this is my dissertation about breast cancer

1. Ahmed Abd Al-Hassan Abd
Supervised By:
Dr.Emad Al-Saaberi
Breast CancerBreast Cancer

2. Case Study:
Old lady with 72 years, she is retired teacher, she is feeling by small protrusion ( lump ) in the right breast in inferomedial
side of the breast below the areola, cover by skin , she appear normal without pain , this state continuous for two months
then less than month appear redness of small area adjacent to lump, otherwise is normal.
She was begin worry about this, because of had previous experience with breast cancer in left breast in 1986, also she had
family history with cancer, her brother had osteocarcinoma, daughter of her aunt had breast cancer and her aunt had GIT
cancer, so, she went to out clinic and after examination and investigation, she was definitely diagnosed with breast
carcinoma (invasive lobular carcinoma) in right one.
She was treated by lumpectomy and then taken adjuvant therapy= 16 fraction of radiotherapy+taken Arimidex 1mg
(aromatase inhibitor).
She also had hypertension, diabetes and osteoporosis, so, she taken valsartan 160mg for hypertension and Glucophage
500mg for diabetes and bisphosphonate for osteoporosis

3. Epidemiology of Breast Cancer:
▪ Globally, breast cancer is the most frequent cancer among women; comprising about 23 % of all female cancers
▪ Breast cancer (women only) was the second most common cancer (comen after lung cancer) with nearly 1.7 million
new cases in 2012.
▪ It is the fifth most common cause of death from cancer in women.
▪ The common type of breast cancer is invasive ductal carcinoma.

4. Basic Medical Sciences:
▪ Breast is modified sweat gland and it is composed of 15 to 20 lobes, which are each composed of several
lobules.
▪ The mature female breast extends from the level of the second or third rib to the inframammary fold at the sixth or
seventh rib. It extends transversely from the lateral border of the sternum to the anterior axillary line.
▪ The breast receives its principal blood supply from :
 Perforating branch of the internal mammary artery
 Lateral branches of the posterior intercostal arteries
 Branches from the axillary artery, including:
 Highest thoracic artery
 Lateral thoracic artery
 Pectoral branch of thoracoacromial artery

5. ▪ Lymphatic drainage of the breast:
 There is more than 75% of breast lymph drainage into axillary lymph node groups, while less than 25% of
breast lymph drainage into internal mammary lymph node.
 Axillary lymph nodes groups:
 These lymph nodes groups are divided to three levels according to the pectorals minor muscle :
 Level I : include the posterior and later group of axillary lymph node those located in the lower border of the
lateral surface of the pectorals minor muscle.
 Level II : include the central group of axillary lymph node that is located behind the pectorals minor muscle,
also this level involve the interpectoral group (Rotter's lymph nodes) which located between pectorals minor
and pectorals major muscle.
 Level III : include the apical group or called subclavicular group or called infraclavicular group that located in
the medial border of superior surface of the pectorals minor muscle.
 Internal mammary lymph nodes:
 These lymph nodes drainage the internal medial side of the breast.

6. Breast Development and Function:
▪ Breast development and function are initiated by a variety of hormonal stimuli, including estrogen,
progesterone, prolactin, oxytocin, thyroid hormone, cortisol, and growth hormone.
▪ Estrogen, progesterone, and prolactin especially have profound trophic effects that are essential to
normal breast development and function.
▪ Prolactin is the primary hormonal stimulus for lactogenesis in late pregnancy and the postpartum
period.
▪ In the female neonate, circulating estrogen and progesterone levels decrease after birth and remain
low throughout childhood because of the sensitivity of the hypothalamic-pituitary axis to negative
feedback from these hormones.
▪ At the beginning of the menstrual cycle, there is an increase in the size and density of the breasts,
which is followed by engorgement of the breast tissues and epithelial proliferation.

8. Pathophysiology of breast cancer:
 The mechanizm of breast cancer not clear, but generally the Cancer is a group of diseases in which a cell in the
body has been transformed and begins to grow and divide out of control. It results from multiple mutations or
changes in DNA structure in the genes that activate cell growth, called proto-oncogenes, and those that ensure
that DNA replication and repair are normal, called growth-suppressor or tumor-suppressor genes.
 Mutations that activate proto-oncogenes to oncogenes disturb the regulation of the cell cycle and the rate of cell
proliferation. Mutations that disrupt tumor-suppressor genes lead to an increased incidence of these proto-
oncogene–activating mutations.
 Such mutations may be inherited, causing a predisposition to a type of cancer. They also may arise from DNA
replication or copying errors that remain uncorrected, from chemicals or radiation that damages DNA, from
translocation of pieces of chromosomes from one chromosome to another during replication, or from
incorporation of viral encoded DNA into the genome or increase exposure to the stimulus such as increase
exposure to estrogen hormone in breast cancer .

9. Sign and symptoms:
The patient with breast cancer may presented with some characteristics that is related
to breast cancer and these characteristics are:
Palpable mass (lump) in 55% of cases, located in the upper outer quadrant of the breast in 60% of cases.
Abnormal mammogram without a palpable mass in 35% of cases.
Skin change-color or dimpling (peau d'orange)
Nipple retraction or skin retraction or skin ulceration
Axillary mass

10. Investigation:
In cancer as a generally there are tests for diagnosis and at the same time there is test for help in
determination the treatment for patient.
The tests for diagnosis of breast cancer:
Imaging tests: mammography and ultrasound (help in differentiate between mass and cyst)
Special test: fine needle aspiration (FNA)
While the tests that help in determination the treatment for patient are:
Immunohistochemical test: to determine if the patient need to adjuvant hormonal therapy or no.
Pathological stage test: to help if the patient need to chemotherapy or no.
Complete blood count: in order to see if the patient fitness to take chemotherapy, should be the
hematological aspects taken in mind:
The WBC shouldn't be less than 4000/mm²
The platelet shouldn't be less than 100000/mm²
The hemoglobin shouldn't be less than 10 g/dl

11. Treatment:
My patient is treated with:
1.Lumpectomy in the right breast
2.Then 16 fraction of radiotherapy
3.And taken hormonal therapy------ Arimidex 1mg (aromataze inhibitor)➤

12. Psychological aspects:
 Stress constitutes a potential threat to health and adjustment cause many serious
physical complaints among human beings due to its direct effect on body’s
biological systems such as the nervous system, digestive system, respiratory
system, and cardiovascular system.
 My patient is rapid become anxious but at the same time rapid become relax, she
is exposed to bad psychological aspects after death of her father, after that she
had multi-fibroid in her uterus and had menorrhagia that lead to done
hysterectomy that made her in anxious and stress then after two year appear, she
had left breast cancer that lead to done left mastectomy.

13. Discussion:
Old age female presented with lump in her right breast in inferomedial side below the areola, this
lump is painless, she had in past history hysterectomy and breast cancer in left breast that lead to
done left mastectomy, and also this female is nulliparity and had early menarche before 12 years
old, all these risk factors made her prone for another breast cancer in the remain right breast tissue,
so, actually she had breast cancer again but in the right breast, in the first left breast cancer, she is
treated with mastectomy and adjuvant radiotherapy (20 fraction), but the mistake is, she isn't taken
adjuvant hormonal therapy although she had positive tumor estrogen receptors because of the
adjuvant hormonal therapy wasn't detect at those days, so, she stay in risk to had recurrence tumor
and that actually happen in the right breast after 27 year. In the second cancer in the right breast, she
is treated with lumpectomy then had adjuvant radiotherapy (16 fraction) and then take adjuvant
hormonal therapy (Arimidex).

14. Generally a patient with breast cancer, and the tumor estrogen receptors positive, we
can give tamoxifen (estrogen receptors inhibitor) or arimidex (aromatase enzyme
inhibitor) as adjuvant hormonal therapy, so, why here in this patient, we might use
the arimidex rather than tamoxifen and at the same time the both drug had very
good effective? The answer of this question is related to found some differences
between them, the first difference is the tamoxifen can be used for premenopausal
female or postmenopausal while the arimidex is used in postmenopausal female, but
this difference isn't exclude use the tamoxifen in postmenopausal female exactly in
this old age and postmenopausal woman, so, the main difference that made the
arimidex is the perfect adjuvant hormonal therapy for postmenopausal is the arimidex
given long survival rate than tamoxifen.

15. Thanks