Lecture on breast carcinoma for medical students. Encompasses basic sciences, triple assessment, classifications and principles of management on the number one cancer in Malaysia.
5. Epidemiology
• Most common cancer amongst women worldwide (23% of
all female cancers)
• Asian countries, incidence is still lower but increasing trend
Westernisation of breast cancer risk factors
• In Malaysia
– The most common cancer (18%)
– 29.1 per 100 000 population
– Peak incidence 50 – 59 y/o
– Race
• Chinese 38.1 per 100 000
• Indian 33.7
• Malay 25.4
• 1% of BC involve male patient
6.
7. Risk factors
Modifiable
• Prolonged estrogen
exposure
– Early menarche (<10 y/o)
– Nulliparity
– Late 1st child-birth (>30 y/o)
– No breast feeding (<6/12)
– Late menopause (>55 y/o)
– OCP use (>6/12)
– HRT
– Obesity
• Previous breast irradiation
Non-modifiable
• Family history
• Genetic predisposition (e.g.
BRCA 1 & 2 mutations)
8. Triple assessment
• Clinical features
– History
– Physical examination
• Radiological features
– Ultrasonography (<35 y/o)*
– Mammography + ultrasonography (≥35 y/o)
• Histological/Cytological features
– Fine needle aspiration – cytology
– Core needle biopsy – histology
22. Investigations
Ultrasonography
• <35 y/o
• Suspicious features
– Lesion height > width
– Irregular margins
– Heterogenous
– Posterior enhancement
– Associated suspicious
lymphadenopathy
Mammography
• >35 y/o
– Dense breast tissue in younger
women will mask significant
findings reduce its
sensitivity & specificity
• Suspicious features
– Architectural distortion
– Lesion
• Spiculated
• Irregular margins
• Heterogenous
• Clustered pleomorphic
microcalcifications
23. • MRI breast
– Mainly supplementary
– Indications
• Ambiguous but suspicious MMG
• Pregnancy, especially late trimester
• Implants
• Young women suspected with hereditary disease
24.
25.
26. Tissue diagnosis
• After imaging has been performed to avoid
architectural disturbance that might disrupt
radiologist’s interpretation & pain to patient
• Latest guidelines all breast lumps –
irrespective of palpability – must be sampled
under image guidance (USG or MMG)
• Two options
– FNAC
– CNB
27. Staging
• CECT TAP
– Gold standard
• CXR + USG abdomen
– Compromise
– Only in limited-resources setting
• Bone scan
– Only if have pathological fracture or symptoms suggestive of bone
metastases
• CT brain
– Only if have symptoms suggestive of brain metastases
• PET scan
– Only to resolve nature of ambiguous, suspicious lesions picked up on
CT scan
– Limited efficacy if metastases are small (<5mm), mucinous carcinoma
35. Mastectomy Wide local excision
Pros … …
Cons Disfiguring Might need second surgery
Must undergo post-op RT
Cosmetic outcome might
not be satisfactory
Contraindications - High tumour : breast ratio
Unable to undergo post-op
RT
Not willing or not suitable
to undergo 2nd surgery
Centrally located tumour
36.
37. Radiotherapy
• Post op External beam RT, image modulated RT
• Intra op single dose, spherical applicator, only on WLE site, new
technology
• Indications
– Post-breast conserving surgery
– Involved mastectomy margins
– Locally advanced disease (T3 or N2)
• Location
– Chest wall
– Infraclavicular
– Supraclavicular
– Axillary
– Whole brain RT