BREAST CANCER SCREENING

Ayman Linjawi, MD, FRCSC Consultant General and Oncology Surgery

Founder, CEO, Medical Reference Clinics

Jeddah, Saudi Arabia

متى كان السرطان في موضع يمكن استئصاله كله كالسرطان الذي يكون في الثدي أو في

الفخد ونحوهما من اUعضاء اRتمكنة Oخراجه بجملته ،إذا كان مبتدءاً صغيراً فافعل. أما متى تقدم فa ينبغى أن تقربه فاني ما استطعت أن أبرىء منه أحدا.

وg رأيت قبلى غيري وصل إلى ذلك

كتاب التصريف +ن عجز عن التأليف

أبو القاسم الزهراوي

BREAST CANCER SCREENING

The revolution in breast cancer management happening nowadays is in the early detection of the disease.

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

0 1 2 3 4 5 6 7 8 9 10

Years

Cm

Cm

•  Expected Period of Tumor Growth

BREAST CANCER SCREENING

•  60 to70% of the cases are sporadic. •  20 to 30% are familial. •  Only 5% are due to inheritance of mutated

gene.

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.

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%.

BREAST CANCER SCREENING

•  The chances of doing breast conservative surgery is much more and therefore better cosmetic result.

•  Reduce the need for chemotherapy.

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 ??

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.

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.

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.

DIAGNOSIS OF EARLY BREAST CANCER

•  Ductal lavage by ductoscope or by angiocath introduce through the nipple. Low sensitivity.

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.

BIOPSY OF EARLY BREAST CANCER

stereotactic or

Ultrasound guided needle localization for surgical excisional biopsy

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.

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.

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.

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

INJECTION TECHNIQUES

INJECTION TECHNIQUES

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

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%

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

Montreal General Hospital

Royal Victoria Hospital

Centre universitaire de santé McGill

McGill University Health Centre

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