HEGAZY SURGERY

1. Development and Physiology
During adolescence, the breast is composed primarily of dense fibrous stroma
and scattered ducts lined with epithelium.In the breast, this hormone-
dependent maturation (thelarche) entails increased deposition of fat,
formation of new ducts by branching and elongation, and the first
appearance of lobular units.
The postpubertal mature or resting breast contains fat, stroma, lactiferous
ducts, and lobular units. During phases of the menstrual cycle or in
response to exogenous hormones, the breast epithelium and lobular stroma
undergo cyclic stimulation. In the late luteal (premenstrual) phase, there is
an accumulation of fluid and intralobular edema. It is probable that this
edema produces both pain and breast engorgement.
With pregnancy, there is diminution of the fibrous stroma to accommodate the
hyperplasia of the lobular units. This formation of new acini or lobules is
termed the adenosis of pregnancy and is influenced by high circulating
levels of estrogen and progesterone and by levels of prolactin that steadily
increase during gestation.
After birth, there is a sudden loss of the placental hormones. A continued high
level of prolactin is the principal trigger for lactation.

2. Milk line

3. The protuberant part of the human breast is generally
described as overlying the second to the sixth ribs
and extending from the lateral border of the sternum
to the anterior axillary line.
Actually, a thin layer of mammary tissue extends
considerably further, from the clavicle above to the
seventh or eighth ribs below and from the midline to
the edge of the latissimus dorsi posteriorly.
This fact is important when performing a mastectomy,
the aim of which is to remove the whole breast.

4. The axillary tail of the breast is of
surgical importance. In some
normal subjects it is palpable
and, in a few, it can be seen
premenstrually or during
lactation.
The lobule is the basic structural
unit of the mammary gland.
The number and size of the
lobules vary enormously: they
are most numerous in young
women.
From 10 to over 100 lobules
empty via ductules into a
lactiferous duct, of which there
are 15–20.

5. The ligaments of Cooper are hollow conical projections of fibrous
tissue filled with breast tissue; the apices of the cones are
attached firmly to the superficial fascia and thereby to the skin
overlying the breast. These ligaments account for the dimpling
of the skin overlying a carcinoma.
The areola contains involuntary muscle arranged in concentric
rings as well as radially in the subcutaneous tissue.
The areolar epithelium contains numerous sweat glands and
sebaceous glands, the latter of which enlarge during
pregnancy and serve to lubricate the nipple during lactation
(Montgomery’s tubercles).
Near its apex lie the orifices of the lactiferous ducts. The nipple
contains smooth muscle fibers arranged concentrically and
longitudinally; thus, it is an erectile structure, which points
outwards.

6. The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph
nodes. The axillary nodes receive approximately 85% of the drainage and are arranged in
the following groups:
• lateral, along the axillary vein;
• anterior, along the lateral thoracic vessels;
• posterior, along the subscapular vessels;
• central, embedded in fat in the centre of the axilla;
• interpectoral, a few nodes lying between the pectoralis major and minor muscles;
• apical, which lie above the level of the pectoralis minor tendon in continuity with the lateral
nodes and which receive the efferents of all the other groups.
The apical nodes are also in continuity with the supraclavicular nodes and drain into the
subclavian lymph trunk, which enters the great veins directly or via the thoracic duct or
jugular trunk.
The sentinel node is defined as the first lymph node draining the tumour-bearing area of the
breast.
The internal mammary nodes are fewer in number. They lie along the internal mammary
vessels deep to the plane of the costal cartilages, drain the posterior third of the breast and
are not routinely dissected although they were at one time biopsied for staging.

7. 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 and a tissue sample taken for either
cytological or histological analysis the so called triple
assessment.

8. Fine-Needle Aspiration
It can be done with a 22-gauge needle, an appropriate size syringe. Its
main utility is the differentiation of solid from cystic masses, but it
may be done whenever a new dominant, unexplained mass is found
in the breast.
A cytologic examination of the aspirated material is performed
This simple procedure is postponed only if mammography is necessary
and there is worry that a small hematoma, resulting from needle
puncture, might confuse the radiographic evaluation.
Carcinoma will not be missed if a surgical biopsy is done when
(1) needle aspiration produces no cyst fluid and a solid mass is
diagnosed,
(2) the cyst fluid produced is thick and blood tinged, and
(3) fluid is produced but the mass fails to resolve completely.
(4)rapid accumulation of fluid after initial aspiration (<2 weeks).

10. BREAST IMAGING
• Breast radiographic imaging is used to detect small, nonpalpable breast
abnormalities, to evaluate clinical findings, and to guide diagnostic
procedures.
• Mammography is the most sensitive and specific imaging test currently
available, though 10% to 15% of clinically evident breast cancers have no
mammographic correlate.
• Screening mammography is performed in efforts to detect breast cancer
that is not clinically evident.
• Ultrasonography is not used as a screening tool or in the evaluation of
mammographic microcalcifications, but in a directed fashion to evaluate a
breast mass and characterize it as cystic or solid.
• Magnetic resonance imaging (MRI) is the imaging method of choice to
evaluate implant rupture. It may be used in (occult breast cancer). MRI
sensitivity for invasive cancers approaches 100% but is only 60% at best for
DCIS.
• Computed tomography appears to be the best way to image internal
mammary nodes and to evaluate the chest and axilla after mastectomy.

11. Mammogram

13. Magnetic resonance imaging (MRI) is of increasing interest to
breast surgeons in a number of settings:
• It can be useful to distinguish scar from
recurrence in women who have had
previous breast conservation therapy
for cancer (although it is not accurate
within 9 months of radiotherapy
because of abnormal enhancement).
• It is the best imaging modality for the
breasts of women with implants.
• It has proven to be useful as a screening
tool in high-risk women (because of
family history).
• It is less useful than ultrasound in the
management of the axilla in both
primary breast cancer and recurrent
disease Magnetic resonance imaging scan of the breasts
showing carcinoma of the left breast (arrows).
(a) Pre-contrast; (b) postgadolinium
contrast; (c) subtraction image.

14. Large-Core Needle Biopsy
• LCNB increasingly is
the diagnostic method
of choice to
histologically evaluate
nonpalpable
mammographic
abnormalities. In
experienced centers,
it is considered the
standard of care

15. ABNORMAL DEVELOPMENT
• Absence of breast tissue (amastia) and absence of the nipple (athelia) are
rare anomalies.
• Unilateral rudimentary breast development is much more common, as is
adolescent hypertrophy of one breast with lesser development of the other.
In contrast, accessory breast tissue (polymastia) and accessory nipples
(supernumerary nipples) are both common. Supernumerary nipples are
usually rudimentary and occur along the milk line from the axilla to the pubis
in both males and females. They may be mistaken for a small mole.
However, accessory nipples are removed only for cosmetic reasons.
• True polythelia refers to more than one nipple serving a single breast, which
is rare.

16. Accessory breast
• Accessory breast tissue is
commonly located above the
breast in the axilla. Rudimentary
nipple development may be
present, and lactation is possible
with more complete development.
Accessory breast tissue, which
may present as an enlarging mass
in the axilla during pregnancy, is
treated by surgical removal if it is
large or cosmetically deforming, or
it is removed to prevent
enlargement during future
pregnancy.

17. Supernumerary Nipples
• More common than
supernumerary breasts
• Found along milk line
• May darken during
pregnancy
• Not dangerous

18. Inverted Nipples
• This may occur at puberty or later in
life. Retraction occurring at puberty,
also known as simple nipple inversion,
is of unknown aetiology (benign
horizontal inversion). In about 25% of
cases it is bilateral. It may cause
problems with breast-feeding and
infection can occur, especially during
lactation, because of retention of
secretions.
• Recent retraction of the nipple may be
of considerable pathological
significance. A slit-like retraction of the
nipple may becaused by duct ectasia
and chronic periductal mastitis but
circumferential retraction, with or
without an underlying lump, may well
indicate an underlying carcinoma

19. ANDI
[Aberrations of Normal Development and Involution (ANDI)]
Aetiology
The breast is a dynamic structure that undergoes changes
throughout a woman’s reproductive life and, superimposed upon
this, cyclical changes throughout the menstrual cycle. The pathogenesis of
ANDI involves disturbances in the breast physiology extending from a
perturbation of normality to well-defined disease processes. There is often
little correlation between the histological appearance of the breast tissue
and the symptoms.

20. Fibrocystic Changes
• Fibrocystic condition (FCC), previously referred to as fibrocystic
disease in up to 90% of women.
• FCC appears to represent an exaggerated response of breast
stroma and epithelium to anormal level of variety of circulating and
locally produced hormones and growth.
• Symptomatically, the condition presents as premenstrual cyclical
mastalgia with pain and tenderness .
• Breast examinations range from mild, bilaterally symmetrical
alterations in texture ,to nodularity and dense, firm breast tissue
with palpable lumps, to the frequent appearance of gross cysts.
• Mammographically, FCC is usually seen as bilaterally symmetrical
diffuse or focal radiologically dense tissue.
• Ultrasonography alone may be used in women under 30 years of
age.
• By ultrasound, cysts exist in up to one third of women 35 to 50 years
of age, with most of these being nonpalpable.
• Because a mass due to fibrocystic condition may be difficult to
distinguish from carcinoma on the basis of clinical findings,
suspicious lesions should be biopsied.

21. Clinical presentation of FCC
Painful, often multiple, usually
bilateral masses in the breast.
Rapid fluctuation in the size of the
masses is common.
Frequently, pain occurs or
worsens and size increases
during premenstrual phase of
cycle.
Most common age is 30–50. Rare
in postmenopausal women not
receiving hormonal
replacement.

22. Treatment
• Breast pain associated with generalized fibrocystic condition is best treated
by avoiding trauma and by wearing a good, supportive brassiere during the
night and day.
• Hormone therapy is not advisable similarly, tamoxifen because of their side
effects.
• Oil of evening primrose (OEP), a natural form of gamolenic acid, has been
shown to decrease pain in 44–58% of users.
• Aspiration of a discrete mass suggestive of a cyst is indicated to alleviate
pain and, more importantly, to confirm the cystic nature of the mass. The
patient is reexamined at intervals thereafter. If no fluid is obtained by
aspiration, if fluid is bloody, if a mass persists after aspiration, or if at any
time during follow-up a persistent or recurrent mass is noted, biopsy should
be performed.

23. Breast Cysts
• Cysts within the breast are fluid-filled, epithelium-lined cavities that may
vary in size from microscopic to large, palpable masses .
• Cysts are generally discovered by physical examination and confirmed by
ultrasound or needle aspiration.
• Most women with new cyst formation are first seen after the age of 35 and
rarely before the age of 25 years.
Cyst fluid can be straw colored, opaque, dark-greenish, and even contain
flecks of debris.
• The only reliable indication for submitting fluid for cytology is the
presence of a residual mass after aspiration of the fluid. If the cyst
recurs multiple times (more than two times is a reasonable rule), cytology is
justified. Finally, surgical removal of a cyst may be indicated if the
cytology is suspicious or the cyst recurs multiple times.

24. Galactocele
• A galactocele is a milk-filled cyst, well circumscribed. It
usually occurs after the cessation of lactation or when
feeding frequency has been curtailed significantly.
• The pathogenesis of galactocele is not known, but it is
thought that inspissated milk within ducts is responsible.
The lump is usually located in the central portion of the
breast or under the nipple. Needle aspiration produces
thick, creamy material that may be tinged dark-green or
brown.
• Although it appears purulent, the fluid is sterile.
• Treatment is needle aspiration. Withdrawal of thick milky
secretion confirms the diagnosis; operation is reserved
for cysts that cannot be aspirated or that become
infected.

25. Fibroadenoma
Fibroadenoma (adenofibroma) is a benign tumor composed of stromal
and epithelial elements.
Fibroadenomas appear in teenage girls and women during their early
reproductive years.
Clinically, they present as firm well circumscribed ,highly mobile within
the breast tissue , solitary tumors that may increase in size over
several months of observation. At operation, fibroadenomas appear
to be well-encapsulated masses that may easily detach from the
surrounding breast tissue.
Ultrasound usually clearly shows the difference between cysts and fibro
adenomas.
The treatment of fibroadenoma follows that for any unexplained solid
mass within the breast. Most patients undergo excisional biopsy to
remove the tumor and establish the diagnosis.
Cryoablation is not appropriate for all fibroadenomas because some
are too large to freeze or the diagnosis may not be certain.

26. Phyllodes tumor
• Phyllodes tumor :It may reach a large size and, if
inadequately excised, will recur locally. The lesion can
be benign or malignant. If benign, phyllodes tumor is
treated by local excision with a margin of surrounding
breast tissue. The treatment of malignant phyllodes
tumor is more controversial, but complete removal of the
tumor with a rim of normal tissue avoids recurrence.
Because these tumors may be large, simple mastectomy
is sometimes necessary. Lymph node dissection is not
performed, since the sarcomatous portion of the tumor
metastasizes to the lungs and not the lymph nodes.

27. Milk engorgement
Lactational mastitis and
Breast abscess
Milk engorgement presented with dull aching pain associated with mild pyrexia , breast is
enlarged with no signs of inflammation
Mastitis describes a generalized cellulites of breast tissue that may involve a large area
of the breast but may not form a true abscess.
Mastitis presents with erythema of the overlying skin, pain, and tenderness to palpation.
There is induration of the skin and underlying breast parenchyma. Mastitis commonly
complicates lactation, possibly as a result of bacteria( staph. Aurieus) ascending in
ductal tree of the breast through the nipple.
Predisposing factors includes : milk engorgement ,nipple retraction , cracked nipple ,bad
hygiene , DM
Local measures such as application of heat, or use of a mechanical breast pump on the
affected side, administration of broad-spectrum antibiotics. In many situations, the
differential diagnosis of acute mastitis includes inflammatory carcinoma.
Breast abscess present with , thropping pain associated with hectic fever ( never wait
for fluctuation ) and signs of acute inflammation.
Treatment of breast abscise is drainage

29. Non lactating breast abscess
and duct ectasia
• Commonly occurs in the subareolar breast tissue and
may be recurrent. Subareolar duct ectasia and
obstruction of major ducts may lead to proliferation of
bacteria and subsequent abscess. Further destruction of
the normal ductal openings leads to fistula formation and
chronic recurrent abscess.
• Mammary duct ectasia, is an inflammatory condition that
causes distortion and dilation of the lactiferous sinuses
under the nipple. It is a common entity and is frequently
responsible for nipple inversion in older women.
• The treatment is major duct excision .

30. Duct ectasia

31. Breast pain
• Breast pain is common symptom.Usually it is of functional origin and
uncommonly is a symptom of breast cancer.
• For those women with breast pain and an associated palpable
mass, the presence of the mass should be the focus of evaluation
and treatment.
• For patients without a mass, the evaluation should be guided by
whether the pain is cyclical or noncyclical.
• Normal ovarian hormonal influences on breast glandular elements
frequently produce cyclical mastalgia. It is predominantly
experienced in the luteal phase of the menstrual cycle and abates
with menstruation.
• Noncyclical mastalgia is more likely to be the result of a non breast
etiology or of a specific significant breast condition. A careful
history and physical examination should eliminate musculoskeletal
causes such as cervical radiculopathy, costochondritis, or intercostal
muscle strain. Gastroesophageal reflux disorder, symptomatic
gallstones, cardiovascular disease, and pulmonary pathology are
fairly obvious after a brief patient interview.
• Breast cellulitis (mastitis), inflammatory breast cancer causes breast
pain.

32. Investigation
• Women 30 years of age and older with cyclical or
noncyclical mastalgia should undergo
mammography. The exception to this rule is when the
clinical breast examination reveals focal tenderness and
breast ultrasound detects a simple cyst. In this instance
the work-up can be terminated with reassurance and
without a mammogram.
• If the mammogram is abnormal or the ultrasound reveals
a complex cyst or solid lesion, further evaluation of the
mass should commence.
• For patients younger than 30 years of age without focal
breast pain, the initial management should be
symptomatic.

33. Treatment
• If the clinical breast examination and mammography are
normal, 85% of women respond to reassurance that mastalgia is a
common, benign condition.
• For the 15% of women who do not, wearing a supportive
brassiere and taking ibuprofen 600 to 800 mg every 8 hours during
symptomatic days may be adequate to relieve symptoms.
• Primrose oil results in symptomatic relief in 58% of patients with
cyclical and 38% of patients with noncyclical mastalgia.
• More aggressive therapies include danazol, a synthetic androgen
that decreases ovarian function .
• Bromocriptine, a longacting dopaminergic drug that suppresses
prolactin.
• Tamoxifen provided symptomatic relief in 75% of

34. Nipple Discharge
• Nipple discharge is common and is rarely associated with an underlying
carcinoma.
• It is important to establish whether the discharge comes from one breast or
from both breasts, whether it comes from multiple duct orifices or from
just one, and whether the discharge is grossly bloody or contains blood.
• A milky discharge from both breasts is termed galactorrhea. In the
absence of lactation or history of recent lactation, galactorrhea may be
associated with increased production of prolactin. Serum prolactin is
diagnostic.
• Unilateral, non milky discharge coming from one duct orifice is surgically
significant and warrants special attention . However, the underlying cause is
rarely a breast malignancy. The most common cause of spontaneous nipple
discharge from a single duct is a solitary intraductal papilloma in one of
the large subareolar ducts directly under the nipple. If an occult cancer is
found, it is usually an intraductal carcinoma.
• Fibrocystic change, or cystic mastopathy, typically produces multiple-duct
discharge and is another commonly associated finding.
• Subareolar duct ectasia, producing inflammation and dilation of large
collecting ducts under the nipple, is a common finding that usually produces
multiple-duct discharge.

35. Gynicomastia
Hypertrophy of normal male breast tissue; can be divided into 2 categories:pubertal hypertrophy (ages 13–17),
senescent hypertrophy (age >50) Associated with some recreational and therapeutic drugs digoxin, thiazides,
estrogens, phenothiazines, theophylline Marijuana
• Idiopathic Hypertrophy of the male breast may be unilateral or bilateral. The breasts enlarge at puberty and
sometimes present the characteristic of female breasts .
• Hormonal Enlargement of the breasts often accompanied stilbestrol therapy for prostate cancer, now rarely
used. It may also occur as a result of a teratoma of the testis, in anorchism and after castration.
• Rarely, it may be a feature of ectopic hormonal production in bronchial carcinoma and in adrenal and pituitary
disease. Body builders may use steroids to improve their physique, which may cause gynaecomastia. Some
even go so far as to take tamoxifen to mask this symptom.
• Associated with leprosy Gynaecomastia is very common in men suffering from leprosy. This is possibly
because of bilateral testicular atrophy, which is a frequent accompaniment of leprosy.
• Associated with liver failure Gynaecomastia sometimes occurs in patients with cirrhosis as a result of
failure of the liver to metabolise oestrogens. It is associated with drugs that interfere with the hepatic
metabolism of oestrogens. It is also seen with certain drugs such as cimetidine, digitalis and spironolactone.
• Associated with Klinefelter syndrome Gynaecomastia may occur in patients with Klinefelter’s syndrome, a
sex chromosome anomaly having 47XXY trisomy
Symptoms and signs include unilateral or bilateral breast enlargemen Surgery is indicated if enlargement is
primary and does not regress and breast is cosmetically unacceptable

36. Fat Necrosis
Fat necrosis is a rare lesion of the breast but is of clinical importance
because it produces a mass (often accompanied by skin or nipple
retraction) that is indistinguishable from carcinoma even with
imaging studies.
Trauma is presumed to be the cause, though only about 50% of
patients give a history of injury. Ecchymosis is occasionally present.
If untreated, the mass effect gradually disappears.
The safest course is to obtain a biopsy. Needle biopsy is often
adequate, but frequently the entire mass must be excised, primarily
to exclude carcinoma.
Fat necrosis is common after segmental resection, radiation
therapy, or flap reconstruction after mastectomy.

37. Risk Factors for Breast Cancer
• Age: is probably the most important risk factor that clinicians use in everyday clinical practice. Breast cancer is rare in persons younger
than 20 years of age. Thereafter, the incidence increases to 1 in 93 by age 40, 1 in 50 by age 50, 1 in 24 by age 60, 1 in 14 by age 70,
and 1 in 10 by age 80.
• Gender is also an important risk factor. Males are at risk for breast cancer, although the incidence in males is less than 1% of the
incidence in females
• Histologic Risk Factors
■ Aytpia or Cancer on Previous Biopsy
■ Atypical ductal hyperplasia (ADH)
■ Atypical lobular hyperplasia (ALH)
■ Lobular carcinoma in situ (LCIS)
■ Previous history ductal carcinoma in situ (DCIS)
■ Previous history of invasive breast cancer
• Thoracic Radiation Before Age 30
■ Infant thymus radiation
■ Frequent fluoroscopy for TB
■ Multiple x-rays for scoliosis
• Family History—Three Generations Maternal and Paternal
■ Known or suspected gene mutation(BRCA1 and BRCA 2)
■ Early age onset <40
■ Bilateral breast cancer
■ Breast and/or ovarian cancer
■ Male breast cancer
■ Ethnicity , e.g., Jewish ancestry with family history
■ Cluster of rare tumors in a biological family
• Reproductive Risk Factors
■ >5 years of combined estrogen/ progesterone hormone replacement therapy
■ Age at menarche <12
■ Nulliparity
■ Age at firstborn >30
■ Age at menopause >55

38. 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. The disease may be entirely in situ, an increasingly common finding
with the advent of breast cancer screening, or may be invasive cancer.
• The degree of differentiation of the tumour is usually described using three grades:
well differentiated, moderately differentiated or poorly differentiated.
• Previously, descriptive terms were used to classify breast cancer (‘scirrhous’,
meaning woody, or ‘medullary’, meaning brain-like). More recently, histological
descriptions have been used.
• Gene array analysis of breast cancers has identified five subtypes. Some of these
correlate with known markers such as oestrogen receptor status. There are specific
gene signatures that are said to correlate with response to chemotherapy or poor
prognosis

39. Current nomenclature
• Ductal carcinoma is the most common variant with lobular carcinoma
occurring in up to 15% of cases.
• Rarer histological variants, usually carrying a better prognosis, include
colloid carcinoma, whose cells produce abundant mucin, medullary
carcinoma, with solid sheets of large cells often associated with a marked
lymphocytic reaction, and tubular carcinoma.
• Invasive lobular carcinoma is commonly multifocal and/or bilateral.
• Cases detected via the screening programme are often smaller and better
differentiated than those presenting to the symptomatic service and are of a
special type.
• 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. 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.

40. • In situ carcinoma is pre-invasive cancer that has not breached the epithelial
basement membrane. This was previously a rare, usually asymptomatic,
finding in breast biopsy specimens but is becoming increasingly common
because of the advent of mammographic screening; In situ carcinoma may
be ductal (DCIS) or lobular (LCIS), the latter often being multifocal and
bilateral. Both are markers for the later development of invasive cancer,
which will develop in at least 20% of patients.
• 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.

41. PATHOLOGY OF BREAST
CANCER
Classification of Primary Breast Cancer
• Noninvasive Epithelial Cancers
Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS) or intraductal carcinoma Papillary, cribriform, solid, and comedo types
• Invasive Epithelial Cancers (percentage of total)
Invasive lobular carcinoma (10–15)
Invasive ductal carcinoma
• Invasive ductal carcinoma, NOS (50–70) NOS, nothing otherwise specified
• Tubular carcinoma (2–3)
• Mucinous or colloid carcinoma (2–3)
• Medullary carcinoma (5)
• Invasive cribriform (1–3)
• Invasive papillary (1–2)
• Adenoid cystic carcinoma (1)
• Metaplastic carcinoma (1)
• Mixed Connective and Epithelial Tumors
Phyllodes tumors, benign and malignant
Carcinosarcoma
Angiosarcoma
.

42. PATHOLOGY OF BREAST
CANCER (Spread)
• Local (direct)
Breast ,skin, pectoral fascia ,muscle ,rips
• Lymphatic to (axillary ,internal mammary )
lymph node
Embolization
Permeation
• Blood

43. Clinical picture
• Painless breast lump
• Early findings: Single, nontender, firm to
hard mass with ill-defined margins;
or mammographic abnormalities and no
palpable mass.
• Later findings: Skin or nipple retraction;
axillary lymphadenopathy; breast
enlargement, erythema, edema, pain;
fixation of mass to skin or chest wall.

47. INVESTIGATIONS
• FNAC: Most experienced clinicians would not leave a suspicious dominant mass in the breast
even when FNA cytology is negative unless the clinical diagnosis, breast imaging studies,
and cytologic studies were all in agreement, such as a fibrocystic lesion or fibroadenoma.
• • Ultrasound: best for young women/ dense breasts. Ultrasonography is performed primarily to
differentiate cystic from solid lesions but may show signs suggestive of carcinoma.
• Mammography
• Biopsy (‘Trucut’/open surgical): usually provides definitive histology (may be radiologically guided if
lump is small or impalpable bdetected by mammography as part of breast screening programme).
• As an alternative in highly suspicious circumstances, the diagnosis may be made on frozen
section of tissue obtained by open biopsy under general anesthesia. If the frozen section is
positive, the surgeon can proceed immediately with the definitive operation.
This one-step method is rarely used today except when a cytologic study has suggested cancer but is
not diagnostic and there is a high clinical suspicion of malignancy in a patient well prepared for the
diagnosis of cancer and its treatment options.
In general, the two-step approach—outpatient biopsy followed by definitive operation at a later date—
is preferred in the diagnosis and treatment of breast cancer, because patients can be given time
to adjust to the diagnosis of cancer, can consider alternative forms of therapy, and can seek a
second opinion if they wish. There is no adverse effect from the short delay of the two-step
procedure.

48. Biomarkers
• The ER and PR status and HER-2/neu status of the
tumor should be determined at the time of initial biopsy.
• PR status may be more sensitive than ER status in
determining which patients are likely to respond to
hormonal manipulation.
• The presence of HER-2/neu amplification predicts the
response to trastuzumab (Herceptin), a monoclonal
antibody that binds to the HER-2/neu receptors.
• Other studies such as proliferation indices may be
performed.
• These markers may be obtained on core biopsy
specimens, which will be necessary to institute
neoadjuvant therapy.

49. • Once tissue diagnosis is reached we
should stage the patient with
• a careful clinical examination, LFT’s, CXR
bone scan and abdominal ultrasound

51. American Joint Committee on Cancer Staging
System for Breast Cancer, 2002
• (p)T (Primary Tumor)
• Tis Carcinoma in situ (lobular or ductal)
• T1 Tumor ≤2 cm
• T1a Tumor ≥0.1 cm; ≤0.5 cm
• T1b Tumor >0.5 cm; ≤1 cm
• T1c Tumor >1 cm; ≤2 cm
• T2 Tumor >2 cm; ≤5 cm
• T3 Tumor >5 cm
• T4 Tumor any size with extension to chest wall or skin
• T4a Tumor extending to chest wall (excluding pectoralis)
• T4b Tumor extending to skin with ulceration, edema, satellite nodules
• T4c Both T4a and T4b
• T4d Inflammatory carcinoma

52. 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

53. American Joint Committee on Cancer
Staging System for Breast Cancer, 2002
• (p)N (Nodes)
• N0 No regional node involvement, no special studies
• N1 Metastasis to 1–3 axillary nodes and/or int. mammary positive by biopsy
• N1(mic) Micrometastasis (>0.2 mm, none >2.0 mm)
• N1a Metastasis to 1–3 axillary nodes
• N1b Metastasis in int. mammary by sentinel biopsy
• N1c Metastasis to 1–3 axillary nodes and int. mammary by biopsy
• N2 Metastasis to 4–9 axillary nodes or int. mammary clinically positive, without
axillary metastasis
• N2a Metastasis to 4–9 axillary nodes, at least 1 >2.0 mm
• N2b Int. mammary clinically apparent, negative axillary nodes
• N3 Metastasis to ≥10 axillary nodes or combination of axillary and int. mammary
metastasis
• N3a ≥10 axillary nodes (>2.0 mm), or infraclavicular nodes
• N3b Positive int. mammary clinically with ≥1 axillary node or >3 positive axillary nodes
with int. mammary positive by biopsy
• N3c Metastasis to ipsilateral supraclavicular nodes

54. American Joint Committee on Cancer
Staging System for Breast Cancer, 2002
• M (Metastasis)
• M0 No distant metastasis
• M1 Distant metastasis

56. American Joint Committee on Cancer
Stage Grouping
• Stage TNM
• 0 Tis, N0, M0
• I T1, N0, M0
• IIA T0, N1, M0
T1, N1, M0
T2, N0, M0
• IIB T2, N1, M0
T3, N0, M0
• IIIA T0, N2, M0
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
• IIIB T4, N0, M0
T4, N1, M0
T4, N2, M0
• IIIC Any T, N3, M0
• IV Any T, any N, M1

57. Prognosis of breast
cancer• The best indicators of likely prognosis in breast cancer remain
tumour size and lymph node status; however, it is realised that some
large tumours will remain confined to the breast for decades
whereas some very small tumours are incurable at diagnosis.
• Hence, the prognosis of a cancer depends not on its chronological
age but on its invasive and metastatic potential. In an attempt to
define which tumours will behave aggressively, and thus require
early systemic treatment, a host of prognostic factors have been
described. These include the histological grade of the tumour,
hormone receptor status measures of tumour proliferation such as
S-phase fraction, growth factor analysis and oncogene or oncogene
product measurements.

58. Treatment of cancer
of the breast• The two basic principles of treatment are to reduce the
chance of local recurrence and the risk of metastatic
spread.
• Treatment of early breast cancer will usually involve
surgery with or without 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.
• At the other end of the spectrum, locally advanced or
metastatic disease is usually treated by systemic therapy
to palliate symptoms, with surgery playing a much
smaller role.

59. Algorithm for management of
operable breast cancer
• Achieve local control
• Appropriate surgery
■ Wide local excision (clear margins) and radiotherapy, or
■ Mastectomy ± radiotherapy (offer reconstruction – immediate or
delayed)
■ Combined with axillary procedure
■ Await pathology and receptor measurements
■ Use risk assessment tool; stage if appropriate
• Treat of risk of systemic disease
■ Offer chemotherapy if prognostic factors poor; include
Herceptin if Her-2 positive
■ Radiotherapy as decided above
■ Hormone therapy if oestrogen receptor or progesterone
receptor positive

60. The multidisciplinary team
approach
• As in all branches of medicine, good doctor–patient communication plays a
vital role in helping to alleviate patient anxiety.
• Participation of the patient in treatment decisions is of particular importance
in breast cancer when there may be uncertainty as to the best therapeutic
option and the desire to treat the patient within the protocol of a controlled
clinical trial. As part of the preoperative and postoperative management of
the patient it is often useful to employ the skills of a trained breast
counsellor and also to have available advice on breast prostheses,
psychological support and physiotherapy, when appropriate.
• In many specialist centres 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. This has
been shown to be good for the patient, to lead to higher trial entry and to
improve the mental health of the professionals in the breast team.

61. Local treatment of
early breast cancerLocal control is achieved through surgery and/or
radiotherapy
The aims of treatment are:
■ ‘Cure’: likely in some patients but late recurrence is
possible
■ Control of local disease in the breast and axilla
■ Conservation of local form and function
■ Prevention or delay of the occurrence of distant
metastases

62. Surgery
Surgery still has a central role to play in the management of breast cancer but
there has been a gradual shift towards more conservative techniques,
backed up by clinical trials that have shown equal efficacy between
mastectomy and local excision followed by radiotherapy.
• It was initially hoped that avoiding mastectomy would help to alleviate the
considerable psychological morbidity associated with breast cancer but
recent studies have shown that over 30% of women develop significant
anxiety and depression following both radical and conservative surgery.
After mastectomy women tend to worry about the effect of the operation on
their appearance and relationships, whereas after conservative surgery they
may remain fearful of a recurrence.

63. Mastectomy
• Mastectomy is indicated for large tumours (in relation to the size of the
breast), central tumours beneath or involving the nipple, multifocal disease,
local recurrence or patient preference.
• The 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.
• The modified radical (Patey) mastectomy is more commonly performed and
is thus described below.The breast and associated structures are dissecte
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.
• Simple mastectomy involves removal 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.

64. Conservative breast
cancer surgeryThis is aimed at removing the tumour plus a rim of at least 1 cm of normal breast tissue.
This is commonly referred to as a wide local excision.
The term lumpectomy should be reserved for an operation in which a benign tumour is
excised and in which a large amount of normal breast tissue is not resected.
• A quadrantectomy involves removing the entire segment of the breast that contains
the tumour. Both of these operations are usually combined with axillary surgery,
usually via a separate incision in the axilla.
• There is a somewhat higher rate of local recurrence following conservative surgery,
even if combined with radiotherapy, but the long-term outlook in terms of survival is
unchanged. Local recurrence is more common in younger women and in those with
high grade tumours and involved resection margins.
• Patients whose margins are involved should have a further local excision (or a
mastectomy) before going on to radiotherapy.
• Excision of a breast cancer without radiotherapy leads to an unacceptable local
recurrence rate.

65. axillary surgery
• There are various options that can be used to deal with the axilla,
including sentinel node biopsy, sampling, removal of the nodes
behind and lateral to the pectoralis minor (level II) or a full axillary
dissection (level III).
• The role of axillary surgery is to stage the patient and to treat
the axilla. The presence of metastatic disease within the axillary
lymph nodes remains the best single marker for prognosis; however,
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.
• Axillary surgery should not be combine with radiotherapy to
the axilla because of excess morbidity.
• Removal of the internal mammary lymph nodes is unnecessary.

66. Radiotherapy
• Radiotherapy to the chest wall after mastectomy is indicated in selected
patients in whom the risks of local recurrence are high. This includes
patients with large tumours and those with large numbers of positive nodes
or extensive lymphovascular invasion.
• There is some evidence that postoperative chest wall radiotherapy improves
survival in women with node-positive breast cancer.
• It is conventional to combine conservative surgery with radiotherapy to the
remaining breast tissue. Recurrence rates are too high for treatment by
local excision alone except in special cases (small node-negative tumours
of a special type).

67. Adjuvant systemic therapy
• It is now widely accepted that the outcomes of treatment are predetermined
by the extent of micrometastatic disease at the time of diagnosis.
• Variations in the radical extent of local therapy might influence local relapse
but probably do not alter long-term mortality from the disease. However,
systemic therapy targeted at these putative micrometastases might be
expected to delay relapse and prolong survival.
• Lymph node-positive and many higher risk node-negative women should be
recommended adjuvant combined chemotherapy.
• Women with hormone receptor- positive tumours will obtain a worthwhile
benefit from about 5 years of endocrine therapy, either 20 mg daily of
tamoxifen if pre-menopausal or the newer aromatase inhibitors
(anastrozole, letrozole and exemestane) if post-menopausal.

68. Hormone therapy
• Tamoxifen has been the most widely used ‘hormonal’ treatment in breast
cancer. Reduce the annual rate of recurrence by 25%, with a 17% reduction
in the annual rate of death. The beneficial effects of tamoxifen in reducing
the risk of tumours in the contralateral breast have also been observed, as
has its role as a preventative agent . 5 years of treatment is preferable to 2
years.
• Other hormonal agents that are also beneficial as adjuvant therapy have
been developed.
• These include the
LHRH agonists, which induce a reversible ovarian suppression and thus have
the same beneficial effects as surgical or radiation-induced ovarian ablation
in pre-menopausal receptor-positive women, and the oral aromatase
inhibitors for post-menopausal women. The latter group of compounds are
now licensed for treatment of recurrent disease, in which they have been
shown to be superior to tamoxifen.

69. Chemotherapy
• Chemotherapy using a first-generation regimen such as a 6-monthly cycle
of cyclophosphamide, methotrexate and 5- fluorouracil (CMF) will achieve a
25% reduction in the risk of relapse over a 10- to 15-year period.
• CMF is no longer considered adequate adjuvant chemotherapy and modern
regimens include an anthracycline (doxorubicin or epirubicin) and the newer
agents such as the taxanes.
• Chemotherapy was once confined to pre-menopausal women with a poor
prognosis (in whom its effects are likely to be the result, in part, of chemical
castration effect) but is being increasingly offered to post-menopausal
women with poor prognosis disease as well. Chemotherapy may be
considered in node-negative patients if other prognostic factors, such as
tumour grade, imply a high risk of recurrence. The effect of combining
hormone and chemotherapy is additive although hormone therapy is started
after completion of chemotherapy to reduce side-effects.
• Primary chemotherapy (neoadjuvant) is being used in many centres for
large but operable tumours that would traditionally require a mastectomy
(and almost certainly postoperative adjuvant chemotherapy). The aim of this
treatment is to shrink the tumour to enable breast-conserving surgery to be
performed.

70. • Newer ‘biological’ agents will be used
more frequently as molecular targets are
identified – the first of these, trastuzamab
(Herceptin), is active against tumours
containing the growth factor receptor c-
erbB2.
• Other agents currently available include
bevacizumab, a vascular growth factor
receptor inhibitor, and lapitinab, a
combined growth factor receptor inhibitor.

71. Follow-up of breast cancer
• Patients with breast cancer used to be followed for life to detect recurrence
and dissemination. This led to large clinics with little value for either patient
or doctor. It is current practice to arrange yearly or 2-yearly mammography
of the treated and contralateral breast. There is a move to return the patient
early to the care of the general practitioner with fast-track access back to
the breast clinic if suspicious symptoms appear. There is currently no
routine role for repeated measurements of tumour markers or imaging
other than mammography.

72. Breast reconstruction
• Despite an increasing trend towards conservative surgery, up to 50% of women still
require, or want, a mastectomy. These women can now be offered immediate or
delayed reconstruction of the breast. Few contraindications to breast reconstruction
exist.
• The easiest type of reconstruction is using a silicone gel implant under the pectoralis
major muscle. This may be combined with prior tissue expansion using an
expandable saline prosthesis first (or a combined device), which creates some ptosis
of the new breast.
• If the skin at the mastectomy site is poor (e.g. following radiotherapy) or if a larger
volume of tissue is required, a musculocutaneous flap can be constructed either from
the latissimus dorsi muscle (an LD flap) or using the transversus abdominis muscle
(a TRAM flap ). The latter gives an excellent cosmetic result in experienced hands
but is a lengthy procedure and requires careful patient selection.
• To achieve symmetry the opposite breast may require a cosmetic procedure such as
reduction or augmentation mammoplasty, or mastopexy.
• External breast prostheses that fit within the bra are the most common method of
restoring volume fill and should be available for all women who do not have an
immediate reconstruction.

73. MODERN TREATMENT FOR EARLY BREAST
CANCER
• Shift from radical mastectomy to modified radical mastectomy to procedures that preserve
the breast (conservative breast surgery ). Large size tumor is only a relative contraindication to
breast conservation. Subareolar tumors, also difficult to excise without deformity, are not
contraindications to breast conservation. Clinically detectable multifocality is contraindication to
breast-conserving surgery. The patient—not the surgeon—should be the judge of what is
cosmetically acceptable.
• The approach to the axillary nodes is also evolving. Many specialists are becoming more
selective about the need for axillary dissection to axillary staging , and the use of sentinel node
biopsy is replacing routine axillary dissection for women with clinically negative lymph nodes.
• Whole-breast radiation after surgical removal of the primary tumor. Radiotherapy after partial
mastectomy consists of 5–7 weeks of five daily fractions to a total dose of 5000–6000 cGy.
• Adjuvant Chemotherapy: In practice, most medical oncologists are currently using systemic
adjuvant therapy for patients with either node-negative or node-positive breast cancer.
• Targeted Therapy Her-2/Neu Overexpression :Trastuzumab (Herceptin), a monoclonal antibody
that binds to the HER-2/neu receptors, when studied in the metastatic setting, has proved
effective in combination with chemotherapy in patients with HER-2/neu overexpression.
Vascular Endothelial Growth Factor (VEGF) Bevacizumab (Avastin) is a monoclonal antibody
directed against VEGF.
• Hormonal :decrease recurrence and mortality by 25% in women with ER-positive tumors
regardless of menopausal status.
• Neoadjuvant Chemotherapy The use of chemotherapy or hormonal therapy prior to resection of
the primary tumor (neoadjuvant) is gaining popularity.

74. EARLY INVASIVE BREAST
CA
• Discuss options with patient, based on pathology, size sit of the tumor, size of the
breasts, and patient desire .
• Must: 1. Treat the entire breast and 2. Either assess (with SLN biopsy , and treat if
positive) or prophylactically treat / sample the axillary nodes.
• The breast can be treated by lumpectomy (with a clearly negative margin) and 5,000
cGy breast radiotherapy(XRT). Breast XRT doesn’t impact survival, but it decreases
local recurrence by 20%. This breast-conserving treatment is best if the tumor is <
T3 (no extension and < 5 cm), it is unifocal, and the breast is not too small for an
acceptable cosmetic result.
• Total mastectomy w/ or w/out immediate reconstruction is also acceptable.
• The axillary nodes can be staged with axillary dissection of level 1 and 2 nodes or
SLN biopsy (s) SNL Bx is inappropriate for multiple CA's.
• Add 5,000 cGy chest wall/axillary XRT for patients with > 3 positive nodes
• Adjuvant Chemotherapy, Targeted Therapy ,. Hormonal and Neoadjuvant
Chemotherapy
• All patients get routine flow up with CXR, exam for local recurrence, and bi- or
contra- lateral mammography

75. Treatment of Locally Advanced and
Inflammatory Breast Cancer
The treatment of locally advanced breast cancer has been changing. The
disease is heterogeneous and defies a uniform treatment approach. Prior to
the 1970s, treatment included surgery and radiation, with little effect on
survival. When surgery is used alone, local relapse rates in the range of
30% to 50% can be anticipated and the long-term cure rates rarely exceed
30%. Similar results are reported when radiation therapy is the sole
modality of treatment. These poor results suggest that locally advanced
disease is actually metastatic in most patients, emphasizing the role of
chemotherapy in these patients. A trimodality approach with the addition of
chemotherapy improved both disease-free and overall survivals.
Inflammatory breast cancer was once a uniformly fatal disease that claimed its
victims after a median survival of 9 to 12 months. Current approaches
emphasize aggressive use of combined modality treatment, which includes
chemotherapy, mastectomy, and radiation therapy

76. Paget’s Disease
• Paget’s disease of the breast clinically presents as nipple erythema and mild eczematous scaling
and flaking, progressing to nipple crusting, skin erosions, and ulceration. The condition spreads
outward off the nipple and onto the areola and surrounding skin of the breast .
• The clinical differential diagnosis of scaling skin and erythema of the nipple-areolar complex
includes eczema, contact dermatitis, postradiation dermatitis, and Paget’s disease.
• A skin specimen containing Paget’s cells and a lactiferous duct secures the diagnosis and can be
obtained by nipplescrape cytology or biopsy.
• More than 97% of patients with Paget’s disease have an underlying breast carcinoma. Paget’s
may present with (54%) or without (46%) a mass. Invasive breast cancer coexists with Paget’s
disease in 93% of patients with a mass and in 38% of patients without a mass.
• For patients considering breast preservation, presurgical evaluation should include evaluation for
occult multicentric disease with mammography with retroareolar spot compression views. Some
advocate breast MRI. For patients with Paget’s disease confined clinically and radiologically to the
nippleareolar complex, surgery may include excision of the nipple-areolar complex with at least a
2-cm cone of retroareolar tissue, encompassing all radiographic abnormalities.
• Alternatively, simple mastectomy with or without an axillary node procedure is probably the most
common way Paget’s disease is treated in the United States. Nodal evaluation may be based on
identification of an invasive component preoperatively or if invasive cancer is

78. Male Breast Cancer
The majority of men with breast cancer (50% to 97%) present with a breast mass. In addition to local
pain and axillary adenopathy, other presentingnsymptoms include those of the nipple (retraction,
ulceration, bleeding, and discharge). Evaluation includes breast imaging studies and, when there
is uncertainty of a diagnosis of gynecomastia, needle or surgical biopsy.
The negative prognostic factors for breast cancer in men are the same as in women and
include nodal involvement, tumor size, histologic grade, and hormone receptor status.
When matched for age and stage, survival is similar to that in women.
The treatment of carcinoma in the male breast depends on the stage and local extent of the tumor.
Small tumors, movable across the chest wall, may be treated by local excision and radiation, if
preferred and technically feasible, or by mastectomy. Nodal evaluation by sentinel node biopsy or
axillary dissection is governed by the presence of invasive disease.
Breast tumors in men more commonly involve the pectoralis major muscle, probably because breast
tissue in men is scant. If the underlying pectoral muscle is involved, modified radical mastectomy
with excision of the involved portion of muscle is adequate treatment and may be combined with
postoperative radiation therapy.
There is little experience with adjuvant chemotherapy or hormonal therapy in male breast cancer.
Because most of these tumors are hormone sensitive, the use of adjuvant tamoxifen for node-
positive and high-risk node-negative patients seems logical. For men at substantial risk for
metastatic disease, adjuvant chemotherapy can be offered.

79. SCREENING
• Because the prognosis of breast cancer is closely related to stage at
diagnosis it would seem reasonable to hope that a population screening
programme that could detect tumours before they come to the patient’s
notice might reduce mortality from breast cancer. Screening by
mammography in women over the age of 50 years will reduce cause-
specific mortality by up to 30%. A programme of 3-yearly mammographic
screening for women between the ages of 50 and 64 years (now increased
to 70 years).

80. Familial breast cancer
• Recent developments in molecular genetics and the identification of a number of breast cancer
predisposition genes (BRCA1, BRCA2 and p53) have done much to stimulate interest in this area.
Yet women whose breast cancer is due to an inherited genetic change actually account for less
than 5% of all cases of breast cancer.
• A much larger number of women will have a risk that is elevated above normal because of an as
yet unspecified familial inheritance. These women have a risk of developing breast cancer that is
2–10 times above baseline.
• Women who are thought to be gene carriers may be offered breast screening (and ovarian
screening in the case of BRCA1, which is known to impart a 50% lifetime risk of ovarian cancer),
usually as part of a research programme, or genetic counselling and mutation analysis. Those
who prove to be ‘gene positive’ have a 50–80% risk of developing breast cancer, predominantly
while pre-menopausal. Many will opt for prophylactic mastectomy. Although this does not
completely eliminate the risk, it does reduce it considerably.
• For the great majority of women with a positive family history, who are unlikely to be carriers of a
breast cancer gene, there are no currently proven breast cancer screening manoeuvres, although
this is under investigation.
• Tamoxifen given for 5 years appears to reduce the risk of breast cancer by 30–50% and newer
agents are currently under trial.
• Thus, these women are best served by being assessed and followed-up, preferably in a properly
organised family history clinic.

81. Pregnancy
Breast cancer presenting during pregnancy or lactation tends to be at a later stage, presumably
because the symptoms are masked by the pregnancy; however, in other respects it behaves in a
similar way to breast cancer in a nonpregnant young woman and should be treated accordingly.
Thus, treatment is similar with some provisos:
• radiotherapy should be avoided during pregnancy, making mastectomy a more frequent option
than breast conservation surgery;
• chemotherapy should be avoided during the first trimester but appears safe subsequently;
• most tumours are hormone receptor negative and so hormone treatment, which is potentially
teratogenic, is not required.
Becoming pregnant subsequent to a diagnosis of breast cancer appears not to alter the likely
outcome, but women are usually advised to wait at least 2 years as it is within this time that
recurrence most often occurs.
The risk of developing breast cancer with oral contraceptive use is only slight, and disappears 10
years after stopping the oral contraceptive pill.
Hormone replacement therapy does increase the risk of developing breast cancer if taken for
prolonged periods and in certain high-risk groups.
HRT may also prolong symptoms of benign breast disorders such as cysts and mastalgia and make
mammographic appearances more difficult to interpret.