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carcinoma of breast


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Dr Sajid's presantation

Dr Sajid's presantation

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  • 1.  
  • 2. Breast carcinoma By Dr:Sajid Ali Abbasi Topic Presentation
  • 3.
    • Modified sweat gland
    • Greater part of gland lies in sup: fascia
    • Small part pierces deep fascia i.e. axillary tail
    • It has protuberant part & axillary tail
    • Protuberant part extends vertically from 2 nd -6 th ribs & Horizontally from lat:border of sternum to midaxillary line
    • Thin layer of Mammary tissue extends from clavicle above to 7 th – 8 th rib below and from midline to the edge of L.D post:
    • Axillary tail can be seen pre-menstrualy or during lactation.
  • 4.  
  • 5.
    • Parenchyma of breast consist of 15 to 20 lobes
    • Each lobe is made up of 20-40 lobules
    • Lobules are basic structural units of mammary glands
    • consist of variable number of
    • alveoli
    • 1O to over 1OO lobules empty into lactiferous duct.
    • Each lactiferous duct is provided just prior to its termination a dilated ampulla i.e. reservoir for milk or abn: discharge
    Lobes and ducts
  • 6.
    • Breast is supported and attached to chest wall by these ligaments
    • Hollow conical projections
    • Account for the dimpling of the skin overlying carcinoma
    Ligaments of Cooper
  • 7.
    • Pigmented circular area that surrounds base of nipple
    • Contains involuntary muscles
    • Areolar epithelium contains numerous sweat & sebaceous glands
    • Sebaceous glands enlarge during pregnancy & serve to lubricate nipple during lactation.
  • 8.
    • Erectile structure which points outward
    • Covered by thick skin with corrugations
    • Near its apex lie the orifices of lactiferous ducts
    • Nipple contains smooth muscle fibers arranged concentrically and longitudinally
  • 9.  
  • 10.
    • Med: by memory branch of int:thoracic artery
    • Ant:by intercostal branch of int:thoracic artery
    • Lat:by mammary br of lat thoracic +lat br of 2-5 post:intercostal arteries & thoraco acromial br of axillary artery
  • 11.
    • Vein follows arteries
    • Converge towards the nipple where they form anastomatic venous circle
    • Sup:veins drain into int: thoracic vein
    • Deep veins drain into int: thoracic,axillary & post: intercostal vein
    • Derived from ant:and lat:cutaneous branches of 2-6 intercostal nerves
  • 12.
    • Lymphatics of the breast drain predominantly into axillary & internal mammary lymph nodes
    • Axillary nodes receive approx. 85% of drainage
    • Ant axillary or pectoral nodes drain lateral quadrant of breast
    • parasternal l.nodes drain lymph from medial quadrant
    • inferior quadrant’s lymph may pass deeply in to abdominal lymph nodes
    • The sentinel l.node is defined as first axillary node draining the breast.
  • 13.  
  • 14.
    • Global Carcinoma.
    • Common cause of death in middle aged women in western countries.
    • 200 times more common in females
    • The disease is fatal in 25 % of the cases
    • 2nd most common cause of death (after Ca lung)
    • 1 million women newly diagnosed each year
    • Less incidence in Asia
    Breast carcinoma introduction
  • 15.
    • As is the case with all cancers, cause of breast cancer is also unknown
    • Three sets of influences appear to be important
    • mutation in tumor suppressor genes i-eBRCA1&BRCA2
    • Endogenous estrogen excess or hormonal imbalance
    • exogenous estrogens
    • irradiation
    2:Hormonal influances 1:Genetic changes 3:Environmental factors Pathogenesis
  • 16.
    • Common in western world accounting for 3-5%of all deaths in women
    • In developing countries it accounts <3 per cent of deaths.
    • Extremely rare before 20 years
    • Risk of ca breast increasing with age
    • Decreased incidence after the menopause
    • < 1 per cent are males
    • It occurs more commonly in women with family history
    Epidemiology and Risk factors Geographical Age Gender Genetics
  • 17.
    • More common in obese
    • Link between diets low in phyto-oestrogens & Soya is ass: with ca
    • High saturated fat diet, red meat
    • Inc: alcohol intake – inc: risk
    • Longer reproductive span inc:risk ( early menarche, late menopause )
    • Nulliparity inc:risk ( higher number of pregnancies is protective )
    • Oral contraceptives inc:risk
    • Prolonged exposure to ex:estrogens postmenopausally i.e. HRT inc risk
    • Breast feeding is protective
    DIET Endocrine
  • 19.
    • 85% of ca arises in ducts, thus ductal ca is most common variant
    • Most frequently upper outer quadrant is involved
    • lobular ca occur in up to 15% of cases
    • Breast cancers are divided in to…
    • DCIS
    • LCIS
    • Lobular
    • Medullary
    • Colloid
    • Tubular
    • Inflammatory Ca
    Classification 1-Non Invasive (IN SITU) 2-Invasive
  • 20.
    • In situ carcinoma is pre-invasive ca
    • Usually asymptomatic
    • Both i.e. DCIS,LCIS are markers of late development of invasive ca
    • LCIS is usually multifocal and bilateral
    • Best treatment is for in situ ca is subject of number of on going clinical trials
    Non Invasive (IN SITU)
  • 21.
    • Usually associated with DCIS
    • Ca produce desmoplastic response which replaces normal breast fat thus forms hard palpable mass
    • Advanced ca may cause i.e. dimpling of skin, retraction of nipple, fixation of chest wall
    • Usually associated with LCIS
    • More frequently metastasize than ductal ca
    • Usually multiple and bilateral
    Invasive carcinoma 1:Invasive ductal ca 2:Invasive lobular ca
  • 22.
    • Comprises of about 2% of cases
    • Clinically resemble fibroadenomas
    • Rare subtype often present as well circumscribed mass
    • Tumor cells produce abundant quantity of extracellular mucin
    3:Medullary ca 4:colloid(mucinous) ca
  • 23.
    • It rarely present as palpable mass
    • Microscopically ca consist of well formed tubules
    • Lymph node metastasis is rare
    • Prognosis is excellent
    • Highly aggressive, most of tumor have distant metastasis
    • Fortunately rare
    • Usually without palpable mass
    • Presents as painful, swollen & warm breast
    • May mimic breast abscess
    • Prognosis is extremely poor
    5:Tubullar ca 6:Inflammatory Ca
  • 24.
    • Superficial manifestation of an underlying breast Ca
    • Presents an eczema like condition of nipple or areola
    • First there is erosion of nipple
    • Eventually nipple disappear
    • MICROSCOPICALLY- Loose ovoid cells with clear abundant & pale staining cytoplasm
    Paget’s disease of nipple
  • 25.
    • 1: Fixation to chest wall – cancer –en- cuirasse
    • 2:retraction or dimpling of skin
    • 3:localized lymphedema
    • 4:Peau d’orange(orange peel)
    Features common to all invasive cancers
  • 26. orange-peel appearance- peau d’ orange.
  • 27.
    • Pt often Presents with hard Painless lump
    • Nipple may be deviated, displaced, retracted or destroyed.
    • Mild aches & Pricking sensation
    • Distortion of shape of breast
    • General malaise & loss of weight
    • Change in size of breast
    • Backache, caused by infiltration & collapse of lumbar vertebrae.
    Clinical Presentation
  • 28.
    • Invades other portion of breast, skin, pectoral muscle and chest wall.
    • Primarily to axillary L.N. & internal mammary chain of lymph nodes
    • In advanced stage– supra clavicular with contra latera lL.Ns may also be involved.
    • Through this route metastases occur in skeleton, liver, lungs and brain
    The Spread Local Spread Lymphatic spread Bloodstream
  • 29. SKELETAL
    • L - Lumber vertebrate
    • F - Femur
    • T - T.vertebrae
    • R- RIBS
    • S- Skull
    • Metastasis may occur in liver,lungs & brain
  • 30.
    • Two traditional systems of classification
    • I. The Manchester system
    • II.The international union against cancer i.e. TNM Staging system.
  • 31.
    • Growth confined to breast
    • Growth confined to breast and affected lymph nodes in ipsilateral axilla
    • a) Large skin involvement or peau d’orange but limited to breast
    • b) Tumor fixed to pectoral muscles, but not chest wall
    • c) ipsilateral lymph nodes matted together or fixed to chest wall
    • a) Wide skin involvement of breast
    • b) Complete fixation of tumor to chest wall
    • c) Distant metastasis
    Manchester system Stage1 Stage II Stage III Stage IV
  • 32.
    • TIS ca in-situ
    • T1 <2cm
    • T2 2-5cm
    • T3 >5cm
    • T4 tumour of any size
    • N0 No nodal involvement
    • N1 Mobile involved axillary nodes
    • N2 Fixed involved nodes
    • N3 Inv ipsilateral supraclavicular nodes
    • M0 No metastasis
    • M1 +ve distant metastasis
    TNM CLASSIFICATION PRIMARY Tumor Nodal involvement Metastasis
  • 33.
    • Ca in situ or tumor less than 2 cm in size with no nodal involvement
    • Tumor of less than 2cm in size with mobile involved lymph node
    • Tumor of 2-5cm in size with fixed involved lymph node +no known distant metastasis
    • Any tumor, any nodal involvement with Known distal metastasis
    Staging according to TNM Stage1 Stage2 Stage 3 Stage4
  • 34. Diagnosis should be made by combination of 1:clinical assessments 2:radiological imaging 3:cytological or thru histological analysis DIAGNOSIS
  • 35.
    • it own does not exclude breast ca
    • It is very safe investigation
    • sensitivity of test inc with age as the breast becomes less dense
    • Useful in young women with dense breast in whom mammograms are difficult to interpret
    • Useful in distinguishing cystic from solid lesions
    • Useful to localized in impalpable lumps
    CLINICAL IMAGING 1.Mammography 2.Ultrasound
  • 36.
    • Gold standard for imaging the breast of Patients with implants
    • PT’s with suspected recurrent disease
    • Useful as a screening tool in high risk women
    • least invasive technique of obtaining cell diagnosis
    • False negatives do occur thru sampling error
    • Invasive ca can’t be distinguished from in situ disease
    3.MRI 4.FNAC
  • 37.
    • To reduce the chance of local recurrence
    • To reduce the risk of metastatic spread
    • Surgery
    • Radiotherapy
    • Adjuvant systemic therapy
    MANAGEMENT Two basic principles of treatment TREATMENT MODALITIES
  • 38.
    • Two Aspects of surgery
    • Mastectomy
    • Conservative breast surgery
    • Large tumor related to size of the breast
    • Central tumor beneath the areola or involving nipple
    • Multi focal disease
    • Local recurrence
    • Patients preference
  • 39.
    • Removal of breast tissue with axillary tail usually attached with few lymph nodes of anterior axillary group
    • No dissection of axilla
    • Simple mastectomy is often followed by radiotherapy
    TYPES OF MASTECTOMY 1)Simple Mastectomy
  • 40.  
  • 41.  
  • 42.  
  • 43.  
  • 44.  
  • 45.
    • It includes
    • Excision of whole breast
    • All axillary lymph nodes
    • All fat and fascia of the anterior chest wall
    • Excision of pectoralis major and minor muscles.
    • More commonly performed
    • Excised Mass is composed of
    • Whole breast
    • Large portion of skin overlies the tumor and nipple
    • All fat, fascia, and lymph nodes of axilla
    • Pectoralis minor muscle divided or retracted
    • With preserving of axillary vein, nerve to serratus anterior & lattissimus dorsi
    2)RADICAL MASTECTOMY (HALSTED) 3) Modified radical (Patey mastectomy)
  • 46.
    • Small tumor related to the size of breast
    • Availability of radiotherapy facility
    • Patient preference
    • Involves removal of lump or tumor with rim of 1cm normal breast tissue.
    • Term lumpectomy is reserved for operation in which benign tumour is excised and large amount of normal breast is not resected
    • Removing the entire segment of the breast which contain the tumor.
    • Radiotherapy to the remaining breast tissue
    • Quadrantectomy, axillary dissection & radiotherapy is known as QUART
    Conservative breast surgery 1) WIDE LOCAL EXCISION 2) Quadrantectomy
  • 47.
    • After mastectomy
    • High grade tumour
    • Large nodal involvement
    • Multifocal disease
    • Extensive lymphovascular invasion
    • AIM:
    • To delay the relapse
    • To prolong the survival
    • Indications:
    • Lymph node positive women
    • Poor prognosis
    • Hormonal receptor positive women
    • Old patient
  • 48.
    • Tamoxifen is widely used hormonal treatment
    • If pat is premenopausal get benefit from 2omg daily of tamoxifen
    • New aromatase inhibitors i.e.anastrozole,letrozole etc are used if pat is post menopausal
    • It reduces risk of cancer in contra lateral breast
    • Other hormonal agents are being developed i.e. LHRH
    • The aim of this Rx is to shrink tumor to enable breast preserving surgery.
    • 6 months cycles of cyclophosphamide, methotrexate and 5-FU achieve 25% reduction in risk of relapse
    • Chemotherapy may be considered in node –ve pts if there is hi risk of recurrence
    • This Rx is confined to premenopausal women.
  • 49. Thank You