a group presentation on breast carcinoma

1. BY STUDENTS OF
MEDICAL COLLEGE, KOLKATA
BATCH 2011( gr. ‘D’; 187-197)

2. TOPICS OF DISCUSSION
01. INTRODUCTION,EPIDEMIOLOGY & RISK FACTORS ,BY SHAHBAZ AHMAD
02. PATHOLOGY OF BREAST CARCINOMA , BY MASUDA KHATUN
03. CLINICAL FEATURES , BY RAKIB SAIKH
04. INVESTIGATIONS, BY SALMA NASRIN
05. TNM STAGING, BY MANABENDRA MANDAL
06. SURGICAL ANATOMY AND SURGERIES , BY SAYAN SAHA
07. BREAST CONSERVATION THERAPY , BY MD KHALILULLAH
08. RADIOTHERAPY , BY TARIK AZIZ BISWAS
09. CHEMOTHERAPY & HORMONAL THERAPY, BY REGIA SULTANA
10. TREATMENT PROTOCOL, BY SAYEEDA ZAHAN
11. PROGNOSIS , PREVENTION & RECENT ADVANCES, BY IMDADUL HOQUE.

3. INTRODUCTION
BY SHAHBAAZ AHMED
ROLL NO.-193

4. International situation
• Worldwide, breast cancer is the most common
invasive cancer in women.
• The incidence of breast cancer is lowest in
less-developed countries and greatest in the
more-developed countries.
• The number of cases worldwide has
significantly increased since the 1970s(mainly
due to lifestyle changes)

5. EPIDEMIOLOGY IN INDIA
• What makes us worried about the trend of
breast cancer in India???
• 1)Age shift
• 2)Rising number of cases
• 3)Late presentation
• 4)Lack of awareness and screening

6. The horizontal line lower down represents the
age groups: 20 to 30 years, 30 to 40 yrs and so
on. And the vertical line represents the
percentage of cases.
Age shift: Breast cancer now more common in 30's and
40's

7. Rising incidence of breast cancer in India
Breast cancer is now the most common cancer
in most cities in India, and 2nd most common
in the rural areas.

8. RISK FACTORS
• HORMONAL
• Increased exposure to estrogen
• Factors that increase the number of menstrual cycles(early
menarche,nulliparity,late menopause)
• Exercise and longer lactation period are protective(factors that
decrease the number of menstrual cycles are protective).
• Older age at first live birth is also a risk factor.
• Obesity increases the risk.
• OCP do not increase the risk.
• Hormone replacement therapy in postmenopausal women
increase the risk.

9. NON-HORMONAL RISK FACTORS
1.Chest wall irradiation
2.Diet- eg.foods with high fat content
alcohol consumption
3.Sex-women are 100 times at a greater risk than men
4.Age-More common in 35 to 75 years of age.
5.History of breast cancer
6.Benign breast disease eg. Atypical ductal hyperlasia
Intraductal papilloma
7.Geographical-Disease of white western women

10. 8.Genetic risk factors
a)BRCA 1 and 2 gene mutation
b)Cowden’s disease
c)Ataxia telengiectasia
d)Li-Fraumeni syndrome

11. • BRCA gene
• Mechanism-
.Both BRCA genes are tumor suppressor genes that produce
proteins that are used by the cell in an enzymatic
pathway that makes very precise, perfectly matched repairs to
DNA molecules that have double-stranded breaks.
.Harmful mutations in any of these genes disable the gene or
the protein that it produces.

12. BRCA GENE
BRCA 1
• Located on chromosome 17
• Associated with invasive
ductal carcinoma
• Poorly differentiated
• Hormone receptor negative
• Early age of onset
• Bilateral
• Also associated with
ovarian,colon and prostate
cancers.
BRCA 2
• Located on chromosome 13
• Associated with invasive
ductal carcinoma
• Well differentiated
• Hormone receptor positive
• Early age of onset
• Bilateral
• Also associated with
ovarian,colon,prostate,panc
reas,bladder cancers

13. RISK ASSESSMENT MODELS
• GAIL MODEL
• The Breast Cancer Risk Assessment Tool (the Gail model) was
designed by researchers at the National Cancer Institute and
the National Surgical Adjuvant Breast and Bowel Project as a tool
for health care providers.
• The tool calculates a woman's risk of developing breast cancer
within the next five years and within her lifetime (up to age 90). It
takes into account seven key risk factors for breast cancer.
• Age
• Age at first period
• Age at the time of the birth of her first child (or has not given birth)
• Family history of breast cancer (mother, sister or daughter)

14. • Number of past breast biopsies
• Number of breast biopsies showing atypical hyperplasia
• Race/ethnicity
Women with a five-year risk of 1.67 percent or higher are classified as
"high-risk.“
• It gives the average risk for a group of women with similar risk
factors.
• LIMITATIONS
• The Breast Cancer Risk Assessment Tool does not give a good
estimate of risk in some women including those with:
1)A personal history of invasive breast cancer, ductal carcinoma in situ
(DCIS) or lobular carcinoma in situ (LCIS)
2)A strong family history of breast cancer, who may have an inherited
gene mutation

15. Claus model
• Is based on empiric data from the Cancer and
Steroid Hormone Study
• Consists of a series of tables that provide risk
estimates for women with a positive family
history of breast cancer
• Estimates a woman’s risk of breast cancer
based on her current age, the number of first-
and second-degree relatives with breast
cancer (up to two); and their age at onset.

16. BENEFITS
• The Claus Model includes:
• Paternal family history
• Age at diagnosis of relatives
• LIMITATIONS OF THE CLAUS MODEL
• Is not suitable for use with women who have
three or more relatives with breast cancer
• Does not take into account other risk factors

17. PATHOLOGY OF BREAST
CARCINOMA
BY
MASUDA KHATUN
ROLL NO-196

18. CLASSIFICATION
In situ carcinoma Invasive carcinoma
Duct carcinoma in situ
Lobular carcinoma in situ
Invasive duct carcinoma
Invasive lobular carcinoma
Medullary carcinoma
Colloid carcinoma
Papillary carcinoma
Tubular carcinoma
Inflammatory carcinoma
Carcinoma with metaplasia

19. DUCT CARCINOMA IN SITU
• Proliferation of malignant mammary ductal
epithelial cells without any invasion to
basement membrane
• Predominantly occurs in female breast
• Accounts for 5% of male breast cancer

20.  atypical hyperplasia of ductal epithelium
filling of duct
Tumor size 3-5 cm
 Palpable mass 30-75%
Nipple discharge 30%

21. 4 types- comedo pattern
Solid pattern
Papillary pattern
Cribriform pattern
Risk of invasive carcinoma is five fold
increased, in ipsilateral breast and in same
quadrant-DCIS is anatomical precursor of
invasive carcinoma

22. DUCTAL CARCINOMA IN SITU: COMEDO TYPE
CENTRAL ZONE OF NECROSIS WITH CALCIFICATION

23. DUCTAL CARCINOMA IN SITU: CRIBRIFORM TYPE
WITH ROUND REGULER ‘’COOKIE CUTTER” SPACES,LUMENS ARE FILLED
WITH CALCIFYING SECRETORY MATERIAL

24. DUCTAL CARCINOMA IN SITU: SOLID PATTERN
DUCTS ARE COMPLETELY FILLED AND DISTORTED LOBULES

25. DUCTAL CARCINOMA IN SITU: PAPILLARY PATTERN
DELICATE FIBROVASCULER CORE EXTENDED INTU DUCTS

26. LOBULAR CARCINOMA IN SITU
Origin-terminal duct lobular unit
Lacks cell adhesion protein E-cadherin-
discohesive and round cells
Normal nucleocytoplasmic ratio
Mucin positive signet cells
Rarely distorts underlying architecture

27. LOBULER CARCINOMA IN SITU

28. SALIENT FEATURES OF DCIS AND LCIS
LCIS DCIS
AGE 44-47 54-58
INCIDENCE 2-5% 5-10%
CLINICAL SIGN NONE MASS,PAIN,DISCHARGE
MAMMOGRAPHIC
SING
NONE MICROCALCIFICATION
MULTICENRICITY 60-90% 40-80%

29. LCIS DCIS
BILATERALITY 50-70% 10-20%
AXILLARY
METASTASIS
1% 1-2%
SUBSEQUENT
CARCINOMA
 INCIDENCE
25-35% 25-70%
 LATERALITY BILATERAL IPSILATERAL
 INTERVAL TO
DIAGNOSIS 15-20 YRS 5-10 YRS
 HISTOLOGIC TYPE DUCTAL DUCTAL

30. INFILTRATING DUCT CARCINOMA-NST
INCIDENCE- 80% of breast cancers
AXILLARY LYMPH NODE METASTASIS- 60%
5th to 6th decade
TUMOR-firm to hard, irregular border, central
streaks of chalky white stroma, foci of
calcification
Well, modarate and poorly differentiated
varieties

31. INFILTRATING DUCT CARCINOMA : ACCORDING
TO GENE EXPRESSION PATTERN
ER HER2/neu
Luminal A Positive Negative
Luminal B Positive Positive
Normal basal
like
Positive Negative
Basal like Negative Negative
HER2 over
expression
Negative Positive

32. INFILTRATING DUCT CARCINOMA

33. INFILTRATING LOBULER CARCINOMA
• Incidence-10%
• Bilateral and multicentric
• Dyscohesive infiltrating cells in single file
pattern
• Signet ring cell-intra cytoplasmic mucin
droplet

34. INFILTRATING LOBULER CARCINOMA

35. OTHER IMPORTANT TYPES
• MEDULLARY CARCINOMA :
 Brain like consistency
 Triple negative receptor pattern
 better 5 year survival
• COLLOID CARCINOMA
 extra cellular mucin pool
 better prognosis

36. MEDULLARY CARCINOMA

37. COLLOID CARCINOMA
MALIGNANT CELL LIE WITHIN POOLS OF EXTRA CELLULER MUCIN

38. • INFLAMMATORY CARCINOMA
Most aggressive
Common in pregnancy and lactation
Mimics acute mastitis
Ductal or lobular type
Rapid metastasis

39. PAGET’S DISEASE OF NIPPLE
Superficial manifestation of invasive or
non invasive ductal carcinoma
Pagets cell with hyper chromatic nuclei
and cytoplasmic halo
Crusted, scaly lesion, ulceration and
destruction of nipple

40. PAGET’S DISEASE OF NIPPLE

41. CLINICAL FEATURES OF BREAST
CARCINOMA
~BY RAKIB SAIKH
ROLL NO.-189

42. SYMPTOMS
 A LUMP OR AREA OF THICKENED TISSUE
OF BREAST
A CHANGE IN SIZE OR SHAPE OF ONE OR
BOTH BREAST
DISCHARGE FROM THE NIPPLE ; MAY BE
BLOOD STREAKED
A LUMP OR SWELLING EITHER OF ARMPITS
RASH ON OR AROUND NIPPLE
CHANGE IN APPEARANCE OF NIPPLE

44. LATE SIGN AND SYMPTOMS
WHEN CANCER GROWS LARGER OR SPREAD
TO
OTHER PARTS OF BODY
 BONE PAIN
 LOSS OF APPETITE
 WEIGHT LOSS
 JAUNDICE
 HEADACHE
 DOUBLE VISSION
 MUSCLE WEAKNESS

45. PHYSICAL EXAMINATION OF BREAST
IT IS CARRIED OUT IN DIFFERENT POSITION
WITH THE ARMS BY THE SIDE OF THE BODY
WITH ARMS RAISED STRAIGHT OVER THE HEAD
WITH THE HAND ON HER WAIST (PRESSING AND
RELAXING)
WITH PATIENT BENDING FORWARD
SUPINE POSITION

47. BREAST INSPECTION
BOTH THE BREASTS ARE INSPECTED IN THEIR
ENTIRETY AND FOLLOWING POINTS ARE NOTED
 POSITION : WHETHER DISPLACED IN ANY
DIRECTION
SIZE AND SHAPE : WHETHER LARGER OR SMALLER
THAN ITS FELLOW
ANR PUCKERING OR DIMPLING ?
IN PRESENCE OF A SWELLING OR ULCER
,DETERMINE ITS POSITION,SIZE, SHAPE AND
SURFACE

48. SKIN OVER THE BREAST
LOOK FOR
COLOUR AND TEXTURE
ENGORGED VEINS
DIMPLE,RETRACTION OR
PUCKERING;OFTEN NOTICE IN
SCIRRHOUS CA
PEAU D’ ORANGE APPEARANCE OF
SKIN
ULCERATION AND FUNGATION

49. NIPPLE INSPECTION
LOOK FOR
 POSITION : IN CA ,THE NIPPLE
OF AFFECTED SIDE DRAWN
UP TOWARDS
THE LUMP
 SIZE AND SHAPE :IS IT
PROMINENT ,FLATTENED OR
RETRACTED
 SURFACE :LOOK FOR ANY
CRACKS ,FISSURE OR ECZEMA
 DISCHAGE

50. AREOLA
LOOK FOR
COLOUR
SIZE : DIMINUTION OF SIZE IS SOMETIMES SEEN IN
SCIRRHOUS CA
SURFACE AND TEXTURE : LOOK FOR CRACK
,FISSURE,ULCER,SWELLING OR DISCHAGE. IN PAGETS
DISEASE ,AREOLA BECOMES BRIGHT RED IN EARLY STAGE
AND IS DESTROYED LEAVING A RED WEEPING ULCER.
AXILLA & SUPRACLAVICULAR FOSSA SHOULD BE
INSPECTED FOR ANY SWELLING DUE TO
ENLARGED LYMPH NODES

51. PALPATION OF BREAST
ON PALPATION THE FOLLOWING POINTS SHOULD
BE NOTED
LOCAL TEMPERATURE & TENDERNESS : WARM & TENDER
SWELLING IN INFLAMMATORY CARINOMA
SITUATON :COMMONLY FOUND IN UPPER & OUTER
QUADRANT
NUMBER
SIZE & SHAPE : USUALLY UNEVEN IN CARCINOMA
SURFACE : USUALLY UNEVEN
MARGIN : WELL DEFINED

52. PALPATION OF BREAST
 CONSISTENCY : WHETHER CYSTIC, FIRM ,HARD OR STONY HARD.
CARCINOMA IS
STONY HARD IN CONSISTENCY
 FLUCTUATION : IF CYSTIC ,FLUCTUATION IS POSITIVE
 TRASLUMINATION TEST : OPAQUE IN SOLID TUMOUR
 WHEYHER FIXED TO THE SKIN ,BREAST TISSUE OR UNDERLYING
STRUCTURES

53. EXAMINATION OF LYMPH NODE
LEVEL I : ANTERIOR ,POSTERIOR & LATERAL
GROUP OF LN
LEVEL II : CENTRAL GROUP OF LN
LEVEL III : APICAL GROUP OF LN

54. INVESTIGATION OF CA BREAST
BY SALMA NASRIN
ROLL NO. -195

55. • Any patient presented with a breast lump or other symptoms
suspicious of carcinoma , the diagnosis should be made by the
so-called Triple Assessment , which includes:
1. clinical assessment,
2. radiological imaging and
3.a tissue sample taken for either cytological or histological
analysis.
 The positive predictive value (PPV) of this combination
should exceed 99.9 per cent

57. INVESTIGATIONS
• FOR CONFIRMATION OF
DIAGNOSIS:
A. IMAGING
i) Mammography
ii) Ultrasonography(USG)
iii) Magnetic Resonance
Imaging(MRI)
B. BIOPSY
i) Fine Needle Aspira-
tion Cytology(FNAC)
ii) Trucut Biopsy
iii) Open Biopsy
• FOR STAGING AND
METASTATIC WORK-UP:
i) CT Scan Chest
ii) Chest X-RAY
iii)Abdominal USG
iv) Whole Body Bone Scan
v) Sentinel Node Biopsy
vi) PET-Scan

58. MAMMOGRAPHY
SCREENING
 Asymptomatic women
> 40 years
 Positive family history
 Two views:-
1. Mediolateral Oblique ( For outer quadrants + axilla)
2. Cranio-caudal (For medial quadrants)
DIAGNOSTIC
 Indicated for pain
and/or Lump,
discharge etc

60.  Suspicious findings of
carcinoma of breast:
1.Solid irregular mass
2. Spiculation
3. Microcalcification
4. Architectural distortion
5. Asymmetrical thickening
of breast tissues etc.
Fig: A small, spiculated mass is seen in the right breast
with skin tethering in mammography (CC view)

62. Advantages:
1. Non-invasive
2. Minimum radiation
hazards
3. Can be used as screening
tool.
Disadvantages:
1. False Positivity around
5%.
2. Not ideal for younger
women.

63. ULTRASONOGRAPHY
• Particularly useful in
young women with dense
breasts in whom
mammograms are
difficult to interpret.
• Used to distinguish cysts
from solid lesions
• To localise impalpable
areas of breast
pathology.
• Axillary lymph nodes can
be assessed.
Fig: Ultrasonography images of
malignant breast lesions

64. • ADVANTAGES
1. Cost -effective,
2. No radiational
hazards
3. Can guide FNAC and
Core biopsy.
• DISADVANTAGE:
Not ideal for lesions of
1 cm diameter or less.
Fig: USG showing benign cystic lesion
Fig: USG showing malignant irregular lesion

65. MRI
INDICATIONS:
1.When axillary nodes are
positive for malignancy but
primary is unknown.
2. To distinguish scar from
recurrence in women who
have had previous breast
conservation therapy.
3. To assess for multifocality and
multicentricity.
4. Best imaging modality for the
breasts of women with
implants.
5. Useful as a screening tool in
high-risk women (because of
family history).

66. CORE NEEDLE BIOPSY
 The method of choice to
sample palpable/non-
palpable image- detected
breast abnormalities.
 Can be performed under
 Stereotactic ( mammographic)
 Ultrasonographic or
 MRI guidance.
 PROCEDURE: Local
anaesthesia small
incision insertion of 11
gauge needle sample
obtained with vacuum
assistance.
Fig: USG guided core needle biopsy

67. ADVANTAGES:
1. Permits the analysis of breast
tissue architecture which can
not be done by FNAC.
2. Low complication rate, minimal
scarring, and a lower cost
compared with excisional
breast biopsy.
3. Hormone receptor status can
be assessed.
DISADVANTAGES: Sampling error
may occur. Fig: Lobular carcinoma in
situ in core needle biopsy

68. FNAC
 The least invasive
technique of obtaining a cell
diagnosis and is rapid and
very accurate.
 DISADVANTAGES:
1. Can not differentiate
between invasive and non-
invasive cancer.
2. Hormone receptor status
cannot be assessed.
Fig: FNAC showing
ductal carcinoma cells.

70. INVESTIGATION ALGORYTHM FOR CA BREAST
ROUTINE TESTS:
1. Complete blood count: ?anaemia
2. Chest X-Ray: metastatic features
3.LFT: any increase in ALP
A suspicious case DIAGNOSTIC TESTS:
of CA breast
METASTATIC WORK-UPS

71. DIAGNOSTIC TESTS
Mammography ( score4/above)
Core Needle Biopsy
Features suggestive of If diagnosis remain equivocal
carcinoma despite imaging +core biopsy
Immunohistochemistry
o ER, PR status Incisional Biopsy
o HER-2/neu status
o KI-67 Index etc Confirmation

72. METASTATIC WORK-UP
1. Axillary Lymph Node assessment USG of axilla
Sentinel Lymph Node Biopsy
2. Chest X-Ray Cannon Ball appearance
Lymphangiectasia
3. USG of Abdomen ( if hepatospleenomegaly and/or raised ALP)
4. Whole Body Bone Scan ( in case of stage T3 and T4/ bone pain
/increased ALP)
5. CT–scan of chest and abdomen

73. Fig: Cannon Ball Appearance in Chest X-ray.
Fig: Whole Body Bone Scan

74. TNM staging
~BY MANABENDRA MONDAL
ROLL NO.-192

75. PRIMARY TUMOUR
• TX Primary tumour cannot be assessed
• T0 No evidence of primary tumour
• Tis Carcinoma in situ
• Tis (DCIS) Ductal carcinoma in situ
• Tis (LCIS) Lobular carcinoma in situ
• Tis (Paget’s) Paget’s disease of the nipple NOT associated with invasive
carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying
breast parenchyma. Carcinomas in the breast parenchyma associated
with Paget’s disease are categorized based on the size and characteristics
of the parenchymal disease, although the presence of Paget’s disease
should still be noted

76. • T1 tumour ≤ 20 mm in greatest dimension
• T1mi tumour ≤ 1 mm in greatest dimension
• T1a Tumour > 1 mm but ≤ 5 mm in greatest dimension
• T1b Tumour > 5 mm but ≤ 10 mm in greatest
dimension
• T1c Tumour > 10 mm but ≤ 20 mm in greatest
dimension
• T2 Tumour > 20 mm but ≤ 50 mm in greatest
dimension
• T3 tumour > 50 mm in greatest dimension

77. • T4 Tumour of any size with direct extension
to the chest wall and/or to the skin (ulceration
or skin nodules)
• T4a Extension to the chest wall, not including
only Pectoralis muscle
adherence/invasion
• T4b Ulceration and/or ipsilateral satellite
nodules and/or oedema (including peau
d’orange) of the skin, which do not meet the
criteria for inflammatory carcinoma
• T4c Both T4a and T4b
• T4d Inflammatory carcinoma

79. REGIONAL LYMPH NODES
• NX Regional lymph nodes cannot be assessed (for example,
previously removed)
• N0 No regional lymph node metastases
• N1 Metastases to MOVABLE ipsilateral level I, II axillary lymph
node(s)
• N2 Metastases in ipsilateral level I, II axillary lymph nodes that
are CLINICALLY FIXED OR MATTED; / in clinically detected ipsilateral
internal mammary nodes in the
absence of clinically evident axillary lymph node metastases
• N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed
to one another

80. • N3 Metastases in ipsilateral infraclavicular (level III axillary)
lymph node(s) with or without level I, II axillary lymph node
involvement; or in clinically detected ipsilateral internal
mammary lymph node(s) with clinically evident level I, II
axillary lymph node metastases; or metastases in ipsilateral
supraclavicular lymph node(s) with or without axillary or
internal mammary lymph node involvement
• N3a Metastases in ipsilateral infraclavicular lymph node(s)
• N3b Metastases in ipsilateral internal mammary lymph
node(s) and axillary lymph node(s)
• N3c Metastases in ipsilateral supraclavicular lymph node(s)

83. DISTANT METASTASIS
MX: Metastasis cannot be assessed
M0: There is no sign of cancer spread
cM0(i+): There is no sign of cancer on
physical examinations or x-rays but cancer
cells are present in blood, bone marrow or
lymph nodes far away from breast
M1: Distant detectable metastasis

84. STAGING
• Stage 0: Tis N0 M0
• Stage IA: T1 N0 M0
• Stage IB: T0 N1mi M0 or T1 N1mi M0
• Stage IIA: T0 N1 M0 or T1 N1 M0 or T2
N0 M0
• Stage IIB: T2 N1 M0 or T3 N0 M0

85. • Stage IIIA: T0 N2 M0 or T1 N2 M0 or T2 N2
M0 or T3 N1 M0 or T3 N2 M0
• Stage IIIB: T4 N0 M0 or T4 N1 M0 or T4 N2
M0
• Stage IIIC: Any T N3 M0
• Stage IV: Any T Any N M1

87. TREATMENT OF BREAST
CARCINOMA
Sayan Saha
Roll No.-187

88. TREATMENT OF BREAST CARCINOMA
• LOCOREGIONAL
THERAPY
 SURGERY
 RADIOTHERAPY
• SYSTEMIC THERAPY
 CHEMOTHERAPY
 HORMONAL THERAPY
 MONOCLONAL
ANTIBODY
These are used singly or in combination

89. TREATMENT DEPENDS UPON:-
• AGE
• SIZE OF THE TUMOR
• AXILLARY LN STATUS
• STAGE OF MALIGNANCY
• BIOLOGIC
AGRESSIVENESS
• RECEPTOR STATUS OF
TUMOR
• MULTICENTRICITY &
MULTIFOCALITY
• MENSTRUAL STATUS
• SIZE OF BREAST
• AVAILABILITY OF
RADIOTHERAPY
• PATIENT’S CHOICE
• PROPHYLACTIC/THERAP
EUTIC/PALLIATIVE

90. SURGICAL ANATOMY

91. ANATOMY OF BREAST

92. BLOOD SUPPLY OF BREAST

93. LYMPHATIC DRAINAGE OF BREAST

94. Cont…..

95. SURGICAL DIVISION OF LYMPHNODES OF AXILLA

96. SURGERY

97. SURGERY AVAILABLE:-
1.TOTAL(SIMPLE) MASTECTOMY
2.TOTAL MASTECTOMY WITH AXILLARY CLEARENCE
3.HALSTED RADICAL MASTECTOMY
4.MODIFIED RADICAL MASTECTOMY
i) PATEY’S OPERATION
ii)SCANLON’S OPERATION
iii)AUCHIONCLOSS OPERATION
5.BREAST CONSERVATION SURGERY

98. TOTAL (SIMPLE) MASTECTOMY
 Surgical removal of whole breast tissue superficial to pectoral
fascia.
 Axillary radiotherapy as no pathological staging performed
 Structures removed:-
tumor + breast tissue + nipple &areola + skin.

99. TOTAL MASTECTOMY WITH AXILLARY CLEARENCE
TOTAL MASTECTOMY
with level I axillary LN clearence
 NIPPLE AND AREOLA SPARING
SURGERY:-
 Tumor 2-3 cm away from alveolar border
 Smaller breast size and minimal ptosis
 No prior breast surgery
 BMI<40KG/M2
 No tobacco use
 No breast irradiation
 No collagen vascular disease

100. RADICAL MASTECTOMY OF HALSTED
TISSUE REMOVED:
Tumor + entire breast + areola& nipple + skin over
tumor + pectoralis major & minor + fat + fascia +
level I,II,III axillary lymph node + few digitaions of
serratus anterior
TISSUE PRESERVED:
Axillary vein
Bell’s nerve
Cephalic vein
COMPLICATIONS: Lymphedema & Lymphangiosarcoma

101. MODIFIED RADICAL MASTECTOMY
STRUCTURES REMOVED:-
Tumor + breast tissue + skin , nipple, areola + level
I,II,III LN( level III not all variety) + pectoralis
minor(except AUCHINCLOSS MRM)
STRUCTURES PRESERVED:-
 Nerve to serratus anterior
 Nerve to latissimus dorsi
 Intercostobrachial nerve
 Axillary vein
 Cephalic vein
 Pectoralis major muscle

102. MODIFIED RADICAL MASTECTOMY
it is of 3 types:-
1.PATEY’S MODIFIED RADICAL MASTECTOMY:-
 Pectoralis major preserved but pectoralis minor removed
 Level III LN removed
2.SCANLON’S MODIFIED RADICAL MASTECTOMY:-
 Pectoralis minor incised and divided
 Level III LN removed
3.AUCHINCLOSS MODIFIED RADICAL MASTECTOMY:-
Pectoralis minor retracted and left intact
Level III LN not removed
It is practiced nowadays widely.

103. STEPS OF MODIFIED RADICAL MASTECTOMY
Anaesthesia
Patient position
Antiseptic dressing &
draping
Incision
Two transverse elliptical
incisions, including the
nipple areola complex and
skin overlying the tumor
together with skin margins
that lie 1-2 cm from the
cephalic and caudal
extents of the tumor.

104. Raising skin flap
• Skin & subcut. fat from
mammary tissue
• Ideal thickness 7-8mm
• Bleeding stop by
diathermy
• Extent
Raising the breast
• Separate breast tissue
from fascia covering
pectoralis major.

105. • Breast is lifted above from boundary:
 Laterally : anterior margin of latissimus dorsi
 medially : mid sternal line
 Superiorly : subclavius muscle
 Inferiorly : 2-3 cm inferior to infra-mammary fold

106. Axillary dissection:-
• P. major retracted and
lateral border of P. minor is
cleared by removing level l
LN & areolar tissue
• If PATEY’S MRM : pectoralis
minor muscle dissected &
level l,ll,lll LN cleared.
• If AUCHINCLOSS MRM:
Pectoralis minor is
retracted & upto level ll LN
is cleared
• Lymphatics & tissue
removal should not done
superior to axillary vein.
Done when sentinel lymphnode
biopsy is positive

107. Hemostasis secured &
drains are placed
Sutured
COMPLICATIONS OF MODIFIED RADICAL
MASTECTOMY
 PEROPERATIVE
o Anaesthetic complications
o Hemmorhage
o Injury to nearby nerves & muscles
 POSTOPERATIVE
EARLY
o Seroma/lymph collection(30-50%)
o Seconday infection

108. o Flap necrosis
o Pain & numbness
o Shoulder dysfunction
o Winging of scapula
LATE
o Lymphedema
o Lymphangiosarcoma
(stewart treve’s syndrome)
 3-5 yr after lymphedema
development
 Ipsilateral limb
 Multiple subcutaneous
nodule
 Require amputation
WINGING OF SCAPULAFLAP NECROSIS
PROLONGED LYMPHEDEMA

109. BREAST RECONSTRUCTION
 Patient have undergone modified radical mastectomy
 WHY? MRM PSYCHOLOGICAL STRESS BR RESULT
 Ideal candidate??
 TYPES:-
IMMEDIATE:-
Early stage of malignancy where neoadjuvant therapy works good & no
need to give post operative radiotherapy
Maximum amount of breast skin preserved
Cost-effective
DELAYED:- (AFTER 3-9 MONTH)
INDICATION: 1.locally advanced disease
2.post operative radiation required
ADVANTAGE: 1. post operative radiation allowed
2. Avoid fibrosis and flap necrosis where TRAM flap is used

110. TYPES OF FLAP
1.PEDICLED FLAP
 Latissimus dorsi
myocutaneous flap
 TRAM flap
2.FREE FLAP
 TRAM flap
 Gluteus maximus
myocutaneous flap
 Anterolateral
thigh flap
3.SILICON COMPOUND
GEL prosthesis under pectoral
muscle
4.EXPANDABLE SALINE
PROSTHESIS
COMPLICATIONS OF FLAP

111. SURGICAL OPTIONS FOR BREAST RECONSTRUCTIONS
• Prosthetic only reconstrutions
1.saline/silicon prosthesis
• Autologus & prosthetic reconstructions
2.Thoraco epigastric flap with implant
3.Latissimus dorsi flap with implant
Autologus reconstruction
4.TRAM
5.Extended latissimus dorsi flap
6.Free TRAM
7.DIEP & SIEP flap
8.SGAP & IGAP flap

112. TRAM flap
 Most commonly used in post mastectomy breast
reconstruction
 Superior epigastric artery gives the blood supply

113. LATISSIMUS DORSI FLAP

114. ALLOPLASTIC MATERIALS
• ARTIFICIAL SILICONE FLAP • EXPANDABLE SALINE
PROSTHESIS
ARTIFICIAL SILICONE GEL FLAP PLACED UNDER
PECTORALIS MAJOR MUSCLE

115. BREAST CONSERVATION THERAPY
BY MD. KHALILULLAH
ROLL NO. - 190

116. BREAST CONSERVATION THERAPY
 BREAST CONSERVATION involves:
1. Resection of the primary breast cancer with a margin
of normal appearing breast parenchyma.
2.Adjuvant radiation therapy
3.Assessment of regional lymph node status
 BCT- the standard treatment for stage 0, I and II invasive
breast cancer.
 Other terms that refer excision of primary breast cancer with
preservation of the breast: lumpectomy, partial mastectomy,
tylectomy, quadrantectomy, wide local excision etc.

117. WHY B.C.T. IS PREFERABLE?
ADVANTAGES OF
B.C.T.:
 1.Similar survival rate
compared to total
mastectomy.
 2.Improved quality of life
and asthetic outcome.
 3.Allows preservation of
breast shape and skin as
well as preservation of
sensation
 4.provides psychological
advantage.

118. INDICATION OF B.C.T.
 Stage I and stage II invasive breast cancer.
 It can also be done in stage IIIA T3N1M0.
 Factors favouring breast conservation surgery:
1. Smaller monocentric tumour,
2. Younger age,
3. Treatment carrying in specialised centre,
4. Favourable physical factors,
5. Localisation of tumour,
6. Patient compliance

119. ELIGIBILITY FOR BREAEST CONSERVATION
Those criteria are responsible for decreased
local recurrence after BCT.
• 1. Tumour size: up to 5 cm , with clinically
positive nodes
• 2. Margins: At least 2-3mm clear margin should
be obtainable.
• 3. Histology: Invasive lobular and cancers with
extensive intraductal components.
• 4. Patients’ Age : Local recurrence is higher for
younger women.

120. CONTRAINDICATION OF BCT
ABSOLUTE :
 1. Locally wide spread disease
 2. Multicentricity
 3. Diffuse ( malignant ) microcalcification
 4. Pregnancy of 1st or 2nd trimester
 5. Persistently positive surgical margin
 6. Patients with mutation on BRCA1 and BRCA2 gene
 7. Already irradiated thoracic wall
RELATIVE:
 1. Large Tumour/Breast ratio
 2. Collagen vascular disease (except rheumatoid arthritis)
 3. Tumour location

121. METHODS BREAST CONSERVATIVE THERAPY
WIDE LOCAL EXCISION LUMPECTOMY
(LUMPECTOMY) + +SENTINEL LYMPH QUART i.e.
AXILLARY DISSECTION NODE BIOPSY QUADRANTECTOMY
+RADIOTHERAPY +RADIOTHERAPY +AXILLARY DISSEC-
TION+RADIOTHERAPY
CTART
CHEMOTHERAPY
+RADIOTHERAPY

122. WIDE LOCAL EXCISION
It is removal of unicentric tumour with 1 cm clearance margin.
 PRINCIPLES:
 Incision made directly over the lump.
 Skin flap should not be raised.
 Normal breast parenchyma of 1 cm clearance with excision of tumour
done.
 Pectoral fascia – not opened (usually).
 The tumour specimen i.e. removed, should be
1. Marked after placing in orientation grid
2. Assessed by specimen radiography
3.looked for clearance margin by Frozen Section Biopsy
 Drain not placed, deeper cavity not closed/obliterated.
 Skin closed cosmetically.
 Along with this, axillary dissection through separate incision and
radiotherapy to breast and chest wall is given.

123. WIDE LOCAL EXCISION

124.  SENTINEL LYMPH NODE BIOPSY:
-Standard care in the management of the axilla in patient with
clinically node negative disease.
- Localisation of sentinel lymph node(SLN): By injection of patent
blue dye and radioisotope-labelled albumin in the sub-dermal
plexus around the nipple or over the peri-tumour region.
- Diagnosis can be made by: a)Frozen section analysis
b)Touch imprint cytology
c) molecular method ( cytokeratin
. -19)
 Interpretation : i) If node is detected negative, no further nodal
dissection is needed.
ii) If positively detected, axillary block dissection is
done( for SLN in axilla).
• Sensitivity: 90% for patent blue dye
95%for Tc 99 labelled albumin.

126. QUADRANTECTOMY
 Removal of entire segment
/quadrant with ductal
system with 2-3 cm normal
breast tissue clearance.
 Done as a part of QUART
therapy which also includes
axillary dissection ( level I
and II ) through separate
incision and radiotherapy to
breast area.

128. COSMETIC CHALLENGES
Several deformities can occur due to
 Resection of primary tumour using an incision directly over
the tumour,
 Closing the skin with out re-approximating any breast tissue.
1. Volumetric deformity
2. Retraction deformity
3. Skin-pectoral muscle adherence
4. Lower pole deformity
REMEDY : Oncoplastic surgeries.

130. DISADVANTAGES OF BCT
o Higher chance of
recurrence, even after RT.
o Needs radiotherapy after
surgery.
o Equal psychological
morbidity as with total
mastectomy but here due
to fear of recurrence.

131. RADIOTHERAPY IN BREAST
CARCINOMA
-
PRESENTED BY
TARIK AZIZ BISWAS
ROLL NO: 191

132. INDICATION
CONSERVATIVE BREAST SURGERY
TOTAL MASTECTOMY
MODIFIED RADICAL MASTECTOMY
BONE SECONDARIES
ATROPHIC SCHIRROUS CARCINOMA

133. RADIOTHERAPY IN BREAST
CONSERVATIVE SURGERY
 RADIATIONS FOLLOWING LUMPECTOMY
 DURATION : 6 -7 WEEKS
 INITIAL RADIATION INCLUDES ENTIRE BREAST FOR FIRST 5 -5 ½
WEEKS.
 ‘BOOST’ RADIATION FIELD INCLUDES THE TISSUE IMMEDIATELY
SURROUNDING THE SITE OF INITIAL TUMOUR FOR LAST 1- 1 ½
WEEKS.
 THERAPY BEGINS 3 TO 6 WEEKS FOLLOWING SURGERY IF NO
CHEMOTHERAPY PLANNED.
 IF CHEMOTHERAPY PLANNED, RADIATION BEGINS 4 WEEKS
FOLLOWING COMPLETION OF CHEMOTHERAPY

134. POST MASTECTOMY
RADIOTHERAPY
DURATION : 5 TO 6 ½ WEEKS OF DAILY THERAPY
RADIATION INCLUDES CHEST WALL TISSUE AND
DRAINING LYMPH NODE
THE NEED FOR A ‘BOOST’ FIELD WITHIN CHEST
WALL TISSUES IS DETERMINED BY TUMOUR
FACTOR AND PRESENCE/ABSENCE OF
RECONSTRUCTION .

135. POST MODIFIED RADICAL
MASTECTOMY RADIOTHERAPY
RECOMMENDED TO PATIENT WITH :
FOUR OR MORE AXILLARY LYMPH
NODE INVOLVED(STAGE 1 & 2)
LOCALLY INVASIVE TUMOUR
CHARACTERISTICS &
INFLAMMATORY CANCER (T3 OR T4 )
TUMOUR CELLS WITHIN THE DEEP
MARGIN OF RESECTION.

136. TYPES OF RADIATION
I. EXTERNAL RADIATION : MOST COMMON TYPE OF
RADIATION ,TYPICALLY GIVEN AFTER LUMPECTOMY
AND SOMETIMES MASTECTOMY.
II. INTERNAL RADIATION
III. INTRAOPERATIVE RADIATION
BRACHYTHERAPY :RADIATION TO THE
BREAST BY PLACE RADIOACTIVE SEEDS
INTO BREAST TISSUE.

138. PARTIAL BREAST IRRADIATION :
RADIATION THERAPY THAT USING BOTH
EXTERNAL BEAM THERAPY &
BRACHYTHERAPY
CRITERIA :
 SMALL LESSION (< 3 cm)
 NON LOBULAR INVASIVE
HISTOLOGY
 SINGLE FOCUS LESSION
 NEGATIVE SURGICAL MARGIN
 < 3 LN INVOLVED WITHOUT
EXTRACAPSULAR EXTENSION

139. CONTRAINDICATION
 CONNECTIVE TISSUE
DISEASE SUCH AS
SCLERODERMA OR
VASCULITIS
 PREGNANT
 ALREADY HAD
RADIATION TO THAT
AREA OF BODY
SIDE EFFECTS
 HEAVINESS AND
SWELLING IN BREAST
 WEAKNESS
 LYMPHEDEMA
 SUNBURN TYPE SKIN
IRRITATION
 CARDIAC TOXICITY

140. CHEMOTHERAPY & HORMONAL
THERAPY
BY
REGIA SULTANA
ROLL NO.-197

141. INTRODUCTION
Chemotherapy and/or endocrine therapy
improves survival in those women who are at
greatest risk of relapse.
The choice of adjuvant systemic therapy will be
based on known prognostic factors including:
• Nodal status
• Histological grade and tumour size
• Oestrogen receptor/progesterone receptor
status
• Menopausal status

142. HORMONAL
THERAPY
Principles:
• Used in ER/PR +ve patients only
• All age groups included now
• Relatively safe
• Easy to administer
• Adequate prophylaxis against Ca of opposite breast
• useful in metastatic carcinoma
• Reduces recurrence-improves quality of lives and
longevity

143. MEDICAL
• Oestrogen receptor antagonist-
Tamoxifen,raloxifen
• Progesterone receptor antagonist
• Oral aromatase inhibitor-
letrozole,
anastrozole,exemestane,aminoglutethimide
• Androgens-inj. Testosterone propionate
fluoxymestrone
• LHRH agonists-Goserelin (medical
oophorectomy)
• Progestogen- medroxyprogesterone acetate

144. SURGICAL
• Ovarian ablation by-
1) Surgery (bilateral oophorectomy)
2) Radiation
• Adrenalectomy
• Pituitary ablation

145. • Anti oestrogen
1. Tamoxifen
 given for 5 years or more
 to be started only after completion of chemotherapy
 given in pre and post menopausal women
 After binding to estrogen receptors in the cytosol
,tomoxifen blocks the uptake of estrogen by breast
tissue.
 toxic effects like bone pain,hot
flushes,nausea,vomiting,fluid retention.
 long term risk is endometrial carcinoma

146. 2.Raloxifen
it is selective oestrogen receptor antagonist
it reduces endometrial carcinoma

147. AROMATASE INHIBITORS
given in post menopausal women
inhibits the enzyme aromatase,so oestrogen
synthesis is reduced
side effects are cardiac problems,osteoporosis
Commonly used aromatase inhibtors:
a. aminoglutethimide
b. Letrozole,anastrozole

148. • Aminoglutethimide:
 Blocks synthesis of oestrogen-medical adrenalectomy.
 Cortisone supplement is needed.
• Letrozole:
 Non-steroidal competitive inhibitor of aromatase
 it reduces oestrogen level by 98%
 More expensive,more effective
 side effects are vaginal bleeding,vaginal dryness,night
sweats,hot flushes,osteoporosis

149. CHEMOTHERAPY Approach
Adjuvant therapy neoadjuvant therapy
palliative therapy
-in early breast cancer -in locally advanced
-in advanced/
-stage I & II breast cancer(LABC)
metastatic cancer
T1NI,T2N1,T3N0 -stage IIIA,IIIB
-stage IV

150. ADJUVANT CHEMOTHERAPY
Considered in all cases of early breast cancer
irrespective of-
• Menopausal status
• Hormone receptor status
• Nodal status

151.  Indication
• <0.5 cm in size, node -ve: minimal benefit and not recommended
• 0.5-1 cm in size,node -ve : given if she has unfavourable prognostic
features
• >1cm in size,hormone receptor -ve: chemotherapy is appropriate
DRUG REGIMEN
• 1st line drugs:Anthracyclines- Cyclophosphamide
Adriamycin
5 fluorouracil
Epirubicin
• 2nd line drugs:Taxanes-Paclitaxel
Docetaxel
• 3rd line drugs:Gemcitabine

152.  Duration: 6 cycles 3 weekly or,
4 cycles 3 weekly
Side effects:
alopecia,
bone marrow suppression
cystitis
megaloblastic anaemia
GIT disturbances
nephritis

153. NEOADJUVANT THERAPY
• It refers to administration of drugs prior to surgery to reduce
locoregional burden of tumour.
• Indication:
-large operable tumour
-micrometastasis
 After neoadjuvant therapy response of tumour is assessed.it may
be-
 complete clinical response(cCR):the growth becomes impalpable
clinically.
 Partial pathological response(pPR):the resected specimen shows
viable microscopic disease in a patient with cCR.
 Complete pathological response(cPR):if no microscopic growth is
seen.

154. NEOADJUVANT CHEMOTHERAPY
o ER/PR –ve patients respond better.
o Good general condition of patient is needed.
o Trastuzumab can be given alongwith
neoadjuvant setting.
 Advantages
 downstage the disease
Increases chances of breast conservation
Early systemic control is achieved
Inoperable tumour becomes operable

155. ANTI HER 2/neu THERAPY
Drugs
a. Trastuzumab
b. Pertuzumab
c. Bevacizumab
d. Lapitinab

156. TRASTUZUMAB
• It is a monoclonal antibody against tyrosine kinase
receptor(HER 2 receptor)
• Administered in HER 2 +ve patients
• It has cardiac side effects.
• When it is combined with taxane based chemotherapy
it improves disease free survival by 50%
 If one gets trastuzumab as neoadjuvant she has to
receive trastuzumab after surgery also.
 Where as pertuzumab is not given after surgery.

157. • BEVACIZUMAB
Vascular growth factor receptor inhibitor
• LAPITINAB
inhibit both HER2 and EGFR

158. Treatment protocol
BY SAYEEDA ZAHAN
ROLL NO - 194

159. IN SITU CARCINOMA

160. AIM
Prevent or
detect at an
early stage of
invasive cancer

161. MANAGEMENT
DCIS (DUCTAL CARCINOMA IN SITU):
 >4 cm of disease
 More than one quadrant
MASTECTOMY
NO
LUMPECTOMY FOLLOWED
BY RADIOTHERAPY
YES

162.  Low grade DCIS,solid,cribriform,papillary, <0.5
cm of disease
LUMPECTOMY
without
RADIOTHERAPY

163. LCIS (LOBULAR CARCINOMA IN SITU)
BILATERAL MAMMOGRAPHY
•Second
carcinoma
BILATERAL
MASTECTOMY
•Limited
carcinoma
•No second
carcinoma
I. FOLLOW UP
II. CHEMOTHERAPY
WITH TAMOXIFENE
III. BILATERAL
MASTECTOMY

164. EARLY BREAST CARCINOMA

165. AIM
Achieve possible cure
Control of local diseases in the breast and
axillae
Conservation of local form and function
Prevention of delay of the occurrence of
distant metastases
Prevention of local recurrence

166. MANAGEMENT
 BREAST CONSERVING SURGERY with assessment of
axillary lymph node status followed by radiotherapy
 MASTECTOMY with assessment of axillary lymph
node status ,if
 Prior radiation therapy to breast and chest wall
 Involved surgical margin or unknown margin status
 Multicentric disease
 Collagen vascular diseases

167. ADJUVENT CHEMOTHERAPY
INDICATION :
• Node positive cancers
• Cancers that are >1cm
• Node negative cancer of >0.5cm when adverse
prognostic features are present

168. REGIMENS :
A. HER2-Neu + disease
 Single agent therapy : trastuzumab alone
or trastuzumab and
taxane
 Combination therapy : AC-Paclitaxel plus
trastuzumab
: AC-Docetaxel plus
trastuzumab

169. B. HER2-Neu – disease : CMF regimen
(cyclophosphamide,
methotrexate,
5-FU )
: AC regimen
(adriamycine,
cyclophosphamide)
C. ER/PR+disease : Tamoxifene therapy

170. LOCALLY ADVANCED
CARCINOMA OF BREAST

171. AIM
• Prevent distant metastases
• Prevent local recurrences
MANAGEMENT
Neoadjuvent chemotherapy
-anthracycline based
Response assessment

172. LACB
Neoadjuvent chemotherapy
RESPONSE NO RESPONSE
Bilateral mammography

173. RESPONSE NO RESPONSE
If operable chemotherapy
Mastectomy
Adjuvent
radiotherapy
Response no response
If operable not operable
Mastectomy Radiotherapy
Adjuvant If operable
radiotherapy mastectomy
Hormone treatmement if ER/PR positive

174. METASTATIC CARCINOMA OF
BREAST

176. AIM
• Improve quality of life
• Relieve pain of secondaries like bone, lungs
• Relieve neurological problems like
convulsions, space occupying cranial problems
• Other symptomatic relief

177. MANAGEMENT
Metastatic breast carcinoma with
systemic diseases
ER/PR+ ER/PR- HER2-Neu+
HER2-Neu-

178. ER/PR+
Visceral or epidural diseases
YES NO
CHEMO-
THERAPY PRE POST
MENOPAUSAL MENOPAUSAL

179.  PREMENOPAUSAL : Tamoxifene +/- ovarian
ablation
 POSTMENOPAUSAL : Aromatase inhibitor
• Tamoxifene
• Fulvestrant
• Medroxy-
progesterone

180. ER/PR-
HER2-Neu-
CHEMOTHERAPY

181. HER2-Neu+
ER/PR+ ER/PR-
trastuzumab trastuzumab
(single or (single or
Combition) combination)
or
Aromatase
inhibitor

182. NOTE THE FOLLOWING
• Bone secondaries : bisphosphonate
• Pleural effusion : - intercostal tube drainage
- pleurodesis
• Causes of death in carcinoma of breast :
1. secondaries in lung : heamoptysis,
: respiratory failure
2. spine involvement : quadriplegia
3. secondaries in brain
4. cancer cachexia

183. INFLAMMATORY BREAST
CARCINOMA
–T4d locally advanced carcinoma of breast
( stage IIIb)
 neoadjuvent chemotherapy and radiotherapy
 surgery ( if downstaged ) + axillary clearence

184. CARCINOMA OF BREAST IN
PREGNANCY

185. A. 1ST TRIMESTER : - MRM
(modified radical mastectomy)
- if axillary node positive
Termination of
pregnancy +
chemotherapy

186. B. 2ND TRIMESTER : - MRM / BCS*
-Chemotherapy
carefully
C. 3RD TRIMESTER : - MRM / BCS*
- after delivery
chemotherapy
suppression of
lactation
*HERE RADIOTHERAPY IS GIVEN AFTER
DELIVERY

187. NOTE THE FOLLOWING :
Hormonal treatment is
contraindicated : TERATOGENIC
Radiotherapy is also not given
MRI is the investigation of choice
Can become pregnant 2 yrs after
completion of treatment

188. FOLLOW UP
Clinical examination in detail @regular interval
Yearly / 2 yearly mammography of the treated
and contra lateral breast
Bone scan , CT chest/abdomen , tumor
markers – not routinely done

189. TREATMENT OF RECURRENCE
• PREVIOUS MASTECTOMY
Chemotherapy
Antiestrogentherapy
Radiotherapy ( if
previously not received )

190. • PREVIOUS LUMPECTOMY
 Mastectomy with reconstruction
 Chemotherapy
 Antiestrogen therapy

191. PROGNOSIS,PREVENTION &
RECENT ADVANCES IN BREAST
CARCINOMA
-PRESENTED BY
IMDADUL HOQUE
MEDICAL COLLEGE, KOLKATA
ROLL NO-188

192. PROGNOSTIC FACTORS
MAJOR FACTORS
INVASIVE VS IN-SITU
DISTANT METASTASES
LYMPH NODE METASTASES
TUMOUR SIZE
LOCALLY ADVANCED DISEASE
INFLAMMATORY CARCINOMA

193. MINOR FACTORS
HISTOLOGIC SUBTYPE
HISTOLOGIC GRADE
ER & PR
HER2/ neu RECEPTOR
LYMPHOVASCULAR INVASION
PROLIFERATIVE RATE
DNA CONTENT
RESPOND TO NEOADJUVANT THERAPY
GENE EXPRESSION PROFILING

194. PREVENTION
PRIMARY LEVEL OF PREVENTION:
NO OR LIMIT ALCOHOL
MAINTAIN A HEALTHY DIET
AVOID LONG-TERM HORMONE THERAPY
STAY PHYSICALLY ACTIVE
EAT FOODS HIGH IN FIBRES
EMPHASIZES OLIVE OIL
AVOID EXPOSURE TO PESTICIDES

195. SECONDARY LEVEL OF PREVENTION
BREAST SCREENING LEADS TO EARLY DIAGNOSIS OF BREAST CANCER.
IT CAN BE DONE BY FOLLOWING WAYS-
BREAST SELF EXAMINATION(BSE) BY THE PATIENT.
EXAMINE BOTH BREASTS.
REMIND THE PATIENT THAT 90% OF BREAST
LUMPS ARE NOT CANCER.
IF ANY DOUBTFULL SWEELING IS
PALPABLE,CONSULT THE SURGEON.
AMERICAN CANCER SOCIETY RECOMMENDS
MONTHLY BSE AFTER 20 YEARS OF AGE.
PALPATION BY A PHYSICIAN.
MAMMOGRAPHY.

196. MAMMOGRAPHIC SCREENING
DONE IN-
ASYMPTOMATIC WOMEN OVER THE AGE OF 40 YEARS
WHO ARE AT A AVERAGE RISK OF BREAST CANCER.
ASYMPTOMATIC WOMEN UNDER THE AGE OF 40
YEARS WHO HAVE POSITIVE FAMILY HISTORY OF
BREAST CARCINOMA.
DONE IN A 3 YEAR INTERVAL.
REDUCES CAUSE-SPECIFIC MORTALITY BY UPTO 30%.

197. ADVANTAGES:
CAN DETECT SMALL TUMOURS.
AVOIDS EXPENSIVE & TOXIC
TREATMENT FOR ADVANCED CANCER.
EXTRA YEARS OF PRODUCTIVITY.
REASSURANCE IF NEGATIVE.
LIFE YEARS GAINED BECAUSE MORE
CURABLE EARLY CANCERS DETECTED.

198. DISADVANTAGES:
EXPOSURE TO RADIATION.
FALSE POSITIVITY AROUND 5%.
COST OF ADDITIONAL CASES TREATED.
MORBIDITY OF TEST.
‘OVERDIAGNOSIS’, eg. DCIS
ANXIETY IN POSITIVE.
FALSE REASSURANCE OF FALSE NEGATIVE.

199. IF SCREENING TEST IS POSITIVE, THEN WHAT TO DO?
CHEMOPREVENTION:
TAMOXIFEN.
RALOXIFEN.
PREVENTIVE SURGERY:
PROPHYLACTIC MASTECTOMY
↓ BREAST CANCER BY 95%
PROPHYLACTIC SALPINGO-OOPHORECTOMY
IF PRE-MENOPAUSAL,50% ↓ IN BREAST
CANCER.

200. RECENT ADVANCES IN BREAST
CARCINOMA
ETIOLOGY OF BREAST CANCER:
EFFECT OF EXERCISE,WEIGHT GAIN OR LOSS,DIET
GENETIC TESTING FOR BRCA1 & BRCA2 GENE
MUTATION
‘SISTER STUDY’ FUNDED BY NATIONAL INSTITUTE OF
ENVIRONMENTAL HEALTH SCIENCES(NIEHS)
CHEMOPREVENTION:
RETINOIDS – NATURAL OR SYNTHETIC FORMS OF
VIT-A HAVE THE ABILITY TO DESTROY THE GROWTH
OF CANCER CELLS. EFFECTIVE IN PREMENOPAUSAL
WOMEN AND THOSE WHOSE TUMOURS AREN’T
ERTROGEN POSITIVE.
.

201. FLAXSEED- HIGH IN LIGNAN, A NATURALLY
OCCURING COMPOUND THAT LOWERS
CIRCULATING ESTROGENS IN THE BODY.
DECREASES ESTROGEN PRODUCTION-ACTS
LIKE TAMOXIFEN-INHIBIT THE GROWTH OF
BREAST CANCER TUMOURS.LIGNANS ARE
ALSO ANTIOXIDANTS WITH WEAK
ESTROGEN-LIKE CHARACTERISTICS.THESE
CHARACTERISTICS MAY BE THE MECHANISM
BY WHICH FLAXSEED WORKS TO DECREASE
HOT FLUSHES.
NEW IMAGING TESTS:
SCINTIMAMMOGRAPHY(MOLECULAR
BREAST IMAGING)
PET SCAN

202. TREATMENT:
ONCOPLASTIC SURGERY
NEW CHEMOTHERAPY DRUGS- PARP
INHIBITORS
TARGETED THERAPIES
HER2/neu TARGETTING DRUGS-
TRASTUZUMAB,PERTUZUMAB,ADO-
TRUSTUZUMAB EMTANSINE, LAPATINIB
ANTI-ANGIOGENESIS DRUGS-
BEVACIZUMAB
OTHER TARGETTED DRUGS-
EXEMESTANE,LETROZOLE
BISPHOSPHONATES-PAMIDRONATE,ZOLEDRONIC
ACID
DENOSUMAB
VITAMIN-D

203. THANK YOU