Breast cancer can be locally advanced. The document discusses the anatomy, vasculature, lymphatics, and nerves of the breast. It then covers the pathology, epidemiology, genetics, classification, clinical features, and risk factors of breast cancer. Locally advanced breast cancer is discussed in terms of ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma (ILC). Grading, genetic predisposition, male breast cancer, and phyllodes tumors are also summarized.

1. Breast Cancer-Locally
Advanced
Dr Gebrekirstos Hagos
Clinical Oncology OR-I
AAU-SOM
March 27,2018
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2. contents
Introduction
Anatomy –Artery -Lymphatic
-Vein -Nerves
 Pathology -Epidemiology -Genetics
-Classification -Clinical features
-Risk factors -Staging
References
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3. Introduction
• Breast are most prominent superficial
structures of anterior thoracic wall overlying
P.Major and P minor muscles
• At greatest prominence of breast is nipple
which is surrounded by circular pigmented
area -areola.
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4. Anatomy
• Its base , attached surface extends :
-Vertically 2nd -6th ribs
-Transversely Sternal edge –MAL
The superolateral quadrant is prolonged
towards the axial , Axillary tail of spence
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5. Anatomy….
• Breast lie upon the deep pectoral fascia which in
turnover lie pectoral major and serratus anterior
• Superficial pectoral fascia which is continuous with
abdominal superficial fascia envelopes the breast
• These 2 fascia layers are connected with suspensory
ligament of cooper, natural means of breast support
• Between breast and the fascia is submamarry space
which allow some degree of movement
• Nipple project from center of anterior breast and
mostly in 4th ICS
• Skin covering nipple and areola is darker than rest of
skin because rich in melanocytes
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7. Anatomy ….
• Breast undergo dramatic change in size ,shape and
function in relation to puberty, pregnancy and lactation
• Breast contains 3 major structures
1) skin
2) subcutaneous tissues
3)Breast tissue
epithelial lobule-structural and functional unit
duct
stromal adipose
fibrous
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8. Anatomy …..
• Breast skin is thin containing hair follicles ,
sebaceous gland and exocrine sweat gland
• Nipple has abundant sensory nerve ending
sebaceous and sweat gland but lacks hair follicles
• Nipples composed mostly circularly arranged
muscles which compress lactiferous duct during
lactation.
• For description of cysts or tumors breast is
divided in to 4 quadrants .
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10. Vasculature of breast
• Arteries
Internal Thoracic artery —subclavian artery
Lateral thoracic —Axially artery
Posterior intercostal artery - thoracic aorta
from 2nd-4th ICS
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12. Vasculature of breast
• Veins
Axillary vein –main
Internal thoracic vein
Posterior intercostal vein –route to CNS metas
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14. vasculature of breast
 Axillary LN-75%
Axillary LNs are grouped to 03 in relation to P.
minor
Level I
Level II
Level III
 Internal mammary LN
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18. • Nerves
From anterior and lateral cutaneous branch of
4th -6th intercostal nerves to give sensory fiber to
skin and sympathetic fiber to muscles and blood
vessels
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19. Pathology of breast
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20. ETHIOPIA – GLOBOCAN
Female cancer -2012
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21. 21

22. Breast Pathology
1) Non proliferative
(Cyst, fibrosis, adenosis)
breast 2) Proliferative with no atypia 1.5-2 R.R
pathology (Epithelial hyperplasia, sclerosis
adenosis, papilloma, complex adenosis)
3) Proliferative with atypia 4-5 R.R
(ADH,ALH)
4) Malignant –in situ type
- invasive
-other histology (lymphoma,
sarcoma, phyllodes tumor)
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23. Pathology cont…
• Most breast malignancy are epithelial-Carcinoma
• Breast ca are diverse groups ,differentiate
microscopic appearance and biological behavior.
• In situ type
1) DCIS based growth pattern,
2) LCIS Cytological features
not anatomical origin
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24. LCIS
• 1st described in 1941
• Large non uniform sized discohesive epithelil cells
which fills the acinar space in varying degree.
• In mastectomy specimen-90 % multicenter
-35-59 % bilateral
Loss of E-cadherin ,addhesion molecule-95%
Mostly found in premenopausal age ~ 45 yrs
Is marker of increase risk not precursor
Invsive ca can develop in both breast (IDC vs ILC)
Tamoxifen decrease the risk of invasive ca
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25. DCIS
• Is proliferation of preassembly malignant
epithelial cells in ductal system with no
invasion to the stromal on light microscope.
It encompass heterogenious groups lesion w/c
differ
 clinical presentation
 histological appearance
 biological behavior
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26. Classification of DCIS
Histologically sub classified
1)Comedo based on:
2) Papillry
3) Cribriform - Architectural growth
pattern
4) Micropapilary - Cytological features
5) Solid - cell necrosis
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27. Comedo
• Central prominent necrosis-
calcificationmamograp
hic detection
• Large tumor
• Nuclear pleomorphism
• More often associated with
invasion
• Prominent mitotic
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28. Invasive breast ca
 IDC NST/NOS ------------------80%
 ILC-------------------------------------10%
 Medullary ca-------------------------------------4%
 mucinous/colloid ca---------------------------2%
 papillary ca---------------------------------------2%
 Tubular ca----------------------------------------2%
 Paget’s disease of nipple
 Inflammatory breast cancer
 Rare ca(adenoid cystic, squamous cell ,apocrine)
-
- - -
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29. Infiltrative Ductal Ca
• Most common (70-80%)
• Grossly hard , gray-white invade tissue haphazardly
• Microscopically cords & nests tumor cells with various
amount of gland formation.
• Induce fibrous response as infiltrate breast
parenchyma clinically palpable, radiologic density
• 60% LN+ve at presentation
• In 5th -6th decades
• Divided in to 3 grades
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30. Grading
• To sub classify the invasive ductal ca
A)Nuclear grading-well differentiated
- moderately differentiated
-poorly differentiated
B) Histologic Grading
-tubule formation
-nuclear pleomorphic has Pxtic
importance
- mitotic activities
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31. Histopathology Grade

32. ILC
• 2nd most common
• Microscopically cells insidiously infiltrate the
mammary stromal and adipose tissue with
few fibrous reaction.
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33. IDC vs ILC
• Multi central and bilateral –ILC
• Rel.Old age, low grade,more ER/PR +ve-ILC
• Late met, and met to unusual site(peritonium ,
meninges & GIT)-ILC
?Better prognosis-ILC
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34. RF of Breast ca
• A) Non modifiable -Gender, age, FxHx, race,
age at menarche & menopause, benign
breast diseases
• B) Modifiable - parity, age at 1st birth,
radiation exposure , HRT
 Exercise, vegetables, young age at first
delivery and long breast feeding are protective
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35. Inherited Predisposition of Breast ca
• Mutation of breast ca susceptible gene BRCA 1
& 2 is associated with increase in breast ca
• Account for 5-10 % Breast ca
• ADD with varying penetrance and risk
Breast ca-26-85%
ovarian Ca BRCA1-16-63%
BRCA 2-10-27%
Other genetic mutation -TP53, PTEN,CHECK2
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36. Other Ca associated with BRCA
mutation
• Male breast ca
• Fallopian tube ca BRCA 1&2
• Prostate ca
Melanoma
Gastric ca BRCA 2
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37. Genetic of breast ca
• FxHx is one RF of Breast ca
• Breast ca susceptible gene is categorized to 3
1) Rare high peneterance-
BRCA1,2,PTEN,STK11/LKB1,CDH1
2) Rare intermediate penetrance –
CHECK2,ATM,BRIP1,PALB2
3) Common low penetrance
FGFR2,MAP3K1,CASP8
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42. 42

43. Male breast ca
• Due to increase Estrogen
decrease Androgen
RF- klinfelter syndrome(47XXY) 14-50% increase
risk & account 3% male breast
- BRCA1 & 2 carriers
-CLD
-Mumps orcitis
- undescended testis
*Gynecomastia alone not RF
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44. • Breast ca in male:
-old median age(M:F=60:53)
-Late dx
-High % ER/PR +ve
-BCS is rare
*CF, stage to stage prognosis and Rx same in
both sex
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45. Phyllodes tumors
• Groups of lesion varying from completely
benign to fully malignant.
• Clinically smooth, round, painless multi
nodular lesion difficult to distinguish from
fibro adenoma.
• Mean age of Dx-4th decade
• Histologically contains epithelial and
connective tissues
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46. • Classified in to
1)Benign based tumor margin,
2)Border line cellular atypia, mitotic
3) malignant activity
23-50% are malignant
Local excision to –ve margin is appropriate for
both benign & malignant
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47. • When phyllodes tumor metastasize the
behave like sarcoma and most site is lung.
• Axillary met in 5% only so ALND not indicated
• When systemic treatment of phyllodes tumor
applied it is based on sarcoma guideline.
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48. Male breast ca
• Due to increase Estrogen
decrease Androgen
RF- klinfelter syndrome(47XXY) 14-50% increase
risk & account 3% male breast
- BRCA1 & 2 carriers
-CLD
-Mumps orcitis
- undescended testis
*Gynecomastia alone not RF
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49. • Breast ca in male:
-old median age(M:F=60:53)
-Late dx
-High % ER/PR +ve
-BCS is rare
*CF, stage to stage prognosis and Rx same in
both sex
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50. Phyllodes tumors
• Groups of lesion varying from completely
benign to fully malignant.
• Clinically smooth, round, painless multi
nodular lesion difficult to distinguish from
fibro adenoma.
• Mean age of Dx-4th decade
• Histologically contains epithelial and
connective tissues
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51. • Classified in to
1)Benign based tumor margin,
2)Border line cellular atypia, mitotic
3) malignant activity
23-50% are malignant
Local excision to –ve margin is appropriate for
both benign & malignant
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52. • When phyllodes tumor metastasize the
behave like sarcoma and most site is lung.
• Axillary met in 5% only so ALND not indicated
• When systemic treatment of phyllodes tumor
applied it is based on sarcoma guideline.
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53. References
• Devita,Hellman,and Rosengerg’s
• Robbins And Cotrans Pathologic
• Uptodate
• Clinically Oriented Anatomy
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54. Thank you!
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