A precise and intensely summarised core of fundamental principles and information about Breast cancer.

1. Breast cancer Management
Prepared by :
Osama A. Abdulkareem
Supervised by :
Dr.Dildar H.Musa

2. • Introduction
• Aetiological Factors
• Pathology
• Clinical manifestation
• Treatment
• Follow up
• Screening
• Male breast cancer
• References
Contents

3. Introduction:
Breast cancer is the second leading
cause of cancer death in women. It is
rarely diagnosed in women younger than
age 25, the incidence rises steadily to
reach a peak around the age of menopause.

4. Aetiological Factors

5. • Genetics
• Geographical
• Gender
• Geriatric (Age)

6. Duration of menses
Diet

7. • Past Medical Hx of exposure to Radiation
• Polyps

8. Pathology

9. Ductal Carcinoma In Situ(DCIS):
• Calcification and mammography
• Comedocarcinoma
• Combined Tx(excision and Tamoxifen )
• Crusting over nipple(paget disease of nipple)
Carcinoma in Situ
Lobular Carcinoma In Situ(LCIS):
• Monomorphic(making FNA Dx difficult)
• Massless(usually doesn’t form mass)
• Multiple (both breasts)
• Mastectomy(bilateral breast removal or Close follow up )
Papillary carcinoma in situ
Ductal Carcinoma In Situ(DCIS)& Lobular Carcinoma In Situ(LCIS)

10. Invasive Ductal Carcinoma:Dominant type80%
• Clinically: it forms a hard palpable mass.
• Histologically: consists of sheets of malignant glands or
cells run in abundant fibrous stroma, therefore somtimes
called scirrhous carcinoma.
• Receptors: 2/3 of these cases express estrogen &
progesterone
Invasive or Infiltrative carcinoma

11. Lobular Carcinoma(15%):
• Metastasis
• Multi centric
• MRI
Infiltrating Ductal & Lobular
Carcinoma
Medullary Carcinoma
Mucinous (colloid) Carcinoma
Apocrine carcinoma
Secretory carcinoma
Invasive Papillary Carcinoma
Tubular Carcinoma
Inflammatory carcinoma

12. Invasive or Infiltrative carcinoma
others
5%
ILC
15%
IDC
80%

13. Grading

14. Histological grading
Bloom Richardson recommended by WHO
3 variant
1. The degree of tubular differentiation (1, 2, 3)
2. The nuclear pleomorphism (1, 2, 3)
3. The mitotic activity (1, 2, 3)
Each variant is scored from 1-3
The addition of the 3 variant score together lead to a
total of 3-9 this will be graded to
Grade I (3,4,5)
Grade II (6,7)
Grade III (8,9)

15. Spread of breast cancer:
•Local: to skin, pectoralis muscle and chest
wall
•Lymphatic spread – tumor in outer
quadrant & central region spread to axillary
LN – tumors in inner quadrant spread to
LN along the internal mammary glands.
• Distant metastasize by blood eventually
occur to the bones (homing theory), lung,
liver & brain.

16. Sentinel node biopsy
This technique has become the standard of care in the
management of the axilla in patients with clinically node-
negative diseaseThe sentinel node is localised peroperatively
by the injection of patent blue dye and radioisotope-labelled
albumin in the breast. The recommended site of injection is in
the subdermal plexus around the nipple, although some still
inject on the axillary side of the cancer. The marker passes to
the primary node draining the area and is detected visually
and with a hand-held gamma camera. Peropererative
diagnosis allows completion axillary clearance if nodal disease
is detected.

17. Diagnosis

18. • History and Physical Examination
• Mammography both breast
• Biopsy (FNAC,Truecut)
• CBP
• CXR and U/S
• Liver function test ( Alkaline phosphatase)
• MRI,CT
• Bone scan

19. Clinical manifestation

20. Painless lump 80%:
Location

21. Red flags (Features raise the suspicion to
malignancy)
• Breast mass with adherence to skin or
deep fascia, muscles, or chest wall &
called fixation .
• Retraction & dimpling of nipple or skin
• Lymphedema & palpable axillary LNs
• Thickened skin around hair follicles
(Peau d’ orange)

22. Eczematous skin changes
Discharge from nipple
vague pain ,pricking ,heaviness……
Symptoms related to metastasis

23. Treatment

24. Conservative breast cancer surgery:
• Wide excision or quadrant economy
• Axillary Sx
• DXT
if

25. Mastectomy(breast removal):
• Indications :
1. large tumours (in relation to the size of
the breast).
2. central tumours beneath or involving the
nipple.
3. multifocal disease.
4. local recurrence.
5. patient preference.

26. Mastectomy(breast removal):
• Simple mastectomy
• Radical ( patey )
• Radical (halsted)

27. What are Indications ?
1 . A l l p a t i e n t s t h a t a r e t r e a t e d
conservatively(Not mastectomized)
2. Is given after the mastectomy solely in
the following cases:
I.Very large tumour
II.Large number of positive lymph nodes.
III.Extensive lymphovascular invasion
Radiotherapy

28. What radiotherapy is it?
Deep X ray(DXT)
When do we give it?
Postoperatively
To which part of bady has to be given?
Chest wall

29. What are they ,for how long and benefit?
6-monthly cycle of cyclophosphamide,
methotrexate and 5-Fuorouracil (CMF) will
achieve a 25% reduction in the risk of
relapse over a 10–15-year period.

30. • Do we give post menopausal with poor
prognosis too?
• Do we give it to pt with negative lymph
nodes?
• Can it be given with hormonal therapy?
• And what is the effect of combining both?

31. Chemotherapy used to be prescribed only to
premenopausal women with a poor prognosis (in
whom its effects are likely to be the result, in
part, of a chemical castration effect) but it is now
also offered to postmenopausal women with poor
prognosis disease. Chemotherapy may be
considered in node-negative patients if other
prognostic factors, such as tumour grade, imply
a high risk of recurrence. The effect of combining
hormone and chemotherapy is additive.hormone
therapy is started after completion of
chemotherapy to reduce side effects.

32. Hormonal Therapy

33. Tamoxifen :it has now been shown to reduce the annual rate of
recurrence by 25%, with a 17% reduction in the annual rate of death. Beneicial
effects of tamoxifen in reducing the risk of tumours in the contralateral breast have
also been observed.
Aromatase Inhibitors (AI): used for post menopausal pts
seems to be superior to tamoxifen in term relapse free survival and additional
reduction in contralateral disease,this includes Letrozole (Femara) Anastrozole
(Arimidex)and Exemestane (Aromasin)
LHRH:goserelin (Zoladex) and leuprolide (Lupron
Fulvestrant (Faslodex)
Hormonal Therapy
Seth Dory

34. Like the inflammatory breast cancer and
fungating tumours.
Palliative chemotherapy or hormonal
Therapy
Toilet mastectomy :occasionally is done
(but may worsen the outcome)
Locally advanced inoperable breast
cancer

35. Occasionally it presented with metastasis
and the primary is occult,we know is breast
c a b y t h e a i d o f
immunohistochemistry.Management should
be aimed at palliation of the symptoms and
treatment of the breast cancer, usually by
endocrine manipulation with or without
radiotherapy.
Treatment of advanced breast
cancer

36. Reconstruction :
• Breast reconstruction:
1.selicone gel implants
2.Masculocutanous flaps:
I. latissimus dorsi muscle (an LD lap)
II.the transversus abdominis muscle (a TRAM lap
• Nipple reconstruction
• Manipulation of the other side to achieve symmetry
• Prosthetics: 1. Breast prosthesis
2. Nipple prosthesis

37. Treatment:
Surgery Radiotherapy Systemic Reconstructive
Excision DXT Hormonal Breast
Simple
mastectomy
Chemotherapy
Nipple
Radical
mastectomy
Immunotherapy
Prosthesis

38. Tx of pregnant

39. The disease tends to behave similarly to that of non
pregnant therefore the Txis similar with the following
exceptions:
• Radiotherapy should be avoided
• Chemotherapy should be avoided only in the 1st
trimester
• Hormonal therapy is potentially teratogenic
(Note:the pregnancy seems to not be affecting the
outcome,and regarding whether is possible to conceive
after Dx,is recommended to at least wait 2 year as the
disease tends to reoccur in first 2 years after Tx.

40. Follow up
• It is current practice to arrange yearly or 2-
yearly mammography of the treated and
contralateral breast.
• There is currently no routine role for repeated
measurements of tumour markers or imaging
other than mammography.

41. Screening

42. Screening
The incidence rate carcinoma in situ rose in the
U.S.A. due to screening for breast cancer, by
combination of 3 elements:
• Self examination
• Mammography(50-70 years)
• FNA cytology
Note:MRI is used to screen those at very high risk or where
radiation might be hazardous (Li-Fraumeni syndrome).

43. Male breast cancer:
• 0.5%
• Risk factors (BRCA genes)
• Infiltrating DC
• Aggressiveness
• Tx

44. Male Breast ca
of the male breast accounts for less than 0.5% of all cases of breast cancer.
The known predisposing causes include gynaecomastia and excess
endogenous or exogenous oestrogen. As in the female it tends to
present as a lump and is most commonly an infiltrating ductal
carcinoma. The implications for men who carry a BRCA gene
alteration depends on whether the alteration is in BRCA1 or BRCA2.
Men who carry a BRCA1 gene alteration, may have a slightly higher
risk of male breast cancer. About 1% or 1 in 100 men who carry
BRCA1 develop breast cancer. Some studies suggest there may be a
slight increase in the risk of prostate cancer, but this is not
conclusive. Men who carry a BRCA2 gene alteration have a higher
lifetime risk of developing prostate cancer. 1 in 4 - 1 in 5 (20-25%) of
men who carry BRCA2 develop prostate cancer at some point. Most
of these prostate cancers occur over the age of 45. Men who carry a
BRCA2 alteration also have a higher chance of getting breast cancer.
The chance of this is about 1 in 14 (7%).

45. • Bailey, H. (2018) Bailey & Love’s short practice of
surgery. 27th edition. Edited by N. S. Williams, P. R.
O’Connell, and A. W. McCaskie. Boca Raton, FL:
CRC Press.
• Browse’s Introduction to The Symptoms and Signs of
Surgical Disease.
• American cancer society .
• osmosis.org
REFERENCES