Breast Cancer introduction, types, clinical features, investigation & management.

1. Carcinoma Breast
Virendra Palsaniya
ESIC Medical co
ll
ege, Hyderabad

2. CANCER
A disease that is characterized by uncontrolled cell growth in an
organ, the site the cells originate from.
BREAST CANCER
Begins in the breast tissue and may start in the duct or lobe of
the breast. When the "controls" in breast cells are not working
properly, they divide continually and lump or tumor is formed.

3. INCIDENCE
30% of all female cancers
20% of cancer related deaths in females
2-4% bilateral
2-5% hereditary
Lump in the breast-most common presentation (75%)
10% presents with pain
35-45% with mutation of BRCA1 gene 70% blood spread
occurs to bones
Incidence in India is one in 100 women.

4. RISK FACTORS
…

8. ...

10. 3 MEDALLARY CARCINOMA
-Large so
ft
we
ll
circumscribed
4 MUCINOUS CARCINOMA
-Bulky and so
ft
5 TUBULAR CARCINOMA
-Diagnosed only when more than 75% of the tumor is
tubular formation
6 PAPILLARY CARCINOMA
-Presence of papi
ll
ae
7 MASTITIS CARCINOMATOSIS
-Most malignant form
- During pregnancy & lactation

12. Diagnosis of Breast cancer
Clinical Examination
Radiology
-Mammography - > 35y
-USG - < 35y
Pathology
-FNAC
-Core (Tru-cut) Biopsy

13. I - Clinical Presentation
A. Symptomatic Cases:
1. Painless lump
2. Pain
3. Nipple discharge
4. Paget's disease of the nipple
5. Mastitis carcinomatosa (in
fl
ammatory carcinoma)
6. Skin manifestations of breast cancer
7. Metastatic presentation
(if this is the only presentation - occult presentation)
-Regional axi
ll
ary or supraclavicular L.N
-Distant metastasis
-May be the 1st complaint
B. Asymptomatic Cases:
Discovered accidenta
ll
y during screening programs

15. 1- Painless lump:
discovered accidenta
ll
y by the patient (e.g. during bathing) or
by physician during screening programs on examination
usua
ll
y:
not tender
irregular shape and surface
i
ll
de
fi
ned edge or we
ll
-circumscribed edge
hard consistency
fr
eely mobile (at early stages), but become
fi
xed either
to overlying skin or underlying tissues (in late stages)
2- Pain:
due to in
fi
ltration of nerves, infection with mastitis
carcinomatosa

16. 3-Nipple discharge:
• Bloody in - duct carcinoma
• Past like in - comedo carcinoma
• Necrotic discharge - in degenerating carcinoma
4- Paget's disease of the nipple:
• Crusty,
fl
aking lesion
• Gradual onset over months or years
• Associated with underlying breast malignancy
• Diagnosis con
fi
rmed by needle or wedge biopsy
• Mammography is mandatory

17. Bloody nipple discharge
Paeu d’orange appearance

18. 5- Mastitis Carcinomatosa (In
fl
ammatory Carcinoma):
Usua
ll
y in pregnant & lactating
• Breast is painful
• Skin - erythematous, warm & oedematous
6- Skin manifestation of breast cancer:
Due to Cooper's ligament in
fi
ltration:
1) Dimpling 2) Tethering 3) Puckering
Due to direct skin in
fi
ltration:
4) Skin
fi
xation 5) Ulceration 6) Fungation
7) Nipple retraction 8) Paget's disease of nipple
Due to lymphatic involvement:
9) Peau d'orange (Pitted edema) 10) Sate
ll
ite nodules
Due to venous involvement:
11) Dilated veins

19. II - Radiology
1- Mammography
Def: Low voltage compression X-ray taken
in 2 directions (craniocaudal- mediolateral)
Indication:
- female> 35
- doubtful mass
- Nipple discharge
- Paget's disease
- F
ll
ow up
Accuracy: 90%
2- Xeroradiography
As mammography but image
recevied on selenium plate
-more accurate & easier reading
3- Ductography :
to identify
fi
ll
ing defect in the duct

20. 4- Ultrasonography
- female < 35 years
- di
ff
erentiate cystic
fr
om solid
5- MRI
- di
ff
erentiate
fi
brosis & recurrence

21. Radiographic imaging of breast tissue

25. IV - INVISTIGATION FOR
METASTASES
LUNG : X-ray & CT
LIVER : liver function test -U/S-CT
BONE : bone survey & scan
BRAIN : CT

28. N (L.N. status)
(All - Ipsilateral)
Nx -Regional L.N. cannot be assessed (previously removed)
No -regional L.N. metastasis
N1 -Ipsilateral mobile axillary L. N.
N2 -Ipsilateral
fi
xed axillary L. N.
(
fi
xed to one another or to other structures)
N3 -Ipsilateral infraclavicular L.N.
-ipsilateral internal mammary with axillary L.N.
-Ipsilateral supraclavicular L. N.

29. M(Metastasis)
Mo - No evidence of metastasis
M1 - Distant metastasis (Lung, Bone, Liver, Brain)
- Contralateral breast or Lymph nodes

31. Prognosis
I- Tumor related factors:
1. L.N. status:
a. Number of L.N.
b. Size of L.N.
c. Level of L.N
2. Tumor size:
3. Tumor grade
4. T.N.M staging
5. Metastasis
6. Tumor site
7. Histopathologic type
8. Biological markers:
1) Hormone receptor status
2) Cathepsin D
3) P53
4) HER-2/neu

32. II- Patient related factors:
1. Age
2. Sex
3. Pregnancy
4. Obesity

33. Breast Cancer Treatment
Treatment for breast cancer is o
ft
en a combination of
the fo
ll
owing treatments:
Surgery
Chemotherapy
Radiation
Hormone Treatment

34. Treatment
I.
Early breast cancer:
Non invasive (Stage 0) -
Surgery + Adjuvant (postoperative) therapy
Stage I & II -
Surgery + Adjuvant (postoperative)therapy
II. Advanced breast cancer:
Stage III (Locally advanced) -
Neoadjuvant (preoperative) therapy + Surgery
Stage IV (Metastatic) -
Systemic therapy + Limited Surgery

35. Early Breast Cancer
(Stage I & II)
Surgery
removing the area of concern and some normal tissue
surrounding it is ca
ll
ed a lumpectomy
removing the breast is ca
ll
ed a mastectomy (most women
with breast cancer wi
ll
not need the breast removed )
lymph nodes
fr
om under the arm may be removed with
either surgery

36. I- Surgery
1. Mastectomy:
Indications:
1. Tumor > 4 cm
2. Multi-centricity
3. Central (retroareolar) location
Types:
1. Sparing mastectomy + immediate breast reconstruction
2. Traditional mastectomy + late breast reconstruction
2. Breast Conservative Surgery (B.C.S):
Indications:
1. Tumor < 4cm
2. No multi-centricity
3. Peripheral location

37. Mastectomy
A. Traditional Non Sparing Mastectomy
1. Super (Extended) radical (Urban)
2. Radical mastectomy (Halstedt)
3. Modi
fi
ed radical mastectomy
-Patey's operation
-Auchen-closs operation
4. Total mastectomy
5. Simple mastectomy
6. Toilet mastectomy
B. Sparing Mastectomy
1. Skin sparing mastectomy (S.S.M)
2. Nipple sparing mastectomy (N.S.M)
3. Subcutaneous mastectomy

39. Indications of
BREAST CONSERV
ATION THERAPY
1. Single tumor (no multi-centricity)
2. Tumor size <<4 cm (clinically & mammography)
3. Peripheral location (not central or retroareolar)
4. No signs of local advancement (T4).
5. No or N1 (no extensive nodal involvement).
6 Mo (no metastasis)

40. Contraindications
1. Multi-centricity - high incidence of local recurrence
2. Tumor size =/> 4 cm or increased tumor/breast ratio.
3. Central (retroareolar) location - bad cosmetic
result.
4 Signs of local advancement (T4).
5. N2 or N3
6. Metastasis (M1).
7. Pregnancy (3rd trimester; radiotherapy can not be
delivered)
8 Collagen vascular disease - high toxicity of
radiotherapy.

41. Early Breast Cancer
(Stage I&II)
Radiotherapy
standard treatment a
ft
er a
lumpectomy to reduce the
chance of the breast cancer
coming back in the same
breast
is also ca
ll
ed local treatment
because it a
ff
ects only the area
being treated with radiation

42. II- Adjuvant (postoperative)therapy
1.
Radiotherapy:
Indications:
1. After all cases of B.C.S. (must be taken within one month to
tumour bed and remaining part of breast)
2. After mastectomy (must be taken within 6 months); if:
- Tumor =/> 4 cm
- >4 +ve L.N. or extra-nodal disease
- Grade III
- Lymphovascular emboli (invasion)

43. II.
Systemic Therapy: Choice is according to:
1. L.N. status
. - ve L.N.
◦ Low risk - No systemic therapy
◦ Tumor < 1 cm
◦ Grade I
◦ ER +ve
Age > 35 years
o Moderate or high risk - systemic
therapy
II. +ve L.N. -Systemic therapy

44. Axillary Surgery in Breast Cancer
1-Axi
ll
ary lymph node dissection (ALND):
At least levels I & II axillary lymph nodes should be
removed
2- Sentinel L.N. biopsy:
Sentinel L.N. = 1st L.N. to drain the cancer
accepted with clinically negative axillary L.N.
3-Axi
ll
ary L.N. sampling:
Excision of the lowest 4 or 5 palpable L.Ns from level I &
sent separately for histopathologic examination.

45. First
Neo adjuvant chemotherapy (3-4 cycles)
Then
Surgery
Then
Post operative chemotherapy (6 cycles)
Then
Post operative radiotherapy
Late Breast Cancer
Stage III(locally Advanced)

46. Late Breast Cancer
Stage IV (Metastatic)
1- Pa
ll
iative systemic therapy is the Main line of treatment

47. 2- Surgery:
1. For primary tumor -Palliative Toilet Mastectomy
(as simple mastectomy), but indicating only in
ulcerating and fungating tumors with infection.
2. For metastases -
• Laminectomy for spinal cord compression.
• Internal
fi
xation of pathological long bone
fractures.
• Pleurodesis (chest tube + intrapleural Bleomycin)
for malignant pleural e
ff
usion.

48. - Growth of many breast cancers can be blocked
by taking hormone therapy.
- Treatment is in the form of pill which is taken
for 10 years.
- May be recommended for women who have a
breast cancer that is sensitive to hormone.
Hormone Treatment

49. Thank
You