PATIENT SEEKS MEDICAL ATTENTION WHEN:
• Backache may be a symptom in breast cancer
often in advanced breast cancer.
NOTE: The General symptoms of any cancer are usually NOT present in
• Duration of symptoms.
• Age at menarche.
• Number of pregnancies and age at first full-term pregnancy.
• Lactational history.
• Age at menopause or surgical menopause (i.e.,
• Prior history of breast biopsies or breast cancer.
• Mammogram history.
• Oral contraceptive and hormonal replacement therapy.
• Family history of breast and gynecologic cancer, including the
age at diagnosis. This should include at least two generations
as well as any associated cancers, such as ovary, colon,
prostate, gastric, or pancreatic.
HISTORY MUST INCLUDE:
A family history of breast cancer
• In a single first-degree relative is associated with a doubling of risk.
• If two first-degree relatives (e.g., a mother and a sister) have breast cancer,
the risk is further elevated.
Late age at first full-term pregnancy
• Women with a first birth after age 30 years have twice the risk of
those with a first birth before age 18 years.
High body-mass index after menopause
Exposure to ionizing radiation
Oral Contraceptive Pill and HRT
BRCA1 & BRCA2
• Screening for BRCA gene mutations should be reserved for women who
have a strong family history of breast or ovarian cancer
• 50% chance of developing a breast cancer, and a 20% chance of
developing ovarian cancer.
• Mutations carry a lower risk for breast cancer and account for 4% to 6% of
all male breast cancers
Prior Breast Biopsies
– No increased risk is associated with adenosis, cysts, duct ectasia, or
– There is a slightly increased risk with moderate or florid hyperplasia,
papillomatosis, and complex fibroadenomas.
– Atypical ductal (ADH) or lobular hyperplasia (ALH) carries a 4- to 5-fold
increased risk of developing cancer. 8
• Posture should be defined first.
4. NIPPLE & AREOLA
Palpate the NORMAL BREAST FIRST.
USE the FLAT of FINFERS.
TEMPERATURE & TENDERNESS FIRST.
IF LUMP is found note the followings:
• Axillary lymph nodes are classified according to their
anatomic location relative to the pectoralis minor muscle.
• Level I nodes. Lateral to the pectoralis minor muscle
• Level II nodes. Posterior to the pectoralis minor muscle
• Level III nodes. Medial to the pectoralis minor muscle and
most accessible with division of the muscle
• Rotter's nodes. Between the pectoralis major and the minor
FNAC CORE EXCISIONAL INCISIONAL
STEREOTACTIC USG NLB
FOR PALPABLE MASS
• Fine-needle aspiration biopsy (FNAB) is reliable and accurate, with
sensitivity greater than 90%. FNAB can determine the presence of
malignant cells and estrogen and progesterone receptor status but does
not give information on tumor grade or the presence of invasion.
• Core biopsy is preferred over FNAB. It can distinguish between invasive
and noninvasive cancer and provides information on tumor grade as well
as receptor status.
• Excisional biopsy should primarily be used when a core biopsy cannot be
done. It is performed in the operating room; incisions should be planned
so that they can be incorporated into a mastectomy incision should that
subsequently be necessary. Masses should be excised as a single specimen
and labeled to preserve three-dimensional orientations.
• Incisional biopsy is indicated for the evaluation of a large breast mass
suspicious for malignancy but for which a definitive diagnosis cannot be
made by FNAB or core biopsy. For inflammatory breast cancer with skin
involvement, an incisional biopsy can consist of a skin punch biopsy. 21
HISTOLOGICALTYPESOF CA BREAST
DUCTAL LOBULAR MEDULLARY MUCINOUS TUBULAR
• DCIS and
LCIS are lesions with malignant cells that have
not penetrated the basement membrane of
the mammary ducts or lobules, respectively.
• DCIS, or intraductal carcinoma, is treated as a malignancy
because DCIS has the potential to develop into invasive
• It is usually detected by mammography as clustered
• Physical examination is normal in the majority of patients.
• It may advance in a segmental manner, with gaps between
• It can be multifocal (two or more lesions >5 mm apart
within the same index quadrant) or multicentric (in
Assessment of NODES in DCIS :
Sentinel lymph node biopsy may
be considered when there is a
reasonable probability of finding
invasive cancer on final pathologic
(Size >4 cm, Palpable, or High grade)
A positive sentinel node indicates
invasive breast cancer and
changes the stage of the disease;
a completion axillary dissection is
• It may be multifocal and/or bilateral.
• LCIS has loss of E-cadherin (involved in cell–cell
adhesion), which can be stained for on pathology
slides to clarify cases that are borderline DCIS
Invasive Breast Cancer
Histology consists of Five different subtypes.
1.Infiltrating Ductal (75% to 80%)
2.Infiltrating Lobular (5% to 10%)
3.Medullary (5% to 7%)
5.Tubular (1% to 2%)
STAGES 1 2 3A
6 MONTHS AFTER
6 MONTHS AFTER
6 MONTHS BEFORE
Management of Axilla
• Approximately 30% of patients with clinically
negative exams will have positive lymph
nodes in an axillary lymph node dissection
(ALND) specimen. The presence and number
of lymph nodes involved affect staging and
thus prognosis. Thus, sentinel lymph node
biopsy was developed to provide sampling of
the lymph nodes without needing an ALND.
Axillary LymphNode Dissection(ALND)
Patients with clinically positive lymph nodes, with
positive SLN should undergo ALND for local control.
ALND involves the following:
– Removal of level I and level II nodes and, if grossly involved,
possibly level III nodes. Motor and sensory nerves are
preserved unless there is direct tumor involvement.
– An ALND should remove 10 or more nodes. The number of
nodes identified is often pathologist dependent.
– Patients with 4 or more positive lymph nodes should undergo
adjuvant radiation to the axilla. Selective patients with 1 to 3
positive nodes may also benefit from radiation therapy to
• Adjuvant chemotherapy is given in
appropriate patients after completion of
– All node-positive patients should receive adjuvant
• Regimens are guided by the tumor biomarkers. Typical
regimens comprise four to eight cycles of a
combination of cyclophosphamide and an
anthracycline, followed by a taxane administered
every 2 to 3 weeks.
• Patients should receive neoadjuvant chemotherapy
(often cyclophosphamide combined with an
anthracycline and taxane), followed by surgery and
radiation. The high response rates seen with this
regimen for stage IIIB allow modified radical
mastectomy to be carried out, with primary skin
closure. Adjuvant radiation to the chest wall and
regional nodes and adjuvant chemotherapy follow
surgery. SLNB may be used in selected patients with
clinically negative axilla.
• Approximately 20% of patients with stage III disease
present with distant metastases after appropriate
staging has been performed
– Inflammatory CA (T4d)
• This is characterized by erythema, warmth, tenderness, and
edema (peau d'orange).
• It represents 1% to 6% of all breast cancers.
• An underlying mass is present in 70% of cases. Associated
axillary adenopathy occurs in 50% of cases.
• It is often misdiagnosed initially as mastitis.
• Skin punch biopsy confirms the diagnosis.
• Approximately 30% of patients have distant metastasis at
the time of diagnosis.
• Inflammatory breast cancer requires aggressive multimodal
therapy because median survival is approximately 2 years,
with a 5-year survival of only 5%.