1. BREAST CANCERBREAST CANCER
Mizan Kidanu
March,18/2013

2. OUTLINEOUTLINE
Introduction
Epidemiology
Risk factors
Classification
Diagnosis
Treatment
Prognosis

3. INTRODUCTIONINTRODUCTION
• Two ventral bands of thickened
ectoderm (mammary ridges,
milk lines)
• These ridges disappear after a
short time, except small portions
that persist in the pectoral
region
• when normal regression fails
accessory breasts (polymastia)
or accessory nipples (polythelia)
may occur

4. ANATOMYANATOMY
Location
 2nd
to 6th
rib
 lateral border of
sternum to anterior
axillary line
 lies on pec. major
and seratus anterior
Contains:
 Fat, glandular tissue,
suspensory ligament

5. • Blood supply
internal mammary
axillary artery
intercoastal arteries
• Venous drainage
axillary vein
internal thoracic vein
lateral thoracic vein
intercoastal vein
•Lymphatic drainage
axillary LNs ~85%
internal mammary LNs

6. •Axillary LNs
receive approximately
85% of the drainage
grouped into:
lateral
anterior
posterior
central
apical
interpectoral

7. Axillary LNs
 with respect to pectoralis
minor muscle they are
grouped into:
Level-I
Level-II
Level-III

8. EPIDEMIOLOGYEPIDEMIOLOGY
Is the most common female cancer (26%)
2nd
common cause of cancer death in women
Main cause of death in women ages 40-59 yrs
Mortality rates have declined since the use of
screening mammography and improvements of
adjuvant therapies
Invasive ductal ca is the commonest type

9. Relative distributionsRelative distributions
 Upper outer quadrant ~ 60%
 Upper inner quadrant ~12%
 Lower outer quadrant ~ 10%
 Lower inner quadrant ~ 6%
 Central quadrant ~ 12%
60% 12%
6%10%
12%

10. RISK FACTORSRISK FACTORS
 Sex - >99% occur in females
 Early menarche, late menopause, nulliparity,
older age at first live birth
 Age - is rare below 20 yeas of age
 Radiaton exposure
 Family Hx of breast CA
 Genetic factors … BRCA-1 or BRCA-2
 Prior breast cancer
 Obesity
 Dietary factors
 Smoking & increased alcohol consumption
 Hormone replacement therapy & OCP

11. CLASSIFICATIONCLASSIFICATION
Carcinoma in situ, CISCarcinoma in situ, CIS
 Ductal carcinoma in situ(DIS)Ductal carcinoma in situ(DIS)
 Lobular Carcinoma in situ(LIS)Lobular Carcinoma in situ(LIS)
Invasive carcinomaInvasive carcinoma
 DuctalDuctal
scirrhous carcinoma
medullary
mucinous (colloid)
papillary
tubular
 LobularLobular
 Paget’s disease of the nipple

12. Carcinoma in-situCarcinoma in-situ
 Malignant cells in the duct system or lobules but
no invasion of the basement membrane
 Since the use of screening mammography there is
a 14-fold increase in the incidence
 Multicentricity - refers to the occurrence of a 2nd
breast cancer outside the breast quadrant of the
primary cancer (or at least 4 cm away)
 Multifocality - refers to the occurrence of a 2nd
cancer within the same breast quadrant as the
primary cancer (or within 4 cm of it)

13. LCIS
marker of increased risk for invasive
breast carcinoma, not anatomic
precursor
bilateral in 50-70%
develops only in the female breast
multicentric in 60-90%
DCIS
anatomic precursor of invasive ductal
carcinoma
multicentricity for DCIS is 40-80%
bilateral in 10-20%

14. CLINICAL FEATURESCLINICAL FEATURES
Lump
hard, painless swelling
Change in the skin
puckering
Peau d’orange
skin ulceration
skin nodules
Nipple changes
distortion, inversion
discharge
eczema (paget’s disease)
Metastatic disease
regional LNs
distant sites

15. SPREAD OF BREAST CANCERSPREAD OF BREAST CANCER
Local spread with in the breast
involves the skin & fascia
chest wall and
other portions of the breast
Regional spread of breast cancer
axillary LNs
internal mammary LNs
Supraclavicular LNs
Hematogenous (distant) spread
in order of frequency, are bone, lung,
pleura, soft tissues, and liver.

16. Axillary nodal metastasesAxillary nodal metastases
Common site of spread (45% at presentation)
Spread depends on the primary tumor (size)
Clinical assessment is unreliable
Axillary nodal spread Vs prognosis
number of nodes affected
level of nodal disease

17. DIAGNOSISDIAGNOSIS
History
duration of illness
associated symptoms (pain, headache, cough,
nipple discharge)
age at menarche and menstruation status
(pre or postmenopausal)
age at first delivery
family history of breast cancer,….

18. Physical examination
Inspection
arms by her side or straight
up in the air
hands on her hips
arms extended forward in a
sitting position leaning
forward to accentuate any
skin retraction
symmetry, size, and shape,
peau d'orange, nipple or skin
retraction or erythema

19.  Palpation
supine position
examine all quadrants
examine with the palmar
aspects of the fingers
avoiding a grasping or
pinching motion
assesses all three levels of
axillary lymphadenopathy
location, size, consistency,
shape, mobility, fixation,...

20. InvestigationsInvestigations
CBC, Blood group & Rh,
FNAC, core needle biopsy,
Mammography, breast u/s,
MRI, ductography
ER/PR status determination
Metastasis - LFT, CXR, CT,
MRI, abd u/s,….

21. Characterstics of malignant
lesions in mammography:
architectural distortion
solid mass with or without
stellate features
microcalcifications
stippled calcifications
asymmetric thickening of breast
tissues
nipple retraction

22. Triple AssessmentTriple Assessment
Any patient with a breast lump or other
symptoms suspicious of carcinoma, the Dx
should be made by a combination of:
1. Clinical assessment
2. Radiological imaging and
3. Tissue sample (cytological or histological)
Positive predictive value is 99.9%

23. TNM StagingTNM Staging
Primary tumor (T)
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: carcinoma in situ
T1 : ≤2 cm in greatest dimension
T2: >2 cm but not >5 cm in greatest dimension
T3: >5 cm in greatest dimension
T4: any size with direct extension to (a) chest
wall or (b) skin

24. Regional lymph nodesRegional lymph nodes
N0: no regional LN involvement
N1: moveable ipsilateral axillary
LAP
N2: Ipsilateral axillary LNs fixed
or matted; Ipsilateral internal
mammary LN in the absence
of axillary LN involvement
N3: Ipsilateral infraclavicular
LAP; Ipsilateral axillary &
internal mammary; Ipsilateral
supraclavicular
M0: No distal metastases
M1: Distal metastases
Distal metastasesDistal metastases

25. Stage groupingStage grouping
Stage 0: TisN0M0
Stage I: T1N0M0
Stage IIA: T0N1M0; T1N1M0; T2N0M0
Stage IIB: T2N1M0; T3N0M0
Stage IIIA: T0N2M0; T1N2M0; T2N2M0;
T3N1M0
Stage IIIB: T4anyNM0
Stage IIIC: AnyTN3M0
Stage IV: AnyT AnyNM1

26. MANAGEMENT OF BREAST CANCERMANAGEMENT OF BREAST CANCER
Multidisciplinary
Surgeons
Radiotherapists
Oncologists
Pathologists
Other professionals
councellors
breast care nurses

27. Treatment for breast ca entails:
 Local control
surgery & radiotherapy
 Systemic control
hormone & chemotherapy

28. SURGERYSURGERY
1-Wide local excision (lumpectomy)
2-Total (simple) mastectomy
 removes all breast tissue, nipple areola complex, and
skin
3-Modified Radical Mastectomy (MRM)
 preserves pectoralis major and minor muscles, allowing
removal of level I & II but not level III axillary
4-Radical mastectomy
 removes all breast tissue, skin, nipple areola complex,
pectoralis major and minor muscles, and level I, II, &
III axillary LNs

29. Factors affecting type of treatmentFactors affecting type of treatment
Lymph node status
 +ve node: needs adjuvant treatment
Size and extent of tumor
 large tumors recur more often
Histology
 CIS: no adjuvant treatment
Hormone receptors status
Age and/or menopausal status

30. Treatment of early breast cancerTreatment of early breast cancer
((Stage I & IIStage I & II))
Breast conservation - resection of the primary
breast ca with a normal margin, adjuvant
radiation therapy, and assessment of regional
lymph node status
Mastectomy with sentinel lymph node and/or
axillary LN dissection

31. Breast conserving surgeryBreast conserving surgery
Excision of the tumor with a rim of
normal tissue
lumpectomy
segmental mastectomy
partial mastectomy
quadrantectomy

32. Contraindications for breast
conserving operations(BCS)
tumor >4cm
multicentricity
centrally located tumors
poor tumor differentiation
node positive disease
positive margin after re-excision
Hx of previous radiotherapy
pregnancy

33. HORMONAL THERAPYHORMONAL THERAPY
Immunoassays & immunohistochemical
methods are employed to measure levels of ER
Patients with significant increase in ER
respond favourably to endocrine therapy
E.g: Tamoxifen therapy

34. CHEMOTHERAPYCHEMOTHERAPY
Adjuvant chemotherapy for early invasive
breast ca is indicated in all patients with:
node-positive cancers
tumor >1 cm
node-negative cancers of >0.5 cm with adverse
prognostic features (blood vessel or lymph vessel
invasion, high histologic grade, HER-2/neu
overexpression, and negative hormone receptor
status)

35. Locally advanced breast cancerLocally advanced breast cancer
(( Stage-IIIStage-III))
 Neoadjuvant chemotherapy
 Usually a modified radical
mastectomy (MRM)
 Followed by adjuvant
radiation therapy

36. Breast ca with distant metastasisBreast ca with distant metastasis
((Stage IVStage IV))
Aim of management
 provide palliation
 symptomatic relief
Treatment
 combination chemotherapy
 toilet mastectomy
 radiotherapy
 Tamoxifen therapy in ER positive

37. COMPLICATIONS OF MASTECTOMYCOMPLICATIONS OF MASTECTOMY
Seromas - the most common
Wound infections
Hemorrhage
Lymphedema - increased risk in:
 extensive ALND
 the delivery of radiation therapy
 the presence of pathologic lymph nodes
 obesity
Nerve injury

38. FOLLOW UPFOLLOW UP
Assess local recurrence, especially in BCT
Assess the contralateral breast
Detect psychiatric morbidity
Allow provision of prosthesis
Early detection & treatment of metastatic
disease

39. PROGNOSIS OF BREAST CAPROGNOSIS OF BREAST CA
5-year survival rate
Stage 5yr survival
I 100%
IIa 92%
IIb 81%
IIIa 67%
IIIb 54%
IV 18%