.5cm T1b → 0.5 -1cm T1c → 1-2cm T2 → 2-5 cm T3 → > 5cm T4 → any size with: T4a → fixation to chest wall (ribs, pectoralis, intercostal muscles) T4b → Skin involvement peau d'orange - ulceration - fungation -satellite nodules T4c → a & b T4d → mastitis carcinomatosa
  23. 23. N (L.N. status):- All → Ipsilateral Nx Regional L.N. cannot be assessed (previously removed) N0 No regional L.N. metastasis N1 Ipsilateral mobile axillary L.N. N2 Ipsilateral fixed axillary L.N. (fixed to one another or to other structures) N3 Ipsilateral infraclavicular L.N. ipsilateral internal mammary with axillary L.N. Ipsilateral supraclavicular L.N. M (Metastasis):- M0 → No evidence of metastasis M1 → • Distant metastasis (Lung, Bone, Liver, Brain) • Contralateral breast or L.Ns.
  24. 24. T.N.M. Staging Stage 0 • carcinoma in situ Stage I • T < 2 cm, no nodes Stage II • T 2 to 5 cm, +/- nodes Stage III • locally advanced disease, fixed lymph nodes and variable tumor size Stage IV • distant metastases (bone, liver, lung, brain)
  25. 25. Prognosis I- Tumor related factors: 1- L.N. status: • 1) Number of L.N. • 2) Size of L.N. • 3) Level of L.N 2- Tumor size: 3- Tumor grade 4- T.N.M staging 5- Metastasis 6- Tumor site 7- Histopathologic type 8- Biological markers: • 1) Hormone receptor status • 2) Cathepsin D • 3) P53 • 4) HER-2/neu II- Patient related factors: 1- Age 2- Sex 3- Pregnancy 4- Obesity
  26. 26. BREAST CANCER TREATMENT Treatment for breast cancer is often a combination of the following treatments: Surgery Chemotherapy Radiation Hormone Treatment
  27. 27. Treatment I- Early breast cancer: • Non invasive (Stage 0) → Surgery ± Adjuvant (postoperative) therapy • Stage I & II → Surgery + Adjuvant (postoperative) therapy II- Advanced breast cancer: • Stage III (Locally advanced) → Neoadjuvant (preoperative) therapy + Surgery • Stage IV (Metastatic) → Systemic therapy ± Limited Surgery
  28. 28. Early Breast Cancer Stage I & II Surgery ◦ removing the area of concern and some normal tissue surrounding it is called a lumpectomy ◦ removing the breast is called a mastectomy (most women with breast cancer will not need the breast removed) ◦ lymph nodes from under the arm may be removed with either surgery
  29. 29. Mastectomy A. Traditional Non Sparing Mastectomy 1. Super (Extended) radical (Urban) 2. Radical mastectomy (Halstedt) 3. Modified radical mastectomy  Patey’s operation  Auchen-closs operation 4. Total mastectomy 5. Simple mastectomy 6. Toilet mastectomy B. Sparing Mastectomy 1. Skin sparing mastectomy (S.S.M) 2. Nipple sparing mastectomy (N.S.M) 3. Subcutaneous mastectomy
  30. 30. Indications of BREAST CONSERVING THERAPY 1. Single tumor (no multicentricity) 2. Tumor size <4 cm (clincally & mammographic) 3. Peripheral location (not central or retroareolar) 4. No signs of local advancement (T4). 5. N0 or N1 (no extensive nodal involvement). 6. M0 (no metastasis) Contraindications 1. Multicentricity → high incidence of local recurrence 2. Tumor size > 4 cm or ↑ tumor/breast ratio. 3. Central (retroareolar) location → bad cosmetic result. 4. Signs of local advancement (T4). 5. N2 or N3 6. Metastasis (M1). 7. Pregnancy (3rd trimester; radiotherapy can not be delivered). 8. Collagen vascular disease → high toxicity of radiotherapy.
  31. 31. Early Breast Cancer Stage I & II Radiation ◦ standard treatment after a lumpectomy to reduce the chance of the breast cancer coming back in the same breast ◦ is also called local treatment because it affects only the area being treated with radiation
  32. 32. Axillary Surgery in Breast Cancer 1- Axillary lymph node dissection (ALND):  At least levels I & II axillary lymph nodes should be removed 2- Sentinel L.N. biopsy:  Sentinel L.N. = 1st L.N. to drain the cancer  accepted with clinically negative axillary L.N. 3- Axillary L.N. sampling:  Excision of the lowest 4 or 5 palpable L.Ns from level I & sent separately for histopathologic examination.
  33. 33. Late Breast Cancer Stage III (Locally Advanced)  First • Neo adjuvant chemotherapy (3-4 cycles)  Then • Surgery  Then • Post operative chemotherapy (6 cycles)  Then • Post operative radiotherapy
  34. 34. Late Breast Cancer Stage IV (Metastatic)  1-Palliative systemic therapy is the Main line of treatment
  35. 35. Hormone Treatment ◦ growth of many breast cancers can be blocked by taking hormone therapy ◦ treatment is in the form of a pill which is taken for 5 years ◦ may be recommended for women who have a breast cancer that is sensitive to hormones