1. BREAST CANCER
SCREENING
Ayman Linjawi, MD, FRCSC
Consultant General and Oncology Surgery
Founder, CEO, Medical Reference Clinics
Jeddah, Saudi Arabia

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3. BREAST CANCER SCREENING
The revolution in breast cancer
management happening nowadays is in
the early detection of the disease.

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• Expected Period of Tumor Growth

7. BREAST CANCER SCREENING
• 60 to70% of the cases are sporadic.
• 20 to 30% are familial.
• Only 5% are due to inheritance of mutated
gene.

8. Screening modalities
• Mammogram is the gold standard.
• US alone is not enough but my help with
the use of mammogram.
• MRI for mammographic findings of dense
breast and BRCA positive patients.
• Genetic testing only for the inheritance type
of the disease.

9. BREAST CANCER SCREENING
ADVANTEGES
• The fact that non-palpable breast cancer found at
mammography has more than 90% 10 years
survival rates where as 10 years survival rates of
palpable breast cancer dose not exceed 60%,
makes it worth it to screen patients.
• DCIS, nearly all of which are found only by
mammography have a 10 years survival rates in
excess of 99%.

10. BREAST CANCER SCREENING
• The chances of doing breast conservative
surgery is much more and therefore better
cosmetic result.
• Reduce the need for chemotherapy.

11. ACS AND NCI SCREENING PROGRAM
• Annual mammogram for all women 50 years old
or above.
• Annual or every 2 years mammogram for women
40-49 years old (new data suggest it is even more
important to start at 40).
• Clinical examination Q 6 months or 3 months for
high risk patient.
• Breast self-examination monthly ??

12. BREAST CANCER SCREENING
• These screening measures end-up by
discovering a new era of the disease as non-
palpable breast lesion with suspicious
density or micro-calcification.
• Therefor we should be ready to manage this
cases in a correct way.

13. DIAGNOSIS OF SCREENING
DETECTED BREAST CANCER
Mammogram still the most important
diagnostic test. It can show suspicious
disease or micro-calcification in a breast with
normal clinical exam.

14. DIAGNOSIS OF EARLY BREAST
CANCER
• Ultrasound is used to localize the lesion but not in
the screening of patient.
• MRI, because of the low resolution, it is not
commonly used.
• Ductoscopy, small (less than 2 mm) scope is
introduced through the nipple for ductal
visualization and brush biopsy. So far, it is not
convenient for its local pain effect and low
sensitivity.

15. DIAGNOSIS OF EARLY BREAST
CANCER
• Ductal lavage by ductoscope or by
angiocath introduce through the nipple.
Low sensitivity.

16. BIOPSY OF EARLY BREAST
CANCER
Stereotatic biopsy, digital computerized x-ray
machine can calculate and localize the lesion
in 3D using axis X, Y and Z.

17. BIOPSY OF EARLY BREAST
CANCER
stereotactic or
Ultrasound guided
needle localization
for surgical
excisional biopsy

18. Early Breast Cancer, Diagnosis
• By ultrasound or mammogram, we
should be able to localize and biopsy
the suspicious nonpalpable lesion and
therefore, to establish the diagnosed.

19. MANAGEMENT OF EARLY
BREAST CANCER
• SURGERY: All invasive and DCIS smaller than
5cm will require Lumpectomy followed by
radiation.
• Any invasive tumor or DCIS 5cm or more will
require sentinel lymph node biopsy or formal
axillary node dissection.
• CHEMOTHERAPY: Any invasive tumor more
than 1.5cm with good performance status will
need adjuvant chemotherapy.

20. Early Breast Cancer, Treatment
• Any tumor or DCIS, regardless the size,
considered as high grade tumor, ER-ve or
has a positive lymphovasculer invasion most
probably will need adjuvant chemotherapy.
• Large tumors (5cm or more) with no
metastasis will require neoadjuvant
chemotherapy.

21. SENTINEL LYMPH NODE
BIOPSY
 SLNB reliably identifies patients with
axillary nodal involvement, allowing
axillary dissection to be limited to those
who will benefit from the procedure
 Studies of SLNB followed by ALND
demonstrate that SN can be identified
in almost 98% of patients

22. INJECTION TECHNIQUES

23. INJECTION TECHNIQUES

24. SUGGESTIVE CHRITERIA FOR
INHERITED DISEASE
• Multiple relatives are affected with breast
cancer or ovarian cancer or both.
• Two or more generations are affected
through maternal or paternal.
• Early onset of BC.
• More than one primary BC or BC and
ovarian cancer

25. GENETIC TESTING
• BRCA1 associated with increase risk of
both BC and ovarian cancer
• BRCA2 is associated with increase risk of
both BC and ovarian cancer and male BC
• Both mutated genes will increase the risk of
BC and OC up to 85%

26. GENETICS IN EARLY BREAST CANCER
• Study of the oncogenes and tumor suppressor genes
in breast cancer was of special interest.
• Apoptotic genes (p53, BcL2 and Bax) showed
significant results.
• Expression of mutant p53 significantly associated
with poor prognosis where as Bax expression
associated with decrease in recurrence rate.
Expression of BcL2 is significantly associate with ER/
PR expression and therefore may indicate the need of
Tamaxifin.
Prognostic Significance of p53, bcl-2, and Bax Expression in Early Breast Cancer.
Linjawi A., Kontogiannea M, Halwani F., Edwardes M., Meterissian S., American College of Surgeons, jan. 2004

27. Montreal General
Hospital
Royal Victoria
Hospital
Centre universitaire de santé
McGill
McGill University Health Centre

28. CONCLUSION
• We are much behind in detecting breast cancer
and all the efforts should be directed to early
catch-up of the disease.
• The early detection the best cosmetic results.
• Mammogram is the best screening test, starting at
the age of 40 significantly improve the over all
survival rate.
• BRCA1 & 2 genetics study is only preserved for
the 5% of the patients whom inherited the mutated
gene