Cancer of breast

1. WATYEKERE SAMSON CLAUS
OKOT RICHARD

2. OUTLINE
Definition
Epidemiology
Anatomy
Etiology
Pathophysiology
Clinical Presentation
Workup
Staging
Treatment and palliative care
Prevention
References

3. DEFINITION
• Breast cancer is defined as a malignant neoplasm of the br
east which may arise from the epithelial lining of the lobu
le, ducts or the nipples

4. EPIDEMIOLOGY
• This is second most common cancer after lung cancer BUT the
most common in women
• White/caucasian women have a higher risk than black women
BUT the cancer is more aggressive in black women.
• The ratio is 1 in 8 women and the ratio of men to women is
1:100
• In Uganda 2021; the incidence rate of breast cancer was 21.3 in
100,000 while the mortality rate was 10.3 in 100,000 which
means that almost half of the women who acquire the disease
will die.
• The problem is believed to be due to delayed diagnosis. 89%
present in the III or IV stage when its difficult to treat.

5. ANATOMY
Boundaries
• Superiorly: 2nd rib
• Inferiorly: 6th rib
• Medially: lateral border of the sternum
• Laterally: mid-axillary line
– Axillary tail of Spence projects from its upper and lateral part and extends
through a foramen of Langer in the deep fascia to enter the axilla

6. Structure
• Breast composed of:
– Glandular tissue
– Fibrous tissue
– Adipose tissue
• 15-20 lobes, each lobe is divided i
nto lobules
– Acini (alveolus)  lobule  lobe
• Lobules are separated by Cooper’s
ligaments
• Each lobe pours secretion into the
lactiferous duct

7. Shape
• Dome –shaped i.e. round and hemispherical
• The nipple (which is directed downwards and laterall
y) forms the apex of the dome
• The nipple is surrounded by areola which contains b
oth sebaceous and sweat glands.
• During pregnancy, the sebaceous glands enlarge and
appear as elevations known as tubercles of Montgom
ery (sebaceous glands)
• About 15-20 small openings for the underlying lactif
erous (milk) ducts are seen at the nipple

8. Relations
• The base of the mammary
gland lies over the
pectoralis major (2/3),
serratus anterior (1/3) and
external oblique
aponeurosis (1/3)

9. Anatomical quadrants
• Divided into 4 quadrants and a tail
• The quadrants are:-
– Upper outer quadrant
– Upper inner quadrant
– Lower outer quadrant
– Lower inner quadrant
• The upper outer quadrant contains the
most glandular tissue
• Breast tissue extends from the upper outer
quadrant into the axilla, forming the axillar
y tail of Spence

10. Blood supply
• Arterial supply is from three sources:-
From axillary artery via lateral thoracic and thoracoacromial
branches
supply the lateral and superior part of the breast
 From internal thoracic artery via its 2nd to 4th perforating
branches supply the medial aspect of the breast
 From the posterior intercostal arteries via their lateral per
forating branches; a relatively unimportant source supply
the lateral part of the breast
• The venous drainage is to the corresponding veins i.e. axillary
and internal thoracic veins

12. Lymphatic Drainage
• Lymphatic drainage of the breast is to:-
– Axillary lymph nodes (>75%)
– Internal mammary (thoracic) nodes (20-25
%)
– Intercostal nodes (<5%)
• Axillary lymph nodes are arranged in five ana
tomical groups:-
– Apical –in the apex of the axilla
– Central- in the axillary fat
– Anterior (pectoral)-along the lateral thorac
ic vessels
– Posterior (subscapular)-along the subscapu
lar vessels
– Lateral (brachial)-along the axillary vein

13. Breast Innervation
• Branches of intercostal tho
racic nerves (T3-T5)
• Supraclavicular nerves

14. ETIOLOGY/RISK FACTORS
• Etiology unknown, but several risk factors have bee
n identified
• These are classified as follows:-
– Socio-demographic risk factors
– Hereditary factors (genetics & family history)
– Hormonal factors
– Dietary factors (saturated fat)
– Lifestyle factors
– Factors related to breast conditions
– Environmental factors

16. Socio-demographic risk factors
• Age
• Sex (100:1)
• Area of residence (developed country lifestyle)
• Socio-economic status
• Race (caucasian)

17. Age
• The incidence of breast cancer increases with age and
is rare before the age of 20 years
• In Africa, the peak age incidence is about one deca
de less, so that the majority of the patients are pre-
menopausal
• Numerous theories have been proposed to explain thi
s difference, including age at menarche, time of first d
elivery, parity, socio-demographic factors, body mass
index, and underlying genetic difference

18. Socio-economic status
• Women of higher SES are at greater risk for br
east cancer [2-fold]
• The influence of socioeconomic status are thou
ght to be mediated by differing reproductive pa
tterns with respect to parity, age at first birth, a
nd age at menarche

19. Genetic predisposition
• The mutated genes BRCA 1 and BRCA 2 are r
esponsible for  30-40% of inherited breast ca
ncer

20. Family history of breast cancer
• A family history of breast cancer is associated
with an increased risk of the disease
• The risk is greatest in patients with first-degree
relatives (mother or sister) affected, especially
if under the age of 50 when the disease devel
oped

21. Hormonal factors
• Prolonged exposure to and higher concentrations of endogen
ous estrogen increase the risk of breast cancer
– Early age at menarche [≤ 12 years]
– Late age at first pregnancy [>30 years ]
– Late menopause [55years]
– Nulliparity at the age of 40 years
– Note: prolonged lactation/breast feeding is protective
• Exogenous estrogens e.g. oral contraceptive drugs have been
shown to increase the risk of developing breast cancer

22. Lifestyle risk factors
• Weight gain
– Obesity is associated with a twofold increase in the risk of b
reast cancer in postmenopausal women whereas among pre
menopausal women it is associated with a reduced incidence
• Alcohol intake
– Some studies have shown a link between alcohol consumption a
nd incidence of breast cancer, but the relation is inconsistent an
d the association may be with other dietary factors rather than al
cohol

23. Factors related to breast conditions
• Individuals who have a prior history of breast disease have a
n increased risk of developing breast cancer.
• Women with atypical ductal or lobular hyperplasia have
a 4-5 times higher risk of developing breast cancer
• Proliferative lesions without atypia, such as moderate hyp
erplasia and sclerosing adenosis, are associated with a slight
ly increased risk
• Other common non-proliferative changes such as palpable
cysts, fibroadenomas and duct papillomas are not associate
d with a significantly increased risk

24. Environmental factors
• Exposure to ionizing radiation increases the ri
sk of developing breast cancer
• Environmental exposures to organic chlorines
and other environmental/synthetic estrogens
like cosmetics and phytoestrogens found in fo
od have also been postulated to increase the ri
sk

25. PATHOPHYSIOLOGY
• Site
• Macroscopically
• Microscopically
• Spread

26. Site
• Breast cancer may arise from the epithelium of
the duct system anywhere from the nipple end
of major lactiferous ducts to the terminal duct
unit which is in the breast lobule
• It is more common in the upper outer quadr
ant

27. Macroscopically/ gross appearance
• Ulcerating
• infiltrating
• Satellite nodules
• Retraction
• Dimpling
• Peau d’orange
• Fungating
• Solid mass
Why the skin of the breast looks like an or
ange peel?
Due to obstruction of the superfici
al lymphatics of the breast

28. Microscopically/histopathologically
• Classified as:-
– Non-invasive
• Lobular carcinoma in situ [LCIS]
• Ductal carcinoma in situ [DCIS]
• Pagets disease of the nipple
– Invasive
• Lobular carcinoma
• Ductal carcinoma
• Mucinous / colloid carcinoma
• Medullary carcinoma

29. Spread
• Direct
• Lymphatic
• Blood
• Transcoelomic implantation

30. Direct (local) spread
• To the:-
– Skin over the breast
– Pectoral muscles
– Chest wall

31. Lymphatic spread
• By:-
– Permeation
– Embolization
• 75% to the axillary lymph nodes
• The remaining to the internal mammary lymph nod
es

32. Blood (hematogenous) spread
• To distant sites via blood vessels eg lungs, live
r, bones, brain etc

33. Transcoelomic spread
Through mediastinal lymph nodes, it may sprea
d into peritoneal cavity causing secondaries in th
e liver, peritoneum and ovary forming a Krukenb
erg tumor

34. CLINICAL PRESENTATION
• History
• Physical examination

36. History
• Symptoms referring to the breast
– Breast lump
– Nipple discharge
– Nipple or skin changes
– Axillary mass or pain
– Arm swelling

37. Breast lump
• Duration
– Short duration- traumatic, Inflammatory, abscess, ? malign
ancy
– Long duration- benign conditions
• Mode of onset
– Sudden onset- traumatic, Inflammatory, abscess
– Gradual onset- benign conditions
• Progression
– Fast growing- malignancy
– Slow growing- benign conditions
• Is it painful?
– Painful- traumatic, Inflammatory, abscess
– Painless- neoplastic conditions
– Initially painless then painful malignancy

38. Nipple discharge
• Character & quantity
– Bloody discharge- intra-ductal Papilloma or carcino
ma
– Pus discharge- abscess
– Milky discharge- galactocele
– Serous or greenish discharge- fibroadenosis or mam
mary ductal ectasia

39. Nipple or skin changes
• Nipple- retraction, ulcerat
ion, inversion
• Skin - retraction,
ulceration

40. Axillary mass or pain
• May be involvement of the axillary tail or ax
illary lymph nodes

41. • Symptoms with reference to possible metastatic dis
ease
– Cough, chest pain, SOB – lung involvement
– Jaundice- liver metastasis
– Bone pain – bone metastasis
– Features of brain metastasis
• Past medical history of breast disease
• Family history of breast cancer

42. • Reproductive History
– Age at menarche
– Menstrual history
– Age at first pregnancy
– Age of onset of menopause
– Number of pregnancies, and abortions (including crimi
nal abortions)
– Duration of breast-feeding
– History of hormone use including contraceptive

43. Physical examination
• General examination
• Local examination
• Systemic examination

44. General examination
• Weight, Height & surface area
• Wasting
• Jaundice
• Dyspnea
• Anemia

45. Local examination
• Examination should be carried out in both sitt
ing and supine position
• includes:-
– Inspection
– Palpation
– Lymph node examination

47. Inspection
• Position
– With the arms by the side of the body- to assess the level of the
nipples
– With the arms raised straight above her head- lumps or dimple
will be more marked
– With the hands pressing on her hip- abnormal movement of the
nipple or exaggeration of the dimples will be evident
– With the patient bending forward from the wrist so that the bre
asts fall away from the body- failure of one nipple to fall away
indicates abnormal fibrosis behind the nipple
• Inspect systematically starting with the normal breast

48. Nipple
• Position- compare levels on both sides, elevation cancer
or inflammatory swelling due fibrosis
• Size & shape prominent: underlying cyst or swelling
retracted: malignant, fibrosis
• Surface  look for cracks, ulceration, fissure or eczema
• Discharge

49. Areola
• Look for:-
– Cracks
– Ulceration
– Fissure
– Eczema
– Discharge

50. Skin over the swelling
• Look for:-
– Erythema
– Infiltration
– Ulceration
– Satellite nodules
– Skin dimpling
– Peau d'orange

51. Palpation
• Position: sitting initially  recumbent position
• Look for:-
– Local temperature & tenderness
– Location [which quadrant]
– Size & shape
– Margin
– Consistency
– Fixation to skin, breast tissue, pectoral muscles & chest
wall

52. Lymph node examination
• Includes:-
– Axillary lymph nodes
– Supraclavicular lymph nodes
• Note:-
– Number
– Size
– Location
– Fixation to other nodes or underlying structures
– Clinically suspicious or benign

53. Systemic examination
• Respiratory examination R/O lung involvement
• Abdominal examination R/O liver involvement
– Rectal/Vaginal examination R/o Krukenberg’s tumor of t
he ovary
• CNS examination R/O brain metastasis
• MSS examination R/O bone metastasis

54. WORK UP
• Divided into two main categories:-
– Diagnostic investigations
– Staging investigations
• Aim:-
– To assess the general condition of the patient
– To assess the extent of the disease
– To confirm diagnosis
– To plan for treatment

56. Diagnostic investigations
• Breast imaging
• Pathological investigations

57. Breast imaging
• Mammography
– First choice imaging technique in symptomatic patients aged ≥ 30 years
Breast ultrasound
• Is complimentary to mammography
• Provides added information e.g. solid / cystic mass, true size of lesions
• It may be the technique of choice in the breast lumps of young women who have de
nse breast tissue
MRI of breast:
• To differentiate scar from recurrence.
• For imaging of breasts of women with implants.
• To evaluate the management of axilla and recurrent
• disease.
• It is useful in screening females with high-risk group and
• young women and in pregnancy.
• Lesion undetermined by US or mammography is assessed
• by MRI.

59. Pathological investigations
• Fine needle aspiration cytology
– Has high degree of accuracy and when a diagnostic sample of
malignant cells is obtained, definitive surgery may go ahead
without need for open biopsy
– Can be done with or without mammography or US- guided
• Core Biopsy
– Done when FNAC is inconclusive, can be done under US gui
dance (enables histological exam)
• Open biopsy
– Excisional biopsy
• For small lesions
• Impalpable lesions may require mammographic localization
– Incisional biopsy
• For big lesions

60. Staging investigations
• Laboratory investigations
• Imaging investigations

61. Laboratory investigations
• Full blood count
• Serum urea and creatinine [RFT]
• Liver Function Test [LFT]

62. Imaging investigations
• Chest X-ray R/O lung metastasis
• Abdominal (liver) US R/O liver metastasis
• Skeletal survey R/O bone metastasis
• Bone scan
• CT scan
• MRI

63. TRIPLE ASSESSMENT
• A pre-operative diagnosis using triple assessm
ent is essential before treatment is undertaken
• This involves:-
1. Clinical evaluation
2. Breast imaging
3. Pathological examination

64. Clinical evaluation
• This involves:-
– Thorough history
– Local and systemic clinical examination as above

65. Breast imaging
• Imaging procedures offered include:-
– Mammography
– Breast ultrasound
– MRI

66. Pathological examination
• This include:-
– Fine needle aspiration cytology
– Core biopsy
– Open biopsy
• Incisional biopsy
• Excisional biopsy (affected tissue plus surrounding area)

67. STAGING
• Aim
– To assess the extent of the disease
– To assess the prognosis of the disease
– To plan for treatment modality
• Criteria
– TNM system
– Manchester

72. G-Histopathological Grading
• G1 Well differentiated
• G2 Moderately differentiated
• G3 Poorly differentiated

74. TREATMENT
• Goals of treatment
• Modalities of treatment /treatment options
• Mode of treatment

75. Goals of treatment
• Goals of Treatment include:-
– Cure
– Extend Survival i.e. to improve the quality of life
– Palliation i.e. to relieve symptoms

76. Modalities of treatment /treatment options
• Counseling
• Surgery
• Radiotherapy
• Chemotherapy
• Hormonal therapy
• Immunotherapy

77. Counseling
• Like in all cancers the diagnosis of breast cancer is fright
ening and exposes the patient and her family to psycholo
gical torture
• Proper counseling should be part and parcel of the entire
management strategy
• Good counseling enables the patient and her family to co
pe with the stress that is part and parcel of cancer and adj
ust to their life styles
• Counseling should continue during treatment and during
follow up

78. Surgery
• Breast conserving surgery
– surgical excision of the tumor + with surrounding margins (lum
pectomy)
• Mastectomy(surgical removal of the affected breast)
– Simple
– Modified
– Toilet
• Surgery of the RLN(Regional lymph nodes)
– Axillary lymph node dissection [ALND]
– Sentinel lymph node biopsy [SLNB]

79. Radiotherapy
• Use of high-energy rays to stop breast cancer cell
s from growing and dividing
• Can be given as part of the primary treatment or a
s palliative
• Can be given after surgery [adjuvant] or before su
rgery [neo-adjuvant]
• Given as an external beam radiotherapy to the bre
ast, axilla and supraclavicular nodes

80. Chemotherapy
• Use of anticancer drugs to kill breast cancer cells
• Can be used as an adjuvant or neo-adjuvant therapy
• Regimes include:-
– CMF every 3 weeks for 6 cycles
• C= Cyclophosphamide 600mg/m2 i.v.
• M=Methotrexate 40mg/m2 i.v.
• F=5-Fluorouracil 600mg/m2 i.v.
– CAF
• C= Cyclophosphamide 600mg/m2 i.v
• A= anthracycline
• F=5-Fluorouracil 600mg/m2

81. Hormonal therapy
• Can be given as an adjuvant therapy after surgery or
as treatment for systemic disease
• Classified as:
– 1st line treatment
• Antiestrogen eg Tamoxifen 20mg daily for 2-5 years
– 2nd line treatment
• Aromatase inhibitor eg Anastrozole 1mg daily
• Medroxyprogesterone acetate 0.4-1.5g daily

82. Immunotherapy
• Use of monoclonal antibodies directed against
breast cancer cells
• Still under investigation
• Include:
– Trastuzumab

83. Mode of treatment
• Depends on a variety of factors including:-
– The size of the breast tumor
– Location of the tumor
– The stage of the cancer
– Hormonal receptor status eg ER or PR
• Divided into 4 main categories according to the stage:-
– Management of early breast cancer
– Management of locally advanced breast cancer
– Management of metastatic and locally recurring breast cancer
– Management of breast cancer occurring during pregnancy

84. Management of early breast cancer (stage I & II)
• Aim of treatment: Cure
• Treatment options
– Counseling
– Surgery
• Breast conserving surgery- only for stage I [T1N0M0, T2N0M0) tumor size < 3cm
• Mastectomy – for stage II and stage I for multifocal ,central or tumor > 3cm
– Adjuvant Radiotherapy
• Done after BCS or mastectomy
• To reduce risk of local recurrence
• To plan for ease radiotherapy
– Incision should be short and transverse
– Physiotherapy of the ipsi-lateral shoulder joint should start on day 1 Post-operative
– Adjuvant systemic [chemotherapy and hormonal] therapy
– Neo-adjuvant systemic therapy may be given to down stage the cancer

85. Follow up after treatment for early breast cancer
• Aims:-
– To detect recurrence at an early stage and thus early tr
eatment
– To detect and manage treatment related toxicity
– To screen for new primary in the contra-lateral breast
– To provide psychological support

86. Follow up……..
• Follow up involves the following:-
– Palliative care team [Hospice] & Other health workers
• To provide psychological care
• To provide symptomatic care
– Pain management
– Vomiting
– Mammography
• Patients who had mastectomy should have mammography of the opposit
e breast every 2 years
• For patients who had BCS both breasts should have mammography ever
y 2 years
– TCA (Team Care Arrangements)
• Patients should be seen at 3 and 6 months following radiotherapy and t
hen once every year for life

87. Management of locally advanced breast ca
ncer [stage III]
• Aim of treatment: Palliative
• 2 principle objectives of management
– To achieve local control
– To prevent or to delay the distant metastasis
• Multimodalities of treatment including:-
– Counseling
– Surgery:
• Toilet mastectomy should be able to close the surgical flap, othe
rwise neo-adjuvant systemic therapy should be done to down st
age the disease

88. Modalities of treatment of stage III …
• Radiotherapy
• Can be given as palliative, neo-adjuvant or adjuva
nt
• Chemotherapy
– Can also be given if the patient can tolerate it
– Can be given as adjuvant, neo-adjuvant or palliative
therapy
• Hormonal therapy

89. Management of metastatic and locally recurring breast
cancer
• The treatment of metastatic and locally recurring
breast cancer are the same
• Aim:
– Palliation depending on individual patient
• Modalities
– Surgery:
• Chest wall involvement →re-excision and flap reconstructio
n
• Recurrence after BCS→ mastectomy
• Chest wall Radiotherapy± Surgery

90. • Chemotherapy for those who can tolerate it
• For extensive metastases → Chemotherapy ± hormon
al therapy or both
• In elderly or unfit patient, it is better to start with hormo
nal therapy
• Bone involvement, spinal cord compression and superio
r vena cava obstruction syndrome →Radiotherapy
• Pathological fractures→ splintage
• Pleural effusion→UWSD + intra-pleural bleomycin or
tetracycline instillation
• Hypercalcaemia → I.V. rehydration, if fails→ bisphos
phonates

92. Management of Breast cancer in pregnancy
• Multi-disciplinary approach involving the surgeo
ns, medical and radiation oncologists, obstetrician
s is needed
• Termination of pregnancy is not necessary and
does not improve survival
• 1st / 2nd trimester:
– Radiotherapy and chemotherapy should be delayed un
til delivery
– Mastectomy and axillary clearance is the treatment of
choice

93. • 3rd trimester
– Ideally treatment should be delayed until after delivery a
t about 32/40 → treatment as for non-pregnant patien
t
– Hormonal therapy should be avoided
• Lactation
– Patients receiving chemotherapy should not be allowed
to breastfeed as some of drugs [e.g cyclophosphamide
and methotrexate] are secreted in breast milk and could
be harmful to the child

94. Palliative care in Breast cancer
• Definition
– Active total care of patients whose disease is not re
sponsive to curative treatment
– Involves control of pain and other symptoms rel
ated to the disease or treatment modalities
– Also deals with psychological , social and spiritu
al problems of the patient

95. Palliative care …..
• Palliative care team [Hospice]
– Is multi-disciplinary team of doctors, nurses, social workers, s
upport staff and volunteers of various categories
• Palliative care options include:-
– Pain control using the WHO criteria for analgesia for somatic
pain
• Step 1: NSAIDs + Paracetamol
• Step 2: NSAIDs + Paracetamol + Weak opioid [Codeine]
• Step 3: NSAIDs + Paracetamol + Strong opioid [Morphine]
– Control of infections→ crushed metranidazole for fungating le
sions
– Control of nausea / vomiting→ steroids + anti-emetics
– Appetite stimulants → Corticosteroids
– Counseling / Social support

96. PREVENTION
• Primary prevention
– Difficulty
– Modification of risk factors
– Health education → ↑ awareness of the risk factors
• Secondary prevention
– BSE(Breast Self Examination)
– Clinical breast examination
– Mammography screening
• Tertiary prevention
– rehabilitation

99. Breast self examination
• Breast self-examination plays a major role in early detection and
intervention of breast carcinoma.
• Ideally done once a month just after the menstruation, as during this
time breasts are less engorged.
• In postmenopausal age group it is done at monthly regular intervals.
• Examine both breasts
™
Remind the patient that 90% of breast lumps are not cancer.
™
Better way is in lying down position with arm raised with a mattress
support behind
™
Palpation should be using the fingers over all quadrants of the breast
™
If any doubtful swelling is palpable, consult the surgeon
™
American Cancer Society recommends monthly BSE after 20 years of
age
™
Nursing mother should perform BSE just after feeding the baby.

103. MALE BREAST CANCER
• Gynaecomastia and excess estrogen are said to be the etiological
factors along with BRCA2 as a common association
• Usually infiltrating duct carcinoma
• Presentation, spread and behaviour are the same as carcinoma of the
female breast.
• Tamoxifen is very useful in carcinoma of the male breast.
• Carcinoma of the male breast has a poorer prognosis than carcinoma
of the female breast
• LHRH agonists are often used e.g. Goserelin 3.6 mg/ 28 days for 2
years. BUT it produces reversible CHEMICAL CASTRATION.
• Bilateral orchidecomy wich was earlier used is nolonger commonly
advocated

105. References
• Bailey and Love’s Short Practice of Surgery
27th Edition, Pages 871-878
• SRB’s Manual of Surgery, Pages 530-564
• Medscape