GENERAL SURGERY TOPIC BREAST CANCER INFILTRATIVE TYPE

1. A case of Infiltrative ductal
carcinoma
DR MUHAMMED MUNEER.M
MS GENERAL SURGERY
SGMC & RF
TRIVANDRUM KERALA
23-07-2015

2. Case Summary (MRD 1059357)
 SIMI -34 years old house wife presented with a painless
lump in the left breast, associated with bloody discharge
from nipple- 2 months duration.
 It was noticed first while taking a bath, a lump in her
left breast inner lower quadrant, about a size of grape
 Bloody discharge from the nipple while pressing the
breast
 Not assoc. with pain ,or rapid increase size,
 No h/o any swelling in her axilla or c/l breast, no h/o
chest pain, cough, hemoptysis, breathlessness, jaundice,
back ache, pain in the limbs, head ache
 Her appetite is good , no h/o of any weight loss

3.  She had a Past history of hypothyroidism and valvular
heart disease
 No family history of breast disease, ovarian diseases.
 Patient attain menarche at an of age 13 yr, her cycles
are irregular, and assoc with dysmenorrhoea,- 6 months,
1st
child birth was at age 30.
 No h/o usage of any OCP/HRT/ Infertility rx
 O/E- general examination .

4.  Local xn of left breast- no visible asymmetry,
nipple & areola is normal, no local rise of temp,
tenderness, a single ovoid ,non tender ,well
defined lump about a size of 2 x 1.5 cm ,
palpable in the lower medial quadrant of left
breast, with firm consistency.
 Skin over the lump is normal , it is not fixed to
skin, chest wall & pectoralis major muscle.
 No palpable lymph node in the axilla,
supraclavicular area.
 c/l breast and axilla is normal

5.  Xn of Abdomen- NAD
 Pelvic examination-WNL
 Xn of chest – NAD
 No tenderness over skull and spine.
 PROVISIONAL DIAGNOSIS-Ca breast
 DIAGNOSTIC INVESTIGATION –
 usg,mammogram,FNAC

6. DIAGNOSTIC
INVESTIGATION
Dense fibroglandular
densities
Micro ca+-medial
inferior quadrant, & sub
areolar
Multiple punctate ca+
foci +
No definite mass
No thickening of skin or
distortion of nipple
Enlarged axillary nodes-
but fatty hilum
preserved.

8. sonography
 Ducts are prominent with nodular appearance in both
breast, a lobulated mass 13x9mm ,medial quadrant of
left breast with punctate ca+ in it . Internal echos and
ca+ foci noted in some ducts in inferomedial quadrant. A
small hypoechoic mass ?fibroadenoma 12x7mm
supe.quadrant of left breast.
 Impression – scattered punctate calcification with
areas of clusters of microca+ showing pleomorphism
noted in the Lt breast involving inferomedial and deep
subareolar region– malignancy (ductal carcinoma) has to
be considerd.
 BIRADS IV

9. FNAC, +ve for malignant cells.
 Hb 13.1
 Tc -10000 , ESR 12
 TSH-4.53, T3-1.12, T4-7.27
 RFT, LFT –WNL
 RBS-89
 SCREENING –VE
 CXR- NAD
 ECG- NAD

10. Surgery planned- Microdochectomy &
lumpectomy

11. Technique : squeeze the breast and
nipple until a drop of discharge is seen

12. cannulate the duct using a lacrimal probe or cannula

13. secure cannula in place with 3/0 suture passed
through the skin along side the duct opening

15. Make a radial eliptical incision into the nipple along
the line of the probe encircling the duct orifice

17.  Dissect the skin of the areola away from
the underlying breast for approx 1cm on
each side of the probe and excise the
breast segment containing the probe ,
along with the underlying lump.

19. GROSS
Specimen sent for HPE

20. HPR- IDC –NOS with extensive
ductal ca insitu change
 Measuring -2.2x1x1cm.
 Adjascent breast tissue shows ductal
ca insitu, intra ductal hyperplasia, &
fibrocystic changes grade 1, PT2 , all
margins free of neoplasm .
 MRM was done via stewart incision.

21. MRM SPECIMEN
 NO RESIDUAL NEOPLASM
 1 / 10 AXILLARY LYMPH NODES -
METASTASIS
 LEVEL 2 & LEVEL 3 LYMPH NODES
- REACTIVE CHANGE
T2N1M0. Stage II . EBC

22. discussion

23. discussion
 Nipple discharge accounts for about
5% of all breast symptoms
 2~15% of women who undergo
surgery for nipple discharge are found
to have an underlying breast carcinoma

24. Bloody NIPPLE DISCHARGE
 I=NONBLOODY;
1-FIBROCYSTIC DISEASE
2-DUCTECTASIA
 II=BLOODY;
1-DUCT PAPILLOMA; MOST COMMON
2-DUCTECTASIA; COMMON
3-DUCT CARCINOMA;VERY RARE

27. NORMAL DUCT DUCT PAPILLOMA

28. Nipple discharge
Nipple dischargeNipple discharge
Bilateral (multiductal)Bilateral (multiductal) UnilateralUnilateral
Physiological
Pathological
Fibroadenosis
Papillomatosis
Duct ectasia
Physiological
Pathological
Fibroadenosis
Papillomatosis
Duct ectasia
Mammography
U/S
Mammography
U/S
Uniducta
l
Uniducta
l
Fibroadenosi
s
Papillomatosi
s
Duct ectasia
?? carcinoma
Fibroadenosi
s
Papillomatosi
s
Duct ectasia
?? carcinoma
Multiduct
al
Multiduct
al
Duct papilloma
Duct carcinoma
Duct ectasia
Chronic absces
??? fibroadenosis
Duct papilloma
Duct carcinoma
Duct ectasia
Chronic absces
??? fibroadenosis
Cytology,prolactin,ductographyCytology,prolactin,ductography
MicrodochectomyMicrodochectomy

29. Galoctography /ductography
 Primary indication for ductography is nipple discharge,
particularly when bloody.
 Though helping in reaching a diagnosis ,is not
essential, since excision of bloody duct system is
indicated regardless of finding.
 A contrast medium is injected into the discharging duct
& a mammogram taken-filling defect surrounded by
contrast – intraductal papilloma.
 Cancer appears as irregular mass or as multiple
intraluminal filling defect or abrupt obstuction.
 Duct ectasia or fibrocystic disease may appear as
dilated cystic structure.

30. BLOODY NIPPLE DISCHARGE more s/o cancer if
it is spontaneus, u/l, localised to a single duct
occur in women age 40yrs or more or assoc with
a mass.
It is s/o a benign condition if it is b/l or
multiductal in orgin,occurs in women age <39 or
less, or milky or blue green in colour.

31. Thank you

32. Thank you

33. Management of Breast
Symptoms
 Breast Lump - always need to exclude
Ca
 Breast examination - Is there a lump
or localised nodularity?
 Is there no lump or diffuse nodularity?
 Tripple Assessment
 1. FNA
 2. U/S
 3. Mammography

34. Palpable Breast Lump - Solid Mx
FNA solid lumpFNA solid lump
Cytology
Mammography > 35
U/S
Tru-cut ® biopsy (lump > 2cm)
Cytology
Mammography > 35
U/S
Tru-cut ® biopsy (lump > 2cm)
suspicious or carcinomasuspicious or carcinoma
benignbenign
observe but excise if :
• age >35
• Pt requests
• pain
• increasing size
• equivocal cytology
observe but excise if :
• age >35
• Pt requests
• pain
• increasing size
• equivocal cytology
Manage as for breast cancerManage as for breast cancer

35. No Palpable Breast Lump Mx
no lump or
diffuse nodularity
no lump or
diffuse nodularity
age < 40age < 40
age > 40age > 40
re-examine 6/52re-examine 6/52
reassurereassure
benignbenign
Cytology
Mammography
U/S
Cytology
Mammography
U/S
reassurereassure
benignbenign
suspicious or carcinomasuspicious or carcinoma
Manage as for breast cancerManage as for breast cancer

36. Breast Lump – Cyst and Mx
O/E discrete lump or localised nodularity presentO/E discrete lump or localised nodularity present
FNAFNA
cysticcystic
no blood
no residual lump
then no cytology
no blood
no residual lump
then no cytology
solidsolid
re-examine in 6/12
reassure
re-examine in 6/12
reassure
bloody fluid
residual lump
then do cytology
& mammography
bloody fluid
residual lump
then do cytology
& mammography
excisional biopsyexcisional biopsy
no lump or
diffuse nodularity
no lump or
diffuse nodularity

37. History of breast surgery
 1894 – Radical mastectomy by William
Halsted
 1967 – Modified Radical Mastectomy
 1981 – Breast conservation surgery
(lumpectomy and removal of axillary
lymph nodes)
 Studies have shown that there is no
difference in the outcome in all these
three types of surgery

38. Local recurrence rates after lumpectomy +RT,
lumpectomy alone and mastectomy
Trial Follo
w-up
Lumpecto
my
And RT
Lumpecto
my
alone
Mastecto
my
NSABP-
B06
8
yrs
10% 39% 8%
EORTC 8
yrs
15% NA 9%
Jacobsen
etal
10yrs
17% NA 9%
European
EORTC/DB
CG
10
yrs
10% NA 9%

39. When can we try to save your
breast?
 Size is the most important criteria. The lump must
be small enough to be excised with a good margin
of normal breast tissue
 The tumour must be a single lump with no disease
elsewhere in the breast – mammogram before
surgery is essential to rule out multifocal disease
 The patient must agree to radiotherapy and have
no other diseases which make radiotherapy
impossible
 CONTRAINDICATION OF BCS-
 T3 T4 Tumors, N2 OR M1
 MULTIFOCAL AND MULTICENTRIC DISEASES
 COLLAGEN VASCULAR DISEASES
 EXTENSIVE in situ COMPONENT
 Larger and central tumor in small breast

40. Why is there no difference whatever type
of surgery is done?
 Even when a breast cancer is 1 cm, cancer
cells can go into the blood and lymphatic
vessels and be carried to any part of the body
 Hence surgery alone usually cannot cure the
patient
 Systemic therapy such as chemotherapy or
hormone therapy will also be required
 However surgery is important to get rid of
all obvious gross cancer

41. Radiotherapy
 After lumpectomy, radiotherapy is
essential, otherwise the local
recurrence rate is unacceptably high
 Without radiotherapy, the local
recurrence can be as high as 40%

42. Indication for RT in EBC
 4 or more +VE LN
 High grade tumor
 Resected margin +ve
 Skin and chest wall involvment
 Size > 5 cm

43. Role of Chemotherapy in EBC
 NODE +VE cases
 HER2 +VE CASES
 TRIPPLE –Ve Cases
 >0.5 cm size and < 70 yr of age.

44. Mastectomy
 No physical
handicap
 The degree of
emotional
handicap
depends on the
patient

45. Breast conservation surgery
 Breast contour is
preserved
 Requires
radiotherapy
 Generally less
depression and
better body
image

46. Breast conservation surgery
 Occasionally may
cause a lot of
distortion if the
lump is large or too
close to the nipple
 In such cases, may
require plastic
surgery or a
mastectomy is
necessary

47. What if I cannot save my
breast?
 If the lump is too big to be safely
removed with a margin of normal tissue,
or there are multiple cancers in the
breast, and mastectomy is required,
immediate breast reconstruction is
possible and has been shown to be safe

48. Is there a way of saving my breast even if I
have a big tumor?
 Primary chemotherapy may be able to
shrink the tumor so that BCS can be done
 Not standard practice, but can be safely
done if the patient wants BCS and is not
willing to have a mastectomy
 Not advisable in Stage 3 locally advanced
breast cancer

49. What is Stage 3 locally
advanced breast cancer?
 Cancer involving
the skin or the
whole breast
 Chemotherapy
can be given first
to shrink it
 Mastectomy after
chemotherapy

50. Is breast conservation surgery
commonly carried out?
 In USA, figures of BCS are more than 70%
 Early detection is the most important factor
in determining whether your breast can be
saved

51. Follow-up after breast
conservation surgery
 Mammogram at 6 months after
radiotherapy
 Mammogram yearly afterwards
 If local recurrence detected,
mastectomy must be carried out

52. Conclusion
 Breast conservation surgery gives the
same outcome as mastectomy
 Selection of patients important
 Education and counseling of patients is
important
 Awareness programes should emphasize
that with early detection.