Breast cancer is the most important medical challenge that we are facing in present time. I want to focus on the breast cancer after taking about normal anatomy and development of the breast. I will concern about: 1. what is the breast cancer! 2. Clinical features 3. How to detect 4. Management and prognosis. I want to work and keep researching on Breast cancer to find the remedy to save lives.

1. Breast Cancer
Eman A. Abu Qwaider
Faculty of Medicine -Al-Quds University

2. Outline of the presentation
The outline of my presentation is as follows:
 Anatomy of the Breast
 Development and Physiology of the Breast
 What is the Breast Cancer and
Epidemiology
 Risk factors of Brest Cancer
 Clinical Presentation of Breast Cancer
 Types of Breast Cancer
 Detection
 Management
 Prognosis

3. Breasts are modified apocrine sweat glands, present
bilaterally in pectoral region within layers of
superficial fascia and Rest on deep fascia.

4. Anatomy of the Breast
Extent: Vertically-
2nd to 6th ribs.
Horizontally-
lateral border of sternum
To anterior-axillary line.

5. Axillary tail of Spence is a prolongation of upper,
outer quadrant in axillary direction passes under
axillary fascia
 The axillary tail of the breast is of surgical importance.
 In some normal subjects
it is palpable and,
in a few, it can be seen
Premenstrually
or during lactation.
 A well-developed axillary tail
Is sometimes mistaken for
a mass of enlarged
lymph nodes
or a lipoma.

6. The lobule is the basic structural unit of the
mammary gland and milk-forming
glandular unit of the breast .
Each breast consists of ~15- 20 lobes
of secretory tissue .
Each lobe has one lactiferous duct
that opens on the areola.
Lobes (and ducts) arranged radially,
embedded in connective tissue
& adipose of superficial fascia .
Lobes composed of lobules,
Lobules comprise alveoli

7. Each lactiferous duct is lined with a spiral
arrangement of contractile myoepithelial cells and
is provided with a terminal Ampulla (collection
sites of lactiferous sinuses), a reservoir for milk or
abnormal discharges.

8. Fibrous connective tissue bands that extend from
the deep pectoral fascia to superficial dermal
fascia that provide structural support referred to
as Cooper’s Suspensory Ligaments.

9. Ligaments may retract when breast tumors are
present, so these ligaments account for the
dimpling of the overlying a carcinoma.

10. Left breast is usually slightly larger .
Base is circular, either flattened or concave
Separated from pectoralis major muscle by
fascia, retromammary space.

11. Surface Anatomy of the Breast
Outer surface :convex, skin covered .
Nipple: At fourth intercostal space ,Small conical/cylindrical
prominence below center .The nipple is covered by thick
skin with corrugations.
Near its apex lie the orifices
of the lactiferous ducts.
The nipple contains
smooth muscle fibres
arranged concentrically
and longitudinally;
thus, it is an erectile structure,
which points outwards.

12. The nipple Surrounded by Areola: pigmented
ring of thin skinned region lacking hair,
sweat glands ,Contains areolar glands which
have a dark pigment that intensifies with
pregnancy and Circular and radial smooth
muscle fibers that cause nipple erection.

13. The breast is divided into quadrants by
vertical and horizontal lines across the
nipple :
RUQ
RLQ
LUQ
LLQ

14. Blood supply :
Arterial:
1.Axillary artery via
The lateral thoracic And
Thoracoacromial branches
2.Internal mammary A. via
It’s perforating branches
3.Adjecent intercostal A,
Venous:
Follows arterial supply
Axillary vein responsible
For majority of
venous drainage

15. Innervations: derived from:
a.Anterior & lateral cutaneous nerves of
thorax
b. spinal segmentsT3 – T6

16. The lymphatics of the breast drain predominantly into the
axillary and internal mammary lymph nodes.The
axillary nodes receive approximately 85% of the
drainage and are arranged in the following groups:
• lateral, along the axillary vein;
• anterior, along the lateral thoracic vessels;
• posterior, along the subscapular vessels;
• central, embedded in fat in the centre of the axilla;
• interpectoral, a few nodes lying between the pectoralis major
and minor muscles ; Rotter’s nodes
• apical, which lie above the level of the pectoralis minor tendon
in continuity with the lateral nodes and which receive the
efferents of all the other groups.
Lymphatics drainage from nipple , areola , and lobules all
drain in a Subareolar Lymphatic Plexus.

18. There is a quadrants –wise drainage:
Lateral quadrant: Axillary nodes and supraclvicular
through the pectoral , interpectoral and
deltopectoral.
Medial quadrant: parasternal nodes .
Lower quadrant :inferior phrenic (abdominal)
nodes .

19. Levels of lymphatics drainage:
Level 1: lateral to lateral border of pectoralis
minor .
Level 11: deep to pectoralis minor .
Level 111:medial to medial border of pectoralis
minor .

20. Development and Physiology of
the Breast
Embryologically: Ectoderm
Breast development is occasionally seen in neonates
as a consequence of maternal estrogens crossing
the placenta.
Babies of both sexes may be affected and lactation
can occur “witches milk “, sometimes complicated
by abscess formation.
Female breast development commences shortly
before menarche .It may be a symmetrical and
uncomfortable and cause parental anxiety .

21. The breasts increase in size in the second half of
each menstrual cycle , following ovulation .Mild
pain and tenderness are common during this
phase.
In pregnancy and lactation, the size and texture of
the breast change profoundly making clinical
assessment more difficult .

22. Functionally:
part of reproductive system
1.Respond to sexual stimulation
2. Feed babies

23. Breast Cancer

24. What is the Breast Cancer ??
Breast cancer is a malignant tumor that
starts in the cells of the breast , arises
from the ductal tissue of the breast and,
arises from the ductal tissue of the breast
and, less commonly, the lobulartissue.

25. Epidemiology
Breast cancer is the most commonly
diagnosed cancer in women.
 The second Leading cause of death in
women
1/8 of women will develop breast cancer

26. Risk factors of Breast Cancer :
 Some risk factors, such as age, sex and family history,
can't be changed
 Whereas others, including weight, smoking and a poor diet, are
under control
1) Sex: only 1% of breasts cancers occur in men.
2) Age:
Your chances of developing breast cancer increase
with age. Close to 80 percent of breast cancers
occur in women older than age 50. In your 30s,
you have a one in 233 chance of developing
breast cancer. By age 85, your chance is one in
eight.

27. 3) Personal history of breast cancer :. If any women has
had breast cancer in one breast, she has an increased
risk of developing cancer in the other breast.
4) Family history : If you have a mother, sister or
daughter with breast or ovarian cancer or both, or a
male relative with breast cancer, you have a greater
chance of also developing breast cancer. In general, the
more relatives you have who were diagnosed with breast
cancer before reaching menopause, the higher your own
risk. If you have one first-degree relative — a mother,
sister or daughter — who was diagnosed with the
disease before age 50, your risk is doubled. If you have
two or more relatives, your risk increases even more.
Just because you have a family history of breast cancer
doesn't mean it's hereditary, though. Most people with a
family history of breast cancer (familial breast cancer
risk) haven't inherited a defective gene, such as BRCA1
or BRCA2. Rather, cancer becomes so common in
women who live into their 80s and beyond that random,
noninherited breast tumors may appear in more than
one member of a single family.

28. 5) Genetic predisposition: Between 5 percent and 10 percent of
breast cancers are inherited. Defects in one of several genes,
especially BRCA1 or BRCA2, put you at greater risk of
developing breast, ovarian and colon cancers. Usually these
genes help prevent cancer by making proteins that keep cells
from growing abnormally. But if they have a mutation, the
genes aren't as effective at protecting you from cancer.
6) Radiation exposure: . If you received radiation
treatments to your chest as a child or young adult,
you're more likely to develop breast cancer later in life.
Your risk is greatest if you received radiation as an
adolescent during breast development.
7) Excess weight.
The relationship between excess weight and breast cancer is
complex. In general, weighing more than is healthy
increases your risk, particularly if you gained the weight
as an adolescent. But risk is even greater if you put the
weight on after menopause.Your risk also is greater if
you have more body fat in the upper part of your body.
This is thought to be because of an increased conversion of
steroid hormones to estradiol in the body fat.

29. 8) Early onset of menstrual cycles: especially
before age 12, Experts attribute this risk to the
early exposure of the breast tissue to estrogen.
9) Late menopause: after age 55
10) First pregnancy at older age: after age 30, .
Although it's not entirely clear why, an early
first pregnancy may protect breast tissue
from developing genetic mutations that
result from estrogen exposure.
11) Race:White women are more likely to
develop breast cancer than black, but black
women are more likely to die of the disease
because their cancers are found at a more
advanced stage and more aggressive .

30. 12) Hormone therapy:
13) Birth control pills:The risk seems to be greater
for women who use birth control pills for four
or more years before their first full-term
pregnancy,
14) Smoking: Evidence is mixed on the relationship
between smoking and breast cancer risk. Some
studies show no link between cigarette smoking
and exposure to secondhand smoke and breast
cancer. Others suggest that smoking increases
breast cancer risk. Exposure to secondhand smoke
and breast cancer risk remains an area of active
research.
15) Excessive use of alcohol: women who drink
more than one alcoholic beverage a day have
about a 20 percent greater risk of breast
cancer than do women who don't drink.

31. 16) Precancerous breast changes (atypical
hyperplasia, lobular carcinoma in situ).
17) Absence of lactation; 5%, reduction of
risk per 12 month breast lactation.
18) Previous breast biopsy .
19) Low social class

32. Clinical features
• Palpable, hard, irregular, fixed breast lump,
usually painless.
• Nipple retraction and skin dimpling.
• Nipple eczema in Paget’s disease.
• Peau d’orange (cutaneous oedema
secondary to lymphatic obstruction).
• Palpable axillary nodes.

34. Clinical
features
of Breast
Cancer

35. The relationship of carcinoma of the
breast to the quadrants of the
breast:

36. The spread of Breast Cancer
 Local spread : The tumor increases in size and invades other
portions of the breast. It tends to involve the skin and to penetrate the
pectoral muscles and even the chest wall if diagnosed late.
 Lymphatics metastasis : Lymphatic metastasis occurs
primarily to the axillary and the internal mammary lymph nodes.
Involvement of supraclvicular nodes and of any contralateral lymph nodes
represents advanced disease.
 Spread by the bloodstream: It is by this route that
skeletal metastases occur, lumbar vertebrae, femur, thoracic
vertebrae, rib and skull are affected and these deposits are
generally osteolytic. Metastases may also commonly occur in the
liver, lungs and brain and, occasionally, the adrenal glands and
ovaries.

37. Diagram showing the most likely sites for
local and distant spread of metastases in
secondary (advanced) breast cancer.

38. Breast Cancer Types
Ductal Carcinoma In Situ: Ductal Carcinoma in
Situ (DCIS) is a non-invasive breast cancer where abnormal
cells have been contained in the lining of the breast milk duct.
Invasive Ductal Carcinoma: means that
abnormal cells that originated in the lining of the
breast milk duct have invaded surrounding tissue.

39. Invasive (or infiltrating) lobular
carcinoma: starts in the milk-producing glands
(lobules)

40. Inflammatory breast cancer: is a less
common form of breast cancer that may not
develop a tumor and often affects the skin, makes
the skin on the breast look red and feel warm. It
also may give the breast skin a thick, pitted
appearance that looks a lot like an orange peel.

41. In its early stages, inflammatory breast cancer is often mistaken
for an infection in the breast (called mastitis) and treated as an
infection with antibiotics. If the symptoms are caused by cancer,
they will not improve, and a biopsy will find cancer cells.

42. Paget disease of the nipple: This type of
breast cancer starts in the breast ducts and spreads to the
skin of the nipple and then to the areola. It is rare,
accounting for only about 1% of all cases of breast cancer.
The skin of the nipple and areola often appears crusted,
scaly, and red, with areas of bleeding or oozing.The woman
may notice burning or itching.

43. Triple Negative Breast Cancer: Triple
negative breast cancer means that the cells in the tumor
are negative for progesterone, estrogen, and HER2/neu
receptors.
Metastatic Breast Cancer: Metastatic breast
cancer is cancer that has spread beyond the breast,
sometimes into the lungs, bones, or brain.

44. OtherTypes
Less common types of breast cancer include
Medullary Carcinoma,Tubular Carcinoma,
Papillary carcinoma ,Adenoid cystic
carcinoma and Mucinous Carcinoma.

45. Screening and diagnosis
 Screening – looking for evidence of
disease before signs or symptoms appear
– is the key to finding breast cancer in its
early, treatable stages. Depending on age
and risk factors, screening may include
breast self-examination, examination by
nurse or doctor, mammograms
(mammography) or other tests.
 Self breast examination is an option
beginning at age 20.

46. Recommendations for Breast
Cancer detection in asymptomatic
women:
FrequencyExaminationAge group
•Monthly
•Every 3 years
•Breast self-examination
•Clinical breast examination
20-39
•Monthly
•Annually
•Annually
•Breast self-examination
•Clinical breast examination
•Mammography
40 and order

47. Breast self exam

48. Investigation
Triple assessment:
clinical/radiological/cytological.
Radiological assessment: mammography
(ultrasound in young women with dense
or large breasts).
Features on mammography: irregular,
speculated, radio opaque mass with
microcalcification.

50. Normal Mammography

51. Abnormal mammogram. Note parenchymal
asymmetric density in Subareolar area.
Suspicious for malignancy

53. Cytological assessment: FNAC or core
biopsy.

54. Breast biopsy: excision biopsy occasionally
required for diagnosis.

56. Staging investigations for proven carcinoma:
all: chest X-ray, FBC,
serum alkaline phosphatase,
γ-glutamyl transpeptidase, serum calcium
(suggest liver or bone metastases);
if clinically indicated: isotope bone scan,
ultrasound scan of
liver, brain CT scan.
Breast tissue for hormone receptor status
(ER±), important for treatment and
prognosis.

57. TNM System for Breast Cancer
Tx: Cannot assess primary tumor
T0: No evidence of primary tumor
T1: ≤ 2 cm
T2: ≤ 5 cm
T3: > 5 cm
T4:Any size, with direct extension to chest wall or with
skin edema or ulceration
Nx: Cannot assess lymph nodes
N0: No nodal mets
N1: Movable ipsilateral axillary nodes
N2: Fixed ipsilateral axillary nodes
N3: Ipsilateral internal mammary nodes
Mx: Cannot assess mets
M0: No mets
M1: Distant mets or supraclavicular nodes

59. DCIS or LCISStage 0
Invasive carcinoma ≤ 2 cm in size (including carcinoma in situ with
microinvasion)
without nodal involvement and no distant metastases.
Stage 1
Invasive carcinoma ≤ 5 cm in size with involved but movable
axillary nodes and no distant metastases, or a tumor > 5 cm
without nodal involvement or distant metastases
Stage II
Breast cancers > 5 cm in size with nodal involvement; or any
breast cancer with fixed axillary nodes; or any breast cancer with
involvement of the ipsilateral internal mammary lymph nodes; or
any breast cancer with skin involvement, pectoral and chest wall
fixation, edema, or clinical inflammatory carcinoma, if distant
metastases are absent
Stage III
Any form of breast cancer with distant metastases (including
ipsilateral supraclavicular lymph nodes)
Stage IIII
Staging system for breast cancer.

61. Management
Early breast cancer:
(No evidence of distant spread at time of diagnosis.)
 • Local treatment is usually either:
lumpectomy + radiotherapy to breast; or
simple mastectomy.
 • Treatment for axillary lymph nodes is usually either:
axillary dissection (at time of surgery) and removal; or
radiotherapy to axilla.
 • Prevention of systemic spread is usually either:
hormonal therapy (e.g. tamoxifen); or
adjuvant chemotherapy (cyclophosphamide, methotrexate,
5-FU) if high risk (positive lymph nodes, bad histological
features).
Prognosis depends on lymph nodes status, tumor size and
histological grade: overall 80% 10-year survival rate.

63. Late breast cancer
(Distant spread at time of diagnosis.)
• Local treatment is directed at controlling local
recurrence
lumpectomy/mastectomy/radiotherapy.
• Distant metastases: radiotherapy to relieve
pain from bony metastases,
chemotherapy (tamoxifen, cytotoxics,
aminoglutethamide) to control
tumour load.
Prognosis: poor, only 30–40% respond to
treatment with mean
survival of 2 years, by which time the non-
responders have usually
died.

64. Prognosis
The five survival rate is:
 Stage 1: 94%
 stage II: 70-85%
 Stage III : 48%-52%
 Stage IV: 18%

65. Frequency of follow-up care
 Follow-up periodically until final discharge after
10 years after surgery.
 Schedule for hospital follow-up :
 Visits every 3 months for one year +
(adjuvant therapy)
 Visits every 6 months for 4 years
 Yearly visit for 5 years
Mammography :- yearly for patients
underwent breast conservation surgery
-Twice yearly for patients underwent
mastectomy
Other investigations: [Serology, CT, MRI, or
Biopsy if symptoms or signs