1. BREAST CANCER
By WAN AWATIF

2. OUTLINE
• Introduction
• Risk factors
• Clinical features
• Staging
• Investigation
• Management

3. INTRODUCTION
• The common cause of death in middle-aged
women in Western countries.
• in women amongst all races from the age of 20
years in Malaysia for 2003 to 2005.
* Breast cancer is most common in the Chinese,
followed by the Indians and then, Malays.
* Breast cancer formed 31.1% of newly
diagnosed cancer cases in women in 2003-2005.

5. RISK FACTORS

6. BREAST CARCINOMA – RISK FACTORS

7. BREAST CARCINOMA – RISK
FACTORS

8. BREAST CARCINOMA – RISK
FACTORS

9. CLINICAL FEATURES
• Breast lump
• Dry scaling / red weeping.
• Blood stained nipple discharge
• Painless
• Site : commonly in the upper outer quadrant
• Tumour fixation : -
-Breast distortion
-flattening of contour
-dimpling or puckering of the overlying skin
-Nipple retraction
• Nipple eczema in Paget’s disease

10. • Firm to hard in consistency
• Irregular and indistinct edge
• Mobile, softer and well circumscribed (esp in
mucoid and medullary ca)
• In advanced :
Skin ulceration
Must palpate axillae
Infiltration and supraclavicular
areas
Oedema

12. BREAST - SKIN CHANGES
• Retracted nipple
• Asymmetry
• Skin changes

13. BREAST – SKIN CHANGES
• Swelling
• Skin necrosing
• Inflammation

15. CLASSIFICATION – BREAST CARCINOMA
 NON-INVASIVE/IN SITU  Colloid (mucinous)
CARCINOMA carcinoma
 Intraductal carcinoma  Papillary carcinoma
 Lobular carcinoma in situ  Tubular carcinoma
 Adenoid cystic carcinoma
 INVASIVE CARCINOMA  Secretory carcinoma
 Infiltrating ( invasive )  Inflammatory carcinoma
duct carcinoma – NOS
 Carcinoma with metaplasia
 Infiltrating ( invasive )
lobular carcinoma
 Medullary carcinoma  PAGET’S DISEASE OF THE
NIPPLE

16. DUCTAL CARCINOMA IN SITU
• Most DCIS  detected by calcifications
on mammography/mammographic
density - periductal fibrosis surrounding
a DCIS/rarely palpable mass/ nipple
discharge/incidental finding on a biopsy
for another lesion.
• Spreads through ducts & lobules 
extensive lesions  entire sector of a
breast.
• DCIS – involves lobules – acini
distorted, unfolded  appear as small
ducts.

17. PAGET’S DISEASE OF NIPPLE

18. INVESTIGATION- TRIPLE ASSESSMENT
54. NICE guidelines 2009; 55. KCE Belgian guideline, 2007

19. Triple Assessment
• All patients presenting with breast symptom
should have a full clinical examination
• If a localised abnormality is present, >>>
mammography and /or ultrasound
examination
• >>>>core and /or FNAC depending on the
clinician’s, radiologist’s and pathologist’s
experience.
19
55. Belgian Guideline 2007

20. • In young women (< 40 years old), ultrasound
should be the initial imaging modality as part
of the triple assessment

21. MAMMOGRAPHY
• a screening tool
• Detects:
- Lumps
- changes in breast tissue
- calcifications too small to be found in a physical exam.
• Soft tissue radiographs are taken by
-placing the breast in direct contact with ultrasensitive film
• Very safe investigation -expose to low-voltage.
• Sensitivity increases with age (breast become less dense)
• Screening procedure
– monitoring patients at high risk for breast ca
– Women > 40 years
• 5% of Br Ca can be missed.
• Mammogram: does not exclude Br Ca.

23. ULTRASOUND
• Useful in young women with dense breast.
• Distinguish cysts from solid lession
• Localise impalpable areas of breast pathology
• Not useful as a screening tool

25. BIOPSY
• 3 ways
– Fine needle aspiration
– Core needle biopsy
– Incisional / excisional open biopsy
• Microscopic examination

27. Core Biopsy (CB) in
combination with Fine Needle
Aspiration Cytology (FNAC)
Core biopsy in combination with
FNAC may be used where facility
and expertise are available
27

28. Others
• Baseline investigation
• detection of metastatic disease:
– liver function tests
– serum calcium
– chest radiograph
– isotope bone scan
– liver ultrasound scan
– CT brain
- in cases where suspicion is great clinically

30. TNM CLASSIFICATION

31. Stage I : T1 N0 M0
Stage II A : T1 N1 M0 / T2 N0 M0
Stage II B : T2 N1 M0 / T3 N0 M0
Stage III A : T1 N2 M0 / T2 N2 M0 /
T3 N1 M0 / T3 N2 M0
Stage III B : T4 any N M0 / any T N3 M0
Stage IV : any T any N M1

32. MANCHESTER SYSTEM
•distant metastases other than the
axillary nodes or
•satellite nodules on breast or
•supraclavicular nodal involvement

34. EARLY BREAST CA
Stage I : T1 N0 M0
Stage IIA :
• T0 N1 M0 Breast conservation is
• T1 N1 M0 appropriate. It is an
alternative to Mastectomy
• T2 N0 M0
Stage IIB - T2 N1 M0

35. Breast conservation
• Removal of the tumour only
• tumour should be <4cm in size for BCT.
• >>>> radiotherapy.
• Patient should be willing to take radiotherapy and come for
regular follow up.
• Absolute contraindications:
 Pt’s wish to avoid radiotherapy
 Multifocal invasive breast breast cancer
 Large tumour in a small breast
 Widespread of ductal carcinoma in situ. (DCIS)
• Then pt needs to do a mastectomy.

36. RADIOTHERAPY
• Improving local control
• After BCT for early invasive BC

37. MASTECTOMY
1. Radical Mastectomy (Halsted)
• Stage III, IV
• Excision of pectoralis major muscle, excision of
breast, axillary LN, pect. major & minor
• no longer indicated
2. Simple mastectomy -
– removes breast only, with no dissection of axilla
(except for axillary tail - usually attached to a few
LN in the anterior group)

38. MASTECTOMY
Indications:
Indications:
large tumour (( in relation to breast size)
large tumour in relation to breast size)
central tumours beneath or involved the nipple
central tumours beneath or involved the nipple
local recurrence
local recurrence
absolute C/I to radiotherapy
absolute C/I to radiotherapy
pt’s preference
pt’s preference
skin/ collagen vascular disease that may be
skin/ collagen vascular disease that may be
complicated by radiotherapy
complicated by radiotherapy
inavailability of radiotherapy facilities or non-
inavailability of radiotherapy facilities or non-
compliance with radiotherapy
compliance with radiotherapy

39. 3. Modified Radical Mastectomy:
1. Patey
• the whole breast
• large portion of skin, the centre of which overlies the tumour,
but always include the nipple
• all of the fat, fascia, LN of axilla
• preservation of axillary vein & nerves to serratus anterior,
pectoralis major & latissimus dorsi
4 Total mastectomy w/ or w/o radiation:
1. Crile – Total mastectomy
2. Mc Whirter – Total mastectomy and radiation (Axilla,
• supraclavicular and internal mammary
nodes)

41. 5. Subcutaneous Mastectomy:
• Nipple is retained / for T1s
5. Quandrantectomy, axillary, radiotherapy
(QUART)
• Quadrant of the breast that has the CA is resected
• (quadrant of breast tissue, skin and
superficial pectoralis fascia)
• Unacceptable cosmetic result

43. AXILLARY TREATMENT
• At least 4 of LN from axillary fat for analysis.
• Can be done w or w/o the removal of pectoralis minor
muscle.
• Axillary sample- removal of 4/> LN from proximal ant/
pectoral & central gp of draining LN in axilla
• Axillary dissection: dissecting the axilla to various anatomical
levels-
– level I: removal of LN lateral to inferior border of pec.
Minor
– level II : removal of level I LN & those behind & in front of
pec. Minor
– level III : removal of all the lymphatic tissue
• Axillary clearance ; level III axillary dissection

44. complications of axillary treatment:
intraoperative- damage to nerves
postoperative- wound
complications, lymphoedema

46. BREAST RECONSTRUCTION
• By plastic surgeons or specialist breast surgeons.
• Method is depend on shape of contralateral
breast and chest wall.
• Can be made either of a silicone implant or
autologous material or both methods.
• Indicated for;
– < 55 yrs old
– DCIS, LCIS & Stage I & II BC
– pt who are undergoing prophylactic mastectomy

47. • Chemotherapy:
– Cyclophosphamide, metrotrexate , 5-fluorouracil (CMF) = gold
standard.
– combination of chemotherapeutic agent containing
doxorubicin can be used
– Administration of chemotherapy ( 2/> agents) improves
survival rate
– Side effect: nausea, vomiting, myelosuppression, alopecia,
thrombocytopenia, exercise intolerance
47

48. • Hormonal Therapy:
Anti-estrogen:
a. Tamoxifen – a non-steroidal anti-estrogenic
compound that compete w/ estrogen at
receptor site.
– Estrogen receptor assay should be
determined; if negative chance of success is
very low
48

49. Mechanism of action of tamoxifen
as an antitumor agent
Anti-estrogen effects
- blockage of estrogen receptor
Local effects - independent of
oestrogen receptor
Decrease TGFα stromal
cell
+
Increase TGFβ
-
49

50. Aromatase inhibition within
the breast tumour cell
P-450 Aromatase
tumour
+ NADPH-cytochrome P-450 reductase
growth
ANDROGENS OESTROGENS
(Testosterone, (Oestradiol, oestrone)
androstenedione,
16-OH-testosterone)
Aromatase Inhibitors
50

51. Therapeutic Approach for Breast Cancer
A. Carcinoma in Situ:
1. DCIS:
a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifen
b. Total mastectomy w/ or w/o tamoxifen
c. Breast-conserving surgery w/o radiation therapy
2. Lobular Carcinoma in Situ:
a. Observation after diagnostic biopsy
b. Tamoxifen to decrease the incidence of subsequent breast cancer
c. Bilateral prophylactic total mastectomy, w/o axillary dissection
51

52. Follow - up
• ALL pts with BC should be F/U
• Objectives of F/U:
– support & counselling
– detect potentially curable conditions ( such as
local recurrence of cancer in the breast
following BCT & to detect new cancers in
opposite breast)
– manage pts in whom metastatic develops, &
to determine outcome

53. • During F/U:
– history, P/E
– advise pt to do BSE monthly
– annual mammography after therapy for primary
BC
– after BCT, the first mammogram should be
performed 6 months after completion of
radiotherapy

54. THANK YOU