Carcinoma of breast is the second common killer disease in women after carcinoma of cervix in developing countries like India whereas it is the number one killer in western world. It can also run in families associated with BRCA1 & BRCA2 genes. Early diagnosis is almost curative and that is why they are doing mass screening like mammogram to pick up this cancer early.

1. CARCINOMA
BREAST
S
AANN OOVVEERRVVIIEEWW
V
M
C

2. Dr.BB..SSEELLVVAARRAAJJ,,MMSS;;MMcchh;;
S
•PEDIATRIC SURGEON
V
M
C
•SVMCH&RC
•PONDICHERRY- 605102

3. OBJECTIVES
S
•Etiopathogenesis
•Types &Clinical features
V
M
C
•Investigations
•Staging
•Treatment of EBC, LABC&ABC

4. ANATOMY
S
V
M
C

5. ANATOMY
S
V
M
C

6. ETIOPATHOGENESIS
Incidence of Sporadic, Familial, and Hereditary Breast Cancer
Sporadic breast cancer 65–75%
Familial breast cancer 20–30%
Hereditary breast cancer 5- 10%
S
BRCA1 a 45%
BRCA2 35%
p53 a (Li-Fraumeni syndrome) 1%
STK11/LKB1a (Peutz-Jeghers syndrome) <1%
PTENa (Cowden disease) <1%
MSH2/MLH1a (Muir-Torre syndrome) <1%
ATMa (Ataxia-telangiectasia) <1%
Unknown 20%
V
M
C

7. Risk Factors
S
Major factors
Gender
Age
Previous breast cancer
Family history and genetic predisposition (BRCA 1 or 2 mutations)
V
M
C
Intermediate factors
Alcohol and diet
Endocrine factors:
Early menarche
Late menopause
Hormone replacement therapy
Nulliparity
Irradiation
Benign proliferative breast disease (e.g. multiple papillomatosis)
Smoking & OCPs not a risk factor

8. TYPES
S
Classification of Primary Breast Cancer
Noninvasive Epithelial Cancers
Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS)
V
M
C
Invasive Epithelial Cancers (Percentage of Total)
Invasive lobular carcinoma (10%-15%)
Invasive ductal carcinoma
Invasive ductal carcinoma, NOS (50%-70)
Tubular carcinoma (2%-3%)
Mucinous or colloid carcinoma (2%-3%)
Medullary carcinoma (5%)
Invasive cribriform carcinoma (1%-3%)
Invasive papillary carcinoma (1%-2%)
Adenoid cystic carcinoma (1%)
Metaplastic carcinoma (1%)

9. Clinical Features
S
• Visible / Palpable Lump
• Hard Consistency
• Non Tender
• Paget’s Disease of the Nipple
• Skin
Tethering/dimpling/puckerin
V
M
C
• Low mobility
• Axillary Lymphnodes+
• Nipple Retraction
• Nipple Discharge
g
• Peau d’Orange
• Skin Ulceration / Fungation

10. Clinical Features
S
The location of breast cancer is as follows:
Upper outer quadrant: 60%
V
M
C
Central area : 12%
Lower outer quadrant: 10%
Upper inner quadrant: 12%
Lower inner quadrant: 6%

11. Clinical Features
S
V
M
C

12. Clinical Features
S
V
M
C
Peau d’ orange
Appearance

13. Clinical Features
S
Skin dimpling and
puckering are inspectory
findings
V
M
C
Tethering is due to
infiltration of Astley
cooper’s ligaments and is
confirmed by palpation

14. Clinical Features
S Nipple retraction-
Recent, Unilateral,
V
M
C
circumferential
infiltration and fibrosis
of lactiferous ducts

15. Clinical Features
S
Nipple discharge
suggestive of
malignancy if:
V
M
C
1. Spontaneous
2. Unilateral
3. From single duct
4. Bloody discharge
5. Asso with mass
6. Age > 40 yrs

16. Skin Ulceration
S
V
M
C

17. Paget’s Disease of Nipple
S
Eczema like condition
Malignant cells in the
V
M
C
subdermal layer
Red flat ulcer, nipple
erosion

18. Paget’s Disease of Nipple
S
Paget’s Disease of
Nipple
Eczema of Breast
Unilateral Bilateral
Itching absent Itching present
V
M
C
Absence of oozing Presence of oozing
Scales Vesicles absent Scales Vesicles present
Nipple destroyed Nipple intact
Underlying lump may be
present
No underlying lump present
Edges are distinct Edges are indistinct
No response to treatment Responds to treatment
Occurs at menopause( old
age)
Seen in lactating women(
young women)

19. INVESTIGATIONS
S
“The choice of initial diagnostic evaluation after
V
M
C
the detection of a breast lump should be
individualised for each patient according to the
age, perceived cancer risk and characteristics
of the lesion.”

20. INVESTIGATIONS
S
V
M
C

21. INVESTIGATIONS
S
• Radiological Investigations
• Ultrasonography
• Mammography
• Pathological Investigations
• Staging
Investigations
• Xray Chest
V
M
C
• Fine Needle Aspiration Cytology
FNAC
• Core Needle BiopsyTrucut Biopsy
• Needle Localisation Biopsy
• Stereotactic Biopsy
• Open BiopsyIncisional
Excisional
• Sentinel node Biopsy
• Abdominal
Ultrasound
• Radionucleide
Bone Scan
• CT Brain

22. Mammography
S
• Irregular Margins
• Ill-defined margins
• Asymmetry
V
M
C
• Clustered pleomorphic
microcalcification
• Architectural distortion
• Stellate or spiculated
appearance

23. Mammography
S
V
M
C

24. Ultrasonography
S
• High frequency 7MHz
probe is used although 10
to 13MHz preferable
• Differentiate solid and
cystic lesions
V
M
C
• Malignant appearing
masses
1.Irregular margins
2.Hypoechoic
3.Posterior acoustic
shadow
4.Vertical growth
appearance (TALLER than
wide)

25. FNAC
S
• 1.5 inch 22 gauge needle
attached to a 10 ml syringe is
used
• With or without image guidance
• FNAC-DISADVANTAGES
V
M
C
1. FALSE NEGATIVE rate
high
2. Inadequate specimen
3.Requires skilled
cytopathologist
4. Cannot differentiate in situ vs
invasive lesions

26. Trucut Needle Biopsy
S
Core needle Biopsy
• Done using a 14 gauge needle or Tru
cut needle
• ADVANTAGES
V
M
C
1. Lower FALSE negative rates
2. Doesn't need specially trained
cytopathologist
3.Adequate samples are obtained
4.Can differentiate in situ vs invasive
lesions
5.Can confirm-ER/PR/Her 2 neu status

27. Investigations for Nonpalpable
Lumps
S
Image
guided biopsies
1.USG guided FNAC or core
V
M
C
needle biopsy(if mass is
visualised)
2. Needle localising biopsy
3. STEREOTACTIC needle
biopsy
(when no mass present
but micro calcifications seen
mammographically)

28. Sentinel Node Biopsy
S
• LLYYMMPPHHAAZZUURRIINN
BBLLUUEE DDYYEE
• TTcc9999 SSUULLPPHHUURR
CCOOLLLLOOIIDD
V
M
C
• AAccccuurraaccyy 9999%%

29. Sentinel Node Biopsy
S
INDICATIONS CONTRAINDICATIONS
• High-risk IN SITU
cancer, non-palpable
breast cancer
• Altered drainage of breast.eg-
Augmentation surgery
V
M
C
• T1 or T2 carcinoma
and especially good
prognosis tumors
(mucinous, papillary
and adenoid cystic)
• Recent
mammoplasty,pregnancy
• Allergy to dye or radiocolloid
• Inflammatory Ca
• Axillary mets

30. Other Investigations
S
1.CXR-PA VIEW
2.CT CHEST
3.USG – ABDOMEN AND PELVIS
V
M
C
4.SKELETAL SURVEY/ Tc99 BONE SCAN
5.MRI BREAST- Voluminous breast/ Implant
rupture
6.PET SCAN- Follow up to detect residual disease
7.Tumor Marker- CA- 15/3

31. AJCC Staging
S
T (Primary Tumor)
Tis Carcinoma in situ (lobular or ductal)
T1 Tumor 2 cm
T2 Tumor 2 cm, 5 cm
T3 Tumor 5 cm
M (Metastasis)
V
M
C
T4 Tumor any size with extension to the
chest wall or skin
N (Nodes)
N0 No regional node involvement
N1 Metastasis to 1-3 axillary nodes
N2 Metastasis to 4-9 axillary nodes
N3 Metastasis to 10 axillary nodes
M0 No distant
metastasis
M1 Distant metastasis

32. AJCC Staging
S
• Stage 1 and stage 2 –
EBC
V
M
C
• Stage 3 – LABC
3a- T3, N 1,2,
3b- T4, ANY N
3c- N3, ANY T
• Stage 4- ABC

33. Management-Multimodality
S
• Surgery
• Curative
• Palliative
V
M
C
• Radiotherapy
• Chest Wall
• Axilla
• Supraclavicular
• Chemotherapy
• Hormonal Therapy

34. Management
S
EBC LABC ABC
•Stage 1 2
• Breast conservation
•Stage 3
• MRM+Adjuvant RT+
•Stage 4
•Toilet Mastectomy
V
M
C
treatment
Lumpectomy
Wide local excision
Quadrantectomy
Axillary dissection
Radiotherapy
• Modified radical
mastectomy
Adjuvant CT +/- HT
• Neoadjuvant CT+MRM+
Adjuvant RT CT+/- HT
• Adjuvant RT CT +/-
HT

35. S
Breast Conservation Treatment
V
M
C

36. Management- LABC
S
Classification of LABC
•LABC Operable at Presentation
•T3, N1, M0
V
M
C
•LABC Inoperable at Presentation
•T4, Any N, M0
•Any T, N2 or N3, M0
•Inflammatory Carcinoma of Breast
•T4d, N0, M0

37. Management- LABC
S
Treatment of Operable LABC
MRM K Adjuvant Radiotherapy (RT) Adjuvant
Systemic Chemotherapy (CT) +/- Hormone Therapy
V
M
C
(HT)
Neoadjuvant CTK To attempt to Down-Stage
lesions for Breast Conservation Surgery
Tumor Responding K BCS K CT,RT +/- HT
Non-responders K MRM K CT with RT +/-
HT

38. Management- LABC
S
Treatment of Inoperable LABC
Aim of Treatment: To make the disease operable and achieve
loco – regional control, hence improve patients quality of life
V
M
C
Neoadjuvant CT K MRM K CT RT +/- HT
Advantages of Neoadjuvant CT
To make the tumor operable
To assess tumor response to CT

39. Management- MRM
S
V
M
C

40. Prognostic Factors
S
1.Axillary nodal status( most important)
2.Tumour size
3.ER/PR Status – Both positive- good prognosis
4.Histological grade of tumour
V
M
C
5.Her 2neu overexpression – aggressive malignancy-poor
prognosis
6.Proliferating rate
1.DNA flow cytometry – aneuploid – poor
prognosis
2.S phase fraction – low S phase – good prognosis

41. Prognostic Factors
S
5 yr survival – Ca Breast
Stage 1 – 90%
V
M
C
Stage 2 – 70%
Stage 3 – 40 %
Stage 4 – 20 %

42. Adjuvant Chemotherapy
S
To deal with occult metastasis
Always use combination chemotherapy
More effective in pre-menopausal
CT + HT CT / HT alone
Drugs used:
Schedule used commonly:
CAF q21d x 6cycles
Cyclophosphamide: 500mg/m2 D1
5 – FU: 500mg/m2 D1 D8
V
M
C
Cyclophosphamide
Methotrexate
5 – FU
Anthracyclines: Doxorubicin,
Epirubicin
Taxanes: Paclitaxel, Docitaxel
Doxorubicin: 50mg/m2 D1
Regimen of choice: TAC
Good efficacy irrespective of
ER/PR/HER-2 neu status

43. Neoadjuvant Chemotherapy
S
CT given before Local Control of disease
It does not provide any survival advantage
Helps decide response of tumor to CT
V
M
C
Indications:
1.To downstage Operable LABC for BCT
2.To downstage Inoperable LABC for operability
3.Inflammatory Breast Cancer
4.In EBC, to improve cosmetic appeal after BCS, for large
tumor in small breast

44. Neoadjuvant Chemotherapy
S
Usually 2 – 4 cycles are given till maximum shrinkage
is achieved
Choice of drugs are the same as for Adjuvant CT –
V
M
C
CAF / TAC
If tumor is resistant then non cross resistant drugs can
be used as second line CT

45. Hormone Therapy
S
ER+/PR+ K 80% chance of
favorably response to HT
Most commonly used agent
KTamoxifen
Dose: 20mg/day, Oral
V
M
C
All (pre/post menopausal)
patients with ER/PR+ LABC
should undergo HT for 5yrs.
Can be given in combination
with CT
Side effects: Hot flushes,
sexual dysfunction,
endometrial cancer,
thromboembolism
Hot flushes K
Venlafaxine, Paroxetine

46. Hormone Therapy
S
CCllaassss AAggeennttss
SSeelleeccttiivvee eessttrrooggeenn rreecceeppttoorr
mmoodduullaattoorrss ((SSEERRMMSS))
TTaammooxxiiffeenn,, RRaallooxxiiffeennee,,
TToorreemmiiffeennee
V
M
C
AArroommaattaassee iinnhhiibbiittoorrss AAnnaassttrroozzoollee,, LLeettrroozzoollee,,
EExxeemmeessttaannee
PPuurree aannttiieessttrrooggeennss FFuullvveessttrraanntt
LLHHRRHH aaggoonniissttss GGoosseerreelliinn,, LLeeuupprroolliiddee
PPrrooggeessttaattiioonnaall aaggeennttss MMeeggeessttrrooll
AAnnddrrooggeennss FFlluuooxxyymmeesstteerroonnee
HHiigghh-ddoossee eessttrrooggeennss DDiieetthhyyllssttiillbbeessttrrooll

47. Hormone Therapy
S
Trastuzumab or Herceptin
Monoclonal antibody that targets the HER-2 neu
oncogene
V
M
C
Her 2 neu codes for a growth factor that is overexpressed
in 25% to 30% of breast cancers
Her 2 neu over-expression indicates aggressive nature of
malignancy.
Trastuzumab may be used for Her 2 neu positive
tumours in adjuvant or neo adjuvant setting

48. Radiotherapy
S
Indications for PMRT:
4 Positive axillary nodes
V
M
C
1. 2. Tumour size 5 cm
3. Positive surgical margins
4. As a part of LABC PROTOCOL

49. Followup
S
Monthly self examination of the breast
Regular physical examination following mastectomy is necessary
Every 4 months for years 1 and 2,
V
M
C
Every 6 months for years 3 through 5,
Every 12 months thereafter
Contralateral mammogram yearly
Routine bone scans, skeletal surveys, CT of abdomen and brain- Not
necessary, Yield is low