Breast cancer for undergrad the lect.pptx

Surgery Lectures for undergraduates
Breast Cancer
(1)
Ahmed Ellabban
Hamed Rashad
Professors of surgery - Egypt

Breast Disorders
 Congenital
 Traumatic
 Infilammatory
 Benign
 Neoplastic
 Miscellenous (cyst, gynacomastia,…)

Overview
 Aetiology
 Pathology
 Complications
 Staging
 Diagnosis
 Screening
 Treatment

Aetiology (risk factors)
 Genetic, familial
 Hormonal disturbances: increased oestrogen,
increased progesterone
 Age: higher with age
 Obesity: increase risk
 Parity: increase in non-pregnant, in in non-lactating,
increase in delayed pregnancy
 Past history of irradiation or hormonal treatment

Aetiology (risk factors)
 Benign tumours of breast, may change to
malignant
 Other endocrine tumours of thyroid, uterus, ..etc
 Environmental factors: diet, geographic distribution
 Viruses: +ve milk virus
 Biological factors: cell kinetic, P53, HER2/New

Pathology
A. Benign
Epithelial, ductal papilloma, adenoma
Mixed fibroadenoma
Connective tissue: Lipoma, fibroma
B- Malignant
Non infiltrating:
Carcinoma in situ : DCIS (Ductal carcinoma in situ)
LCIS (Lobular carcinoma in situ)

Pathology
Infiltrating
Paget’s disease
Ductal carcinoma
Scirrhous (78%): commonest
Medullary
Mucinous
Tubular
Papillary
Adenoid cystic
Lobular carcinoma (10%): bilateral (35 %), multifocal
(80 %)

Pathology
Others:
Sarcoma & lymphoma
Squamous carcinoma
Secondaries
Inflammatory cancer breast - Acute lactic mastoiditis

Complications of Breast cancer
1. Spread:
 Direct: skin , fascia, muscles
 Lymphatic:
– Local => pectoral, central, lateral, internal mammary
– Distant
 Blood: spine, liver, brain
 Transcelomic: liver, abdomen, ovary, pelvis, ..etc
2. Skin infiltration: ulceration, funigation, haemorrahge
3. 2ry infection
4. General: cachexia, malaise ..etc

Staging (TNM)
Stage Tumour size Node Mets TNM
0 Tis Not palpable N0 M0 TisN0M0
1 I T1 < 2cm N0 M0 T1N0M0
2 II T2 2-5 cm N1 (one group, one side,
mobile)
M0 IIa T1N1M0
IIb T2N0M0
3 IIIa T3 > 5 N2 (Local LNs, 2 groups,
one side, fixed)
M0 T3N2M0
IIIb T4 (any size with infiltration of skin
and fascia)
N3 (distant LNs,
supraclavicular)
M0 T4N3M0
4 IV T4 (any size + local infiltration) N distant metastasis M1 Tany Nany M1

Diagnosis
A. History: 7 symptoms
1. Pain
2. Mass: characters 12-S (site, size, shape, surface,…)
3. Discharge: serous, serosanguinous, pus, blood
4. Skin, nipple changes
5. Axially sweeling
6. Lactation history
7. Complications: metastasis to lung, ribs, vertebrae,
abdomen, brain.

Diagnosis
B. Examination
 General: for metastasis
 Local breast examination:
 Exposure clavicle to umbilicus
 Position: symmetrical
 Examine:
o Sitting
o Hands raised
o Leaning forward
o Hands on waist

Diagnosis
o Supine
 Breast (14 areas, 7x2)
 Examinee all areas if any change
 Last area is pathological areas
 Examine normal side first
 Comment on any mass (size, site, surface, skin..etc)
 Report on staging (TNM)

Screening for Breast Cancer
 For early detection in groups
1. Patient self examination
2. Mammography (> 35Y)
3. Ultrasonography (<35 Y)
4. FNAB

Investigations for Breast Cancer
Laboratory Radiology Pathology (Biopsy)
 Tumour markers (CEA)
 Oestrogen and
progesterone receptors
 HER2/NEW factors of
increased tumour growth
 Mammography
 Ultrasound
 CT
 For metastasis
Chest x ray
Abdominal US
Bone Xray
Bone scan
 FNAB
 True cut biopsy
 Incision biopsy < 2 cm
 Excision biopsy > 2 cm
 Frozen section
 Non-palpable => guided
biopsy, US, mammography,
stereotactic

Treatment of BC
 Options:
1. Surgery (mastectomy) => types
2. Radiotherapy (pre- and post)
3. Chemotherapy (preoperative for downstaging or
postoperative)
4. Hormonal therapy
5. Biological drug (targeted)
6. Adjuvant therapy (before surgery or after surgery)
7. Reconstruction ( implant, flap,…)

Treatment of BC
 Factors:
1. Breast cancer stage , grade
2. Hormone receptor (positive)
3. HER2/NEW => protein causes faster growth

Treatment of BC
 Principles of treatment
 Stage TIS: breast conservative surgery (BCS) =>
lumpectomy ( < 4cm, non-aggressive tumour, mobile,
monofocal)
 Stage I & II: Aim: cure 40 %
Surgery + post operative radiotherapy or chemotherapy
 Stage III & IV: Aim: palliative
– Palliative surgery, radiotherapy, chemotherapy, hormonal,
– Sedatives
– NB
 Her +ve: Hormonal treatment
 if BRCA +ve ( prophylactic mastectomy in case of no malignancy

Surgery for Breast cancer (Mastectomy)
1. Lumpectomy: BCS => indications (tumour < 4 m,
N0M0, low pathology)
2. Subcutaneous mastectomy: preserve nipple and skin.
3. Simple mastectomy: remove breast with skin.
4. Radical mastectomy.
5. Modified radical mastectomy: preserve pectoralis
major
6. Super radical mastectomy: remove internal mammary
lymph nodes
7. Axillary lymph nodes dissection + sentinel biopsy
8. Breast reconstruction: muscle flap – implant

Surgery Lectures for undergraduates
Breast Cancer
(2)
Ahmed Ellabban
Hamed Rashad
Professors of surgery - Egypt

Anatomy
1. Chest wall.
2. Pectoral muscles.
3. Lobules (glands that make
milk).
4. Nipple surface.
5. Areola.
6. Lactiferous duct tube
that carries milk to the nipple
7. Fatty tissue.
8. Skin.

Subclavian
nodes
Axillary
nodes
Lateral
pectoral
nodes
Parasternal
nodes
Lymph Nodes of the Breast

All breast
lymph
nodes are
medial to
the
subclavian
vein

Incidence of Br. Ca.:
 Breast cancer is the commonest cancer in women .
 The life time probability risk of developing breast
cancer is 1 in 7 in USA (cancer statistics, 2004)
1 in 12 in England.
Tuesday, March 12, 2024 33

BREAST CANCER
RISK FACTORS

Risk factors of br. Ca. :
- About 90 – 95 % of all br. Ca. Are sporadic with about 5 –
10 % inherited
1- Female gender
2- Age
- br. Ca. Is rare before age 20
- incidence increase with age
- there is a slight downward trend during
menopausal years ( menopausal hook )

3- Geographic variations
higher in developed countries
- higher incidence in populations migrating
from nations with low incidence.
4- Productive risk factors
a- Early Age at menarche
b- Late menopause

c - Nulliparity → increases risk
d- Higher numbers of births → decreases
risk
e- Bilateral oophrectomy before age 45 →
decreases risk

5- Age at first pregnancy
- after age 30 → increases risk twice than those
before 20
- after age 35 → higher risk even more than
nulliparas
- earlier age at the second child reduces risk

6- Lactation
Lactation may give reduced
risk ( for at least 30 months)

7- Family history
 Up to 10% is due to genetic predisposition
- inherited as autosomal dominance
- BRCA1 o long arm of chromosome 17
- BRCA2 on long arm of chromosome 13 n
(males with Br.Ca.

 A women’s risk of br.ca. is 2 or more times
greater if she has first or second degree
relative
( mother – sister – daughter ) who
develop br.ca. → the greater the risk.
 The younger the first degree relative the
development of br.ca. the higher risk
7- Family history

8 .Multiple primary neoplasm:
– Hx of primary breast CA ---> 4x fold increase of
primary CA
– Hx of primary CA of uterus and ovary ----> 1-1.5 risk
9 .Irradiation:
– Multiple exposure
– Had radiotherapy for breast CA of contralateral breast

10- Obesity
- before menopause → no
- after menopause → higher risk
Fat is an important source of oestrogen
production postmenopausal.

11- Benign breast disease
risk Disease type
No risk - Mild hyperplasia
- Duct ectasia
- Simple fibro adenoma
- Microcysts
- Periductal mastitis
-Adenosis
Slightly increased risk
1.5 – 2 times
- Gross cysts
- Moderate & florid hyperplasia
- Papilloma
- Sclerosing adenosis
- complex fibroadenoma
Moderately increased
risk 4-5 times
- Atypical hyperplasia
44

12- Diet
- fat
- dietary fibre , vit.C , vit.E , selenium - vit.A
→ modest protection
- phytooestrogen in soy → decreases risk
- caffeine → no increased risk
- alcohol → increases risk esp. Two drinks /
day

13- Radiation
Radiation exposure especially between
puberty & age 30 → increases risk

14- Oral contraceptive pills
Slightly increased the risk – not clinically
significant
as :
- women on pills are more likely to be
examined at regular intervals → br.ca. Is
more likely to be detected earlier

15- postmenopausal
oestrogen replacement
- HRT → increases the risk of br.ca.
- oestrogen combined with progesterone →
reduce risk of endometrial carcinoma but not
br.ca.
- other non hormonal preparations are
available for ttt of menopausal symptoms

BREAST CANCER
PATHOLOGY

Histological Classification of Breast Cancer
Cancers of the Mammary Gland can be Classified:
1. Histogenesis – duct, lobule (acini)
2. Histologic Characteristic – adenocarecinoma, epidermoid
CA, etc.
3. Gross Characteristic – Scirrhous, colloid,
medullary, papillary, tubular
4. Invasive Criteria – Infiltrating, in-situ

Pathology of breast cancer
 Breast cancer arises in terminal duct ( lobular unit )
 Histological classification
1- Non-invasive
- ductal ca. Insitu 6%
- lobular ca. Insitu 0.2%
2- Invasive
- no special type 68%
- special types
- lobular
classical 3%
variants 7%
- tubular 3%
- cribriform 3%
- medullary 3%
- mucinous 2%
- microinvasive 2%
- papillary 1%
- other rare types 1.8%

Histological Classification of Breast Cancer
Infiltrating Carcinoma of the Breast:
1. Paget’s disease of the nipple (1%):
 Primary carcinoma of mammary duct that invaded the skin
 Chronic eczematoid lesion of the nipple
 Tenderness, itching, burning and intermittent bleeding
 Palpable mass in the subareolar area
 PAGET cells:
 Characterictic cells
 Large cell w/ clear cytoplasm and binucleated
 80% non-infiltrating CA
 100% 5yr survival

Paget's disease

Paget disease of nipple :
Clinically resemble eczema.

Paget's histology

Pathological types

Ductal ca.insitu

-- Neoplastic cells are still
within the ductules and
have not broken through
into the stroma. Note that
the two large lobules in
the center contain
microcalcifications. Such
microcalcifications can
appear on mammography
Ductal carcinoma in-situ

Invasive ductal
carcinoma

Lobular ca.insitu
Lobular
carcino
ma in
situ

Invasive Lobular Carcinoma
 Often clinically and mammographically
occult, and therefore microscopically more
extensive than expected
 Propensity to be multifocal and bilateral
 Propensity to metastasize to unusual sites:
– Gyn tract, GI tract
 Same prognosis as infiltrating ductal
carcinoma, when matched for stage
 Usually ER/PR positive, C-erbB-2 negative

Infiltrating Lobular Carcinoma
 2nd most common form of invasive
breast cancer.
 Gross:
– May or may not form a mass
 Micro:
– Single cells and linear profiles of malignant
cells with low nuclear grade,
characteristically show minimal mitotic
activity

Infiltrating lobular carcinoma
lines of cells
Single cells and
linear profiles
of malignant
cells with low
nuclear grade
Linear
arrangement
of malignant
cells

BREAST CANCER
DIAGNOSIS

BREAST CANCER
DIAGNOSIS :
1--CLINICAL

Central
20
Upper outer:
50%
Upper inner
10%
Lower inner:
10%
Lower outer
outer: 10%
Location of breast
tumor

 History:
 Change in general appearance of breast (size, symmetry)
 New or persistent skin changes
 New nipple inversion
 Breast pain – Rare
 Breast mass (how it was discovered, duration, change in
size, location)
 Relationship of mass to menstrual cycles
 Nipple discharge (unilateral vs. bilateral, color)
 Medications (e.g. hormones)
 Risk factors for breast cancer
Evaluation: History

Breast cancer diagnosis
1-Clinical diagnosis
 Lump
- puckering - dimpling
- retraction - nipple discharge
- peau de orange - retracted nipple
- change in size- pain or tenderness
- scaling around nipple
- sore on the breast that doesn’t heal
 Axillary mass

Examination of the Breast
 Inspection
– Symmetry
– Skin / nipple changes
– Bulges / retractions
 Palpation
– Breast
– Axilla
– Supraclavicular

Inspection
Peau d’Orange
Puckering

Inspection
Nipple retraction

Inflammatory carcinoma: common in
pregnancy

Signs and Symptoms
79
Most common:
lump or
thickening in
breast. Often
painless
Change in color
or appearance
of areola
Redness or pitting
of skin over the
breast, like the
skin of an orange
Discharge
or
bleeding
Change in size
or contours of
breast

Paget's disease

Presentation of cancer breast
Skin ulceration & nodules Inflammatory carcinoma

Presentation of cancer breast
Skin dimpling & nipple
retraction
Ulcerating mass

Palpation (Lump)
 A palpable non-tender irregular mass
that feels firm or hard fixed to breast
tissues with flat undersurface and felt
bigger by the tips of the fingers than
the flat of the hand is almost always
malignant

 Any breast lump must have a definitive
diagnosis
 The combination of (Triple approach)
- clinical examination
- mammography
- fine needle cytology
Allows a definitive diagnosis to be made , in
most cases if not → lump is excised

BREAST CANCER
DIAGNOSIS:
1-CLINICAL EXAMINATION
2—IMAGING
3—METASTATIC WORK UP
5- BIOPSY

Patient Workup
 FNA vs. Core Biopsy
 Cyst aspiration & cytology
 Ultrasound
 Mammography
 MRI
 PET

Diagnostic mammography
 Essential .... - Can detect non palpable
lesions
- multicentric tumours
- size of suspicious mass
- axilla
 Bilateral ....- another ca in second breast
- base line following second
breast

Normal mammogram (dense
breast)
Mammogram technique

Malignant micro-calcification Invasive ductal carcinoma

Carcinoma
Stellate mass
with micro
calcifications

Mammography
Cancer, deep in the
right breast

Mammography - Reporting
BIRADS - Breast Imaging Reporting and Data
System
Category Assessment Recommendations
0 Incomplete Additional views
1 Negative Routine - 12 months
2 Benign Routine - 12 months
3 Probable Benign F/U short term - 6 mos.
4 Suspicious Biopsy considered
5 Cancer suggested Appropriate action

Other diagnostic imaging techniques
 Ultrasound
- differentiate between cystic & solid lesions
- evaluate lesions in women with dense
breast
- helps to distinguish benign and malignant
lesions

Ultrasound
 Benign
– Elliptical shape
(wider than tall)
– Complete tine
capsule
 Malignant
– Hypoechoic,
spiculated ‫مشرشر‬
– Taller than wide
– Irregular margins

Elliptical shape (wider than tall)

Breast ultrasound
Breast cancer speculated
hypo echoic mass Breast cancer

Other diagnostic imaging techniques
 MRI
- detect tumours less than 1cm
- helpful in dense breast
- best in recurrent cases

MRI
Cancer, deep
in the right
breast

MRI
Pre Gadolinium Post Gad Color Overlay
blue=benign

3—Metastatic work up
a-chest x-ray– CT scan
b-Abdominal ultrasonography
c-?Bone scan `

Tests to find whether the
cancer has spread
 Chest x-ray: the lungs.
 Bone scan: the bones.
 CT scan (computed tomography):
the chest and/or abdomen.
 MRI : brain and spinal cord.
 Ultrasound: other parts

BREAST CANCER
DIAGNOSIS :
3--BIOPSY

Percutaneous biopsy
 Palpable lesions
1- fine-needle aspiration cytology
2- core-needle biopsy
3- surgery

Percutaneous biopsy
 Non palpable lesions
1- stereotactic needle-core biopsy
computerized------mammographic guided
2- ultrasound-guided needle-core biopsy
3- mammotome biopsy using a vacuum-
assisted systems under LA

BIOPSY Techniques

Biopsy
Closed surgical techniques
Closed surgical techniques
•
• FNA: Fine needle
FNA: Fine needle
aspiration cytology
aspiration cytology
•
• Core needle biopsy
Core needle biopsy
•
• Stereotactic
Stereotactic biopsy
biopsy

LN FNA is positive for
metastatic carcinoma

Fine Needle Aspiration

FNA
 Fast, inexpensive
 96% accuracy
 Institution dependent
 Unable to
differentiate b/w in
situ vs invasive CA
 Ca cells take blue dye

Stereotactic Biopsy
 Suspicious
mammographic
abnormalities
 Patients lay prone

Biopsy of palpable lesions
 Excision biopsy
- tumours less than 2cm with safety margin
- excision for frozen section
 Incisional biopsy
- bigger tumours
- for diagnostic purposes

BREAST CANCER
STAGING

Breast cancer staging
TNM classification
Tis in situ
T1 <2 cm T1a >0.5-1cm T2c >1-2 cm
T2 >2-5 cm
T3 >5 cm
T4a involvement of chest wall
T4b involvement of skin – ulceration
- infiltration
- peau d’orange
- stellate nodules
T4c a and b together
T4d inflammatory cancer 126

N0 no regional node metastasis
N1 mobile ipsilateral nodes
N2 fixed ipsilateral nodes
N3 internal mammary nodes
.
Mo no evidence of metastasis
M1 distant metastasis including ipsilateral
supraclavicular nodes
.

Stage I T1,N0,Mo
Stage IIA
T1,N1,M0
T2,No,Mo
Stage IIB
T2,N1,M0
T3,N0,M0

Stage III A T0-2,N2,M0
T3,N1or2,M0
Stage III B T4,N0-2,M0
Stage IIIC any T,N3,Mo
Stage IV any T, any N,M1

Use of staging investigation
 Stage I - full blood count
- liver functions
- routine lab tests
- x-ray chest
 Stage II - As above
- liver scan ( Abdominal ultrasound )
- ± Bone scan
 Stage III & IV - AS above
- Ca. & phosphate
- liver scan (Abd US)
- Bone scan

BREAST CANCER
TREATMENT

Factors considered during
examination
 Breast cancer stage & grade
 Hormone receptor status
 HER2/neu status

Hormone receptor status:
 Hormone receptors are proteins in cells that can
attach to hormones.
 Estrogen and progesterone are hormones that fuel
breast cancer growth.
 Breast cancers are tested for hormone receptors.
 If the tumor has them, it is often called ER positive,
PR positive,
 About 2 out of 3 breast cancers have at least one of
these receptors.

HER2/neu status:
 About 1 out of 5 breast cancers have
too much of a protein called HER2/neu.
 Tumors with increased levels of
HER2/neu are called HER2-positive.
 These cancers tend to grow and spread
faster than other breast cancers

The main breast cancer
treatment options
 Surgery
 Radiation therapy
 Biological therapy (targeted drug
therapy)
 Hormone therapy
 Chemotherapy

Adjuvant and Neo-
adjuvant therapy
Adjuvant therapy:
 After surgery
 Combat metastasis.
 Chemotherapy,
hormone therapy
and radiotherapy.
Neo-adjuvant therapy:
 Before surgery
 Reduce tumors
- Radiation therapy
- Chemotherapy

Treatment
 Breast cancer is usually treated with surgery,
which may be followed by chemotherapy or
radiation therapy, or both.
 A multidisciplinary approach is preferable.
Hormone receptor-positive cancers are often
treated with hormone-blocking therapy over
courses of several years.

Breast cancer treatment
 Once the patient has been staged , decisions
have to be made about “appropriate therapy”
 The alternatives should be discussed with the
patients and they should be encouraged to
participate in the decision

1 - Surgery
 Mastectomy: Removal of the
whole tissue.
 Lumpectomy: Removal of a small
part of the tissue.

1 – Surgery - Types
 Lumpectomy
 Partial or segmental mastectomy
 Simple mastectomy
 Modified radical mastectomy
 Sentinel lymph node biopsy
 Axillary lymph node dissection

1 – Surgery - Reconstruction
 Reconstruction with implants
 Reconstruction with a tissue flap
 Deep inferior epigastric perforator
(DIEP) reconstruction
 Reconstruction of the nipple and areola

Lymph node surgery
 Axillary lymph node dissection: about 10 to 40
lymph nodes are removed.
 Usually done at the same time as the mastectomy
or breast-conserving surgery.
 Sentinel lymph node biopsy: is used to
determine if cancer has spread to the lymph nodes
under the arm without removing many of them.
 A blue dye/radioactive substance is injected in
order to identify the sentinel lymph nodes which
drains lymph from the tumor.
 They are then removed.

Principles of adjuvant treatment to
cut the way of metastases
Once cancer starts 1 it tends to metastasize 2
Adjuvant therapy may stop this 3

2 - Medication
Three adjuvant breast cancer treatment after
surgery.
1- Hormone Blocking Therapy: Some
breast cancers require estrogen to continue growing.
These ER+ cancers can be treated with drugs that either
block the receptors,
e.g. Tamoxifen, or alternatively block the production of estrogen
with an Aromatase inhibitor, e.g. Anastrozole or Letrozole. The
use of tamoxifen is recommended for 10 years.

Hormone therapy for
breast cancer
Drugs used to block estrogen
 Tamoxifen
 Toremifene (Fareston®)
 Fulvestran

2 - Medication
2- Chemotherapy: Chemotherapy is
predominantly used for cases of breast cancer
estrogen receptor-negative (ER-) disease. The
chemotherapy medications are administered in
combinations, usually for periods of 3–6 months.
 One of the most common regimens, known as "AC",
combines Adriamycin(Doxorubicin)+
Cyclophosphamide.
 Another common treatment Cyclophosphamide +
Methotrexate+ Fluorouracil (or "CMF").

Chemotherapy
 Chemotherapy (chemo) is the use of
cancer-killing drugs.
 Intravenously, given as a shot, or
taken as a pill or liquid.
 They enter the bloodstream and reach
most parts of the body.
 Combats metastasis.
 Damage some normal cells.

2 - Medication
3- Targeted Therapy:
Monoclonal Antibodies: Drugs that target HER2
HER2: protein that increase cancer growth.
 Trastuzumab (Herceptin): IV
 Pertuzumab (Perjeta®): IV
 Ado-trastuzumab emtansine (Kadcyla™)
 Lapatinib (Tykerb): pill

3 - Radiotherapy
 Radiotherapy is given after
surgery to the region of the tumor
bed and regional lymph nodes, to
destroy microscopic tumor cells
that may have escaped surgery.

External beam partial breast irradiation
 Targeted tissue :
Tumour bed + 2-3
cm (breathing
margin)
 34-38 Gy BID over
5-7 days

Radiation beam skims over the surface of
the chest wall, ribs and luring

Surgical Management:
1. Radical Mastectomy (Willi Meyer, Halsted)
 Stage III, IV
2. Extended Radical Mastectomy
 Hardley – 21% of outer quadrant and 44% inner quadrant
tumor has (+) internal mammary nodal involvement.
1. Wangesteen (Classical RM + Internal mammary mediastinal
and supraclavicular LN)
2. Urban (CRM + ipsilateral half of sternum, part of 2nd to 5th rib
and pleura and internal mammary LN)
3. Modified Radical Mastectomy:
1. Patey – preserved pectoralis major
2. Madden / Auchincloss – preserved both the pectoralis major
and minor
4. Total mastectomy w/ or w/o radiation:
1. Crile – Total mastectomy
2. Mc Whirter – Total mastectomy and radiation (Axilla,
supraclavicular and internal mammary nodes)

Therapeutic Approach for Breast
Cancer
A. Carcinoma in Situ:
1. DCIS:
a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifen
b. Total mastectomy w/ or w/o tamoxifen
c. Breast-conserving surgery w/o radiation therapy
2. Lobular Carcinoma in Situ:
a. Observation after diagnostic biopsy
b. Tamoxifen to decrease the incidence of subsequent breast cancer
c. Study, Tamoxifen versus raloxifene in high-risk postmenopausal
women
d. Bilateral prophylactic total mastectomy, w/o axillary dissection

Cancer
4. Inflammatory Breast Carcinoma:
– 3 – 5% 5 year survival
– Main role of surgery is in the diagnosis
– Primary therapy is chemotherapy and radiotherapy and if possible
surgery (mastectomy).
CAF ----- regression ------> extended mastectomy (level I) ---------->
irradiation of axillary and skin flap (30% - 5 yr survival)
5. Breast Cancer and Pregnancy/Lactation:
– The risk of aggressive and distant metastasis is profound due to high
level of estrogen and progesterone secreted from the placenta and
corpus luteum.
– Treat patient as if she is not pregnant
– Lactation should be suppressed promptly, even if biopsy was benign
because milk from transected lactiferous will drain via the biopsy site
– If patient is undergoing radiotherapy and chemotherapy for breast
CA, advice patient not to get pregnant. ( advice not to use
contraceptive pills).
Treatment:
 MRM / Segmental resection + radiation (after delivery)
 (+) axillary ---> chemotherapy is delayed on the 2nd trimester (single
agent) 11 – 12% teratogenicity on 1st trimester.

Cancer
6. Breast Cancer in Men:
– Factors:
a. Klinefelter syndrome
b. Estrogen therapy
c. Testicular feminizing syndromes
d. Irradiation
e. Trauma
– Age: 60-70y/o
– s/sx: breast mass, nipple retraction and/or discharge,
ulceration and pain.
– Commonly ER positive and well differentiated
– Prognosis is similar w/ female
– Treatment:
 MRM + radiation if with ulceration and high grade
 Orchiectomy / chemotherapy

Surgical Management:
5. Subcutaneous Mastectomy:
 Nipple is retained / for T1s
6. Quandrantectomy, axillary, radiotherapy (QUART)
 Quadrant of the breast that has the CA is resected
(quadrant of breast tissue, skin and superficial pectoralis
fascia)
 Unacceptable cosmetic result
7. Partial Mastectomy and Radiation:
 Lumpectomy, segmental resection or tylectomy
 Histologically free margin of breast CA (1cm)
 Advent of supervoltage radiotherapy with skin sparing effect
 Frozen section evaluation of margin
 To determine adjuvant chemotherapy adequate sampling of
axillary LN (level I), curvilinear incision should be done
– If LN (+) ----> adjuvant chemotherapy

Variation of breast surgery :
Local control

Treatment of invasive
breast cancer
Local control
Conservation therapy
- extended radical mastectomy and super radical didn’t
give better results so it was thought that “If more was
not necessarily better why not less”
- conservative surgery was introduced with results near
to mastectomy

Indication of breast conservation :
T1-T2(≤4CM) N0,N1,M0
T2 >4cm in large breast

 Wide local excision
- Aim is to remove the palpable lesion with a 1cm margin
of surrounding normal breast tissue
- Incision is placed along langer’s lines except when it
jeopardizes further mastectomy if needed
- Removal of skin overlying the lesion is un necessary
unless very superficial or there is a scar of previous
biopsy

Elliptical incision

The other skin flap

Pectoral fascia not removed

Axillary incision

Whole axillary contents are
removed

Nerve to serr anterior and
latis dosi

Ax vein & nerves viewed

Wounds are sutured with
axillary drain

Post-operative radiotherapy
 Given through linear accelerator to deliver
high energy x-ray with 40-50 GY (equivalent
to 4000-5000 rad) given to the breast over 4
weeks in daily fractions
 Addition of radiotherapy to lumpectomy
reduce local recurrence from 25-39% to
5-10%

Mastectomy for breast
cancer
 Historically ideal hypothesis was
→ centrifugal spread of br.ca. Cells
→ LN acts as filters → spread occurs when their capacity is
exhausted
 Radical
 Extended or super radical
 Fore quarter amputation 1920
 Modified R.M. (Patey)
 Total mastectomy + limited axillary dissection level II

INDICATION FOR
MASTECTOMY
 Large bulky tumour
 Multicentric disease
 Likelyhood that cosmetic outcome of breast
conservative surgery and radiotherapy may be
poor
 Patient preference and choice

Technique of mastectomy
 Incision : - elliptical with equal lengths to avoid
dog ear
- including nipple ,areola & biopsy site with
4cm on either side
- extends from lateral border of sternum to
mid-axillary line
 Skin flap: - up to clavicle
- medially to sternum
- down to rectus sheath
- lateral to edge of latissmus dorsi

After removal of the breast
and axilla

Prevention of breast
cancer
 Chemoprevention
- Tamoxifen (Nolvadex)
- Raloxifene (Evista)
 Preventive surgery
- Prophylactic mastectomy
- Prophylactic oophorectomy

Prevention of breast
cancer
 Alcohol consumption X
 Physical exercise - more
 Diet – less red meat & fat + more fibers
 Postmenopausal hormone therapy X
 Bodyweight - less
 Breast cancer screening if possible
 Breastfeeding – more than 30 months

Cancer’s Seven Warning Signals
+ Unexplained loss of weight

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