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BREAST CANCER -most common female cancer -rising by 1% each year, related to financial status * Risk factors: 1) Age

40-50 ) !eogra"hy: less in #ar $ast % lo& income countries ') $arly menarche, late meno"ause (large estrogen history) 4) )ulli"arity, late age of first "regnancy 5) *ral contrace"ti+es, ,-. /) #amily history 0) 1onising radiation 2) 3iet (alcohol, smo4ing, high fat diet) * Genetics: -5-6A-17 (5-10% breast ca): high life-time ris4 (es"8 "remeno"ausal) 9 20% chance by age 00 -associated o+arian cancer also -:ro"hylactic surgery, tamo;ifen (un4no&n benefit yet) * Screening: Age < 40, monthly self e;am, '-yearly 6linical 5reast $;am Age = 40-50, annual 6>-, annual 65$ (3ay /-15), e+ery month ?elf 5reast $;am * Diagnostic mammography: i) "al"able mass on 65$, ii) s4in changes (dim"ling, erythema), iii) ni""le retraction7discharge, i+) focal "ain, "re+ious "ersonal history of 6a -detected @lum"A: de"ends on gro&th rate, siBe, immobile (only 1cm mass can be felt) -this a""lies from &omen = '5C &omen belo& '5 should ha+e D? to rule out cyst (younger breast more sensiti+e to radiation) -3iff diag: cyst, fibroadenoma, infecti+e mastitis ("ainful, s&ollen), galactocele * Diagnostics: 1) >-ray ) D? (dense breastsC unclear mass on ;C "al"able mass not seen on ;) ') 6. (E?6.), E-1: staging 4) :$.-6.: metastases 5) :,3 (#)A, core bio"sy): histological F immunohistochem (#1?,): estrogen, ,$- neu * Pathology: -more common in G breastC 50% u""er outer Huadrant 1) 3uctal carcinoma (I0%): -36 in situ: in '0-50% "rogresses to in+asi+e -commonly scirrhous carcinoma (dense fibrous stroma) -ty"ically contain microcalcifications, s"iculated, irregular (;-ray) -.y"es of in+asi+e ductal (but &ith better "rognosis): medullary, mucinous, tubular, :agetJs ) Gobular carcinoma: (10%) -ty"ical architectural distortion (;-ray) - 0% de+elo" contralateral ca * TMN Staging: .1: K cmC . : -5cmC .': 5cmC .4: in+asion of chest &all, s4in, inflammation )1: K' a;illary lym"h nodesC ) : 4-I a;illary lym"h nodes ( or internal mammary)C )': 10 a;illary nodes (or infracla+7su"racla+8 nodes) :rognostic factors: other than .E) of course i) $strogen-rece"tors (/0%) L good prognosis ii) ,$- neu o+ere;"ression ( 0-'0%) L poor prognosis

* Therapy: $arly stage (.1-.', )0-1) 1) ?urgery: Mastectomy7Gum"ectomy F a;illary dissection -'0% F nodes im"al"ableC must ta4e min 4 lym"h nodesC must ta4e sentinel (draining lym"h node, inMect dye into tumor, see &here it drains first) ) Adjuvant radiotherapy (50!y, 5fractions) -care ta4en to minimiBe heart % lung -too much damage done if radioth gi+en together &ith chemoN ') AdMu+ant chemothera"y -CMF: cyclophosphamide methotre!ate "-F# -AC: $o!oru%icin cyclophosphamide -Trastu&uma% (,$- neu rece"tor: % cell cycle, % angiogenesis) -effecti+e &hen gi+en in combination &ith chemoth (combination &ith anthracyclines is "rohibited due to double cardioto;icity) -gi+ing neoadMu+ant chemoth (before surgery) has "ro+en to be Must as effecti+e as adMu+ant (good as can conser+e breast, smaller o"erationC bad as ca can "rogress if not effecti+e) 4) AdMu+ant hormone thera"y: (in $-F cases) -Tamo!i'en (5yrs): for both "re- % "ost-meno"ausal &omen -?ide-effects: increased ris4 of endometrial cancer ( 85; as stimulates $-), thromboembolism, hy"erli"idemia, steatosis ("rotects from osteo"orosis) -gi+en together &ith chemothera"y reduces its "otencyN -Aromatase inhi%itors (androgens O(aromatase) estrogens): may be better for "ost-meno"ausal &omen Gocally ad+anced (.4, ) -') -more than year sur+i+al 1) Chemotherapy -in $--F: aromatase inhibitor (better for ad+ance disease than tamo;ifen) -in $--: cyclo"hos"hamide, do;orubicin ) Adjuvant radiotherapy Eetastasised disease -6ommon mets: lung, li+er, bone, brain -for $-F: best to use aromatase inhibitors or !n-, antagonists -for $--: (ha+e &orse "rognosis) cyclo"hos"hamide, do;orubicin, 5#D -for ,$- neu F: .rastuBumab -:alliati+e radiothera"y