Breast cancer

ANATOMY OF THE BREAST

• The mammary gland is a modified sweat gland present in superficial
fascia of the pectoral region.
• Forms an accessory sex organ of female reproductive system
• Remains rudimentary in male but becomes well-developed in female
at puberty
• Extent:
Vertically: 2nd to 6 th
Horizontally:lateral border of sternum to mid-axillary line.
ARTERIAL SUPPLY
• The breast is highly vascular.
• It is supplied by the following arteries:
1. Internal thoracic (mammary) artery,
through its perforating branches, which
pierce the 2nd, 3rd, and 4th intercostal
spaces.
2. Axillary artery, through its lateral
thoracic, superior thoracic, and
acromiothoracic branches.
3. Posterior intercostal arteries through
their lateral branches.
Venous drainage
The venous drainage of breast
takes place by the following veins:
1. Axillary vein.
2. 2. Internal thoracic vein.
3. 3. Posterior intercostal veins.

The veins follow the arteries.

NERVE SUPPLY
 primarily somatosensory.
 It is derived from 2nd to 6th
intercostal nerves through
their anterior and lateral
cutaneous branches.
 These nerves provide
sensory innervation to the
skin and carry autonomic
fibres to the smooth muscle
and blood vessels of the
breast.
Lymphatic drainage
Level 1 Lateral to lateral border of
pectoralis minor (anterior, posterior&
lateral group
Level 2 Central axillary nodes located under
pectoralis minor muscle

Level 3.Apical & infraclavicular nodes

medial to pectoralis minor muscle.
It is difficult to visualize & remove unless
pectoralis muscles are sacrificed or divided.
BBD
• Benign breast changes are more common in women of child-bearing age,
peaking between the ages of 30 and 50, whereas the incidence of breast
cancer peaks during the postmenopause
• A very common finding and results in a diagnosis in approximately one
million women annually in the United States.
• Of all breast lumps, 60 to 80% are benign
• Mastalgia and fibrocystic changes are common (around 50% of all women
over the age of 30).
• Fibroadenomas occur in 25% of women; they are the most common benign
tumors of the breast and do not require treatment.
• 80% of women who have a breast biopsy do not have breast cancer.
BREAST BENIGN DISEASE
Symptoms of BBD
tenderness.
A lump that can be felt through the skin or nipple skin .
Irritation ,redness
 scaling on the nipple and/or skin of the breast
CLASSIFICATION OF BBD
✓ Amastia & Athelia
✓ Mastalgia- Fibrocystic disease
✓ Fibroadenoma & Breast Cysts
✓ Fat Necrosis
✓ Duct Ectasia
✓ Phyllodes tumor
✓ Galactocele
✓ Mastitis & Breast Abscess
✓ Mondor's disease
Amastia and Athelia
 Breast tissue with or without a nipple or just
nipple and areola alone can occur any where
along the milk line
 Total lack of breast tissue( amastia) or of nipple
(athelia) is unusual.
 supernumerary nipples -polythelia & breast-
polymasita are quite common
 Unilateral amastia is often associated with
absence of the pectoral muscles→ Poland's
syndrome
FIBROCYSTIC DISEASE
Affects premenopausal women and is characterized by
• cyst formation
• hyperplasia of duct epithelium (epitheliosis),
• enlargement of lobules (adenosis)
• fibrosis.
May vary in extent and degree in any one breast.
This condition is the result of abnormal response to hormonal changes and
can be associated with menstrual irregularities.
Ill-defined area of induration or firm swelling, often painful prior to
menstruation. (cyclical mastalgia)
MANAGEMENT
Mammography and ultrasonography typically show normal breast
tissue.
✓ Despite negative imaging studies, a biopsy should be performed to
r/o malignancy
✔ Reassrance, simple analgesia and a supportive bra often help.
FIBROADENOMA
✔Fibroadenoma is a benign tumor of breast consisting of glandular and
connective tissue elements.
✓ Commonest benign breast tumor. The typical patient is 15 to 35 years
✓ Well-circumscribed, solid masses represent hyperplastic lobules.
✓Smooth, encapsulated mass that is freely mobile- "breast mouse" rubbery
in consistency and non-tender.
✔USG shows a mass with smooth margins;
Trucut biopsy confirms diagnosis
✓ Fibroadenomas >2cms size or those with inconclusive biopsy should
excised
BREAST CYST
• Commonly occurs between age 30 to 50
• Is due to non-integrated involution of stroma & epithelium
• Appearance: blue-domed cyst (single/ multiple; unilateral/ bilateral)
Treatment:
• Fluid aspiration (greenish-yellow; can be sent fluid cytology)
• Hemorrhagic fluid and recurrent cysts can be excised for histological
exam to r/o Carcinoma
PHYLLODES ✓ Other names: cystosarcoma phyllodes,
TUMOR serocystic disease of Brodie
✓ Usually occurs in age > 40
✓ Presentation: Very large, firm, mobile,
non-tender lump with uneven lobulate
surface.
Wide variation in appearance (from
benign to potentially malignant)
Treatment:
enucleation/ wide excision/ mastectomy
✓ Rarely becomes sarcoma
DUCT ECTASIA
✔Is a peri-ductal inflammation with duct dilation
✓ Presentations: MARD (mass, abscess, retraction, discharge)
✓ Subareolar mass
✓ Slit-like nipple retraction
✓ Brown/green/ blood-stained nipple discharge
Abscess & fistula just below & around areola
✓ Treatment: wide excision of all affected ducts
DUCT PAPILLOMA
✓This benign lesions of the lactiferous duct wall occur centrally
beneath the areola In 75% of cases.
✓ They most commonly produce a bloody nipple discharge, some times
associated with pain
✓ They are solitary proliferation of ductal epithelium
✓ Intraductal papillomas should be treated by excision of a duct as a
wedge resection.
✓Treatment: simple excision (microdochectomy)
FAT NECROSIS
✓ Occurs following blunt injury to breast (may be acute/ chronic),
usually in obese, middle-aged females
✓ Painless, firm, fixed mass with ill-defined margins
✓ May even have skin tethering & nipple retraction
✓ This condition is also difficult to clinically distinguish from Ca (hence,
FNAC/ core biopsy is needed)
✓ Treatment: Surgical excision, the excised mass is an infiltrative
yellowish white mass
GALACTOCELE
✓ Is a solitary sub-areolar cyst filled with milk during lactation.
✓ Formed by obstruction to a duct in the puerperium. The milk
retained proximal to the obstruction eventually becomes cheese-like
✓ Appears as a painless lump weeks - months after cessation of breast
feeding
✓ Complication→ Infection
✓ Treatment Excision Aspiration or Surgical
CHRONIC MASTITIS
✓ Chronic intramammary abscess: Pus encapsulated by thick-walled
fibrous tissues. Difficult to clinically distinguish from Ca.
✓TB breast: Presents with multiple chronic abscesses & sinuses. A/w
active pulmonary TB/ cervical adenitis.
Bacteriological & pathological confirmation are required.
Treatment: anti-TB drugs
✓ Chronic granulomatous mastitis, Actinomycosis breast
ACUTE MASTITIS- BREAST ABSCESS
✓ Is usually due to Staph Aureus
✓ Breast mastitis is an infection that commonly affects women who
breast-feeding (especially during the first two months after childbirth)
but can occur in all women at any time .
Sore & cracked/ inverted nipple is the route of infection, the usual
mode of infection is via the nipple, the infection being carried by
suckling infant.
✓ Part or all of the breast is intensely: painful, hot, tender, red, and
swollen
✓ Ultrasound: used to localize the abscess
✓ FNAC: used to exclude underlying carcinoma especially in chronic
Breast abscess where the abscess become encapsulated with a thick
fibrous capsule & the condition can't be distinguished from a carcinoma
without a biopsy.
Needle Aspiration: to confirm presence of pus.
✓Mammogram: to exclude underlying carcinoma.
• MANAGEMENT:
Simple Needle Aspiration: using a wide bore needle under loc
anesthesia.
 Guided drainage: under image control with radiological or ultrasound
techniques a tube drain can be inserted & left until the cavity has
collapsed.
Surgical drainage: it is the most certain method, not only can all loculi
be reached, but also dead tissue can be removed. The cavity is then
dressed regularly & left open to heal by secondary intention.
MONDOR’S
DISEASE
A syndrome of sclerosing
superficial thrombophlebitis
of the veins of the anterior
thoracic wall.

The most commonly involved

vessel is the superior
epigastric vein producing a
palpable cord in the inferior
outer quadrant of the breast.
Pathophysiology
• incompletely understood. Inciting factors such as direct trauma from
tight clothing, surgery, or underlying system diseases such as breast
cancer or hypercoagulable states
Diagnosis
A clinical one confirmed by history and physical alone.
In cases where the clinical picture is not definitive, ultrasound is
considered the first line . FINDINGS-a non-compressible, hypoechoic
tubular structure which is the superficial vein.
Color Doppler should be used to confirm the diagnosis by demonstrating
the absence of flow within the vein.
Treatment
Warm compresses, nonsteroidal anti-inflammatory medications, and abstinence from
irritating clothing or activities are first-line therapy.

Prognosis
usually a self-limiting condition resolving in six to eight weeks. In cases where the
situation is secondary to a hypercoagulable state, the prognosis is directly linked to the
inciting condition.

Complications
As with any thromboembolic disease, there is a small chance of the development of a
deep venous thrombosis.
TAKE HOME MESSAGE
✓ Benign breast disorders & diseases are common
The aetiopathogenesis is complex and not fully understood
✓ Lump and pain are the most common complaints
Evaluation is done by Triple assessment
✓ Treatment is based on the natural history of clinical problems
✓Treatment must be tailored to individual needs
BREAST CARCINOMA
 CARCINOMA BREAST
 Epidemiology
Etiopathogenesis
 Types & Clinical features
 Investigations
 Staging
 Treatment of EBC, LABC&ABC
Prognosis and Follow up
EPIDEMIOLOGY
• Globally, most frequently diagnosed malignancy, accounting
for over two million cases each year .
• It is also the leading cause of cancer death in women
worldwide.
• In the United States, breast cancer is the most common
female cancer, and the second most common cause of cancer
death in women
• Uganda, has a breast cancer age-standardized incidence and
mortality rate of 21.3/100,000 and 10.3/100,000 respectively,1
indicating that almost half of Ugandan women with breast
cancer will die of their disease.
• These high mortality rates can be attributed to late stage
diagnosis for women with breast cancer.
• up to 89% of women in Uganda present with stage III or IV
when breast cancer is more difficult to treat, and outcomes
poor
• Breast cancer mortality rates have been decreasing since
the 1970s .
• This decrease in mortality is due to improved breast cancer
screening and improvements in adjuvant therapy
Why did I get breast cancer? Risk Factors?
 Family history of breast cancer
One affected 1st degree relative: 1.8 fold risk
Two affected 1st degree relatives: 2.9 fold risk.
 Genetic Mutations (i.e BRCA 1, BRCA 2)
5-10% of breast cancer.
 Hormone factors (total lifetime estrogen exposure)
Early menarche, late onset menopause, nuliparity (or older age of first childbirth >30 yrs).
Post-menopausal estrogen/progesterone replacement
 Dense Breast Tissue, prior abnormal/atypical breast biopsies.
 Obesity (especially post-menopausal obesity).
 Prior ionizing radiation to chest area (esp at young age <25-30 years).
 Alcohol (excess of 2 drinks/day)
Risk Factors

# Female
# Age

85% of patients diagnosed with breast cancer have no

family history of breast cancer and no major
identifiable risk factor.
Biology of Breast Cancer- Determine behavior of cancer cell Tumor

Grade - How abnormal is the cancer cell behaving? How quickly is it dividing
(i.e growing)?
Grade 1 less aggressive, tend to grow slowly, less likely to spread
Grade 2-intermediate growth, most common type
Grade 3 most aggressive, tend to grow quickly, more likely to spread
Tumor Biomarkers - proteins expressed by tumor cells that can inform what
is driving growth, and also direct treatments
Estrogen receptor
Progesterone receptor
HER-2 overexpression (positive)
Classification of Primary Breast Cancer
1) Noninvasive Epithelial Cancers
a) Lobular carcinoma in situ (LCIS)
b) Ductal carcinoma in situ (DCIS).
2)Invasive Epithelial Cancers (Percentage of Total)
c) Invasive lobular carcinoma (10% - 15%)
d) Invasive ductal carcinoma
 Invasive ductal carcinoma, NOS (50% - 70)
 Tubular carcinoma (2% - 3%)
 Mucinous or colloid carcinoma (2 6 - 3% )
 Medullary carcinoma (5%)
 Invasive cribriform carcinoma (1 0 - 3% )
 Invasive papillary carcinoma (1%-2%)
 Adenoid cystic carcinoma (1%)
 Metaplastic carcinoma (1%)
Estrogen Receptor Positive
• Most common type of breast cancer
• Estrogen receptor positive cancer
cells (ie ER+) express estrogen receptor
• Estrogen is a primary female sex
hormone
• Estrogen hormone can bind to the
receptor and signal the cancer cell to
grow.
• Also serves as a target to treat the
cancer- by blocking the estrogen or
the estrogen receptor
HER2-Positive
• HER2 protein is a growth receptor that
signals cell to grow/divide
• HER2 positive cancer cells over-express
HER2 proteins which causes too many
growth signals and rapid cell growth
• Aggressive subtype of breast cancer that
historically had a poor prognosis.
We now have very effective drugs that
target HER2 overexpressing cells and have
drastically improved survival
Triple Negative

• Triple negative breast cancers do not express the estrogen receptor and
do not over-express the HER2 protein and don’t express progesterone
receptor (PR)
• TNBC is typically observed in young AA women and Hispanic women
who carry a mutation in the BRCA1 gene.
• TNBC is characterized by a distinct molecular profile, aggressive nature
and lack of targeted therapies

• chemotherapy is usually part of treatment

Clinical presentation
Visible / Palpable Lump-Hard Consistency- Non Tender- Low mobility
Axillary Lymphnodes+
Nipple Retraction
Nipple Discharge
Skin Tethering/dimpling/puckering
Peau d'Orange
 Skin Ulceration / Fungation
Location of breast
cancer
Upper outer quadrant: 50%
Central area: 18%
Lower outer quadrant: 11%
Upper inner quadrant: 15%
Lower inner quadrant: 6%
INVESTIGATIONS-TRIPPLE
ASSESSMENT
MAMMOGRAPHY
ULTRASONOGRAPHY
Breast Imaging Reporting and Data System
(BI-RADS): Final Assessment Category
INVESTIGATIONS- NON PALPABLE
MASS
STAGING-TNM
STAGING
Management -MultimodalityTreatment
Surgery-Curative- Palliative
Radiotherapy -Chest Wall-Axilla-Supraclavicular
Chemotherapy
Hormonal Therapy
MANAGEMENT
MANAGEMENT OF LABC
• Classification of LABC
1) Operable at Presentation -T3, N1, M0
2) LABC Inoperable at Presentation- T4, Any N MO-Any T, N2 or N3,
MO
3) Inflammatory Carcinoma of Breast T4d, NO, MO
Treatment of Operable LABC
 MRM → Adjuvant Radiotherapy (RT) & Adjuvant Systemic
Chemotherapy (CT) +/- Hormone Therapy (HT)2.

Neoadjuvant CT→ To attempt to Down-Stage lesions for Breast

Conservation Surgery
Tumor Responding → BCS → CT,RT +/- HT
Non-responders → MRM → CT with RT +/- H.
Lumpectomy vs Mastectomy
• Bigger Surgery ≠ Better Survival
NSABP B-06
• >2,000 women randomized to
lumpectomy vs mastectomy
• 20 years follow-up
• No difference in overall survival
• Lumpectomy is safe and chances
of survival are exactly the same
as mastectomy
Breast Conservation vs Mastectomy? How do you decide
which is right for you?

• Tumor size • Presence of germline

• Breast size genetic mutations that
• Tumor location increase risk of future
breast cancer(BRCA 1,
BRCA 2, etc)
Role of Radiation Therapy
• Reduce risk of cancer recurrence
• Generally indicated after breast conserving therapy to reduce risk of
local recurrence
• Radiation is not usually indicated after mastectomy however may be
recommended in some circumstances (based on large tumor size and
node status)
Role of Systemic Therapy
• Most patients with invasive breast cancer will be
recommended some kind of systemic therapy
• Not all patients need chemotherapy
• The amount of breast surgery we perform does NOT change
how much systemic therapy that is recommended
• Systemic therapy is given based on the BIOLOGY of your
breast cancer
Role of Systemic therapy
Estrogen receptor positive:
 Anti-estrogen treatment (i.e Tamoxifen or Aromatase Inhibitor).
 Chemotherapy/Immunotherapy is often avoided, however may still be recommended
based on lymph node status, tumor characteristics.
Genomic testing (i.e Oncotype Dx, Mammaprint, etc) may be helpful in determining
benefit from adding chemotherapy.

HER 2 positive:HER2 directed therapy (ie Herceptin)Usually administered in combination

with chemotherapy

Triple Negative
Chemotherapy mainstay of treatment.
PROGNOSTIC FACTORS
1.Axillary nodal status( most important)
2.Tumour size
3.ER/PR Status - Both positive- good prognosis
4.Histological grade of tumour
5. Her 2neu overexpression - aggressive malignancy- poor prognosis
6.Proliferating rate
-DNA flow cytometry - aneuploid - poor prognosis
-S phase fraction - low S phase - good prognosis
Nottingham
Prognostics Index
(NPI)
A prognostics measure that
predicts operable primary
breast cancer survival.
The NPI value is calculated
based on the size of the
tumor, the number of lymph
nodes, and the tumor grade
Indications for PMRT(Post Mastectomy Radio Therapy

1. > 4 Positive axillary nodes

2. Tumour size> 5 cm
3. Positive surgical margins
4. As a part of LABC PROTOCOL
Summary
Treatment of invasive breast cancer
Local therapy: remove main tumor in breast, stage cancer by evaluating lymph nodes,
sometimes radiation therapy indicated to decrease chance of recurrence
Systemic therapy: treatment to whole body, treatment varies based on sub-type of
cancer.
Prognosis depends on cancer stage and tumor biology
Bigger surgery is not better treatment in most cases
Treatment plans are highly personalized based on
• Stage at presentation
• Biology of tumor (e.g tumor grade/subtype)
• Patient factors (age, other health problems, family history/genetic mutation status,
personal preferences)
Lastly,
A breast cancer diagnosis feels like an emergency, but you have TIME

Be comfortable with your treatment team

Understand your treatment options
Make informed decisions that are right for you