Breast carcinoma is the most common cancer in women worldwide. The most common histological type is invasive ductal carcinoma, which usually presents as a painless lump in the upper outer quadrant of the breast. Risk factors include increasing age, family history, genetic factors, reproductive factors and lifestyle factors. Staging involves the TNM system, with treatment depending on stage - ranging from surgery such as mastectomy for early stages to chemotherapy, hormonal therapy and radiation for advanced stages.

1. Breast Carcinoma
Dr Sunil K S Gaur

2. Facts
• M/C cancer in women worldwide
• M/C cancer in urban women of India
• 2nd m/c cause of cancer related death in women
• M/C cause of death in Ca breast patient – malignant pleural effusion
• M/C histological type – Invasive ductal carcinoma (IDC)
• Most aggressive type – Inflammatory breast carcinoma
• M/C site – upper outer quadrant
• M/C site of metastasis – bone

3. Risk Factors

5. Risk Factors (contd.)
Non-modifiable
• Increasing age
• Female sex
• High socio-economic status
• Family history – ca breast
• Genetic factors – BRCA1, BRCA2, etc.
• Early menarche/late menopause
• Past history of ovarian, endometrium
or contralateral breast cancer
Modifiable
• Nulliparity/late 1st pregnancy
• Not breast-feeding
• Hormone replacement therapy –
combined (oestrogen + progesterone)
• Obesity
• Diet – alcohol, fat, processed foods
• Radiation exposure – e.g., RT for
lymphoma

6. Pathology

7. Histological Classification
• In situ – does not cross the basement membrane
 DCIS – Ductal carcinoma in situ
 LCIS – Lobular carcinoma in situ
• Invasive
 Lobular carcinoma (10-15%)
 Ductal carcinoma (70-80%) – M/C type
 Inflammatory carcinoma (rare)
 Colloid (mucinous) carcinoma (2%) – extracellular pools of mucin
 Medullary carcinoma (4%) – lymphoreticular infiltrates
 Tubular carcinoma (2%) – survival upto 100%

8. LCIS vs DCIS
DCIS LCIS
Structure involved Lactiferous ducts Lobules
More common Less common
Clinical sign Nipple discharge, mass None
Mammography Microcalcifications None
Sites Unicentric Multicentric
Laterality Unilateral Often bilateral
Subsequent cancer
• Type Ductal Ductal (or lobular)
• Pathogenesis Direct precursor of IDC Only a risk factor for
development of invasive
cancer
• Breast involved Ipsilateral Any

9. Molecular Classification
ER PR Her-2/Neu Ki-67
(proliferation)
Remarks
Luminal A + + – Low Best prognosis; Hormonal
therapy
Luminal B + + + High Triple positive
Her-2/Neu rich – – + High Trastuzumab
Basal like – – – High Triple negative;
BRCA gene;
Worst prognosis
Normal breast like – – ___________ ___________ Well differentiated
• On the basis of gene expression (relative quantities of mRNA for different genes), 5 subtypes
have been identified
• These corelate with prognosis and response and thus have taken clinical importance

10. Grading
• Can be:
 Well differentiated
 Moderately differentiated
 Poorly differentiated
• Based on three factors:
 Nuclear pleomorphism
 Mitotic count
 Tubule formation
• Commonly, a numerical grading system based on the scoring of these three
individual factors is used, grade I, II and III.

11. Multiple Tumours
Multifocal
• 2nd lesion within the same quadrant
as previous
• within 5 cm
Multicentric
• 2nd lesion outside the quadrant as
previous one
• beyond 5 cm

12. Clinical Features

13. Clinical Features
• Most breast cancers will present as a painless hard lump, fixed to
surrounding breast tissue
 Most frequent in upper outer quadrant
 May be associated with indrawing of the nipple or dimpling of skin
• Nipple discharge – 2nd m/c presentation
• Can spread in 3 manners:
 Local spread – Skin, muscles or chest wall
 Lymphatic spread – Axillary, internal mammary nodes
 Hematogenous spread – Bones, liver, lungs, brain

14. Cutaneous Manifestations
• Dimpling of skin – infiltration of Cooper’s ligaments
• Nipple retraction – infiltration of lactiferous ducts skin not ‘invaded’
• Nipple discharge – bloody
• Nipple erosion – Paget’s disease Tis (if no lump)
• Peau d’ orange – obstruction of dermal lymphatics
• Skin ulceration, fungation T4a
• Cancer-en-cuirasse – multiple nodules; armour coat appearance
• Inflammatory breast carcinoma T4d

15. Peau d’ orange

16. Cutaneous Manifestations (contd.)

17. Deep Infiltration
• Pectoralis major
• Latissimus dorsi mobile mass becomes fixed on contraction of muscle
• Serratus anterior
• Chest wall – ribs, intercostal muscles; mass is fixed T4b

18. Lymphatic Spread
• Axillary lymph nodes – 75%
• Internal mammary – 25%; from posterior one-third of the breast
• Initially, hard mobile lymph nodes; later, become fixed
• From axillary LN, spread occurs to supraclavicular LN
• Involvement of supraclavicular nodes and of any contralateral lymph nodes
represents advanced disease
• Can result in lymphoedema of the upper limb – brawny oedema

19. Haematogenous Spread
• Bones
 lumbar vertebrae > femur > thoracic
vertebrae > rib > skull
 osteolytic lesions
 painful, tender, hard swelling with
disability
• Lungs – malignant pleural effusion
and ‘canon ball’ secondaries
• Liver
• Brain
• Soft tissues
• Adrenals

20. Haematogenous Spread (contd.)

21. Paget’s Disease of Breast
• Superficial manifestation of an underlying intraductal carcinoma
• It presents as an erosion of the nipple and areola
• Initially, mimics eczema which persists despite local treatment
• Later, the nipple eventually disappears
• Microscopically, large, ovoid cells with abundant, clear, pale-staining
cytoplasm in the Malpighian layer of the epidermis – Paget cells

22. Eczema vs. Paget’s disease
Eczema
1. Bilateral
2. Itching present
3. Vesicles present
4. Nipple is intact
5. No lump
Paget’s disease
1. Unilateral
2. Itching absent
3. Vesicles absent
4. Nipple gets destroyed
5. Lump may be palpable

23. Inflammatory breast carcinoma
• Highly aggressive cancer
• Result of blockage of the
subdermal lymphatics with
carcinoma cells.
• Clinical features:
 Painful, swollen breast, which is
warm with cutaneous oedema
 Usually no mass is palpable
 Mimics mastitis
 Involves at least one-third (>33%) of
the breast

24. Inflammatory breast carcinoma
(contd.)
• Investigation:
 A skin biopsy will confirm the
diagnosis
• Treatment:
 Multimodal approach
 aggressive chemotherapy +
radiotherapy + salvage surgery
• It used to be rapidly fatal but the
prognosis has improved
considerably.

25. Staging

26. Staging –
T stage
• TNM staging used
• Latest is AJCC 8th edition

27. Staging –
N stage

28. Staging –
M stage

29. Staging –
Stage
groups

30. Pragmatic Classification
Early

31. Investigations

32. Triple assessment
• In any patient who presents with
a breast lump or other symptoms
suspicious of carcinoma, the
diagnosis should be made by a
combination of
 clinical assessment
 radiological imaging
 cytological or histological analysis
• The positive predictive value
(PPV) of this combination exceeds
99.9%

33. Mammography
• Features of malignancy on
mammography are
 high density solid mass
 with irregular, ill-defined margins –
due to invasion in surrounding
tissues
 with heterogenous appearance –
necrotic areas
 showing microcalcifications – fine
stippled calcium

34. Treatment

35. Modalities
1. Surgery
Local therapy
2. Radiotherapy
3. Chemotherapy
Systemic therapy
4. Hormonal therapy
• The care of breast cancer patients is undertaken as a joint venture
between the surgeon, medical oncologist, radiotherapist and allied
health professionals such as the clinical nurse specialist.

36. Stagewise Treatment
Pragmatic Group Stages Treatment
Early breast cancer (EBC) I, IIA, IIB • SLNB + Mastectomy + HT
• SLNB + BCS + RT + HT
• If SLNB (+) then axillary dissection
Locally advanced breast
cancer (LABC)
IIIA, IIIB, IIIC • NACT + MRM + Adjuvant CT/RT + HT
Metastatic breast cancer
(MBC)
IV • Palliative CT + HT + RT + Palliative
surgery
Abbreviations:
SLNB – Sentinel lymph node biopsy HT – Hormonal therapy;
BCS – Breast conservative surgery RT – Radiotherapy;
NACT – Neo-adjuvant chemotherapy MRM – Modified radical mastectomy
CT - Chemotherapy

37. Mastectomy
Types of Mastectomy Structures removed
Simple or Total Mastectomy Removal of breast tissue, nipple-areola
complex, skin
Extended Simple Mastectomy Simple mastectomy + level I axillary
LN dissection
Modified Radical Mastectomy Simple mastectomy + level I, II
axillaryLN dissection
Halsted’s Radical Mastectomy Removal of breast tissue, nipple-
areola complex, skin, pectoralis
major & minor & level I, II, III
axillary LNs.

38. Modified Radical
Mastectomy
• Types:
1. Patey’s procedure: Pectoralis minor removed
2. Scanlon’s procedure: Pectoralis minor muscle is
divided but not removed
3. Auchincloss’ procedure: Pectoralis minor is
retracted but not divided
• Auchincloss’ procedure is widely practiced nowadays.
• Boundaries:
 Lateral: Anterior margin of latissimus dorsi muscle
 Medial: Sternal border
 Superior: Clavicle
 Inferior: Up to upper 1/4th of rectus sheath

39. Breast Conservative Therapy
• BCT = SLNB + BCS + RT
• Breast tissue, nipple-areolar complex and skin
are preserved
• Suitability for BCT:
 Solitary lesion
 Small tumour in a large breast (small Tumour/Breast
ratio)
 Radiotherapy available and no contraindication
 Patient motivated and agreeing to regular follow-up

40. BCT (contd.)
• Types of BCS:
1. Wide local excision (WLE) – with a margin of 1 cm of normal
tissues
2. Quadrantectomy – removal of entire quadrant of breast
3. Skin sparing mastectomy (SSM)
• Contra-indications:
 Pregnancy
 Multicentric lesions
 Centrally located tumour
 Large tumour in a small breast

41. Sentinel Lymph Node Biopsy
• A sentinel lymph node is defined as the first lymph node to which
cancer cells are most likely to spread from a primary tumour.
• Done in early breast cancer with clinically node negative axilla
• Dyes used:
1. Radioactive Tc-99m labelled sulphur colloid – injected 2-24 hours
before the surgery and hand held gamma camera is used to identify the
location of SLN
2. Isosulfan blue dye – injected at the time of surgery and dissection is
done to visualise the blue dye containing lymphatics which are traced
to locate the SLN
• Injected in subareolar region or near the primary tumour.

42. SLNB (contd.)
• SLN is removed and sent for
histopathology.
• If cancer cells detected in SLN then
axillary lymph node dissection is
undertaken.

43. Chemotherapy
• Given in any patient with:
 tumour size >1 cm (or)
 tumour size <1 cm with high risk
features
• Older regime of CMF is no longer
considered adequate
 Cyclophosphamide
 Methotrexate
 5-fluorouracil
• Modern regimes include
anthracyclines (adriamycin or
epirubicin) and taxanes
 Paclitaxel
 Adriamycin
 Cyclophosphamide
• Newer drugs:
 Trastuzumab – for HER-2 positive
tumours
 Ixabepilone – anthracycline and
taxane resistant tumours
 Lapatinib – second line HER-2
therapy
 Sunitinib – refractory metastatic
breast cancer

44. Hormonal Therapy
• Given only in patients with ER/PR (+) tumours
• Drug of choice:
 Pre-menopausal – Tamoxifen (selective estrogen receptor modulator)
 Post-menopausal – Anastrozole, letrozole (aromatase inhibitors)
• Continued for 5-10 years
• Surgical ablation can also be done by bilateral oophorectomy

45. Thank you