This document provides an overview of malignant breast diseases, including: - The anatomy and lymphatic drainage of the breast. - Common presentations of breast cancer such as lumps, skin changes, and nipple discharge. - Risk factors, pathology, staging, and molecular markers of breast cancer. - Treatment options for breast cancer including surgery, radiation, chemotherapy, hormone therapy, and targeted therapies. - Screening, reconstruction after mastectomy, and palliative care for advanced disease.

1. MALIGNANT BREAST DISEASES
Dr Amit Kumar Shrestha
MDGP Second Year Resident
( NAMS)
Bharatpur Hospital
Department of General Surgery
2074-05-20

2. COMPARATIVE AND SURGICAL ANATOMY
- Breast overlies second to 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.

3. • The axillary tail of the breast is of surgical importance, sometimes mistaken for a
mass of enlarged lymph nodes or a lipoma.
• The lobule is the basic structural unit of the mammary gland.
• The ligaments of Cooper are hollow conical projections of fibrous tissue filled
with breast tissue; account for the dimpling of the skin overlying a carcinoma.
• The areola contains involuntary muscle ,numerous sweat glands and sebaceous
glands, the latter of which enlarge during pregnancy and serve to lubricate the
nipple during lactation (Montgomery’s tubercles).
• The nipple is covered by thick skin with corrugations. Near its apex lie the orifices
of the lactiferous ducts.

4. The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph nodes. The axillary
nodes receive approximately 85 per cent of the drainage and are arranged in the following groups:
• lateral,
• anterior,
• posterior,
• central,
• interpectoral,
• apical,
-The apical nodes are in continuity with the supraclavicular nodes and drain into subclavian lymph trunk, which enter
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 drain the posterior third of the breast

5. INVESTIGATION OF BREAST SYMPTOMS
Mammography
The sensitivity of this investigation increases with age as the
breast becomes less dense

6. Ultrasound
-particularly useful in young women with dense
breasts in whom mammograms are difficult to
interpret, and in distinguishing cysts from solid
lesions

7. Magnetic resonance imaging
Needle biopsy/cytology
• Cytology is obtained using a 21G or 23G needle and 10-mL syringe
• Fine-needle aspiration cytology (FNAC) is the least invasive technique of obtaining a cell diagnosis and is
rapid and very accurate
Large-needle biopsy with vacuum systems
• The sampling error decreases as the biopsy volume increases and using 8G or 11G needles allows more
extensive biopsies

8. Triple assessment

9. THE NIPPLE
• Absence of the nipple is rare and is usually
associated with amazia (congenital absence of the
breast).
• Supernumerary nipples not uncommonly occur
along a line extending from the anterior fold of the
axilla to the fold of the groin. This constitutes the
milk line of lower mammals.

10. Nipple retraction
• Retraction occurring at puberty, also known as simple nipple inversion,
• It may cause problems with breastfeeding and infection can occur, especially during lactation,
because of retention of secretions.
• Recent retraction may be of considerable pathological significance.
• Slit-like retraction may be caused by duct ectasia and chronic periductal mastitis
• circumferential retraction, with or without an underlying lump, may well indicate an underlying
carcinoma
Treatment
usually unnecessary and the condition may spontaneously resolve during pregnancy or lactation.
• Simple cosmetic surgery can produce an adequate correction but has the drawback of dividing
the underlying ducts.
• Mechanical suction devices have been used to evert the nipple, with some effect.

11. Cracked nipple
• during lactation and forerunner of acute infective mastitis.
• If the nipple becomes cracked during lactation, it should be rested for 24–48
hours and the breast should be emptied with a breast pump.
Papilloma of the nipple
• same features as any cutaneous papilloma and should be excised with a tiny disc
of skin.
• Alternatively, the base may be tied with a ligature and the papilloma will
spontaneously fall off.

12. Retention cyst of a gland of Montgomery
• These glands, situated in the areola, secrete sebum and if they become
blocked a sebaceous cyst forms.
Eczema
rare condition and is often bilateral; it is usually associated with eczema
elsewhere on the body. It is treated with 0.5 per cent hydrocortisone (not a
stronger steroid preparation).
Paget’s disease
• must be distinguished from eczema. The former is caused by malignant cells in
the subdermal layer
• and is usually associated with a carcinoma within the breast. Eczema tends to
occur in younger people who have signs of eczema elsewhere

13. Discharges from the nipple
Treatment
• exclude a carcinoma by occult blood test and
cytology.
• Simple reassurance may then be sufficient
• if the discharge is proving intolerable,
Microdochectomy
Cone excision of the major ducts (after
Hadfield)(subareolar resection)

14. CARCINOMA OF THE BREAST
Epidemiology
• 234,190 cases of invasive breast cancer and 60,290 cases of in situ breast cancer would be
diagnosed in 2015
• In the United States, Breast cancer is the second leading cause of cancer-related deaths, second
to lung cancer, with approximately 40,000 deaths
• Breast cancer is also a global health problem, with more than 1 million cases of diagnosed
worldwide each year.

15. Aetiological factors
Geographical
• commonly in the Western world, 3–5 per cent of all deaths in women.
• In developing countries it accounts for 1–3 per cent of deaths.
Age
• extremely rare below the age of 20 years but, thereafter, the incidence steadily
rises so that by the age of 90 years nearly 20 per cent of women are affected.
Gender
• Less than 0.5 per cent of patients with breast cancer are male.

16. Genetic
more commonly in women with a family history of breast cancer than in the
general population.
Diet
diets low in phyto-oestrogens., A high intake of alcohol
Endocrine
• Breast cancer is more common in nulliparous women and breastfeeding in
particular appears to be protectivelong-term exposure
• combined preparation of HRT does significantly increase the risk of developing
breast cancer
Previous radiation

19. Pathology
• arise from epithelium of the duct system anywhere from 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.
• Commonly, a numerical grading system based on the scoring of three individual factors
(nuclear pleomorphism, tubule formation and mitotic rate) is used, with grade III cancers
roughly equating to the poorly differentiated group.

20. • Ductal carcinoma is the most common variant with lobular carcinoma occurring in up to 15 per cent
• Inflammatory carcinoma is highly aggressive cancer that presents as a painful, swollen breast, which is warm
with cutaneous oedema.
• In situ carcinoma is preinvasive cancer that has not breached the epithelial basement membrane
• Staining for oestrogen and progesterone receptors is now considered routine, as their presence will indicate
the use of adjuvant hormonal therapy with tamoxifen or an aromatase inhibitor
• Tumours are also stained for c-erbB2 (also known as HER-2/neu) (a growth factor receptor) as patients who
are positive can be treated with the monoclonal antibody trastuzumab (Herceptin®)

21. The spread of breast cancer
Local spread
• 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.
Lymphatic metastasis
• 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.
• 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
Spread by the bloodstream
• It is by this route that skeletal metastases occur,
• Metastases may also commonly occur in the liver, lungs and brain and, occasionally, the adrenal glands and
ovaries

22. Clinical presentation
• found most frequently in the upper outer quadrant
• Most will present as a hard lump, which may be associated mwith indrawing of the nipple.
• As the disease advances locally there may be skin involvement with peau d’orange or frank ulceration and
fixation to the chest wall
• About 5 per cent of breast cancers in the UK will present with either locally advanced disease or symptoms
of metastatic disease.
• Currently, a chest radiograph, full blood count and liver function tests are all that are recommended for
screening of patients with early-stage breast cancer.

24. Staging of breast cancer

27. Treatment
• 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.

29. Surgery
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.
Patey mastectomy
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.
-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 thoracodorsal trunk)
should be preserved.

30. Conservative breast cancer surgery
This 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.
Sentinel node biopsy
This technique has become the standard of care in the management of the axilla in
patients with clinically node-negative disease.

31. Radiotherapy
• Radiotherapy to the chest wall after mastectomy is indicated in selected patients
in whom the risks of local recurrence are high.
• patients with large tumours and large numbers of positive nodes or extensive
lymphovascular invasion.
• 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).

32. Adjuvant systemic therapy

33. Hormone therapy
• Women with hormone receptor positive tumours will obtain a worthwhile benefit
from about five years of endocrine therapy, either 20 mg daily of tamoxifen if
premenopausal or the newer aromatase inhibitors (anastrozole, letrozole and
exemestane) if postmenopausal.
• It is no longer appropriate to give hormone therapy to women who do not have
oestrogen or progesterone receptor-positive disease
• Tamoxifen is a selective ER modulator that has antagonistic and weak agonistic
effects. It is generally well tolerated; the most common side effect is hot flashes
or vasomotor symptoms, which occur in less than 50% of patients.
• Potentially serious but rare effects include increased risk of thromboembolic
disease and uterine cancer.

34. • tamoxifen in reducing the risk of tumours in the contralateral breast
have also been observed, as has its role as a preventative agent (IBIS-I
and NSABP-P1 trials).
• AIs block the conversion of the hormone androstenedione into
estrone by inhibition of the aromatase enzyme. This enzyme is
present in adipose tissue, breast tissue, breast tumor cells, and other
sites
• There is an increase in bone density loss with patients on an AI and a
bone density scan is advised prior to commencement with treatment
of underlying osteopenia or osteporosis.

35. Chemotherapy
• Chemotherapy using a first-generation regimen such as a six monthly cycle of cyclophosphamide,
methotrexate and 5-fluorouracil (CMF) will achieve a 25 per cent 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 premenopausal women with a poor prognosis but is being
increasingly offered to postmenopausal 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.

36. -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
-Newer ‘biological’ agents will be used more frequently a 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, an oral combined growth factor receptor inhibitor.

37. Follow up of breast cancer
• current practice to arrange yearly or two-yearly mammography of the treated
and contralateral breast.
Breast reconstruction
• The easiest type of reconstruction is using a silicone gel implant under the
pectoralis major muscle
• 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)

38. Screening for breast cancer
• breast screening by mammography in women
over the age of 50 years will reduce cause-
specific mortality by up to 30 percent.
Familial breast cancer

39. Treatment of advanced breast cancer
• In metastatic disease without evidence of a primary tumour , management should be aimed at
palliation of the symptoms and treatment of the breast cancer, usually by endocrine manipulation
with or without radiotherapy
Locally advanced inoperable breast cancer
-These 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 but
often incision through microscopically permeated tissues results in a worse outcome.

40. Sarcoma of the breast
• usually of the spindle-cell variety and accounts for 0.5 per cent of malignant tumours of the
breast.
• Sarcoma tends to occur in younger women between the ages of 30 and 40 years.
• Treatment is by simple mastectomy followed by radiotherapy.
• The prognosis depends on the stage and histological type.
Metastases
• On rare occasions cancer elsewhere may present with a metastasis in the breast.
• The breast is also occasionally infiltrated by Hodgkin’s disease and other lymphomas.

41. REFERENCES-
1.SABISTON TEXT BOOK OF SURGERY, 20TH EDITION
2.BAILEY AND LOVES SHORT PRACTICE OF SURGERY,26TH EDITION

42. THANK YOU