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THE BREAST Dr.JAMIL SAWAKED. LATISSIMUS DORSI TERES MAJOR SERRATUS ANTER ANATOMY.

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Presentation on theme: "THE BREAST Dr.JAMIL SAWAKED. LATISSIMUS DORSI TERES MAJOR SERRATUS ANTER ANATOMY."— Presentation transcript:

1 THE BREAST Dr.JAMIL SAWAKED

2 LATISSIMUS DORSI TERES MAJOR SERRATUS ANTER ANATOMY

3

4 RIBS &intercost.m PECTORALIS MAJOR FAT LOBE AMPULLA 20 MAJOR LACT.ORIFICES LACTOCYTE MAJOR LACT.DUCT IS THE SITE OF DUCTAL CA.

5 THEIR CONTRACTION CAUSES SKIN DIMPLING PEAU d`ORANGE IS DUE TO OEDEMA OF SKIN LYMPHATIC

6 DUCT SYSTEM MAJOR DUCT

7 MINOR] OR [MINOR] OR TERMINAL [ TERMINAL] MINOR DUCT IS THE SITE OF LOBULAR CARCINOMA

8 INTERNAL MAMMARY L.N. SENTINEL L.N PECTORAL LAT.THOR.V RPOSTERIO LATERAL APICAL 85% OF THE BREAST DRAIN INTO THE AXILLA CENTRAL LONG THORACIC N SUPERIOR THORACIC V. SUBSCAP.V

9 IF IT IS FILLED WITH MILK IT IS GALACTOCELE

10 MASTITIS; PLUGGED DUCT OR CRACKED NIPPLE,[STAPHYLLOCOCCI] ABSCESS

11 60% OF MASTITIS IN LACTATING WOMEN 60% OF MASTITIS IN LACTATING WOMEN

12 TYPES OF MASTITIS TYPES OF MASTITIS  MASTITIS NEONATORUM  MASTITIS OF PUBERTY  LACTATING MASTITIS  SPECIFIC MASTITIS;  1-T.B MASTITIS  2-SYPHILITIC MASTITIS  3-ACTINMYCOSIS

13 BENIGN BREAST DISEASE  FIBROADENOMA  FIBROCYSTIC DIS  DUCTECTASIA  BENIGN CYSTS  LIPOMA:VERY RARE [DANGEROUS TO DIAGNOSE LIPOMA] [DANGEROUS TO DIAGNOSE LIPOMA]

14 FIBROADENOMA BREAST MOUSE SMALL ONES COULD BE LEFT ALONE

15

16 Giant fibroadenoma> 5 CM CAN BECOME MALIGNANT

17 DUCTECTASIA

18 CYSTOSARCOMA PHYLLOIDES  THOUGHT TO BE MALIGNANT [NOTICE THE NAME] BUT IT IS NOT. MAY REACH HUGE SIZE &ULCERATE HOWEVER THERE ARE WORRYING MITOTIC FIGURES SOMETIMES DENOTING MALIGNANT POTENTIAL

19 FIBROCYSTIC DISEASE[ANDI]

20 BLUE DOMED CYST

21 WHEN A BENIGN BREAST DISEASE BECOMES WORRYING?  WHEN A PATHOLOGY SPECIMEN SHOWS ATYPICAL HYPERPLASIA SHOWS ATYPICAL HYPERPLASIA  FLORID HYREPLASIA CARRIES AMILD RISK  NB;METAPLASIA AND MILD HYPERPLASIA CARRY AND MILD HYPERPLASIA CARRY NO RISK NO RISK

22 CYSTS  ANDI  LYMPHATIC CYSTS  HYDATID CYST  GALACTOCELE  SEROCYSTIC DISEASE OF BRODIE  INTRACYSTIC PAPILLIFEROUS CA  COLLOID DEGENERATION OF CA.  PAPILLARY CYSTADENOMA

23 CYSTS  BENIGN  MALIGNANT MANAGEMENT OF A CYST MANAGEMENT OF A CYST ASPIRATE & OPERATE OR CORE BIOPSY IF; 1-BLOODY ASPIRATE 2-DID NOT DISAPPEAR COMPLETELY AFTER ASPIRATION 3-RECURES IN 6 WEEKS

24 NIPPLE DISCHARGE  I=NONBLOODY; 1-FIBROCYSTIC DISEASE 1-FIBROCYSTIC DISEASE 2-DUCTECTASIA 2-DUCTECTASIA  II=BLOODY; 1-DUCTECTASIA; COMMON 1-DUCTECTASIA; COMMON 2-DUCT PAPILLOMA; MOST COMMON 2-DUCT PAPILLOMA; MOST COMMON 3-DUCT CARCINOMA;VERY RARE 3-DUCT CARCINOMA;VERY RARE

25 BLOODY NIPPLE DISCHARGE BLOODY NIPPLE DISCHARGE

26 NORMAL DUCT DUCT PAPILLOMA

27 MICRODOCHECTOMY FOR BLEEDING NIPPLE MICRODOCHECTOMY FOR BLEEDING NIPPLE BLEEDING SEGMENT IS REMOVED AND SUBMITTED TO HISTOPATHOLOGY PROBE DETERMINE FIRST WHICH ORIFICE OR SEGMENT IS BLEEDING BY PRESSING AROUND THE AREOLA

28 BREAST CANCER 1.DUCTAL CARCINOMA [90%] 2.LOBULAR CARCINOMA[<10%] 3.PAGET`S DISEASE 4.INTRACYSTIC PAPILLIFEROUS CA 5.SARCOMA

29 What Are the Risk Factors for Breast Cancer?  1-Age; INCREASING AGE  2-Race;WHITE++.RARE IN JAPAN,  3-Individual or family history of breast cancer  4-A history of ovarian cancer  5-A genetic predisposition (mutations to the BRCA1 or BRCA2 genes cause 2% to 3% of all breast cancers)  6-Estrogen exposure;MENARHE,MENOPAUSE  7-Atypical hyperplasia of the breast  8-Lobular carcinoma in situ (LCIS)  9-Lifestyle factors (obesity, lack of exercise, alcohol use)  10-Radiation  1-Age; INCREASING AGE 25:1/20, :1/ :1/50. 55:1/33. 60:1/24. 80:1/10. 25:1/20, :1/ :1/50. 55:1/33. 60:1/24. 80:1/10.  2-Race;WHITE++.RARE IN JAPAN,  3-Individual or family history of breast cancer  4-A history of ovarian cancer  5-A genetic predisposition (mutations to the BRCA1 or BRCA2 genes cause 2% to 3% of all breast cancers)  6-Estrogen exposure;MENARHE,MENOPAUSE  7-Atypical hyperplasia of the breast  8-Lobular carcinoma in situ (LCIS)  9-Lifestyle factors (obesity, lack of exercise, alcohol use )  10-Radiation

30 About 15%?[3-15]of breast cancers are inherited Approximately 80% of hereditary breast cancer is caused by mutations in the BRCA1 or BRCA2 genes.P53 has a role too Women who inherit a BRCA mutation have a 50% to 85% chance of developing breast cancer in their lifetime Women with especially strong family history may consider preventive surgery to remove breast tissue and/or chemoprevention Several other genetic syndromes can increase breast cancer risk

31 SITES LT.BREAST 60% 12% 10% 6% 12% RT.LT

32 MODE OF SPREAD OF DUCTAL CARCINOMA MODE OF SPREAD OF DUCTAL CARCINOMA  LOCAL  LYMPHATIC  BLOOD; BONE SOFT TISSUE 1-LUMBER V. 1-LIVER 1-LUMBER V. 1-LIVER 2-FEMUR 2-LUNG 2-FEMUR 2-LUNG 3-THORAC V. 3-BRAIN 3-THORAC V. 3-BRAIN 4-RIBS 4-KIDNEY 4-RIBS 4-KIDNEY 5-SKULL 5-ADRENALS 5-SKULL 5-ADRENALS

33 DIAGNOSIS DIAGNOSIS TRIPLE ASSESSMENT TRIPLE ASSESSMENT  1-CLINICAL: A-AGE. B-EXAMINATION B-EXAMINATION  2-IMAGING : A-US. B-MAMMOGRAM B-MAMMOGRAM  3-PATHOLOGY: A-FNA. B-CORECUT B-CORECUT

34 FNA & CORECUT FNA & CORECUT  FNA [CYTOLOGY EXAMINATION] HAS 5% FALSE –VE MOSTLY DUE TO SAMPLING ERROR SAMPLING ERROR  CORECUT [TRUCUT] IS A TISSUE HISTOPATHOLOGY THAT IS MORE ACCURATE AND TELLS YOU ABOUT THE GRADE & INVASIVENESS; IN-SITU OR INVASIVE THE GRADE & INVASIVENESS; IN-SITU OR INVASIVE

35 MAMMOGRAM MAMMOGRAM MALIGNANT MALIGNANT  1-CALCIFICATION; CLUSTER[5-6] OF BRANCHED FINE MICROCALCIFICATION CLUSTER[5-6] OF BRANCHED FINE MICROCALCIFICATION  2-ARCHITECTURAL CHANGES; SPIKY DENSE IRREGULAR MASS SPIKY DENSE IRREGULAR MASS BENIGN BENIGN WELL DEFINED ROUNDED MASS WITH HALO SIGN; CYST,FIBROADENOMA

36 MAMMOGRAM CONVENTIONAL & DIGITAL CONVENTIONAL & DIGITAL  IT IS NON USED FOR YOUNGER WOMEN BECAUSE THEIR DENSE BREAST TISSUE GIVES FALSE POSITIVE RESULTS  BUT IT IS GOOD FOR THE SOFT BREASTS BECAUSE THE GLANDULAR TISSUE IS SEPERATED BY FAT PLANES

37

38 FIBROADENOMA ON MAMMOGRAM

39 MRI IS THE MOST SENSITIVE IS THE MOST SENSITIVE 1- CAN PICK UP CARCINOMA IN-SITU 2- DIFFERENTIATES BETWEEN LOCAL RECURRENCE AND FIBROSIS

40 MRI  NO RADIATION BUT MAGNETIC FIELD  1-CAN VISUALIZE A PALPAPABLE MASS WHICH IS NOT SEEn ON U/S OR MAMMOGRAM  2-CAN BE USEFUL IN YOUNG WOMEN  3-CAN LOCATE BREAST CANCER WITH AXILLARY L.N. METS BUT BREAST FREE ON US OR MAMMOGRAM  4-CAN DETECT MULTICENTRIC LESION  5-CAN DIFFERENTIATE BETWEEN RECURRENCE AND FIBROUS TISSUE  6-CAN DETECT SILICON LEAK  DISADVANTAGES  1-CANNOT DETECT CALCIFICATIONS  UBOS:UNIDETIFIED BRIGHT OBJECTS  DISLODGE CERTAIN METALS;RACEMAKER  EXPENSIVE

41 POSITRON EMISSION MAMMOGRAM SHOWS [MULTIFOCAL LESION] POSITRON EMISSION MAMMOGRAM SHOWS [MULTIFOCAL LESION]

42 RETRACTED BREAST

43 SWOLLEN BREAST WITH NIPPLE RETRACTION

44 CANCER EN-CUIRASSE درع المحارب MULTIPLE LOCAL RECURRENCE

45

46 LYMPHOEDEMA COMBINATION OF SURGERY &RADIOTHERAPY ON THE AXILLA CAN CAUSE THIS

47 Axillary venous thrombosis in ca. breast Axillary venous thrombosis in ca. breast

48 DIFF.DIAGNOSIS OF MASTITIS & MASTITIS CARCINOMATOSA DIFF.DIAGNOSIS OF MASTITIS & MASTITIS CARCINOMATOSA MASTITIS CARCINOMATOSA MASTITIS CARCINOMATOSA [INFLAMMATORY CARCINOMA] [INFLAMMATORY CARCINOMA]  IS THE MOST MALIGNANT OF ALL BR. CA.  MASTECTOMY IS RARELY INDICATED BECAUSE IT IS LATE  NO CONSTITUTIONAL SYMPTOMS  NO FEVER  NO LEUCOCYTOSIS  SKIN OEDEMA > 1/3 OF THE BREAST  IN BOTH THE BREAST IS WARM,TENDER  BOTH OCCUR IN CHILD BEARING PERIOD  DIFFICULT TO DISTINGUISH SOMETIMES EXCEPT BY CORECUT BIOPSY.  US & MAMMOGRAM ARE USELESS BECAUSE THERE IS NO MASS

49 DIFF.DIAGNOSIS OF PAGET`S DISEASE &ECZEMA OF THE NIPPLE DIFF.DIAGNOSIS OF PAGET`S DISEASE &ECZEMA OF THE NIPPLE PAGET`S DISEASE PAGET`S DISEASE  THERE IS AN UNDERLYING BREAST CANCER  UNILATERAL  NIPPLE DESTRUCTION  BOUNDRIES OF THE LESION IS WELL DEMARKATED DEMARKATED  DOES NOT RESPOND TO STEROID LOCAL THERAPY

50 PAGET`S DISEASE OF THE BREAST

51

52 LOBULAR CARCINOMA ARISE FROM THE TERMINAL DUCTS COULD BE MULTIFOCAL.IT IS BILATERAL IN 20% OF CASES IN UNILATERAL CASES ALWAYS WATCH THE OTHER BREAST LCIS DOES NOT NEED FURTHER ACTION EXCEPT CAREFUL F.U

53 Carcinoma in pregnancy  THEY ARE DIAGNOSED LATE  THEY BEHAVE THE SAME AS NON-PREGN.  THEY ARE TREATED THE SAME  NO BREAST CONSERVING SURGERY  NO RADIOTHERAPY;TERATOGENIC  NO CHEMOTHERAPY IN THE FIRST TRIMESTER  NO HORMONAL THERAPY;BECAUSE THEY ARE HORMONE RECEPT.-VE THEY ARE HORMONE RECEPT.-VE

54 STAGES OF CA. BREAST MASS<2CM. NO L.N. MASS2-5CM.MOB.L.NMASS5-10CM.FIX.L.N OR MASS FIXED TO CHEST WALL SUPRACLAV.L.N.OR DISTANT METS CIS STAGE 0 CARCINOMA IN SITU CONFINED TO BASEMENT MEMBRANE. NON INVASIVE. CLINICALLY; IMPALPABLE I IIIIII IV

55 DCIS & LCIS DCIS & LCIS

56

57 SolidCribiformPapillary Comedo Vascular and Lymphatic Invasion Non-Invasive (In Situ) Cell Growth Subtypes: COMEDO:ACNE

58 INVESTIGATIONS FOR DISTANT METASTASIS INVESTIGATIONS FOR DISTANT METASTASIS  BLOOD S.ALK.PHOSPHATASE S.ALK.PHOSPHATASE GGT[Gamma Glutamin Transferase] GGT[Gamma Glutamin Transferase]  RADIOLOGY CXR CXR US;Liver US;Liver  NUCLEAR ISOTOPE BONE SCAN ISOTOPE BONE SCAN

59 WHAT DOES STAGING MEAN  STAGE I & II :EARLY BREAST CANCER [POTENTIALLY CURABLE DISEASE] [POTENTIALLY CURABLE DISEASE]  STAGE III & IV : ADVANCED CANCER [INCURABLE DISEASE] [INCURABLE DISEASE]

60 WHAT IS THE MOST SIGNIFICANT PROGNOSTIC FACTOR ?  AXILLARY LYMPH NODES INVOLVEMENT & NUMBER;IS THE MOST  NO L.N; 85% 5-YEAR SURVIVAL  3 L.N. ; 50%  >3L.N. : 25-40%  OTHER FACTORS  1-GRADE,2- -VE HORMONE RECEPTORS,3-SIZE, 4-VASCULAR&LYMPH.INVASION, 5-HER 2, 6-EPIDERMAL GROWTH FACTOR 4-VASCULAR&LYMPH.INVASION, 5-HER 2, 6-EPIDERMAL GROWTH FACTOR

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62 MANAGEMENT OF EARLY BREAST CANCER  BREAST CONSERVING SURGERY: WIDE LOCAL EXCISION + AXILLARY WIDE LOCAL EXCISION + AXILLARY CLEARANCE+ LOCAL BREAST RADIOTHERAPY CLEARANCE+ LOCAL BREAST RADIOTHERAPY PROVIDED MASS BREAST RELATION IS ACCEPTABLE

63 INDICATIONS OF MODIFIED RADICAL MASTECTOMY 1. BIG SIZE TUMOUR IN REALATION TO THE BREAST 2.CENTRAL TUMOUR; UNDER THE NIPPLE 3.MULTIFOCAL TUMOUR 4. RECURRENCE AFTER LUMPECTOMY 5. PATIENT`S PREFERENCE

64 Sentinel node biopsy is a technique which helps determine if a cancer has spread (metastisized), or is contained locally. When a cancer has been detected, often the next step is to find the lymph node closest to the tumor site and retrieve it for analysis. The concept of the "sentinel" node, or the first node to drain the area of the cancer, allows a more accurate staging of the cancer, and leaves unaffected nodes behind to continue the important job of draining fluids. The procedure involves the injection of a dye (sometimes mildly radioactive) to pinpoint the lymph node which is closest to the cancer site. Sentinel node biopsy is used to stage many kinds of cancer, including lung and skin (melanoma). Sentinel node biopsy

65 WHAT IS MODIFIED RADICAL MASTECTOMY WHAT IS MODIFIED RADICAL MASTECTOMY A.VEIN Apical Lateral INTERPECTORAL POSTERIOR CENTRAL LONG THORACIC N. SHOULD BE PRESERVED INTERCOSTO- BRACHIAL N. CAN BE SACRIFIED

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67 WHAT IS THE DIFFERENCE BETWEEN THE 2  NO DIFFERENCE IN 5-YEAR SURVIVAL  THERE IS A DIFFERENCE IN LOCAL RECURRENCE  RECURRENCE AFTER LUMPECTOMY IS MORE.TREATED BY MASTECTOMY IS MORE.TREATED BY MASTECTOMY AND THEY DO BETTER AND THEY DO BETTER

68 THE OTHER MODALITIES  CHEMOTHERAPY;== CMF == 1-ADJUVANT & 1-ADJUVANT & 2-NEOADJUVANT 2-NEOADJUVANT  HORMONAL THERAPY; TAMOXIFEN: OESTROGEN BLOCKER LHRH : OVARIAN ABLATION TAMOXIFEN: OESTROGEN BLOCKER LHRH : OVARIAN ABLATION ANASTROZOLE: AROMATASE INHIBITOR INHIBIT ANASTROZOLE: AROMATASE INHIBITOR INHIBIT CONVERSION OF ANROGENS TO OESTROGEN CONVERSION OF ANROGENS TO OESTROGEN  IMMUNE THERAPY; HERCEPTIN [monoclonal antibody] ANTI-HER2  RADIOTHERAPY; LOCAL ACTION

69 BIOLOGICALLY TARGETED THERAPY  MONOCLONAL ANTIBODY ATTACHED TO PROTEIN MOLLECULE ON THE SURFACE OF CANCER CELL TO SLOW ITS GROWTH  ANGIOGENESIS INHIBITOR  SIGNAL TRANSDUCTION INHIBITOR

70 Port-a-cath for systemic chemotherapy Port-a-cath for systemic chemotherapy Chemotherapy kills all dividing cells [malignant or not malignant].so bone marrow GIT and skin are affected.

71 HOW TO EXAMINE YOUR OWN BREASTS TEACH PATIENT LOOK AT THE MIRROR NOTE ANY ABNORMALITY IN YOUR BREASTS OR AXILLAE AT EVERY SHOWER

72 USE PALMER ASPECTS OF USE PALMER ASPECTS OF YOUR FINGERS

73 gynecomastia MOSTLY IDIOPATHIC LIVER DISEASE TESTICULA R ATROPHY DRUGS

74 MALE BREAST CANCER THE SAME LIKE FEMALE BREAST PATHOLOGY & MANAGEMENT BUT THE PROGNOSIS IS WORSE

75 MALE BREAST CANCER


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