Breast cancer is the most common cancer in women. Risk factors include age, family history, lifestyle factors. Diagnosis involves clinical exam, imaging like mammography, and biopsy. Treatment depends on cancer stage but commonly includes surgery, radiation, hormone therapy and chemotherapy. Prognosis depends on cancer stage and tumor characteristics, with 5-year survival rates ranging from 100% for stage I to 18% for stage IV metastatic cancer.

1. BREAST CANCERBREAST CANCER
Mizan Kidanu
March,18/2013

2. OUTLINEOUTLINE
Introduction
Epidemiology
Risk factors
Classification
Diagnosis
Treatment
Prognosis

3. INTRODUCTIONINTRODUCTION
• Two ventral bands of thickened
ectoderm (mammary ridges,
milk lines)
• These ridges disappear after a
short time, except small portions
that persist in the pectoral
region
• when normal regression fails
accessory breasts (polymastia)
or accessory nipples (polythelia)
may occur

4. ANATOMYANATOMY
Location
 2nd
to 6th
rib
 lateral border of
sternum to anterior
axillary line
 lies on pec. major
and seratus anterior
Contains:
 Fat, glandular tissue,
suspensory ligament

5. • Blood supply
internal mammary
axillary artery
intercoastal arteries
• Venous drainage
axillary vein
internal thoracic vein
lateral thoracic vein
intercoastal vein
•Lymphatic drainage
axillary LNs ~85%
internal mammary LNs

6. •Axillary LNs
receive approximately
85% of the drainage
grouped into:
lateral
anterior
posterior
central
apical
interpectoral

7. Axillary LNs
 with respect to pectoralis
minor muscle they are
grouped into:
Level-I
Level-II
Level-III

8. EPIDEMIOLOGYEPIDEMIOLOGY
Is the most common female cancer (26%)
2nd
common cause of cancer death in women
Main cause of death in women ages 40-59 yrs
Mortality rates have declined since the use of
screening mammography and improvements of
adjuvant therapies
Invasive ductal ca is the commonest type

9. Relative distributionsRelative distributions
 Upper outer quadrant ~ 60%
 Upper inner quadrant ~12%
 Lower outer quadrant ~ 10%
 Lower inner quadrant ~ 6%
 Central quadrant ~ 12%
60% 12%
6%10%
12%

10. RISK FACTORSRISK FACTORS
 Sex - >99% occur in females
 Early menarche, late menopause, nulliparity,
older age at first live birth
 Age - is rare below 20 yeas of age
 Radiaton exposure
 Family Hx of breast CA
 Genetic factors … BRCA-1 or BRCA-2
 Prior breast cancer
 Obesity
 Dietary factors
 Smoking & increased alcohol consumption
 Hormone replacement therapy & OCP

11. CLASSIFICATIONCLASSIFICATION
Carcinoma in situ, CISCarcinoma in situ, CIS
 Ductal carcinoma in situ(DIS)Ductal carcinoma in situ(DIS)
 Lobular Carcinoma in situ(LIS)Lobular Carcinoma in situ(LIS)
Invasive carcinomaInvasive carcinoma
 DuctalDuctal
scirrhous carcinoma
medullary
mucinous (colloid)
papillary
tubular
 LobularLobular
 Paget’s disease of the nipple

12. Carcinoma in-situCarcinoma in-situ
 Malignant cells in the duct system or lobules but
no invasion of the basement membrane
 Since the use of screening mammography there is
a 14-fold increase in the incidence
 Multicentricity - refers to the occurrence of a 2nd
breast cancer outside the breast quadrant of the
primary cancer (or at least 4 cm away)
 Multifocality - refers to the occurrence of a 2nd
cancer within the same breast quadrant as the
primary cancer (or within 4 cm of it)

13. LCIS
marker of increased risk for invasive
breast carcinoma, not anatomic
precursor
bilateral in 50-70%
develops only in the female breast
multicentric in 60-90%
DCIS
anatomic precursor of invasive ductal
carcinoma
multicentricity for DCIS is 40-80%
bilateral in 10-20%

14. CLINICAL FEATURESCLINICAL FEATURES
Lump
hard, painless swelling
Change in the skin
puckering
Peau d’orange
skin ulceration
skin nodules
Nipple changes
distortion, inversion
discharge
eczema (paget’s disease)
Metastatic disease
regional LNs
distant sites

15. SPREAD OF BREAST CANCERSPREAD OF BREAST CANCER
Local spread with in the breast
involves the skin & fascia
chest wall and
other portions of the breast
Regional spread of breast cancer
axillary LNs
internal mammary LNs
Supraclavicular LNs
Hematogenous (distant) spread
in order of frequency, are bone, lung,
pleura, soft tissues, and liver.

16. Axillary nodal metastasesAxillary nodal metastases
Common site of spread (45% at presentation)
Spread depends on the primary tumor (size)
Clinical assessment is unreliable
Axillary nodal spread Vs prognosis
number of nodes affected
level of nodal disease

17. DIAGNOSISDIAGNOSIS
History
duration of illness
associated symptoms (pain, headache, cough,
nipple discharge)
age at menarche and menstruation status
(pre or postmenopausal)
age at first delivery
family history of breast cancer,….

18. Physical examination
Inspection
arms by her side or straight
up in the air
hands on her hips
arms extended forward in a
sitting position leaning
forward to accentuate any
skin retraction
symmetry, size, and shape,
peau d'orange, nipple or skin
retraction or erythema

19.  Palpation
supine position
examine all quadrants
examine with the palmar
aspects of the fingers
avoiding a grasping or
pinching motion
assesses all three levels of
axillary lymphadenopathy
location, size, consistency,
shape, mobility, fixation,...

20. InvestigationsInvestigations
CBC, Blood group & Rh,
FNAC, core needle biopsy,
Mammography, breast u/s,
MRI, ductography
ER/PR status determination
Metastasis - LFT, CXR, CT,
MRI, abd u/s,….

21. Characterstics of malignant
lesions in mammography:
architectural distortion
solid mass with or without
stellate features
microcalcifications
stippled calcifications
asymmetric thickening of breast
tissues
nipple retraction

22. Triple AssessmentTriple Assessment
Any patient with a breast lump or other
symptoms suspicious of carcinoma, the Dx
should be made by a combination of:
1. Clinical assessment
2. Radiological imaging and
3. Tissue sample (cytological or histological)
Positive predictive value is 99.9%

23. TNM StagingTNM Staging
Primary tumor (T)
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: carcinoma in situ
T1 : ≤2 cm in greatest dimension
T2: >2 cm but not >5 cm in greatest dimension
T3: >5 cm in greatest dimension
T4: any size with direct extension to (a) chest
wall or (b) skin

24. Regional lymph nodesRegional lymph nodes
N0: no regional LN involvement
N1: moveable ipsilateral axillary
LAP
N2: Ipsilateral axillary LNs fixed
or matted; Ipsilateral internal
mammary LN in the absence
of axillary LN involvement
N3: Ipsilateral infraclavicular
LAP; Ipsilateral axillary &
internal mammary; Ipsilateral
supraclavicular
M0: No distal metastases
M1: Distal metastases
Distal metastasesDistal metastases

25. Stage groupingStage grouping
Stage 0: TisN0M0
Stage I: T1N0M0
Stage IIA: T0N1M0; T1N1M0; T2N0M0
Stage IIB: T2N1M0; T3N0M0
Stage IIIA: T0N2M0; T1N2M0; T2N2M0;
T3N1M0
Stage IIIB: T4anyNM0
Stage IIIC: AnyTN3M0
Stage IV: AnyT AnyNM1

26. MANAGEMENT OF BREAST CANCERMANAGEMENT OF BREAST CANCER
Multidisciplinary
Surgeons
Radiotherapists
Oncologists
Pathologists
Other professionals
councellors
breast care nurses

27. Treatment for breast ca entails:
 Local control
surgery & radiotherapy
 Systemic control
hormone & chemotherapy

28. SURGERYSURGERY
1-Wide local excision (lumpectomy)
2-Total (simple) mastectomy
 removes all breast tissue, nipple areola complex, and
skin
3-Modified Radical Mastectomy (MRM)
 preserves pectoralis major and minor muscles, allowing
removal of level I & II but not level III axillary
4-Radical mastectomy
 removes all breast tissue, skin, nipple areola complex,
pectoralis major and minor muscles, and level I, II, &
III axillary LNs

29. Factors affecting type of treatmentFactors affecting type of treatment
Lymph node status
 +ve node: needs adjuvant treatment
Size and extent of tumor
 large tumors recur more often
Histology
 CIS: no adjuvant treatment
Hormone receptors status
Age and/or menopausal status

30. Treatment of early breast cancerTreatment of early breast cancer
((Stage I & IIStage I & II))
Breast conservation - resection of the primary
breast ca with a normal margin, adjuvant
radiation therapy, and assessment of regional
lymph node status
Mastectomy with sentinel lymph node and/or
axillary LN dissection

31. Breast conserving surgeryBreast conserving surgery
Excision of the tumor with a rim of
normal tissue
lumpectomy
segmental mastectomy
partial mastectomy
quadrantectomy

32. Contraindications for breast
conserving operations(BCS)
tumor >4cm
multicentricity
centrally located tumors
poor tumor differentiation
node positive disease
positive margin after re-excision
Hx of previous radiotherapy
pregnancy

33. HORMONAL THERAPYHORMONAL THERAPY
Immunoassays & immunohistochemical
methods are employed to measure levels of ER
Patients with significant increase in ER
respond favourably to endocrine therapy
E.g: Tamoxifen therapy

34. CHEMOTHERAPYCHEMOTHERAPY
Adjuvant chemotherapy for early invasive
breast ca is indicated in all patients with:
node-positive cancers
tumor >1 cm
node-negative cancers of >0.5 cm with adverse
prognostic features (blood vessel or lymph vessel
invasion, high histologic grade, HER-2/neu
overexpression, and negative hormone receptor
status)

35. Locally advanced breast cancerLocally advanced breast cancer
(( Stage-IIIStage-III))
 Neoadjuvant chemotherapy
 Usually a modified radical
mastectomy (MRM)
 Followed by adjuvant
radiation therapy

36. Breast ca with distant metastasisBreast ca with distant metastasis
((Stage IVStage IV))
Aim of management
 provide palliation
 symptomatic relief
Treatment
 combination chemotherapy
 toilet mastectomy
 radiotherapy
 Tamoxifen therapy in ER positive

37. COMPLICATIONS OF MASTECTOMYCOMPLICATIONS OF MASTECTOMY
Seromas - the most common
Wound infections
Hemorrhage
Lymphedema - increased risk in:
 extensive ALND
 the delivery of radiation therapy
 the presence of pathologic lymph nodes
 obesity
Nerve injury

38. FOLLOW UPFOLLOW UP
Assess local recurrence, especially in BCT
Assess the contralateral breast
Detect psychiatric morbidity
Allow provision of prosthesis
Early detection & treatment of metastatic
disease

39. PROGNOSIS OF BREAST CAPROGNOSIS OF BREAST CA
5-year survival rate
Stage 5yr survival
I 100%
IIa 92%
IIb 81%
IIIa 67%
IIIb 54%
IV 18%