9. ALL WILL GET BREAST AS A SHORT CASE!!
Commonest cancer in women in India now,
esp urban India
Urban women- 30% of all cancers
Incidence in India- 6.2- 39.5 cases per
1,00,000 women
10. GENEDER:
Strongest risk factor for breast cancer!!
Age: West 60-70
◦ India- 45-55
- Aggrawal et al, Breast cancer in India
Occupation:
Address:
11. Three most common symptoms:
◦ 80% come with these:
◦ Pain
◦ Lump
◦ Nipple discharge
Main concern- Separate benign and
malignant
12.
13. Age
Painless lump
Short duration
Increasing in size
ONE HISTORY WHICH TELLS YOU THIS IS DEFINIETLY NOT
CA??
HISTORY OF REGRESSION OF LUMP
ANYTHING THAT REGRESSES IS NEVER CANCER
14. Sanguinous nipple discharge
Skin changes- Swelling, Redness, Ulceration
Nipple changes- Ulceration, Destruction,
recent onset retraction
Associated lump in axilla
Metastatic sypmtoms- Rare (6-10%
metastatic at presentation, in India about 6-
25%)
- Aggrawal et al, Breast cancer in India
15. How does breast cancer most commonly
present?
In India-
Palpable lump-Almost all- 50% LABC in India
- Aggarwal et al. Br Ca in India
17. Pain:
◦ Side
◦ Duration
◦ STAR Square
◦ CYCLICAL V/S NON-CYCLICAL
◦ Diffuse V/s Point pain
o MOST COMMON SYMPTOM- 70% of patients
◦ PAIN MOSTLY INDICATES BENIGN DISEASE
◦ BUT ABOUT 10% BREAST CANCERS CAN PRESNT
WITH PAIN
18. CYCLICAL MASTALGIA:
◦ Physiological: Pre-menstrual edema
◦ Progestrone- Second half of menstrual cycle-
stroma edematous- percieved as pain
- Robins
Fibro-adenosis
Fibro-adenomas
23. Lumps- Reported by patients
Most commonly
◦ Cysts
◦ Fibroadenomas
◦ Ca
◦ Others-
◦ Fibroadenosis
◦ Phylloides
24. Chance of malignancy-
Increases with age
Age <40- 10% of breast lumps- Malignant
Age >50- 60% of breast lumps- Malignant
- Robins
25. Nipple Discharge:
Type
Duration
Side
Single V/s Multiple ducts
Spontaneous V/s Induced
26. Presenting complaint – 5%
Sole presenting complaint of cancer- 1%
Overall mailign in 3-7% of patients
Why?
◦ No TDLUs in nipple
- Management of breast diseases. Ismail Jatoi
28. Pathological nipple discharge:
Most common cause- Benign proliferative
breast disorders
MC Cause- Pappiloma
What percentage of sign ND is a/s/w malign?
◦ 4-21%
But if other assoc features, percentage will
rise-
◦ Mass plus nipple discharge- 61%- malignancy!
34. Lump- Axilla
Opposite breast
Opposite axilla/ Neck
Bone pains, shortness of breath, cough with
hemoptysis, chest pain, RHC pain , abd
distention, jaundice, abd mass
35. Most common sites of breast cancer
metastasis:
Bone- 50-60%
Lung 17-20%
Brain-16%
Liver- 6%
Multiple-10%
Other LNs- 10%
- Patanaphan V et al. South Med J 1988
36. Which are most common sites for metastasis
of breast cancer in order of occurrence:
HR+
◦ Bone-70-80%
◦ Lymph nodes
◦ Visceral- 10-20%
Pleural
Lung
Liver
Brain
37. HER-2 +;
◦ Most common visceral- 30-40%
◦ Brain- 30%
◦ Rem- 70%
TNBC:
◦ Almost same as Her-2 Neu
38. Which bones you will ask for pain?
MC- Lumbar spine
Why?
◦ Intercostal vein- Batson’s venous plexus vertebra
39. Past History:
◦ Co-morbidities
◦ Prev benign breast diseases/ breast biopsies/breast
surgeries
◦ Use of OCP/HRT
40.
41. Personal history:
Menstrual history:
Age at menarche
Pre/ Post menopausal
If pre- Cycles; LMP
Age at menopause
Reproductive history:
Age at first child birth
No of children
Breast fed or not
Duration of breast feeding
42.
43.
44.
45. Strong family history
Pre-invasive lesions-
◦ LCIS
◦ Atypical Ductal Hyperplasia
◦ Atypical Lobular Hyperplasia
Thoracic radiation before age 30
NCCN 2017- Women >35 years with
any of above- Risk estimation
46.
47.
48. ATYPICAL HYPERPLASIA(Category-1)
LCIS(Category-1)
HISTORY OF THORACIC IRRADIATION,
AGE <30 YEARS(Category-2)
Women age 35 and above, 5-year Gail
risk of breast cancer >1.7%(Category-1)
NCCN 2017 Guidlines
ASCO Guidlines 2013
52. What is difference between familial and
hereditary breast cancer?
What percentage each
Familial- 20-30%
- DeVita
- Hereditary- 5-10%
- DeVita
53. BRCA-1 – Located on chromosome 17
BRCA-2- Located on chromosome-13
57. When to consider genetic testing
Management:
BILATERAL SALPINGO-OOPHORECTOMY
BILATERAL PROPHYLACTIC MASTECTOMY
Surveillance- Annual MRI starting at 25
years/ 10 years before first case in family
Chemoprevention
59. Positions
Inspection
◦ Puckering/ Dimpling- Cause
◦ What are ligaments of cooper?
◦ Pea u d’orange
Cause
Arm and Thorax
Axilla, SC Fossa
Opposite
Must not forget
62. Cancers staged using this system:
◦ Invasive carcinoma of the breast
◦ Ductal carcinoma in situ(DCIS) of the breast
Cancers Not staged using this system:
◦ Breast sarcomas
◦ Phyllodes tumour
◦ Breast lymphomas
63. SIGNIFICANT CHANGES:
Two stage groups:
◦ Anatomic Stage Group-
Based on T,N,M categories
◦ Prognostic Stage Group-
Includes T,N,M PLUS
TUMOUR GRADE
STATUS OF BIOMARKERS- ER,PR, HER 2
64.
65. LCIS removed as pTis category!
◦ Benign entity, hence removed
Inclusion of multi-gene panels:
◦ Oncotype Dx
◦ Mammaprint
◦ EndoPredict
◦ PAM50
◦ Breast Cancer Index
69. Infra-clavicular:
Apical or Level-III lymph nodes
Internal mammary lymph nodes:
◦ Located in the intercostal space
◦ Along the edge of sternum
◦ In the endothoracic fascia
70.
71.
72. Inflammatory Carcinoma:
Clinico-pathological entity characterized by:
◦ Diffuse erythema
◦ Edema (Peau d’ orange)
◦ Induration
◦ Involving approximately one-third or more of
breast skin
◦ Of recent onset- Duration less than 6 months
73. Primarily a clinical diagnosis
On imaging-
◦ mass may be detectable
◦ along with characteristic skin thickening
Mass may or may not be palpable
74. Cause of skin edema:
◦ Tumour emboli within dermal lymphatics
Diagnosis:
Histopathological diagnosis of tumour
required
Skin biopsy- Not essential for diagnosis
75. Tumour emboli in dermal lymphatics alone,
no characteristic skin changes?
Tumour to be staged as per size
76.
77. Internal Mammary Lymph Nodes:
Detected by:
◦ Clinical Examination
◦ Imaging studies- CT, MR and ultrasound , not
lymphoscintigraphy
Supraclavicular:
◦ Clinical Examination
◦ Imaging studies- ultrasound ,CT and PET
87. What will you do?
Mammography- B/L Breast
Why B/L?
◦ Synchronous B/L- 1.5-2.5% cases
88. How to read a MG?
Type
Technically adequate
Type of breast density
Lesion:
◦ Location
◦ Density
◦ Borders
◦ Microcalcufications
◦ Surrounding architecural distortion
Any other lesion
Skin
Nipple
Axilla
103. Factors which determine the risk of
recurrence of breast cancer,
regardless of the treatment given
- Hayes D. Predictive and prognostic markers in cancer. Clin Adv Hematol
Oncol, 2011
104. Traditional factors:
Lymph node status
Number of lymph nodes involved
Tumour size
Tumour grade
Still most important
-Cianfrocca M, Goldstein LJ. Prognostic and predictive factors in
early-stage breast cancer. Oncologist 2004
-Carter CL, Allen C, Henson DE. Relation of tumour size, lymph
node status, and survival in 24,740 breast cancer cases. Cancer
1989
-Fung F, Vanniyasingam T, et al. Predictors of 5-year local,
regional, and distant recurrent events in a population-based
cohort of breast cancer patients. Am J Surg. 2017
105. Markers which predict response to specific
therapies:
Most important:
ER
PR
Her-2 Neu
- Hayes D. Predictive and prognostic markers in cancer. Clin Adv Hematol
Oncol, 2011
106. ER Expression:
Measured by IHC
Any staining of 1% or more- Positive
Level-1 Evidence
107. PR Expression:
Measured by IHC
Any staining of 1% or more- Positive
Level-1 Evidence
108. HER 2:
2013 ASCO/CAP Guidelines
IHC- Protein Expression
Confirmed by-ISH-Assess gene copy number
Level-1 Evidence
IHC:
◦ Negative:0 or 1+ staining
◦ Equivocal:2+ staining
◦ Positive:3+ staining
109. FISH
◦ If Equivocal by IHC
Dual Probe FISH:
◦ Negative-HER2/CEP 17 <2.0 AND HER2 copy number <4
◦ Equivocal(Perform alternative ISH):
◦ HER2/CEP 17 <2.0 AND HER2 copy number 4-6
◦ Positive-HER2/CEP 17 =/>2.0 OR HER2 copy number >6
Single probe FISH:
◦ Negative <4 HER 2 copies
◦ Equivocal- 4-6 copies
◦ Positive >6 copies
114. ER, PR, Her-2 Neu
IHC-4 Panel- ER,PR, Her-2 Neu, Ki-67
Oncotype-DX
Endo-Predict
PAM-50
Breast Cancer Index
Mammaprint
Urokinase plasminogen activator
Plasminogen activator inhibitor type-1
115. Oncotype Dx:
Genomic based test- Assessment of 21 genes
Result- Outcome of a mathematical formula
of the weighed expression of each gene
Measured and reported by RT-PCR
Recurrence Score <11- Cut off
Required for- T1-T2 N0 M0, ER-positive,
HER-2 Negative tumours
AJCC- Level-1 evidence
116.
117. Ki-67
Multigene Signature Scores-
◦ Mammaprint
◦ PAM 50
◦ Breast Cancer Index
◦ Endo predict
Level- II Evidence
118. Risk Assessment Models:
Two models:
◦ Adjuvant! Online
◦ Predict
Can be used to assist regarding decisions about
adjuvant therapy in early breast cancer patients
Both are online tools
