This document provides an overview of breast anatomy, physiology, and pathology. It begins with embryology and functional anatomy, describing the development and structure of the breast. It then covers benign breast conditions, risk factors and screening for breast cancer, the natural history and histopathology of breast cancer, and techniques for diagnosing breast cancer including mammography and physical examination.

1. BREAST
Dr Rajeev Kumar Pandit
FCPS 1st Yr Surgery Resident
Manmohan Memorial Medical College
Swoyambhu, Nepal

2. EMBRYOLOGY AND FUNCTIONAL ANATOMY
OF THE BREAST
• Start at the fifth or sixth week of fetal development
• Two ventral bands of thickened ectoderm (mammary ridges, milk
lines)
• Accessory breasts (polymastia)
• Accessory nipples (polythelia)
• Absence of the breast (amastia)
• Symmastia webbing between the breasts
• 15 to 20 secondary buds
• Witch’s milk – transitory, in response to maternal hormones that
cross the placenta
• The breast enlarges in response to ovarian estrogen and
progesterone, which initiate proliferation of the epithelial and
connective tissue elements

3. Functional Anatomy
• 15 to 20 lobes
• Extend vertically from the 2nd or 3rd rib to 6th or 7th rib.
• Transversely from the lateral border of the sternum to the anterior
axillary line
• Posterior surface of the breast rests on the fascia of the pectoralis major,
serratus anterior, and external oblique abdominal muscles, and the upper
extent of the rectus sheath
• Retromammary bursa
• The axillary tail of Spence extends laterally across the anterior axillary fold.
• The upper outer quadrant of the breast contains a greater volume of
tissue.

4. • Nipple-Areola Complex - The areola contains sebaceous glands, sweat
glands, and accessory glands, which produce small elevations on the
surface of the areola (Montgomery’s tubercles)

5. Blood supply :
a) perforating branches of the internal mammary artery;
b) lateral branches of the posterior intercostal arteries; and
c) branches from the axillary artery, including the highest thoracic,
lateral thoracic, and pectoral branches of the thoraco-acromial artery
Veins are:
(a) perforating branches of the internal thoracic vein,
(b) perforating branches of the posterior intercostal veins, and
(c) tributaries of the axillary vein

6. • BATSON’S VERTEBRAL VENOUS PLEXUS, which invests the vertebrae
and extends from the base of the skull to the sacrum, may provide a
route for breast cancer metastases to the vertebrae, skull, pelvic
bones, and central nervous system
• Nerve supply by Lateral cutaneous branches of the third through sixth
intercostal nerves provide sensory innervation

7. Lymphatic drainage

8. PHYSIOLOGY OF THE BREAST
• Estrogen initiates ductal development
• Progesterone is responsible for differentiation of epithelium and for
lobular development.
• Prolactin is the primary hormonal stimulus for lactogenesis in late
pregnancy and the postpartum period
• LH, FSH, and GnRH. These hormones are responsible for the
development, function, and maintenance of breast tissues

9. Gynecomastia
• Enlarged breast in the male, the ductal structures enlarge, elongate, and
branch with a concomitant increase in epithelium
• In the nonobese male, breast tissue measuring at least 2 cm in diameter
is gynaecomastia
• Physiologic gynecomastia three phases of life: due to excess of
circulating estrogens in relation to circulating testosterone
• the neonatal period,
• adolescence, and
• senescence,

10. • Gynecomastia is graded based on
• the degree of breast enlargement,
• the position of the nipple with reference to the inframammary fold
• the degree of breast ptosis and skin redundancy
• Grade I: mild breast enlargement without skin redundancy;
• Grade IIa: moderate breast enlargement without skin redundancy;
• Grade IIb: moderate breast enlargement with skin redundancy; and
• Grade III: marked breast enlargement with skin redundancy and
ptosis

12. Treatment
• Local excision,
• Liposuction or
• Subcutaneous mastectomy
• Danazol

13. INFECTIOUS AND INFLAMMATORY
DISORDERS OF THE BREAST
• Intrinsic (secondary to abnormalities in the breast) or
• Extrinsic (secondary to an infection in an adjacent structure, e.g., skin,
thoracic cavity)

14. Breast Abscess
• May be infectious or noninfectious
• Caused by staphylococcus or streptococcus
• Clinical features – Pain, swelling, erythema, pus point, discharge.
• Investigation- pus culture and tissue biopsy
• Tx- local antibiotics, systemic antibiotics, repeated aspiration, incision and
drainage.
• Zuska’s disease, also called recurrent periductal mastitis, recurrent
retroareolar infections and abscesses. Smoking is risk factor.

15. Hidradenitis Suppurativa
• Chronic inflammatory condition
• Originates within the accessory areolar glands of Montgomery or
within the axillary sebaceous glands
• D/D Paget’s disease of the nipple or invasive breast cancer
• Tx - Antibiotic therapy with incision and drainage.

16. Mondor’s Disease
• Variant of thrombophlebitis that involves the superficial veins of the
anterior chest wall and breast
• “STRING PHLEBITIS”
• Clinical feature - a tender, cord-like structure, acute pain in the lateral
aspect of the breast or the anterior chest wall.
• Tx-
• anti-inflammatory medications and
• application of warm compresses along the symptomatic vein.
• The process usually resolves within 4 to 6 weeks.
• Excision of the involved vein segment when refractory to medical therapy and
symptoms persist.

17. Aberrations of Normal Development and
Involution
• classification of benign breast conditions are the following:
• benign breast disorders and diseases are related to the normal
processes of reproductive life and to involution;
• there is a spectrum of breast conditions that ranges from normal to
disorder to disease;

19. Early Reproductive Years
• aged 15 to 25 years
• usually grow to 1 or 2 cm in diameter and then are stable but may
grow to a larger size
• larger fibroadenomas (≤3 cm) are disorders and giant fibroadenomas
(>3 cm) are disease
• multiple fibroadenomas (more than five lesions in one breast) are very
uncommon and are considered disease
• The precise etiology of adolescent breast hypertrophy is unknown
• Painful nodularity that persists for >1 week of the menstrual cycle is
considered a disorder

22. • Microcalcifications, which vary in shape and density and are <0.5 mm in
size, and fine, linear calcifications, which may show branching.
• Adenomas of the breast are well circumscribed and are composed of
benign epithelium with sparse stroma, which is the histologic feature
that differentiates them from fibroadenomas
• divided into tubular adenomas and lactating adenomas.
• Tubular adenomas are seen in young nonpregnant women
• Lactating adenomas are seen during pregnancy or during the
postpartum period

23. • Fibrocystic Disease - refers to a spectrum of histopathologic changes that
are best diagnosed and treated specifically.
• Breast cyst
• fine needle aspiration or core needle biopsy
• The volume of a typical cyst is 5 to 10 mL
• Pneumocystogram
• complex cyst may be the result of an underlying malignancy
• Fibroadenomas
• self-limiting
• ultrasound examination with core-needle biopsy
• lesions <3 cm- Cryoablation and ultrasound-guided vacuum assisted biopsy.
• Larger lesions - excision

24. • Sclerosing Disorders
• Mammography (mass density with spiculated margins)
• Excisional biopsy and histologic examination
• Periductal Mastitis
• Painful and tender masses behind the nipple-areola complex
• aspirated with a 21-gauge needle
• combination of metronidazole and dicloxacillin
• Ultrasound
• Drainage
• Recurrent abscess with fistula
• Nipple Inversion
• occurs secondary to duct ectasia
• altered nipple sensation, nipple necrosis, and postoperative fibrosis with nipple
retraction
• complete division of these ducts is necessary for permanent correction of the
disorder

25. BREAST CARCINOMA
• RISK FACTORS FOR
BREAST CANCER
• Hormonal and
Nonhormonal

26. Risk Assessment Models
• The average
lifetime risk of
breast cancer
for newborn
U.S. females is
12%.

27. Breast Cancer Screening
• Biennial mammographic screening between the ages of 50 and 74 years
• Annual mammography for women beginning at age 40 years to continue as
long as she is in good health
• The use of MRI for breast cancer screening is recommended by the ACS for
women with a 20% to 25% or greater lifetime risk using risk assessment tools.
• Risk-reducing Surgery
• prophylactic mastectomy reduced their risk by >90%
• BRCA Mutations
• Up to 5% of breast cancers are caused by inheritance of germline mutations such as
BRCA1 and BRCA2
• autosomal dominant
• Identifying hereditary risk for breast cancer is a four-step process that includes: (a)
family history, (b) genetic testing (c) counseling the patient, and (d) interpreting the
results of testing

28. • Risk management strategies for BRCA1 and BRCA2 mutation carriers
include the following:
• 1. Risk-reducing mastectomy and reconstruction
• 2. Risk-reducing salpingo-oophorectomy
• 3. Intensive surveillance for breast and ovarian cancer
• 4. Chemoprevention

30. Epidemiology
• Most common site-specific cancer in women
• Leading cause of death from cancer for women aged 20 to 59 years

31. Natural History
• The median survival was 2.7 years after initial diagnosis
• Primary Breast Cancer
• 80% of breast cancers show productive fibrosis that involves the epithelial
and stromal tissues
• shortens Cooper’s suspensory ligaments to produce a characteristic skin
retraction
• Localized edema (peaud’orange)
• With continued growth, cancer cells invade the skin, and eventually
ulceration occurs
• small satellite nodules
• axillary lymph node involvement

32. • Axillary Lymph Node Metastases
• Ill-defined and soft but become firm or hard with continued growth of the
metastatic cancer
• Adhere to each other and form a conglomerate mass.
• Involvement of contiguous structures in the axilla, including the chest wall
• Distant Metastases
• Successful implantation of metastatic foci occurs after the primary cancer
exceeds 0.5 cm in diameter. (the twenty-seventh cell doubling)
• For 10 years after initial treatment, distant metastases are the most common
cause of death in breast cancer patients

33. HISTOPATHOLOGY OF BREAST CANCER
• LCIS : DCIS ratio of >2:1
• Screening mammography DCIS : LCIS ratio of >2:1
• MULTICENTRICITY is occurrence of a second breast cancer outside
the breast quadrant of the primary cancer (or at least 4 cm away)
• MULTIFOCALITY is occurrence of a second cancer within the same
breast quadrant as the primary cancer (or within 4 cm of it)

34. LCIS Vs DCIS

35. • Lobular Carcinoma In Situ
• from the terminal duct lobular units and develops only in the female breast
• maintain a normal nuclear: cytoplasmic ratio
• Cytoplasmic mucoid globules are a distinctive cellular feature.
• Invasive breast cancer develops in 25% to 35% of women with LCIS
• Ductal Carcinoma InSitu
• Predominantly seen in the female breast, it accounts for 5% of male breast
cancers
• High risk for progression to an invasive cancer
• Proliferation of the epithelium that lines the minor ducts, resulting in
papillary growths within the duct lumina

38. Invasive Breast Carcinoma
• lobular or ductal in origin
• Classification for invasive breast cancer
• 1. Paget’s disease of the nipple
• 2. Invasive ductal carcinoma—Adenocarcinoma with productive fibrosis
(scirrhous, simplex, NST), 80%
• 3. Medullary carcinoma, 4%
• 4. Mucinous (colloid) carcinoma, 2%
• 5. Papillary carcinoma, 2%
• 6. Tubular carcinoma, 2%
• 7. Invasive lobular carcinoma, 10%
• 8. Rare cancers (adenoid cystic, squamous cell, apocrine)

39. Paget’s disease
• Disease of the nipple
• Chronic, eczematous eruption of the nipple, an ulcerated, weeping lesion.
• Associated with extensive DCIS and an invasive cancer.
• A palpable mass may or may not be present.
• A nipple biopsy specimen will show a population of cells that are identical to
the underlying DCIS cells (pagetoid features or pagetoid change).
• Pathognomonic of this cancer is the presence of large, pale, vacuolated cells
(Paget cells) in the rete pegs of the epithelium.
• Paget’s disease may be confused with superficial spreading melanoma
• carcinoembryonic antigen immunostaining in Paget’s disease.
• Surgical therapy - lumpectomy or mastectomy

40. Invasive Ductal Carcinoma
• productive fibrosis (scirrhous, simplex, NST) accounts for 80% of breast cancers
• macroscopic or microscopic axillary lymph node metastases in up to 25% of
screen-detected cases and up to 60% of symptomatic cases.
• occurs most frequently in perimenopausal or postmenopausal women
• fifth to sixth decades
• solitary, firm mass.
• poorly defined margins
• cut surfaces show a central stellate configuration with chalky white or yellow
streaks extending into surrounding breast tissues.
• The cancer cells often are arranged in small clusters, and there is a broad
spectrum of histologic types with variable cellular and nuclear grade

41. Medullary carcinoma
• Grossly, the cancer is soft and hemorrhagic.
• A rapid increase in size may occur secondary to necrosis and hemorrhage.
• On physical examination, it is bulky and often positioned deep within the
breast.
• Bilaterality is reported in 20% of cases
• microscopically :
• (a) dense lymphoreticular infiltrate composed predominantly of lymphocytes and plasma
cells;
• (b) large pleomorphic nuclei that are poorly differentiated and show active mitosis; and
• (c) a sheet-like growth pattern with minimal or absent ductal or alveolar differentiation
• 50% of these cancers are associated with DCIS

42. DIAGNOSIS OF BREAST CANCER
• Presenting signs and symptoms of breast cancer include
• (a) breast enlargement or asymmetry;
• (b) nipple changes, retraction, or discharge;
• (c) ulceration or erythema of the skin of the breast;
• (d) an axillary mass; and
• (e) musculoskeletal discomfort.
• up to 50% of women presenting with breast complaints have no
physical signs of breast pathology.
• Breast pain usually is associated with benign disease

43. Examination
• Inspection
• Position- her arms by her side, with her arms straight up in the air and with her
hands on her hips (with and without pectoral muscle contraction)
• Symmetry, size, and shape of the breast, evidence of edema (peaud’orange),
nipple or skin retraction, or erythema. With the arms extended forward and in a
sitting position, the woman leans forward to accentuate any skin retraction.
• Palpation
• supine position
• with the palmar aspects of the fingers
• axillary lymphadenopathy

45. • Imaging Techniques
• A. Mammography
• Screening mammography is used to detect unexpected breast cancer in
asymptomatic women
• Conventional mammography delivers a radiation dose of 0.1 cGy per study. By
comparison, chest radiography delivers 25% of this dose
• Two views,
• craniocaudal (CC) view
• mediolateral oblique (MLO) view
• Mammography was more accurate than clinical examination for the detection of
early breast cancers, providing a true-positive rate of 90%.

46. Premenopausal Postmenopausal

48. • Current guidelines of the National Comprehensive Cancer Network
suggest that
• normal-risk women ≥20 years of age should have a breast examination at
least every 3 years.
• Starting at age 40 years, breast examinations should be performed yearly and
a yearly mammogram should be taken.
• The benefits from screening mammography in women ≥50 years of age has
been noted above to be between 20% and 25% reduction in breast cancer
mortality

49. • The use of screening mammography in women <50 years of age is
more controversial because of:
• (a) reduced sensitivity;
• (b) reduced specificity; and
• (c) lower incidence of breast cancer

50. • B. Ductography
• Primary indication for
ductography is nipple
discharge
• Intraductal papillomas are
seen as small filling defects
• Cancers may appear as
irregular masses or as
multiple intraluminal filling
defects.

51. • C. Ultrasonography
• Defines cystic masses, and echogenic qualities of specific solid abnormalities
• Does not reliably detect lesions ≤1 cm in diameter
• Sensitivity of examination of axillary nodes ranges from 35% to 82% specificity ranges
from 73% to 97%
• Breast cysts- well circumscribed, with smooth margins and an echo-free center
• Benign breast masses usually show smooth contours, round or oval shapes, weak
internal echoes, and well defined anterior and posterior margins
• Breast cancer characteristically has irregular walls but may have smooth margins with
acoustic enhancement
• The features of a lymph node involved with cancer include
• cortical thickening,
• change in shape of the node to more circular appearance,
• size larger than 10 mm,
• absence of a fatty hilum and
• hypoechoic internal echoes

52. Simple breast cyst
Complex cyst with
solid component
Complex cyst s/o intracystic
papillay tumour

53. fibroadenoma Intraductal papilloma

54. Irregular
mass
Cancer with
calcification
Spiculated
mass

55. • D. Magnetic Resonance Imaging
• evaluation of a patient who presents with nodal metastasis from breast
cancer without an identifiable primary tumor;
• to assess response to therapy in the setting of neoadjuvant systemic
treatment;
• to select patients for partial breast irradiation techniques; and
• evaluation of the treated breast for tumor recurrence.

56. • Breast Biopsy
• Nonpalpable Lesions - Image-guided breast biopsy
• fine-needle aspiration (FNA) biopsy permits cytologic evaluation,
• core-needle permits the analysis of breast tissue architecture and allows the
pathologist to determine whether invasive cancer is present
• Palpable Lesions

57. • Breast Cancer Staging
TNM Staging
• Biomarkers

61. Therapy
• Stage 0
• for LCIS include observation, chemoprevention, and bilateral total mastectomy
• use of tamoxifen as a risk reduction strategy should be considered in women with a
diagnosis of LCIS
• Women with DCIS and evidence of extensive disease (>4 cm of disease or disease in
more than one quadrant) usually require mastectomy
• For women with limited disease, lumpectomy and radiation therapy are generally
recommended
• Adjuvant tamoxifen therapy is considered for DCIS patients with ER-positive disease
• The gold standard against which breast conservation therapy for DCIS is evaluated is
mastectomy
• recurrences were significantly lower in patients who received radiation

62. Early Invasive Breast Cancer (Stage I, IIA, or
IIB)
• stage I and II breast cancer- lumpectomy and radiation therapy
• Recurrence rate was higher in the lumpectomy alone group (39.2%)
compared with the lumpectomy plus adjuvant radiation therapy group
(14.3%)
• mastectomy with axillary staging and breast conserving surgery with
axillary staging and radiation therapy are considered equivalent
treatments.
• Relative contraindications to breast conservation therapy include
• (a) prior radiation therapy to the breast or chest wall,
• (b) persistently positive surgical margins after reexcision,
• (c) multicentric disease, and
• (d) scleroderma or lupus erythematosus.

63. • Adjuvant chemotherapy for patients with early-stage invasive breast cancer is
considered for
• patients with node-positive cancers,
• patients with cancers that are >1 cm, and
• patients with node-negative cancers of >0.5 cm when adverse prognostic features are
present.
• Adverse prognostic factors include
• blood vessel or lymph vessel invasion,
• high nuclear grade,
• high histologic grade,
• HER-2/neu overexpression or amplification, and
• negative hormone receptor status.
• Adjuvant endocrine therapy is considered for
• women with hormone receptor-positive cancers
• use of an aromatase inhibitor is recommended if the patient is postmenopausal.
• ‘SWITCH’ REGIME two years of tamoxifen followed by 3 years of an aromatase inhibitor

64. Advanced Local-Regional Breast Cancer
(Stage IIIA or IIIB)

66. • Internal Mammary Lymph Nodes
• evident on chest radiograph or CT scan,
• may present as a painless parasternal mass with or without skin involvement
• Systemic chemotherapy and radiation therapy are indicated in the treatment
of grossly involved internal mammary lymph nodes

67. Distant Metastases (Stage IV)
• not curative
• but may prolong survival and
• enhance a woman’s quality of life
• Systemic chemotherapy is indicated for women with hormone
receptor-negative cancers, ‘visceral crisis’, and hormone-refractory
metastases.
• women with stage IV breast cancer has been debated after several
reports have suggested that women who undergo resection of the
primary tumor have improved survival over those who do not.

68. Local-Regional Recurrence
• two groups: mastectomy and lumpectomy
• Mastectomy :-
• surgical resection of the local-regional recurrence and appropriate
reconstruction
• Chemotherapy and antiestrogen therapy
• adjuvant radiation therapy is given if the chest wall has not previously
received radiation therapy
• Lumpectomy:-
• mastectomy and appropriate reconstruction.
• Chemotherapy and antiestrogen therapy are considered.

69. Breast Cancer Prognosis
• The 5-year relative survival
• by race was reported to be 90.4% for white women and 78.7% for black
women.
• with localized disease (61% of patients) is 98.6%;
• for patients with regional disease (32% of patients), 84.4%; and
• for patients with distant metastatic disease (5% of patients), 24.3%.

70. SURGICAL TECHNIQUES IN BREAST CANCER
THERAPY
• 1 Excisional Biopsy with Needle Localization
• complete removal of a breast lesion with a margin of normal-appearing breast tissue
• It is important to consider the options for local therapy (lumpectomy vs. mastectomy with
or without reconstruction) and the need for nodal assessment with SLN dissection.
• In general circum-areolar incisions can be used to access lesions which are subareolar or
within a short distance of the nipple-areolar complex
• Elsewhere in the breast, incisions should be placed which are in the lines of tension in the
skin that are generally concentric with the nipple-areola complex
• In the lower half of the breast, the use of radial incisions typically provides the best
outcome
• Radial incisions in the upper half of the breast are not recommended because of possible
scar contracture resulting in displacement of the ipsilateral nipple-areola complex
• curvilinear incisions in the lower half of the breast may displace the nipple-areolar complex
downward

72. Sentinel Lymph Node Dissection
• Sentinel lymph node (SLN) dissection is primarily used to assess the
regional lymph nodes in women with early breast cancers who are
clinically node negative by physical examination and imaging studies.
• larger tumors (T3 N0)
• Use of both radioisotope and dye are better than alone.

73. Breast Conservation
• Breast conservation involves resection of the primary breast cancer
with a margin of normal-appearing breast tissue, adjuvant radiation
therapy, and assessment of regional lymph node.
• Resection of the primary breast cancer is alternatively called
segmental mastectomy, lumpectomy, partial mastectomy, wide local
excision, and tylectomy lymph node status.
• For many women with stage I or II breast cancer, breast-conserving
therapy (BCT) is preferable to total mastectomy because BCT
produces survival rates equivalent to those after total mastectomy
while preserving the breast

74. • BCT advantages over mastectomy
• Better quality of life and aesthetic outcomes. BCT allows for
• preservation of breast shape and skin
• preservation of sensation, and
• psychologic advantage

75. Mastectomy and Axillary Dissection
• Skin-sparing mastectomy
• all breast tissue,
• the nipple-areola complex, and
• scars from any prior biopsy procedures.
• recurrence rate of less than 6% to 8%,
• Total (simple) mastectomy without skin
sparing
• all breast tissue,
• the nipple-areola complex, and
• skin
• Extended simple mastectomy
• all breast tissue,
• the nipple-areola complex,
• skin, and
• the level I axillary lymph nodes
• Modified radical (‘Patey’) mastectomy
• all breast tissue,
• the nipple-areola complex,
• skin, and
• the levels I, II and III axillary lymph nodes
• the pectoralis minor which was divided
and removed by Patey
• Halsted radical mastectomy
• all breast tissue and
• skin,
• the nipple-areola complex,
• the pectoralis major and pectoralis minor
muscles, and the level I, II, and III axillary
lymph nodes

76. • Nipple-areolar sparing mastectomy
• tumor located more than 2–3 cm from the border of the areola,
• smaller breast size,
• minimal ptosis,
• no prior breast surgeries with periareolar incisions,
• body mass index less than 40 kg/m2,
• no active tobacco use,
• no prior breast irradiation, and
• no evidence of collagen vascular disease

77. Modified Radical Mastectomy
• all breast tissue,
• the nipple-areola complex,
• skin, and
• the levels I, II and III axillary lymph nodes
• the pectoralis minor which was divided and removed by Patey
• Both pectoralis minor and major in Halsted Radical mastectomy.
• Complication
• Seromas- Catheters are retained in the wound until drainage diminishes to <30 mL
per day
• Wound infections
• Skin-flap necrosis
• Moderate or severe hemorrhage
• Lymphoedema- decongestive therapy

78. Reconstruction of the Breast and Chest Wall
• pedicled myocutaneous flap or a free flap using microvascular
techniques
• latissimus dorsi myocutaneous flap/ transverse rectus abdominis
myocutaneous (TRAM) flap
• expander/implant reconstruction
• In patients with locally advanced breast cancer, reconstruction is
often delayed until after completion of adjuvant radiation therapy to
ensure that local-regional control of disease is obtained

79. NONSURGICAL BREAST CANCER THERAPIES

80. 1. Radiation Therapy
• used for all stages of breast cancer depending on whether the patient is
undergoing BCT or mastectomy.
• Current recommendations for stages IIIA and IIIB breast cancer are:
• (a) adjuvant radiation therapy to the breast and supraclavicular lymph
nodes after neoadjuvant chemotherapy and segmental mastectomy with
or without axillary lymph node dissection,
• (b) adjuvant radiation therapy to the chest wall and supraclavicular lymph
nodes after neoadjuvant chemotherapy and mastectomy with or without
axillary lymph node dissection, and
• (c) adjuvant radiation therapy to the chest wall and supraclavicular lymph
nodes after segmental mastectomy or mastectomy with axillary lymph
node dissection and adjuvant chemotherapy

81. 2. Chemotherapy Adjuvant
• Adjuvant chemotherapy is of minimal benefit to women with negative nodes and
cancers ≤0.5 cm in size and is not recommended
• Women with negative nodes and cancers 0.6 to 1.0 cm are divided into those
with a low risk of recurrence and those with unfavorable prognostic features that
portend a higher risk of recurrence and a need for adjuvant chemotherapy
• Adverse prognostic factors include
• blood vessel or lymph vessel invasion,
• high nuclear grade,
• high histologic grade,
• HER-2/neu overexpression, and
• negative hormone receptor status
• For women with hormone receptor-negative cancers that are >1 cm in size,
adjuvant chemotherapy is appropriate

82. • Neoadjuvant (Preoperative)
• Current NCCN recommendations for treatment of operable advanced
local-regional breast cancer are neoadjuvant chemotherapy with an
anthracycline-containing or taxane-containing regimen or both,
followed by mastectomy or lumpectomy with axillary lymph node
dissection if necessary, followed by adjuvant radiation therapy
Chemotherapy

83. • Neoadjuvant Endocrine Therapy
• It has most commonly been used in elderly women who were deemed poor
candidates for surgery or cytotoxic chemotherapy
• Antiestrogen Therapy –
A . Tamoxifen
• tamoxifen for 5 years reduced breast cancer mortality by about a third
• toxicity including bone pain, hot flashes, nausea, vomiting, and fluid
retention, Thrombotic events.
• Cataract surgery is more frequently performed in patients receiving tamoxifen
• Endometrial cancer

84. B . Aromatase inhibitors - anastrozole and letrozole
In postmenopausal women, aromatase inhibitors are now considered first-line
therapy in the adjuvant setting or as a secondary agent after 1 to 2 years of
adjuvant tamoxifen therapy
The aromatase inhibitors are less likely than tamoxifen to cause endometrial
cancer but do lead to changes in bone mineral density that may result in
osteoporosis and an increased rate of fractures in postmenopausal women

85. • Anti–HER-2/ neu Therapy
• Patients with HER-2-positive disease appear to have better outcomes with
anthracycline-based adjuvant chemotherapy regimens
• Cardiotoxicity may develop if trastuzumab

86. Nipple Discharge
• May be unilateral or bilateral
• May be serous, bloody, purulent.
• May be associated wit benign or malignant lesion.
• Investigation ductography or biopsy needed

87. Male Breast Cancer
• Fewer than 1% of all breast cancers occur in men
• Male breast cancer is preceded by gynecomastia in 20% of men
• It is associated with radiation exposure, estrogen therapy, testicular feminizing
syndromes, and Klinefelter’s syndrome (XXY)
• peak incidence in the sixth decade of life
• The treatment of male breast cancer is surgical, with the most common procedure being
a modified radical mastectomy
• Adjuvant radiation therapy is appropriate in cases in which there is a high risk for local-
regional recurrence
• Approximately 80% of male breast cancers are hormone receptor positive, and adjuvant
tamoxifen is considered
• Systemic chemotherapy is considered for men with hormone receptor-negative cancers
and for men with large primary tumors, multiple positive nodes, and locally advanced
disease.

88. Phyllodes Tumors
• classified as benign, borderline, or malignant
• gross cut tumor surface its classical leaf-like (phyllodes) appearance
• phyllodes tumors are always monoclonal
• complete excision of the tumor with a 1-cm margin
• Large phyllodes tumors may require mastectomy
• Axillary dissection is not recommended because axillary lymph node
metastases rarely occur.

89. Inflammatory Breast Carcinoma
• Inflammatory breast carcinoma (stage IIIB) accounts for <3% of breast
cancers
• characterized by the skin changes of brawny induration, erythema
with a raised edge, and edema (peaud’orange).
• associated breast mass
• palpable axillary lymphadenopathy, and distant metastases
• Surgery alone and surgery with adjuvant radiation therapy have
produced disappointing results in women with inflammatory breast
cancer

92. • THANK YOU