CARCINOMA OF THE BREAST

DR. ZAHOOR HUSSAIN BHELLAR

ASSOCIATE PROFESSOR
SURGERY
KMC KHAIRPUR MIRS
SURFACE
ANATOMY
• The breast can be considered to be composed of two regions:

• Circular body – largest and most prominent part of the breast.

• Axillary tail – smaller part, runs along the inferior lateral edge of the pectoralis
major towards the axillary fossa.
 A N ATO M IC A L
S TR U C TU R E

• LOBULES (10 – 100)

• LACTIFEROUS DUCT(15-20)
• LIGAMENTS OF COOPER
• AREOLA
• NIPPLE
• PECTORAL FASCIA
• RETROMAMMARY SPACE
 VASCULATURE

• Internal thoracic artery

(Subclavian artery)
• Lat: Thoracic and
Thoracoacromial branches
(Axillary artery)
• Lat: Mammary branches
(PICA)
• Mammary branches (AICA)
LYMPHATICS
1. Lateral (Brachial) Axillary nodes along Axillary vein
2. Anterior, along the lateral thoracic vessels
1. They receive drainage from the lateral aspect of the breast and
abdominal wall, and drain into the central group.
3. Posterior, along the subscapular vessels
4. Central, embedded in fat
5. Interpectoral (Rotter’s nodes),
6. Apical
BER G ’ S L EV E LS
 CARCINOMA OF BREAST

• Breast cancer is the most commonly diagnosed cancer and

the leading cause of cancer deaths in women globally.
• Pakistan has the highest incidence of breast cancer among
Asian countries: one in nine women is at risk of being
diagnosed with breast cancer during their lifetime.
• According to the International Agency of Research on
Cancer 2018 report, 34,066 new cases of breast cancer
had been reported in Pakistani women.
 AETIOLOGY FACTORS

• AGE
• GENDER
• GENETICS ( BRCA1/BRCA2)
• DIET ( LOW PHYTO-ESTROGENS, VIT D DEFICIENCY, HIGH ALCOHOLE INTAKE)
• NULLIPAROUS
• LATE MENARCHE
• EARY MENOPAUSE
• LOCAL HAIR-DYE CONTAINING paraphenylenediamine,
• PREVIOUS RADIATIONS
• HRT
 CLINICAL PRESENTATION

• Most frequently in the upper outer quadrant

• Most cancers will present as hard lump
• Associated with indrawing of nipple
• Peau d’orange skin appearance
• Frank ulceration
 TRIPLE ASSESSMENT

CLINICAL IMAGING PATHOLOGY

AGE EXAMINATION USS MAMMOGRAPHY FNAC CORECUT

CONFIDENT DIAGNOSIS IN 99.9% OF CASES

 ULTRASOUND

• YOUNG WOMEN WITH DENSE BREAST

• DISTINGUISH CYST FROM SOLID LESION
• OPERATOR DEPENDENT
• NOT A SCREENING TOOL
 MAMMOGRAPHY

• LOW VOLTAGE, HIGH AMPERAGE X-RAY

• 0.1cGy RADIATION.
• SENSITIVE TO LESS DENSE BREAST TISSUE
• SCREENING TOOL
• 5% CANCER MISSED
• NORMAL MAMMOGRAM DOES NOT EXCLUDE THE PRESENCE OF CARCINOMA
• TWO VIEWS
• CRANIOCAUDAL :MEDIAL ASPECTS OF BREAST
• MLO : UPPER OUTER AND AXILLARY TAIL
 MAGNETIC RESONANCE IMAGING

• DISTINGUISH SCAR FROM RECURRENCE

• ASSESS FOR MULTIFOCALITY AND MULTICENTRICITY OF
LOBULAR CARCINOMA
• EXTENT OF DCIS
• WOMEN WITH IMPLANTS
• SCREENING TOOL IN HIGH RISK PATIENT
 WHO CLASSIFICATION

• IN-SITU CANCER
• LCIS
• DCIS
• INVASIVE CARCINOMA
• DUCTAL
• LOBULAR
• TUBULLAR
• MUCINOUS
• MEDULLARY
• PAPILLARY
• METAPLASTIC
• INFLAMMATORY
• PAGET’S DISEASE
 IN-SITU CARCINOMA

• PRE-INVASIVE CANCER
• Not breached the epithelial basement membrane
• Marker for later development of invasive cancer.
• Two types
• Ductal carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS)
 DUCTAL
CARCINOMA IN-
SITU
 LOBULAR
CARCINOMA IN-SITU
(LCIS)
 PAGETS DISEASE OF THE NIPPLE

• SUPERFICIAL MANIFESTATION OF UNDERLYING BREAST

CARCINOMA
• ECZEMA LIKE CONDITION OF NIPPLE AND AREAOLA
• EROSION OF NIPPLE
• BIOPSY OF NIPPLE
• MICROSCOPICALLY: LARGE ,OVOID CELLS WITH ABUNDANT,
CLEAR, PALE-STAINING CYTOPLASM IN THE MALPIGHIAN LAYER
OF THE EPITHELIUM.
RELATIONSHIO OF BREAST CARCINOMA TO
THE QUADRANTS OF THE BREAST

12% 60%

20%

6% 10%
THE SPREADOF BREAST CANCER

• LOCAL SPREAD
• LYMPHATIC METASTASIS
• SPREAD BY THE BLOODSTREAM
• SKELETAL METASTASIS
TNM CLASSIFICATION FOR BREAST CANCER
• STAGE I
• T1N0M0
• STAGE II A
• T0N1M0
• T1N1M0
• T2N0M0
• STAGE II B
• T2N1M0
• T3N0M0
• STAGE III A
• T0N2M0
• T1-2 N2 M0
• T3 N1-2 M0
• STAGE IIIB
• T4 N0 -2 M0
• STAGE III C
• ANY T N3 M0
• STAGE IV
• ANY T ANY N M1
 SPECIAL CONDITIONS

• POSITIVE LN IN OPPOSITE BREAST = METASTASIS

• TWO MASSES IN SAME BREAST= STAGE ACC: TO BIG MASS
• MASS IN BOTH BREAST= SEPARATE STAGING FOR BOTH
TREATMENT OF EARLY BREAST CANCER

• AIMS;
• CURE
• CONTROL
• CONSERVATION
• PREVENTION OR DELAY
THE MULTIDISCIPLINARY TEAM APPROACH

BREAST COUNSELLOR
BREAST SURGEON
MEDICAL ONCOLOGIST
RADIOTHERAPIST
CLINICAL NURSE SPECIALIST
PSYCHOLOGICAL SUPPORT
PHYSIOTHERAPIST
 SURGERY

• EXTENDED SIMPLE MASTECTOMY

• SIMPLE MASTECTOMY + REMOVAL OF LEVEL 1 AXILLARY LNs
• RADICAL HALSTED MASTECTOMY
• EXCISION OF BREAST, AXILLARY LYMPH NODES AND PECTORALIS MAJOR AND MINOR MUSCLES
• MODIFIED RADICAL MASTECTOMY
• WHOLE BREAST
• A LARGE PORTION OF SKIN
• ALL OF FAT ,FASCIA AND LYMPH NODES OF AXILLA.( LEVEL 1 AND 11)
• EXTENDE RADICAL MASTECTOMY
• RADICAL MASTECTOMY + REMOVAL OF INTERNAL MAMMARY LNs
• SUPER RADICAL MASTECTOMY
• RADICAL MASTECTOMY+REMOVAL OF INTERNAL MAMMARY,MEDIASTINAL, AND SUPRACLAVICULAR LNs.
 VARIANT’S OF MRM

• AUSCHINCLOSS PROCEDURE
• REMOVES ALL BREAST TISSUES, NIPPLE-AREOLA COMPLEX, SKIN
AND LEVEL 1-2 AXILLARY LNs.
• PATEY’S PROCEDURE
• PECTORALIS MINOR IS REMOVED TO ALLOW COMPLETE
DISSECTION OF LEVEL III AXILLARY LNs.
• SCANLON’S MODIFICATION OF PATEY’S PROCEDURE
• PECTORALIS MINOR IS DIVIDED INSTEAD OF REMOVING
 CONSERVATIVE BREAST CANCER SURGERY

• REMOVING TUMOR PLUS A RIM OF ATLEAST 1 CM OF NORMAL

BREAST TISSUE.
• ADJUVANT RADIOTHERAPY WITH OR WITHOUT AXILLARY LN
STATUS.
 WIDE LOCAL EXCISION
 LUMPECTOMY
 QUADRANTECTOMY
• HIGHER RATE OF LOCAL RECURRENCE
 SENTINEL NODE BIOPSY

• CLINICALLY NODE NEGATIVE DISEASE

• LOCALISED PEROPERATIVELY BY THE INJECTION OF PATENT BLUE DYE AND
RADIOISOTOPE LABELLED ALBUMIN IN THE BREAST.
• SITE OF INJECTION : SUBDERMAL PLEXUS AROUND THE NIPPLE
• DETECTED VISUALLY AND WITH A HAND-HELD GAMMA CAMERA
 RADIOTHERAPY

• LOCALLY ADVANCE BREAST CANCER

• MARGINE POSITIVE AFTER MASTECTOMY
• AFTER BREAST CONSERVATIVE SURGERY
• METASTASIS TO 4 OR MORE LN
 HORMONE THERAPY

• TAMOXIFEN AND RALOXIFENE

• SERM
• REDUCE RISK OF TUMOR IN CONTRALATERAL BREAST
• AROMATASE INHIBITORS
• FOR POSTMENOPAUSAL WOMEN
• FOR RECURRENT DISEASE
• BONE DENSITY LOSS
 CHEMOTHERAPY

• 6 MONTH CYCLE OF
• CYCLOPHOSPHAMIDE
• METHOTRIXATE
• 5-FLUOROURACIL
• ANTHRACYCLINE
• TAXANES
 NEW BIOLOGICAL AGENTS

• TRANSTUZAMAB (HERCEPTIN)
• growth factor receptor c-erbB2
• BEVACIZUMA
• vascular growth factor receptor inhibitor
• LAPATINAB
• oral combined growth factor receptor inhibitor
 FOLLOW UP

• YEARLY OR TWO YEALY MAMMOGRAPHY

 CA BREAST AND PREGNANCY

• RADIOTHERAPY AVOIDED
• CHEMOTHERAPY AVAODED IN 1ST TRIMESTER
• NO HORMONE THERAPY
• MASTECTOMY PREFERRED