The document provides a comprehensive overview of breast carcinoma, discussing its prevalence, anatomy, risk factors, assessment models, methods of spread, and staging criteria. It highlights the differences in incidence rates across regions, the impact of modifiable and non-modifiable risk factors, and various models to assess individual risks for developing breast cancer. The document also details the mechanisms of cancer spread through local invasion, lymphatic pathways, and hematogenous routes, alongside guidelines for staging based on the latest AJCC criteria.

1. RISK
FACTORS,SPREAD,STAGING OF
BREAST CARCINOMA
BY DR. N.SRIDHAR [PG]
UNDER GUIDANCE OF S2 UNIT
DR.N.SRINIVAS RAO M.S
DR.S.MYTHILI DEVI M.S
DR.V.KIRAN KUMAR M.S
DR.M.V.V.HARIKA M.S
DR.R.HARIKA M.S

2. CONTENTS
• Introduction
• Anatomy of breast
• Risk factors for breast carcinoma
• Risk assessment models
• Spread of cancer
• Staging of breast cancer
• 8th
edition AJCC new entries

3. INTRODUCTION
• Breast cancer is the most frequent cancer among woman
• Represents about 25% of all cancers in woman
• Incidence ranges from 27 per 1,00,000 in middle Africa,east asia
• 92 per 1,00,000 in north America
• Western Europe 1 in 9 women develop breast cancer
• Resource poor countries 1 in 28 women develop breast cancer

4. ANATOMY
• Modified sweat gland
• Lies in the superficial fascia of pectoral region
• Divided into four quadants
• Upper medial
• Upper lateral
• Lower medial
• Lower lateral
• Axillary tail of spence:extension of upper lateral
Quadrant

5. EXTENT
• Vertically from 2nd
to 6th
ribs
• Horizontally from lateral border of sternum
to the mid axillary line

6. DEEP RELATIONS
• Breast lies on deep fasica (pectoral fascia)
• Still deeper there are 3 muscles
• Pectoralis major
• Serratous anterior
• External oblique muscle of abdomen
• Breast separated from pectoral fascia by loose
Areolar tissue –retro mammary space

7. BREAST PARENCHYMA
DUCTOLOBULAR UNIT:
• Terminal ductule together with lobule constitute
Terminal ductal lobular unit (TDLU)
• TDLU –most active part of breast
1. responds to oestrogen,Progesterone,prolactin,growth hormone
2. Most of the diseases of breast arises from TDLU
3. 50 % lies in upper outer quadrant ,20% in central region

8. Supportive tissue:
• Comprises fibrous tissue in form of
• Ligaments of cooper
• Adipose tissue
• Blood vessels
• Nerves &lymphatics
• NIPPLE & AREOLA:contain involuntary muscle
• Cicular muscle fibers- SAPPEYS MUSCLE-erection of nipple
• Longitudinal fibers- MYERHOLTZ MUSCLE-retraction of nipple

9. Blood supply
• Internal thoracic artery- subclavian
artery
• Lateral thoracic,superior
thoracic,acromio
Thoracic-axillary artery
• Lateral branches of posterior intercostal
ateries

10. Venous drainage
• veins follow arteries
• First converge towards base of nipple &form
venous circle from where run as
superficial&deep
• Superficial veins drain- internal thoracic &
superficial veins of lower part of neck
• Deep veins-axillary and posterior intercostal
veins

11. RISK FACTORS
• Divided into modifiable and non modifiable
• Events increasing the estrogenic exposure
Early menarche
Late menopause
Nulliparity
Late first pregnancy
Hormone replacement with estrogen
• RELATIVE RISK : INCIDENCE AMONG EXPOSED
---------------------------------------
INCIDENCE AMONG NON EXPOSED

12. MODIFIABLE RISK FACTORS
1. OBESITY:increased risk in post menopausal women
RR =1.29

13. 2. PARITY:- -increased risk in nulliparous women
-first pregnancy >35 yrs of age
3.BREAST FEEDING:protective
>12 months has greater protective effect than
shorter duration
4.AGE AT FIRST CHILD BIRTH:<20 yrs
>35 yrs

14. 4.USE OF HRT:use for >10 yrs increased risk
RR =1.2
5.TOBACCO USE:RR=1.14 for smoking 25 /or more cigarettes/day
RR=1.07 for smoking 20 yrs / more
6.ALCOHOL CONSUMPTION:RR=1.05 for light drinking
RR=1.32 for moderate drinking
RR=1.46 for heavy drinking
7.RADIATION EXPOSURE:RR=6

15. NON MODIFIABLE RISK FACTORS
1.AGE:increased age
median age of presentation around 60 yrs in west
around 48 yrs in middle income nations such as india
2.SEX:female sex risk factor
0.5 – 1 % of all breast cancers occur in males
3.ETHNICITY :American white,African American,parsi in india

16. 4.FAMILY HISTORY OF BREAST CANCER:
• one first degree relative (mother ,sister ,daughter) with breast cancer
RR=2
• Two first degree relatives with breast cancer RR=3
5.GENETIC PREDISPOSITION:
• 5-10% breast cancers hereditary
• BRCA1,BRCA2 mutatons account for 70% of hereditary breast cancers
6.EARLY MENARCHE<12 yrs:risk increases by 5%for each year
RR=1.19 for age <11 yrs

17. 7.LATE MENOPAUSE >55 yrs :
Risk increases by 3% for each year
RR=1.12 for menopause at 55 vs 45 yrs
8.HIGH RISK BREAST LESIONS:
proliferative conditions without atypia RR=1.8-2
complex fibroadenoma RR=3
papillomatosis RR=3
atypical ductal and lobular hyperplasia RR=4-5
Lobular carcinoma in situ RR=8-10

18. RISK ASSESMENT MODELS
• The longer a woman lives without cancer,the lower her risk of
developing breast cancer
• Woman >50 yrs has an 11% lifetime risk of developing breast cancer
• Woman >70 yrs has a 7% lifetime risk of developing breast cancer
• Because risk factors for breast cancer interact,evaluating the risk
conferred by combination of risk factors is diificult
• Several risk assessment models available to predict the risk of beast
cancer

19. GAIL MODEL:
• most frequently used model in the US
• It incorporates AGE
AGE AT MENARCHE
AGE AT FIRST LIVE BIRTH
NUMBER OF BREAST BIOPSY SPECIMENS
ANY HISTORY OF ATYPICAL HYPERPLASIA
NUMBER OF FIRST DEGREE RELATIVES WITH BREST CANCER
• It predicts cumulative risk of breast cancer according to decade of life

20. • A womans relative risks (RR) from several categories multiplied to get
an OVERALL RISK SCORE
• RISK SCORE is then compared to an adjusted population risk of breast
cancer to determine a womans individual / absolute risk
• The output is 5 yr risk and life time risk of developing brest cancer
• Gail and colleagues have also described a revised model that includes
Body weight and mammographic density but excludes age at menarche

22. CLAUS MODEL:
• Based on assumptions about the prevalence of high penetrance
breast cancer susceptibility genes
• Compared with gail model this includes more information about
family history but excludes other risk factors
• This provides individual estimates of breast cancer risk according to
decade of life based on presence of 1st
degree ,2nd
degree relatives
with breast cancer and their age at diagnosis

23. • Neither gail nor claus model accounts for risk associated with mutations
in breast cancer susceptibility genes BRCA1,BRCA2
• BRCAPRO model – mendelian model ,calculates the probability that an
individual is a carrier of a mutation in breast cancer susceptibility genes
• Based on their family history of breast and ovarian cancers
• The probability that an individual will develop breast / ovarian cancer is
derived from this mutation probability ,based on age specific incidence
curves for both mutation carriers and non carriers
• Use of BRCAPRO model is challenging –it requires input of all family
history information regarding breast and ovarian cancer

24. TYRER CUZIK MODEL:
• Attempts to utilise both family history information and individual risk
information
• Family history to calculate the probability that an individual carries a
mutation in one of the breast cancer susceptibility genes
• The risk is adjusted based on personal risk factors

25. SPREAD OF CANCER
• OCCURS BY 3 ROUTES
1. LOCAL SPREAD
2. LYMPHATIC METASTASIS
3. HEMATOGENOUS SPREAD

26. LOCAL SPREAD
• Tumor increase in size & ivades adjacent breast parenchyma
• Involve the skin ,leading to ulceration and satellite nodules /involve
the pectoralis major ,serratous anterior ,chest wall
• Tumor cells release number of growth factors FGF,TGF alpha,TGF beta,
VEGF
• FGF induces mitosis of adjacent fibrocytes- convert to fibroblasts and
lay down collagen (desmoplastic reaction )

28. • Contraction of collagen – shortening of coopers ligament,pulling the
skin inwards and gives rise to telltale signs
• DIMPLING-shortened single coopers ligament
• PUCKERING/TETHERING- many coopers ligaments shrunken
• Nipple retraction

30. LYMPHATIC SPREAD
• LYMPHATIC DRAINAGE:
• LYMPHATIC VESSELS-
1. SUPERFICIAL LYMPHATICS:- drain the skin over the breast except for
the nipple and areola
2. DEEP LYMPHATICS :- drain the parenchyma of breast ,also drain
nipple and areola

31. LYMPH NODES-
Axillary lymph nodes receive approximately 85% of the lymph from
breast,arranged in
1. LATERAL NODES :-along the lower border of axillary vein lying lateral
to thoracodorsal pedicle
2. ANTERIOR/PECTORAL NODES :-b/w lateral borders of pectoralis
major and minor &lateral thoracic vessels- sentinel lymphnodes in
most pts
3. POSTERIOR:- along subscapular &thoracodorsal vessels anterior to
latismus dorsi muscle

33. 4. CENTRAL GROUP:-embedded in fat in the center of axilla
5.ROTTERS NODES :-few nodes lying in b/w pectoralis major and minor
6.APICAL NODES :-lie above and medial to the pectoralis minor tendon
and lateral to first rib receive efferent from all the axillary nodes
Apical nodes are in continuity with the supraclavicular nodes & drain
into the sub clavian lymph trunk enters the great veins directly/via
the thoracic duct/jugular trunk

34. LEVELS OF AXILLARY LYMPH NODES
LEVEL I : below and lateral to lateral border of pectoralis minor muscle
ANTERIOR,POSTERIOR,LATERAL
LEVEL II : infront of and behind pectoralis minor tendon
CENTRAL&ROTTERS LYMPH NODES
LEVEL III : above and medial to medial border of pectoralis minor
tendon
APICAL

36. • INTERNAL MAMMARY NODES :-
Lie along the internal mammary vessels deep to the plane of costal
cartilage,superficial to the parietal pleura
Drain the medial half of the breast
• some lymph also reaches the deltopectoral node,posterior intercostal
nodes,sub diaphragmatic and sub peritoneal lymph plexus

37. • 75% of the lymph from breast drain into axillary lymph nodes
• 20 % into internal mammary nodes
• 5 % into posterior intercostal nodes
• SUB AREOLAR PLEXUS OF SAPPEY :plexus of lymph vessels present
deep to areola drains into anterior group
also has communication with opposite breast
• Lymphatics from deep parts of breast pass through pectoralis major
muscle and clavipectoral fascia apical nodes ,internal mammary
nodes

39. • From the lower and inner parts of breast the lymph vessels form a
plexus over the rectus sheath & peirce costal margin to communicate
with sub peritoneal lymph plexus from there to nodes of liver –
GEROTAS PARAMAMMARY ROUTE

41. • From the sub peritoneal lymph plexus ,cancer cells may drop by
gravity into pelvis – TRANSCELOMIC IMPLANTATION
• Causes metastasis in ovary –KRUKENBERG TUMOR
-large solid tumors
-bilateral
-Occurs in pre menopausal age – release of ovum – raw area of the
ovary

42. HEMATOGENOUS SPREAD :
• At a tumor size of 1-2 mm neo angiogenesis occurs
• Onset of neo angiogenesis ushers rapid growth ,invasion,metastatic
potential
• Hematogenous mets most commonly occurs to skeletal system
Lumbar vertebrae
Neck of femur
Thoracic vertebrae
Rib
Skull

43. • Posterior Intercostal veins ,traverse the posterior aspect of breast
from 2nd
to 6th
intercostal spaces drains into azygous vein
• Azygous vein has communications with batson plexus of veins
• Batsons plexus- valve less veins connect deep pelvic veins and
thoracic veins

45. • Hematogenous mets also occur to liver,lungs,brain
• In limbs these deposits occur above the elbow,above the knee
• Extensive bone marrow replacement by tumor cells may result in
release of immature blasts in peripheral blood ,giving rise to
LEUKOERYTHROBLASTIC ANEMIA

47. STAGING OF BREAST CANCER
• Staging refers to process of finding out the extent of tumor
• 8th
edition of AJCC,TNM staging system is currently used
• In addition to anatomical staging 8th
edition of AJCC,TNM staging
system includes
• Histologic grade
• ER,PR,HER 2 /neu,Ki 67 assessment
• Multigene testing with oncotype DX
• Response to neoadjuvant chemotherapy

52. Reference from
• Bailey &love’s short practice of surgery 28th
edition
• Schwartz’s principles of surgery 11th
edition
• Sabiston text book of surgery 21st
edition

53. THANK YOU