1. 1. 1 | P a g e , , , - , - ( Lymph Nodes) , - , , , , - ( Fine Needle Aspiration Biopsy) (Complete Cure) (micro metastatic disease) - 35-70% , ( , ) ( pectorals major muscle) , - ,
2. 2. 2 | P a g e - 15-20 ( lobes) 20-40 ( lobules) () - , (Lactiferous ducts) 10 , ( Nipple) ( Areola) 25 , , , 1.4 14 (Infiltrating ductal carcinoma) 75% (lobular carcinoma in situ ) 2.8% (Infiltrating Lobular Carcinoma) 15% (Tubular Carcinoma) 1-2% 1-2% (Pagets Disease) 1-4% (Prognosis)
3. 3. 3 | P a g e (Axillary lymph node) (Histologic grade) (e.g. tubular, mucinous [colloid], papillary) (ER/ PR status) HER2 HER2 / (gene amplification / over expression) (Axillary lymph node) ( Axillary lymph node) , 10 70 % 5 (Recurrence rate) 19% 5 1-3 - 30-40% 4-9 44-70% 10 72-82% ( tumor) (histological grade), HER2 5 0 99-100% I 95-100% II 86% III 57% IV 20%
4. 4. 4 | P a g e (Presentation) (History) - 5 % , o o o o (Ductal carcinoma in situ DCIS) o (Lobular carcinoma in situ LCIS) (Benign Breast Disease) -(Radial scar) (Physical Examination) , o o , o ,
5. 5. 5 | P a g e o o (Axilla) (peau d'orange) - o o o o o - (pectoral muscle) , (Collar Bone) (supraclavicular fossa), , - ( Metastasis) (Breathing difficulties) (Localizing neurologic signs) ( Altered cognitive function)
6. 6. 6 | P a g e (Differential Diagnoses) , (cysts), , (metastasis to the breast from other primary sites) , (inflammatory carcinoma) (mastitis) (Dilatation), , (duct etresia) (fibrocystic disease) (Diagnosis) , (imaging) - (Biopsy) ? ? http://www.cpaaindia.org/infocentre/acs/hin/How%20to%20CheckBreast_Template.pdf - - , 1-2 100 ( Microcalcifications) , , , , , , ,
7. 7. 7 | P a g e ... , ... -1, -2 3- ... (suspected multifocal or bilateral tumor) (PET Scanning) , ( 18 FDG) , ( vascularization), ( receptor status) ( recurrences in scarred breasts), , ( axillary involvement), (systemic metastases) HER2 (Receptor Protein) , HER2/neu -2 (HER2-positive) -2 ( human epidermal
8. 8. 8 | P a g e growth factor) -2 5 1 -2 -2 , 20 % - -- (IHC) -( FISH) - --(IHC) -2 -2 0 +3 0-1+ ( Negative HER2) -2 -2 2+ (Equivocal HER2) -2 -( FISH) -2 3+ (Positive HER2) -2 -(FISH) HER2/neu ( ) ( , ) Staging (T),( lymph node) (N), (M) (T) Tx:
9. 9. 9 | P a g e T0: Tis: (DCIS) (Ductal Carcinoma in situ) Tis: (LCIS) (Lobulated Carcinoma in situ) Tis: (Paget disease associated with a tumor is classified according to the size of the tumor.) T1: 2 .. T1mic: 0.1 .. T1a: 0.1 .. 0.5 .. T1b: 0.5 .. 1.0 .. T1c: 1.0 .. 2.0 .. T2: 2.0 .. 5.0 .. T3: 5.0 .. T4: o T4a: (pectoralis muscle) o T4b: ( (peau dorange) o T4c:T4a T4b o T4d: (Inflammatory disease) (N) Nx: N0: N1: (ipsilateral axillary lymph nodes) (movable)
10. 10. 10 | P a g e N2: (ipsilateral axillary lymph nodes) ( ipsilateral internal mammary nodes) o N2a: (ipsilateral axillary lymph nodes) o N2b: (ipsilateral internal mammary nodes) N3: ( ipsilateral infraclavicular or supraclavicular lymph nodes) , ( ipsilateral internal mammary nodes) N3a: (ipsilateral infraclavicular lymph nodes) N3b: ( ipsilateral infraclavicular lymph nodes) N3c: ( ipsilateral supraclavicular lymph nodes) ( Bone), (Liver), (Brain) (Lung) Mx: M0: M1: 0: 99-100% I: 95-100% II: 86% III: 57% V: 20%
11. 11. 11 | P a g e - , -2 Stage Tumor Node Metastases Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 T1 T2 N1 N1 N0 M0 M0 M0 Stage IIB T2 T3 N1 N0 M0 M0 Stage IIIA T0 T1 T2 T3 N2 N2 N2 N1-2 M0 M0 M0 M0 Stage IIIB T4 T4 T4 N0 N1 N2 M0 M0 M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1 2011 NCCN - (stages I II) CBC ( DLC ) (LFTs) (LFTs) III -, , (Pelvis) - carcinoembryonic antigen CEA CA15.3 CA27.29 BRCA1 BRCA2 (Breast Biopsy) (VACNB) - (Histology)
12. 12. 12 | P a g e ... - (Vascularisation) (Tumor Necrosis) - - , I 10 85% III 10 45% Score 1 2 3 A. Tubule formation >75% 10-75% < 10% B. Mitotic count per high-power field (microscope field-dependent) < 7 7-12 >12 C. Nuclear size pleomorphism Near normal Little variation Slightly enlarged Moderate variation Markedly enlarged Marked variation Grade I cancer if the total score (A + B + C) is 3-5 Grade II cancer if the total score (A + B + C) is 6 or 7 Grade III cancer if the total score (A + B + C) is 8 or 9 (Ductal Carcinoma in-situ) (DCIS) DCIS 64000 DCIS ( malignant epithelial cell) ( basement membrane)
13. 13. 13 | P a g e - , , , DCIS 90% (Lobular carcinoma in-situ) -( mammary lobules) , , -2 25 LCIS 2.8 100,000 (70-80 %) 20 (DCIS) , (Invasive Lobular Carcinoma) 5-10% 5%
14. 14. 14 | P a g e 5% A B AB A -2 1-2% (epithelial cells) , (atypical cytoplasm) well-differentiated carcinoma 10% 1-4% ( nipple-areola) ( basement membrane) , (hyperchromatic) (unilateral) -, , , , ( estrogen-receptor- positive) ( lymph-node-negative )
15. 15. 15 | P a g e ... , (Genome Essay) 21 ... (RNA) (recurrence score) 0 100 18 18-31 , 31 (Axillary lymph node dissection) (axilla) 10-40 (20 ) - - (Sentinel lymph node biopsy) ( Sentinel lymph node biopsy) , (sentinel node) / - (sentinel node)
16. 16. 16 | P a g e ( sentinel node) , (resection), , , - (Breast Reconstruction) ( sentinel lymph node biopsy) ( axillary lymph node dissection) - -(Lumpectomy) (Quadrantectomy) - ( re-excision) -
17. 17. 17 | P a g e I II - - 70 2 .. - - - -(Mastectomy) - -(Simple Mastectomy) , ( Pectoral muscle) - (total mastectomy) (double mastectomy) - -( Skin-sparing Mastectomy) , , - , -(Modified radical mastectomy)
18. 18. 18 | P a g e -(Radical mastectomy) , ( pectoral muscles) - (Modified radical mastectomy) (Axillary lymph node dissection) (axilla) 10-40 (20 ) - - (Sentinel lymph node biopsy) ( Sentinel lymph node biopsy) , (sentinel node) / - (sentinel node) ( sentinel node)
19. 19. 19 | P a g e ( ) ( cycles) - (recovery period) (Adjuvant chemotherapy) , - - , (Neoadjuvant chemotherapy) , , (Chemotherapy for advanced breast cancer) , , ? - (combinations) - CMF: , 5-(5-FU)
20. 20. 20 | P a g e CAF (or FAC): , (Adriamycin), 5-(5- FU) AC: (Adriamycin) EC: (Ellence) TAC: (Taxotere), (Adriamyci), AC T:(Adriamycin) - (Taxol) or (Taxotere) [ (Herceptin) HER2/neu ] A CMF: (Adriamycin), CMF CEF (FEC): , , 5-(5-FU) ( ) TC: (Taxotere) TCH: , , (Herceptin)HER2/neu , , , , , , -2 http://chemoregimen.com/Breast-Cancer-c-30-41.html - , - - ( hair follicles) , (Loss of Hunger and over eating) (Nausea and Vomiting) ( )
21. 21. 21 | P a g e ( ) ( ) (Bone loss) (osteoporosis) - - ( ) , ( ) , , , , , , , , -, ( cardiomyopathy) , , MUGA ... , , , , ,
22. 22. 22 | P a g e , ( ) , - , , -2/ () 5 -2 / HER2 () - , -2 / (Growth) -2 ( risk of recurrence) 75 -2 , , , , , , (Congestive heart failure)
23. 23. 23 | P a g e , , -2 , , , , , , , , CEA, CA15.3, CA27.29 60-70% CA15.3, CA27.29 CEA 40% CEA, CA15.3, CA27.29 , ... ... , (Circulating tumor cells) ... , - (ER-positive cancers) / (PR- positive cancers) /
24. 24. 24 | P a g e , (metastatic breast cancer) , , , , (mood swings) , ( endometrial cancer and uterine sarcoma) ( deep venous thrombosis or DVT) ( pulmonary embolism or PE) , , - DVT (, , ) ( heart attack) , 2-3 5 5 5 5
25. 25. 25 | P a g e , , - (osteoporosis and even fracture) -( lumpectomy) -( total mastectomy) (sentinel lymph node dissection) , 75 % ( conventional external beam radiotherapy EBRT) (partial-breast irradiation PBI) EBRT 50-55 Gy 5-6 - , , ( desquamation) , , (fibrosis) ( hyperpigmentation) , (fibrosis), (partial-breast irradiation PBI) - ( ) , ( ), ( ) 5 45 DCIS 3 ..
26. 26. 26 | P a g e - - 5 . 4 ( Axillary supraclavicular lymph nodes) 4500-5000 cGy - (carcinoma in-situ) (Ductal carcinoma in-situ) DCIS 30 % - / , 30 % - 40% - (sentinel lymph node) DCIS 5-6 60 % DCIS (Lobular carcinoma in-situ) / - (bilateral mastectomy) / (Axillary Dissection) ,