THE BREAST
Dr.JAMIL SAWAKED
ANATOMY
TERES MAJOR
LATISSIMUS DORSI
SERRATUS ANTER
FAT
LOBE
MAJOR LACT.DUCT IS
THE SITE OF DUCTAL CA.
RIBS
&intercost.m
AMPULLA
PECTORALIS
MAJOR
20 MAJOR
LACT.ORIFICES
LACTOCYTE
THEIR CONTRACTION CAUSES SKIN
DIMPLING
PEAU d`ORANGE IS DUE TO OEDEMA OF
SKIN LYMPHATIC
DUCT SYSTEM
MAJOR DUCT
[MINOR] OR
[ TERMINAL]
MINOR DUCT IS THE
SITE OF LOBULAR
CARCINOMA
APICAL
CENTRAL
LATERAL
SUBSCAP.V
RPOSTERIO
PECTORAL
LAT.THOR.V
SENTINEL
L.N
LONG THORACIC N
85% OF THE
BREAST DRAIN
INTO THE AXILLA
SUPERIOR
THORACIC V.
INTERNAL
MAMMARY L.N.
IF IT IS FILLED WITH
MILK IT IS GALACTOCELE
MASTITIS;PLUGGED DUCT OR CRACKED
NIPPLE,[STAPHYLLOCOCCI]
ABSCESS
60% OF MASTITIS IN
LACTATING WOMEN
TYPES OF MASTITIS







MASTITIS NEONATORUM
MASTITIS OF PUBERTY
LACTATING MASTITIS
SPECIFIC MASTITIS;
1-T.B MASTITIS
2-SYPHILITIC MASTITIS
3-ACTINMYCOSIS
BENIGN BREAST DISEASE





FIBROADENOMA
FIBROCYSTIC DIS
DUCTECTASIA
BENIGN CYSTS
LIPOMA:VERY RARE
[DANGEROUS TO DIAGNOSE LIPOMA]
FIBROADENOMA
BREAST
MOUSE
SMALL ONES COULD BE
LEFT ALONE
Giant fibroadenoma> 5 CM
CAN BECOME MALIGNANT
DUCTECTASIA
CYSTOSARCOMA
PHYLLOIDES
 THOUGHT TO BE MALIGNANT
[NOTICE THE NAME] BUT IT IS NOT.
MAY REACH HUGE SIZE &ULCERATE
HOWEVER THERE ARE WORRYING
MITOTIC FIGURES SOMETIMES
DENOTING MALIGNANT POTENTIAL
FIBROCYSTIC DISEASE[ANDI]
BLUE DOMED CYST
WHEN A BENIGN BREAST
DISEASE BECOMES WORRYING?
 WHEN A PATHOLOGY SPECIMEN
SHOWS ATYPICAL HYPERPLASIA
 FLORID HYREPLASIA CARRIES AMILD
RISK
 NB;METAPLASIA
AND MILD HYPERPLASIA CARRY
NO RISK
CYSTS








ANDI
LYMPHATIC CYSTS
HYDATID CYST
GALACTOCELE
SEROCYSTIC DISEASE OF BRODIE
INTRACYSTIC PAPILLIFEROUS CA
COLLOID DEGENERATION OF CA.
PAPILLARY CYSTADENOMA
CYSTS
 BENIGN
 MALIGNANT
MANAGEMENT OF A CYST
ASPIRATE & OPERATE OR CORE BIOPSY IF;
1-BLOODY ASPIRATE
2-DID NOT DISAPPEAR COMPLETELY AFTER
ASPIRATION
3-RECURES IN 6 WEEKS
NIPPLE DISCHARGE
 I=NONBLOODY;
1-FIBROCYSTIC DISEASE
2-DUCTECTASIA
 II=BLOODY;
1-DUCTECTASIA; COMMON
2-DUCT PAPILLOMA; MOST COMMON
3-DUCT CARCINOMA;VERY RARE
BLOODY NIPPLE
DISCHARGE
NORMAL DUCT
DUCT PAPILLOMA
MICRODOCHECTOMY
FOR BLEEDING NIPPLE
BLEEDING SEGMENT IS REMOVED AND
SUBMITTED TO HISTOPATHOLOGY
PROBE
DETERMINE FIRST WHICH ORIFICE OR SEGMENT IS BLEEDING
BY PRESSING AROUND THE AREOLA
BREAST CANCER
1.
2.
3.
4.
5.
DUCTAL CARCINOMA [90%]
LOBULAR CARCINOMA[<10%]
PAGET`S DISEASE
INTRACYSTIC PAPILLIFEROUS CA
SARCOMA
What Are the Risk Factors
for Breast Cancer?
 1-Age;INCREASING
INCREASINGAGE
AGE
1-Age;
 25:1/20,000.
2-Race;WHITE++.RARE
45:1/100. 50:1/50.
IN JAPAN,
55:1/33. 60:1/24. 80:1/10.
2-Race;WHITE++.RARE
IN JAPAN,
 3-Individual or family history
of breast cancer
3-Individual
history
of breast cancer
 4-A historyor
offamily
ovarian
cancer
4-A
ofpredisposition
ovarian cancer(mutations to the BRCA1 or
 5-Ahistory
genetic
5-A
genetic
predisposition
(mutations
to the BRCA1
BRCA2
genes
cause 2% to
3% of all breast
cancers)or
BRCA2
genesexposure;MENARHE,MENOPAUSE
cause 2% to 3% of all breast cancers)
 6-Estrogen
6-Estrogen
 7-Atypical exposure;MENARHE,MENOPAUSE
hyperplasia of the breast
7-Atypical hyperplasia of the breast
 8-Lobular carcinoma in situ (LCIS)
8-Lobular carcinoma in situ (LCIS)
9-Lifestyle
9-Lifestylefactors
factors(obesity,
(obesity,lack
lackofofexercise,
exercise,alcohol
alcoholuse
use)
)
10-Radiation
10-Radiation
About 15%?[3-15]of breast cancers are inherited
Approximately 80% of hereditary breast cancer is
caused by mutations in the BRCA1 or BRCA2
genes.P53 has a role too
Women who inherit a BRCA mutation have a 50%
to 85% chance of developing breast cancer in
their lifetime
Women with especially strong family history may
consider preventive surgery to remove breast
tissue and/or chemoprevention
Several other genetic syndromes can increase
breast cancer risk
SITES
LT.BREAST
12%
60%
12%
6%
10%
RT.
LT.
60
60
6
6
MODE OF SPREAD OF
DUCTAL CARCINOMA
 LOCAL
 LYMPHATIC
 BLOOD; BONE
1-LUMBER V.
2-FEMUR
3-THORAC V.
4-RIBS
5-SKULL
SOFT TISSUE
1-LIVER
2-LUNG
3-BRAIN
4-KIDNEY
5-ADRENALS
DIAGNOSIS
TRIPLE ASSESSMENT
 1-CLINICAL:
A-AGE .
B-EXAMINATION
 2-IMAGING :
A-US .
B-MAMMOGRAM
 3-PATHOLOGY: A-FNA.
B-CORECUT
FNA & CORECUT
 FNA [CYTOLOGY
EXAMINATION] HAS 5% FALSE
–VE MOSTLY DUE TO
SAMPLING ERROR
 CORECUT [TRUCUT] IS A
TISSUE HISTOPATHOLOGY
THAT IS MORE ACCURATE
AND TELLS YOU ABOUT
THE GRADE & INVASIVENESS;
IN-SITU OR INVASIVE
MAMMOGRAM
MALIGNANT
 1-CALCIFICATION;
CLUSTER[5-6] OF BRANCHED FINE
MICROCALCIFICATION
 2-ARCHITECTURAL CHANGES;
SPIKY DENSE IRREGULAR MASS
BENIGN
WELL DEFINED ROUNDED MASS WITH
HALO SIGN; CYST,FIBROADENOMA
MAMMOGRAM
CONVENTIONAL & DIGITAL
 IT IS NON USED FOR YOUNGER
WOMEN BECAUSE THEIR DENSE
BREAST TISSUE GIVES FALSE
POSITIVE RESULTS
 BUT IT IS GOOD FOR THE SOFT
BREASTS BECAUSE THE GLANDULAR
TISSUE IS SEPERATED BY FAT PLANES
FIBROADENOMA ON
MAMMOGRAM
MRI
IS THE MOST SENSITIVE
1- CAN PICK UP CARCINOMA IN-SITU
2- DIFFERENTIATES BETWEEN LOCAL
RECURRENCE AND FIBROSIS
MRI
 NO RADIATION BUT MAGNETIC FIELD
 1-CAN VISUALIZE A PALPAPABLE MASS WHICH IS NOT SEEn
ON U/S OR MAMMOGRAM
 2-CAN BE USEFUL IN YOUNG WOMEN
 3-CAN LOCATE BREAST CANCER WITH AXILLARY L.N. METS
BUT BREAST FREE ON US OR MAMMOGRAM
 4-CAN DETECT MULTICENTRIC LESION
 5-CAN DIFFERENTIATE BETWEEN RECURRENCE AND
FIBROUS TISSUE
 6-CAN DETECT SILICON LEAK
 DISADVANTAGES
 1-CANNOT DETECT CALCIFICATIONS
 UBOS:UNIDETIFIED BRIGHT OBJECTS
 DISLODGE CERTAIN METALS;RACEMAKER
 EXPENSIVE
POSITRON EMISSION
MAMMOGRAM SHOWS
[MULTIFOCAL LESION]
RETRACTED BREAST
SWOLLEN BREAST WITH
NIPPLE RETRACTION
MULTIPLE LOCAL
RECURRENCE
CANCER EN-CUIRASSE
‫درع المحارب‬
LYMPHOEDEMA
COMBINATION OF SURGERY &RADIOTHERAPY ON THE AXILLA CAN CAUSE
THIS
Axillary venous
thrombosis in ca. breast
DIFF.DIAGNOSIS OF
MASTITIS
& MASTITIS CARCINOMATOSA










MASTITIS CARCINOMATOSA
[INFLAMMATORY CARCINOMA]
IS THE MOST MALIGNANT OF ALL BR. CA.
MASTECTOMY IS RARELY INDICATED BECAUSE IT IS LATE
NO CONSTITUTIONAL SYMPTOMS
NO FEVER
NO LEUCOCYTOSIS
SKIN OEDEMA > 1/3 OF THE BREAST
IN BOTH THE BREAST IS WARM,TENDER
BOTH OCCUR IN CHILD BEARING PERIOD
DIFFICULT TO DISTINGUISH SOMETIMES EXCEPT BY CORECUT
BIOPSY.
US & MAMMOGRAM ARE USELESS BECAUSE THERE IS NO MASS
DIFF.DIAGNOSIS OF
PAGET`S DISEASE &ECZEMA OF THE NIPPLE





PAGET`S DISEASE
THERE IS AN UNDERLYING BREAST CANCER
UNILATERAL
NIPPLE DESTRUCTION
BOUNDRIES OF THE LESION IS WELL
DEMARKATED
DOES NOT RESPOND TO STEROID LOCAL
THERAPY
PAGET`S DISEASE OF THE
BREAST
PAGET`S DISEASE OF THE
BREAST
LOBULAR CARCINOMA
•ARISE FROM THE
TERMINAL DUCTS
•COULD BE
MULTIFOCAL.IT IS
BILATERAL
IN 20% OF CASES
•IN UNILATERAL
CASES ALWAYS
WATCH THE OTHER
BREAST
•LCIS DOES NOT
NEED
FURTHER ACTION
EXCEPT CAREFUL F.U
Carcinoma in pregnancy






THEY ARE DIAGNOSED LATE
THEY BEHAVE THE SAME AS NON-PREGN.
THEY ARE TREATED THE SAME
NO BREAST CONSERVING SURGERY
NO RADIOTHERAPY;TERATOGENIC
NO CHEMOTHERAPY IN THE FIRST
TRIMESTER
 NO HORMONAL THERAPY;BECAUSE
THEY ARE HORMONE RECEPT.-VE
STAGES OF CA. BREAST
CIS
II
II
III
STAGE 0
CARCINOMA
IN SITU
CONFINED
TO
BASEMENT
MASS<2CM .
MASS2-5CM.MOB.L.N
NO L.N.
MASS5-10CM.FIX.L.N
OR MASS FIXED
MEMBRANE.
TO CHEST WALL
NON
INVASIVE.
CLINICALLY;
IMPALPABLE
IV
SUPRACLAV.L.N.OR
DISTANT METS
DCIS & LCIS
Non-Invasive (In Situ) Cell Growth
Subtypes:
Papillary
Cribiform
Solid
COMEDO:ACNE
Vascular and Lymphatic Invasion
Comedo
INVESTIGATIONS FOR
DISTANT METASTASIS
 BLOOD
S.ALK.PHOSPHATASE
GGT[Gamma Glutamin Transferase]
 RADIOLOGY
CXR
US;Liver
 NUCLEAR
ISOTOPE BONE SCAN
WHAT DOES STAGING MEAN
 STAGE I & II :EARLY BREAST CANCER
[POTENTIALLY CURABLE DISEASE]
 STAGE III & IV : ADVANCED CANCER
[INCURABLE DISEASE]
WHAT IS THE MOST SIGNIFICANT
PROGNOSTIC FACTOR ?
 AXILLARY LYMPH NODES INVOLVEMENT &
NUMBER;IS THE MOST
 NO L.N; 85% 5-YEAR SURVIVAL
 3 L.N. ; 50%
 >3L.N. : 25-40%
 OTHER FACTORS
 1-GRADE,2- -VE HORMONE RECEPTORS,3-SIZE,
4-VASCULAR&LYMPH.INVASION, 5-HER2,
6-EPIDERMAL GROWTH FACTOR
MANAGEMENT OF EARLY
BREAST CANCER
 BREAST CONSERVING SURGERY:
WIDE LOCAL EXCISION + AXILLARY
CLEARANCE+ LOCAL BREAST
RADIOTHERAPY
PROVIDED MASS
BREAST RELATION
IS ACCEPTABLE
INDICATIONS OF MODIFIED
RADICAL MASTECTOMY
1. BIG SIZE TUMOUR IN REALATION
TO THE BREAST
2.CENTRAL TUMOUR;UNDER THE NIPPLE
3.MULTIFOCAL TUMOUR
4. RECURRENCE AFTER LUMPECTOMY
5. PATIENT`S PREFERENCE
Sentinel node biopsy is a technique
which helps determine if a cancer has
spread (metastisized), or is contained
locally. When a cancer has been
detected, often the next step is to find
the lymph node closest to the tumor site
and retrieve it for analysis. The concept
of the "sentinel" node, or the first node
to drain the area of the cancer, allows a
more accurate staging of the cancer,
and leaves unaffected nodes behind to
continue the important job of draining
fluids. The procedure involves the
injection of a dye (sometimes mildly
radioactive) to pinpoint the lymph node
which is closest to the cancer site.
Sentinel node biopsy is used to stage
many kinds of cancer, including lung
and skin (melanoma).
Sentinel node biopsy
WHAT IS MODIFIED
RADICAL MASTECTOMY
LONG THORACIC N.
SHOULD BE PRESERVED
INTERCOSTOBRACHIAL N.
CAN BE
SACRIFIED
Apical
CENTRAL
Lateral
A.VEIN
POSTERIOR
INTERPECTORAL
WHAT IS THE DIFFERENCE
BETWEEN THE 2
 NO DIFFERENCE IN 5-YEAR SURVIVAL
 THERE IS A DIFFERENCE IN LOCAL
RECURRENCE
 RECURRENCE AFTER LUMPECTOMY
IS MORE .TREATED BY MASTECTOMY
AND THEY DO BETTER
THE OTHER MODALITIES
 CHEMOTHERAPY;== CMF ==
1-ADJUVANT &
2-NEOADJUVANT
 HORMONAL THERAPY;
TAMOXIFEN: OESTROGEN BLOCKER
LHRH :
OVARIAN ABLATION
ANASTROZOLE: AROMATASE INHIBITOR INHIBIT
CONVERSION OF ANROGENS TO OESTROGEN
 IMMUNE THERAPY; HERCEPTIN [monoclonal
antibody] ANTI-HER2
 RADIOTHERAPY; LOCAL ACTION
BIOLOGICALLY TARGETED
THERAPY
 MONOCLONAL ANTIBODY ATTACHED
TO PROTEIN MOLLECULE ON THE
SURFACE OF CANCER CELL TO SLOW
ITS GROWTH
 ANGIOGENESIS INHIBITOR
 SIGNAL TRANSDUCTION INHIBITOR
Port-a-cath
for systemic chemotherapy
Chemotherapy
kills all
dividing cells
[malignant or
not
malignant].so
bone marrow
GIT and skin
are affected.
HOW TO EXAMINE YOUR
OWN BREASTS
TEACH PATIENT
LOOK AT
THE
MIRROR
NOTE ANY
ABNORMALITY
IN YOUR
BREASTS OR
AXILLAE AT
EVERY SHOWER
USE PALMER ASPECTS OF
USE
YOUR
PALMER
FINGERS
ASPECTS OF
gynecomastia
MOSTLY
IDIOPATHIC
LIVER
DISEASE
TESTICULA
R ATROPHY
DRUGS
MALE BREAST CANCER
THE SAME LIKE FEMALE BREAST PATHOLOGY & MANAGEMENT
BUT THE PROGNOSIS IS WORSE
MALE BREAST CANCER