Dr George DEJEU
Breast cancer
Key facts
● Total of 35 000 new cases per year; 1 in 9 lifetime risk for women.
● Commonest in Western Europe; least common in Japan and Africa.
● Incidence increases with age.
● One per cent occurs in men.
● Five per cent related to identifiable genetic abnormality (BRAC1, BRAC2,
ataxia–telangectasia genes.)
● Sixty per cent present as symptomatic disease; 40% during screening.
Pathological features
Eighty per cent ductal adenocarcinoma; 20% lobular, mucinous tubular or medullary
adenocarcinoma. Most carcinomas believed to originate as in situ carcinoma before
becoming invasive; 70% express oestrogen or pro- gesterone receptors.
Clinical features
Breast lump
● Commonest presenting symptom.
● Usually painless (unless inflammatory carcinoma).
● Hard and gritty feeling.
● May be immobile (held within breast tissue), tethered (attached to surrounding
breast tissue or skin), or fixed (attached to chest wall).
● Ill-defined; irregular with poorly defined edges.
Nipple abnormalities
● Nipple may be the prime site of disease (Bowen’s disease), presenting as an eczema-
like change.
● Nipples may be affected by an underlying cancer:
● Destroyed.
● Inverted.
● Deviated.
● Associated bloody discharge.
Skin changes
● Carcinoma beneath skin causes dimpling, puckering, or colour changes.
● Late presentation may be with skin ulceration or fungation of the carcinoma through
the skin.
● Lymphoedema of the skin (peau d’orange) suggests local lymph node involvement or
locally advanced cancer.
● Extensive inflammatory changes of the skin are associated with inflammatory
carcinoma (aggressive form).
Systemic features
• Systemic features include weight loss, anorexia, bone pain, jaundice, malignant pleural,
pericardial effusions, and anaemia.
Diagnosis and investigation
Diagnostic tests
• All breast lumps or suspected carcinomas are investigated with triple assessment.
Dr George DEJEU
Clinical examination (as above).
Radiological assessment:
● Mammography usual, particularly over age 35y.
● Ultrasound scan used to assess the presence of involved lymph nodes; sometimes
used under age 35 because increased tissue density reduces sensitivity and
specificity of mammography.
● MRI used in lobular carcinoma to assess the extent of the disease, multifocality, and
the opposite breast.
• Younger women with dense breast tissue. For screening purpose in
patients with strong family history.
Tissue diagnosis
● Core biopsy or fine needle aspiration cytology (FNAC) of the breast lesion 9 axillary
nodes.
● Core biopsy also finds oestrogen receptor status, differentiates between invasive
carcinomas and in situ carcinoma (ductal carcinoma in situ, DCIS).
Staging investigations
Systemic staging is usually reserved for patients following surgical treatment with a tumour
who are at risk of systemic disease.
• Staging CT scan (chest, abdomen, and pelvis).
• Liver ultrasound.
• Chest X-ray.
• Bone scan.
• LFTs, serum calcium.
• Specific investigations for organ-specific suspected metastases.
Treatment
Medical treatment
In non-metastatic disease, medical therapy is adjuvant to reduce the risk of systemic
relapse, usually after primary surgery. It is occasionally used as a treatment of choice of
elderly or those unfit/inappropriate for surgery.
● Endocrine therapy.
● Used in estrogen receptor (ER) +ve patients.
● Anti-oestrogens like tamoxifen or aromatase inhibitors (letrozole).
● Post-menopausal patients—letrozole (caution osteoporosis).
● Premenopausal patients—tamoxifen.
● Herceptin—given in Her-2 receptor +ve patients.
● Chemotherapy (e.g. anthracyclines, cyclophosphamide, 5-FU, methotrexate). Offered
to patients with high risk features (+ve nodes, poor grade, young patients).
In metastatic disease, medical therapy is palliative to increase survival time and includes:
● Endocrine therapy. As above.
● Chemotherapy (e.g. anthracyclines, taxanes, herceptin).
● Radiotherapy. To reduce pain of bony metastases or symptoms from cerebral or liver
disease.
Dr George DEJEU
Surgical treatment
Surgery is the mainstay of non-metastatic disease. Options for treatment of the primary
tumour are as follows.
Wide local excision
● To ensure clear margins.
● Commonest procedure.
● Breast-conserving, provided breast is adequate size and tumour location appropriate
(not central/retro-areolar).
● Usually combined with local radiotherapy to residual breast to reduce risk of local
recurrence.
Simple mastectomy
● Best local treatment and cosmetic result for large tumours (especially in small
breast), central location, late presentation with complications such as ulceration.
● Also used for multifocal tumours or where there is evidence of widespread in situ
changes.
● Adjuvant breast radiotherapy is very rarely necessary.
● Performed with reconstruction at the same time or later stage including:
● Latissimus dorsi flap;
● TRAM flap;
● Prosthesis (see b p. 618).
Surgical management of regional lymph nodes
Axillary node sampling
● Minimum of four nodes should be retrieved.
● Avoids complete disruption to axillary lymph drainage, reducing risk of
lymphoedema.
● Is inadequate for treatment of the axilla. If nodes are +ve, they require adjuvant
radiotherapy to axilla or axillary node clearance.
Axillary node clearance
• Optimizes diagnosis and treatment of axilla.
• Increases risk of lymphoedema greatly.
Sentinel node biopsy
● One or two nodes primarily draining tumour identified by radioactive tracer or dye
injected around tumour and node(s).
● Identify positive nodes, then require a full axillary clearance.
● Avoids major axillary surgery where not necessary.
Surgery for metastatic disease
Surgery in metastatic disease is limited to procedures for symptomatic control of local
disease (e.g. mastectomy to remove fungating tumour).
Ductal carcinoma in situ (DCIS)
Dr George DEJEU
● Precancerous condition.
● Ten to fifty per cent develop invasive ductal cancers.
● Mammograms show microcalcification.
● Pathologically graded to low grade, intermediate grade, and high grade.
● DCIS is treated with wide local excision with clear margin.
● Mastectomy needed in larger breast lesions or multifocal disease.
● High grade DCIS treated by post-operative radiotherapy after wide local excision.
● Axillary surgery is not needed as there is no potential for lymph node metastasis.
