This document provides information on the anatomy, pathologies, investigations, staging, and treatment of breast cancer. It describes the breast anatomy and lymphatic drainage. Common breast pathologies include discharges, duct ectasia, fibroadenomas, and breast cancer. Breast cancer is evaluated using triple assessment involving clinical examination, radiology, and histology. Treatment involves surgery such as mastectomy or breast-conserving surgery, along with chemotherapy, radiation therapy, and hormone therapy depending on the cancer stage.

1. The Breast

3.  Extends from 2nd to 6th rib
 Lateral border of sternum to anterior
axillary line
 Axillary tail
 Ligament of Cooper – responsible for
puckering of skin in CA
 Lobules lactiferous ducts ampulla
nipple

4. Lymphatics
 Axillary (85%) and internal mammary
 Axillary – apical, anterior, posterior,
central, lateral, interpectoral
 Apical supraclavicular subclavian
lymph trunk major veins

5. Pathologies Of The Breast

6. Discharges
 serous/colourless – benign
 Blood stained – malignancy
 Green/black – ductal ectasia

7. Duct Ectasia
Dilatation of
lactiferous ducts
Periductal
mastitis
abscess
Fistula
formation
Stagnant
secretion

8.  Association with smoking
 c/f : discharge, subareolar mass, fistula,
abscess, slit like nipple retraction
 Treatment – rule out malignancy,
antibiotics, excision of all large ducts,
mastectomy

9. ANDI
 Aberrations of normal devolopment and
involution
 Pathology :
1. Cyst formation
2. Fibrosis
3. Hyperplasia of epithelium lining ducts
4. Papillomatosis
 C/F – lumpiness and mastalgia

10.  Treatment for mastalgia :
1. Rule out any other cause
2. Exclude cancer
3. Reassure
4. Adequate support for breast
5. Medications such as danazol, tamoxifene,
LHRH agonist
6. NEVER SURGERY

11. Fibroadenomas
 Benign
 Arises in fully developed breast
 15 -25 yrs
 Hyperplasia of single lobule
 Grows upto 2 -3 cm in size
 Well encapsulated
 Does not require excision unless
1. Suspicious cytology
2. Very large
3. Patient wants to get excised

12. CA Breast

13. Aetiology
 Geography – more in western world
 Age – increasing age
 Genetic
1. BRCA 1/ BRCA2
2. P53
3. Li Fraumen’s syndrome
4. Cowden’s syndrome
 Family history
 Diet – alcohol
 Endocrine –
1. Nulliparity
2. Obese
3. Exogenous hormones
4. Early menarche and late menopause

14. Pathology
 Insitu
1. Lobular
2. Ductal
 Invasive
1. Lobular
2. Ductal

15. Classification
Histological
 Scirrhous
 Medullary
 Inflammatory
 Colloid
 Tubular papillary
 Cribriform
 Paget’s disease of nipple

16. Spread
 Local
 Involves skin, pectoral muscles and chest
wall
 Lymphatic
 Axillary and internal mammary nodes
 Tumors in posterior one third drains into
internal mammary nodes
 Involvement of supraclavicular and
contralateral L/N indicate advanced
disease

17.  Hematogenous
 Skeletal mets to lumbar vertebrae,
femur,thoracic vertebrae,ribs and skull
 Liver, lungs, brain also

18. Clinical features
 Hard lump most commonly in upper
outer quadrant
Cutaneous manifestations
 Peau d’orange – obstruction of dermal
lymphatics
 Dimpling of skin – infiltration of ligament
of Cooper
 Retraction of nipple – infiltration of
lactiferous duct

19.  Ulceration and fungation
 Discharge from nipple
 Axillary or other node enlargement
 Chest pain and hemoptysis
 Bone pain, tenderness, fractures
 Pleural effusion
 Ascites

20. Investigations
 Mammography ( >40 yrs )
 Size and location of lesion
 Microcalcifications
 Spiculations
 Irregular soft tissue shadow
 Ultrasound of breast ( 35 – 40yrs )
 Solid or cystic lesion
 FNAC – if opting for surgery

21.  corecut biopsy – if opting for chemo or
radiotherapy
 Chest X ray / CT chest
 USG abdomen
 X ray spine
 Oestrogen and progesterone receptor
study
 MRI
 Tumour markers
 Sentinel lymph node biopsy

22. Triple assessment
 Clinical
 Radiological
 Histological

23. TNM Staging
T1 : tumor size <2 cm in greatest diameter
T2 : 2-5 cm
T3 : >5 cm
T4 : tumor fixed to chest wall or skin
T4a : fixed to chest wall
T4b : fixed to skin
T4c : T4a + T4b
T4d : inflammatory ca of breast

24. N1 : mobile axillary nodes
N2 : fixed nodes
N3a : infraclavicular
N3b : axillary and internal mammary
N3c : supraclavicular
M0 : no metastasis
M1 : distant metastasis

25. Treatment
 Surgery
 Radiotherapy
 Hormone therapy
 Chemotherapy
Usually a combination of methods are
employed

26. Early breast ca
Options are :
 Modified radical mastectomy (Patey’s
operation)
 Whole breast + nipple + areola + skin over
breast + axillary tail + axillary fat, fascia and
lymph nodes
 Atleast 10 nodes should be removed for
proper staging
 Adjuant chemotherapy +/-

27.  Breast conservative surgery
 Removal of lump with 1-2 cm tumor free
margin + axillary node clearance
 Followed by radiotherapy (must)
 Life long follow up

28. Locally advanced
For both operable and inoperable tumors
 Neoadjuant chemotherapy (3 -4 cycles)
 Reassess
 Surgery
 Followed by adjuant chemo / radio /
hormone therapy
Metastatic
 Palliative chemo / radiotherapy or both
 Palliative mastectomy in case of large
fungating growth

29. Mastectomy complications
 Injury / thrombosis of axillary vein
 Lymphoedema
 Pain / numbness over shoulder
Winged scapula
 Flap necrosis / infection

30. Chemotherapy
 First line
 F = 5 Flurouracil
 A = Adriamycin / E = Epirubicin
 C = Cyclophosphamide
 Second line
 Taxanes = Paclitaxel and Docetaxel

31.  Indications for chemotherapy
 Tumor size >1 cm
 Lymph node positive
 Metastasis present
 Vascular invasion
 High grade tumor ( large number of mitotic
figures )

32. Hormone therapy
 SERM : tamoxifen 10 mg bd for 5 years
 Aromatase inhibitors : Letrozole 2.5 mg od,
Anastrozole
 Progestogens : Medroxyprogesterone
400mg
 Androgens : Fluoxymestrone
 High dose estrogen : Diethylstilbesterol
15mg od
 HER-2/neu receptor antagonist :
transtuzumab
 LHRH agonist : Goserelin 3.6mg monthly

33.  Surgical endocrine ablations
 Bilateral oopherectomy
 Bilateral adrenelectomy
 Pituitary ablation

34. Radiotherapy
 Indications
 After conservative breast surgery
 >4 nodes positive
 T3 tumor >5 cm
 Positive margin / close surgical margin
 High grade tumor
 Inflammatory ca
 External radiotherapy given over breast area,
axilla, internal mammary and supraclavicular
area
 200 cGY units daily , 5 days a week for 6 weeks

35. Reference
 Bailey and Love’s Short Practice of
Surgery
 SRB’s Manual of Surgery