Mass Triple Assessment

Nebda2 be shewayet general knowledge:

-There are 3 main symptoms in the breast:

*LUMP.
mass: surr strcutures: skin and muscles
*PAIN.
character
relation to surr structures
*DISCHARGE.
lymph nodes
neo adjuvant: beofre surgery: for dec the tumor size if locally advanced to do surgery

-Your working diagnosis is always a malignancy, you always try to exclude malignancy in a breast
patient.
chemo: for the metast (adjuvant)
t4a : skin

t4b: muscles
-We need to preserve kam haga:

*LNs —> sentinel LN biopsy.

*Long thoracic nerve of bell —> nerve to serratus anterior —> will cause winging of scapula if injured.

*Thoracodorsal nerve —> nerve to lattismus dorsi —> we use it in flaps for reconstruction after
removal of the breast.

-We need to know eno el breast feeh 4 quadrants + nipple-areola complex + axillary tail of spence.

*Most common site of malignancy —> upper outer quadrant (breast tissue we glands aktar).

*Most dangerous site of malignany —> inner lower quadrant (infra-diaphragmatic LNs).

*DON’T MISS AXILLARY TAIL OF SPENCE IN RISK REDUCING SURGERY OR IN BREAST

EXAMINATION!!!!!

-Breast met2asem le kaza haga histologically:

*Two major structures —> ducts and lobules.

*Two types of epithelial cells —> luminal and myoepithelial.

*Two typer of stroma —> interlobular (thick & dense) and intralobular.

-TDLU is the lobule + it’s terminal duct.

-It’s the origin of most of breast pathologies (ductal pappiloma, duct ectasia).

-Kol makan bytla3 meno different pathologies:

*Lobules and Terminal ducts —> small duct papilloma, hyperplasia, atypical hyperplasia, carcinoma.

*Large ducts —> duct ectasia, large duct papilloma, paget’s disease.

*Intralobular stroma —> fibroadenoma, phyllodes tumour.

*Interlobular stroma —> traumatic fat necrosis, lipoma, fibromatosis, sarcoma.

-BREAST DAYMAN TAFKERAK FE HAGA ESMAHA LOCO-REGIONAL:

*Loco —> breast glands + nipple-areola complex.

*Regional —> axilla + internal mammary LNs.

Ya3ny benfakar ne manage el etnen ezay sawa, mayenfa3sh nefselhom, ay moshkela fel breast
te2asar 3al LNs we kda fa exclude by sentinel LN biopsy.

 Anatomy of the breast.

rectus abdominas and overlying skin replacing breast
3andena 5 hagat related lel anatomy netkalem 3anhom, we ne3raf law kol wahda fehom bazet
te3melena which presentation aw which disease:
glandular element becomes the main relative to the ct , breast lax
1-Blood supply (arterial).
mammogram <30 ct kteer (dense breast abyad)
glandular tissue >30 white dec due to ct dec and fats inc and easier to interpret
2-Blood supply (venous).

fats absent in males

3-Lymphatic drainage.

consistency: connective tissue

4-Nerve supply.
glandular tissue and duct surrounded by ct which is soft
5-Suspensory ligament of cooper.
ct : interlobular (more firm)

interlobular dense modified sweat glands: 20 lobules (acinar and ducts and ct surronding them)
intralob : soft
1-Blood supply of the breast:
epithelial cells are more in malig high pressure lung metast

*Main blood supply is from the internal mammary artery, which arises from subclavian artery,
internal mammary da byemshy gamb el sternum we beytala3 branches lel breast, we fel akher by2leb

musclophrenic artery we superior epigastric artery 3and el 6th intercostal space.

(RIMA WE LIMA ARE RIGHT AND LEFT INTERNAL MAMMARY ARTERIES).

*Lateral thoracic artery da bytla3 men axillary artery, it supplies pectoralis, serratus, subscapularis ribs
and axillary nodes —> we bytala3 external mammary branch that supplies latral border of the chest.

subscap
*Costocervical trunk and thoracic aorta supplies the breast via lateral branches of posterior artery form
intercostal veins:paravertebral veins: metast to the femur bone common and cns
intercostal arteries.
the 3rd part
ANDI: ABERRATION NORMAL DEV INVOLUSION of the

post menst: follow up attachemnt of the pectoralis fascia: watty: el lesion heyb2a raised
ABERRATION: LA8BATA axillary
-Applied anatomy ba2a:
NORMAL BREAST PREMENST AND POST MENST during the
flap
*Anterior rami mammari ARE THE MOST COMMON CAUSES OF POSTOPERATIVE BLEEDING.

*Medial branches of anterior rami mammari supplies the skin causes skin flap necrosis when injured.

*Lateral thoracic artery supplies pectoralis major, through medial and lateral branches —> injury to
both of them will cause muscle atrophy, we da momken yebawaz el sub-pectoral implant.

*Thoracodorsal branch of subscapular artery is a key vessel in breast reconstruction.

hesrsiptin chemo: epidermal growth factor positive

risk inducing surgery : risk reduction
e2 and p2 and her 2 negative superficial

mastectomy: 2-3rd intercostal
luminal b her2 higher than e 2 : herciptin as ttt

myoepithelial: triplle negative cant define the cell line: worst, mastectomy micrototectomy: if there is bleeding by one side of the niplle
2-Venous drainage of the breast:
myoepithelia for the contrtaction!
*Superficial beins of the breast are proximal to skin and drains axillary, internal mammary and
intercostal vessels.

*Phlebitis to one of these superficial veins causes mondor’s disease, they feel like a cord.

—IT’S IMPORTANT THAT YOU DIFFERENTIATE DIMPLING FROM MONDOR’S DISEASE (mondor’s
bya5od pathway of a vein).—
luminal: respond to est and progest
epidermnal growth factor: her2 : malig

er pr her 2
duct ectasia: elastic tissue

cystic: are from the uctal units no elastic tissue triple negative: very bad prog
do chemo high doses

and mestaectomy
3-Lymphatic drainage of the breast:

Axillary LNs:
-Adjuvant therapy:
3*Apical
5 groups *ALL PATIENTS THAT HAVE DONE BREAST CONSERVING SURGERY. *
SOME patients that have done modified radical mastectomy.
*Medial (Central)
terminal duct lobular : malig 3and el acini aktar
*Lateral (Humeral).
fibroadenoma: intralobular
*Anterior (Pectoral).
extralobular: sarcoma (stroma) barra
collecting duct: duct papilloma(bleeding ), duct ectasia (inflamm)
*Posterior (Subscapular).
adjuvant: luminal markers positive

*Feeh other LNs:

group 2 refer to the photo: anatomic origin for diseases !!!!!!!!
sentinel lns biopsy
—> Rotter’s LNs (between pectoralis major and minor).
if no metast donot do axillary evacuation
—> Internal mammary LNs (mesh bena5od biopsy menha ghaleban, fa it’s important eno ne3mel
3aleha post-operative radiotherapy, specially law conservative surgery).

internal mammary lns : malig: can spread very easy to other side

-Levels of axillary LNs:

*Level 1 —> below and lateral to pectoralis minor.

*Level 2 —> wara pectoralis minor.

below and lateral and behind el pectoralis minor
*Level 3 —> above and medial to pectoralis minor.

WE ALWAYS TRY TO PRESERVE LEVEL 3 AXILLARY LNS.

on the humerus
WE DO NOT REMOVE ANY LN LATERAL TO AXILLARY VEIN!!!!!!

dont remove if there os no deposits in the sentinel

-Sentinel LN biopsy is that you inject dye/radiation into the visible mass or tumour and by radiology
bt3raf awel wahda khadet dye, awel wahda dy el sentinel LN, el heya awel wahda by3ady 3aleha el
lymph drainage, law it’s free of malignant cells, you preserve axilla, law feha malignant cells
bene3mel ‘axillary evacuation’.

*Axillary evacuation dy removal of at least level 1 and 2 LNs, momken 3 bas we try to preserve as
much as we can.

*Lymphedema is one of the worst contraindications of axillary evacuation, specially when we remove
level 3.
if there is sentinel free : hormonal
if +ve : chemo

conservative surgery: chemo and radio

(Lymphedema may be treated by lympho-venous bypass, lymph-grafting omental lymphatic flaps or

excisional procedures).
serratus ant: winging of the scapula

intercostobrachial: t2 lateral perforator

4-Nerve supply of the breast:

*Long thoracic nerve —> serratus anterior —> winging of scapula.

*Lateral pectoral nerve —> supplies pectoralis major.

*Medial pectoral nerve —> supplies pectoralis major and pectoralis minor (important on subpectoral
implant, injury leeh will cause muscle atrophy).

*Thoracodorsal nerve —> lattismus dorsi —> reconstruction.

*Intercostobrachial nerve —> sensory supply, affected by diathermy, ye3mel neuroma and electric
like pain, 3ashan kda we cut the nerve rather than electrocautery.

Cancer en cuirasse

5-Suspensory ligament of cooper.

affected in malignancy: shortened and dimpling of the skin.
It’s the connection between the breast and the overlying skin, skin retraction/dimpling is caused due
to invasion of the ligament of cooper by the malignant cells fa by3mel traction 3al ligament le gowa
—> T4a 3ala tol.

-Sometimes cancer grows along the ligament of cooper —> hay5aly el breast attached fel pectoralis
muscle! By examination hatla2y breast is not mobile along the axis of the muscle!

-Lactation disorders:

*Failure to lactate —> sheehan’s syndrome (post-partum hypopituitarism).

*Delayed onset of lactation —> retained placenta momken te3mel keda due to progesterone
secretion, which suppresses lactattion we momken te3mel post partum heamorrhage.

*Galactorrhea —> mostly during el fetam.

nippple: downards and lateral direction for examination

retracted nipple: antenatal peroid: massage for the nipple if didnt : lactation problem

montgomery tubercles during pregnancy

adjuvant: for all patients

 Benign diseases of the breast.

Aham kelma fel breast disease be shakl 3am TRIPLE ASSESSMENT:

*Clinical (history and exam).

latational mastitis is very common
*Imaging (US & mammography).
terminal lobular ductules: carcinoma
*Pathology (core biopsy).

-Benign diseases of the breast:

eg: absence of breast multiple nipples
1-CONGENITAL ANOMALIES (4 diseases).

2-ANDI (abberations of normal breast development and involution):

*Relation to development.

*Relation to cycle.

fibroadenoma young ladies : breast mouse: very mobile

*Relation to menopause/involution.
fibroadenosis: nodular tender breast - young
3-NON ANDI.
andi:fibrocystic disease: fibroadenosis

ANDI dol el howa hagat physiological bas btb2a exagerrated awy fa bt3mel bad effect.

1-Congenital anomalies:

Feeh haga esmaha milk line, da starting from the axillary tail we mekamel lehad el groin, momken
yetla3 feeh kaza anomaly.

*Supernumerary nipple (EXTRA NIPPLE IN THE MILK LINE) it’s only a problem if on the bra line.

*Accessory breast tissue (DD lipoma) (Mostly a breast tissue in the axilla)

—> enlarges with hormones (pregnancy).

history
—> reassurance and explanation.

—> surgical excision for symptomatic woman.

—> liposuction +- excision is the best cosmetically.

Can develop malignant and benign diseases zayo zay el breast tissue el3ady.

*Congenital nipple inversion (DD MOHEM AWY FOR MALIGNANCY).

—> Correct spontaneously during pregnancy or can be everted by simple traction.

—> benign nipple retraction is symmetrical, with central horizontal slit.

—> malignant nipple retraction is eccentric not central, can’t be everted manually + other signs
of malignancy.
is it bilateral? ask her?
*Breast hypoplasia (failure of breast to develop).
heyya kda 3alatool?
—> usually unilateral.
very young
—> Poland syndrome is amastia + absent pectoralis muscle.

—> very difficult to treat, will never look perfect be ay surgery!!

—> either breast reduction lel tabe3y aw breast augmentation lel affected aw combination.

2-ANDI:
cyclic?
3alatool? need to be treated and how it respond to nsaids
-Developmental:

Normal Aberration Disease

*Ductal development —> nipple inversion —> subareolar abscess/mammary duct fistula.

*Lobular development —> fibroadenoma —> juvenile fibroadenoma.

large ducts: subareolar
*Stromal development —> hypertrophy —> gigantomastia.
cyclic changes
or

dev problems
-Cyclic:
problems in the involution

Normal Aberration Disease uni? bi? syst in both breasts

*Epithelial activity —> duct papilloma —> bloody discharge.
uni? single duct? or multiple ducts?
color? red? clear? creamy? brownish?

how did you notice it?

spont discharge or by your action ?
-Pregnancy and lactation:

 Normal Aberrate Disease

*Lactation —> galactocele —> mastitis —> breast abscess

retension cyst
infection
-Involution:

Aberration Disease complication such as: fisula at the edge of the areola
Normal
*Dilatation —> ectasia —> periductal mastitis.
major duct excision
large ducts multiple discharge and inflammation affecting the large ducts

-How to differentiate between benign and malignant lesions affecting TDLU?

*Malignant has no lobular pattern.

*Malignant has no apparent myoepithelial component.

cystic or solid is very imp

*Malignant has random proliferating arrangement, with variable size & ONE CELL TYPE.

MONOCLONALITY IS THE HALLMARK OF MALIGNANCY!!

juvenile: fibroadenoma: distorting and dilated veins
-ANDI may affect both TDLU & large ducts:

*TDLU —> fibroadenoma with it’s variants and sclerosing lesions with it’s variants.

*Large ducts —> duct pappiloma.

giagnotomasia: asymm

macromastia: duct and stromal disease very well capsulated and there is fat: bulge out

fibroadenoma: lobular and juvenile

micrototectomy : bleeding per nipple
if all arge ducts: remove all large ducts: major duct excision

ultrasound: for the youn d age
they involute after menopause and inc with taking e2 again
-ANDI:
mri for the older 4ewayya
cut off= 5 cm if > remove it

can be relapsed !
1-Developmental:
cystosarcoma very rapid growing phyllods: very high cellularity , enlarge very fast and stretch
*Lobular development —> juvenile hypertrophy (disease is gigantomastia) / fibroadenoma (juvenile
fibroadenoma is a disease).

*Ductal development (nipple invesrion & subareolar abscess and mammary duct fistula are diseases).

-Fibroadenomatoid hyperplasia —> fibroadenoma men gher mass.

-Fibroadenoma:

To Diabetic
*Arise from TDLU, not monoclonal.

*Hormone responsive, increase in size during pregnancy.

*Giant fibroadenoma = >5cm.

triple assessment : clinical (history), radio, tissue breast biopsy for pathology
birads: 1: benign , 5: malignant , 4: lazem n4oof, 3 : suspicious
-May be pericanalicular or intracanalicular:
hard birads 4 a , tissue not malig yeb2a la2 m4 malig lazem data kafya
*Pericanalicular —> less stroma + rounded epithelial elemnts.

*Intracanalicular —> more stroma + distorted epithelial elements which is stretched and compressed.

Fibroadenoma is considered a problem if it’s large or painful.

-Management of fibroadenoma:
cyclic nodularity both
check the other side first and have the normal feel
*Triple assessment.

*Excised when —> large >4cm / symptomatic (pain, distortion).

*Reassurance when —> <5cm / proved by biopsy / patient refused excision.

Ya3ny men elakher, fibroadenoma mesh bttshal ela law elset 3ayza teshela, aw large >4 / large we
3amla distortion, aw painful, AY HAGA GHER KDA BTTSAB.

Juvenile fibroadenoma —> rapid growth, multiple, bilateral, recurrence.

MUST BE DISTINGUISHED FORM PHYLLOIDS TUMOUR:

—> growth pattern is pericanalicular.

—> epithelial hyperplasia is a more prominent feature.

asymm nidularity persists after menstrual peroid: do triple assessment
history rdaio and patho
*Phylloids tumour: DILATED VEINS.

*Most common in older age (juvenile fibroadenoma is in young age).

*Leaf-like tumour which may arise from fibroadenama, bas stroma feha high cellularity we atypia, we
aslan heya monoclonal! Momken te3mel core biopsy we mat3rafsh tefara2ha 3an fibroadenoma!

*HIGH RECURRENCE RATE.

*CAN TURN INTO MALIGNANCY.

*Rapid growth.

*Skin invasion.

Fel pathology report —> high cellularity inside stroma.

-Management of phylloids tumours:

*Small —> excised with margin of normal appearing breast (1-cm safety margin).

*Large —> mastectomy.

*NO AXILLARY EVACUATION 3ASHAN DY SARCOMA —> NO LN EXTENSION.

ultrasound is the best modality for lns involved or not (axillary)

preserved hilum
2-Cyclical changes:
no preserved hilum: maliganant
*Mastalgia/nodularity (fibrocystic changes).
hyperechoic w hawaleeha rim : so preserved: normal
if not: malignant
*Hypertrophy & nipple discharge.
small size lesions, scar tissue, nulli, implant, lobular

*To differentiate between fibrocystic changes aw any other mass —> begin the examination with
normal breast.

ductogroaphy: for the ductal papilloma

-Ductal paillomas:

*Most common pathological cause of bloody nipple discharge.

*Te3melaha ductography tela2y filling defect.

*Micro docectomy.

mediolateral: pectoralis msucle

3-Involution:
multicentric: lobular cant be detected that well by mammography
*Hyperplasia —> Mild, Moderate, Severe, With Atypia!

*Duct ectasia.
ductal carcinoma: need surgery and i know where its is
lobular: i cant know it can be anywhere
*Nipple inversion.
not completely aspirated spicemen x ray
*CYSTS.
blood conservative surgery is to remove the tumor only
they are dangerous cases to aspirate

other than this reassure

-Breast cysts:
there will be post acoustic shadowing in the simple
*US IS THE MOST IMPORTANT INVESTIGATION.

*May be simple cyst (not a problem).

anechoic and acoustic shadow : benign cyst
irreg and not anech and super irreg: malignant
*May be a complex cyst (gowaha haga) —> symptomatic.
mass

regular and anechoic: simple

axillary lymoh nodes in the axilla
if there is enhancement: simple
*If simple, sebha.
intracystic papilloma: complex
*If complex —> aspirate & send for cytology.

*If it reaccumlates —> aspirate again / removal.

ductal carcinoma in situ : can be plapable or not

*May use danazol for multiple cystic formation.
if not: i will know it by microcalcifications

and no real mass

andi ductal carcinoma in situ
-Duct ectasia:

*Dilatation of the large ducts —> leakage of milk —> inflammation —> plasma cell mastitis.

(Bilateral, multiple ductal discharge, any colour).

*Ttt: Large duct excision (benshel kol el large ducts).

periductal mastitis: young and somkers and diabetics

recurrent chronic inflammation 3aks el malig which have retraction too

Hyperplasia (mild, moderate, florrid, WITH ATYPIA).

Talama weslet le atypia (Relative Risk 5)—> precursor for malignancy —> in situ —> invasive.

duct or lobular

Ductal carcinoma in situ —> 10 times higher risk for invasie ductal carcinoma IN EXACTLY SAME
SITE (MICRO-CALCIFICATIONS).
non inavsive or preinvasive
can be metast

Lobular carcinoma in situ is not taken out dayman, dy different entity.

Lobular carcinoma in situ —> 10 times higher risk for invasive lobular carcinoma IN DIFFERENT
SITES (ANYWHERE IN THE BREAST).

Hanfara2 ezay been DCIS we LCIS?

Biopsy.

-Traumatic fat necrosis:

history of trauma
*History of trauma + solid mass + biopsy.

benign: lipoma

-Inflammatory diseases:
mastitis cord like
*Mondor’s disease —> reassurance and NSAIDS.
superficial thrombphlebitis of the breast
*Acute mastitis —> acute breast pain and tenderness + history of lactation.

May be neonatal, due to infection from the baby (STAPH AUREUS).

-C/P:

*Hot, generalized painful erythema and edema of a segment of the breast.

*Momken ye7sal abscess —> US aspiration of pus —> limited incision.

-Ttt:

*Antibiotics given early to reduce risk of abscess formation (gram +ve and safe in lactation —>
penicillin).

*Antibiotics for 48 hours + no improvement —> ABSCESS —> referral!!

*Suspected abscess —> US —> drain abscess.

*BREAST CANCER SHOULD BE EXCLUDED IN PATIENTS WITH INFLAMMATORY SOLID

LESIONS / DOES NOT RESOLVE BY ANTIBIOTICS.
irreg anaechoic in us

Mastitis carcinomatous da DD mohem awy.

*Fel non-lactational mastitis.

*Fel lactating woman, no response to antibiotic, no response to aspiration or drainage.

Ya3ny history mastitis + NO LACTATION —> MASTITIS CARCINOMATOSIS.

-Antibioma:

Sterile abscess —> antibiotics keter for an abscess —> mass with no bacteria —> SOLID MASS —>
DD CARCINOMA.

-C/P:

*Previous history of mastitis treated with antibiotics.

*Painless swelling, smooth, non-tender, hard, fixed, no involvement to pectoralis and chest wall.

-DD:

*Non-otherwise specified carcinoma.

-Investigation:

*Triple assessment.

-Ttt:

*Excision and late antibiotics.

*Send for histology.

-Gynecomastia:

Idiopathic

*Ttt after >12 months by combination of surgical excision and liposuction.

 Malignant breast disease:

-Risk factors:

-ARM, F, H, FH, Obesity, No lactation/pregnancy.

*A —> age.

*R —> race (caucasians).

*M —> prolonged menstruation (early menarche and late menopause).

*F —> female gender.

*H —> history of breast cancer.

*FH —> family history of breast cancer.

*Obesity.

*No lactation or pregnancy.

-TRIPLE ASSESSMENT.

-Breast cancer may be preinvasive or post-invasive:

*Preinvasive —> DCIS & LCIS.

*Postinvasive —> Local spread & Metz of ductal or lobular.

-Histological types:

*Most common is Ductal NOS —> non otherwise specified (schirrous).

-Breast cancer may be:

ki 67 : core biopsy: infiltrating duct carcinoma which grade:cellular
*Multifocal —> kaza lesion f nafs el lobe.
2: tmm
no3o eh: ductal or lobular
*Multicentric —> kaza lesion f kaza lobe.
lobular tmm
ductal: nos or specific?

er recptors her? ki67

-DCIS:
accordingly adjuvant is there or not
targetive therapy for her 2 positive
*Momken yeb2a

—> Comedo (complete blockage or solid) —> high grade with extensive necrosis.

—> non-comedo —> low grade with no necrosis.

-Invasive carcinoma:

*Ductal carcinoma is the most common.

*DCIS must be removed, cause it has 10x higher risk to be invasive in the same exact area.

*LCIS shouldn’t be removed, cause it has 10x higher risk to be invasive ANYWHERE in the breast.

Lobular can’t be seen ela accidentally be biopsy, E-cadherin mutation —> loss of action, fa they’re
not connected, hard to isolate tumour we hard eno ye3mel mass. Indian file.

postoperative biopsy core: cant detect the lymphovascular invasion

bv with maligant cells inside
0-1 tmm
1-4 suspecious
>4 distant metastasis

lum a: est positive her 2 negative (milk)— hormonal: antiest

lum b: es positive her2 positive
es positive her 2 negative
triple negative myoepithelial poor prog and agressive
inflamm breast cancer: surgery mastectomy
tripple negative: surgery
Molecular subtypes:

Khalena motafeken en ER we PR +ve dy haga helwa 3ashan responsive to hormonal ttt.

Khalena motafeken en HER2 +ve dy haga wehsha 3ashan indication of invasive cancer.

Khalena motafekeen eno HER2 +ve beyb2a responsive le herceptin ka treatment (immunotherapy).

1-Luminal A (ER+ve, PR+ve, HER2-ve, ki-67 <14%) —> BEST PROGNOSIS.

2-Luminal B (ER/PR +ve we momken both, HER2 +ve/-ve, ki-67 >14%) —> prognosis aw7ash.

3-HER2 (ER -ve, PR -ve, HER2 +ve) —> worse prognosis bas ahsan men basal like 3ashan
herpceptin is an option for treatment la2en HER2 positive.

4-Basal-like (ER-ve, PR-ve, HER2-ve) —> worst prognosis 3ashan no option for treatment la
hormonal wala herceptin (immunotherapy) ma3 en HER2 +ve dy haga wehsha bas ben7ebaha fe
7alet eno ER we PR positive 3ashan ne3raf ne3aleg (excessive chemo —> anthracycline).

*ER positive cancers esmohom —> luminal.

*HER2 enriched subtypes —> momken yeb2a ER+ve aw -ve 3ady, most common fel nas el
3andohom TP53 mutation —> LI FRAUMENI SYNDROME.

*Triple negative cancers dol aw7ashhom ‘basal-like’ —> no hormonal therapy, no immunotherapy.

-Triple assessment:

*Clinical.

*Imaging (discussed fe lecture el radiology).

*Biopsy.

-Kelma soghayara 3al imaging:

*Before age of 35 —> US only due to dense breast and risk of radiation, positive mass? MRI!

*After age of 35 —> mammography + US.

-Biopsy:

*Indications for excisional biopsy (teshel elmass elawel ba3d kda teb3ato pathology):

1-Momken nehtag excisional men gher core biopsy khales:

—> can’t tolerate sterotactic technique (el radiologist el by7ot needle makan el microcalcifications).

—> abnormalities close to nipple or chest wall.

—> complex cyst by US.

—> remnants of cyst after aspiration.

—> previous diagnosis of benign + recurrence after suction / growing cyst aw fibroadenoma /
suspicious radiological findings.

2-Momken ba3d ma ne3mel core biopsy nela2y enena mehtagen excisional:

—> Benign + patient 3ayza teshel, >2cm or painful, high risk lesion (ADH, ALH, papillary lesions).

—> Discordance between clinical and radiological and pathological elements (radial scars).

—> Non-diagnostic specimens with radiological calcifications and absent pathological.

Excisional dy el betshel elmass kolo.

Core dy el betshel heta men elmass.

 screening tool is mammo

6 turnout

Inflammatory

Treatment of breast diseases:

period of exposure to estrogen tumor supressor gene

-Risk factors:
kol lamma keber: exposure zad: higher risk

*ARM (age, race, menstruation prolonged —> early menarche and late menopause).

*F, H, FH (Female gender, History of breast cancer, Family history of breast cancer).

*Obesity.
stopping hormonal therapy
*No lactation, no pregnancy.

antiestrogen (risk reduction: antihormonal)

*Radiation therapy abl keda masalan.

pain: benign: cyclic changes : mestalgia

-Emta teshok en feeh germline mutation in a family:

pain and lump, bloody discharge

*Young age.
benign 3alatool:
*Bilaterality.
gynecomastia: retroareolar firm swelling : male any aberration from this : malignant
fibroadenoma and cyst : mobile
*BRCA1, BRCA2, p53.
fibroadenoma very mobile: breast mouse , lobulated within the breast tossue (firm or hard or cystic)
cyst: spherical and mobile (firm or hard due to tenstion) can be painful hard and hemispherical
*Male breast cancer.
hard w kbeera: maligancy

-Momken ne3mel hagat keter to reduce the risk men abl ma ye7sal breast cancer aslan:

*Chemoprevention —> lazem yb2a ER positive, law pre-menopausal tedy tamoxifen aw raloxifen, law
post-menopausal tedy aromatase inhibitor.

*Prophylactic surgery for women with high lifetime risk >35% —> prophylactic bilateral mastectomy
with reconstruction.
maligngnt: do staging after proving by biopsy

locally advanced: skin or muscles attached : neoadjuvant to dec size

metast: chemo
-Risk categories:

*Population risk —> regular screening 3 yearly starting from 50 years.

*Raised risk —> closer screening, law history of breast cancer —> yearly with MRI.

*High risk —> momken genetic testing aw risk reducing surgery.

metastat?
Breast self examination should be done monthly.
BSE early: surgery
locally advanced : neoadjuvant

When to use MRI for screening:

*Family history (BRCA mutation).

*Radiation to the chest between 10-30 years old.

*Li-fraumeni syndrome, cowden’s syndrome / first degree relative be haga men dol.

*Previous breast surgery (fibrous scar).

T:

T1 —> <2 cm.

T2 —> 2-5 cm

T3 —> >5cm.
neodjuvant
T4 —> chest wall invasion, skin invasion, both (T4c), inflammatory breast cancer (T4d).

N:

and compare for both sides

Nx —> can’t be assessed.

N0 —> no LN metz.

N1 —> mobile & ipsilateral.

N2 —> fixed & ipsilateral.

N3 —> level 3, contralateral, supraclavicular.

M:

Mx —> can’t be assessed.

M0 —> no metz.

M1 —> metz.

(THE PRESENCE OF A SINGLE POSTIVIE LN IS THE SINGLE MOST IMPORTANT PROGNOSTIC

FACTOR, THE MOST IMPORTANT FACTOR THAT DECIEDES OF TAKING CHEMOTHERAPY OR
NOT! BY5ALENA NE3MEL AXIALLY EVACUATION)

NO LNS + PROTONCOGENE: CHEMO

STAGING:
ADJUVANT

*Lehad stage 2B —> ya T1,2 + N1 aw a2al, ya3ny wala weselna T3 wala weselna N2 yeb2a ehna fe
TRIPPLE ASSESS: EXAM+HIST, RADIO, PATHO
stage el 2ola.
LATE :
—> Stage el 2ola —> surgery elawel, ba3d kda adjuvant therapy.
SURGERY AND ADJUVANT

*Stage T3, N0, M0.

EARLY: LOCALLY ADVANCED:
NEOADJUVANT
—> Stage el tanya —> momken surgery momken neoadjuvant aw kda.
SUREGRY
SURGERY
*Stage feha T3,4 aw N2,3.
SKIN AND MUSCLES

—> Stage eltalta —> neoadjuvant therapy, then surgery, then momken adjuvant (LOCALLY
ADVANCED).

*Stage feha M1 —> Systemic treatment.

—> Stage elrab3a —> chemo, radio, immuno, hormonal.

preinavsive found in screening

NEOADUVANT: BEFORE ANY AGRESSIVE

INFLAMMATORY CARCINOMA : sample from the skin

inflammatory duct carcinomas (dermal lymohatcis) if positive this is inflamm if induarated i wont feel it
-Types of treatment:

*Breast surgery.
ki67: in core biopsy
*Local —> radiotherapy.
<14 good prognosis
>14: chemo
*Systemic —> hormonal, chemo, immuno.

*LN surgery.
lcis: lobular carcinoma in situ triple negative: poor prognosis

ductal carcinoma insitu can be detected in mamography

invasive lobular: mri , have more metast
-Ttt is tailored le kol case:

*Stages 1 lehad stage 2B —> surgery el awel (kaza type) we momken additional.

lcis: bilateral and in young

*T3 N0 M0 —> both.
w lazem adawwar el nay7a el tanya
*Stage 3 —> neoadjuvant we momken surgery.
antiestrogen tamoxifen***
dcis: heyya carcinoma kda kda
*Stage 4 —> systemic therapy only.

-Early breast cancer —> surgery we momken radio, we 3ashan tedy post operative chemo aw keda
—> prognositc facors (LN).

-Locally advanced or metastatic disease —> systemic to palliate symptoms.

normal
intraductal hyperplasia
-Treatment of early breast cancer:
hyperplasia with atypia and can be without
carcinoma insitu: conservative and donot look for lns
*CURE.
invasive element: look for lns and we do chemo and surgery carcinoma in situ
invasive ductal carcinoma 3addet el bm
*CONTROL LOCAL DISEASE IN THE BREAST AND AXILLA.

*PRESERVE FUNCTION.
T1: <2 cm
t2: 2-5 cm
*PREVENT AND DELAY METZ.
t3: >5 cm

t4 locally adavnced
skin or muscle or both
-Treatment is surgical, tet5ar any surgury 3ala ay asas?
4a: chest
*7asab age, FH, menopausal status, overall health.
ski: 4b
both: c
*Location of the tumour.
inflammatory breast cancer: d
*Prognostic criteria.
n:
n1: ipsilateral mobile

ductal: specific type: better prognosis n2: ipsi and fixed

MUTATION + BREAST CANCER —> BILATERAL MASTECTOMY.
n3: anywhere like deep cervical or contralaterl
m0 and m1

cut off lns: 4

postoperative chemo depend on lns
1-Breast conserving surgery:
lns : n0 no postoperative chemo
*Remove the tumour with 1 cm safety margin + POST-OPERATIVE RADIOTHERAPY IS A MUST.

Bas lazem:

axillary ln is the single best prognostic

—> TUMOUR SIZE LESS THAN 5 CM.

—> MARGINS CLEAR FROM DCIS & INVASIVE CANCER.

—> YOUNGER WOMAN NEED A RADIATION BOOST TO THE TUMOUR (aktar men eltabe3y).

-Absolute contraindications:

*2 or more primary tumours in separate quadrants of the breast.

*Persistant positive margins after surgery.

*Diffuse microcalcifications.

*PREGNANCY (3rd trimester momken 3ashan arabna men delivery).

*History of prior radiation to the breast region.

-Relative contraindications:

*History of scleroderma / Active SLE.

*Large tumour in a small breast.

*Very large or pendulous breasts, (area of radio mesh mekafeya breast).

2-Mastectomy be anwa3ha:

*Simple mastectomy —> used in risk reducing surgery, we LN 7asab el sentinel.

*Modified radical mastectomy (MRM) (Patey’s) —> whole breast + level 1&2 LNs.

*Radical mastectomy —> patey’s + pectoralis muscles (LESS COMMON).

-Kol dol ma3ahom reconstruction:

*Immediate / Delayed.

—> Usually delayed in patients with locally advanced cancer.

-Reconstruction options:

*Tissue expander and implant (synthetic).

*TRAM (transverse rectus abdominins muscle) (MOST COMMON).

*Latissimus dorrsi flaps.

pagets: ductal invasive
multifocal: conservative
*Perforator abdominal flaps.
multicentric: more invasive

-Surgery to axilla:

*Should be performed le ay inoperable breast cancer.

*Large tumours (T3 and above), lazem nesheel level 1,2,3.

-Axillary node clearance:

*Medial to axillary vein, level 1 we 2 kda kda bytshalo, 3 momken 7asab.

*We use sentinel LN biopsy to know to what extent do we remove.

-Adjuvant therapy:

*ALL PATIENTS THAT HAVE DONE BREAST CONSERVING SURGERY.

*SOME patients that have done modified radical mastectomy.

—> high grade tumour.

—> large tumour size >1cm.

—> LN involvement.

—> poor markers (hormone negative we HER2 w kda).

ER & PR positive —> horomonal (tamoxifen, raloxifene, aromatase inhibitor).

HER2 positive —> herceptin.

Chemo keda keda shaghal ma3 kolo.

Basal like —> aggressive chemo (anthracycline).

Treatment of locally advanced disease:

*Law heya invasive due to size —> neoadjuvant (chemo,immuno,hormonal) 7asab el positive
markers, we momken surgery ba3den. (OPERABLE).

*Law heya invasive le sabab invasion fe3lan fa most probably no surgery ela toilet mastectomy
(removal of the breast ka palliation due to discharge and pain). (INOPERABLE).

—> ER and PR positive hormonal ahsan.

—> Post-menopausal hormonal ahsan.

—> HER2 positive herceptin (trastuzumab) ahsan.

*Inoperable —> including inflammatory breast cancer —> systemic therapy.

*Inoperable —> law hat3melaha surgery hateb2a toilet mastectomy aw radiotherapy.

Treatment of advanced metastatic disease:

*HORMONAL IS THE FIRST LINE IF ER AND PR POSITIVE.

*CHEMOTHERAPY IS USED BEZAT IN YOUNGER WOMEN AND THOSE WITH VISCERAL METZ
AND RAPIDLY GROWING TUMOUR. (Ay haga feha vascularity 3alya w keda).

*Local treatmet (for metz —> radiotherapy for painful bony deposits, internal fixation of pathological
fractures).

Indications for radiotherapy fel3omom: (high risk of local recurrence).

1-Breast conserving surgery.

2-Four or more LNs.

3-Tumour >5cm.

4-Positive surgical margins (LCIS, law DCIS kona shelna).

5-Inflammatory breast cancer.

6-Extensive LVI.

—> MOMKEN LOCAL RADIO FOR LNs.

Management of DCIS:

*Local excision, law mesh 7aso e3mel sterotactic.

*Extensive DCIS / multicentric —> mastectomy.

*Momken post-op radio fel local excision bas mesh shart.

Ma3lomat 3amma:

-Toilet mastectomy is palliative resection we dy el surgery elwaheda el bn3melha lel stage 4.

(Fungating mass, discharge, smelly).

-LVI men gher +ve LN —> chemo.

-Ki-67 3aly —> chemo responsive bas more aggressive bardo.

-Any positive LN = chemotherapy.

-Raloxifinne ahsan men tamoxifen ka side effects bezat VTE w kda.

-Incisions:

*Infamamary (mesh bayna).

*Circum-areolar (small or benign).

*Langer’s lines.

*Radial (axillary inscision).

*Smokers, young age, diabetics —> periductal mastitis —> nipple inversion / tel5bat ma3 ectasia fe
old age generations.

*Paget’s da byb2a 3amel eczema like kda 3ashan howa due to DCIS aw invasive cancer.

*Law itchy we serous discharge w young age w lactatinf —> eczema.

*Law older we no lactation we rahet le dermatogist we mastagabetsh.

sma3menavfhr
 conservative breast surgery for all early stages
tnm staging gruping:
early, surgery first, check patho will she have chemo? targeted? hormonal?
any m1 : stage 4 by def
>5 cm size !!
stage 1: very small lesion
ductal carcinoma insitu with micorcalcifications cant have clear safety margin
ay 7aga n2 : kda locally advanced
age: young
early stage breast canecr: surgery
bcs: post operative radiotherapy on the breast : dec local recc
locally advanced: neo
radio and surgery: locoregional therapies
t4d: stage 3
safety region: 1cm by eye
there are lns
multicentric: remove the whole breast modified radical mastectomy
if contra: modified radical mastectomy
2 or more: mltifocal or multicentric : do mrs
pregnant is contra for bsc due to radio
*******DIFFUSED MALIGNANT APPEARING MICROCALCFICATIONS : CONTRA FOR BCS
DO MODIFIED RADICAL MSTECTOMY

loco regional: radio and surgery

systemic: hormonal and chemo
EARLY SHE DID SURGERY BSC
PATHO: INVASIVE AND DCIS
I WILL GO INSIDE AGAIN I HAVE PROBLEM IN resection margins
LOBULAR CARCINOMA IN SITU: DONOT open again !!!!!!
lobular: modified

simple mastectomy: risk reducing surgery if she have the risk factors
modified mastectomy if bcs is contra
bcs
modified: nipple areolar complex removed
7asetha +ve by plapation
axillary evacuation
or us: +ve
previous scars eg biopsy
here axillary clearance
excess skin
if -ve: sye around the tumor in the operation
pectoralis major intact
remove the sentinel ln if +ve : axillary clearance
if not: no axillary evacuation