Lecture on breast carcinoma for medical students. Encompasses basic sciences, triple assessment, classifications and principles of management on the number one cancer in Malaysia.

1. Breast carcinoma
Chea Chan Hooi
Surgeon
Department of Surgery
Sibu Hospital

2. Content
• Anatomy
• Epidemiology
• Risk factors
• Clinical presentation
• Investigations
• Staging
• Principles of management
• Screening

3. Anatomy

5. Epidemiology
• Most common cancer amongst women worldwide (23% of
all female cancers)
• Asian countries, incidence is still lower but increasing trend
 Westernisation of breast cancer risk factors
• In Malaysia
– The most common cancer (18%)
– 29.1 per 100 000 population
– Peak incidence 50 – 59 y/o
– Race
• Chinese 38.1 per 100 000
• Indian 33.7
• Malay 25.4
• 1% of BC involve male patient

7. Risk factors
Modifiable
• Prolonged estrogen
exposure
– Early menarche (<10 y/o)
– Nulliparity
– Late 1st child-birth (>30 y/o)
– No breast feeding (<6/12)
– Late menopause (>55 y/o)
– OCP use (>6/12)
– HRT
– Obesity
• Previous breast irradiation
Non-modifiable
• Family history
• Genetic predisposition (e.g.
BRCA 1 & 2 mutations)

8. Triple assessment
• Clinical features
– History
– Physical examination
• Radiological features
– Ultrasonography (<35 y/o)*
– Mammography + ultrasonography (≥35 y/o)
• Histological/Cytological features
– Fine needle aspiration – cytology
– Core needle biopsy – histology

9. History
• Breast symptoms
– Lump
– Pain
– Nipple discharge
– Skin changes
– Axillary lump
• Metastatic symptoms
• Screen-detected

10. Physical examination

22. Investigations
Ultrasonography
• <35 y/o
• Suspicious features
– Lesion height > width
– Irregular margins
– Heterogenous
– Posterior enhancement
– Associated suspicious
lymphadenopathy
Mammography
• >35 y/o
– Dense breast tissue in younger
women will mask significant
findings  reduce its
sensitivity & specificity
• Suspicious features
– Architectural distortion
– Lesion
• Spiculated
• Irregular margins
• Heterogenous
• Clustered pleomorphic
microcalcifications

23. • MRI breast
– Mainly supplementary
– Indications
• Ambiguous but suspicious MMG
• Pregnancy, especially late trimester
• Implants
• Young women suspected with hereditary disease

26. Tissue diagnosis
• After imaging has been performed to avoid
architectural disturbance that might disrupt
radiologist’s interpretation & pain to patient
• Latest guidelines  all breast lumps –
irrespective of palpability – must be sampled
under image guidance (USG or MMG)
• Two options
– FNAC
– CNB

27. Staging
• CECT TAP
– Gold standard
• CXR + USG abdomen
– Compromise
– Only in limited-resources setting
• Bone scan
– Only if have pathological fracture or symptoms suggestive of bone
metastases
• CT brain
– Only if have symptoms suggestive of brain metastases
• PET scan
– Only to resolve nature of ambiguous, suspicious lesions picked up on
CT scan
– Limited efficacy if metastases are small (<5mm), mucinous carcinoma

33. Treatment options
• Surgery
• Radiotherapy
• Chemotherapy
• Hormonal therapy
• Targeted therapy
• Symptomatic relief

34. Surgery
• Breast
– Mastectomy
• Radical
• Modified radical
• Skin-sparing
• Nipple-sparing
– Breast-conserving
• Wide local excision/Lumpectomy
• Quadrantectomy
– ± reconstruction (immediate vs. delayed)
• Axilla
– Sentinel lymph node biopsy
– Axillary sampling
– Axillary dissection
– Axillary clearance

35. Mastectomy Wide local excision
Pros … …
Cons Disfiguring Might need second surgery
Must undergo post-op RT
Cosmetic outcome might
not be satisfactory
Contraindications - High tumour : breast ratio
Unable to undergo post-op
RT
Not willing or not suitable
to undergo 2nd surgery
Centrally located tumour

37. Radiotherapy
• Post op External beam RT, image modulated RT
• Intra op  single dose, spherical applicator, only on WLE site, new
technology
• Indications
– Post-breast conserving surgery
– Involved mastectomy margins
– Locally advanced disease (T3 or N2)
• Location
– Chest wall
– Infraclavicular
– Supraclavicular
– Axillary
– Whole brain RT

38. Chemotherapy
• Multiple regimes
• Classical regimes – FEC, CMF (Bonadonna)
• Newer agent – taxanes
• Neoadjuvant, adjuvant or palliative settings

39. Hormonal therapy
• SERM
– Tamoxifen
– Pre-menopausal
– Cons
• DVT
• Endometrial carcinoma
• Aromatase inhibitors
– Steroidal vs. non-steroidal
– Post-menopausal
– Cons
• IHD
• Osteoporosis
WHY?

40. Targeted therapy
• Molecular level treatment targeting specific
antigens present on breast cancer cells
• Options
– HER2 receptor antagonist
• Trastuzumab
– VEGFR antagonist
• Sunitinib
– mTor antagonist
• Everolimus

41. Misc
• Symptomatic, palliative
• Depending on problem
– Pain
– Nausea, vomiting
– Lung metastases
– Bone metastases
– Obstructive jaundice
– Brain metastases

42. TQ!
Q&A?