This document summarizes information about breast carcinoma, including: - Pakistan has the highest rate of breast cancer in Asia, with approximately 90,000 new cases diagnosed annually. - Common risk factors include age, family history, obesity, lack of breastfeeding, and environmental toxins. - Screening is recommended annually with mammography after age 40. Diagnosis involves biopsy of suspicious lumps. - Treatment options include surgery, chemotherapy, radiation therapy, hormone therapy, and reconstruction as needed.

1. BREAST CARCINOMA
Ahmed Mashood Khan
House Officer
Surgical Unit 2

2. INTRODUCTION
• Pakistan alone has the highest rate of Breast Cancer than any
other Asian country as approximately 90000 new cases are
diagnosed every year out of which 40000 die. (jpma)
• Is the most common cause of death in middle aged women in
western countries

3. Which country has the highest rate of Breast Cancer
worldwide?

4. According to the the research conducted by American
Institute for Cancer Research in 2018, Belgium has the
highest rate of breast cancer in women about 113.2 Age
standardized rate per 100,000

5. ETIOLOGY
• Geographical: common in western world
• Age: extremely rare below the age of 20 years
• Gender: Less than 0.5 per cent in male
• Diet: low phyto-estrogen, high alcohol intake
• Genetic
• Endocrine: long term HRT
• Radiation history

6. OTHER RISKS FACTORS
• Menarche Age, early menarche is a risk
• Age at first Live Birth
• Lack of breast feeding is a risk
• First-Degree Relatives with Breast Cancer
• Carcinoma of the contralateral breast or endometrium
• Obesity in old age ~ increase in estrogen
• Environmental Toxins
• Tobacco

7. Screening
• After 40 years mammography indicated

8. PATHOGENESIS
1. Genetic Changes
• Mutation of proto-oncogen( overexpression of HER2)
• Mutation of tumor supressor gene (BRCA1,BRCA2) in breast
epithelium
2. Hormonal Influence /Sporadic Breast Cancer
• Endogenous/exogenous estrogen excess or hormonal
imbalance ! cause mutations or generate DNA-damaging
free radicals ! Tumor.

10. Total Cancers
In Situ Carcinoma* 15-30
Ductal carcinoma in situ, DCIS 80
Lobular carcinoma in situ, LCIS 20
Invasive Carcinoma 70-85
Ductal 80
Lobular carcinoma 10
Tubular/cribriform
Mucinous (colloid)
Medullary carcinoma
Papillary carcinoma
Inflammatory Carcinoma (Rule out Breast Abcess)
Metaplastic carcinoma, (Squamous)

11. SPREAD OF BREAST CANCER
1. Local spread: to the skin, the pectoral muscles and even
the chest wall if diagnosed late
2. Lymphatic: primarily to the axillary and the internal
mammary lymph nodes
3. Blood stream: skeletal metastases, liver, lungs, brain,
adrenal, ovaries

12. Clinical Features
• Found most frequently in the upper outer quadrant
• Discrete, painless, movable mass
• Will present as:
• Hard lump, which may be associated with in drawing
of the nipple
• Locally advanced cases: skin involvement with peau
d’orange or frank ulceration and fixation to the chest
wall
• Paget’s disease of the nipple

13. Paget’s Disease
Peau d’Orange

15. Prognosis

18. Ultrasonography
Can tell about the demarcations and echogenicity of the structures

19. complex
complex

20. • MRI
• CT
• PET/ CT
• Sodium Fluoride PET
• FDG PET

21. Mammography
• Beneficial in finding occult malignancies
• All women 30 years or older with a breast mass
• Spot compression views and magnification views are recommended
• Multi-focal or multi-centric disease should be noted
• Palpable breast mass – sensitivity 82% to 94% ( Rule Out)
– specificity 55% to 84% for detecting breast cancer ( Rule In)

22. Medial-lateral oblique view
cranio-caudal view

25. Biopsies
• FNA
• Core Needle
• Surgical (open) - Incisional and Excisional

29. Treatment

30. Neoadjuvant Therapy
Preoperative therapy is used to shrink breast cancer.
It may help plan future treatment for early, high-risk cancers. It may lessen the amount of tissue removed at
surgery. It also may allow locally advanced cancers to be treated with surgery.
HER2 antibodies + chemotherapy if the cancer is HER2 positive.

31. Surgery
• Breast Conserving Surgery - Lumpectomy and Quadrantectomy
- followed by radiotherapy. Not indicated in familial disorders
due to increased risk of breast cancer recurrence
• Mastectomy
1. Simple Mastectomy
2. Radical Mastectomy
3. Modified Radical Mastectomy

32. " Removal of only
the breast +
Region of the axillary
tail of breast " No
dissection of the axilla

33. Includes excision of:
• The breast
• Axillary lymph nodes
• Pectoralis major and minor muscles
• No longer indicated
RADICAL HALSTED MASTECTOMY

34. " Breast and
associated
structures#
dissected en
bloc
" Excised
mass is
composed of: •
Whole breast
• Large portion of
skin centre
overlies the tumor
but always
includes the
nipple
• All of the fat,
fascia and lymph
nodes of the axilla

35. • Stage the patient and to treat the axilla
• Presence of metastatic disease within the axillary lymph
nodes - best single marker for prognosis
• Major determinant of appropriate systemic adjuvant therapy
• But treatment does not affect long-term survival
AXILLARY SURGERY

36. • Sentinel node biopsy
• Sampling
• Removal of the nodes behind and lateral to the pectoralis minor or a
full axillary dissection
How to Deal with Axilla?

37. SENTINEL NODE BIOPSY
• Standard of care in the management of the axilla
• In patients with clinically node-negative disease
• Sentinel node is localised peroperatively by the injection of patent blue
dye and radioisotope labelled albumin in the breast

39. Breast Reconstruction

40. Chemotherapy and Hormonal Therapy
• Hormonal Therapy given to hormone receptor positive patients
SERM (Tamoxifen)
• Reduces the annual rate of reoccurrence and death rate
• Reduces risk of tumors in contralateral breast
• Optimal duration of treatment is 5 years
LHRH agonist
Leuprolide
• for pre-menopausal receptor positive women
Induce a reversible ovarian suppression
Has same effects as surgical or radiation induced ovarian ablation
Oral Aromatase Inhibitors
Anastrazole
• For post-menopausal women
• Treatment of recurrent disease
Has been shown superior to Tamoxifen

41. Chemotherapy
CMF
• Cyclophosphamide, Methotrexate and 5 Fluorouracil
• 25% reduction in the risk of relapse over 10 to 15 years period
Anthracyclines ( Doxorubicin or epicubicin )
Herceptin - Trastuzumab (MAB)

42. • Combined hormonal and chemotherapy have additive effect
• All hormone receptor positive patients should receive tamoxifen.
• ER - patients should receive chemotherapy.
Hormonal therapy is started after completion of chemotherapy
to reduce side effect
• Given to stop recurrence
• Chemo based on tumor size and nodal involvement
• Chemo is given to high risk group patients despite receptor status
• High dose chemotherapy in heavy lymph node involvement has no
advantage

43. Chemotherapy:
o Route Oral or IV
o Given in cycles, consisting of a treatment period followed by a
recovery period.
o No. of cycles depends on the types of drugs used
o Not given for much more than 6 months
Hormonal therapy:
o every day for 5 years

44. Psychological Support

46. Thank You