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Breast Cancer and its Management

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Breast Cancer and its Management

  1. 1. 1 Management of BreastManagement of Breast CancerCancer ByBy Hussein M. KhaledHussein M. Khaled Prof. Medical OncologyProf. Medical Oncology Vice PresidentVice President Post graduate Studies and ResearchPost graduate Studies and Research Cairo UniversityCairo University
  2. 2. 2 BREAST CANCERBREAST CANCER Worldwide incidence in females*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 EasternEastern EuropeEurope JapanJapan Australia/Australia/ New ZealandNew Zealand South CentralSouth Central AsiaAsia NorthernNorthern AfricaAfrica SouthernSouthern AfricaAfrica CentralCentral AmericaAmerica WesternWestern EuropeEurope NorthNorth AmericaAmerica
  3. 3. 3 CANCER CONTROLCANCER CONTROL EARLYEARLY DETECTIONDETECTION DIAGNOSISDIAGNOSIS PRIMARYPRIMARY PREVENTIONPREVENTION TREATMENTTREATMENT
  4. 4. 4 BREAST CANCERBREAST CANCER Signs and symptoms at presentationSigns and symptoms at presentation  Mass or painMass or pain in the axillain the axilla  Palpable massPalpable mass  ThickeningThickening  PainPain  Nipple dischargeNipple discharge  Nipple retractionNipple retraction  Edema or erythemaEdema or erythema of the skinof the skin
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  6. 6. 6 BREAST CANCERBREAST CANCER Diagnosis pathDiagnosis 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. 7 Staging Classification of Breast TumourStaging Classification of Breast Tumour
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  9. 9. 9 Early Breast CancerEarly Breast Cancer
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  12. 12. 12 NSABP B-06:NSABP B-06: Effect of Lumpectomy v. Mastectomy on SurvivalEffect 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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  14. 14. 14 HT
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  17. 17. 17 HER2 testing algorithmHER2 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
  18. 18. 18 Locally Advanced Breast CancerLocally Advanced Breast Cancer
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  26. 26. 26 What elements drive therapy decision making ? Prognosis Treatment efficacy Treatment toxicity Co morbidity
  27. 27. 27 ER +ER + ER -ER - ER +ER + ER -ER - T1a (0-5 mm)T1a (0-5 mm) T1b (6-10 mm)T1b (6-10 mm) T1c (11-20 mm)T1c (11-20 mm) NCINCI NCCNNCCN*)*) St. GallenSt. Gallen GUIDELINE RECOMMENDATION FOR CHEMOTHERAPY FOR STAGE I BREAST CANCER Not RecommendedNot Recommended OptionalOptional RecommendedRecommended *) NCCN = National Comprehensive Cancer Network*) NCCN = National Comprehensive Cancer Network
  28. 28. 28 www/Adjuvant on line !www/Adjuvant on line !
  29. 29. 29 TheThe Breast Health Global Initiative (BHGI)Breast Health Global Initiative (BHGI) Guideline Publication 2003Guideline Publication 2003 CONSENSUSCONSENSUS STATEMENTSSTATEMENTS Early Detection PanelEarly Detection Panel Diagnosis PanelDiagnosis Panel Treatment PanelTreatment Panel
  30. 30. 30 BHGI GLOBAL SUMMIT 2005:BHGI GLOBAL SUMMIT 2005: Guideline StratificationGuideline Stratification Breast J 2006;12 Suppl 1:S117-120
  31. 31. 31 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 DiagnosisDiagnosis
  32. 32. 32 Controversial Issues :Controversial Issues :  FNAC or Frozen SectionsFNAC or Frozen Sections  5 or 10 years of HT5 or 10 years of HT  T and AIT and AI  Type of CTType of CT  Herceptin and othersHerceptin and others  Pre or post op CTPre or post op CT  Ov ablationOv ablation  Cases who do not need systemic treatmentCases who do not need systemic treatment
  33. 33. 33 Cancer TreatmentCancer Treatment S Chemo. Radio. Types of cancer treatment Application of cancer treatment Cost of cancer treatment
  34. 34. 34 Situation AnalysisSituation Analysis EgyptEgypt
  35. 35. 35 EGYPT Gharbia Population–based registryGharbia Population–based registry
  36. 36. 36 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
  37. 37. 37 GLOBAL STATISTICS:GLOBAL STATISTICS: Age-Specific Rates / 100,000 Females (all ages)Age-Specific Rates / 100,000 Females (all ages) Globocan 2002 (IARC)
  38. 38. 38 The National Cancer InstituteThe National Cancer Institute   Cairo UniversityCairo University www.nci.cu.edu.egwww.nci.cu.edu.eg Cairo University National Cancer Institute
  39. 39. 39 NCI Most Common Sites in Males andNCI Most Common Sites in Males and femalesfemales
  40. 40. 40 National Cancer RegistryNational Cancer Registry
  41. 41. 41 ProportionProportion Cumm. %Cumm. % <35<35 35-35- 40-40- 45-45- 50-50- 55-55- 60-60- 65-65- 70+70+ 7.77.7 12.612.6 14.814.8 17.617.6 16.216.2 10.410.4 11.211.2 5.05.0 4.54.5 7.77.7 20.320.3 35.135.1 52.752.7 68.968.9 79.379.3 90.590.5 95.595.5 100.0100.0 Age structure ofAge structure of Female breast cancer patients.Female breast cancer patients.
  42. 42. 42 EgyptEgypt US SEERUS SEER 20-2420-24 25-2925-29 30-3430-34 35-3935-39 40-4440-44 45-4945-49 50-5450-54 ………… 1.41.4 9.89.8 28.928.9 63.663.6 96.796.7 171.5171.5 181.2181.2 1.31.3 7.17.1 25.225.2 61.761.7 117.5117.5 192.1192.1 253.1253.1 Age-specific Incidence Rates of Breast cancerAge-specific Incidence Rates of Breast cancer in younger age groups: Egypt and US SEERin younger age groups: Egypt and US SEER
  43. 43. 43 Magnitude of Breast Cancer in Egypt: 2025Magnitude of Breast Cancer in Egypt: 2025  Population size: 51 million femalesPopulation size: 51 million females  Crude incidence rate: 55.1./100,000 femalesCrude incidence rate: 55.1./100,000 females  Incidence: 14,000Incidence: 14,000  28,000 breast cancer cases28,000 breast cancer cases  Prevalence: 42,000Prevalence: 42,000 84,000 breast cancer cases84,000 breast cancer cases Magnitude of Breast Cancer in Egypt: 2050Magnitude of Breast Cancer in Egypt: 2050  Population size: 64 million femalesPopulation size: 64 million females  Crude incidence rate: 68.8./100,000 femalesCrude incidence rate: 68.8./100,000 females  Incidence: 14,000Incidence: 14,000  44,000 breast cancer cases44,000 breast cancer cases  Prevalence: 42,000Prevalence: 42,000 132,000 breast cancer cases132,000 breast cancer cases Projection of Magnitude of Breast CancerProjection of Magnitude of Breast Cancer in Egypt: 2025, 2050in Egypt: 2025, 2050
  44. 44. 44 Breast cancer T stage 1984 - 2006, Port Said, EgyptBreast 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
  45. 45. 45 Cancer Control in EgyptCancer Control in Egypt
  46. 46. 46 Inflammatory Breast Cancer (IBC)  Swollen  Erythema  Peau d’Orange  Frequently Mistaken for Mastitis
  47. 47. 47 Clinico–Pathological CorrelationClinico–Pathological Correlation in Breast Cancer Casesin Breast Cancer Cases (2002)(2002)  Revision of the slides of 212 patients.Revision of the slides of 212 patients.  Only 16 patients had both clinical and pathological featuresOnly 16 patients had both clinical and pathological features of IBC (8%)of IBC (8%)  Age distributionAge distribution 4 patients4 patients 35 yrs or less35 yrs or less 8 patients8 patients 45 yrs or less45 yrs or less 8 patients8 patients More than 45 yrsMore than 45 yrs The youngestThe youngest 25 yrs25 yrs The oldestThe oldest 76 yrs76 yrs
  48. 48. 48  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”
  49. 49. 49 Tumor emboli and LYVE-1 and RhoC expression in IBC tumors fromTumor emboli and LYVE-1 and RhoC expression in IBC tumors from Egypt and the United StatesEgypt and the United States
  50. 50. 50 RhoC Scoring and Tumor Emboli for Egyptian patients with IBC and non-IBC IBC (N=IBC (N=46)46) No. (%)No. (%) Non-IBC (N=Non-IBC (N=64)64) No. (%)No. (%) PP-value-value RhoC ScoreRhoC Score 11 22 33 44 1 (2)1 (2) 5 (10)5 (10) 2020 (44)(44) 20 (44)20 (44) 24 (38)24 (38) 29 (45)29 (45) 7 (10)7 (10) 4 (6)4 (6) <<0.00010.0001 RhoC CategoriesRhoC Categories 1-21-2 3-43-4 6 (13)6 (13) 40 (87)40 (87) 53 (83)53 (83) 11 (17)11 (17) <0.0001<0.0001 Tumor EmboliTumor Emboli Mean ± SDMean ± SD 0-10-1 2-82-8 9+9+ 14.1 ± 14.014.1 ± 14.0 1 (2)1 (2) 1919 (41)(41) 26 (57)26 (57) 7.0 ± 12.97.0 ± 12.9 32 (50)32 (50) 18 (28)18 (28) 14 (2214 (22 <0.0001<0.0001 <0.0001<0.0001
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  53. 53. 53 Cairo University National Cancer Institute Thank you

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