BREAST CANCER

Mizan Kidanu (MD)

October 13/2015
OUTLINE
Embryology and Anatomy
Epidemiology
Risk factors
Classification
Diagnosis
Treatment
References
 EMBRYOLOGY
Two ventral bands of thickened
ectoderm (mammary ridges, milk
lines)

These ridges disappear after a short

time, except small portions that
persist in the pectoral region

when normal regression fails

accessory breasts (polymastia) or
accessory nipples (polythelia) may
occur
 ANATOMY
Location
2nd to 6th rib
lateral border of sternum
to anterior axillary line
lies on pectoralis major
and serratus anterior ms

Contains:
Fat, glandular tissue,
suspensory ligament
 Blood supply
internal mammary
axillary artery
intercoastal arteries

Venous drainage
axillary vein
internal thoracic vein
lateral thoracic vein
intercoastal vein
 Axillary LNs
receive approximately
>75% of the drainage

grouped into:
lateral
anterior
posterior
central
apical
interpectoral

Internal mammary LNs

 Axillary LNs
with respect to pectoralis
minor muscle they are
grouped into:
Level-I

Level-II

Level-III
 EPIDEMIOLOGY
Is the most common site specific female cancer

2nd common cause of cancer death in women

Mortality has declined since the use of screening

mammography and improvements of adjuvant therapies

20% of breast cancer recurrences are locoregional, >60%

are distant, and 20% are both local-regional and distant
Relative distributions

Upper outer quadrant ~ 60%

Upper inner quadrant ~12%

60% 12%
Lower outer quadrant ~ 10%

Lower inner quadrant ~ 6%

10% 6%

Central quadrant ~ 12%

RISK FACTORS
Sex - >99% occur in females
Early menarche, late menopause, nulliparity, older
age at first live birth
Age - is rare below 20 yeas of age
Radiation exposure
Family Hx of breast Ca
Genetic factors BRCA-1 or BRCA-2
Prior breast cancer
Obesity
Dietary factors
Smoking & increased alcohol consumption
Hormone replacement therapy & OCP,....
CLASSIFICATION
Carcinoma in situ (CIS)
Ductal carcinoma in situ(DIS)
Lobular Carcinoma in situ(LIS)

Invasive carcinoma
Ductal
scirrhous carcinoma (No Special Type-NST)
Medullary
Mucinous (colloid)
Papillary
Tubular
Lobular
Pagets disease of the nipple
 Carcinoma in-situ
Malignant cells in the duct system or lobules but no
invasion of the basement membrane

Since the use of screening mammography there is a 14-fold

increase in the incidence

Multicentricity - refers to the occurrence of a 2nd breast

cancer outside the breast quadrant of the primary cancer
(or at least 4 cm away)

Multifocality - refers to the occurrence of a 2nd cancer within

the same breast quadrant as the primary cancer (or within 4
cm of it)
 LCIS
marker of increased risk for invasive breast carcinoma,
not anatomic precursor
multicentric in 60-90%
bilateral in 50-70%
develops only in the female breast

DCIS
anatomic precursor of invasive ductal carcinoma
multicentricity for DCIS is 40-80%
bilateral in 10-20%
CLINICAL FEATURES
Lump
hard, painless swelling
Change in the skin
puckering
Peaud orange
skin ulceration
skin nodules
Nipple changes
distortion, inversion
discharge
eczema (Pagets disease)
Metastatic disease
regional LNs
distant sites
SPREAD OF BREAST CANCER
Local spread with in the breast
involves the skin & fascia
chest wall and

Regional spread of breast cancer

axillary LNs
internal mammary LNs
Supraclavicular LNs

Hematogenous (distant) spread

in order of frequency, are bone, lung,
pleura, soft tissues, and liver.
DIAGNOSIS
History
duration of illness

associated symptoms (pain, headache, cough, nipple

discharge)

age at menarche and menstruation status (pre or

postmenopausal)

age at first delivery

family history of breast cancer,.

 Physical examination

Inspection
arms by her side or straight up in
the air
hands on her hips
leaning forward to accentuate any
skin retraction

symmetry, size, shape, peaud

orange, nipple or skin retraction or
erythema ,...
 Palpation
supine position
examine all quadrants
examine with the palmar aspects of the
fingers
avoiding grasping or pinching
motion
assesses all three levels of axillary LNs

location, size, number, consistency,

shape, mobility, border, tenderness...
INVESTIGATIONS
CBC, Blood group & Rh,

FNAC, core needle biopsy

Mammography, breast u/s, MRI

ER/PR status determination

Metastasis - LFT, CXR, CT, MRI,

abdominal u/s,.
Triple Assessment
Any patient with a breast lump or other symptoms
suspicious of carcinoma, the Dx should be made by a
combination of:

1. Clinical assessment
2. Radiological imaging and
3. Tissue sample (cytological or histological)

Positive predictive value is 99.9%

TNM Staging
Primary tumor (T)
Tx: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: carcinoma in situ
T1 : 2 cm in greatest dimension
T2: >2 cm but not >5 cm in greatest dimension
T3: >5 cm in greatest dimension
T4: any size with direct extension to (a) chest
wall or (b) skin
Regional lymph nodes Distal metastases

N0: no regional LN involvement M0: No distal metastases

N1: moveable ipsilateral axillary LAP
N2: Ipsilateral axillary LNs fixed or M1: Distal metastases
matted; Ipsilateral internal
mammary LN in the absence of
axillary LN involvement

N3: Ipsilateral infraclavicular and/or

supraclavicular LAP; Ipsilateral
axillary & internal mammary
Stage grouping
Stage 0: TisN0M0
Stage I: T1N0M0
Stage IIA: T0N1M0; T1N1M0; T2N0M0
Stage IIB: T2N1M0; T3N0M0
Stage IIIA: T0N2M0; T1N2M0; T2N2M0; T3N1M0
Stage IIIB: T4 anyNM0
Stage IIIC: AnyTN3M0
Stage IV: AnyT AnyNM1
MANAGEMENT OF BREAST CANCER

Multidisciplinary
Surgeons
Radiotherapists
Oncologists
Pathologists
Other professionals
counselors
breast care nurses
Factors affecting type of treatment
Lymph node status
+Ve node: needs adjuvant treatment
Size and extent of tumor
large tumors recur more often
Histology
CIS: no adjuvant treatment
Hormone receptors status
Age and/or menopausal status
 Treatment for breast carcinoma entails:
Local control
surgery and radiotherapy

Systemic control
hormone and chemotherapy
SURGERY
1-Wide local excision (lumpectomy)
2-Total (simple) mastectomy
removes all breast tissue, nipple areola complex, and skin
3-Modified Radical Mastectomy (MRM)
preserves pectoralis major and minor muscles, allowing
removal of level I and II but not level III axillary
4-Radical mastectomy
removes all breast tissue, skin, nipple areola complex,
pectoralis major and minor muscles, and level I, II and III
axillary LNs
Treatment of early breast cancer
(Stage I & II)

Breast conservation - resection of the primary breast ca

with a normal margin, adjuvant radiation therapy, and
assessment of regional lymph node status

Mastectomy with sentinel lymph node and/or axillary LN

dissection
CHEMOTHERAPY
Adjuvant chemotherapy for early invasive breast
carcinoma is indicated in all patients with:
node-positive cancers

tumor >1 cm

node-negative cancers of >0.5 cm with adverse

prognostic features
HORMONAL THERAPY

Immunoassays & immunohistochemical methods are

employed to measure levels of ER

Patients with significant increase in ER respond favourably

to endocrine therapy

E.g: Tamoxifen therapy

Locally advanced breast cancer ( Stage-III)

Neoadjuvant chemotherapy

Usually a modified radical

mastectomy (MRM)

Followed by adjuvant radiation

therapy
Breast ca with distant metastasis
(Stage IV)
Aim of management
provide palliation
symptomatic relief

Treatment
combination chemotherapy
toilet mastectomy
radiotherapy
Tamoxifen therapy in ER positive
COMPLICATIONS OF MASTECTOMY

Seromas - the most common

Wound infections
Hemorrhage
Lymphedema - increased risk in:
extensive ALND
the delivery of radiation therapy
the presence of pathologic lymph nodes
obesity
Nerve or vascular injury
REFERENCES
Bailey and Loves: Short Practice of Surgery, 25th ed; 2008

Swartzs: Principles of Surgery, 10th ed; 2015

Mastery of Surgery, 5th ed; 2007

Sabiston: Text Book of Surgery, 19th ed; 2013

UpToDate 20.3