Ayesha Mughal
Resident
Ectoderm: Epithelial lining of ducts and
acini.
Mesenchyme: Stroma.
Mammary Ridge: Develops from
ectoderm, at 5th week,...
 Extent:
• 2nd to 6th rib.
• Sternum to mid-axillary line.
 Position:
• Two third over pectoralis major.
• One third ove...
Internal mammary artery.
Axillary Artery.
• Lateral thoracic artery.
• Acromioclavicular Artery.
• Subscapular Artery.
...
Internal Thoracic Vein.
Axillary Vein.
Posterior Intercostal Vein
 Cutaneous branches of intercostal nerves
T4 to T6.
 Sympathetic Supply.
 75% is to Axillary Lymph Nodes.
 25% to Internal Mammary Nodes.
 Sentinel Lymph Node.
 One in eight women will develop breast
cancer in their lifetime.
 Second most common cause of cancer
death among women ...
Ductal Carcinoma In Situ
Lobular Carcinoma In Situ
Invasive Breast Cancer
• Invasive Ductal Carcinoma
• Invasive Lobula...
 Age
 Early Menarche
 Late Menopause
 Nulliparous
 Not breast-feeding
 HRT
 OCP
 Family History
 Li-Fraumeni Synd...
 5 to 10% of all breast cancers.
 p53: A tumor suppressor gene.
 Both BRCA1 and BRCA2 function as tumor-
suppressor gen...
Breast Lump.
Axillary Lump.
Asymmetry.
Pain(very rare).
Skin abnormalities.
Nipple abnormalities.
Triple Assessment
Staging
Treatment
• Surgery
• Radiotherapy
• Systemic Treatment
Clinical
• History
• Examination
Radiology
• Ultrasound
• Mammography
Pathology
• FNAC
• Tru Cut biopsy
20 to 39 years:
• BSE: Monthly
• Clinical Breast Examinaiton: 3 Yearly.
40 years and above:
• BSE: Monthly
• Clinical Br...
Grade I: Well differentiated.
Grade II: Moderately differentiated.
Grade III: Poorly differentiated.


 TNM Staging
• Tumour Size:
 Tis CIS
 T1 <2cm in size
 T2 2 to 5 cm in size
 T3 > 5cm in size
 T4 Involving skin or ...
I: T1,N0,M0
II: T1,N1,M0 or T2,N0-1,M0
III: T4,N0-3,M0
IV: T1-4,N0-3,M1
Size of primary tumour
Nodal status
Tumour grade
ER status
Lymphovascular Invasion
HER-2
Notingham Prognostic Indic...
Breast Conserving Surgery
• WLE
• Quadrantectomy
Mastectomy
• Simple Mastectomy
• Subcutaneous Mastectomy
• Radical Mast...
Clinical exmination, Histology and
Radiology discussed with MDT.
Decision for mastectomy documented.
Patient consented ...
 Supine.
 Ipsilateral arm abducted.
 Examine breast before incision
 Arm prepped and wrapped.
Incision:
 Carefully pl...
 Incision deepened.
 Upper and lower skin flaps raised.
Radiation:
Hormonal:
Chemotherapy:
Prophylactic:
Decreases risk of local recurrence.
Axillary nodal radiation.
For high risk of local recurrence.
Inoperable locally ad...
ER positive plus node positive or high risk
node negative.
For palliation of metastases.
Tamoxifen.
Aromatase Inhibito...
ER negative plus node positive/high risk
node negative.
ER positive and young age.
Stage I disease at high risk of recu...
Axillary lymph node clearance.
Sentinel node biopsy.
Axillary node sampling.
 Chest infection.
 DVT/PE
 Wound infection.
 Hematoma.
 Seroma formation.
 Skin necrosis.
 Lymph edema of arm and b...
Immediate.
Delayed.
Prosthesis.
Tissue expansion.
Myocutaneous flaps.
Nipple reconstruction.
Reduction mammoplasty ...
Radiotherapy
Hormonal Therapy
Ovarian Ablation
Chemotherapy
To decrease the incidence of local
recurrence.
For positive axillary lymph nodes.
To treat axillary recurrence.
To tre...
Breast cancer 2
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Breast cancer 2

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  • In stage I and II disease, the adjuvant radiotherapy decreases the risk of local recurrence, increase the disease free survival but the effect on overall survival is controversial
  • Breast cancer 2

    1. 1. Ayesha Mughal Resident
    2. 2. Ectoderm: Epithelial lining of ducts and acini. Mesenchyme: Stroma. Mammary Ridge: Develops from ectoderm, at 5th week, from axilla to groin(Milk Line) Breast Bud: 10 years age. Nipple: 12 years age.
    3. 3.  Extent: • 2nd to 6th rib. • Sternum to mid-axillary line.  Position: • Two third over pectoralis major. • One third over Serratus Anterior  Suspensory Ligaments: • Divide breast into lobules. • Connect deep fascia to skin.  Lobules: • 15 to 20 lobues, drain into lactiferous ducts and then lactiferous sinus.
    4. 4. Internal mammary artery. Axillary Artery. • Lateral thoracic artery. • Acromioclavicular Artery. • Subscapular Artery. Posterior Intercostal Arteries.
    5. 5. Internal Thoracic Vein. Axillary Vein. Posterior Intercostal Vein
    6. 6.  Cutaneous branches of intercostal nerves T4 to T6.  Sympathetic Supply.
    7. 7.  75% is to Axillary Lymph Nodes.  25% to Internal Mammary Nodes.  Sentinel Lymph Node.
    8. 8.  One in eight women will develop breast cancer in their lifetime.  Second most common cause of cancer death among women overall(lung cancer is number 1).  Incidence increases with increasing age.  One percent of breast cancers occur in men.
    9. 9. Ductal Carcinoma In Situ Lobular Carcinoma In Situ Invasive Breast Cancer • Invasive Ductal Carcinoma • Invasive Lobular Carcinoma • Mucoid Carcinoma • Medullary Carcinoma • Papillary Carcinoma • Cribiform Carcinoma • Tubular
    10. 10.  Age  Early Menarche  Late Menopause  Nulliparous  Not breast-feeding  HRT  OCP  Family History  Li-Fraumeni Syndrome  History of breast disease  Radiation  Obesity  High alcohol intake.
    11. 11.  5 to 10% of all breast cancers.  p53: A tumor suppressor gene.  Both BRCA1 and BRCA2 function as tumor- suppressor genes.  BRCA1 and BRCA2 both are inherited in an autosomal dominant fashion with varying penetrance.  BRCA1: On 17q, also associated with ovarian cancer.  BRCA2: On chromosome 13q, also associated with male breast cancer.  Somatic mutation of p53 in 50% and of Rb in 20% of breast cancers.
    12. 12. Breast Lump. Axillary Lump. Asymmetry. Pain(very rare). Skin abnormalities. Nipple abnormalities.
    13. 13. Triple Assessment Staging Treatment • Surgery • Radiotherapy • Systemic Treatment
    14. 14. Clinical • History • Examination Radiology • Ultrasound • Mammography Pathology • FNAC • Tru Cut biopsy
    15. 15. 20 to 39 years: • BSE: Monthly • Clinical Breast Examinaiton: 3 Yearly. 40 years and above: • BSE: Monthly • Clinical Breast Examination: Annually. • Mammography: Annually.
    16. 16. Grade I: Well differentiated. Grade II: Moderately differentiated. Grade III: Poorly differentiated.  
    17. 17.  TNM Staging • Tumour Size:  Tis CIS  T1 <2cm in size  T2 2 to 5 cm in size  T3 > 5cm in size  T4 Involving skin or chest wall • Nodes:  N0 No lymph node involved  N1 Palpable mobile ipsilateral axillary node  N2 Fixed involved axillary node  N3 Ipsilateral internal mammary node • Metastases:  M0 No distant metastases  M1 Distant metastases
    18. 18. I: T1,N0,M0 II: T1,N1,M0 or T2,N0-1,M0 III: T4,N0-3,M0 IV: T1-4,N0-3,M1
    19. 19. Size of primary tumour Nodal status Tumour grade ER status Lymphovascular Invasion HER-2 Notingham Prognostic Indicator scoring system
    20. 20. Breast Conserving Surgery • WLE • Quadrantectomy Mastectomy • Simple Mastectomy • Subcutaneous Mastectomy • Radical Mastectomy • Modified Radical Mastectomy • Patey Mastectomy
    21. 21. Clinical exmination, Histology and Radiology discussed with MDT. Decision for mastectomy documented. Patient consented and counselled. Side marked.
    22. 22.  Supine.  Ipsilateral arm abducted.  Examine breast before incision  Arm prepped and wrapped. Incision:  Carefully planned  Ellipse  Upper and lower margins should be of equal length  Incision away from obvious tumour
    23. 23.  Incision deepened.  Upper and lower skin flaps raised.
    24. 24. Radiation: Hormonal: Chemotherapy: Prophylactic:
    25. 25. Decreases risk of local recurrence. Axillary nodal radiation. For high risk of local recurrence. Inoperable locally advanced cancer. Metastases Stage I/II disease
    26. 26. ER positive plus node positive or high risk node negative. For palliation of metastases. Tamoxifen. Aromatase Inhibitors. Ovarian Ablation. Progestins. Androgens.
    27. 27. ER negative plus node positive/high risk node negative. ER positive and young age. Stage I disease at high risk of recurrence. Palliation of metastatic disease.
    28. 28. Axillary lymph node clearance. Sentinel node biopsy. Axillary node sampling.
    29. 29.  Chest infection.  DVT/PE  Wound infection.  Hematoma.  Seroma formation.  Skin necrosis.  Lymph edema of arm and breast.  Shoulder stiffness.  Numbness of inner arm.  Risk of damage to nerves.  Poor cosmesis.
    30. 30. Immediate. Delayed. Prosthesis. Tissue expansion. Myocutaneous flaps. Nipple reconstruction. Reduction mammoplasty or mastopexy of contralateral breast.
    31. 31. Radiotherapy Hormonal Therapy Ovarian Ablation Chemotherapy
    32. 32. To decrease the incidence of local recurrence. For positive axillary lymph nodes. To treat axillary recurrence. To treat post mastectomy chest wall: • Grade III, multifocal. • Cancers > 4cm. • Presence of lymphovascular invasion. • >3 positive axillary lymph nodes.

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