This document discusses breast cancer, including its lymphatic drainage, epidemiology, risk factors, screening modalities, biopsy techniques, staging, and types. It provides details on axillary lymph node levels, risk assessment models, classifications of breast cancer, mammography BI-RADS categories, and breast biopsy techniques. The key topics covered are lymphatic drainage, epidemiology, risk factors, screening methods including mammography and MRI guidelines, and biopsy approaches.

1. Speaker:
Shubham Kumar Gupta
Student, 3rd Prof. MBBS (Part-II)

2. BIG PICTURE…
 LYMPHATIC DRAINAGE OF BREAST
 EPIDEMIOLOGY & RISK FACTORS
 SCREENING MODALITIES
 BREAST BIOPSY TECHNIQUES
 TNM STAGING
 EARLY BREAST CANCER
 LOCALLY ADVANCED BREAST CANCER
 HORMONAL STATUS
 AXILLARY LYMPH NODE DISSECTION
 BREAST CA METASTASIS
 CA BREAST DURING PREGNANCY
 PAGET’S DISEASE OF BREAST
 INFLAMMATORY BREAST CA

3. AXILLARY GROUPS OF LYMPH NODES

4. LEVEL RELATION TO PECTORALIS MINOR INCLUDES
I LATERAL ANTERIOR,
POSTERIOR,
LATERAL
II SUPERFICIAL / DEEP CENTRAL LNs,
ROTTER’S LN*
III MEDIAL APICAL
* Although AJCC considers them to be axillary LNs, they are not so from an
anatomical point of view.

5. Lymphatic Drainage of
Breast

6. Epidemiology
EPIDEMIOLOGY - Worldwide :
• Most common cancer in women
• Leading cause of death from cancer for women aged 20-59 yrs.
• 29% of all newly diagnosed cancers in females
• 14% of the cancer-related deaths in women.
EPIDEMIOLOGY - India (2012) :
• Accounts 27% of all malignant cases.
• Incidence rate 25.8 per lakh population
• For every 2 women newly diagnosed with breast cancer,
one lady is dying of it. [144937 / 70218 = 2.06 = round it off to 2]

7. RISK FACTORS FOR BREAST CA
• Non-Modifiable:
Geographical factors
Age
Menstrual factors
Genetic predisposition
Family history
History of irradiation

8. • Modifiable:
Reproductive factors
Obesity
Alcohol
HRT
Decreased physical activity
RISK FACTORS FOR BREAST CA

9. RISK FACTORS FOR BREAST CA
• Histological risk factors:
 Proliferative Breast disease
 Atypical ductal Hyperplasia
 Atypical lobular hyperplasia
 Lobular Carcinoma-insitu (LCIS)

10. Risk Assessment Model
(Gail)
• Developed from case-control data in the Breast Cancer
Detection Demonstration Project; aka the Gail model).
• Incorporates age, age at menarche, age at first live birth,
the number of breast biopsy specimens, any history of
atypical hyperplasia, and number of first-degree relatives
with breast cancer.
• Predicts the cumulative risk of breast cancer according to
decade of life.
• Underestimate the risk for a BRCA1 or BRCA2 mutation
carrier.
• Not used in women with a diagnosis of LCIS or DCIS.

11. CLASSIFICATION OF BREAST CANCER
NON-INVASIVE EPITHELIAL CANCERS
• LCIS
• DCIS/INTRA-DUCTAL CA – Papillary, Cribriform, Solid, Comedo
INVASIVE EPITHELIAL CANCERS (% OF TOTAL)
• Invasive Lobular Ca (10%)
• Invasive Ductal Ca
Tubular Ca (2%)
Mucinous Ca (2%)
Medullary Ca(5%)
Invasive Cribriform Ca (1-2%)
Invasive Papillary Ca (1-2%)
Adenoid Cystic Ca (1%)
Metaplastic Ca (1%)
Invasive ductal Ca, NOS (50-70%)
MIXED TUMORS
• Carcinosarcoma
• Angiosarcoma
• Adenocarcinoma

12. SCREENING MODALITIES
 Self-examination of breast
 Clinical breast evaluation
 Mammography
 Ultrasonography
 Breast MRI (newest recomd.)
# Lifetime Risk Assessment

13. Breast Self-Examination
(BSE)
What to look for?
 Irregular changes in the size and shape of breast
 Lump in the breast
 Irregularity in nipple discharge or tenderness
 Awkward changes in the skin of the breast
Benefits:
 Early detection remains the primary defense available to patients in
preventing the development of life-threatening breast cancer
 For 50-74 year group  30% reduction in mortality
 For 40-49 year group  17% reduction in mortality

14. Clinical Breast Evaluation
(CBE)
• A complete bilateral breast examination should be
performed to look for :
– Variation in breast size
– Fungating masses
– Dimpling or retraction of the skin
– Nipple inversion or excoriation (classic finding of
Paget's disease of the breast, which also does not
present as a breast mass).
• Look for axillary lymph node enlargement.

15. MAMMOGRAPHY
Discussion of when to begin & how often to undergo screening
mammography has now become a more individualized discussion
with patients taking into account their breast cancer risk &
personal risk tolerance.

16. BI-RADS
BIRADS
Category
Description Likelihood
of
malignancy
Recommendation
0 Need more information 2-10% Further imaging needed
1 Normal 0.05-0.1% Routine screening mammography
2 Benign 0.05-0.1% Routine screening mammography
3 Probably benign 0.3-1.8% Short-term follow-up (6 months)
4 Highly suspicious 10-55% Biopsy
5 Malignant 60-100% Biopsy
6 Known Cancer 100% Treat malignancy

17. USG
 Assist in suspicious lesion detected on mammography or
physical examination
 Useful in the guidance of biopsies.
 Differentiating cystic from solid breast masses
 Breast cancer screening specifically in women with
dense breast tissue
 Limitations as screening test:
 Failure to detect microcalcifications
 Poor specificity (34%)

18. MRI
 Highly sensitive to detect malignant changes in the breast.
(independent of breast density )
 American Cancer Society MRI screening criteria :
 BRCA mutation
 First-degree relative with BRCA carrier but untested
 Lifetime risk approximately 20-25% or greater,
 Radiation to chest when aged 10-30 years
 Associated syndromes
 MRI has limited use as a screening tool:
 Cost. 10-fold higher cost than mammography
 Poor specificity (26%)  false-positive results

19. Risk Management
 Chemoprophylaxis :
 Tamoxifen
 Raloxifene.
 Prophylactic mastectomy :
 Reduce the chance of developing breast cancer by 90%.
 BRCA1 and BRCA2 mutation carriers treated with prophylactic
mastectomy

20. Breast Biopsy techniques
 FNAC / FNAB
 Core Needle Biopsy (CNB)
 Incisional Biopsy
 Excisional Biopsy
 Stereotactic core biopsy
 Vacuum-assisted biopsy