HEGAZY SURGERY

1. 1
Management of Breast
Cancer
By
Hussein M. Khaled
Prof. Medical Oncology
Vice President
Post graduate Studies and Research
Cairo University

2. 2
BREAST CANCER
Worldwide incidence in females*
*Incidence per 100,000 population.
Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.
67.4
36.0
28.6
71.7
21.2
25.0
31.5
25.5
86.3
Eastern
Europe
Japan
Australia/
New Zealand
South Central
Asia
Northern
Africa
Southern
Africa
Central
America
Western
Europe
North
America

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CANCER CONTROL
EARLY
DETECTION
DIAGNOSIS
PRIMARY
PREVENTION
TREATMENT

4. 4
BREAST CANCER
Signs and symptoms at presentation
 Mass or pain
in the axilla
 Palpable mass
 Thickening
 Pain
 Nipple discharge
 Nipple retraction
 Edema or erythema
of the skin

5. 5

6. 6
BREAST CANCER
Diagnosis path
Evaluation
for
biopsy
Cyst
aspiration
Biopsy
•Excisional biopsy
•Core-cutting needle biopsy
•Fine-needle aspiration
Palpable
mass
Ductal
carcinoma
in situ
Invasive
cancer
Lobular
carcinoma
in situ
Benign
Insufficient
evaluation,
rebiopsy
If persistent,
short-term
follow-up
with surgeon
Continued
appropriate
screening
Cyst Normal
Nonpalpable
mass
Treatment Path
Needle
localization

7. 7
Staging Classification of Breast Tumour

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Early Breast Cancer

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NSABP B-06:
Effect of Lumpectomy v. Mastectomy on Survival
DISTANTDISEASE-FREESURVIVAL(%)
Cohort A Cohort B Cohort C
Total Mastectomy: 692/265 569/233 494/192
Lumpectomy: 699/302 634/282 520/236
No. of patients / No. of recurrences
YEAR
Lumpectomy + XRT: 714/278 628/253 515/204

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HT

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HER2 testing algorithm
Adapted from Bilous M, et al. Mod Pathol 2003;16:173–82
Hanna W. Breast 2005;14(Suppl.1)S17 (Abstract 10)
+–
FISH/CISH
Patient tumour
sample
IHC
2+ 3+1+0
+
FISH/CISH
+–
Herceptin®
therapy
Herceptin®
therapy
Herceptin®
therapy

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Locally Advanced Breast Cancer

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What elements drive therapy
decision making ?
Prognosis
Treatment
efficacy
Treatment
toxicity
Co morbidity

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ER +
ER -
ER +
ER -
T1a (0-5 mm) T1b (6-10 mm) T1c (11-20 mm)
NCI
NCCN*)
St. Gallen
GUIDELINE RECOMMENDATION
FOR CHEMOTHERAPY FOR
STAGE I BREAST CANCER
Not Recommended Optional Recommended
*) NCCN = National Comprehensive Cancer Network

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www/Adjuvant on line !

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The Breast Health Global Initiative (BHGI)
Guideline Publication 2003
CONSENSUS
STATEMENTS
Early Detection Panel
Diagnosis Panel
Treatment Panel

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BHGI GLOBAL SUMMIT 2005:
Guideline Stratification
Breast J 2006;12 Suppl 1:S117-120

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History
Physical examination
Clinical breast examination
Surgical biopsy
Fine-needle aspiration biopsy
Diagnostic breast ultrasound +/-
diagnostic mammography
Plain chest radiography
Liver ultrasound
Blood chemistry profile / complete
blood count (CBC)
Maximal
Stereotactic biopsy HER-2/neu status
CT scanning, PET scan, MIBI scan,
breast MRI
Sentinel node biopsy
IHC staining of sentinel nodes
for cytokeratin to detect
micrometastases
Enhanced
Diagnostic mammography
Bone scan
On-site cytopathologist
Preoperative needle localization
under mammographic or ultrasound
guidance
Basic
Interpretation of biopsies
Cytology and/or pathology
report describing tumor size,
lymph node status, histologic
type, tumor grade
Limited
Determination and reporting of
ER and PR status
Determination and reporting of
margin status
Core needle biopsy
Image guided sampling
(ultrasounographic +/-
mammographic)
Level of
resources
Clinical Pathology Imaging and lab tests
Diagnosis

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Controversial Issues :
 FNAC or Frozen Sections
 5 or 10 years of HT
 T and AI
 Type of CT
 Herceptin and others
 Pre or post op CT
 Ov ablation
 Cases who do not need systemic treatment

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Cancer Treatment
S
Chemo. Radio.
Types of cancer treatment
Application of cancer
treatment
Cost of cancer treatment

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Situation Analysis
Egypt

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EGYPT
Gharbia Population–based registry

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Rate per 100 000 pop.
Incidence Rates of Common Sites of Cancer
Population Data: Females
37.8
8.1
4.1 3.7 3.7 3.4 3 2.3 2.4
49.6
10.7
6 5.2 5 5.3
3.5 3 3.6
0
10
20
30
40
50
60
Breast NHL Liver Colon-
Rectum
Ovary Bladder Brain&CNS Thyroid Lung
Crude Rate ASIR

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GLOBAL STATISTICS:
Age-Specific Rates / 100,000 Females (all ages)
Globocan 2002 (IARC)

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The National Cancer Institute
Cairo University
www.nci.cu.edu.eg
Cairo University National Cancer Institute

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NCI Most Common Sites in Males and
females

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National Cancer Registry

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Cumm. %Proportion
7.7
20.3
35.1
52.7
68.9
79.3
90.5
95.5
100.0
7.7
12.6
14.8
17.6
16.2
10.4
11.2
5.0
4.5
<35
35-
40-
45-
50-
55-
60-
65-
70+
Age structure of
Female breast cancer patients.

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US SEEREgypt
1.3
7.1
25.2
61.7
117.5
192.1
253.1
1.4
9.8
28.9
63.6
96.7
171.5
181.2
20-24
25-29
30-34
35-39
40-44
45-49
50-54
……
Age-specific Incidence Rates of Breast cancer
in younger age groups: Egypt and US SEER

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Magnitude of Breast Cancer in Egypt: 2025
 Population size: 51 million females
 Crude incidence rate: 55.1./100,000 females
 Incidence: 14,000  28,000 breast cancer cases
 Prevalence: 42,000 84,000 breast cancer cases
Magnitude of Breast Cancer in Egypt: 2050
 Population size: 64 million females
 Crude incidence rate: 68.8./100,000 females
 Incidence: 14,000  44,000 breast cancer cases
 Prevalence: 42,000 132,000 breast cancer cases
Projection of Magnitude of Breast Cancer
in Egypt: 2025, 2050

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Breast cancer T stage 1984 - 2006, Port Said, Egypt
0
10
20
30
40
50
60
70
80
84-1985 86-1988 94-1999 2004 2005 2006
T1 T2 T3 T4
SOURCE: Prof. Dr. Ahmed Elzawawy

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Cancer Control in Egypt

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Inflammatory Breast Cancer (IBC)
 Swollen
 Erythema
 Peau d’Orange
 Frequently
Mistaken for
Mastitis

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Clinico–Pathological Correlation
in Breast Cancer Cases
(2002)
 Revision of the slides of 212 patients.
 Only 16 patients had both clinical and pathological features
of IBC (8%)
 Age distribution
4 patients 35 yrs or less
8 patients 45 yrs or less
8 patients More than 45 yrs
The youngest 25 yrs
The oldest 76 yrs

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 More than 90% of IBC showed positive axillary nodes.
 IBC’s are characterized by:
 High histologic grade tumors with high
Nuclear grade, necrosis and high PCNA and MIB-
1(Ki-67) labeling indices.
 ER & PgR are frequently negative.
 p53 > 70% positivity.
 HER-2/Neu > 60%.
Biologic profile
“ Immunphenotypic signature”

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Tumor emboli and LYVE-1 and RhoC expression in IBC tumors from
Egypt and the United States

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RhoC Scoring and Tumor Emboli for Egyptian patients
with IBC and non-IBC
IBC (N=46)
No. (%)
Non-IBC (N=64)
No. (%) P-value
RhoC Score
1
2
3
4
1 (2)
5 (10)
20 (44)
20 (44)
24 (38)
29 (45)
7 (10)
4 (6) <0.0001
RhoC Categories
1-2
3-4
6 (13)
40 (87)
53 (83)
11 (17) <0.0001
Tumor Emboli
Mean ± SD
0-1
2-8
9+
14.1 ± 14.0
1 (2)
19 (41)
26 (57)
7.0 ± 12.9
32 (50)
18 (28)
14 (22
<0.0001
<0.0001

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Cairo University National Cancer Institute
Thank you