Breast cancer poses a significant burden in developing countries like Kenya. At Kijabe Hospital in Kenya, most breast cancer patients present with locally advanced disease and the median age of patients is younger than in Western countries. Treatment options are limited by costs and available resources. For poorer patients, treatment typically involves a mastectomy with adjuvant therapies if the tumor can be removed, while wealthier patients may receive breast conserving surgery and more comprehensive adjuvant treatment. Radiotherapy, an important part of breast conservation, is often not available locally and requires travel to Nairobi. Management strategies in low-resource settings must be tailored to the economic realities of individual patients.
New Developments in Breast Reconstruction Surgerybkling
Deborah Axelrod, MD, of NYU Langone Perlmutter Cancer Center, and Rachel Bluebond-Langner, MD, of NYU Langone Medical Center discuss the latest research in autologous breast reconstruction, fat injection, pre-pectoral implants, and oncoplastic surgery.
Disclaimer: Graphic medical imagery.
New Developments in Breast Reconstruction Surgerybkling
Deborah Axelrod, MD, of NYU Langone Perlmutter Cancer Center, and Rachel Bluebond-Langner, MD, of NYU Langone Medical Center discuss the latest research in autologous breast reconstruction, fat injection, pre-pectoral implants, and oncoplastic surgery.
Disclaimer: Graphic medical imagery.
Awareness and current knowledge of breast cancerMehwish Iqbal
Breast cancer remains a worldwide public health dilemma and is currently the most common tumour in the globe.
Awareness of breast cancer, public attentiveness, and advancement in breast imaging has made a positive impact
on recognition and screening of breast cancer. Breast cancer is life-threatening disease in females and the leading
cause of mortality among women population. For the previous two decades, studies related to the breast cancer
has guided to astonishing advancement in our understanding of the breast cancer, resulting in further proficient
treatments. Amongst all the malignant diseases, breast cancer is considered as one of the leading cause of death in
post menopausal women accounting for 23% of all cancer deaths. It is a global issue now, but still it is diagnosed in
their advanced stages due to the negligence of women regarding the self inspection and clinical examination of the
breast. This review addresses anatomy of the breast, risk factors, epidemiology of breast cancer, pathogenesis of breast
cancer, stages of breast cancer, diagnostic investigations and treatment including chemotherapy, surgery, targeted
therapies, hormone replacement therapy, radiation therapy, complementary therapies, gene therapy and stem-cell
therapy etc for breast cancer.
Modified Sweat gland
Lies in the deep pectoral
fascia
Boundaries:
clavicle superiorly,
the lateral border of the latissimus muscle laterally,
the sternum medially
inframammary fold inferiorly
Management of Early Breast Cancer (by Dr. Akhil Kapoor)Akhil Kapoor
Comprehensive discussion on Management of Early Breast Cancer along with NCCN guidelines.
Slides prepared by Dr. Akhil Kapoor
(Resident, Department of Radiation Oncology,
Acharya Tulsi Regional Cancer Treatment & Research Institute, Bikaner, Rajasthan, India
Awareness and current knowledge of breast cancerMehwish Iqbal
Breast cancer remains a worldwide public health dilemma and is currently the most common tumour in the globe.
Awareness of breast cancer, public attentiveness, and advancement in breast imaging has made a positive impact
on recognition and screening of breast cancer. Breast cancer is life-threatening disease in females and the leading
cause of mortality among women population. For the previous two decades, studies related to the breast cancer
has guided to astonishing advancement in our understanding of the breast cancer, resulting in further proficient
treatments. Amongst all the malignant diseases, breast cancer is considered as one of the leading cause of death in
post menopausal women accounting for 23% of all cancer deaths. It is a global issue now, but still it is diagnosed in
their advanced stages due to the negligence of women regarding the self inspection and clinical examination of the
breast. This review addresses anatomy of the breast, risk factors, epidemiology of breast cancer, pathogenesis of breast
cancer, stages of breast cancer, diagnostic investigations and treatment including chemotherapy, surgery, targeted
therapies, hormone replacement therapy, radiation therapy, complementary therapies, gene therapy and stem-cell
therapy etc for breast cancer.
Modified Sweat gland
Lies in the deep pectoral
fascia
Boundaries:
clavicle superiorly,
the lateral border of the latissimus muscle laterally,
the sternum medially
inframammary fold inferiorly
Management of Early Breast Cancer (by Dr. Akhil Kapoor)Akhil Kapoor
Comprehensive discussion on Management of Early Breast Cancer along with NCCN guidelines.
Slides prepared by Dr. Akhil Kapoor
(Resident, Department of Radiation Oncology,
Acharya Tulsi Regional Cancer Treatment & Research Institute, Bikaner, Rajasthan, India
Fertility And Pregnancy Outcome In Cancer PatientsMamdouh Sabry
Better life of Cancer patients during childhood and age reproductive period regarding fertility, fertility preservation and pregnancy outcome is the main concern.concentrating upon different safe diagnostic modalities, management and outcome.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
Organ preservation in kenyan breast cancer patients by peter bird
1. Organ Preservation in Kenyan
Breast Cancer Patients
Mr Peter Bird FRACS, Kijabe Hospital
2. World Breast Cancer Burden
• Breast cancer is the second most common cancer in the world, most
common cancer in women
– Fifth cause of death from cancer overall
• 1.67 million new cancer cases diagnosed in 2012 (25% of all cancers)
• Slightly more cases in less developed (883,000 cases) than in more
developed (794,000) regions
• Incidence rates vary nearly four-fold across the world regions
– Rates ranging from 27 per 100,000 in Middle Africa/Eastern Asia to 96 in
Western Europe
• The range in mortality rates between world regions is less than that
for incidence because of the more favorable survival of breast cancer
in (high-incidence) developed regions
– Mortality rates range from 6 per 100,000 in Eastern Asia to 20 per
100,000 in Western Africa
• More breast cancer deaths in LMICs than HICs
WHO IARC GLOBOCAN 2012
3. Estimated Breast Cancer Incidence Worldwide
WHO International Agency for Research on Cancer
GLOBOCAN 2012
Estimated age standardized rates per 100,000
4. Estimated Breast Cancer Mortality Worldwide
WHO International Agency for Research on Cancer
GLOBOCAN 2012
Estimated age standardized rates per 100,000
5. Kijabe Breast Cancer Study
2001-2007
• 125 female, 4 male between 2001 and 2007
• Excluded wazungu, non-IDC tumours
• Median age 47 (range 26-76)
• Mean parity 4.1
• Mean size of tumour (clinical) 6.8cm
• Average length of history – 12 months
• LABC 59%
Bird PA, Hill AG, Houssami N. Poor Hormone Receptor Expression in East African Breast
Cancer: Evidence of a Biologically Different Disease? Ann Surg Oncol., March 2008
6. Kijabe Breast Cancer Cases
2011-12
• 59 cases Jan 11 to Feb 12
• 48 IDC (NOS); 11 special types
• Median age 45
• 62.5% under 50yo
• LABC 48% 0
20
15
10
5
7.
8. Halsted’s Radical
Mastectomy Series
Ann Surg 1894
• 50 cases of radical mastectomy (not
consecutive?)
• Average age 51
• All 50 with nodal disease, so Stage II or III
• LABC 33/48 (68%)
• 27 of 50 (54%) prognosis regarded as
“hopeless or unfavourable” after surgery &
path assessment
• 6% local recurrence rate (“Return of the
disease in the field of operation”)
William Halsted 1852-1922
Halsted WS. The results of operations for the cure of cancer of the breast performed at the
Johns Hopkins Hospital from June 1889 to January 1894. Ann Surg 1894 Vol 20: 497-555
9. Halsted’s
Radical
Mastectomy
• Removal of skin,
breast, axillary
nodes to level III,
pectoralis muscles
• IM nodes not
removed
• Chest wall defect
skin grafted after
granulating
11. The Biology of Breast Cancer
Fisher’s Hypothesis:
Most, if not all, patients with breast cancer
have disseminated disease by the time a
clinical diagnosis is established; that is,
breast cancer is a systemic disease at
presentation and local therapies have no
influence on survival
Bernard Fisher 1918 -
"I cannot emphasize too strongly the fact
that internal metastases occur very early
in cancer of the breast, and this is an
additional reason for not losing a day in
discussing the propriety of an operation.“
W HALSTED 1894
12. The Biology of Breast Cancer
• Fisher’s hypothesis tested in multiple prospective RCTs
in early BC in High Income Countries
• Increased local recurrence in breast conserving surgery
compared to RM or MRM, but no difference in survival
in over 25 years of follow up
• Survival has improved with less surgery, because of
earlier diagnosis, and treatment with adjuvant
therapies, including RT to the chest wall
13. Treatment Options for
Breast Cancer
• SURGERY
– Breast conserving or mastectomy, with lymph node
examination (ALND or SLNB)
• CHEMOTHERAPY
– Before or after surgery. Anthracyclines, taxanes etc
• HORMONAL THERAPY
– SERMs, AIs, LHRH analogues, oophorectomy
• TARGETED BIOLOGICAL THERAPY
– Trastuzumab, new dual therapies very promising
• RADIOTHERAPY
– Teletherapy, brachytherapy, intraop RT (TARGIT trial)
14. Management of Breast Cancer
in Kijabe, Kenya
• Patients of highly variable economic status –
determines extent of surgery
• Breast conserving surgery and full adjuvant
therapies offered to wealthier patients with early
stage disease
• 30% BC pts last six months (9/30) cf. 10% in 2008 series
• Poor patients get mastectomy & AD alone if the
tumour can be macroscopically excised
• Wide excision on the chest wall helped by flap
coverage techniques, and often a Level III AD
15. Fifty-six Latissimus Dorsi
Myocutaneous Flaps at Kijabe Hospital
P Bird, 2000-2014
Indication Number
of cases
Pathology Complications Local recurrence
Coverage of anterior
chest wall defect
45 Breast
malignancy, soft
tissue sarcoma
3 minor flap-skin
dehiscences
2
Augmentation after
partial mastectomy
5 Breast cancer None 0
Delayed BR 3 Breast cancer Implant
Migration
N/A
Coverage of
posterior chest wall
defect
1 Recurrent soft
tissue sarcoma
None 0
Neck contracture 1 Burn 1 minor flap-skin
dehiscence
N/A
Immediate BR 1 Breast cancer None 0
24. Treatment Options for
Breast Cancer
• SURGERY
– Breast conserving or mastectomy, with lymph node examination
(ALND or SLNB)
• CHEMOTHERAPY
– Before or after surgery. Anthracyclines, taxanes etc
• HORMONAL THERAPY
– SERMs, AIs, LHRH analogues, oophorectomy
• TARGETED BIOLOGICAL THERAPY
– Trastuzumab, new dual therapies very promising
• RADIOTHERAPY
– Teletherapy, brachytherapy, intraop RT (TARGIT trial)
– Crucial part of BCS option!
25. Radiotherapy Resources
in Africa 2010
Kenya and Neighbours 8
Kenya 2 (Private 7)
Ethiopia 2
South Sudan 0
Somalia 0
Uganda 1
Tanzania 3
Population: 243 million
Australia (public) 33
Australia (private) 26
Population: 23 million
Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
26. Radiotherapy Resources
in Africa 2010
Abdel-Wahab et al, Status of radiotherapy resources in Africa: an IAEA analysis Lancet Oncol 2013
27. Treatment Options and
Costs in Kijabe and Kenya
Mastectomy USD700
(At Kijabe)
Radiotherapy USD200
(Done at KNH. USD4-5000 in private facilities)
Chemotherapy USD1000
(Done in Nairobi)
Hormonal Rx USD650
(5 years of tamoxifen)
TOTAL USD2550
28. Ethiopia (92m)
Somalia (10m)
Kenya (44m)
South Sudan (11m)
Uganda (38m)
Tanzania (48m)
Annual GNI per Capita
2013
Rank
S Sudan $1120 139
Kenya $930 145
Tanzania $630 156
Uganda $510 162
Ethiopia $470 164
Somalia Unknown
Norway $102,610 1
Australia $65,520 4
USA $53,670 8
UK $39,140 18
30. Management of Breast Cancer
in Kijabe, Kenya
• Patients of highly variable economic status –
determines extent of surgery
• Breast conserving surgery and full adjuvant
therapies offered to wealthier patients with early
stage disease
• 30% BC pts last six months (9/30) cf. 10% in 2008 series
• Poor patients get mastectomy & AD alone if the
tumour can be macroscopically excised
• Wide excision on the chest wall helped by flap
coverage techniques, and often a Level III AD
31. Why are Breasts Important?
• Providing nourishment to our children
• Allowing strong bonding between mother
and child
• Having two maintains a healthy body image
• As a sexual organ in some (all?) cultures
32.
33.
34. Bathsheba at Her Bath
Rembrandt, 1654
“One evening
David got up
from his bed
and walked
around on the
roof of the
palace. From
the roof he
saw a woman
bathing. The
woman was
very
beautiful...”
2 Samuel 11:2
35.
36.
37.
38.
39. Breast Conservation Surgery
Loss of a breast causes significant
psychosocial damage, embarrassment
and loss of self-esteem. Breast
surgeons strive to preserve the breast
to keep the woman psychologically
healthy and socially confident
40. Breast Conservation Surgery
The best reconstructive option is no
reconstruction...perform breast
conserving surgery (BCS) when
ever possible!
57. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
58. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
59. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
60. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
61. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
62. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
63. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
64. Margins in Stage I & II Breast
Conserving Surgery
Moran et al Int J Radiation Oncol Biol Phys 2014
65. Conclusions
• Unacceptable disparity of healthcare exists
between African countries and HICs
• Most BCs in Africa present locally advanced and
multidisciplinary treatment is unaffordable
• BC management in LMICs must be tailored to
best fit the economic circumstances
• Surgery is the mainstay of treatment in Kenya
and Kenyan surgeons need to be taught
techniques to meet this challenge