Breast Carcinoma
Dr Bina Ravi
Associate professor and Consultant
Surgery
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What to know ?
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Incidence and risk factors
Clinical presentation
Spread –staging
Diagnosis
Treatment
Breast examination- clinician
How/ what to examine in breast -patient
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Risk factors
1.
2.
3.
4.
Geographical-western society
Early menarche, 11y
Age- increasing age
Pregnancy-nulliparity, late first childbirth 2x,
high risk > 35y
5. Family History -10% genetic, BRCA1& BRCA
2, ovary Ca
6. Benign Breast Disease – Atypical Hyperplasia
-4 times risk increased
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Risk Factors
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7. Cancer in other breast
8. High saturated fat in diet, alcohol
9. BMI- >35 pre/ post menopausal
10. Ionising radiation –after age 10
11. Exogenous hormone- oral pills,
hormone replacement therapy in
postmenopausal, DES in pregnancy
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Environmental
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Radiation –yes
Electromagnetic field –no
Pesticides -?
Lifestyle --Diet
Alcohol
Physical activity
Tobacco
Hormones - endogenous
• High hormone levels
• Post menopausal obesity
• Increased bone density
Hormones - exogenous
• HRT- yes
• Estrogen replacement therapy -?
• OCPs - no
Sites of cancer
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Prognostic Factors
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Chronological –
T size,
Ax LN metastasis
Stg I - 84%,
Stg II -71%,
Stg III - 48%,
StgIV -18%
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Biological Prognostic Factors
• Histology-Tubular, cribriform, mucinous,
papillary, microinvasive
• Grade- 1, 2, 3
• Lymphatic, Vascular invasion
• Proliferation markers
• DNA content- aneuploidy,diploidy
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AJCC Classification
• T – tumor
• N – lymph node metastasis
• M – distant organ metastasis
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TNM -T
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Tis- cancer in situ
T1-<2cm (1a,1b,1c)
T2->2cm-5cm
T3->5cm
T4a- chest wall
T4b- skin-ulcer,nodule, peau d’orange
T4c-T4a +T4b,
T4d- inflammatory Carcinoma
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TNM - N
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No- No nodes
N1- Palpable, mobile, ipsilateral Ax N
N2- Fixed involved ipsilateral Ax N
N3- Int Mammary nodes,supraclav
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M -metastasis
• Mo –no distant metastasis
• M1 – distant metastasis present – brain ,
bones( spine, ribs, long bones – path
fractures), lungs( lung infiltration, pleural
effusion , liver, pelvis and peritoneum
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Advantage of TNM staging
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Universal use
Popularity
Uniformity of clinical staging
Chronological age of disease
Determine prognosis of disease
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Infiltrating Breast Cancer
Breast cancer cells cross the lining of
the milk duct or lobule, and begin to
invade adjacent tissues. This type of
cancer is called "infiltrating cancer." In
this picture, you can see the breast
cancer cells invading the milk duct.
http://www.bcdg.org/
Breast cancer is
considered infiltrating
or invasive if the
cancer cells have
penetrated the
membrane that
surrounds a duct or
lobule.
This type of cancer
forms a lump that can
eventually be felt by a
physical examination.
Types of breast cancer
• In situ
– Intraductal (DCIS)
– Intralobular (LCIS)
• Invasive
– Infiltrating ductal carcinoma
– Tubular carcinoma
– Medullary carcinoma
– Mucinous carcinoma
Tis – In Situ carcinoma
Carcinoma in
situ:
Intraductal
carcinoma,
lobular carcinoma
in situ, or Paget’s
disease of the
nipple with no
tumor
• Tis - Carcinoma in
situ.
• Tis (DCIS) - Ductal
carcinoma in situ.
• Tis (LCIS) Lobular carcinoma
in situ.
• Tis (Paget’s) Paget’s disease of
the nipple with no
tumor
.
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Lobular carcinoma in situ/ invasive
restricted to an initial site (in situ) or
invasive.
In situ lobular carcinoma has the danger
of being initially diagnosed as hyperplasia
associated with fibrocystic breast
disease.
The invasive form - shows multiple sites
in the breast.
In most cases where both breasts are
involved, it is usually lobular carcinoma.
Paget’s disease of breast
• Rare condition almost always associated with
underlying breast cancer, usually invasive or
intraductal carcinoma.
• Associated with a red, scaly lesion on the nipple
and surrounding tissue, and there may or may
not be a discharge from the nipple.
• Sometimes in early stages of the condition it
may be misdiagnosed as eczyma, dermatitis or
psoriasis, if signs of the underlying cancer are
not readily apparent.
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Malignant phyllodes tumor
• Periductal stromal tumor- fibroepithelial
tumors
• Rare <1 % of all breast tumors
• Wide local excision –potential for
recurrence
• Mastectomy
Stage and Survival
Stage
5 yr survival
I
85 %
II
66 %
III
41 %
IV
10 %
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Clinical Presentation
• Painless lump- upper outer quadrant 60%
• Nipple retraction, nipple discharge, nipple
areola ulceration
• Peau d orange
• Ulceration/ chest wall fixation
• Axillary masses/ Lymphoedema of arm
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Abnormal signs and
symptoms
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Change in breast size
Pain or tenderness
Redness
Change in nipple position
Scaling around nipples
Sore on breast that does not heal
Abnormal signs and symptoms
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Puckering
Dimpling
Retraction
Nipple discharge
Thickening of skin or lump or “knot”
Retracted nipple
Clinical presentation - mets
• Brain- visual , headaches, vomiting,
seizures
• Lungs –dyspnoea, cough with, without
hemoptysis,
• Bones –pains, fractures, paraplegia
• Liver- anorexea, wt. loss, jaundice
• Peritonium- distension , obstruction,
masses –pelvis tumor
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Clinical examination
• Performed by doctor or
trained nurse practitioner
• Annually for women over
40
• At least every 3 years for
women between 20 and
40
• More frequent
examination for high risk
patients
Nipple retraction
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Palpable lump :
• Mammography to view other breast as
well.
• 9-69% LCIS in opposite breast
• Multi-centricity 44(Mx)-84(MR)%
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LUMP - Triple assessment
• Clinical breast exam by surgeon
• Imaging – Mammogram +/- ultrasound
• FNAC (fine needle aspiration cytology)
and Tru cut biopsy
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Investigations
• Mmg, USG,MRI, FNA, Core Biopsy• Tissue tumor markers –ER PR, HER2 neu
• Chest X ray, CT scan (Chest and
abdomen), skeletal survey
• ABC – CT, PET, Bone scan/ Skeletal
survey, CA- 125
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MRI : in staging
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Tumor size
No under estimation of size
Mammography:14%
US :18%
Most accurate assessment of size
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Thermograph
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Thermograph is one of the newest
ways to detect breast cancer.
Thermograph is a thermal image
of the breast tissue.
It can also detect cancer before
the traditional mammogram can.
www.breastthermography.com
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Picture from breastthermography.com
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Stage 1
• Tumor < 2.0 cm in
greatest
dimension
• No nodal
involvement (N0)
• No metastases
(M0)
Stage II
• Tumor > 2.0 < 5 cm
or
• Ipsilateral axillary
lymph node (N1)
• No Metastasis (M0)
Stage III
• Tumor > 5 cm (T3)
• or ipsilateral axillary lymph nodes
fixed to each other or other structures
(N2)
• involvement of ipsilateral internal
mammary nodes (N3)
• Inflammatory carcinoma (T4d)
Stage IV (Metastatic breast
cancer)
• Any T
• Any N
• Metastasis (M1)
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Mets in scapula – PET CT
Treatment
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Multi disciplinary team management
Surgeon
Radiologist
Pathologist
Medical Oncologist
Radiation Oncologist
Oncology Nurse/ Psychologist
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surgery
Radiotherapy
Psycho
Chemotherapy
Hormones
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Treatment
• Stage I and Stage 2
• Surgery –Breast conservation therapy
• Gold standard for T I, T2 and downstaged
By (neoadjuvant) Stage T3
• Radiotherapy
• Adjuvant systemic therapy
• Chemotherapy / Hormone
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Radical mastectomy
Modified radical mastectomy
Simple mastectomy
Segmental resection
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Axillary dissection
• To stay
• L1, L2
• L3 when indicated
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The Sentinel node
Gamma probe or naked eye
With dye, With isotope
Best results with combination of isotope and dye
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Sentinel node biopsy
Gamma probe
Mastectomy
Stage 3, 4
• Neoadjuvant chemotharapy- anthracyclin
• Breast Conservation Surgery or Modified
Mastectomy
• Radiotherapy/ chemotherapy/ hormone
• LR- ax- supraclavicular
• Inflammatory Ca- chemotherapy- surgeryRadiotherapy
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Chemotherapy- drugs
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Cyclophosphamide
Anthracyclins
Taxanes
Methotrexate
5 Flourouracil
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Types of Chemotherapy
• Neo adjuvant chemotherapy – drugs
given before surgery for local control of
tumor
( reduce the size)
• Adjuvant chemotherapy – drugs given
after surgery
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Targeted therapy
• Her 2 neu receptors + ve
• Herceptin-Trastuzumab – monoclonal
antibodies against Her 2 receptor
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Anti Hormones
• Estrogen +ve and Progesterone +ve
(receptors)
• antiestrogen drugs
• Tamoxifen, Raloxifen
• Aromatase inhibitors -postmenopausal
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Radiation Therapy
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After Breast conservation therapy
After Mastectomy –
Brachytherapy- on the table
Teletherapy- upto 6 weeks
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Genes
• Lack of Suppressor genes
–Inherited = Germ line
–Acquired = Somatic
–Gene mutation, deletion,
–Loss of expression = silencing
• Proto-Oncogene activation
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Predictors of Micromets
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TNM stage
Histological subtype
Gene amplification – neu, C-myc
Number of positive lymph nodes
Nuclear grade
Proliferation index
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Physical examination-Breast
• Inspection
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Physical examination-Breast
 Palpation
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Clinical examination- axilla
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Clinical examination- axilla
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Thanks
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Screening
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Clinical Breast Examination
Breast Self Examination
Ultrasonography
Mammography-50-70yrs most beneficial
Frequency- 2-3 yrs
Localisation- guidewire,FNA, core biopsy
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Screening: Current view
FREQUENCY OF SCREENING
• Should be 2 yrs
• Lead time is 3 yrs
• Steep rise in interval cancer rates in
3rd yr
• Annual screening finds less cases
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Screening: Current view
screening in < 50 yrs
• 36%-45% reduction in mortality
• Short lead time in younger – 2.26yrs
• More frequent screening required
• Less cost effective
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LN and survival
Axillary LN 5 yr
10 yr
survival % survival %
78.1
64.9
+
46.5
24.9
1–3
62.2
37.5
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13.4
>4
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Group
Very low
risk
Low risk
High risk
Locally
advanced
Metastatic
5-yr
Example
survival
> 90 % DCIS
Rx
70-90% No +
favourable
histopatholoy
< 70% N+ /
unfavourable
pathology
< 30% Inflammatory/
large primary
Locoregional
 systemic
---
Local
Locoregional
+ systemic
Primary
systemic
Primary
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1997 vs. 2002
N3a →
Excluded
N3a →
Metastasis in
Ipsilateral
Infraclavicular
lymph node (s)
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1997 vs. 2002
N2b –
Excluded
N2b →
clinically apparent
ipsilateral internal
Mammary nodes in
the Absence of
clinically evident
axillary lymph node
metastasis.
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1997 vs. 2002
N3b –
Excluded
N3b →
Metastasis in
ipsilateral
internal mammary
and
axillary lymph
nodes
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1997 vs. 2002
N3c –
Excluded.
N3c →
Metastasis in
Ipsilateral
Supraclavicular
lymph node(s)
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AJCC 2002
infraclavicular lymph nodes
=
N3
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supraclavicular lymph nodes
• N3
• M1
√

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1997 vs. 2002
Stage I T1 N0 M0
Same
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1997 vs. 2002
Stage IIA
• T0 N1 M0
• T1 N1 M0
• T2 N0 M0
Stage IIA
• T0 N1 M0
• T1 N1 M0
• T2 has been
removed
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1997 vs. 2002
Stage IIB
• T2 N1 M0
• T3 N0 M0
Stage IIB
• T2 N1 M0
• T3 has been
removed
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1997 vs. 2002
Stage IIIA
1. T0 N2 M0
2. T1 N2 M0
3. T2 N2 M0
4. T3 N1 M0
5. T3 N2 M0
Stage IIIA
1. T0 N2 M0
2. T1 N2 M0
3. T2 N2 M0
4. T3 N1 M0
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1997 vs. 2002
Stage IIIB
1. T4 Any N M0
2. Any T N3 M0
Stage IIIB
1. T4 N0 M0
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1997 vs. 2002
Stage III c
Excluded
Stage IIIC
• Any T N3 M0
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1997 vs. 2002
Stage IV
Stage IV
• Any T Any N M1 • Any T Any N M1
• T4 N2 M0
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Prognostic Factors In Breast
Cancer - Beyond TNM
Traits of a Naughty Cell
1. Genes
2. Adhesion
3. Invasion
4. Proliferation
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Genes
• Lack of Suppressor genes
–Inherited = Germ line
–Acquired = Somatic
–Gene mutation, deletion,
–Loss of expression = silencing
• Proto-Oncogene activation
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US guided Vacuum assisted biopsy
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Ductal lavage & ductoscopy
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Ductal papilloma seen by
Ductoscopy
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Ductoscopy
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Digital mammography
•  Recall rates 11% vs. 15%
• Less biopsies
• further studies required
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MRI
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Gadolinium :0.1 mmol/kg
80%-100% SENSITIVE
> 80% SPECIFIC
Uses morphological and physiological
properties
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FDG-PET
• Sensitivity 70-90%
• Specificity 85-95%
• Good predictive value to response of neoadjuvant chemo
• Detecting ER,PR,Axilla,Mediastinal LN
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Screening: Current view
> 70
yrs
• No randomised trials shown
mortality benefit
• No conclusive evidence
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Digital mammography
DISADVANTAGES
• HIGH COST
• LIMITED RESOLUTION OF
DISPLAY MONITOR
• LIMITED STORAGE
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MRI : DCIS AND EIC
• 77% sensitive
• Relative insensitive for microcalcification
For EIC
• 81% SENSITIVE : mammography-62%
• 93% specific: mammography- 81%
• reduce positive margins after BCT
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Digital mammography
• Records images in digital format
Advantages
• Manipulation possible
• Teleradiology possible
• Used in CADD
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MRI: Multicentricity& multifocality
Multifocal
• 60-100% sensitive
Multicentric
• 95-100% sensitive
• 82-97%specific
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MRI: neoadjuvant CTX
• 97% SENSITIVE
• MR-RODEO specially useful
• Most accurate method to assess
response to CTX
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Axilla
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The Sentinel node
Gamma probe or naked eye
With dye, With isotope
Best results with combination of isotope
and dye
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Non-Palpable lesion: 99mTc
Sestamibi / Tetrafosmin Scan
• Sensitivity for T1a=26%
• Sensitivity for T1b=56%
• Sensitivity for T1c=95%
• Sensitivity for T2=97%
(T1a=0.1 to 0.5, T1b=0.5 to1, T1c=1 to2,
T2=2-5) cm
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Staging system 6th AJCC
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Micromets- IHC, RT PCR 0.2 to 2mm
Isolated tumor cells <0.2mm
Total n of LN, 1-3, 4-9, >10, LN>2mm
Supraclavicular LN
Infracclavicular LN
Sentinel LN
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Summary of 6th AJCC
• Micrometastases
• number of involved axillary lymph
nodes (H/E or IH)
• Infraclavicular lymph nodes = N3
• Supraclavicular lymph nodes
= N3 √
( not M1any more)
• Internal mammary nodes
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Breast conservation
• Gold standard for T I, T2 and downstaged
By (neoadjuvant) Stage T3
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New Rx
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Laser Interstitial
RF ablation
Cryo
Vacuum assisted excision biopsy
Focused high frequency US
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Axillary dissection
• To stay
• L1, L2
• L3 when indicated
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Adjuvant RT
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Intra op
Pre op
Post op
Markers showing resistance to RT
(Cyclin D1, Neu & EGFR)
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Current Recommendations FOR
HRx
• St Gallen Consensus Statement 2000
• Endocrine treatment for HR + tumors
• Ovarian ablation with or without tamoxifen for
node –ve, medium or high risk
• Ovarian ablation with tamoxifen for node positive
disease
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Drug Resistance
•  resistance to CMF if  erbB 2
•   erbB 2 – use Doxorubicin
•  HSP 27   Doxorubicin resistance
 treatment with Toremifene
(Doxorubicin resistance removed )
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Hormonal Resistance
•  EGFR -  Resistance to
Tamoxifen
•  PS2 -  response to hormone
(ER+, PR+ but PS 2 -ve)
•  Cathepsin D indicate response to
endocrine therapy
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Predictors Of Efficacy Of
Systemic Adjuvant Therapy
• Hormone Receptors ER , PR
• neu Amplification =  response to
doxorubicin
• P 53 Mutations
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Predictors Of Organ – Specific
Metastases
• PTHrP-expression  marrow
• Vimentin  Visceral
• L-myc Polymorphism  lung mets
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Predictors of Micromets
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TNM stage
Histological subtype
Gene amplification – neu, C-myc
Number of positive lymph nodes
Nuclear grade
Proliferation index
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Radiation Resistance
• Cyclin D1
• Her 2 = neu
• EGFR
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Prognostic Indicators In N-•
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HSP 27
 C-MYC
 P 53
 Nm-23
 angiogenesis
Integrin
UPA ; PAI
•Cathepsin D
•PS-2
•EGFR
•erbB-2
•AGNORS
•Familial syndromes
•S- Phase fraction
= POOR PROGNOSIS
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Non-Palpable lesion:MR>Mx
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Multi-centricity,
tumor size,
multifocality,
dense breast tissue
Local recurrence in conserved breast
Residual disease in conserved breast
Assess response to neoadjuvant chemo
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Non-Palpable lesion:
• Mx as screening 30% reduced mortality
in 50-64y
• (??<49= √√ Selected high risk
• MR-CE RODEO as better alternative to
those who can afford.
• Sestamibi Scan to localize intraoperative and pre-biopsy stereo-tactic
localisation.
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Stewart Incision
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Anatomy of Axilla
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Preserve vessels &
nerves
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Drain Placement
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Incisions
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Incisions on Breast
curvilinear
radial
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Subareolar Incision
Subareolar incision
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Penrose drain
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Inframammary incision
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Scientific basis of
symptoms and signs in
breast diseases
Dr Bina Ravi
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Common manifestations of
breast diseases
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Pain
Lump
Nipple discharge
Changes in the nipple and/or areola
Changes in breast size and shape
Chronic pus discharging sinus
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Pain and tenderness but no
lump
• Cyclical mastalgia
– Premenstrual enlargement of the breast under
the influence of estrogen and progesterone.
• Non cyclical mastalgia
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Painless lump
• Carcinoma
• Cyst
• Fibroadenoma
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Lump
•
Solid lump
– Carcinoma
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•
•
Original transformed cell is approx. 10 µ
Must undergo atleast 30 duplications to
produce 109 cells ; a size of 1 g clinically
detectable smallest size
Only ten further doublings needed to produce
a tumor containing 1012 cells weighing approx
1 kg
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BREAST LUMP
– Differences in cell kinetics between
malignant and benign cells
• Higher proportion of cells in the dividing
phase
• Increased life span of the cells
• A relatively prolonged or normal cell
cycle time
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Cysts
• Normally integrated involution of breast
stroma and epithelium occurs with aging .
• The involution of stroma occurring faster
than that of epithelium results in
persistence of alveoli which form
microcysts.
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Painful lump
• Breast abscess
• Cyst
• Periductal mastitis
• Rarely a carcinoma
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Breast abscess
• Acute
– Lactational
– Nonlactational
• Periductal mastitis/duct ectasia
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Chronic breast abscess/pus
discharging sinus
• Tuberculosis of breast
– Bacilli reach the breast from
• Axillary/ mediastinal/ cervical lymph nodes
• Directly from underlying ribs
– Axillary or breast sinus in 50% of cases
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Changes in breast size and
shape
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Pregnancy
Carcinoma
Benign hypertrophy
Rare large tumors
Gynecomastia
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Gynecomastia
Gynecomastia
Neonatal
period
Physiological
Pathological
Adolescence
Senescence
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Physiological gynecomastia
• Excess of circulating estrogen in
comparison to circulating testosterone.
– Neonatal: placental estrogens
– Adolescence: excess of estradiol relative to
testosterone
– Senescence: fall in circulating testosterone
levels and a relative hyperestrinism.
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Pathological gynecomastia
• Hormonal disorders
• Drugs with estrogenic activity- digitalis,
estrogens, anabolic steroids, marijuana
• Drugs that enhance estrogen synthesishCG
• Drugs that inhibit the action or synthesis of
testosterone-cimetidine, ketoconazole
spironolactone, phenytoin.
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Abnormality in the nipple and/or
areola
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Accessory nipples/ breast
Nipple inversion
Nipple retraction
Nipple discharge
Paget’s disease / eczema
187
Accessory nipples
• Around fifth week of
fetal development, two
ventral
bands
of
thickened
ectoderm
evident in the embryo.
188
Accessory nipples
• In most mammals, paired breasts develop along
these ridges, extending from the future axilla to
the future inguinal area.
• These ridges not prominent in the human
embryo and disappear except for a small portion
which may persist in the pectoral region.
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Accessory nipples
• Polymastia
(accessory breasts )
and polythelia
(accessory nipples)
may occur along the
milk line when normal
regression fails.
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Nipple inversion
•
Condition in which the nipple is pulled in.
– Congenital
– Acquired
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Congenital
nipple inversion
– Ingrowth of ectoderm forms a primary tissue
bud in the mesenchyme.
– The primary bud initiates the development of
15 to 20 secondary buds.
– Epithelial cords develop from these and
extend into the surrounding mesenchyme.
192
Congenital
nipple inversion
– Major ducts develop which open into a
shallow mammary pit.
– During infancy a proliferation of the
mesenchyme transforms the mammary pit
into the nipple.
– Inverted nipple results from failure of the pit
to elevate above the skin.
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Acquired nipple inversion
• Disorder of development of major
lactiferous (subareolar) ducts which
prevents the normal protrusion of the
nipple
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Nipple retraction
•
When a part of the nipple is drawn in at the
site of a single duct
•
Acquired causes in order of frequency
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–
–
–
–
Duct ectasia
Periductal mastitis
Carcinoma
Fat necrosis
Tuberculosis
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Nipple retraction
• Lesions in a major lactiferous duct result in the
shortening of the duct
• This results in the nipple being pulled towards
the side of lesion.
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•
Displacement- cranial/caudal variation in
the position of the nipple with reference
to the normal position of the nipple.
•
Deviation- medial/lateral variation in the
position of the nipple
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Nipple discharge
• Discharge from multiple ducts
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


Pregnancy
Lactation
Hormonal
Drug induced
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Single duct

Blood or blood tinged discharge
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

Carcinoma and
Duct papilloma.
Brown, green or black discharge

Duct ectasia


Dilatation of ducts with stasis of secretions and
secondary infection
Discharge of the infected secretions and debris.
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Mammary fistula
• Communication
between a major
subareolar breast
duct and the skin
• Skin opening usually
periareolar
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Mammary fistula
• Cause
– Drainage of non lactational breast abscess
– Spontaneous discharge/ after biopsy from
periductal mastitis
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Paget’s disease
• Epidermotropic theory
• Intraepidermal
transformation theory
• Vs. eczema
202
Skin changes
• Dimpling/puckering
• Satellite nodules
• Peau d’ orange
• Ulceration
203
Dimpling/puckering
• Seen in
– Carcinoma breast
– Fat necrosis
• Fibrotic shortening of the ligaments of
Astley Cooper - fibrous bands of
connective tissue that separate various
breast lobules and insert into the dermis
perpendicularly.
204
Tumor tethering to skin
• Most lumps can be
moved within the arc
as shown without
moving the skin.
• When the lump is
pulled outside the arc
the skin indents.
205
Tumor tethering to skin
• The skin can not be lifted off the tumor
mass.
• Tethered lesions pucker and pull the skin
inwards by distorting the fibrous septa.
206
Fixity to skin
• If a lump cannot be
moved without
moving the skin, it is
fixed to the skin.
• Implies that the
tumor has invaded
the skin.
207
Fixity to skin
• Plateau sign
208
Ulceration
• Direct invasion of the skin in continuity
209
Peau d’ orange
• Usually occurs as a
result of obstruction of
the dermal lymphatics
with the tumor cells.
• Edema of the skin
deepens the mouth of
the sweat glands and
the hair follicles
210
Peau d’ orange
• Can also be caused
by extensive axillary
lymph node
involvement
– Metastatic tumor
– Primary diseases of
the axillary nodes
– Axillary dissection
211
Satellite nodules
• Invasion of multiple
areas of skin by the
cancer cells
• Results from
retrograde
embolization of tumor
cells from the involved
lymphatics
212
Loss of infraclavicular hollow
• Enlargement of the
apical
(infraclavicular)
group of lymph
nodes .
213
Lymphedema
• Brawny edema usually
due to extensive
neoplastic infiltration of
the axillary lymph nodes
• May also result from
destruction of lymphatics
after axillary dissection or
radiotherapy.
214
Cancer en cuirasse
• Characterized by
multiple cancerous
nodules and
thickened infiltrated
skin like a coat of
armour in the arm
and the chest wall.
215
Bone pains
• Occur in cases of breast cancer with distant
skeletal metastasis
• Commonly lumbosacral vertebrae, pelvis ,
femur.
• Metastasis to the vertebral column
• Vertebral plexus of Batson communicates with
the posterior intercostals veins which drain a
part of the breast.
216
Brachial plexopathy
• Tumor infiltration into the brachial plexus.
217
Brachial plexopathy-Pain
• 85% of cases.
• Distribution depends on the site of plexus
involvement.
• Typically radiates in the sensory
distribution of the lower plexus
218
Brachial plexopathyParesthesias
• Seen in 15% cases
• Distribution
– Ulnar-with infiltration of the lower plexus or
– Median nerve distribution with lesions of the
upper plexus
219
Postoperative loss of cutaneous
sensation
•
•
•
Intercostobrachial nerve , the lateral
cutaneous branch of the second
intercostal nerve
Usually sacrificed during axillary
dissection.
Supplies the skin over the medial aspect
of the arm.
220
Physical examination-Breast
• Inspection
221
Physical examination-Breast
 Palpation
222
Clinical examination- axilla
223
Clinical examination- axilla
224
Hearing the words ….
“ you have breast cancer ”
is an overwhelming and
commonly devastating
experience .
225
226
• Breast cancer requires a multi-specialty
or multidisciplinary approach .
• Tailored to the patient's :
- Stage at presentation .
- Breast conservation or reconstruction .
- Estimation of risk of recurrence .
- Benefits and toxicities of adjuvant
therapies .
227
228
The management will depend on :




Tumor Stage .
Menopausal status .
Hormone receptor status .
Treatment preferences .
229
230
Breast cancer is an ancient disease ,
described by the Egyptians “3000 years”
Subsequently various articles about breast
cancer and its treatment “Greek &Roman”
Surgery “oldest method” .
Changing fashions in the treatment
EVOLUTION OF
TREATMENT
231
Empiric
era
Presimistic
era
optimistic
era
Realistic
era
232
Pre Galen period .
Hippocrate “ NO Rx ” .
Extensive surgery “ Roman ”.
233
Galen period
“ 131 -203 AD ”
Excess black bile .
Excision + control Hemorrhage Avoid ligature .
Dark ages .
Amputation .
Breast ca arose when LN coagulated “Hunter 1728 -93”
234
Breast ca started localy
LN
systemic
En block resection
“ henry ,
1757 ”
“ Bernard , 1773 “
19th century , GA & antiseptic .
Mortality 20 %.
Recurrence “ Moore , 1867 ”.
Halsted mastectomy “ Recurrence , cure “ .
• Halsted Extension .
235
236
Not
curable
Morbidity
Prevention
Early
diagnosis
Medical
oncology
Biology of
Breast ca
237
1st randomized control study , conservative vs
radical mastectomy “ Guey’s 1972 ”
Survival :
No difference Stage I
Worse Stage II
Delay conservative surgery
contradict believes local control didn’t
influence survival .
238
• Canadian , 1997 studies highlighted the
importance of local control on survival &
suggest :
* Micrometastases in locoregional
lymphatics
systemic metastases .
* Eradication of locoregional metastases
improves survival.
239
240
241
Wide Local excision + Radiotherapy +
LN dissection .
Complete excision with free margin .
Cosmetic .
242
•
•
•
•
•
•
•
•
Tumor < 2cm .
Tumor / breast ratio .
Limited extension .
Not multicenteric
No LAP .
low grade .
+ve receptors .
-ve margin .
243
ABSOLUTE
 Multicentric .
 Diffuse microcalcification.
 +ve margin.
RELATIVE
 Collagen disease.
 Pregnancy .
 Previous irradiation.
244
OVERALL SURVIVAL
100
MASTECTOMY
BCT
80
60
40
20
0
WHO
MILAN
1972-79 1973-80
NSABP
NCI
EORTC DENMARK
1976-84 1979-89 1980-86 1983-89
245
246
1851 women / 20 years
247
248
249
Cosmetic
Psychology
Survival
Recurrence
Rx
duration
Cost
250
Eighteen-year results in the treatment of early
breast carcinoma with mastectomy versus breast
conservation therapy
Radiation Oncology Branch, National Cancer Institute,
Bethesda, Maryland, USA.
After follow-up :
- No difference in overall or disease-free survival in
BCT / mastectomy
- No significant difference in the incidence of
contralateral breast carcinoma
Poggy MM et al
Cancer August , 2003
251
European Organization for Research and Treatment
of Cancer , 10801 trial
Department of Surgery, The Netherlands Cancer Institute,
Amsterdam.
BCT and mastectomy demonstrate similar
survival rates in a trial in which the
great majority of the patients had stage
II breast cancer.
Van Dongen et al
J Natl cancer inst. ,2000
252
253
Decision belongs to each
woman to make , and her
personal issues are most
important .
Regardless of the final
decision those women who
are actively involved are
most satisfied with Rx
outcome .
254
255
External beam
Brachytherapy
256
Accelerated partial breast irradiation “ABPI” .
HDR , LDR .
Advantage :
Convenience .
 Short duration of RX .
 Localized area .

257
258
* Previous studies show that local
recurrences after breast-conserving
treatment occur in the site of the primary
tumor.
* The need for postoperative radiotherapy on
the whole breast is challenged in favor of
radiotherapy limited to the area of the breast
at high risk of recurrence .
259
Full-dose intraoperative
radiotherapy with electrons during
breast-conserving surgery.
Office of the Scientific Director, Milan, Italy.
 Intraoperative RT reduces irradiation to the
skin, subcutaneous tissue, and contralateral
breast and lung.
 It appears to be a promising method for
irradiating conservatively treated breasts .
 Avoids the long period of postoperative RT
Arch Surg. 2003 Nov;
Veroesi et al
260
Local recurrence rates in breast cancer
patients treated with intraoperative
electron-boost radiotherapy versus
postoperative external-beam
electron-boost irradiation
Department of Senology, General Hospital, Salzburg, Austria.
 Immediate IORT boost yielded :
- Excellent local control figures.
- Superior to conventional postoperative
boost in a short-term follow-up.
Strahlenther Onkol. 2004 Jan.,
Reitsamer et al
261
d/t:
Localy advanced disease
Eligibilty issues for
radiotherapy .
262
Verily to Allah,belongs what He took and to
him belongs what He gave , and every thing with
Him has an appointed time … and then He
ordered for her to be patient and hope for Allah is
reward.
263
T0 No evidence of tumor
TIS CIN
T
T1 Tumor < 2 cm
T2 Tumor 2 – 5 cm
T3 Tumor > 5 cm
Tumor of any size with direct
extension to the chest wall or skin
N0 No lymph node involvement
N
N1 Movable ipsilateral axillary LN
N2 Fixed ipsilateral axillary LN
N3 ipsilateral internal mammary LN
M
N0 No distant metastasis
N1 Distant metastasis
264
STAGE 0
STAGE I
STAGE II
II a
II b
STAGE
III
II a
TIS N0
M0
T1 N0
M0
T0 N1
T1 N1
T2 N0
M0
M0
M0
T2 N1
T3 N0
M0
M0
T0
T1
T2
T3
M0
M0
M0
M0
N2
N2
N2
N1,2
T4 Any N M0
AnyT N3 M0
AnyT Any N M1
265