Breast Cancer in Lebanon Prepared and presented by Najla El Bizri, MD

Laboratory Medicine

April 25th, 2014. Saida Public Library, Saida Municipality.

INTRODUCTION

• Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death in women.

• In the US breast cancer accounts for 29% of all cancers in women and is second only to lung cancer as a cause of cancer deaths.

• 1/8 women with Breast cancer are < 45y

• 2/3 women with Breast cancer are > 55y

Uptodate 20.3

What about Breast cancer in Lebanon?

• Breast cancer was the most frequent malignancy in females in Lebanon (Over one third of all female cancers).

• Same rates observed in all earlier hospital-based studies in the country. Azar HA. Cancer in Lebanon and the near east. Cancer January-February 1962;15:66-74. Ghosn M et al.

The cancer registry at the Hotel Dieu de France Hospital. Leb Med J 1992;40:4-10. El-Saghir NS et al. Cancer in Lebanon: analysis of 10220 cases from the American University of Beirut Medical Center. Leb Med J 1998;46:4-10.

• ASR (38.9 per 100,000, 1998).• Lower than that observed for the US (90.7), UK (68.8), France (78.8) or

Occupied Territories (77.4)

• Much higher than other developing countries of the region such as Algeria.

5.8 5.2

2.2 1.8

16

4.5

0.7

42.3

17.6

15.2

3.55

4.13.2

2 1.4 0.9 0.4 0.20

5

10

15

20

25

30

35

40

45

Colon Rectum Lung Breast Prostate NHL L LeukemiaBladder M Leukemia Other leukemia

Males

Females

RELATIVE FREQUENCY OF CANCER SITES BY GENDER

7.1 6.4

1.5 1.4

15.7

5.9

0.9

38.2

15.4 15.6

3

7.65.9

2.5 1.6 1.8 1.1 0.2 0.20

5

10

15

20

25

30

35

40

Colo

n

Rec

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Lung

Bre

ast

Pro

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Bla

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L Leu

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M L

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2004

Colon Rectum LungBreast

Prostate NHL L LeukemiaBladder M Leukemia Other leukemia

38.2

PRIMARY SITES N

AGE-SPECIFIC RATES PER 100,000 CRUDE

RATESASR

UN 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75+

Oro-pharynx 46 2 0.59 1.44 0.63 3.52 1.96 7.59 9.93 16.55 2.54 2.59

Stomach 88 10 0.00 0.58 0.94 6.17 9.82 14.41 23.17 38.62 4.85 5.13

Colon-rectum 151 24 0.20 0.86 2.51 7.93 25.52 39.44 81.65 154.4 8.32 14.65

Liver 26 4 0.00 0.00 0.44 2.62 2.82 14.34 13.79 1.43 1.43 1.53

Pancreas 50 0 0.00 0.31 0.00 5.24 6.07 24.27 30.34 2.76 2.76 2.93

Lung & bronchus 224 13 0.00 0.63 7.49 19.63 49.30 70.62 121.37 12.34 13.35 13.17

Bone 32 2 1.73 0.00 0.44 3.93 1.52 2.21 0.00 1.76 1.76 1.92

Skin melanoma 26 6 0.00 0.63 1.76 5.24 2.28 6.62 8.28 1.43 1.43 1.55

Breast 1302 137 0.58 17.26 134.82 244.09 203.28 221.78 262.05 71.74 71.76 78.26

Cervix uteri 81 4 0.29 0.31 4.41 16.36 13.69 24.27 11.03 4.46 4.46 4.95

Corpus uteri 88 10 0.29 0.63 3.08 14.40 16.69 25.38 30.34 4.85 4.85 5.30

Ovary 16 8 0.00 0.00 0.00 5.89 3.79 2.21 0.00 0.88 0.88 1.06

Kidney 38 7 0.29 0.31 2.20 2.62 4,55 11.03 8.28 2.09 2.09 2.21

Bladder 106 21 0.00 0.31 2.20 10.47 21.24 33.10 71.71 5.84 5.84 6.25

CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2003

PRIMARY SITES N

AGE-SPECIFIC RATES PER 100,000 CRUDE

RATESASR

UN 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75+

Oro-pharynx 31 5 0.5 0.5 0.3 2.0 2.4 1.4 0.5 1.0 1.6 1.55

Stomach 134 30 0.5 0.3 0.6 4.8 9.0 13.9 3.2 5.1 6.7 6.70

Colon-rectum 283 65 0.4 0.0 1.7 1.0 23.4 34.2 5.2 14.0 14.2 14.2

Liver 42 10 0.0 0.3 0.0 1.6 3.6 3.5 0.9 1.8 2.1 2.10

Pancreas 57 8 0.0 0.0 0.0 2.4 4.2 7.7 1.5 2.5 2.9 2.85

Lung & bronchus 215 38 0.2 0.0 0.6 3.6 22.2 34.2 5.5 6.4 10.8 10.75

Bone 39 6 1.8 1.6 1.7 2.4 1.2 0.7 0.3 0.5 2.0 1.95

Skin melanoma 23 3 0.0 0.0 0.0 2.4 1.2 2.1 0.6 0.8 1.2 1.15

Breast 1383 267 0.2 1.3 11.1 96.9 194.2 183.3 16.9 19.3 69.5 69.15

Cervix uteri 94 20 0.0 0.0 0.9 6.0 11.4 12.5 1.3 1.5 4.7 4.70

Corpus uteri 125 29 0.0 0.0 0.0 3.6 18.0 20.2 1.7 2.8 6.3 6.25

Ovary 166 35 0.3 1.0 1.6 8.2 23.4 14.6 3.1 3.1 8.3 8.30

Kidney 37 6 0.9 0.3 0.6 0.4 3.6 3.5 0.6 1.3 1.9 1.85

Bladder 110 37 0.4 0.5 0.3 1.2 6.6 12.5 1.6 5.1 5.5 5.50

CANCER INCIDENCE RATES AMONG FEMALES IN LEBANON 2004

• Screening programs are widely adopted by most academic and health centers

• Changes in certain reproductive factors:• Mean age at marriage of women has increased from 23.2 years in 1970 to

27.5 in 1996

• Total fertility rate has steadily declined from 4.4 to 2.5United Nations. Health and reproduction. In: The female and male in Lebanon: a statistical profile. The Lebanese Republic, 2000 pp.57-65

Why Breast Cancer has increased in Lebanon?

Hospitalized Cases of Malignant Neoplasms of the Breast by Age, 2010-2011.

Hospitalized Cases of Malignant Neoplasms of the Breast by Age, 2010-2011.

• Breast Cancer is spread over all age groups with a peak of cases in the age group 45-50. There were 1742 breast cancer female patients admitted 7088 times either for surgery or chemotherapy.

• There was an increase in the number of cases between 2011 and 2010, which could be due to increased awareness and hence early diagnosis. The shift in peak cases to older age groups deserves further investigation.

Percent Breast Ca out of total Female Neoplasms by Qadaa, 2011

Percent Breast Ca out of total Female Neoplasms by Qadaa, 2011• 40.9% of those are Breast cancer cases with a proportion ranging from as

low as 30.6% in Baalback to as high as 54.6% in Matn.

• Comparing with last year’s percents, the lowest percent ever recorded then was for Baalback (22.9%).

• Taking a quick look at the comparison between the two years 2009 and 2010, there are district with a significant increase in percent of Breast Ca out of total female neoplasms (Aley,Baalback, Batroun, Beirut, West Bekaa, Bint Jbeil, Hermel, Kesserwan, Zahleh, and Marjeyoun), while Koura experienced a significant drop in that percent, with a National increase by 2.6%.

• The age pattern at diagnosis is typical of that in low-risk countries

• Increase in the rate up to the 5th decade, around menopause, and a decrease thereafter. Rodriguez-Cuevas Et al. Breast carcinoma presents a decade earlier in Mexican women

than in women in the United States or European countries. Cancer 2001;91:863-868

• Median age at diagnosis was 52 years (range 22-92).

• Around 43% of cases presenting before the age 50 compared to median age of 63 years for developed countries such as the US. Bosch X. Early development of breast cancer in Mexican women. The Lancet Oncology 2001;2:194

What about Breast cancer in Lebanon?

Breast Cancer incidence in Lebanon,by ICD-O.

RISK FACTORS

• The presence of breast cancer risk factors does not mean that cancer is inevitable: many women with risk factors never develop breast cancer.

• Instead, risk factors help to identify women who may benefit most from screening or other preventive measures.

• It is important to remember that breast cancer can also occur in women who have no identifiable risk factors.

• The average woman has about a 10 to 15 percent chance of developing breast cancer if she lives into her 90s.

• On the other hand, the risk of developing breast cancer in a woman with a strong family history of the disease who has inherited one of the genes that predispose her to breast cancer is over 50 percent.

STRONG RISK FACTORS

MODERATE RISK FACTORS

OTHER RISK FACTORS

STRONG RISK FACTORS

• Increasing ageOverall, 85 percent of cases occur in women 50 years of age and older,

While only 5 percent of breast cancers develop in women younger than age 40.

• Family historyWomen who have a family history of breast or ovarian cancer are at a higher risk for breast

cancer.

Women who have an especially strong family history (eg, two or more first-degree relatives [a mother, daughter, or sister] with breast or ovarian cancer, particularly before menopause) have a greater than 50 percent chance of developing breast cancer.

This represents an approximately five- to 10-fold increase in a woman's baseline risk of developing breast cancer.

• Inherited genetic mutation in one of two genes, called BRCA1 and BRCA2.

• Previous breast cancerWomen who have had cancer in one breast have an increased risk of developing cancer in the

other breast (x3-4 times). This is especially true if a woman has an inherited BRCA mutation.

• 20-30% of women with breast cancer have at least one relative with a history of breast cancer.

• However, only 5-10% of women with breast cancer have a hereditary predisposition .

• Having 1 first-degree relative: multiplies risk by 2

• Having 2 first-degree relatives: multiplies risk by 5.

• BRCA1 and BRCA2 mutations: responsible for 3-8% of all cases of breast cancer, and 15-20% of familial cases.

• BRCA1: x 55-65% increased risk in both breasts.

• BRCA2: x45% increased risk in both breasts.

MODERATE RISK FACTORS

• Density of the breasts on mammogramWomen whose mammograms show many dense areas of tissue have an

increased risk.

• Biopsy abnormalitiesWomen who have had a prior breast biopsy that revealed a proliferative

abnormality (excessive growth of the glandular breast tissue, also called hyperplasia) have an increased risk for breast cancer.

• Exposure to radiationWomen who have undergone high-dose radiation therapy to the chest region,

usually as part of cancer treatment, have an increased risk for breast cancer.

OTHER RISK FACTORS• Age at time of reproductive events

The longer a woman is exposed to estrogen, the greater her risk for breast cancer.

Estrogen exposure is increased if a woman began menstruating at or before 11 years of age, or if she experiences menopause at age 55 years or older.

• Pregnancy and breastfeeding

Women who have never given birth are more likely to develop breast cancer after menopause than women who have given birth multiple times.

The timing of a first pregnancy also appears to play a role.

• Hormone replacement therapy (HRT)

As a woman ages, the breast's glandular tissue, the tissue in which breast cancer arises, is gradually replaced by fat. HRT includes estrogen, which slows or reverses this process.

• Weight Obese women are more likely than thin women to develop breast cancer

after menopause.

• AlcoholWomen who drink alcohol have an increased risk of breast cancer, perhaps

due to elevated levels of estrogen in the body.

• Presence of other cancersWomen who have been diagnosed with cancer of the endometrium, ovary,

or colon are more likely to develop breast cancer than women who do not have these cancers.

SYMPTOMS

BREAST LUMP• You or your healthcare provider may find a breast lump by looking at or feeling

your breast.

• It is difficult to determine by examination alone if a lump is caused by breast cancer.

• All new breast lumps should be evaluated by a healthcare provider to determine if further testing is needed.

Women age 30 and older:

• Women who are age 30 or older who find a new breast lump will need a diagnostic mammogram, and usually an ultrasound, as well.

• If the lump appears suspicious on the mammogram and/or the ultrasound, a breast biopsy is usually recommended.

Women under age 30:

• If you are under 30 years and you find a lump before your menstrual period, you may be advised to have a repeat breast examination after your period has ended.

• In this age group, breast lumps are often caused by hormonal changes and will resolve after your menstrual cycle.

• If the lump does not go away when your period is over, you will likely need further testing with a breast ultrasound or needle aspiration biopsy to determine whether the lump is fluid filled or solid.

• Mammograms are not usually performed in women under 30 years old, although a mammogram may be needed if the ultrasound does not provide enough information.

CYST

• Ultrasound of the breast may be recommended to determine whether a lump is fluid filled or solid.

• Fluid-filled cysts are notusually caused by cancer.

Treatment for a fluid-filled cyst, if necessary, usually includes draining the fluid with a needle.

• Ultrasound of the breast may be recommended to determine whether a lump is fluid filled or solid.

Women with a solid or "complex" (fluid and solid) breast nodule are usually advised to have a biopsy.

TAKE-HOME MESSAGE

BREAST CANCER SCREENING RECOMMENDATIONS

• Breast cancer screening includes tests to detect breast cancer at an early stage, before a woman discovers a lump.

• The chance of dying from breast cancer has declined by about a 1/3 over the past few decades. This is due, in part, to the use of breast cancer screening to find cancer at an earlier stage.

BREAST CANCER SCREENING METHODS

• There are 3 main ways to screen for breast cancer:

Breast self-exam

Breast exam with your

doctor or nurse

Mammogram

Breast exam by your doctor or nurse: Clinical Breast Exam (CBE).• Your doctor or nurse might

perform a breast exam on a regular basis as part of breast cancer screening.

• During the exam, the doctor or nurse will look at the breasts and then carefully feel • Both breasts

• And the area under both arms.

• The ACS recommends that women in their 20s and 30s should have a clinical breast exam (CBE) every 3 years.

• Starting at age 40, women should have a CBE every year.

Breast Self-Exam (BSE).

• Breast self-exam (BSE) is an option for women starting in their 20s.

• It’s a way of finding changes in your own breasts.

• The best time to perform breast self-exam is about one week after your menstrual period ends, when the breasts are least lumpy.

• If you do not have menstrual periods, you can pick one day each month.

Mammogram

• A mammogram is a breast x-ray.

• Each breast is X-rayed individually. The breast is flattened between two panels.

• If possible, try to avoid scheduling your mammogram just before or during your menstrual period, when the breasts are more sensitive.

When to start mammograms?

• The American Cancer Society recommends beginning mammograms at age 40.

How often to have a mammogram?

• Women who choose to have breast cancer screening beginning at age 40 are usually screened once per year until age 50.

• After age 50, most expert groups recommend breast cancer screening every 1 to 2 years, depending on the woman's individual risk of breast cancer.

When to stop mammograms?

• Most expert groups recommend that women continue to get routine mammograms and clinical breast exams as long as the woman is expected to live at least 10 years.

Mammogram results

A radiologist will review and interpret the mammogram.

Can detect lesions• as small as

100 um• 1-2 y before

being noticed by BSE

What if my mammogram is abnormal?

• If your mammogram is abnormal, you will need further testing.

• In 90 percent of cases, breast cancer is not found.

Breast MRI

• Magnetic resonance imaging (MRI) uses a strong magnet rather than X-rays to create a detailed image. It requires injection of a contrast agent into a vein.

• It is not as good as a mammogram for certain breast conditions, such as ductal carcinoma in situ (a type of noninvasive or early breast cancer). In addition MRI testing is more likely to identify suspicious findings that turn out not to be cancer.

• Breast MRI may be recommended, in addition to mammography, to help find breast cancer in young women (particularly those with dense breasts) with a high risk for developing breast cancer (such as those with a very strong family history or a breast cancer gene).

Breast biopsy

• If breast cancer is suspected, the next step is to sample the abnormal area with a core needle biopsy to confirm the diagnosis.

• If possible, the technique should be performed using x-ray guidance, with mammography, ultrasound, or MRI.

• It is performed with local anesthesia and do not require sedation.

What is a breast biopsy?

• Doctors use different methods to do breast biopsies.

• They can: 1. Use a large needle to take 1

or more small samples of tissue from the breast (Fine needle biopsy).

2. Use a needle with a special tip and special imaging equipment to do a Core needle biopsy.

3. Do an operation to take out part or all of the abnormal tissue (surgical biopsy).

What happens after a breast biopsy?

• After a biopsy, you might have bruising, bleeding, or get an infection. These problems are less common with fine or core needle biopsy than after a surgical biopsy.

• You will likely get the results of your biopsy in about a week.

Benign?

Premalignant?

Malignant?

Benign

Malignant

In situ cancers

Invasive cancers

Types of Breast Cancer

In situ breast cancer

• The earliest breast cancers are called "in situ" cancers.

• Ductal carcinoma in situ (DCIS)

• If cancers arise in the ducts of the breast (the tubes that carry milk to the nipple when a woman is breastfeeding) and do not grow outside of the ducts, the tumor is called ductal carcinoma in situ .

• However DCIS may develop into invasive cancers if not treated.

• If abnormal cells arise in the lobules of the breast (where breast milk is made), and they do not extend outside of the breast lobule, this are referred to as

lobular carcinoma in situ (LCIS).

• LCIS is not considered a true cancer but instead is considered a risk factor for developing cancer in the future in either breast.

Invasive breast cancer

• The majority of breast cancers are referred to as invasive breast cancers because they have grown or "invaded" beyond the ducts or lobules of the breast into the surrounding tissue.

• Several varieties of invasive breast cancers are possible (eg, ductal, lobular, medullary, tubular, metaplastic).

• In general, they are all treated similarly.

HAS THE BREAST CANCER SPREAD?

• Once a diagnosis of breast cancer is established, the next important questions to be answered are the following:

• How extensive is the cancer involvement within the breast?

• Is there evidence that the tumor has spread outside of the breast?

Metatstatic breast cancer

• When tumors spread to areas outside the breast through the blood and lymph vessels, they are called "metastatic cancers."

The importance of the axillary lymph nodes

• One of the first sites of breast cancer spread is to the lymph nodes located in the armpit (axilla).

• These nodes (referred to as axillary lymph nodes) can become enlargedand can sometimes be felt during a breast examination.

• The presence or absence of lymph node involvement is one of the most important factors in determining the long-term outcome of the cancer (prognosis), and it often guides decisions about treatment.

PREVENTION

Lifestyle changes

• Minimize the use of postmenopausal hormones. Consider non-estrogen alternatives (eg, bisphosphonates for treatment of osteoporosis rather than hormones)

• Although this may not necessarily be a lifestyle choice, having a first child at an earlier age may decrease risk.

• Breast feeding for at least 12 months can decrease breast cancer risk.

• Avoiding adult weight gain and maintaining a healthy weight may reduce postmenopausal breast cancer risk.

HOW TO PREVENT BREAST CANCER?

HOW TO PREVENT BREAST CANCER?

• Bilateral mastectomy is effective in preventing new breast cancers but is not an accepted strategy for most women except for the few with very high genetic risk.

• Removal of the ovaries is not recommended for breast cancer prevention in most women, except for those with BRCA1 or BRCA2 gene mutation.

• Medications: Women who are already at higher than average risk can significantly lower their risk of developing breast cancer by taking tamoxifen, raloxifene, or an aromatase inhibitor, such as exemestane, for five years.

TREATMENT

• Surgery is considered primary treatment for early-stage breast cancer; many patients are cured with surgery alone.

• The goals of breast cancer surgery include complete resection of the primary tumor with negative margins to reduce the risk of local recurrences and pathologic staging of the tumor and axillary lymph nodes (ALNs) to provide necessary prognostic information.

• Adjuvant treatment of breast cancer is designed to treat micrometastatic disease.

• Adjuvant treatment for breast cancer involves radiation therapy and systemic therapy (including a variety of chemotherapeutic, hormonal and biologic agents).

Choice of treatment

• At the time breast cancer is diagnosed and/or treated, the cancer should be studied for the presence of two types of proteins:

Hormone receptors (estrogen and progesterone receptors)

HER2.

Hormone receptors (estrogen and progesterone receptors) • More than one-half of breast cancers require the female hormone

estrogen to grow, while other breast cancers are able to grow without estrogen.

• If hormone receptors are present within a woman’s breast cancer, she is likely to benefit from treatments that lower estrogen levels or block the actions of estrogen. These treatments are referred to as endocrine or hormone therapies.

• In contrast, women whose tumors do not contain any ER or PR do not benefit from endocrine therapy, and it is not recommended.

HER2

• HER2 is a protein that is present in about 1out of every 5 breast cancers.

• The presence of HER2 in the breast cancer identifies women who might benefit from treatments directed against the HER2 protein.

• Drugs that target the HER2 protein include trastuzumab (Herceptin) and lapatinib (Tykerb®).

RECONSTRUCTIVE BREAST SURGERY

BREAST CANCER SURVIVORSHIP

• 5 year survical in localized breast cancer: 80%

Frequently asked questions:

• Do deodorants and perspirants cause breast cancer? No

• Does drinking warm bottled water causes breast cancer? No

• Does injury to the breast causes breast cancer? No

• Does smoking increases the risk of breast cancer? Yes (proven in 2012).

• Can women having silicone breast implants still do mammograms? Yes.

• Women who are breastfeeding can still have mammograms? Yes, but the result will be less accurate (more dense tissue).

Where to get more information?

• National Cancer Institute

(www.cancer.gov/cancertopics/pdq/screening/breast/Patient)

• National Library of Medicine

(www.nlm.nih.gov/medlineplus/mammography.html)

• People Living With Cancer: The official patient information website of the American Society of Clinical Oncology

(www.cancer.net/portal/site/patient)

• National Comprehensive Cancer Network

(www.nccn.com)

• American Cancer Society

(www.cancer.org)

• Susan G. Komen Breast Cancer Foundation

(www.komen.org)

بيروتفي الئحة المراكز المعتمدة

مستشفيات خاصةمستشفى حداد راهبات الوردية

مستشفى اللبناني الجعيتاوي

مستشفى القديس جاورجيوس

مستشفى بيروت

مستشفى العناية باألم والطفل

مستشفى فؤاد خوري

مستشفى الرسول األعظم

مستشفى الساحل

فقط يوم السبت)مستشفى طراد والمركز الطبي )

مستشفى البرج

مستشفى الزهراء

حكوميةمستشفيات مستشفى الكرنتينا

مستشفى رفيق الحريري الجامعي

مراكز طبية خاصةمركز السان مارك الطبي

المجموعة الطبية المتحدة

مركز األطباء لألشعة

مؤسسة مخزومي

مركز مار الياس لألشعة

مركز الظريف الطبي

المراكز الطبية الدولية فرع األشرفية

المراكز الطبية الدولية فرع الطيونة

المركز اللبناني الكندي

الصليب االحمر اللبناني

مركز كاريتاس

مركز الصليب األحمر المصيطبة

المركز التحاليل الطبية

الهيئة الصحية اإلسالمية مركز دار الحوراء الصحي

مؤسسة الحريري الطبية مركز طريق الجديدة الصحي

اإلجتماعي

المركز الطبي للتصوير الشعاعي الدورة

المتنفيالئحة المراكز المعتمدة

مستشفيات خاصةمستشفى مار يوسف

مستشفى أبو جودة

مستشفى مركز الشرق األوسط الصحي

مستشفى بحنس

مستشفى هارون

مراكز طبية خاصة

مختبر سان جورج الطبي

مركز السان مارك الطبي

عاليه/لجنة األمهات في لبنان

المركز الطبي للتصوير الشعاعي بعبدا

مركز حمانا الصحي

جبل لبنانفيالئحة المراكز المعتمدة

حكوميةمستشفيات

مستشفى بعبدا الحكومي

مستشفى البوار فتوح كسروان الحكومي

مستشفيات خاصةمستشفى الحياة

مستشفى سان شارل

مستشفى بهمن

مستشفى المشرق

كسروان وجبيلفيالئحة المراكز المعتمدة

مستشفيات خاصةمستشفى سيدة لبنان

مستشفى سيدة مارتين

مستشفى سيدة المعونات

مستشفى سان جورج

مستشفى سان لويس

مراكز طبية خاصةمركز جونيه للتصوير على األشعة وتشخيص الرادار

سنتر سانت تريز

مختبر فيفدال الطبي

المراكز الطبية الدولية فرع الذوق

الشمالفيالئحة المراكز المعتمدة

حكوميةمستشفيات مستشفى طرابلس الحكومي

مستشفى سير الضنية الحكومي

مستشفى بشري الحكومي

مستشفى تنورين الحكومي

مستشفى إهدن الحكومي

مستشفى الدكتور عبد هللا الراسي حلبا الحكومي

مستشفيات خاصةرحال-مستشفى عكار

مستشفى البرجي

مستشفى البير هيكل

مستشفى االسالمي الخيري

مستشفى المظلوم

مستشفى المنال

مستشفى النيني

مستشفى الكورة

مستشفى مركز الشمال االستشفائي

مستشفى مركز اليوسف الطبي

مستشفى الحنان الخيري

مستشفى الخير

مستشفى شاهين

مستشفى سيدة السالم الراهبات االنطونيات

مراكز طبية خاصة

مركز التصوير الشعاعي الطبي

مؤسسة الحريري الطبية مركز طرابلس الصحي

اإلجتماعي

مركز محمد الجسر لألشعة

الشوففيالئحة المراكز المعتمدة

مستشفيات خاصةمستشفى عين وزين

مستشفى مركز بعقلين الطبي

مراكز طبية خاصةمركز خالدة للتحاليل الطبية والتصوير الشعاعي

مؤسسة الحريري الطبية مركز عرمون الصحي

اإلجتماعي

مستشفى عثمان

مركز التشخيصي الطبي

الجنوبفيالئحة المراكز المعتمدة

حكوميةمستشفيات مستشفى صور الحكومي

مستشفى مرجعيون الحكومي

مستشفى النبطية الحكومي

مستشفى صيدا الحكومي

مستشفى ميس الجبل الحكومي

مسشتفى حاصبيا الحكومي

مستشفى سبلين الحكومي

مستشفيات خاصةمستشفى عالء الدين

مستشفى دالعة

مستشفى غندور

مستشفى حمود

مستشفى جبل عامل

شعيب-مستشفى الجنوب

مستشفى جبيلي

مستشفى مركز لبيب الطبي

مستشفى اللبناني اإليطالي (نجم)

مستشفى حيرام

الهيئة الصحية اإلسالمية)مستشفى بنت جبيل )

مراكز طبية خاصةمركز العناية الطبي اإلجتماعي عين إبل

مؤسسة الحريري الطبية مركز عين الحلوة الصحي

اإلجتماعي

مركز صيدا الطبي

مركز الجنوب للتشخيص الطبي

مركز الصليب األحمر البازونية

مجمع نبيه بري لتأهيل المعوقين الصرفند

الهيئة الصحية اإلسالمية مركز الجنوب الطبي النبطية

الصحي

البقاعفيالئحة المراكز المعتمدة

حكوميةمستشفيات

مستشفى بعلبك الحكومي

مستشفى الهرمل الحكومي

مستشفى راشيا الحكومي

زحلة-مستشفى الرئيس الياس الهراوي الحكومي

مستشفيات خاصةمستشفى دار األمل الجامعي

مستشفى الدكتور حامد فرحات

مستشفى تل شيحا

مستشفى الططري

مستشفى اللبناني الفرنسي

مستشفى رياق

مستشفى البقاع

الهيئة الصحية اإلسالمية)الهرمل -مستشفى البتول )

مراكز طبية خاصة

مركز بعلبك الصحي اإلجتماعي

مركز البقاع لترقق العظم وأمراض الثدي

مركز عرسال الحكومي الصحي اإلجتماعي

مؤسسة الحريري الطبية مركز البقاع الصحي اإلجتماعي

مؤسسة الحريري الطبية مركز القرعون الصحي اإلجتماعي

الهيئة الصحية اإلسالمية مركز شمسطار الصحي

الهيئة الصحية اإلسالمية مركز النبي شيت الصحي

الهيئة الصحية اإلسالمية مركز فرج بلوق الصحي

References

• Uptodate 20.3

• Robbins and Cottrans pathologic basis of diseases.

• Lebanese Ministry Of Public Health website

• Lebanese National Cancer Registry website

• Various internet resources