1) Breast cancer is a major global health problem, with most cases occurring in developing countries. Ghanaian studies show that patients often present with advanced-stage disease and experience poor outcomes. 2) Early breast cancer is defined as stage 0, 1, or 2 based on tumor size and lymph node involvement. Treatment involves surgery such as breast-conserving therapy or mastectomy, followed by radiation and/or systemic therapies based on tumor biomarkers. 3) Ductal carcinoma in situ (DCIS) is a non-invasive proliferation of malignant cells within breast ducts. Diagnosis is often from mammography screening, and management involves surgery such as lumpectomy plus radiation therapy based on prognostic factors.

1. M A N A G E M E N T O F E A R LY B R E A S T
C A
D R . P H I L I P M E N S A H
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2. BACKGROUND
• Cancer is an important factor in the global burden of disease.
• The estimated number of new cases each year is expected to rise from 10 million in 2002 to 15
million by 2025,with 60% of those cases occurring in developing countries.
• One in 4 deaths is due to cancer
• Estimated new cancer cases: 1,665,540. Estimated deaths: 585,720
2

3. EPIDERMIOLOGY
3

4. • Very few published data and work on Breast Ca in Ghana
• Clegg-lamptey and Hodasi (june 2007), did ‘A Study On Breast Ca In KBTH:
Assessing The Impact Of Health Education’.
• They found out that;
The majority of the Patient presents in the fifth decade (40 - 49) – 40%
Most women presents with advanced disease (stage 3&4) – 57.6%
Also most patients presents months after symptoms appear
They also identified a high rate of defaults among Patients
4

5. • Work done in CCTH by Prof Debrah et al on Breast Cancer Treatment and Outcomes at
Cape Coast Teaching Hospital, Ghana.
• They concluded:
 Ghanaian women frequently present with advanced stage breast cancer and experience
poor outcomes.
Early Breast Cancer (stage 0, 1 & 2 = 21.1%)
Public health initiatives should focus on dispelling harmful beliefs that delay women from
seeking care.
 Expansion of the national health care system is needed to support breast cancer screening,
diagnostic tests, and treatment.
5

6. STATISTICS OF SURGERIES DONE FOR
MALIGNANT BREAST DISEASE IN CCTH
FROM JAN 2017 – OCT 2020
BCS
15
29%
MASTECTOMY
37
71%
MALIGNANT BREAST SURGERIES
BCS
MASTECTOMY
6

7. IN GENERAL
• Increasing morbidity but decreasing mortality
• Early detection and effective management
• Multidisciplinary team (MDT) approach
• Tailoring therapy to the individual patients' needs
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8. RELEVANT ANATOMY
8

9. • Receives blood from
the medial mammary branches of the anterior perforating branches of the
internal thoracic artery,
the lateral mammary branches of the lateral thoracic artery,
the pectoral branches of the thoracoacromial trunk
the lateral cutaneous branches of the posterior intercostal arteries.
• It Is innervated by the anterior and lateral cutaneous branches of the
second to the sixth intercostal nerves.
9

10. RISK FACTORS FOR BREAST CANCER
1. Early menarche (less than 12 years)
2. Age at full term pregnancy (> 35 years)
3. Late menopause
4. Previous breast ca in one breast
5. Family history of breast ca = worse in first degree relatives
6. Genetics
- BRCA 1 (Ch 17q) associated with ovarian, colorectal and prostate ca
- BRCA 2 (Ch 13q) – tumor suppressor gene (p53)
10

11. • Nulliparity
• Exposure to ionized radiation
• Post-menopausal obesity (increase conversion of steroid hormones to estrogen)
• Diet – fatty foods and alcohol
• Age
• Geographical location – common in the western world
• Hormone replacement therapy
• Gender
• Oral Contraceptive Pills
Protecting factors
1. Breastfeeding for more than 2 years
2. First full term pregnancy less than 21 years
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12. BAD PROGNOSTIC FACTORS
• More than 4 + axillary lymph nodes
• Age < 35
• ER and PR – Negative
• BRCA 1 & 2 – Positive
• HER2 – Positive
12

13. TUMOR GRADING
• It is the measure of the level of
differentiation
• Grade 1 – 3-5 = well diff
• Grade 2 – 6-7 = moderately diff
• Grade 3 – 8-9 = poorly diff
13

14. CLINICAL STAGING (TNM STAGING)
OF BREAST CA
• T0 No evidence of primary tumor
• Tis Carcinoma in situ
• T1 Tumor ≤20 mm in greatest dimension
• T2 Tumor >20 mm but ≤50 mm in greatest
dimension
• T3 Tumor >50 mm in greatest dimension
• T4 Tumor of any size with direct
extension to the chest wall and/or to the
skin
• N0 no regional node involvement
• N1 metastasis to movable ipsilateral
axillary nodes
• N2 metastasis to fixed ipsilateral
axillary nodes
• N3 metastasis to same side internal
mammary nodes
• M0 No clinical or radiographic
evidence of distant metastases
• M1 Distant detectable metastases
14

15. STAGE GROUPING SYSTEM (AJCC)
15

16. EARLY BREAST CARCINOMA
• DEFINITION BASED ON TNM STAGING
• AJCC GROUP STAGING OF STAGE 0, 1 & 2
16

17. PATHOLOGICAL CLASSIFICATION OF
BREAST CANCER
• Non-invasive
- DCIS – Ductal Carcinoma In-situ
- ???LCIS – Lobular Carcinoma In-situ
• Invasive
- Infiltrating ductal carcinoma
- Infiltrating lobular carcinoma
- Others
The Invasive Carcinoma can also be classified as
- Special type (ST) – good prognosis – 15%
- No special type (NST) – POOR PROGNOSIS – 85%
17

18. DCIS
• Before the introduction of mammography, most cases of DCIS remained undetected until they
formed a mass.
• Mammography – 10-fold increase in cases of DCIS
• 75% of all Carcinoma In-situ
• DCIS – It is the proliferation of malignant cells that have not breached the ductal basement
membrane and arise from the ductal epithelium in the region of the Terminal Ductal-lobular
Unit.
18

19. CLASSIFICATION OF DCIS
• The classification is based on the differences in the architectural pattern of the cancer cells and
nuclear features
1. Cribiform
2. Comedo
3. Micropapillary
4. Solid
5. Papillary
First 3 types are the commonest
19

20. DCIS CONT’D
• 66 % of DCIS involves only one quadrant
• In 20% of multicentric DCIS, there is a co-existing invasive carcinoma
• If DCIS is left untreated;
- 50% progress to invasive carcinoma, 25% of them within 3-10 years
• DCIS is found at Autopsy in 20% of women older than 45 years
20

21. DIAGNOSIS
• Clinical Presentation
• Before routine Mammogram;
- Palpable Mass
- Nipple Changes – thickening, discharge or Pagets disease
- Incidental finding in benign biopsy specimen
• Currently screening mammogram is more prevalent, most cases are diagnosed when tumor is
clinically occult.
21

22. MAMMOGRAPHY
• Micro-calcification
• Soft tissue density
• Or both
• USG – Helps in axillary lymph node staging
• MRI – very sensitive in assessing DCIS but cost and accessibility makes it less feasible
22

23. BIOPSY
• Core – needle biopsy
• Excisional biopsy can be done in cases where core-needle biopsy
is inconclusive
- it done with the aid of pre-operative wire localization of
mammographic abnormalities
- Aim at margin-negative resection that can serve a definitive
surgery
• Ideally samples are supposed to be radiographed for presence of
mammographic abnormalities to reduced sampling errors
23

24. MANAGEMENT OF DCIS
• Breast conservation therapy is preferred
• NSABP B-06 TRIAL (ENROLLED 1851) - FOUND NO DIFFRERENCE IN THE OVERALL
SURVIVAL RATE AND DISEASE FREE SURVIVAL BCS AND MODIFIED MASTECTOMY
• Indications FOR BCS
- Tumor positive margins
- Patient willingness to do Radiotherapy
- Availability and accessibility of radiotherapy
- Favorable tumor to breast size ratio – help in adequate margins and acceptable cosmesis
24

25. • CONTRA-INDICATIONS FOR BCS
- Mammographic findings of multi-centricity
- Diffuse calcifications which is suggestive of widespread disease
- Large tumor and association with invasive carcinoma
- Patient preference not to conserve the breast
- Tendency for positive margin
- Modified Radical Mastectomy is preferred in such situations
- Has advantage of being able to do breast reconstruction during or right after initial surgery
25

26. VAN NUY’S PROGNOSTIC INDEX
26
• The treatment of DCIS after excision is guided by the VAN NUY’S Prognostic index.
• Patient with low scores may not need further treatment.
• Intermediate and high scores need further loco-regional treatment, including re-
excision, mastectomy or radiotherapy.
• Low score (4 - 6), intermediate score (7 - 9), high score (10 - 12)
Features 1 2 3
Size (mm) < 15 15-40 > 40
Margins(mm) > 10 1 - 10 < 1
Grade and
Necrosis
Low/intermediate
grade, no comedo
necrosis
Low/intermediate
grade, with
comedo necrosis
High grade,
with/without
comedo necrosis
Age (years) >60 40 - 60 < 40

27. SYSTEMIC THERAPY
• Adjuvant Chemotherapy is not given
• Hormonal and targeted therapy is given on the bases of ER/PR status and Her2 status
27

28. LCIS
• Intraepithelial proliferation of the Terminal Ductal-lobular Unit.
• The proliferation do not penetrate the basement membrane
• Cells are slightly larger and paler than those that line the normal acini but lobular architecture
remains intact
• It is multifocal in 30% of cases and bilateral in 30%, nearly always in the same quadrant on
both breast
28

29. LCIS CONT’D
• The current consensus regarding LCIS is, it’s a marker of subsequent development of invasive
cancer rather than a pre-invasive cancerous lesion
• Mostly found in pre-menopausal women
• Not diagnosed in men because male breast do not have terminal lobular unit
29

30. DIAGNOSIS
• LCIS – it is not diagnosed by clinical assessment or mammography (no mammographic
abnormalities)
• Diagnosis pure on incidental findings on breast biopsy specimen
30

31. MANAGEMENT = SURVEILLANCE
• 6 – 12 months clinical examination
• Annual mammography
• Observation for development of invasive cancer (ipsilateral and contralateral breast)
• Risk Reduction With Tamoxifen For Pre-menopausal Women And Raloxifen In Post-
menopausal Women
31

32. INVASIVE CARCINOMA
• stage 0, 1& 2 – early breast ca
• Stage 3 – locally advanced breast ca
• Stage 4 – advanced breast ca
• Debrah et al (CCTH)
32
Stage Frequency %
0 1 0.5
1 5 2.6
2 34 18.0
3 77 40.7
4 72 38.1
Total 189 100%

33. CLASSIFICATION
- Infiltrating ductal carcinoma – 75%
- Infiltrating lobular carcinoma – 5 % TO 10%
- Tubular carcinoma – 2%
- Medullary – 5% - 7%
- Mucinous or Colloid – 3%
The invasive carcinoma can also be classified as
- Special type (ST) – good prognosis – 15%
- No special type (NST) – POOR PROGNOSIS – 85%
33

34. TRIPLE ASSESSMENT
1. Clinical Assessment
- History
- Examination
2. Imaging
3. Histology/Cytology
34

35. MODALITIES OF MANAGEMENT
INVASIVE BREAST CA(EARLY)
• Surgery
• Radiotherapy
• Chemotherapy
• Hormonal
• Targeted Therapy
35

36. SURGICAL MANAGEMENT FOR INVASIVE
EARLY BREAST CA(T1-3, N0-1, M0)
• BREAST CONSERVATIVE THERAPY
• MODIFIED RADICAL MASTECTOMY
36

37. COMPONENTS OF BREAST
CONSERVATION THERAPY
• Wide local excision
- Curvilinear skin incision
- 1 cm macroscopic free tumor margins
- Remove underlining muscle if involve
- Orient specimen with sutures or clips
- Oncoplastics
• Axillary lymph node dissection
• Radiotherapy to the remainder of the breast
WIDE LOCAL EXCISION
• Lumpectomy
• Segmental mastectomy
• Quadrantectomy
• Tylectomy
• Partial mastectomy
37

38. CONTRAINDICATION FOR
BREAST CONSERVATION
THERAPY
- Patient does not want to conserve breast
- Pregnancy
- Previous radiotherapy to the chest
- Can not afford radiotherapy
- Unfavorable tumor breast ratio
- Multifocal/Multicentric disease
- Unavailability of radiotherapy center's
Consider modified radical mastectomy in this situation
38

39. MODIFIED RADICAL MASTECTOMY
- Removal of the entire breast, nipple and areola
- Axillary lymph node clearance
- Radiotherapy is not a component
39

40. DIFFERENCES
BREAST CONSERVATION
THERAPY
• Radiotherapy is a component
• Markedly reduced local reoccurrence
• Good compliance
• Because of radiotherapy, Breast
reconstruction has to delay
• Can be done for only appropriate
breast to tumor size ratio
MODIFIED RADICAL
MASTECTOMY
• Radiotherapy not a necessity
• Rates of local reoccurrence higher than
in BCT
• Poor compliance
• Breast reconstruction can be
immediate
• Any tumor size
40

41. AXILLARY LYMPH NODE
• Most important prognostic factor (4 or more pathologic positive lymph nodes is associated with
poor prognosis)
• Axillary lymph node dissection
- Pectoralis minor muscle – level 1, 2 & 3
- At least 10 or more lymph nodes should be removed
41

42. RADIOTHERAPY
• Mandatory in BCS (Adjuvant)
• Treats Multicentricity
• External or internal beam
42

43. RADIOTHERAPY
43
• May 14, 2009 and March 27, 2014 (1882 women were enrolled)

44. CHEMOTHERAPY
• Neo-Adjuvant
• Advantage
- to downsize tumors
- To help offer more patients BCT
- Early treatment of distance micrometastatic disease
• Adjuvant
44

45. ADJUVANT CHEMOTHERAPY
• Indications
- Node positive
- HER 2 +
- Triple negative
• Commonly used chemotherapy regimens.,
CAF REGIMEN( Cyclophosphamide, Adriamycin [Doxorubicin] , 5FluroUracil)
 TAXANES – DOCETAXEL, PACLITAXEL
• Started within 6 weeks of surgery
45

46. HORMONAL THERAPY
• Estrogen
• Progesterone
• Tamoxifen - is a selective ER modulator that has antagonistic and weak agonistic effects.
- Thromboembolic disease
• Aromatase inhibitor – A.I.S blocks the conversion of the hormone Androstenedione into
Estrone by inhibition of the aromatase enzyme. Eg Anastrozole, Exemestane, And
Letrozole,
• LHRH Agonist (Goserelin- Zoladex)
• Started after completion of chemotherapy to reduce the side effects
46

47. TARGETED THERAPY
• Her-2 – Human Epidermal Growth Factor - Overexpression
• Trastuzumab Is A Humanized Monoclonal Antibody Developed To Target The Extracellular
Domain Of The Her-2 Receptor.
47

48. MOLECULAR SUBTYPES
LUMINAL A
ER/PR +
HER 2 –
Ki-67 LOW (<14%)
LUMINAL B
HER 2 -
ER/PR +
Ki-67 HIGH
HER 2 +
ER/PR +
ANY Ki-67
HER 2 OVER
EXPRESSION
ER/PR –
HER 2 +
BASAL-LIKE
(TRIPPLE NEGATIVE)
ER/PR –
HER 2 -
NORMAL LIKE
ER/PR +
HER 2 –
KI-67 (V. LOW)
48

49. • Luminal A : Hormonal Therapy
• Luminal B : Hormonal Therapy +/- Anti - HER2
• Her 2 + : Anti - HER 2 + Chemotherapy
• Normal like : Hormonal Therapy
• Triple NEG : Chemotherapy (Commonest Among Africans)
49

50. ONCOPLASTIC SURGERY (BREAST
RECONSTRUCTION)
• The goals of breast reconstruction are
- the restoration of the form and contour of the female breast
- symmetry with the contralateral breast
• Idea improves compliance
- Improve physical and psychology of the patient
• Immediately if no radiotherapy
• 2 years after radiotherapy
• FLAP/TISSUE EXPANDER
50

51. FOLLOW UP
• Recurrence in 2 years
• Intense follow up in the first 2 years
• 6 monthly clinical examinations
• Annual mammography
51

52. 52

53. ALWAYS REMEMBER
• The Heights By Great Men Reached And Kept Were Not Attained
By Sudden Flight, But They, While Their Companions Slept, Were
Toiling Upward In The Night.
Henry Wadsworth Longfellow
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54. REFERENCES
• Courtney M. T. et al, (2017) Sabiston Textbook Of Surgery: The Biological Basis Of Modern
Surgical Practice (20th Ed). Elsevier
• Brunicardi F. C. et al, (2015) Schwartz’s Principles Of Surgery (10 ed). McGrew-Hill Education
• Dayananda B. R., (2018) Clinical Surgery Pearls (3rd Ed). Jaypee Brothers Medical
• Archeampong E. Q. et al, (2015), Baja’s Principles And Practice Of Surgery Including Pathology In
The Tropics (5th Ed). Repro India Ltd
• Feig B.W. et al,
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55. THANK YOU
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