Pain --varying with menstrual cycle --independent of menstrual cycle Lump in the breast --Hard lump -- Firm, poorly defined lump or lumpiness --Soft lump Skin changes in the breast --Skin dimpling or tethering --Visible lump --Peau d’orange (kulit limao) --Redness --Ulceration Nipple disorders --Recent inversion or change in shape --“Eczema” (rash involving nipple or areola, or both) --Nipple discharge Milky Clear Green Blood-stained
NIPPLE DISORDERS --Recent inversion or change in shape suggests a fibrosing underlying lesion such as a carcinoma or mammary duct ectasia but can be malignancy (refer urgently) --“Eczema” (rash involving nipple or areola, or both) if unilateral and persistent, this is the classic sign of Paget’s desease of the nipple, a presentation of breast ca (refer urgently if not responding to treatment) --Nipple discharge1. Milky—pregnancy of hyperprolactinaemia2. Clear – physiological3. Green –perimenopausal, duct ectasia, fibroadenotic cyst4. Blood-stained –possible carcinoma or intraduct papilloma (refer urgently)
PAGET’S DISEASE OF THENIPPLE
SIGNS AND SYMPTOMSMost common:lump orthickening inbreast. Oftenpainless rg Discharge Redness or pitting or of skin over the bleeding breast, like the skin of an orange Change in size or contours of breast Change in color or appearance of areola 9
BREAST CA1. Skin dimpling2. Visible lump3. Peau d’orange4. Surface erythema5. Surface ulceration6. Recent nipple inversion7. Blood-stained nipple discharge8. ‘eczema’ around nipple (Paget’s disease)9. Systemic features:weight loss, anorexia, bone pain, jaundice, malignant pleural and pericardial effusion, anemia
BREAST CA CHARACTERISTIC SIGNS OFBREAST CA
CLINICAL CHARACTERISTICS OF ABREAST LUMP Solitary or multiple Size – in cm Location – quadrant of breast or clock face Contour – smooth and round/ovoid (likely to be benign) or firm/ hard (probable malignancy) Mobility – mobile or fixed Associated changes – skin/nipple retraction, skin tethering, bloody nipple discharge, erythema Axillary lymphadenopathy – enlarged and mobile or enlarged and fixed
1.INHERITED BREASTCANCERBetween 5-10% of breastcancer is inherited from afamily member.This means that themajority of women thatare diagnosed with breastcancer do not have thegenetic mutation. This figure shows that one out of every 10 women willResearch has suggested obtain breast cancer by inheriting a gene from a family member.women who are diagnosedwith breast cancer at ayoung age (less than 45)usually inherited.
INHERITEDGENESBRCA1 (Breast Cancer 1)BRCA2 (Breast Cancer 2)TP53 geneATM gene
BRCA 1 AND BRCA 2Both of these genes code for DNA repair.If a woman has a mutation on either one of thesegenes, the risk of her getting breast cancerincreases from 10% to 80% in her lifetime.Mutations in BRCA1 or BRCA2 account for 40-50%of all cases of inherited breast cancer.These genes are also associated with ovarian cancerin women and prostate cancer in men.These genes can be inherited either from themother or the father.
OTHER INHERITEDGENES THAT CAUSECANCERTP53 gene ATM gene This gene codes for the Females with one tumor suppressor protein defective copy of the p53. ATM gene and one normal copy of the Mutations of this gene gene are at cause Li-Fraumeni increased risk for syndrome, which is a breast cancer. condition that is associated with early onset breast cancer.
2.RISK FACTORS CAUSE BREAST CANCER Factors that Cannot Lifestyle Risks be Prevented Oral Contraceptive Use Gender Nulliparity Aging (40-55 y-o) Hormone Replacement Genetic Risk Factors Therapy (inherited) Not Breast Feeding Family History Alcohol Use Personal History Obesity Menstrual Cycle High Fat Diets Estrogen Physical Inactivity Smoking
3.ENVIRONMENTALFACTORSExposure to irradiationElectromagnetic FieldsXenoestrogensExposure to Chemicals
DIAGRAM OF THEBREASTThe breast is a glandularorgan.It is made up of a network ofmammary ducts.Each breast has about 15-20mammary ducts that lead tolobes that are made up oflobules.The lobules contain cells thatsecrete milk that arestimulated by estrogen andprogesterone which areovarian hormones.
IN SITU BREASTCANCERIn Situ Breast Cancer remains within the ducts orlobules of the breasts.This type of cancer is only detected by mammograms– not by a physical examination.If the cancer is in the duct it is called DuctalCarcinoma in situ.If the cancer is in the lobule of the breast, it iscalled Lobular Carcinoma in situ. This type of cancer is most common among pre-menopausal women. There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other.
INFILTRATING BREAST CANCER Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule.Breast cancer cells cross the lining ofthe milk duct or lobule, and begin toinvade adjacent tissues. This type of This type of cancercancer is called "infiltrating cancer." forms a lump that canIn this picture, you can see the breast eventually be felt by acancer cells invading the milk duct. physical examination.
MORE ON INFILTRATING BREASTCANCER Infiltrating cancer of Infiltrating cancer of the duct the lobules Called “Infiltrating Called “Infiltrating Ductal Carcinoma” Lobular Carcinoma” It is the most common Occurs when cells stream type of breast cancer. out in a single file into the surrounding breast tissue. Cancer cells that are invading the fatty tissue around the duct, This type of cancer is they stimulate the harder to detect on a growth of non- mammogram because cancerous scar like there is no fibrous tissue that surrounds growth. the cancer making it easier to spot.
OTHER TYPES OF BREAST CANCER Cystosarcoma Phyllodes Inflammatory Cancer Accounts for less than one percent of all breast cancers and looks as though the breast is infected. Breast Cancer During Pregnancy Paget’s Disease
COMMON SITE OF SPREAD OFBREAST CA
TNM STAGINGIN BREAST CA
T = Primary Tumor Tis (T0) = carcinoma in situ T1 = less than 2 cm in diameter T2 = between 2 and 5 cm in diameter T3 = more than 5 cm in diameter T4 = any size, but extends to the skin or chest wall
N = Regional Lymph nodes N0 = no regional node involvement N1 = metastasis to movable same side axillary nodes N2 = metastasis to fixed same side axillary nodes N3 = metastasis to same side internal mammary nodes
CLINICAL STAGING T N M 5-Year SurvivalStage 0 Tis N0 M0 > 95%Stage I T1 N0 M0 Overall = 85%Stage II Overall = 66% (Stage IIA) T0 N1 M0 T1 N1 M0 T2 N0 M0 (Stage IIB) T2 N1 M0 T3 N0 M0 Stage III Overall = 41% (Stage IIIA) T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1, N2 M0 (Stage IIIB) T4 Any N M0 Any T N3 M0 Stage IV Any T Any N M1 Overall 10%
THE EFFECT OF TUMOR SIZE ON SURVIVAL As tumor size increases, the chance of survival decreases. Tumor Size Survival
CANCER MADE?Diagnostic tests– all breast lumps or suspected carcinoma Triple assessment 1.Clinical examination 2.Radiological assessment -Mammography usual particularly over age 35y. -Ultrasound sometimes used under age 35 because increased tissue density reduces the sensitivity and specificity of mammography 3.Cytological assessment Fine needle aspiration cytology (FNAC) or occasionally, core needle biopsy Staging investigations 1. Liver ultrasound 2.Chest X-Ray 3.Bone scan 4.Specific investigations for organ-specific suspected metastases.
MAMMOGRAMA Mammogram is a X-ray ofthe breast that takespictures of the fat, fibroustissues, ducts, lobes, andblood vessels.When should a mammogrambe performed? If a lump has been found during self-examination or by a physician Younger women who have a strong history of breast cancer in their family All women over forty Women who have had previous diagnosis of breast cancer.
WHAT MAMMOGRAMSSHOWTwo of the most important mammographicindicators of breat cancers Masses Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer. 42
DETECTION OF MALIGNANTMASSESMalignant masses have a more spiculated appearance benign malignant 43
OTHER FORMS OFDETECTION Sonogram Thermography Transillumination Xeromammograpy Cat Scan MRI Biopsy
TREATMENTS OFBREAST CANCER
MEDICAL TREATMENTNON- METASTASIS DISEASE Adjuvant to reduce the risk of systemic relapse usually after primary surgery. Occasionally used as treatment of choise in elderly or those unfit/inappropriate for surgery Endocrine Therapy1. Anti-estrogens (e.g tamoxifen, LHRH antagonists, aromatase inhibitors)2. Most effective in ER +ve tumours Chemotherapy1. Anthracyclines, cyclophosphamide,5-FU, methotrexate2. Offered to patients with high risk features (+ve nodes, poor grade)
MEDICAL TREATMENTMETASTASIS DISEASE Palliative to increase survival timeEndocrine TherapyAs aboveChemotherapyAnthracyclines, tanaxestRadiotherapyTo reduce pain of bony metastases orsymptoms from cerebral or liver disease
SURGERY MAINSTAY FOR NON METASTASIS DISEASE Mastectomy(radical,modified radical simple) Breast conservation A mastectomy is the (lumpectomy, wide local surgical removal of the excision, quadrantectomy) breast, non-protruding In this surgical procedure, breast tissue, the lymph the breast is conserved and nodes in the armpits and the tumor is removed. some pectoral muscle. Radiation commonly follows a Breast reconstruction lumpectomy to try to rid the surgery may be body of any other cancerous conducted after the cells. removal of the breast.
BREAST CA Wide local excision-commenest procedure -breast conserving provided breast is adequate size and tumour location appropriate (not central/retro-areolar) -usually combined with local radiotherapy Simple mastectomy-best treatment and cosmetic result Surgical management of regional lymph nodes-Axillary node sampling-Axillary node clearance-Sentinel node biopsy Usually the first axillary node to receive lymphatic drainage from the tumour. Before operation, a blue dye and a radiotracer are injected into subareolar areas and at operation the sentinel node is identified visually and by using a device to detect radioactivity. Surgery for metastastic disease: limited to procedures for symptomatic control of local disease (e.g mastectomy to remove fungating tumour)
FOR BREASTCONSERVATIONSURGERY Single lesion clinically and mammographically Tumour not larget than 3cm (4cm in larger breast) No extensive in situ component Tumours more than 2cm away from nipple/areola Lesion of lower histological grade No extensive nodal involvement
PSYCHOLOGICAL IMPACTS OFBREASTCANCER
WHAT DO PATIENTS GO THROUGHAFTER DIAGNOSIS?Depression Reduction ofAnxiety activitiesHostility PanicFear GuiltChanges in life Difficulty adaptingpatterns due to to illnessdiscomfort and pain OverwhelmedMarital/sexual Disappointmentdisruptions
REOCCURRENCES OF BREASTCANCERReoccurrences Therapies Personal Group Therapies Responsibility Single session groups Loss of Hope Time limited groups Denial Long Term groups Traditional Grief Single session with psychologists
FATResearch shows that dietary fat shouldbe 20% or less in order to gainmeaningful protection against cancer.Fat cells make estrogen, which promotesbreast cancer.Diets high in fat are associated with theincreasing breast density in mammograms,which makes interpretation moredifficult.
FIBERFiber provides protection against breastcancer because it has a mechanism thatdecreases the amount of estrogen in thebody.The amount of fiber in the diet affects theactivities of intestinal bacteria, which affectsthe amount of reabsorbed estrogens.
ANTIOXIDANTNUTRIENTSAntioxidants are important in fightingbreast cancer because they can disarmcancer-causing substances called freeradicals.Vitamin CVitamin EBeta-caroteneVitamin ASelenium
OTHER PREVENTATIVE MEASURES Early Detection!!!! Exercise No Smoking!! Good Diet
REFERANCE Essential surgery 4th edition Oxford handbook of clinical surgery 3rd edition The National Cancer Institute wedsite