Introduction

Malignant breast • The commonest cause of death in middle-aged women.

• One in eight women will develop breast cancer
disease • less than 1% are male
• Responsible for 20% of all cancer related deaths in women.
• 20% of cancers detected by screening are in situ
• Invasive cancer will develop in at least 20% of in situ cases.

DR ata ghaith

Distribution of breast cancer

incidence
 • Early menarche
• Late menopause
• Nulliparity
Risk factors Risk factors • Radiation exposure
• Lack of lactation
Hormonal Non hormonal • Alcohol consumption
• Decreased exercise
• High fat diet
• Old age at first live birth
• Postmenopausal obesity

Risk assessment model Risk management

•Gail Model for Breast Cancer Risk • Whether to use HRT

• Age at menarche
• Number of breast biopsies
• Age at first live birth
• Number of 1st degree relatives
with breast cancer
• What age to start screening mammography
• When to use tamoxifen to prevent breast caner.
• When to perform prophylactic mastectomy.

• HRT reduce coronary disease and
osteoporosis by 50%
• Increase the risk of breast cancer
by 30%
• The risk of dying of coronary
disease is much greater than dying
from breast cancer.
• Tamoxifen reduces the risk of
breast cancer by 49% in high risk
group, Gail score ≥ 1.7
• Not certain for low risk group
• Risk of DVT, PE, endometrial
cancer, cataract
• The higher the risk the more
protection
When to do screening mammography?
• Use of screening mammo for women older than 50 reduces mortality from
breast cancer by 33%.
• Use of screening mammo for women 40-49 is of benefit.
When to • he The United States Preventive Services Task Force(CDC)
recommends that women who are 50 to 74 years old and are at
start HRT average risk for breast cancer get a mammogram every two
years.
• Women who are 40 to 49 years old should talk to their doctor or
other health care provider about when to start and how often to
get a mammogram. Women should weigh the benefits and risks
of screening tests when deciding whether to begin getting
mammograms before age 50.
Reduces the risk
by more than 90 %
Tamoxifen Prophylactic
use mastectomy
Only for p BRCA
gene carriers.
Breast cancer
• BRCA 1 are IDC, poorly differentiated and hormone
receptor negative, early age of onset, high
BRCA 1 prevalence of bilt breast cancer and other
associated cancers.
• More frequent in Ashkenazi Jewish.
• AD with varying penetrance
• Tumor suppressor genes
• Loss of both alleles is needed for the initiation of
cancer.
• More than 500 sequence variations in BRCA 1
BRCA 1 • BRCA 1 responsible for 80% of inherited ovarian
cancer.
• Female mutation carriers have 90% risk of
developing breast cancer and 40% risk of
developing ovarian cancer.
• The breast cancer risk for carriers is 85% and 20%
for ovarian cancer.
• Increase male breast cancer risk by 100 fold to 6%.
BRCA 2 • IDC, well differentiated and hormone positive.
• Early age of onset, high incidence of bilat and
associated other tumors.
 Natural Hx of the primary
tumour
• 80% will show element of fibrosis which leads to shortening of the
suspensory ligaments of Cooper, which leads to skin retraction
• Peau d’ orange develops when the lymphatic drainage is disrupted.
• With continued growth the tumour cells will invade the skin causing
oedema.
• A new area of skin then get invaded leading to satellite lesion.
• There is a correlation between the size of the primary tumour and
disease free and overall survival, but there is a close relation with
Axillary LN involvement
• recurrences of breast ca : 20% of recurrences loco-regional, 60% are
distant and 20% are both loco-regional and distant.
Natural Hx of axillary LN mets
• As the tumour grow some tumour cells are shed into cellular space and transported via
lymphatics to regional LNs esp. the axillary LNs
• Then involved LNs get attached to each other and form a matted mass
• Then cancer cells will break through the LN capsule and fix to contiguous structures in
the axilla including the chest wall.
• Typically LNs are involved sequentially from level 1 to level 3
• The most important prognostic factor that correlate with disease-free and overall
survival is axillary LN status.
• Node –ve women have 30% risk of recurrence while node +ve women have 76% risk of
recurrence
• 95% of women who die of breast cancer have distant mets

Natural Hx of distant mets

• Neovascularization >>>>tumour cells can shed into veins to pulmonary circulation or to
vertebral column via Batson’s plexus of vein.

• For the first 10 years following diagnosis distant mets is the most common cause of
death.

• While 60% of mets will happen within the 1st two years, mets might occur as late as 20
to 30 yrs after treatment of the primary cancer.
Carcinoma in situ
• Common site for mets in order of frequency are, bone, lung, pleura, soft tissue and liver.
Basement membrane not penetrated
 LCIS
• Originate from the terminal duct lobular extremely rare in males due to the lack of
lobular development in the male breast.
• Microcalcification typically occur in the surrounding tissue.
• Mostly incidental finding.
• Age 44 -47, which is 15-20 yrs younger than the diagnosis of invasive cancer.
• Invasive cancer develop in 25-35% of women with LCIS and detected synchronously in
5% of cases.
• 65% of subsequent cancers are ductal not lobular so LCIS is regarded as marker of
increased risk of invasive cancer rather than an anatomic precursor.

DCIS
• It account for 5% of male breast cancer.
• Microcalcification happen at the area of necrosis when tumour cells outgrow there
blood supply, which is a common mammographic feature.
• The incidence of breast cancer increase women with DCIS
• The cancer happen in the ipsilateral breast usually in the same quadrant so DCIS is an
anatomic precursor of invasive ductal cancer.

Invasive cancer
Paget’s disease of the nipple
I
II Invasive ductal carcinoma
A Adeno carcinoma NST 80%
B Medullary carcinoma 4%
C Mucinous (colloid) carcinoma 2%
D Papillary carcinoma 2%
E Tubular carcinoma 2%
III Invasive lobular carcinoma 10%
IV Rare cancers ( adenoid cystic, squamous cell, apocrine)
Paget’s disease of the nipple
• Chronic eczematous eruption of the nipple which may progress to
ulcerate.
• Paget’s disease is usually associated with extensive DCIS and may
be associated with invasive cancer.
• The presence of Paget's cells is pathognomonic.
• A skin biopsy is often used to confirm
• a diagnosis of Paget's disease of the nipple
• Treatment ranges from mastectomy to lobectomy

Invasive ductal carcinoma Medullary carcinoma

• Represent 80% of breast cancer • 4% of all invasive breast cancers.

• Had macroscopic or microscopic Axillary LN mets in 60% of cases. • Strong association with BRCA 1.
• 5th to 6th decade. • Bilat in 20% of cases.
• 50% of cases are associated with DCIS.
• 10% are hormone receptor +ve
Mucinous( colloid) carcinoma Papillary carcinoma

• 20% of all invasive cancers • 2% of all invasive cancers

• Bulky tumour in elderly population • 7th decade of life
• Extracellular pools of mucin • Very small tumours
• 66% display hormone receptor • Low frequency of LN involvement
• LN mets in 33% of cases

Tubular carcinoma Invasive lobular carcinoma

• 2% of all invasive cancers • 10% of all invasive cancers.

• 20% of screening mammography cancers • Frequently multifocal, multicentric and bilateral.
• 5th and 6th decade • May be difficult to detect due to insidious growth pattern and subtle mammographic
• 10% had axillary LN involvement features.
• Axillary LN involvement does not adversely affect survival.
• Distant mets are rare
• Long term survival approaches 100%
 Treatment of DCIS

• Widespread disease requires mastectomy

• Limited disease requires Lumpectomy and radiation
treatment • Favorable limited disease can be treated with lumpectomy
alone.
• Adjuvant tamoxifen is considered for all patients
• Women treated with mastectomy had local recurrence and
mortality less than 2%, while women treated with lumpectomy
and radiation have similar mortality but local recurrence of 9%.

Treatment of LCIS treatment

• The current treatment is observation with or without tamoxifen.

mastectomy
• The gaol of treatment is to prevent or to detect the invasive cancer at an early stage that breast conserving
subsequently develop in 25-35% of LCIS (modified radical
• No benefit of excision. surgery
mastectomy MRM
(lumpectomy
)
treatment

• Mastectomy is equal to lumpectomy & radiation. •Sometimes neoadjuvant chemo is used to make the disease operable or permit
• Local recurrence much higher in lumpectomy alone 35% when compared with lumpectomy & radiation conserving surgery
10%
• Need axillary LN status assessment.
• Contra-indications for breast conserving surgery includes prior radiation, involved margin, multicentric
disease and scleroderma or other CT disease.
• Chemo for all node +ve patients, cancers larger than 1 cm or when there is adverse prognostic factors.
• Adverse prognostic factors include, high cellular or histologic grade, HER2/neu overexpression,
hormone receptor –ve and lymphovascular invasion
• Tamoxifen for receptor +ve patient

Internal mammary LNs Distant mets

• Treated with systemic chemo and radio
• Not curative
• May prolong survival and enhance quality of life.
• Hormone therapy is preferred to toxic chemotherapy.
• Palliative care
• Specific surgical treatment to mets consequences.
• Bisphosphonates for bone mets
Loco-regional recurrence
Mammography is the
• Divided into two groups, one had mastectomy and the other had lumpectomy.
• Mastectomy group will undergo surgical resection of the recurrence and appropriate
reconstruction.
primary screening tool.
• Chemo and hormonal therapy are considered and radio if not given before. Recently Digital Mammo for young women or women with dense
breast.
• Lumpectomy group undergo mastectomy and appropriate reconstruction.
• Chemo and hormonal therapy are considered.

Women at normal risk

• Screening Mammo every 2 yrs, 35-49 yrs.
• Then annual screening Mammo.
• In addition to simple breast exame.