Carcinoma of breast: What should be done?

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Understanding the pathophysiology of carcinoma of breast is essential for deciding the optimum treatment for this lethal disease. The bilogical behaviour of the disease should guide radical treatment of the disease. Radical surgery is still the gold standard for treatment. Chemotherapy,radiotherapy and hormonal manipulation are useful adjuncts to surgery.

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Carcinoma of breast: What should be done?

  1. 1. CARCINOMA OF BREAST Dr. Ketan Vagholkar MS., DNB., MRCS., FACS . Professor of Surgery & Consultant General Surgeon.
  2. 2. Risk Factors• Family history • Breast feeding has• Chronic cystic mastitis protective effect• Previous h/o contralateral • Nulliparity is associated breast cancer with high incidence• High socioeconomic • Obesity status • Women having wet• Individuals staying in the cerumen have higher risk western hemisphere of breast cancer• Risk is lowest if the first • Estrogen compounds pregnancy is at 23 yrs of have variable effect in age experimental animals
  3. 3. Etiology• Estrogen window hypothesis – First window opens at menarche leading to unopposed estrogen exposure – Second window opens at menopause – Early menarche with late menopause• Bittner factor – Seen in sucking mice – Similar factor seen in Parsi women in India who have a high incidence of breast cancer
  4. 4. Pathology• Ductal • Lobular – In situ – In situ – Invasive – invasive • Medullaryca with • Mixed lymphoid stroma • Mucoid • Carcinosarcoma • Tubular • Unclassified • Sqamous • Adenoid cystic • Inflammatory • Paget’s disease
  5. 5. Lobular Carcinoma• Gross – Rubbery in consistency• Microscopy – Infiltration of fibroblastic stroma by single cells or lines of cells arranged in single files giving the appearance of ‘ Indian File Pattern’ – Single files disposed in concentric circles around the breast ducts giving rise to ‘targetoid’ lesions – Lobular ca are estrogen receptor positive – Areas of lobular ca in situ may be seen in the same breast
  6. 6. Ductal Carcinoma• Gross • Microscopy – Majority are infiltrating – Variation in the type of ductal type epithelial component and – Types stroma – Cicumscibed – Several patterns seen in • Less common the same tumour • Well defined margins • Variants of ductal ca • Better pronosis – Medullary (encephaloid) – Stillete – Mucoid • Stillete type with typical – Tubular features cancer – Inflammatory • No capsule • Hard in consistency – Paget’s disease of the (scirrhous) nipple • Gritty to cut
  7. 7. Morphology of carcinoma of breast
  8. 8. TNM Staging• T STATUS• Tis-Ca in situ• To-no evidence of primary tumour• T1-size<2cms• T2-size 2-5 cms• T3-size>5cms• T4-extension to chest wall or skin• N STATUS• No-no nodes palpable• N1-mobile axillary LN• N2-fixed axillary LN• N3-palpable supraclavicular LN• M STATUS• Mo-no distant mets.• M1- distant mets
  9. 9. Manchester staging• StageI – Tumor confined to the breast, not adherent to pectoral muscles or chest wall, if adherence this must be smaller than the size of the tumour.• StageII – Primary tumour as in stage I with additional mobile ipsilateral lymph nodes• StageIII – Skin involvement larger than the tumour, tumour fixed to pectoral muscles but not to the chest wall, fixed nodes in axilla.• StageIV – Distant spread either blood ,lymph, invasion of skin beyond supraclavicular nodes,involvement of opposite breast, bone brain, lung & liver involvement.
  10. 10. Hormone receptors• Types (present on breast epithelial cells) – ER-estrogen receptors – PgR-progesterone receptors• Mechanisms – Estrogen binds with ER, resultant complex enters the cell nucleus and binds to areas of chromatin called acceptor sites resulting in production of mRNA by transcription. – mRNA enters cytoplasm and produces various enzymes and proteins one of which is PgR. – The estrogen ER complex induces DNA synthesis and cell growth.• Application – Presence of receptors on tumor tissue suggests good differentiation and hence better prognosis – Patients with receptor positive tumors respond well to hormonal manipulation – Detection of receptors on metastatic deposits will help detect the primary in the breast.
  11. 11. Clinical features• HISTORY • PHYSICAL EXAMINATION• Chief complaints(odp) • General• h/ocomplications(trauma,pain,relation examination(pallor,jaundice,scars of to menses,pus,ulceration,nipple previous surgery) retraction,wt loss axillary • Local examination (privacy,expose swellings,pbone pains,abd lump) both breasts,chaporone)• h/o • INSPECTION etiology(trauma,fever,pain,malignancy • Site,size,nipple in first degree relative,lactation,breast deviation,retraction,tethering of feeding after pregnancy,similar skin,axillary fullness(demontrated by swelling in opposite breast) a.sitting position with hands by the• h/o treatment taken for the lesion side,hands elevated above the head,& bending forwards) • PALPATION • Cosistency,mobility over underlying structures and overlying skin • Avillary LN palpation • Supraclavicular LN palpation • OTHER SYSTEMS • Chest, abdomen ,PV<PR.
  12. 12. Final diagnosis• Type of lesion –benign/malignant• Extent of spread with reference to axillary lymph nodes, supraclavicular LN, abdomen, bone, opposite breast• Staging- TNM/Manchester
  13. 13. Clinical appearances
  14. 14. Clinical appearances
  15. 15. Clinical appearances
  16. 16. Screening for Breast Cancer
  17. 17. Investigations MAMMOGRAPHY• Applications – Screening of patients – Assesing the opposite breast – Support the clinical impression of no malignancy• Findings – Asymmetry – Skin thickening – Irregular masses – Architectural distortions – Clustered pleomorphic microcalcifications
  18. 18. Mammographic findings in malignancy
  19. 19. Mammography
  20. 20. Investigations• USG• To determine whether or not a mass is solid or cystic
  21. 21. Investigations BIOPSY • METASTATIC WORK• FNAC UP• Excision biopsy • Chest x ray• Wedge biopsy • USG/CT abdomen LAB INV. • CT scan of brain in• CBC suspected brain mets.• LFT • Bone scan for detecting bony mets.• Alkaline phosphatase
  22. 22. Bone Scan
  23. 23. Treatment• Surgery• Chemotherapy• Hormonal therapy• Radiotherapy
  24. 24. Surgical Principles• Criteria for inoperability • Principles of surgery – Extensive edema of breast – Removal of entire breast – Satellite nodules of due to multicentricity carcinoma – Removal of axillary lymph – Inflammatory carcinoma nodes to accurately stage – Parasternal tumour the disease – Supraclavicular mets – Arm edema – Distant mets
  25. 25. Surgical options (principles,technique,complications)• Modified radical mastectomy with axillary clearance• Radical mastectomy• Quadrantectomy• Toilet mastectomy
  26. 26. Adjuvant therapy• Chemotherapy • Radiotherapy – Indications – Indications – Selection of patients – Complications – Regimes used – Quart therapy – Precautions – Complications • Hormonal therapy – Indications – Patient selection – Medications
  27. 27. Follow up care• Every 3 months in the • Recurrent disease first year followed by – Loco regional every 6 months – Second primary breast thereafter ca• Annual – Distant mets mammography• Chest x ray• LFT
  28. 28. Prognosis• Lymph Node status – 5 yr survival • 1 node involved-48% • 4 nodes involved-38% • 5 nodes involved-29%• Tumour size – Larger the tumour size ,worst is the prognosis• Stromal reaction – Good prognosis in medullary ca with lymphoid stroma due to better immunological host reaction• Hormonal status – Best prognosis if both receptors are positive (ER, PgR)• Histological grade – Grade I- 81% (5 yr survival rate) – Grade II- 54% (5 yr survival rate) – Grade III-34% (5 yr survival rate)
  29. 29. Overview of benign breast diseases• Fibroadenoma• Fibroadenosis• Fibrocystic disease of the breast• Cystosarcoma phyllodes

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