BREAST CARCINOMA

ATTIRAH NUR ASYURA

DHEPALETCHUMI
DEVIGA
 Risk factor
UNMODIFIABLE MODIFIABLE

• Being a woman
• Oral contraceptives -
• Age remains controversial
• Nulliparous • Hormone replacement
• Early menses therapy

• Late menopause • Not breast feeding

• Genetic factors - mutations in • Obesity / lack of physical

BRCA1 or BRCA2 activity

• Family history of breast cancer • Alcohol

• Previous radiation treatment

 HISTORY TAKING
1. presentation of the lump
Onset
How the patient first noticed
Description of the lump
PAINFUL PAINLESS
- Fat necrosis - Breast carcinoma
- Breast cysts - Fibroadenoma
- Mastitis - Phylloides tumour
- Duct papilloma
Progression
rapid growing in breast carcinoma
Other Ddx : Phylloides tumour

2. Associated symptoms :
skin changes
nipple changes
arm swelling

Constitutional symptoms (LOW, LOA)

History of trauma
3. Risk factor for breast carcinoma

4. Complications (metastasis) :
- Liver--- jaundice,abdomen distension
- Lung--- shortness of breath, cough,
hemoptysis
- Bone--- bone pain (usually begins with spine),
pathological fracture
- Brain--- convulsion
5. If already diagnosed with breast carcinoma,
mention :
- what investigations had been done
- Treatment so far
 PHYSICAL EXAMINATION

 exposure of the patient

INSPECTION
1. Asymmetry
2. Obvious lump/swelling noted
3. Presence of scar
4. Skin and nipple changes
 repeat inspection by asking patient :
 to raise hand above head
To press hands against hip
Leaning forward – fixity to chest wall
PALPATION
1. Palpate the normal
breast first
2. Palpate diseased
breast
3. If there is a lump,
describe the
characteristics
Palpation of axillary lymph nodes : Right hand

L1

L1 LATERAL
L1

ANTERIOR POSTERIOR

APICAL
MEDIAL
L3
Left hand L2

+ palpate supraclavicular LN

• Complete the examination by examine other system for distant

metastasis
DHEPALECTCHUMI A/P
ELAVARASAN
012015100049
 OUTLINE

• TYPES OF CANCER BREAST

• METHOD OF DIAGNOSIS

• STAGING OF BREAST CA
 TYPES OF CANCER BREAST
Non-invasive breast cancer Invasive breast cancer
-pre-invasive cancers -invasive cancers
-not breached the epithelial -breached the epithelial
membrane membrane

A) DUCTAL CARCINOMA IN A) INVASIVE DUCTAL

SITU(DCIS) CARCINOMAMA
B) LOBULAR CARCINOMA IN B) INVASIVE LOBULAR
SITU (LCIS) CARCINOMA
C) INFLAMMATORY CA
D) PAGET’S DISEASE
E) CYSTOSARCOMA
PHYLLODES
DUCTAL CARCINOMA IN SITU
Van Nuys system

1. age

2. type

3. present of
microcalcification

4. extend of
resection margin

5. size of the
INVASIVE LOBULAR CARCINOMA

-multifocal/bilateral
-positive reaction with e-cadherin Antibody

normal Invasive lobular ca

 INFLAMMATORY
CARCINOMA

 rare
 involves 1/3 rd of breast
 highly aggressive
 painful, swollen
 warm with cutaneous edema
 mimic as breast abscess
 biopsy : confirm dx and reveals
undifferentiated cancer cells
 aggressive chemo and radiotx with
salvage breast surgery
 METHODS OF DIAGNOSIS
CLINICAL
DIAGNOSIS

RADIOLOGICAL PATHOLOGICAL
DIAGNOSIS DIAGNOSIS

TRIPLE
DIAGNOSIS
 REFERENCES

• Bailey and love’s short practice of surgery, 27th edition

• Browse introduction to the symptoms and signs of surgical

disease, 5th edition
 N K
H A
T U
YO
Management
of
Breast Cancer
Deviga Samy Velu Raja
10th February 2020, Monday
 Prognostic factors that affect survival

 Younger age at diagnosis

 Tumor size at diagnosis
 Number of nodes with metastasis
 Histologic grade of primary tumor
 Hormone and HER2 receptor status
 Management
• Basic principles are to reduce chance of local
recurrence and risk of metastatic spread
• Treatment include surgery, chemotherapy,
radiotherapy and hormone therapy
 Surgery
Mainstay of treatment of early breast cancer :
• Simple mastectomy
• Modified radical mastectomy
• Radical mastectomy
• Breast conserving surgeries
 Mastectomy indication
1. Large tumors.
2. Central tumors beneath or involving the
nipple.
3. Multifocal disease.
4. Local recurrence.
5. Patient preference
 Simple mastectomy
• Removal of breast tissue
• No dissection of axilla except for the region of
the axillary tail of the breast, which usually has
attached to it a few nodes low in the anterior
group
 Radical Mastectomy
• It is no longer performed
• Removal of:
– Breast tissue
– Overlying skin
– Chest wall muscle
– Axillary nodes I, II, III
– Long thoracic & Thoracodorsal nerve
– Pectoralis minor & major muscle
• Preserves:
– Axillary vein
– Cephalic vein
• Complication:
– No pectoralis major – no bed for breast reconstruction
– Poor cosmetic result
– Lymphoedema of arm
 Modified Radical Mastectomy
• Indication:
– When breast conserving surgery would produce
an unacceptable cosmetic result
– Contraindication to radiotherapy (pregnancy,
previous radiotherapy)
– Patient elect mastectomy
• Patey (remove pectoralis minor), Auchincloss (left pectoralis
minor)
• Removal of:
– The whole breast
– A large portion of skin, the centre of which overlies the
tumour but which always include the nipple.
– All the fat, fascia, and the lymph node of the axilla.
• Preserves
– Axillary vessels
– Long thoracic nerve
– Thoracodorsal nerve
– Cephalic vein
– Pectoralis major
 Breast Conserving Surgery
Lumpectomy
• operation in which a benign tumour is excised and in
which a large amount of normal breast tissue is not
resected

Wide local excision

• Removing the tumour plus a rim of at least 1 cm of
normal breast tissue

Quadrantectomy
• removing the entire segment of the breast that
contains the tumour
Indication
• Tumour < 4cm with proper tumour breast
ratio
• Possible to excise the tumour with tumour
free margin without distrupting breast
cosmetically
Contraindication of breast conserving surgery

– Presence of two/more primary tumour in different quadrants

– > 4cm tumour with improper tumour breast ratio
– History of prior radiation to breast
– Persistent positive margin after 2 attempts
– Excision resulting in cosmetic irregularity
– Non compliance to adjuvant therapy and follow ups
 Sentinel Node Biopsy
Sentinel node- first node that tumour drains to
Biopsy done during the surgery before tumour is removed
2 methods
• Injection during surgery –patent blue dye (methylene blue)
• Injection 1 day prior to surgery- technetium 99
sulphur/radioalbumin
– To avoid unnecessary axillary dissection
 Radiotherapy

Type
– External Beam Breast Cancer Radiation:
Traditional cancer-killing rays delivered by a large
machine.
– Internal Breast Cancer Radiation: Newer
treatments that inject radioactive cancer-killing
treatments only in the affected area.
• Indication
– Resected margin is positive
– All cases of breast conservation surgery
– Pectrolis major involved
– Tumour more than 4 cm
– Complete axillary clearance
– Incomplete axillary clearance with node (+)
 Chemotherapy
• Adjuvant chemotherapy
– Administration of cytotoxic drug after surgery
Indication:
– One or more (+) axillary lymph nodes
– ER negative
– High risk of recurrence
– Grade 3
• Neoadjuvant chemotherapy
– Administration of cytotoxic drug before surgery
– To shrink the tumour to enable breast conserving
surgery to be performed

• Palliative chemotherapy
– Used to improve quality of life rather than survival
– Advanced breast carcinoma
– Metastatic breast carcinoma
 Chemotherapy
• CMF regime - 5 fluorouracil, methotrexate
Cyclophosphamide, Epirubicin

• 6 cycles with 28 days gap

 Adverse effects of Chemotherapy
Hair loss
Nail changes
Mouth sores
Loss of appetite and loss of weight
Nausea and vomiting
Diarrhoea
Increased chance of infection
Easy bruising or bleeding
Fatigue
 Neutropenic sepsis
• Life threatening complication of chemotherapy
• The term is used to describe a significant inflammatory response to a
presumed bacterial infection in a person with or without fever
• Diagnosis
– Neutropenia is usually defined as an absolute neutrophil count (ANC)
<1500 cells/microL and severe neutropenia as an ANC <500 cells/microL or an ANC
that is expected to decrease to <500 cells/microL over the next 48 hours 
– Fever in neutropenic patients is defined as a single oral temperature of >38.3°C or a
temperature of >38.0°C sustained for >1 hour
– Presence of symptoms and sign of sepsis
• Treatment
– Broad-spectrum antibacterials should be given as soon as possible (within 60 minutes)
 Hormone Replacement Therapy
•  It's recommended for women with hormone
receptor-positive breast cancers, and it does not
help women whose tumors are hormone
receptor-negative.
• Selective estrogen receptor modulator –
Tamoxifen
• Reducing the risk of tumours in the contralateral
breast (preventative agent)
• 20mg OD for at least 5 years
• Aromatase inhibitor(anastrazole/letrazole)
– Not ideal for premenopausal women

• Anti HER2 antibody therapy

(trastuzumab,Herceptin)
 Side effects
• Hot flashes
• Vaginal dryness or discharge
• Mood swings
• Uterine cancer
• Strokes