This document provides information on carcinoma of the breast, including: - Breast cancer is the most common cause of death in middle-aged women in western countries. - Aetiological factors for breast cancer include geographical, age-related, genetic, dietary, endocrine, and previous medical history factors. - Breast cancer can be diagnosed through clinical examination, imaging tests, and biopsy. Staging evaluation determines the extent of the cancer and is important for determining prognosis and appropriate treatment.

1. CARCINOMA OF BREAST
Dr. Md. Sherajul islam
MBBS,FCPS,FACS,FMAS
Assistant professor (surgery)

2. CARCINOMA OF THE BREAST
Breast cancer is the most common cause of death in
middle-aged women in western countries
In 2004 approximately one and a half million new
cases were diagnosed worldwide
In England and Wales, 1 in 12 women will develop
the disease during their lifetime

3. Aetiological factors
1. Geographical
occurs commonly in the western world, accounting for 3–5%
of all deaths in women
In developing countries it accounts for 1–3% of deaths
2. Age
extremely rare below the age of 20years
thereafter, the incidence steadily rises ( by the age of 90 years
nearly 20% of women are affected)
3. Gender
More than 99.5 % of patients with breast cancer are female
Less than 0.5% of patients with breast cancer are male

4. Aetiological factors
4. Genetic
occurs more commonly in women with a family history of
breast cancer (Breast cancer in mother, sister, or daughter)
than in the general population.
Breast cancer related to a specific mutation accounts for
about 5% of breast cancers
5. Diet
diets low in Phytoestrogens.
A high intake of alcohol
Consumption of foods with a high fat content

5. 6.Endocrine
Breast cancer is more common in
i. early menarche (under age 12)
ii. late menopause(after age 50)
iii. nulliparous women
iv. late first pregnancy
v. women who do not breastfeed to her child
vi. postmenopausal women
vii. obesity
ix. exogenous hormones
-----in particular the oral contraceptive pill and HRT
---- long-term exposure to the combined preparation of HRT
does significantly increase the risk of developing breast
cancer.

6. 7.Previous radiation
i. Young women who receive mantle radiation therapy for
Hodgkin's lymphoma have a breast cancer risk that is 75
times greater than that of age-matched control subjects
ii. Survivors of the atomic bomb blasts in Japan during
World War II have a very high incidence of breast cancer,
likely because of somatic mutations induced by the
radiation exposure
In both circumstances, radiation exposure during
adolescence, a period of active breast development,
magnifies the deleterious effect

7. 8. Some benign breast disease
have relative risk of developing breast carcinoma on
pathological examination of benign breast
a) Slightly increased risk (1.5–2 times)
--- Hyperplasia, moderate or florid, solid or papillary
----Papilloma with a fibrovascular core
b) Moderately increased risk (5 times) ----- Atypical
hyperplasia (ductal or lobular)
9. Previous medical history
i. Endometrial cancer
ii. Cancer in other breast

8. Factors Associated with Increased Risk of Breast
Cancer
Race White
Age Older
Family history Breast cancer in mother, sister, or daughter (especially
bilateral or premenopausal)
Genetics BRCA1 or BRCA2 mutation
Menstrual history Early menarche (under age 12)
Late menopause (after age 50)
Reproductive history Nulliparous or late first pregnancy
Previous medical history Endometrial cancer
Proliferative forms of fibrocystic disease
Cancer in other breast

9. Pathology
Breast cancer may arise from the epithelium of the
duct system anywhere from the nipple end of the
major lactiferous ducts to the terminal duct unit,
which is in the breast lobule
.

10. may be
entirely in situ carcinoma : is pre-invasive cancer that
has not breached the epithelial basement membrane.
now accounts for over 20% of cancers detected by
screening in the UK
DCIC
LCIC--often being multifocal and bilateral
may be invasive cancer
Invasive ductaance

11. The degree of differentiation
The tumour is usually described using three grades:
 well differentiated
 moderately differentiated
 poorly differentiated
Commonly, a numerical grading system based on the
scoring of three individual factors (nuclear
pleomorphism, tubule formation and mitotic rate)
is used, with gradTer

12. Previously, descriptive terms were
used to classify breast cancer
‘scirrhous’, meaning woody,
‘medullary’, meaning brain-like

13. More recently,
• histological descriptions have been used
• Gene array analysis of breast cancers has identified
five subtypes

14. Current nomenclature
a) Ductal carcinoma is the most common variant
b) lobular carcinoma occurring in up to 15% of cases
c) mixed with both ductal and lobular features
d) Rarer varieties
i. colloid carcinoma,
ii. medullary carcinoma,
iii. tubular carcinoma
iv. Inflammatory

15. There are subtypes of lobular cancer
classical type, which carries a better prognosis
pleomorphic type
Invasive lobular carcinoma is commonly multifocal
and/or bilateral

16. ***Staining for oestrogen and progesterone
receptors is now considered routine, as their
presence will indicate the use of adjuvant hormonal
therapy with tamoxifen or the newer aromatase
inhibitors
• Tumours are also stained for c-erbB2 (a growth
factor receptor) as patients who are positive can be
treated with the monoclonal antibody trastuzumab
(Herceptin), either in the adjuvant or relapse
setting

17. Histological Types of breast cancer
1. Infiltrating ductal (not otherwise specified)
Medullary
Colloid (mucinous)
Tubular
Papillary
2. Invasive lobular
3. Noninvasive
Intraductal
Lobular in situ
4. Rare cancers
Juvenile (secretory)
Adenoid cystic
Epidermoid
Sudoriferous

18. Inflammatory carcinoma
is a fortunately rare, highly aggressive cancer that
presents as a painful, swollen breast, which is warm
with cutaneous oedema
This is the result of blockage of the subdermal
lymphatics with carcinoma cells. Inflammatory
cancer usually involves at least one-third of the
breast and may mimic a breast abscess

19. • A biopsy will confirm the diagnosis and show
undifferentiated carcinoma cells
• It used to be rapidly fatal but with aggressive
chemotherapy and radiotherapy and with salvage
surgery the prognosis has improved considerably

20. Paget’s disease of the nipple
Paget’s disease of the nipple is a superficial
manifestation of an underlying breast carcinoma
It presents as an eczema-like condition of the nipple
and areola, which persists despite local treatment

21. The nipple is eroded slowly and eventually
disappears
If left, the underlying carcinoma will sooner or later
become clinically evident
Nipple eczema should be biopsied if there is any
doubt about its cause
Microscopically, Paget’s disease is characterized by
the presence of large, ovoid cells with abundant,
clear, pale-staining cytoplasm in the
Malpighian(Strat. Basale & Strat. Spinosum) layer of
the epidermis

22. The spread of breast cancer
1. Local spread
The tumour increases in size and invades other portions of
the breast
It tends to involve the skin and to penetrate the pectoral
muscles and even the chest wall if diagnosed late
2. Lymphatic metastasis
Lymphatic metastasis occurs primarily to the axillary and
the internal mammary lymph nodes
Tumours in the posterior one third of the breast are more
likely to drain to the internal mammary nodes

23. • The involvement of lymph nodes has both
biological and chronological significance
• It represents not only an evolutional event in the
spread of the carcinoma but is also a marker for the
metastatic potential of that tumour
• Involvement of supraclavicular nodes and of any
contralateral lymph nodes represents advanced
disease

24. 3.Spread by the bloodstream
a) Bones( skeletal metastases )--in order of frequency
i. the lumbar vertebrae
ii. femur
iii. thoracic vertebrae
iv. rib and
v. skull are affected
( these deposits are generally osteolytic)
b) also commonly occur in the liver, lungs and brain
c) occasionally, the adrenal glands and ovaries

25. Clinical presentation
Although any portion of the breast, including the
axillary tail, may be involved, breast cancer is found
most frequently in the upper outer quadrant

26. Most breast cancers will present as a
1. Painless hard lump, which may be associated with
indrawing of the nipple
2. As the disease advances locally there may be
• skin involvement with peau d’orange
• frank ulceration
• fixation to the chest wall
This is described as cancer-en-cuirasse when the disease
progresses around the chest wall

28. ***About 5% of breast cancers in the UK will present
with either locally advanced disease or symptoms
of metastatic disease
This figure is much higher in the developing world

29. Diagnosis

30. Staging evaluation
These patients must then undergo so that the full
extent of their disease can be ascertained
• Careful clinical examination
• Chest radiograph
• Computerized tomography (CT) of the chest and
abdomen
• isotope bone scan

31. Importance of Staging evaluation
This is important for both prognosis and treatment
a patient with widespread visceral metastases may
obtain an increased length and quality of survival from
systemic hormone therapy or chemotherapy but is
unlikely to benefit from surgery as she will die from her
metastases before local disease becomes a problem
 In contrast, patients with relatively small tumours (< 5
cm in diameter) confined to the breast and ipsilateral
lymph nodes rarely need staging beyond a good clinical
examination as the pick-up rate for distant metastases
is so low

32. Staging of breast cancer
• Classical staging of breast cancer by means of the
TNM (tumour– node–metastasis) or UICC (Union
International Centre of Cancer)

33. TNM classification:
Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS)Ductal carcinoma in situ
Tis (LCIS)Lobular carcinoma in situ
Tis (Paget)Paget disease of the nipple with no
tumor
T1 Tumor 2 cm in greatest dimension
T2 Tumor 2 cm - 5 cm in greatest dimension
T3 Tumor > 5 cm in greatest dimension
T4 Tumor of any size with direct extension to (a)
chest wall or (b) skin and (c)Inflammatory
carcinoma

34. Regional lymph node (N)
NX Regional lymph nodes cannot be assessed (eg, previously
removed)
N0 No regional lymph node metastasis
N1 Metastasis to movable ipsilateral axillary lymph node(s)
N2 Metastases in ipsilateral axillary lymph nodes fixed or matted
N3 Metastasis in ipsilateral infraclavicular lymph node(s) with or
without
axillary lymph node involvement
or
ipsilateral internal mammary lymph node(s metastasis;
or
metastasis in ipsilateral supraclavicular lymph node(s)

35. Distant metastasis (M)
MX Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis

36. Stage grouping
I T1 N0 M0
IIA T1
T2
N1
N0
M0
M0
IIB T2
T3
N1
N0
M0
M0
IIIA T1
T2
T3
T3
N2
N2
N1
N2
M0
M0
M0
M0
IIIB T4
T4
T4
N0
N1
N2
M0
M0
M0
IV Any T
Any T
N3
Any N
M0
M1

37. Treatment of cancer of the breast
The two basic principles of treatment are
1. to reduce the chance of local recurrence and
2. to reduce the risk of metastatic spread

38. Treatment of breast cancer
1. Treatment of early breast cancer
2. Treatment of advanced breast cancer
a) Treatment of locally advanced cancer
b) Treatment of Metastatic cancer

39. Treatment of early breast cancer
The aims of treatment are:
1. Cure’: likely in some patients but late recurrence
is possible
2. Control of local disease in the breast and axilla
3. Conservation of local form and function
4. Prevention or delay of the occurrence of distant
metastases

40. Treatment
Local treatment or Local control
is achieved through surgery and/or
radiotherapy
Systemic therapy
such as chemotherapy or hormone therapy is
added if there are adverse prognostic factors (such
as lymph node involvement, indicating a high
likelihood of metastatic relapse).

41. Surgery: options are
1. Mastectomy with axillary procedure
2. Mastectomy without axillary procedure
3. Local excision followed by radiotherapy.

42. Mastectomy is indicated for
1. large tumours (in relation to the size of the breast)
2. Central tumours beneath or involving the nipple
3. Multifocal disease,
4. Local recurrence
5. If radiotherapy is contraindicated or unavailable
6. Patient preference.

43. Mastectomy
1. Radical Halsted mastectomy.
2. Modified radical mastectomy (Patey mastectomy)
3. Simple mastectomy

44. Radical Halsted mastectomy
Which included excision of the breast, axillary lymph
nodes and pectoralis major and minor muscles.
 is no longer indicated as it causes excessive
morbidity with no survival benefit.

46. Modified radical mastectomy
(Patey mastectomy)
 is more commonly performed.
 The breast and associated structures are
dissected en bloc
and the excised mass is composed of:
the whole breast;
a large portion of skin, the centre of which overlies the
tumour but which always includes the nipple; all of the
fat, fascia and lymph nodes of the axilla.

47. Modified radical mastectomy
(Patey mastectomy)
*The pectoralis minor muscle is either divided or
retracted to gain access to the upper two-thirds of
the axilla.
**The axillary vein and nerves to the serratus
anterior and latissimus dorsi (the thoraco-dorsal
trunk) should be preserved.
***The intercostolbrachial nerves are usually divided
in this operation

48. Simple mastectomy involves
• Excision of only the breast with no dissection of the
axilla, except for the region of the axillary tail of the
breast, which usually has attached to it a few nodes
low in the anterior group.

49. Other mastectomies
1. Subcutaneous mastectomy
2. Skin-sparing mastectomy

50. Conservative breast surgery
1. Wide local
excision
removing the tumour plus a rim of at least 1 cm of normal breast
tissue.
2. Quadrantectomy
involves removing the entire segment of the breast that contains the
tumour.
3. Subcutaneous mastectomy
4. Skin-sparing mastectomy
 Both of these operations are usually combined with axillary surgery.
Excision of a breast cancer without radiotherapy leads to an
unacceptable local recurrence rate.

51. • There is a higher rate of local recurrence following
conservative surgery, even if combined with
radiotherapy
• but the long-term outlook in terms of survival is
unchanged.

52. Subcutaneous mastectomy
usually the preferred option for a prophylactic
mastectomy.
can be performed through a sub-mammary incision
the breast skin, the nipple and the areola are preserved.
immediate reconstruction is then undertaken which can
give excellent cosmesis .
 When a mastectomy is indicated in
malignant disease, preservation of the nipple
and areola will usually be contraindicated

53. Skin-sparing mastectomy
can be used when immediate reconstruction is
planned, and usually results in a better cosmetic
appearance.
 A total mastectomy is performed through a
circumareolar incision.
The nipple and areola are excised with the rest of
the breast, but the breast skin is preserved as an
envelope which receives an immediate
reconstruction.

54. Axillary procedure
1. Sentinel node biopsy.
2. Axillary sampling (lymph node sampling)
3. AXILLARY CLEARANCE (Axillary lymph node
dissection)
i. LEVEL I
ii. LEVEL II
iii. LEVEL III AXILLARY CLEARANCE

55. Sentinel lymph node biopsy (SLNB)
It is based on the principle that the lymphatics will initially
drain to a single node before progressing to further nodal
groups.
A tracer molecule such as patent blue V dye, or
radiolabelled technetium, can be injected into the vicinity
of the primary tumour at operation, allowing it to enter
local lymphatics and become concentrated in the sentinel
node.
Once the sentinel node has been identified it is removed
and subjected to histological examination.

56. Sentinel lymph node biopsy (SLNB)
If the node is free of metastatic deposits then the
axilla can be considered free of disease, as it is
unlikely that more distant nodes are involved.
A positive sentinel node indicates axilliary spread,
demanding further operation or adjuvant therapy.
Its role is currently under investigation in a number
of UK randomized clinical trials.

57. Axillary sampling (lymph node
sampling)
• This is an operation in which the axilla is explored,
and the four most obvious nodes are removed for
histology.
• It only requires entry into the axillary fat to remove
the most easily palpable nodes.

58. AXILLARY DISSECTION / AXILLARY CLEARANCE
(Axillary lymph node dissection) / ELND in axilla
1. Level I axillary dissection
removes the lower axillary nodes (below the lateral
border of pectoralis minor)
2. Level II axillary dissection
3. Level III axillary dissection

59. The three operations which are commonly used to
stage the axilla are
1. A level I dissection
2. Lymph node sampling
3. Sentinel node biopsy

60. The role of axillary surgery is
1. to stage the patient
and
2. to treat the axilla.

61. Axillary surgery
• The presence of metastatic disease within the
axillary lymph nodes remains the best single
marker for prognosis
• Treatment of the axilla does not affect long-term
survival, suggesting that the axillary nodes act not
as a ‘reservoir’ for disease but as a marker for
metastatic potential

62. Axillary surgery
• If mastectomy is performed it is reasonable to clear
the axilla as part of the operation, but if a wide
local excision is planned the surgeon should dissect
the axilla through a separate incision
• Axillary surgery should not be combined with
radiotherapy to the axilla because of excess
morbidity

63. QUART
•Quadrenectomy
•Axillary clearence
•Radiotherapy

64. Algorithm for management of
operable breast cancer
A) Achieve local control by Appropriate surgery
1. Wide local excision (clear margins) and radiotherapy, or
2. Mastectomy ± radiotherapy (offer reconstruction –
immediate or delayed)
3. Combined with axillary procedure
4. Awaiting pathology and receptor measurements
5. Using risk assessment tool & using stage if appropriate
B) Treatment of risk of systemic disease
1. Offer chemotherapy if prognostic factors poor; include
Herceptin if Her-2 positive
2. Radiotherapy in selected cases to reduce local recurrence
3. Hormone therapy if oestrogen receptor or progesterone
receptor positive

65. Treatment of advanced breast cancer
1.Treatment of Locally advanced breast cancer
a) Locally advanced operable breast cancer
b) Locally advanced inoperable breast cancer
2. Treatment of Metastatic carcinoma of the breast
a) Clinically evident metastaic breast carcinoma
b) Occult primary carcinoma

66. A pragmatic classification of breast
cancer
Group Approximate
5-year
survival rate
Example Treatment
Very low-risk’ primary
breast ‘cancer
> 90% Screen-detected DCIS,
tubular or special types
Local
‘Low-risk’ primary
breast cancer
70–90% Node negative with
favourable histology
Locoregional
with/without
systemic
‘High-risk’ primary
breast cancer
< 70% Node positive or
unfavourable histology
Locoregional with
systemic
Locally advanced < 30% Large primary or
inflammatory
Primary systemic
Metastatic -- -- Primary systemic
** DCIS, duct carcinoma in situ.

67. Locally advanced inoperable breast
cancer
Locally advanced inoperable breast cancer, including
inflammatory breast cancer, is usually treated with systemic
therapy, either chemotherapy or hormone therapy
Occasionally, ‘toilet mastectomy’ or radiotherapy is required
to control a fungating tumour

68. Occult primary carcinoma
Breast cancer may occasionally present as metastatic
disease without evidence of a primary tumour (that is
with an occult primary)
The diagnosis is made partly by exclusion of another site for
the primary tumour and may be confirmed by histology
with special immunohistological stains of the metastatic
lesions
Management should be aimed at palliation of the
symptoms and treatment of the breast cancer, usually by
endocrine manipulation with or without radiotherapy

69. Metastatic carcinoma of the breast
Aim of treatment of metastatic carcinoma of breast
1. Control of specific symptoms
2. Systemic therapy to control the disease
3. Local therapies for symptoms of metasteses

70. Control of specific symptoms
1.For pain---- combination analgesics regimens
NSAIDs
Opoid drugs
Amitriptyline/carbamazepine/gabapentin
TENS
Psychotherapy
2.For symptoms of hypercalcaemia ( non-specific
deterioration of health,confusion,abdominal
symptoms,dehydration and ultimately renal failure
and coma)
Rehydration (oral, IVI)
Bisphosphonate

71. Systemic therapy
Clinically evident Metastatic carcinoma of the breast
will also require palliative systemic therapy to
alleviate symptoms

72. Local therapies for symptoms of
metastases
1. Painful bony metastases – local radiotherapy
2. Pathological fractures -- internal fixation
3. Pleural effusion-- Drainage± instillation of
bleomycin as a tumoricidal & pleuradhesis
4. Ascites –Drainage
5. Spinal cord compression– an oncological emergency
require rapid neurosurgial/ radiotheray assessment
6. Brain metastases– High dose steroids follwed by RT
, local excision + RT for sigle metastases

73. BREAST RECONSTRUCTION AFTER CANCER
SURGERY
1. Internal prosthesis – silicon gel under
pectoralis major
2. Flap
TRAM flap
LD

74. Flap
Reconstruction with latissimus dorsi flap
Reconstruction with Transversus abdominus muscle flap

75. External appliance

77. Familial predisposition of breast
carcinoma
As yet unknown genetic factors that cause individual to have
up to 30% lifetime risk of developing breast cancer include:
1. First-degree relative with breast cancer under 40 years
old
2. Two first-degree relatives with breast cancer under 60
years old
3. Three first-degree relatives with breast cancer at any age
4. First-degree relative with breast and ovarian cancer
5. First-degree relative with bilateral breast cancer

78. Modalities of treatment of breast
carcinoma
1. Surgery
2. Radiotherapy
3. Chemotherapy
4. Hormone therapy
5. Immunotherapy
6. Reconstructive surgery