This document provides an overview of breast anatomy, epidemiology, risk factors, and pathology of breast cancer. It discusses the anatomy of the breast and its blood supply. It notes that breast cancer is the most common cancer in women worldwide and outlines risk factors such as age, family history, genetics, reproductive history, and lifestyle factors. The document also describes different histological types of breast cancer including in situ and invasive ductal and lobular carcinomas. It discusses molecular subtypes defined by gene expression and prognosis.

1. Surg Cdr Chaminda Amarasekara
Maj D B Ayer
Maj Balachandra Menon
Guide Surg Capt R Shankaran

2.  Anatomy
 Epidemiology
 Risk factors & Causes of breast cancer
 Breast cancer pathology
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3.  From the level of 2nd/3rd rib to the
inframammary fold at 6th /7th rib.
 Transversely from the lateral border of the
sternum to the mid-axillary line.
 posterior surface of the breast rests on the
fascia of the
◦ pectorals major
◦ serrates anterior
◦ external oblique
◦ upper extent of the rectus sheath
 The axillary tail pierces the fascia and lies in the
axilla
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5. 10/8/2017 5

6.  The breast receives its principal blood
supply from:
◦ internal mammary artery
◦ posterior intercostal arteries
◦ axillary artery,
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7.  toward the axilla
◦ Perforating
branches of the
internal thoracic
vein
◦ Perforating
branches of the
posterior
intercostal veins
◦ Tributaries of the
axillary vein
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8.  Batson’s vertebral venous plexus
Route for breast cancer metastases to the
◦ Vertebrae
◦ Skull
◦ pelvic bones
◦ central nervous system.
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9.  Anterior (pectoral) group
 Posterior (subscapular)
group
 Lateral group:
 Central group
 Infraclavicular
(deltopectoral) group
 Apical group
Level1
Level II
Level iii
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10.  Lateral cutaneous branches of the third through
sixth inter- costal nerves provide sensory
innervation of the breast (lateral mammary
branches) and of the anterolateral chest wall.
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12.  Most common site-specific cancer in
women
 Second leading cause of death from cancer
second to lung cancer
 More than 1 million cases diagnosed
worldwide annually
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13.  Incidence decreased from1999to 2006 2%
year
 2006-2010 breast cancer incidence rates
were stable.
 Survival rates in women with breast cancer
steadily improved over the last decades
5 year survival rate 90% during 1995-2005
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14.  Risk Factors That Cannot be Modified
 Risk Factors That Can be Modified
 Histological Risk Factors*
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15. Factors That Cannot be
Modified
◦ Increasing age
◦ Female sex
◦ Menstrual factors
◦ Early age at
menarche
◦ Older age at
menopause
◦ Family history of
breast cancer
◦ Genetic
predisposition
◦ Personal history
of breast cancer
◦ Race, ethnicity
◦ History of
radiation
exposure
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16.  Risk Factors That Can Be Modified
◦ Reproductive factors
◦ Age at first live birth
◦ Parity
◦ Lack of breast feeding
◦ Obesity
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17.  Risk Factors That Can Be Modified ctd…
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o Alcohol consumption
o Tobacco smoking
o HRT
o Decreased physical activity
o Shift work (night shift)
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18.  Histological risk factors
◦ Proliferative breast disease
◦ Atypical ductal Hyperplasia
◦ Atypical lobular Hyperplasia
◦ Lobular Carcinoma in situ
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19.  Gail Model
◦ Age
◦ Race
◦ Age at menarche <12 yrs.
◦ Age at first live birth <18 yrs.
◦ No of previous breast biopsies
◦ Presence of proliferative disease with atypia
◦ No of 1st degree relative
◦ Underestimate BRCA1 & BRCA 2
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20.  Genetic
 Hormonal
 Environmental
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21.  10% breast cancers are familial (90%
sporadic)
 Positive Family History, especially in 1st
degree relatives (mother, daughter, sister)
confers increased risk for breast cancer
 Tumor suppressor genes (BRCA1, BRCA2)
 Risk is greatest with:
 Relative with BILATERAL disease
 Relative affected at a YOUNG AGE
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22.  Responsible for up to 1/2 of “inherited”
breast cancers (5% of cancers)
 Increased risk of ovarian and colon
cancers (“Breast-Ovarian” cancer gene)
 Breast cancer develops in >50% of
these women by age 50 (“Early onset”
breast cancer gene)
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23.  Responsible for up to 30% of inherited
breast cancer
 Characterized by increased risk of
breast cancer in women and MALE
breast cancer (“Male Breast Cancer”
gene)
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24.  Due to Inherited p53 Tumor Suppressor
Gene Mutation (cell cycle checkpoint)
 Family cancer syndrome characterized
by increased risk of breast cancer,
osteosarcoma, soft tissue sarcomas,
brain tumors, leukemia, other
 Accounts for approximately 1% of
breast cancers detected before age 40
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25.  Early menarche, late menopause, null
parity, late age at first term pregnancy
 Oophorectomy before age 35 DECREASES
the risk of breast cancer.
 Oral contraceptive use and hormone
replacement therapy may be associated
with a increased risk
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26.  4-5 fold greater incidence in
industrialized countries
 Increased risk may be related to:
◦ Higher fat diet
◦ Earlier menarche
◦ Less physical activity
◦ Decreased parity
◦ Later age at parity
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27. ◦ Radiation therapy for Hodgkin’s Disease in
young women
◦ Survivors of atomic bomb blasts
 Increased risk when exposure is at a young
age, little increase in risk after age 40
◦ Indicates that the risk is GREATEST to the
developing and hormonally cycling breast
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28.  Presence of a history of breast pathology
increases risk of breast cancer
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29. HISTOLOGICAL
DIAGNOSIS
ESTIMATES,RR
 Non proliferative
disease
 Proliferative disease
with out atypia
 Proliferative disease
with atypia
◦ And strong family history
 LCIS
 1.0
 1.3-1.9
 3.7-4.2
 4-9
 >7
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30.  Multicentricity refers to the occurrence of a
second breast cancer outside the breast
quadrant of the primary cancer (or at least 4
cm away)
 Multifocality refers to the occurrence of a
second cancer within the same breast
quadrant as the primary cancer (or within 4
cm of it).
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31.  Non Invasive Epithelial Cancers
 Invasive Epithelial Cancers
 Mixed Connective Epithelial Tumors
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32.  Lobular Carcinoma in situ
 Ductal Carcinoma in situ or Intra ductal
Carcinoma
◦ Papillary
◦ Cribriform
◦ Solid
◦ comedo
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33.  Invasive Lobular Carcinoma (10%)
 Invasive Ductal Carcinoma
◦ Invasive Ductal Carcinoma NOS (50-70%)
◦ Tubular Carcinoma (2%-3%)
◦ Mucinous or Colloid Carcinoma(2%-3%)
◦ Medullary Carcinoma(5%)
◦ Invasive Cribriform Carcinoma (1%-3%)
◦ Invasive Papillary Carcinoma (1%-2%)
◦ Adenoid Cystic Carcinoma(1%)
◦ Metaplastic Carcinoma(1%)
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34.  Phyllodes tumors benign & malignant
 Carcinosarcoma
 Angiosarcoma
 Adenocarcinoma
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35.  LCIS recognized risk factor development of
Ca
 Pleomorphic LCIS is more aggressive
histopathologic sub type
 If pleomorphic LCIS is associated with
calcification can be detected
mamographically
 DCIS are usually mixed morphologic types
 The solid and comedo type are generally
higher grade lesions
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36.  Invasive breast cancers have been described
as lobular or ductal in origin.
 Current histologic classifications recognize
special types of breast cancers (10% of total
cases), which are defined by specific
histologic features.
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37.  To qualify as a special-type cancer, at least
90% of the cancer must contain the defining
histologic features.
 About 50-70% of invasive breast cancers are
described as invasive ductal carcinoma of no
special type (NST).
 These cancers generally have a worse
prognosis than special-type cancers.
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38.  Microarray- based expression profiling
 Microarray is a chip containing spots
arranged in orderly fashion
 Contains unique DNA fragments which
match to specific gene(ER,HER2 etc)
 5 main molecular subgroups were identified
which defer in there insintric gene list
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39.  3 ER positive
◦ Luminal A (ER+(high levels), Ki 67 low
grade,
excellent prognosis
Luminal B (ER+ HER2+,high Ki
67expression,high grade :Poor prognosis
Normal-like (ER+, good prognosis),but
poorly characterized, may be the result of
sample contamination with normal tissue
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40.  2ER negative
◦ HER2 positive (ER-,Bad Prognosis)
◦ Basal –like( ER -, bad prognosis, Good
response to chemotherapy
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41.  There may be 3 more, recently described, ER
negative types
◦ Apocrine group
◦ Interferon groupClaudin-low group( s/o cancer
stem cell like phenotype
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42.  Defined as invasive carcinoma involving
superficial dermal lymphatic spaces
 Poor prognosis (T3 disease)
 Erythema and induration of the skin, so
called “inflammatory changes”
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43. Inflammatory carcinoma
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44.  Invasion of the SKIN of the nipple or
areola by malignant cells, singly or in
small nests
 Associated with an underlying cancer:
either IN SITU OR INVASIVE carcinoma
 Clinically-erythema, scaling, ulceration
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45. 10/8/2017 45
Paget’s
disease: nipple
ulceration