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
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
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
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
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
26. 26
What elements drive therapy decision
making ?
Prognosis
Treatment
efficacy
Treatment
toxicity
Co morbidity
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
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
BHGI GLOBAL SUMMIT 2005:BHGI GLOBAL SUMMIT 2005:
Guideline StratificationGuideline Stratification
Breast J 2006;12 Suppl 1:S117-120
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
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
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
NCI Most Common Sites in Males andNCI Most Common Sites in Males and
femalesfemales
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
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
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
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
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
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
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
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1. Breast Cancer: Worldwide Incidence in Females
Breast cancer is the third most frequent cancer worldwide and the most common malignancy among women (21% of all new cancer cases). Incidence rates are high in all developed countries, except Japan, and highest in North America with 86.3 cases per 100,000. Incidence rates for selected countries are shown on the map.
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16. Breast Cancer: Signs and Symptoms at Presentation
Although the use of mammography is increasing, more than 80% of all breast cancers are still diagnosed as a result of symptoms, most often a painless mass. However, as many as 10% of patients present with breast pain and no mass. Less common symptoms include nipple discharge, nipple erosion or ulceration, diffuse erythema of the breast, axillary adenopathy, and symptoms associated with distant metastases.
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22. Breast Cancer: Diagnosis Path
Any dominant breast mass lesion should be biopsied.
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This slides summarize the real problem, 3 standards all pretending the classification low-high risk
Three gold standards makes it a little bit busy and to be spoilt for choice highlights the real issuethat the gold standard is not that shiny at all, not to mention all local adapted variants on these standards
Also if ones wander away from the standard one enters non validated territory
Maybe it is time for one new gold standard?
MammaPrint?