Download MBBS CA Breast Modified Lecture PPT

INTRODUCTION
v Most common cancer among
females ? Ca. Breast
v Leading cause of death among

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women of 40 ? 55 yrs.
v NICPR- most frequently seen
cancer among Indian women.
v Annual incidence in Kerala ?
14.9/lakh

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TOPICS
PRESENTED BY
ANATOMY OF BREAST
Abdul Kalam
A

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ETIOPATHOLOGY
Adila Rahim
VARIANTS OF CA BREAST
Afsana Faby Khan
TNM STAGING

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Ahna Ahmed
HISTORY, CLINICAL EXAMINATION
Abi Shamsudheen
INVESTIGATIONS
Aiswarya S

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TREATMENT OF LABC
Alex Shibu
TREATMENT OF LABC
Alfia Hussain
PROGNOSIS ,COMPLICATIONS, FOLLOW UP Alida Francis

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Abdul Kalam C.J
Roll no. 1

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DEVELOPMENT
? Modified sweat gland ,derived from

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ectoderm
? Development begins at 5th or 6th week of
intrauterine life
? Ectodermal thickening in the chest area -
mammary ridge/milk line/line of

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Schultz
? Axil a to inguinal region
? In humans, these ridge disappears except
for a small portion over pectoral region

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Formation of mammary gland

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? Persisting part of the mammary ridge is first
converted into a mammary pit
? Secondary buds(15-20) grow down from floor of the
pit
? These buds divide & subdivide to form lobes

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? Entire solid system is canalized later
Growth of mammary gland, at puberty caused by;
? Estrogen ? development of ductal system.
? Progesterone ? stimulates development of secretary
alveoli

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q SITUATION:
Superficial fascia of pectoral region
q EXTENT OF BASE
?Vertically ? second to sixth rib in the

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mid clavicular line
?Horizontally ? from lateral border of
sternum to anterior axillary line
?A thin layer of mammary tissue extends
from below the clavicle to 7th/8th rib and

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from midline to edge of lattismus dorsi
posteriorly ( surgical imp.)

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Divided into 4 quadrants :
? UPPER INNER
? UPPER OUTER
? LOWER INNER
? LOWER OUTER

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AXILLARY TAIL OF SPENCE -
Passes through an opening in the deep fascia
(Foramen of Langer) and lies deep to deep
fascia
Upper outer quadrant is the most frequently affected quadrant by

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carcinoma (60%) as the breast tissue is denser in this area

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DEEP RELATIONS
? Deep pectoral fascia
? Muscles
i. Pectoralis major

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i . Serratus anterior
i i.External oblique
? Anterior chest wall

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STRUCTURE
? Skin

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? Parenchyma
? Stroma

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SKIN
q NIPPLE
? A conical projection in 4th

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intercostal space
? Contains circular and
longitudinal muscles
? Pierced by 15-20 lactiferous
ducts

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? Supplied by 4th intercostal
nerve
Infiltration of the lactiferous duct by tumor and subsequent fibrosis causes
RECENT RETRACTION OF THE NIPPLE

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q AREOLA

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? Skin surrounding the base
of the nipple
? Pigmented circular area
? Contains sebaceous, sweat
and accessory glands

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MONTGOMERY'S TUBERCLES are sebaceous gland that are enlarged during pregnancy and lactation.
They produce oily secretions that lubricate nipple and areola and prevent it from cracking

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PARENCHYMA
? Compound tubulo -alveolar gland

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? 15-20 lobes - each has a cluster of
alveoli, and is drained by a lactiferous
duct
? Lobule- basic structural unit
? 10- 100 lobules ductules

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lactiferous duct.
? Lactiferous sinus is the terminal
dilatation of the duct. It act as a
reservoir for milk or abnormal
discharge

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? Terminal duct + lobule = Terminal Duct Lobular Unit
(TDLU)
Most cancers and benign lesions arise in the terminal duct either inside or just

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proximal to the lobule.

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STROMA
i. Fibrous stroma
1. Supporting framework of the

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gland
2. Forms septa known as the
suspensory ligaments of Cooper
3. Anchor the skin to the pectoral
fascia

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ii. Fatty stroma
1. Main bulk of the gland
2. Distributed all over the breast;
3. except beneath the areola &
nipple

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Infiltration of the suspensory ligaments of Cooper by tumor cells
result in puckering or dimpling of the skin

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BLOOD SUPPLY
q ARTERIAL SUPPLY
? Perforating branches of internal thoracic

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Artery
? Branches of axil ary artery
i. Lateral thoracic artery
i . Superior thoracic artery
i i. Thoracoacromial artery

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? Lateral branches of 2nd - 4th posterior
intercostal arteries

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q VENOUS DRAINAGE
? Veins follow the arteries. First they converge

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around the nipple to form an anastomotic
venous circle and then form 2 sets of veins
? Superficial veins - internal thoracic vein and
into the superficial veins of the lower part of
neck

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? Deep veins - axillary and posterior intercostal
veins

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Batson's vertebral venous plexus

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? Network of valveless veins
? Through posterior intercostal
veins , venous drainage
communicates with
paravertebral venous plexus

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Route for metastasis to the axial skeleton and Central nervous
system --- most common site : LUMBAR VERTEBRA

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NERVE SUPPLY
? Anterior and lateral
cutaneous branches of

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4th to 6th intercostal
nerves
? Sensory fibres to skin and
autonomic fibres to
smooth muscles and

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blood vessels
Nerves do not control the secretion of milk (controlled by prolactin
hormone)

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LYMPHATIC DRAINAGE

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q LYMPHATIC VESSELS
? Superficial lymphatics ?
skin over the breast
? Deep lymphatics -
parenchyma, nipple and areola

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? Subareolar plexus of Sappey -
a lymphatic plexus deep to areola

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? The subareolar plexus of Sappey and outer quadrant of breast ->
pectoral -> central -> apical.
? Part of upper quadrant also directly drain to deltopectoral and

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apical nodes.
? Inner quadrant -> internal mammary nodes and contralateral
breast.
? Lower inner quadrant ? traverses through the plexus in rectus
sheath ?communicate with subperitoneal plexus

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q LYMPH NODES
? Axil ary nodes (85%)
? Internal mammary(Parasternal) nodes
? Intercostal nodes

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? Some lymph also reaches
i. Supraclavicularnodes
i . Cephalic(deltopectoral) node
i i. Subdiaphragmatic lymph plexus
iv. Subperitoneal lymph plexus

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Sentinel node is defined as the first lymph node draining the tumour-bearing
area of the breast

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? Axil ary nodes :

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Groups:
? Anterior(pectoral) ?
Main drainage
? Posterior (subscapular)
? Lateral(brachial)

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? central
? Apical
? Interpectoral (Rotters)

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LEVELS OF AXILLARY NODES

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BERG 'S LEVEL
? Defined by their relationship to
pectoralis minor muscle
? Level 1 -Below and lateral
(anterior, lateral, posterior)

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? Level 2 ? Behind
(central, inter pectoral)
? Level 3 - Above and medial
(apical)

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AETIOLOGY
AND
PATHOLOGY
OF
CARCINOMA BREAST

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Adila Rahim
ROLL NO: 3

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AETIOLOGICAL FACTORS
1.Geographical

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? commonly seen in Western world
2.Age
- rare < 20 years
then incidence with age
by 90 years ? 20 % women

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are affected

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3.Gender
females > males {< 0.5 %}
4. Genetic
BRCA 1

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BRCA 2
p53

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5.Family history
- more common in women with a family h/o breast & ovarian
cancer

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- 3-5 times more risk if first degree relative has Ca.breast
- accounts for less than 5% of all breast cancer
6. Diet
low in phyto-oestrogens
7. Alcohol intake

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increase the risk of developing Ca. breast

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8. Endocrine
Protective factors :
- breast feeding
- first child at early age

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- late menarche
- early menopause
Risk factors:
- nulliparous women
- obesity ( increased conversion

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of steroids to estradiol in body
fat )

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9. Oral contraceptives and HRT
The benefits of these treatment will far outweigh

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the small putative risk; however ,long term
exposure to combined preparation of HRT does
significantly increase the risk.

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10. Previous exposure to radiation
- Hodgkin's disease ? radiotherapy ? increased risk ? decade

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after treatment
- higher risk if radiotherapy received during breast
development

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PATHOLOGY

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? Arises from the
epithelium of duct
system
? From the nipple end of
the major lactiferous

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duct to the terminal
duct unit which is in the
breast lobule

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PATHOGENESIS
? Genetic changes

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? Hormonal influences
? Environmental variables

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Genetic changes
? Over expression of HER2/NEU proto-oncogene
? Mutations of tumor suppressor genes like P53

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? Gene array analysis of breast cancers has identified five
major subtypes:
1. luminal A : ER+ , Her-2-ve
2. luminal B : ER+ ,PR+ , Her-2+
3. Her-2 receptor positive: ER-ve

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4. triple negative : ER-ve , PR -ve , Her-2 -ve
5. miscellaneous group

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? Mutation in BRCA1 or BRCA2 genes
- responsible for one third
of hereditary breast Ca

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- BRCA1 gene ?
at chromosome 17 (50-80% risk)
- BRCA2 gene ?
at chromosome 13
Both are classic tumour suppressor genes and cancer arises

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only when both alleles are inactivated or defective

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Hormonal influences
? Increased exposure to estrogen
? Stimulate production of growth factors ( TGF- ,PDGF
, FGF )

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? Promote tumor development

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SPREAD OF BREAST CANCER
By 3 means :
Local spread
Lymphatic metastasis

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Spread by bloodstream

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LOCAL SPREAD
Tumour increases in size
Invades other portions of breast
? It tends to involve skin

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? May penetrate pectoral muscles and
even the chest wall if diagnosed late

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LYMPHATIC METASTASIS
? Primarily to axillary and internal mammary lymph
nodes

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? Tumours in the posterior one third of the breast drain
to the internal mammary nodes

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SPREAD BY THE BLOODSTREAM
? By this route skeletal metastases occur

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? Lumbar vertebrae, femur, thoracic vertebrae, rib and skull; deposits
are osteolytic
? Common sites : liver , lungs, brain , adrenal glands and ovary

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TRANSCOELOMIC SPREAD

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? Through mediastinal LN into peritoneal cavity.
? Cause secondaries in liver, peritoneum, ovary (Krukenberg tumours)
Note :
-- Present concept of Krukenberg ? haematogenous and lymphatic
modes.

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-- Older concepts of transcoelomic spread no longer accepted.

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Afsana Faby Khan
A Roll no.

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fsana F 4aby Khan
Roll no. 4

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HISTOLOGICAL VARIANTS
?According to whether they have penetrated the limiting basement
membrane.

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?Those remain within ? NON INVASIVE/IN SITU CA.
?Those that spread beyond ? INVASIVE/INFILTRATING CA.
? PAGET'S DISEASE OF NIPPLE -- Cancer of nipple-areola complex ----
--- often associated with underlying INSITU/INVASIVE CA.

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IN SITU INVASIVE

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qDUCTAL CA. IN SITU(DCIS)
qINVASIVE DUCTAL CA.
qLOBULAR CA. IN SITU(LCIS)
?NO SPECIAL TYPE(NST)
?SPECIALISED TYPES

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qINVASIVE LOBULAR CA.
qINFLAMMATORY CARCINOMA
qOTHERS

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DUCTAL CARCINOMA IN SITU

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? Subtypes : Solid
HIGH GRADE
Comedo
Micropapillary
Papillary

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LOW GRADE
Cribriform
? Frequently associated with calcifications:
MAMMOGRAPHY detection
? Excellent prognosis

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? May turn invasive ? same breast and quadrant as early DCIS

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VAN NUYS SCORING FOR DCIS
? SCORING BASED ON
?Patient's age
?Grade of DCIS
?Resection margin

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?Size of disease
TOTAL SCORING
An attempt to objectively determine aggressiveness of
DCIS in terms of likelihood of "local recurrence".

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POINTS POINTS
1
2
3

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(CM)
DCIS SIZE (CM)
<=1.5
1.6-4.0
>=4.1

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DCIS GRADE
GRADE 1
GRADE 2
GRADE 3
NO NECROSIS

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NECROSIS
EXCISION MARGIN(MM)
>10
1-9
<1

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(MM)
PERSON'S AGE
>60
40-60
<40

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Each of these factors scored from 1-3 & sum-total of values for 3 parameters taken.
POINTS
%OF LOCAL
5 YR SURVIVAL
RISK

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PROCEDURE
RECURRENCE
4-6
1%
97-99%

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LOW
LUMPECTOMY ONLY
7-9
20%
73-84%

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INTERMEDIATE
LUMPECTOMY + RT
10-12
50%
34-51%

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HIGH
TOTAL MASTECTOMY

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LOBULAR CARCINOMA IN SITU
? Usually incidental finding ? calcification rare

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? May turn invasive in one-third women.
? Often, multifocal and bilateral.
? Marker of increased risk of Ca. of both breasts

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DCIS LCIS

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FOOTE AND STEWART CLASSIFICATION OF
INVASIVE CA BREAST

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INVASIVE DUCTAL CARCINOMA

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? Most common type of breast cancer --
70? 80 %
? Usually associated with DCIS
? Desmoplastic response ? hard, palpable
mass

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? 2/3RD ? Estrogen /Progesterone
expression
1/3RD - HER2/NEU overexpression

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INVASIVE LOBULAR CARCINOMA

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? In about 15% cases
? Subtypes:
? classic -- better prognosis
? pleomorphic
? Multifocal &/ bilateral- use of MRI for assessment

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? In mixed type, if predominant lobular ? immunohistochemical analysis with
e-cadherin antibody positive .
? Almost al ? hormone receptor expression; HER2/NEU overexpression rare.

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DUCTAL CA.
LOBULAR CA.

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SCIRRHOUS CARCINOMA

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? Adenocarcinoma with productive fibrosis.
? Hard, non-capsulated, whitish yellow, irregular
? Cartilaginous consistency
? Microscopy ? malignant cells + fibrous stroma

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MEDULLARY / ENCEPHALOID CARCINOMA
? Sheets of anaplastic cells
+ marked lymphocytic reaction.
? Mistaken for fibroadenoma, clinically.
? High in women with BRCA1 mutations.

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? Lack estrogen / progesterone receptors
+
TRIPLE NEGATIVE
No HER2/NEU overexpression

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PAPILLARY CARCINOMA
? Rare
? Seen in postmenopausal women
? Tumors in the form of papil ary structures
? Circumscribed and can be focally necrotic

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? Prognosis better

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COLLOID/MUCINOUS
CARCINOMA
? Rare, better prognosis

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? Older people
? Tumour cells ? abundant mucin
? Soft, gelatinous, well-circumscribed
? Express hormone receptors ;
No overexpression of HER2/NEU

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TUBULAR CARCINOMA
? Excellent prognosis
? Well formed tubules
? Seen as irregular mammographic densities

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? Express hormone receptors ;
No HER2/NEU overexpression

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INFLAMMATORY CARCINOMA /

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MASTITIS CARCINOMATOSIS
? Rare, highly aggressive , in lactating/pregnant women
? Poor differentiation ; diffusely infiltrative.
? Painful, swollen breast --- warm-- erythematous ---
---cutaneous edema ---usually no palpable mass

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? Ca. cells infiltrate subdermal lymphatics - block
? Atleast one-third of breast involved ? mimics breast abscess.

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PAGET'S DISEASE OF NIPPLE

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? Superficial manifestation of underlying
breast carcinoma on nipple-areola
complex
? Eczema-like condition --- slow erosion and
disappearance of nipple.

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? Microscopy
? PAGET'S CELLS :
large oval cells +
abundant, clear, pale stained cytoplasm
- in Malpighian layer of epidermis

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TNM Staging
Of
Breast Cancer
Ahna Ahmed

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Roll no. 5

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T = TUMOR SIZE
TX ? can't be assessed
T0 ? no palpable tumor
Tis (DCIS) - Ductal carcinoma in situ

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Tis (Paget) ? Paget disease of nipple not
associated with invasive
carcinoma and/or carcinoma in
situ
T1 ? Tumor 2cm

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T2 ? Tumor > 2 cm but 5 cm
T3 ? Tumor > 5 cm

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T4 ? tumor of any size with direct extension to
the chest wal and/or to the skin (ulceration /

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macroscopic nodules )
T4a - extension to chest wal
T4b - skin involvement in the form of ulceration ,
macroscopic satel ite nodules or oedema
(including peau d' orange) that doesn't meet

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the criteria for inflammatory carcinoma
T4c - T4a + T4b
T4d - inflammatory carcinoma

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N = REGIONAL LYMPH NODES

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NX - regional lymph nodes cannot be assessed
N0 - nodes absent
N1 - mobile ipsilateral axillary lymph nodes ( level I , II )
N2 - N2a - ipsilateral fixed axillary lymph node ( level I , II )
N2b - ipsilateral internal mammary node +ve in the absence

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of axillary lymph nodes
N3 - N3a - ipsilateral infraclavicular lymph nodes
N3b - ipsilateral internal mammary lymph nodes and
axillary lymph nodes
N3c - ipsilateral supraclavicular lymph nodes

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METASTASIS
M1 - Metastasis Present
M0 - Metastasis Absent

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SUMMARY OF STAGING
? Stage I and II - Early breast cancer (EBC)

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? Stage II A and II B and II C - Locally advanced breast cancer
(LABC)
? Stage IV - Metastatic breast cancer (MBC)

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LOCALLY ADVANCED BREAST CARCINOMA
Primary tumor > 5cm (T3)

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Chest wall extension (T4a)
Skin involvement (T4b)
Inflammatory carcinoma (T4d)
Fixed axillary lymph node(N2a)
Internal mammary node(N2b)

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N3 lymph node
No evidence of distant metastasis

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-
L
A
B
C HISTORY

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?55 yr old postmenopausal obese female presents with a swelling in
the right breast.
?Elder sister died of Carcinoma breast at age of 40 yrs.
A
R

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I
O
?No history of bony pain, hemoptysis, dyspnea.
?No history of jaundice, headache, seizures.
?Menarche at age of 13 yrs.

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?Married at 25 yrs.
?First childbirth at 28 yrs.
?3 children ? al were breastfed.
C
A

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S
E
S
C
E

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N
?History of recent retraction of right nipple.
?No history of discharge from nipple.

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INSPECTION

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?Entire affected breast is at higher level than left.
?Breast as whole pul ed up and contracted compared to normal side.
?Dilated veins seen on overlying skin.
?Retraction and elevation of right nipple.
?Visible lump - 6x7 cm ? upper and lower outer quadrants of R.breast.

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?Edema of skin over mass + peau d' orange appearance.
?Few satellite skin nodules seen ? confined to same breast.

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PALPATION
?Local rise of temperature

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?Fixity of skin over mass
?Hard lump ? fixed to breast
?Also fixed to pectoral muscles
?No fixity to chest wall
?Visible axillary swelling on right side- matted, hard lymph nodes 5x3 cm

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involving both pectoral & central groups.
?No infraclavicular nodes
?Empty supraclavicular fossa ? no palpable nodes.
?No edema of right arm
?Contralateral breast and axilla - normal

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?No cervical LN enlargement.
?No hepatomegaly and ascites
?No evidence of chest consolidation/ pleural effusion
?Lumbar spine - normal

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HISTORY
AND
CLINICAL

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EXAMINATION
Abi Shamsudheen
Roll no. 2

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HISTORY TAKING
? AGE

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? SPECIFIC COMPLAINTS
1. LUMP - Duration
- Onset
- Rate of growth
2. PAIN

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3. DISCHARGE FROM NIPPLE
4. RETRACTION OF NIPPLE
5. SKIN CHANGES ? Ulceration, Fungation
6. SWELLING IN AXILLA
7. UPPER LIMB EDEMA

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NIPPLE DISCHARGE
BLOOD
CARCINOMA, PAPILLOMA
PURULENT
MAMMARY ABCESS

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GREENISH
DUCT ECTASIA
MILK
LACTATION ,GALACTOCELE
SEROUS

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FIBROCYSTIC DISEASE, DUCT ECTASIA

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To rule out metastasis:
? Bone pain ,swelling and pathological fracture
? Dyspnoea , haemoptysis , chest pain
? Jaundice , abdominal distension

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? Headache , vomiting , seizures
General Symptoms: Loss of weight and appetite

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PAST HISTORY
? Previous breast surgeries,
? Biopsies in same/ opposite breast

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? Exposure to radiation
? Hysterectomy, oophorectomy
? Hormone replacement therapy
? Dyslipidemia

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? MENSTRUAL HISTORY - Age at menarche

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- Age at menopause
? OBSTETRIC HISTORY - Age at first full term pregnancy
- No of pregnancies
- Lactational history
- H/o long term OCP use

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? FAMILY HISTORY - Breast or ovarian cancers
- Any other malignancies like colorectal ca. or ca. prostate

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CLINICAL EXAMINATION
? Obtain consent
? Adequate privacy

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? Patient exposed to the waist in a well lit room
I. SITTING
I . RECUMBENT
I I.SEMI-RECUMBENT (45o)
IV.LEANING FORWARDS

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INSPECTION
Sitting and:
i. Arms by the side
i . Arms raised above head
i i.Arms on hip

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iv.Bending forwards

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ASYMMETRY
V
BREAST
ISIBLE SWELLING

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DIMPLING, PUCKERING
SKIN
PEAU D' ORANGE, ULCERATION,
FUNGATION, SKIN NODULES
DI

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NIPPLE-
SCHARGE
AREOLAR
C DE
OMPLEX

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STRUCTION
DEPRESSION (Retraction)
DISCOLOURATION
DISPLACEMENT
DEVIATION

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CA
ARMS
NCER EN CUIRASSE
&THORAX
BRAWNY EDEMA

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PALPATION
? Normal breast first
? Local rise in temperature
? Tenderness
? Lump - site, size, shape, extent, surface, borders, consistency

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- discrete lumps
- multifocal& multicentric
? Fixity to -breast tissue
-skin
-pectoralis major

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-chest wal

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REGIONAL LYMPH NODE EXAMINATION
? AXILLARY,
? SUPRACLAVICULAR

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? INFRACLAVICULAR NODES
? Consistency
? Mobile or fixed

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EXAMINATION FOR DISTANT METASTASES
? CONTRALATERAL BREAST AND AXILLA

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? CHEST ? Pleural effusion, Consolidation
Chest wall nodules
? ABDOMEN - Hepatomegaly
- Ascites
- Ovarian mass (Krukenberg tumor)

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? BONY TENDERNESS - vertebrae, long bones, skull
? CNS - Focal neurological deficit

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INVESTIGATIONS
Aiswarya .S

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Rol no : 6

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SPECIFIC INVESTIGATIONS
? DIAGNOSTIC - TRIPLE ASSESSMENT

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? METASTATIC ? STAGING INVESTIGATION
? TREATMENT RELATED

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TRIPLE ASSESSMENT
CLINICAL
IMAGING

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PATHOLOGY
AGE
USG
FNAC
EXMN

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Mammography
Corecut
Positive predictive value should exceed 99.9%

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MAMMOGRAPHY
? MAMMOGRAM: soft tissue Xray of breast.

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? Preferred for females above 35 yrs
? Xray plate is kept in direct contact with breast and a low voltage high
amperage Xray is used (0.1cGy)
? Breast is held within a compression device.

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Indications of mammography

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SCREENING
? Positive family history
? General population >40 [ in some countries]
? Axillary node palpable no lump palpable.
? Coarse nodular breast.

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? Fibroadenosis
DIAGNOSTIC
? Evaluation of suspicious breast lump.
? Imaging guided biopsy
FOLLOW UP

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Post operative follow up

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CRANIOCAUDAL VIEW
? From above downward

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MEDIOLATERAL OBLIQUE VIEW
? From side to side

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SUPPLEMENTARY VIEWS
? Cleopatra/ Axil ary view
-Exaggerated craniocaudal view.

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-Better imaging of lateral portion of breast to
axillary tail.
? Cleavage/ val ey view
-Better view of posteromedial portion of both
breasts

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MAMMOGRAPHIC FINDINGS OF
CA BREAST
? Mass lesion with clustered pleomorphic microcalcification
? Speckled mass lesion, ill defined margins, high density compared to
surroundings

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? Architectural distortion with Stellate lesions
? Taller than wider

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CONTRAST MAMMOGRAPHY

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? Standard iodinated IV contrast agent is injected in one of major
mammary duct and then soft tissue X-ray is taken.
? Intraductal tumor(ductal papilloma)- smooth filling defect.
? Ductal carcinoma ? irregular filling defect.

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DIGITAL MAMMOGRAM

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? X ray film is replaced by detectors.
? X rays converted to electrical signals.
? Obtained data stored to computer.
? Better resolution.

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XEROMAMOGRAPHY

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? Photoconductor is used to produce final image on selenium paper
? ADVANTAGE : edge enhancement effect- useful in dense breasts
? DISADVANTAGE : exposure to high radiation dose and selenium plates
are needed

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BI - RADS

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? The Breast Imaging Reporting and Data System.
? Used to categorize the degree of suspicion of
malignancy for a mammographic abnormality.
? BENEFITS:
increased clarity in reporting

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improved communication
facilitate research across different
institutions

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CATEGORY
RISK FACTOR

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MANAGEMENT
0
NEED ADDITIONAL
NA
NEED ADDITIONAL

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IMAGING / PRIOR
IMAGING
EXAMINATIONS
1
NEGATIVE

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ESSENTIALLY 0% ROUTINE
SCREENING
2
BENIGN
ESSENTIALLY 0% ROUTINE

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SCREENING
3
PROBABLY BENIGN
>0% BUT2%
SHORT INTERVAL

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FOLLLOW UP

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4
SUSPICIOUS
4a. Low suspicion for TISSUE
malignancy

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DIAGNOSIS
(>2% to 10%)
4b. Moderate
suspicion (>10%
to50%)

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4c. High suspicion
(>50% to 95%)
5
HIGHLY
>95%

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TISSUE
SUGGESTIVE OF
DIAGNOSIS
MALIGNANCY
6

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BIOPSY PROVEN 100%
SURGICAL
MALIGNANCY
EXCISION
WHEN

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CLINICALLY
APPROPRIATE

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ULTRASONOGRAPHY
? Useful in young women (<35yrs) with dense breast
? Helps to distinguish cysts from solid lesions

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? Looks for the :margin of lesion
: internal echoes
: retro tumour acoustic
shadowing
: compressibility

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: dimensions

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? Cheaper
? Easily available
? No risk of radiation
? USG axilla ? to asses axilla and to do guided

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FNAC of node

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MALIGNANT LESION
BENIGN LESION
Irregular margin,
Smooth, rounded with well

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irregular internal echoes, -defined margins,
irregular posterior
with weak internal echoes
shadowing,
& compressibility.

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non compressibility,
ratio b/w AP to width
dimensions more than 1

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DISADVANTAGES:

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? False negative values
? 2% false positives
? Micro calcification cannot be detected
? Operator dependent
? Lesions <1cm may not be identified

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MRI
? To differentiate scar from recurrence in women who
have had previous BCS
? to assess multifocality & multicentricity in lobular
cancer

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? to assess the extent of high grade ductal carcinoma in
situ(DCIS)
? to image the breasts of women with implants
? used as a screening tool in high risk women

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Ductography
:Contrast study of ducts in case of unilateral nipple discharge.

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:craniocaudal & mediolateral views
Breast ductal endoscopy
:Direct visualisation of tumour in DCIS and Invasive ductal carcinoma
:Techniquely difficult and demanding.
Thermography

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:Malignant tumours are detected through different thermographic
method
: Not very sensitive test

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FINE NEEDLE ASPIRATION CYTOLOGY
? Done with 23G needle using FNAC aspiration special

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syringe
? Lump held firmly ? needle passed ? continuous
aspiration ? material collected on a slide
? Air dried or wet fixed with 95% ethanol
? Cytology ? after staining under microscopy

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? Minimum of six aspirations are done

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? Stains used ?
Leishman(air dried),
Papanicolaou,

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Hematoxylin& eosin(wet
fixed)
? Done as an OP
procedure, Reliable &
Cheap

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? It is least painful

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FNAC SCORING
? C0 : No epithelial cel s
? C1 : Scanty epithelial cel s

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? C2 : Benign cel s
? C3 : Atypical cel s
? C4 : Suspicious cel s
? C5 : Malignant cel s

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DISADVANTAGES OF FNAC

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? False positive results <2%
? False negative: sampling error (but can repeat upto 3
times if suspicious)
? Cannot differentiate b/w invasive and in situ
carcinoma

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? Hormone receptor status cannot be assessed

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CORECUT / TRUCUT BIOPSY
? Done under local anaesthesia
? Obtains the core of tissue
? Gives clear histologic evidence

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? Differentiate between in situ and invasive Ca.
? ER, PR, Her2 status can be studied
? Mandatory before treatment of LABC

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IMAGE GUIDED BIOPSIES

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? Done when lump is not clearly palpable.
1. USG guided core needle biopsy
2. Stereotactic mammographic core needle biopsy
3. Mammography guided wire localisation
4. MRI guided core needle biopsy

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LARGE NEEDLE BIOPSY WITH VACUUM
SYSTEMS
? Using 8G or 11G needles
? Useful ? microcalcification / complete excision of benign lesions

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MAMMOTOME

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? A vacuum assisted breast biopsy device that uses image guidance
such as x-ray, USG or MRI to perform breast biopsies
? Done as op procedure
? Removes only a small amount of healthy tissue and do not require
sutures

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INCISION BIOPSY
? Lesions >4cm ? core biopsy &
FNAC fails ? but lesion is
suspicious of malignancy in

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clinical examination and
mammography

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EDGE BIOPSY
? Done if ulceration or fungation present

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STAGING INVESTIGATIONS

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? Chest X-ray
? X-ray spine
? CT ? chest, abdomen, brain
? MRI spine / pelvis
? Radioisotope bone scan

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:T3, T4 advanced disease
:Advanced nodal disease
:Bone pain, bone swelling, pathological fractures
:Chest/ liver secondaries
? PET scan

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? USG abdomen

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ROUTINE INVESTIGATIONS
? Hb
? TC, DC
? Platelet count

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? Serum electrolytes
? Liver function tests
? Renal function tests
? Tumor markers : , CEA, CA15-3,
CA27-29

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NEWER INVESTIGATIONS
? Stereotactic core biopsy using computer mammography
? Vacuum assisted biopsy using 11G biopsy probe
? Needle localised biopsy under mammographic guidance
? I125 seed localisation biopsy

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TREATMENT OF LABC
Alex Shibu
Roll no : 7

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Treatment of LABC
CHEMO
SURGERY
CHEMO
Sandwich therapy

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o NEOADJUVANT CHEMOTHERAPY
o SURGERY
o ADJUVANT CHEMOTHERAPY

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o Radiotherapy
[local breast field and axilla(concurrent)]

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o Hormone therapy
(selective estrogen receptor modulator ? tamoxifen;
aromatase inhibitors ? letrozole, anastrozole)
o Targeted therapy
( trastuzumab in HER2/neu positive cases)

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CANDIDATES FOR NEOADJUVANT THERAPY
? LABC ? stage I I breast cancer
? HER2-neu positive cases
? Triple negative disease
? Early disease if BCS not possible due to large

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tumour in small breast

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AIMS OF NEOADJUVANT
CHEMOTHERAPY
Down staging
Chemo sensitivity assessment

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Treat micro metastasis

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SANDWICH THERAPY
? First anterior / neo-adjuvant
chemotherapy 3 - 4 cycles given.
? Followed by mastectomy - total or

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modified radical mastectomy (MRM--
usually after 3 cycles of initial
chemotherapy).
? Further chemotherapy (remaining cycles).

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Different regimens are:
? One day dose of all drugs of the regimen used as a standard at 3
weekly cycles for 6 cycles for stage II --CAF regime
? AC regime (Adriamycin and cyclophosphamide) with taxanes or
AC regime (4 cycles) followed by taxanes (4 cycles )are also used.

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RESPONSE
? COMPLETE RESPONSE: no palpable tumour
? PARTIAL RESPONSE: > 50% decrease in size
? NON RESPONDERS: < 50% decrease in size or
increase in size up to 25%

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? PROGRESSIVE: > 25%increase in size

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? Nonresponders and progressive disease -
RT to breast, chest wall, axilla and
supraclavicular region; taxanes;
hormone therapy; surgery if operable.

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? Responders - Total mastectomy/MRM.
After surgery remaining 2 or 3 cycles of
chemotherapy are completed.
Later hormone therapy should be given
for 5 years (tamoxifen 20 mg OD).

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ADVERSE EFFECTS
Alopecia
Cystitis
Leukopenia
Stomatitis

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Marrow suppression
GIT toxicity
Cirrhosis
Neuropathy
Cardiac toxicity

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MODIFIED RADICAL MASTECTOMY
ADVANTAGES OVER RADICAL MASTECTOMY
Cosmetically better accepted
Function of shoulder maintained
TYPES

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v Patey's operation
v Scanlon's operation
Modifications of
v Auchincloss' operation
Patey's operation

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PATEY'S OPERATION
Total mastectomy with clearance of al axil ary LN &
removal of pectoralis minor
SCANLON'S OPERATION
Pectoralis minor is divided to reach level l l LN

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AUCHINCLOSS' OPERATION
Pectoralis minor left intact.
Axil ary lymph node dissection done.
It is the currently done method.

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STEWART INCISION
? Oblique, elliptical incision angled
towards axilla
? Should include entire areolar complex
and previous scars if present

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? Should be 1 ? 2 cm away from the
tumour margin, 2 skin edges should be
of equivalent length

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EXTENT OF DISSECTION

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Medially , lat. Border of sternum
Laterally , mid axillary line
Superiorly , till clavicle
Inferiorly , till costal margin near insertion of rectus sheath

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STRUCTURES REMOVED

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?
Whole Breast With Tumour
?
Skin Over The Tumour
?

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Nipple-areola Complex
?
Pectoral Fascia
?
Fat , Fascia & LN Of Axilla

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STRUCTURES PRESERVED
-
Pectoralis major and minor
-
Bell's nerve ? Long thoracic nerve

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- Thoracodorsal trunk
- Medial and lateral pectoral nerve
-
Intercostobrachial nerve
-

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Axillary vein
-
Cephalic vein

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COMPLICATIONS OF MRM
Intra-op

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Bleeding
Injury to nerve
Early post-op
Chronic pain & numbness of UL
Wound infection

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Hematoma
Seroma
Flap necrosis
Late post-op
Lymphoedema and Lymphosarcoma

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Fibrosis
Frozen shoulder
Local recurrence

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RADIOTHERAPY

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HORMONAL THERAPY
TREATMENT OF INFLAMMATORY CARCINOMA
BREAST RECONSTRUCTION
Alfia Hussain
Roll No. 8

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RADIOTHERAPY
INDICATIONS
? Breast conservation surgery (breast Irradiation after surgery)
In LABC -

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? >4 positive Axillary lymph node.
? Level iii node , supraclavicular , internal mammary lymph node.
? Tumour size >5cm.
? Resection margin positive.
? Involvement of chest wall.

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? Lymphovascular invasion.
? Inflammatory carcinoma.

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MODES
EBRT(External Beam Radio Therapy)

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Given over breast area, axilla, supraclavicular, internal mammary
area.
BRACHYTHERAPY
Radiation source is placed inside or close to the area requiring
treatment.

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HORMONAL THERAPY
Administered only if ER/PR positive.
Gives prophylaxis against carcinoma of opposite breast.
IN PREMENOPAUSAL WOMEN

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?
Tamoxifen
?
Ovarian ablation by surgery / by LHRH agonist / by radiation
?

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Progestogens -- medroxyprogesterone 400 mg
?
Androgens -- fluoxymesterone

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In postmenopausal women
?

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Tamoxifen
?
Aromatase inhibitor like Letrozole 2.5 mg OD
?
Progestogens

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?
Androgens
?
Medical adrenalectomy using Mitotane

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TAMOXIFEN
It is a selective estrogen receptor modulator-SERM
Has anti estrogenic action in breast tissue & estrogenic action on other
tissues

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Dose- 20 mg/day for a period of 5 years.
Adverse effects- Hot flushing,weight gain,bone pain , amenorrhoea,
increased risk of thromboembolism, vaginal dryness & atrophy, endometrial
carcinoma

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LETROZOLE
In postmenopausal women estrogen is produced from androgens
secreted by adrenals
Inhibit aromatase enzyme that convert adrenal androgens to estrogen

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Dose-2.5mg /day for a period of 5yrs
Adverse effects- vaginal dryness, hot flushes, vaginal bleeding,
osteoporosis, cardiovascular problems

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TARGETED THERAPY -TRASTUZUMAB
Given in HER-2 / neu positive cases
Monoclonal antibody blocking HER-2/neu receptors on cell membrane.
Given as IV infusion.
Dose

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Loading - 4mg/kg
Maintenance - 2mg/kg/week for 1year
Adverse effect- Cardiac side effects.

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In LABC
? Radiotherapy is given pre operatively in case of non

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responders to chemotherapy to reduce size and
down stage disease and post operatively if indicated.
? Hormone therapy should be started in al ER/PR +ve
patients after completion of chemo and carried on
for 5yrs.

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? Targeted chemotherapy can be safely administrated
with neoadjuvant chemotherapy prior to
mastectomy.

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TREATMENT OF
INFLAMMATORY CARCINOMA

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Pre-operative :
? Chemotherapy
? External radiotherapy
Surgery whenever possible after that chemotherapy and
Tamoxifen is given.

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+/- Breast reconstruction

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BREAST RECONSTRUCTION

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IMMEDIATE
In early stages of malignancy or in more advanced stages where the
response to neoadjuvant chemotherapy is good. Not in LABC.
Advantages
- preservation of maximum breast skin envelope

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- psychological and economical benefit
Disadvantages
-radiation to prosthesis
-prolonged surgical procedure

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DELAYED

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Done 3-9 months after surgery
Indications
Locally advanced diseases
Post operative radiation is needed
Unfit for prolonged surgery

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Advantages

Avoids prosthesis exposure to radiation
Avoids fibrosis and fat necrosis in TRAM flaps

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Methods of Reconstructions

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? Breast implants or expander.
? Flap reconstruction.
? Combined flap and implant or expander.
? Oncoplastic techniques.

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SILICONE IMPLANTS
? most common type
? submuscular - placed below pectoralis major
? subcutaneous ? if RM done

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FLAP RECONSTRUCTION
? LATISSMUS DORSI FLAP-
? 1st mucocutaneous flap to be
used.
? Based on THORACODORSAL

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ARTERY

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TRAM FLAP
? Most commonly used flap
? Skin and adipose tissue composition

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are very similar between the breast
and the abdominal wall
? Based on superior epigastric artery
or free flap using microvascular
anastomoses of inferior epigastric to

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thoracodorsal vessel.

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COMBINED
? Prior tissue expansion using an expandable saline
prosthesis followed by replacement with silicon implant.

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? LD/TRAM flap and silicon implant.
? In order to create some ptosis for the reconstructed
breast

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NIPPLE-AREOLAR RECONSTRUCTION

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? Done 2 ? 3 months after initial surgery under local anesthesia
? Nipple is created from local flaps of breast mount or prosthetic nipple
? Areola pigmentation (after 3wks of nipple creation) created using Ful
thickness skin graft from hyperpigmented non hairy area of body(groin) or
by medical tattooing.

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EXTERNAL BREAST PROSTHESIS

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PROGNOSIS,
FOLLOW UP,
COMPLICATIONS

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ALIDA FRANCIS
ROLL NO. 9

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PROGNOSIS
? The best indicators of prognosis are
-Tumour size

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-Grade
-Lymph node status

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PROGNOSTIC FACTORS
GOOD PROGNOSIS
1.Absence of any LN involvement

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2.Stages I and II
3.Tumour size <1 cm
4.Histological grade ? classic lobular, tubular, cribriform ,
medullary , mucinous, papillary , adenoid cystic
5.ER + and PR + tumours

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BAD PROGNOSIS
1. Younger age(age<35 years)
2. Higher grade
3. Inflammatory ca.
4. Extensive in situ involvement

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5. Lymph nodal involvement(more than 3 histologically positive
nodes)
6. Ca. male breast
7. c-erb B2 (HER2/neu)
8. p53 tumour suppressor gene mutation

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9. Aneuploidy
10.Inner and lower quadrant tumours

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ELSTON ELLIS
MODIFIED SCARFF BLOOM RICHARDSON GRADING
1

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2
3
NUCLEAR
Smal
Intermediate

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Large
PLEOMORPHISM
Uniform
Nuclei
Prominent

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Nuclei
Nuclei
MITOTIC COUNT
<10% Mitosis 10-20% Mitosis >20% Mitosis
TUBULE

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75% Cel s In 10-75% Cel s In <10% Cel s In
FORMATION
Tubule Form Tubule Form
Tubule Form

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GRADING OF TUMOR

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G R A DE
S CORE
1 3-5
2 6-7
3 8-9

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Nottingham Prognostic Index
(.2xTumor size in cm) + grade+ stage
Tumor grade : EEMBR histologic grade of tumor
Lymph node stage:
0 nodes : stage 1

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upto 4 nodes : stage 2
>4 nodes : stage 3

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INTERPRETATION OF NPI
BASED ON 5 YEAR SURVIVAL

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>/=2 to </=2.4 : 93%
>2.4 to </=3.4 : 85%
>3.4 to </=5.4 : 70%
>5.4 : 50%

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FOLLOW UP

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* Patients with breast cancer should be followed for life to
detect recurrence and dissemination.
* Physical examination at regular intervals
* Self examination
* Yearly/ 2 yearly mammography of both breast

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* Bone scan/ CT chest, abdomen/ tumor markers- not
regular routine follow up

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COMPLICATIONS
1.ULCERATION 2.FUNGATION 3.METASTASIS

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DISCUSSION OF CASE SCENARIO
? 55 yr old postmenopausal obese female pt.
? Lump in Rt. Breast
? Recent retraction of nipple
? +ve family h/o breast cancer

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CARCI
CA N
RCIO
N M
OM A

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A B
BR R
EA EA
ST ST
? O/E, hard lump fixed to breast tissue

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Peau d'orange appearance
Nipple retraction & elevation
Skin nodules & skin fixity
STAGING:
Matted axillary LN

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STAG
T4bIN
N G
2 :aM0
? T4

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STAbGNE2a
II M
IB 0
LABC

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