1. By Dr. Celine Tey

2. TECHNIQUE OF BREAST EXAMINATION

6.  Pain --varying with menstrual cycle
--independent of menstrual cycle
 Lump in the breast
--Hard lump
-- Firm, poorly defined lump or lumpiness
--Soft lump
 Skin changes in the breast
--Skin dimpling or tethering
--Visible lump
--Peau d’orange (kulit limao)
--Redness
--Ulceration
 Nipple disorders
--Recent inversion or change in shape
--“Eczema” (rash involving nipple or areola, or both)
--Nipple discharge
Milky
Clear
Green
Blood-stained

7. NIPPLE DISORDERS
 --Recent inversion or change in shape
suggests a fibrosing underlying lesion such as a carcinoma or
mammary duct ectasia but can be malignancy (refer urgently)
 --“Eczema” (rash involving nipple or areola, or both)
if unilateral and persistent, this is the classic sign of Paget’s
desease of the nipple, a presentation of breast ca
(refer urgently if not responding to treatment)
 --Nipple discharge
1. Milky—pregnancy of hyperprolactinaemia
2. Clear – physiological
3. Green –perimenopausal, duct ectasia, fibroadenotic cyst
4. Blood-stained –possible carcinoma or intraduct papilloma (refer
urgently)

8. PAGET’S DISEASE OF THE
NIPPLE

9. SIGNS AND SYMPTOMS
Most common:
lump or
thickening in
breast. Often
painless
rg
Discharge Redness or pitting
or of skin over the
bleeding breast, like the
skin of an orange
Change in size
or contours of
breast
Change in color
or appearance
of areola 9

10. BREAST CA
1. Skin dimpling
2. Visible lump
3. Peau d’orange
4. Surface erythema
5. Surface ulceration
6. Recent nipple inversion
7. Blood-stained nipple discharge
8. ‘eczema’ around nipple (Paget’s
disease)
9. Systemic features:weight loss,
anorexia, bone pain, jaundice,
malignant pleural and pericardial
effusion, anemia

11. BREAST CA
CHARACTERISTIC SIGNS OF
BREAST CA

12. CLINICAL CHARACTERISTICS OF A
BREAST LUMP
 Solitary or multiple
 Size – in cm
 Location – quadrant of breast or clock face
 Contour – smooth and round/ovoid (likely to be
benign) or firm/ hard (probable malignancy)
 Mobility – mobile or fixed
 Associated changes – skin/nipple retraction, skin
tethering, bloody nipple discharge, erythema
 Axillary lymphadenopathy – enlarged and mobile or
enlarged and fixed

13. CAUSES
1. Inherited
2. Risk Factors
3. Environmental Factors

14. 1.INHERITED BREAST
CANCER
Between 5-10% of breast
cancer is inherited from a
family member.
This means that the
majority of women that
are diagnosed with breast
cancer do not have the
genetic mutation.
This figure shows that one out of every 10 women will
Research has suggested
obtain breast cancer by inheriting a gene from a family
member.
women who are diagnosed
with breast cancer at a
young age (less than 45)
usually inherited.

15. INHERITED
GENES
BRCA1 (Breast Cancer 1)
BRCA2 (Breast Cancer 2)
TP53 gene
ATM gene

16. BRCA 1 AND BRCA 2
Both of these genes code for DNA repair.
If a woman has a mutation on either one of these
genes, the risk of her getting breast cancer
increases from 10% to 80% in her lifetime.
Mutations in BRCA1 or BRCA2 account for 40-50%
of all cases of inherited breast cancer.
These genes are also associated with ovarian cancer
in women and prostate cancer in men.
These genes can be inherited either from the
mother or the father.

17. OTHER INHERITED
GENES THAT CAUSE
CANCER
TP53 gene ATM gene
This gene codes for the Females with one
tumor suppressor protein defective copy of the
p53. ATM gene and one
normal copy of the
Mutations of this gene gene are at
cause Li-Fraumeni increased risk for
syndrome, which is a breast cancer.
condition that is
associated with early
onset breast cancer.

18. 2.RISK FACTORS CAUSE BREAST CANCER
Factors that Cannot Lifestyle Risks
be Prevented Oral Contraceptive Use
Gender Nulliparity
Aging (40-55 y-o) Hormone Replacement
Genetic Risk Factors Therapy
(inherited) Not Breast Feeding
Family History Alcohol Use
Personal History Obesity
Menstrual Cycle High Fat Diets
Estrogen Physical Inactivity
Smoking

19. 3.ENVIRONMENTAL
FACTORS
Exposure to irradiation
Electromagnetic Fields
Xenoestrogens
Exposure to Chemicals

20. NORMAL BREAST
Breast profile
A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage
Enlargement
A normal duct cells
B basement membrane (duct wall)
C lumen (center of duct) 20
Illustration © Mary K. Bryson

21. DIAGRAM OF THE
BREAST
The breast is a glandular
organ.
It is made up of a network of
mammary ducts.
Each breast has about 15-20
mammary ducts that lead to
lobes that are made up of
lobules.
The lobules contain cells that
secrete milk that are
stimulated by estrogen and
progesterone which are
ovarian hormones.

22. IN SITU BREAST
CANCER
In Situ Breast Cancer remains within the ducts or
lobules of the breasts.
This type of cancer is only detected by mammograms
– not by a physical examination.
If the cancer is in the duct it is called Ductal
Carcinoma in situ.
If the cancer is in the lobule of the breast, it is
called Lobular Carcinoma in situ.
This type of cancer is most common among pre-menopausal
women.
There is also a slight chance that if a woman has this type
of cancer she is at risk that it would occur in the other.

23. DUCTAL CARCINOMA IN
SITU (DCIS)
Ductal
cancer
cells
Normal
ductal
Carcinoma refers to any cell
cancer that begins in the
skin or other tissues that 23
cover internal organs
Illustration © Mary K. Bryson

24. INVASIVE DUCTAL CARCINOMA
(IDC – 80% OF BREAST CANCER)
Ductal cancer cells
breaking through
the wall
 The cancer has spread to the
surrounding tissues
24
Illustration © Mary K. Bryson

25. RANGE OF
DUCTAL CARCINOMA IN
SITU
Illustration © Mary K. Bryson
25

26. INVASIVE LOBULAR CARCINOMA
(ILC)
Lobular cancer
cells breaking
26
through the wall
Illustration © Mary K. Bryson

27. CANCER CAN ALSO INVADE LYMPH OR
BLOOD VESSELS
Cancer cells
invade
lymph duct
Cancer cells
invade
blood vessel
27
Illustration © Mary K. Bryson

28. INFILTRATING BREAST CANCER
Breast cancer is
considered infiltrating
or invasive if the
cancer cells have
penetrated the
membrane that
surrounds a duct or
lobule.
Breast cancer cells cross the lining of
the milk duct or lobule, and begin to
invade adjacent tissues. This type of
This type of cancer
cancer is called "infiltrating cancer." forms a lump that can
In this picture, you can see the breast eventually be felt by a
cancer cells invading the milk duct. physical examination.

29. MORE ON INFILTRATING BREAST
CANCER
Infiltrating cancer of Infiltrating cancer of
the duct the lobules
Called “Infiltrating Called “Infiltrating
Ductal Carcinoma” Lobular Carcinoma”
It is the most common Occurs when cells stream
type of breast cancer. out in a single file into
the surrounding breast
tissue.
Cancer cells that are
invading the fatty
tissue around the duct, This type of cancer is
they stimulate the harder to detect on a
growth of non- mammogram because
cancerous scar like there is no fibrous
tissue that surrounds growth.
the cancer making it
easier to spot.

30. OTHER TYPES OF BREAST CANCER
Cystosarcoma Phyllodes
Inflammatory Cancer
Accounts for less than one percent of all breast
cancers and looks as though the breast is
infected.
Breast Cancer During Pregnancy
Paget’s Disease

31. COMMON SITE OF SPREAD OF
BREAST CA

33. TNM STAGING
IN BREAST CA

34. T = Primary Tumor
Tis (T0) = carcinoma in situ
T1 = less than 2 cm in diameter
T2 = between 2 and 5 cm in
diameter
T3 = more than 5 cm in diameter
T4 = any size, but extends to the
skin or chest wall

35. N = Regional Lymph nodes
N0 = no regional node involvement
N1 = metastasis to movable same side axillary nodes
N2 = metastasis to fixed same side axillary nodes
N3 = metastasis to same side internal mammary nodes

37. CLINICAL STAGING
T N M 5-Year Survival
Stage 0 Tis N0 M0 > 95%
Stage I T1 N0 M0 Overall = 85%
Stage II Overall = 66%
(Stage IIA) T0 N1 M0
T1 N1 M0
T2 N0 M0
(Stage IIB) T2 N1 M0
T3 N0 M0
Stage III Overall = 41%
(Stage IIIA) T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1, N2 M0
(Stage IIIB) T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1 Overall 10%

38. THE EFFECT OF TUMOR SIZE ON
SURVIVAL
As tumor size
increases, the chance
of survival
decreases.
Tumor Size
Survival

39. HOW DO
YOU
DETECT
BREAST
CANCER?

40. CANCER MADE?
Diagnostic tests– all breast lumps or suspected carcinoma
 Triple assessment
1.Clinical examination
2.Radiological assessment
-Mammography usual particularly over age 35y.
-Ultrasound sometimes used under age 35 because
increased tissue density reduces the sensitivity and
specificity of mammography
3.Cytological assessment
Fine needle aspiration cytology (FNAC) or occasionally,
core needle biopsy
 Staging investigations
1. Liver ultrasound
2.Chest X-Ray
3.Bone scan
4.Specific investigations for organ-specific suspected
metastases.

41. MAMMOGRAM
A Mammogram is a X-ray of
the breast that takes
pictures of the fat, fibrous
tissues, ducts, lobes, and
blood vessels.
When should a mammogram
be performed?
If a lump has been found
during self-examination or
by a physician
Younger women who have a
strong history of breast
cancer in their family
All women over forty
Women who have had
previous diagnosis of breast
cancer.

42. WHAT MAMMOGRAMS
SHOW
Two of the most important mammographic
indicators of breat cancers
 Masses
 Microcalcifications: Tiny flecks of calcium – like
grains of salt – in the soft tissue of the breast
that can sometimes indicate an early cancer.
42

43. DETECTION OF MALIGNANT
MASSES
Malignant masses have a more spiculated appearance
benign
malignant
43

44. BREAST SELF
EXAMINATIO
N

45. OTHER FORMS OF
DETECTION
Sonogram
Thermography
Transillumination
Xeromammograpy
Cat Scan
MRI
Biopsy

46. TREATMENTS OF
BREAST CANCER

47. MEDICAL TREATMENT
NON- METASTASIS DISEASE
 Adjuvant to reduce the risk of systemic relapse usually after
primary surgery.
 Occasionally used as treatment of choise in elderly or those
unfit/inappropriate for surgery
Endocrine Therapy
1. Anti-estrogens (e.g tamoxifen, LHRH antagonists,
aromatase inhibitors)
2. Most effective in ER +ve tumours
Chemotherapy
1. Anthracyclines, cyclophosphamide,5-FU, methotrexate
2. Offered to patients with high risk features (+ve nodes,
poor grade)

48. MEDICAL TREATMENT
METASTASIS DISEASE
 Palliative to increase survival time
Endocrine Therapy
As above
Chemotherapy
Anthracyclines, tanaxest
Radiotherapy
To reduce pain of bony metastases or
symptoms from cerebral or liver disease

49. SURGERY
MAINSTAY FOR NON METASTASIS DISEASE
Mastectomy
(radical,modified radical
simple) Breast conservation
A mastectomy is the (lumpectomy, wide local
surgical removal of the excision, quadrantectomy)
breast, non-protruding In this surgical procedure,
breast tissue, the lymph the breast is conserved and
nodes in the armpits and the tumor is removed.
some pectoral muscle.
Radiation commonly follows a
Breast reconstruction lumpectomy to try to rid the
surgery may be body of any other cancerous
conducted after the cells.
removal of the breast.

50. BREAST CA
 Wide local excision-commenest procedure
-breast conserving provided breast is adequate size and
tumour location appropriate (not central/retro-areolar)
-usually combined with local radiotherapy
 Simple mastectomy-best treatment and cosmetic result
 Surgical management of regional lymph nodes
-Axillary node sampling
-Axillary node clearance
-Sentinel node biopsy
Usually the first axillary node to receive lymphatic drainage
from the tumour. Before operation, a blue dye and a radiotracer
are injected into subareolar areas and at operation the sentinel
node is identified visually and by using a device to detect
radioactivity.
 Surgery for metastastic disease: limited to procedures for
symptomatic control of local disease (e.g mastectomy to
remove fungating tumour)

51. FOR BREAST
CONSERVATION
SURGERY
 Single lesion clinically and mammographically
 Tumour not larget than 3cm (4cm in larger
breast)
 No extensive in situ component
 Tumours more than 2cm away from nipple/areola
 Lesion of lower histological grade
 No extensive nodal involvement

52. PSYCHOLOGICA
L IMPACTS OF
BREAST
CANCER

53. WHAT DO PATIENTS GO THROUGH
AFTER DIAGNOSIS?
Depression Reduction of
Anxiety activities
Hostility Panic
Fear Guilt
Changes in life Difficulty adapting
patterns due to to illness
discomfort and pain Overwhelmed
Marital/sexual Disappointment
disruptions

54. REOCCURRENCES OF BREAST
CANCER
Reoccurrences Therapies
Personal Group Therapies
Responsibility Single session groups
Loss of Hope Time limited groups
Denial Long Term groups
Traditional
Grief
Single session with
psychologists

55. PREVENTIO
N

56. FAT
Research shows that dietary fat should
be 20% or less in order to gain
meaningful protection against cancer.
Fat cells make estrogen, which promotes
breast cancer.
Diets high in fat are associated with the
increasing breast density in mammograms,
which makes interpretation more
difficult.

57. FIBER
Fiber provides protection against breast
cancer because it has a mechanism that
decreases the amount of estrogen in the
body.
The amount of fiber in the diet affects the
activities of intestinal bacteria, which affects
the amount of reabsorbed estrogens.

58. ANTIOXIDANT
NUTRIENTS
Antioxidants are important in fighting
breast cancer because they can disarm
cancer-causing substances called free
radicals.
Vitamin C
Vitamin E
Beta-carotene
Vitamin A
Selenium

59. OTHER PREVENTATIVE MEASURES
Early Detection!!!!
Exercise
No Smoking!!
Good Diet

60. REFERANCE
 Essential
surgery 4th edition
 Oxford handbook of clinical surgery 3rd edition
 The National Cancer Institute wedsite