Dr. Ali Andaleeb - L2.pdf

‫‪13 Nov.2022‬‬ ‫‪DISEASES OF THE BREAST‬‬ ‫‪Part 2‬‬ ‫↑‬ ‫حرفيا الكالم ال الجم كلمات االنسان الواعي‪.‬كالم كبير‬ ‫شز...

‫‪13 Nov.2022‬‬ ‫‪DISEASES OF THE BREAST‬‬ ‫‪Part 2‬‬ ‫↑‬ ‫حرفيا الكالم ال الجم كلمات االنسان الواعي‪.‬كالم كبير‬ ‫شز كي‬ ‫‪ B i‬حرفيا‬  CARCINOMA OF THE BREAST D Breast cancer is the most common cause of death in middle-aged women in western - countries. The incidence is expected to continue rising as the population ages. Aetiological factors D Geographical Carcinoma of the breast occurs commonly in the western world ② Age - Carcinoma of the breast is extremely rare before the age of 20 years ③ Gender Less thane0.5% of patients with breast cancer are male. - - Diet There is some evidence that there is a link with diets low in phytoestrogens. Alcohol consumption is associated with an increased risk. ⑪ Genetic It is more common in- women with a family history of breast cancer, and a specific - mutation accounts for about 5% of breast cancers Firs degree relative G mother-sister-daughter - e common  life time expure to estorgen higher El menopause feeding menche-late E Endocrine estungen non Breast early - - Breast cancer is more common in nulliparous women.Breast-feeding in particular, having a first child at an early age, late menarche and early menopause appears to be protective. In postmenopausal women, breast cancer is more common in the obese. -- Long-term exposure to the combined preparation of HRT does significantly increase the risk of developing breast cancer. ⑯ Previous radiation Women who had been treated with mantle radiotherapy as part of the management of Hodgkin’s disease were found to have higher risk. ② Histological Pathology The disease may be entirely in situ or may be invasive cancer. ninvasive - not reach the basements mambrane In situ carcinoma may be ductal (DCIS) or lobular (LCIS). Both are markers for the init - 8% - later development of invasive cancer, which will develop in at least 20% of - patients. In situ carcinoma is usually asymptomatic preinvasive cancer that has not breached - the epithelial basement membrane. It is now becoming increasingly common because of the advent of mammographic screening. Commonly, a numerical grading system (the Van Nuys system ) based on the scoring of three individual factors (nuclear pleomorphism, tubule formation and mitotic rate) is used, with grade III cancers roughly equating to the poorly differentiated group.  DCIS patients who classified with a high score or grade may get benefit from intern radiotherapy after excision, whereas those of low grade, whose tumour is completely excised, need no further treatment. Mastectomy ,often constitutes overtreatment in many cases. Invasive ductal carcinoma(infiltrating ductal carcinoma) is the most common variant(50-70%), with lobular carcinoma occurring in up to 15% of cases. Occasionally, the picture may be mixed with both ductal and lobular features. Rarer histological variants, usually carrying a better prognosis, Invasive lobular carcinoma is commonly multifocal and/or bilateral Inflammatory carcinoma is a fortunately rare, highly aggressive cancer, usually involves at least one-third of the breast and may mimic a breast abscess.. It used to be rapidly fatal but with aggressive chemotherapy and radiotherapy and with salvage surgery the prognosis has improved considerably.  ductal = invasiveeinoma Paget’s disease of the nipple is a superficial manifestation of an underlying breast carcinoma. It presents as an eczema-like condition of the nipple and areola, which persists despite local treatment.. If left, the underlying carcinoma will sooner or later become clinically evident. us Yumra More recently, histological descriptions have been used, and with the increasing application of molecular markers, it is likely that much more information about an individual tumour will be routinely reported, such as its likelihood of metastasis and to which therapeutic agents it will be susceptible. There are specific gene signatures that correlate with response to chemotherapy or poor prognosis. Staining for oestrogen and progesterone receptors is now routine, as their presence will indicate the use of adjuvant hormonal therapy. Tumours are also stained for a specific growth factor receptor (Her-2 )as patients who are positive can be treated with the monoclonal antibody. The spread of breast cancer Local spread It tends to involve the skin and to penetrate the pectoral muscles and even the - - chest wall if diagnosed late. > - Lymphatic metastasis The most (85 commonaixillary (N) % & Lymphatic metastasis occurs primarily to the axillary and the - > internal mammary lymph nodes(posterior one-third ). The involvement of lymph nodes is a marker for the metastatic potential of that tumour. Involvement of supraclavicular nodes and of any contralateral lymph nodes represents advanced disease. Spread by the bloodstream It is by this route that skeletal metastases occur, (lumbar vertebrae, femur, thoracic en vertebrae, rib and skull). Metastases may also commonly occur in the liver, lungs and brain. Lobulal is mas ins ↳ by chance - > 19 histophelto & $10 ↳ tissue Lobular 11 Treatment => Just 3 Lobe I di & S - invasive I feature & Two important se bobula , & o righty left ? Is local inscion O is es left sity Im 53 Gright ?ue : in & ductal S - right - invasive left : &. Clinical presentation Breast cancer is found most frequently in the upper outer quadrant. Most breast cancers will present as a hard lump, which may be associated with indrawing of the nipple or overlying skin. peau d’orange or frank ulceration ( due to skin involvement). Cancer-en-cuirasse when the disease progresses around and fixed to the chest wall. About 5% of breast cancers in the UK will present with either locally advanced disease or symptoms of metastatic disease. These patients must then undergo a thorough staging evaluation which is important for both prognosis and treatment (systemic hormone therapy or chemotherapy ). In contrast, patients with relatively small tumours ( bret Stage - Cancer It is becoming clear that the biological variables rather than anatomical mapping of tumour that influence outcome and treatment. Therefore, Classical staging of breast cancer by means of the TNM (tumour–node–metastasis) criteria is used nowadays less = often. A pragmatic approach would be to classify patients according to the treatment that they require. To IM gol TIM No , S do - Prognosis of breast cancer The prognosis of a cancer depends not on its chronological age but on its invasive and metastatic potential. Inspite of that, the best indicators of prognosis in breast cancer remain tumour size, histological grade , lymph node and hormone receptor status. Distant Distant astage Treatment of cancer of the breast The two basic principles of treatment are to reduce the chance of local recurrence and the risk of metastatic spread. Treatment of early breast cancer will usually involve surgery with or without radiotherapy. Systemic therapy is added if there are adverse prognostic factors such as lymph node involvement. Local treatment of early breast cancer Local control is achieved through surgery and/or radiotherapy. Surgery still has a central role to play in the management of breast cancer but there has been a gradual shift towards more conservative techniques (local excision followed by radiotherapy). Mastectomy is indicated for large tumours (in relation to the size of the breast), central tumours beneath or involving the nipple, multifocal disease, local recurrence or patient preference. The radical Halsted mastectomy is no longer indicated ,whereas the modified radical (Patey) mastectomy is more commonly performed. Simple mastectomy involves removal of only the breast with no dissection of the axilla, In Patey mastectomy The breast and associated structures are dissected en bloc and the excised mass is composed of : the whole breast; a large portion of skin, the centre of which overlies the tumour but which always includes the nipple; all of the fat, fascia and lymph nodes of the axilla. The axillary vein and nerves to the serratus anterior and latissimus dorsi (the thoraco- dorsal trunk) should be preserved. Conservative breast cancer surgery This is aimed at removing the tumour plus a margin of normal breast tissue( wide local excision). The term lumpectomy should be reserved for an operation in which a benign tumour is excised  Quadrantectomy involves removing the entire segment of the breast that contains the tumour. Both of these operations are usually combined with axillary surgery, usually via a separate incision in the axilla. There are various options that can be used to deal with the axilla, including sentinel node biopsy sampling, removal of the nodes behind and lateral to the pectoralis minor (levelII) or a full axillary dissection (level III). There is a somewhat higher rate of local recurrence following conservative surgery, even if combined with radiotherapy , which is more common in younger women and in those with high-grade tumours and involved resection margins. Local excision of a breast cancer without radiotherapy is associated with an unacceptably high local recurrence rate except in special cases (small node-negative tumours of a special type) The role of axillary surgery is to stage the patient and to treat the axilla. The presence of metastatic disease within the axillary lymph nodes remains the best single marker for prognosis. It is now known that only hormone receptor-positive patients, irrespective of age, benefit from treatment with tamoxifen.