Procceding of the 1st Scientific Conference on Women s ... · Procceding of the 1st Scientific...

Procceding of the 1st Scientific Conference on Women’s Health CREWH/HMU – March 28-29, 2018

1

Open-label uncontrolled pilot study of clinical and hsitopathological study of 28 cases of breast

cancer female patients correlated with treatment & prognosis in Erbil-Iraq city

Suhail M. Najjar(*), Salah A. Ali (**)

* Consultant Surgeon In Zheen internatonal Hospital Erbil- Iraq, Surgical Anatomist in Anatomy

Department. Of Hawler Medical college,

** Basic and clinical Pathologist in Hawler Medical University, Clinical Pathologist in Well-fare

Hospital Erbil-Iraq

Background and objectives: As far as breast cancer is still the commonest malignant neoplasm of

female community & one of the main cause of death threatening the life of millions of women to

identify some clue for treatment we selected this group of patient and evaluated their condition with

long term follow up to know the prognosis and outcome of management for such malignant neoplasm.

Methods: Totally 28 females with different breast cancer studied from different aspects including;

clinical manifestations and presentation, histopathological diagnosis and management including

chemotherapy, radiotherapy ,hormonal therapy ,immunotherapy & surgery evaluated for more than 15

years to know the prognosis of such patient.

Result: The result of this study showed that most patients (age 40) was presented in stage II (13 / 28

cases, 48%) followed by stage III (43%), then stage I (9%) for age 40 most cases was in stage III (8

of 15 cases, 53%) followed by stage II(42%).

Conclusions: Most cases diagnosed in late stage due to poor education or misdiagnosis. The toxic

environmental factors may play an important role in mapping the prognosis and survival rate of breast

carcinoma patients rather than a genetic mutation enhancing.

Keywords: Breast cancers, management, follow up & prognosis.

Introduction

Breast cancer, which is considered to be

most prevalent female malignancy, and it is the

main cause of death in middle-aged women and

its incidence is elevated1 The malignant breast

neoplasms are usually caused by their abnormal

growth and uncontrolled proliferation of

epithelial cells within the terminal duct and

lobular parts of the breast. The cancerous cells

can attack and destroy surrounding normal

tissue, and spread throughout all parts of the

body via blood stream or lymph fluid to

metastasize to new sites. Breast cancer mainly

occurs in females, although less commonly,

males can also be affected by this type of

cancer. Worldwide, breast cancer is the second

most common cancer in the world and

represents 9% of global cancer burden2It has

been proposed that breast cancer is a

multifactorial disease and it,s etiology is

interaction of genetic and environmental

factors3. Almost 90% of breast cancers occur

sporadically, but without known predisposing

genetic alterations, the remaining 10% are

linked to genetic causes which include

mutations in tumor suppressor genes, mostly

BRCA1 and BRCA24 .

The incidence of breast

Abstract


2

cancer depends on the regions and countries,

likely due to differences in racial and ethnic

make-up, economy and social situations health

resources, and life style patterns5 .

Methods

Totally 28 cases of females with breast cancer

collected since may 2000 till dec 2016 the

study include presentation majority of them

presented with breast mass initially

mammography followed by FNA cytology

proved to be malignant then different types of

surgical procedures performed according to

their situation then routine histopathology &

immunohistochemical (ER,PR,Her2) studies

were performed then the patient were treated by

oncologist according to standard protocols and

they were evaluated by one checkup every

three months for 15 years. Categorical and

continuous variables were compared using

independent t –test and identified standard

deviation using Microsoft SSPS version 19 to

measure. P value. P value less than 0.05 is

regarded as significant, less than 0.01 highly

significant and above 0.05 non significant.

Results

Half of the study sample aged between 30 to 49

years old and only three patients had positive

family history of the breast cancer. The

majority were Muslim (table 1). Fifty percent

of the satdy sample, their size of breast mass

was more then 5cm and the most of them

(67.85%0 located right side and upper outer

(57.14). near 40% had the illness between 1-5

months. The majority (71.42%) of the tumor

classified as infilterative ductal carcinoma. The

highst percentage (46.43%) of the tumor were

grade 3 and stage 2 (table 2). Table 3 showed

that molecularly based distribution of Luminal

B is predominant but not all cases under-run the

tests. Most of cases managed by quadrectomy

or simple mastectomy and axillary clearance.

Only one cases received no any adjuctive

theraphy anf four cases received more than one

course of chemotherapy. Another cases refused

any therapy. From 28 cases, 17 cases were

survived for more than 5 years and 7 more than

10 years and 9 cases died before continuation

of 5 years survival (Table 4).

Figure 1 to 6 show radiological and histological

of breast cancer among patients as example.

Table 1- Demographic carachteristics of sample

Variables No. %

Age

- 30-44

- 45 -49

- 50-59

- ≥ 60

7

7

12

2

25

25

42.85

7.15

Family

history

- Positive

- Negative

3

25

10.71

89.29

Religion

- Muslim

- Christian

22

6

78.57

21.43


3

Table 2- Clinical characteristics of patients

Variables No. %

Type

- Size 2-5cm

- Size > 5cm

- Nipple discharge

- Generalized breast

mass

- Ulcer with mass

11

14

1

1

1

39.28

50

3.57

3.57

3.57

Side

- Right side

- Left side

19

9

67.85

32.14

Anatomical site

- Upper inner

- Upper outer

- Lower inner

- Lower outer

- Entir breast

7

16

1

2

2

25

57.14

3.57

7.14

7.14

Duration of illness

- < 1 month

- 1-5 months

- > 5 months

10

11

7

35.71

39.28

25

Histopathological

classification

- Carcinoma insitue

(ductal & lobular)

- Infilterative ductal

carcinoma

- Carcinomatouse

mastitis

- Cytosarcoma of

pylloidies

- Lobular carcinom

4

20

1

1

2

14.28

71.42

3.57

3.57

3.57

Grade

- Grade 1

- Grade 2

- Grade 3

- Grade 4

4

9

13

2

14.28

32.14

46.43

7.14

Stage

- Satge 1

- Stage 2

- Satge 3

3

13

12

10.72

46.43

42.85

Table 3- Immunhistochemistry stains of the

sample

IHC

stains

ER+ PR+ Her2+ Molecular

basis

Negative 11 14 20 Triple

negative/4

Positive 11 10 8 Luminal

B/7

Strong

positive

5 4 0 Luminal

A/6

Total 28 28 28 17

Table 4- Management of the study sample

Type of operation

- No operation

- Lumpectomy with axillary

biopsy

- Quadrectomy with axillary

clearance

- Simple mastectomy +

axillary clearance

- Modified radical

mastectomy

1

5

7

12

3

3.57

17.85

25

42.85

10.71

Postoperative theraphy

- Hormonal

- Radiotherapy

- Chemotherapy (one

course)

- Chemotherapy (more than

one course)

23

10

24

4

82.14

35.71

85.71

14.28

Survival duration

- Not seen

- <5 years

- 6-10 years

- > 10 years

2

9

12

5

7.14

32.14

42.85

17.85


4

Figure 1- Mammography left breast indicated

the site of the lesion.

Figure 2 - Mammography of post Lumpectomy

after 4 years (right breast)

No recurrences only scar

Figure 3- A case of left breast IDC

stage II - Mammography

Figure 4- A case of Eroding left breast

carcinoma, first presented before 2.3 years by

right breast inflammatory carcinomatosa

managed by radical excision, adjuvant DXRT

and chemotherapy


5

Figure 5 - Histopathology of infiltrative ductal

carcinoma H&E x400

Figure 6- FNAC of infiltrative ductal

carcinoma H&EX1000

Discussion

For many years, there has been a widespread

impression among clinicians that breast cancer

in younger women is an aggressive disease,

whereas among older women (≥ 60 years) the

disease has a more indolent nature. This study

has, to some extent, supported these ideas that

all nine cases less than 30 years were died

within first five years of follow up. While

tumors known to have an aggressive nature

occur in all age groups, the increased incidence

of grade III cancers among younger women

does suggest a less favorable prognosis for this

age group 6

.

The two peak age were affected included 35-

45years and ≥50 years, this may fulfill

mentioned international map of age distribution

but lastly some younger ages are also observed,

putting in mind that last ten years included

these young ages which correlates the wear and

tear stress of the area conditions as blamed to

be cause for Ca breast although studies result

for stress effects on carcinoma of breast are

non-conclusive 7

The majority of cases in this study were stage

2(48%), stage 3(43%) and then stage 1(9%).

Such findings have also been documented in

some Arabic countries, while in developed

countries, most patients present with an early

stage7 .This is mainly due to the lack of health

education, delay medical consultation, absence

perfect health system of screening programs,

rejection of management strategy and defects in

follow-up. This result was also in agreement

with study in Iran who concluded that stage II

is the most prevalence followed by stage III did

by Mosavoui8.

A case attended in stage IIIB when the husband

asked for the cause, he blamed the non-

availability of female doctor in this specialty

(religious Custom). This cause may be regarded

one of the causes of delay presentation9.

Molecular based classification this studies

triple negative model predominance in the

cases are analogous with the internationally

mentioned heterogeneity of breast cancer cases,

and showed GIII nature tumor cells 10

A case of Cystosarcoidus phylloidus was

presented in 2006 with the age of 45 years only

affected left breast locally followed by

recurrences frequently with variable intervals

until spread to the contralateral breast and

whole the chests wall died by 5 years we

couldn't help her other than limited surgical

excisions, of such a locally malignant case11

as

it was changed to leiomyosarcoma.

The strange cases in our study were the story of

four friend medical doctors the only common

thing which combine them together was that

they lived in musoul for six years renting an old


6

house (north of Iraq) during their under

graduating medical school and after their

graduation by 8-10 years they developed very

aggressive breast cancers in same intervals after

they were distributed in different countries after

their graduation and died within 4-5 years

period ( the mentioned area is an old area well

known by rich sulfur contained earth or may be

pollution but till now the area is not studied for

this purpose). This may fulfills with

environmental causes as mentioned in various

resources should be studied in the future 12

The recurrences were as usually mentioned by

various references included: Two cases of local

chest wall invasion encuerase by cystosarcoma

phylloidus which had been changed to

lieomyosarcoma, and ICD case end stage in

which also bone metastasis involved ( left

Superior pubic ramus), 2 cases of pulmonary

invasions, 2 cases of liver metastasis, a case of

thoracolumbar vertebral invasion, and two

cases of brain metastasis by these metastasis we

observed correctness of idea proposed that

breast cancer is intrinsically a systemic disease.

New molecular technologies, such as DNA

microarrays, support the idea that metastatic

capacity might be an inherent feature of breast

tumors 13

. AS we observed certain (5) cases

alive after 10 years of their breast CA accident

and developed no metastasis three of these are

above 65 years age, while cases with SII and

fully cured with optimize treatment and after

2.4 years developed Metastasis and died. We

have to mention these cases were younger age

group.

As we observed from basic molecular

classification the Triple negative cases were

predominant which indicate heterogeneity and

aggressiveness of the tumors cellular character

and by grading distribution were grad III10

Mainly quadrectomy and simple mastectomy

surgeries were applied and all in general locally

were cured, except two cases developed local

recurrence and treated accordingly which

indicate competition of simple mastectomy or

quadrectomy with edge free margins with

radical mastectomy.

Conclusion

In this study we concluded the following:

1. The incidence of left breast cancer were

higher than that of right breast

2. In this country still breast cancer were

diagnosed in late stage due to lack of

education of females.

3. If patients were treated properly even in

second stage the prognosis is amnestic

and aggressive surgical operations were

not essential.

4. Although genetic factors are blamed in

all researches as 10% of causes of

carcinoma of breasts, but in this study

well observed environmental and stress

factors are blamed as a main causes.

5. No relation found between CA breast

and chronic diseases like hypertension

and Diabetes mellitus.

6. In our area Oncologists are still

managing patients by depending on

classical staging methods rather than

molecular basis.

Competing interests

The authors declare that they have no

competing interests.

References

1. Parkin D. M. and Coleman M. P., "Changes

in diet and changes in cancer risk",

Observational studies. IARC Sci Publ, 1990,

PP. 93-111.

2. Parkin D. M., Bray F., Ferlay J. and Pisani

P., "Estimating the world cancer burden",

Globocan. Int. J. Cancer, 2001, 94, pp. 153-

156.

3-Ponder B. A., "Cancer genetics", Nature,

2001, 411, pp. 336-341.

4- Deng C. X., "BRCA1: cell cycle checkpoint,

genetic instability, DNA damage response

and cancer evolution", Nucl. Acids Res,

2006, 34(5), pp.1416-1426.


7

5- McPherson K., Steel C. M. and Dixon J. M.,

"Breast cancer epidemiology", risk factors

and genetics. Br. Med. J., 2000, 321, pp.

624-628.

6. Britta Weigelt"Breast cancer metastasis:

markers and models" Nature Reviews

Cancer, 2005, 5, 591–602.

7- Donald, E. H., Kenneth, C. C., Paul, H. L.,

"Histologic Grade, Stage, and Survival in

Breast Carcinoma", Cancer, 2003, Vol. 98,

No. 5, pp. 908-917.

8 - Mousavi, S. M., Montazeri, A.,

Mohagheghi, M. A., Jarrahi, A. M.,

Harirchi, I., "Breast cancer in Ira: An

epidemiological review". The Breast

Journal, 2007, Vol. 13, No. 4, pp. 383-391.

9. Saadat, Sabiha. “Can We Prevent Breast

Cancer?” International Journal of Health

Sciences, 2008, 2.2: 167–170. Print.

10. Kornelia Polyak," Heterogeneity in breast

cancer" J Clin Invest. 2011 Oct 3; 121(10):

3786–3788

11. Abeer, A. Al-Mowali, Sawsan, S. Al-

Haroon and Saad, A Abdualah., "Study of

BRCA1 and BRCA2 Gene Mutations in

Relation to Clinico-pathological Criteria of

Breast Cancer in Basrah", Research Journal

of Pharmaceutical, Biological and Chemical

Sciences, 2014, Vol. 5, No. 5, pp. 1217-

1222.

12. Minouk J. etal (Psychological stress,

adverse life events and breast cancer

incidence: a cohort investigation in 106,000

women in the United Kingdom): Breast

Cancer Research, 2016 18:72.

13. S Ambs, S P Hussain, and C C Harris "

Interactive effects of nitric oxide and the p53

tumor suppressor gene in carcinogenesis and

tumor progression". FASEB, 1997 11:443-8

Procceding of the 1st Scientific Conference on Women s ... · Procceding of the 1st Scientific...

Documents

Transcript of Procceding of the 1st Scientific Conference on Women s ... · Procceding of the 1st Scientific...