BREAST CANCER
Arsalan Altaf Shaikh
15/105
► Breast cancer is the leading cancer killer among women aged 20–59 years worldwide.
► In Asia, Pakistan has the highest rate of breast cancer.
► Breast cancer may arise from the epithelium of the duct system anywhere from the
nipple end of the major lactiferous ducts to the terminal duct unit, which is in the
breast lobule.
RISK FACTORS
► Non-Modifiable:
Age (>40 years)
Genetic: BRCA1, BRCA 2 mutations
Family history of breast cancer (first or second degree relative)
Early Menarche / Late Menopause
Pervious biopsy with atypical hyperplasia, LCIS, DCIS
► Modifiable:
Obesity
Diet (low phytoestrogen diet, increased alcohol intake)
Nulliparous
Exogenous hormones (OCPs, HRT)
Not breast feeding
► Histologic subtype/ Invasive:
Infiltrating Ductal Carcinoma (MOST COMMON)
Infiltrating Lobular Carcinoma
Mucinous Carcinoma
Medullary Carcinoma
Tubular Carcinoma
► In-Situ Carcinoma:
Ductal Carcinoma In-Situ
Lobular Carcinoma In-Situ
Paget disease
► Inflammatory Carcinoma
Triple Assessment
Noninvasive Carcinomas
1) Ductal carcinoma in situ:
Fills ductal lumen/ arise from ductal atypia
Microcalcification on mammography
2) Lobular carcinoma in situ:
Does Not produce mass of calcification, Incidental finding
Increase risk of cancer in either breast (vs DCIS, same breast and quadrant)
3) Paget Disease:
Eczematous patches over nipple and areolar skin.
Invasive carcinomas
1) Invasive ductal:
Firm, fibrous, rock hard mass with sharp margins.
Sub-types: Tubular Mucinous
2) Invasive Lobular:
Orderly row of cells “Single file”/ dec. E-cadherin
Bilateral and multiple
3) Medullary:
Anaplastic cells growing in sheets + Lymphocytes and plasma cells
Well circumscribed, mimics fibroadenoma
4) Inflammatory:
Invasion of dermal lymphatic spaces
Painful, warm, swollen, erythematous skin, peau d’ orange
Mistaken for mastitis
Metastasis
Local spread – skin, pectoral muscles and even the chest wall
Lymphatic metastasis
• Primarily to the axillary and internal mammary lymph nodes( mainly from tumors
involving posterior one third of the breast)
• Involvement of supraclavicular nodes and of any contralateral lymph nodes represent
advanced disease
Spread by bloodstream
• Skeletal metastasis, osteolytic deposits on lumbar vertebrae, femur, thoracic vertebrae,
rib and skull.
• Liver, lungs, brain and adrenal metastasis.
TNM Classification
The degree of differentiation of the tumour is usually described using three grades: well differentiated,
moderately differentiated or poorly differentiated.
Grade III roughly equating to the poorly differentiated group.
Treatment
Multi-disciplinary team approach is opted, surgeon, medical oncologist, radiotherapists, clinical
nurses.
Approach: Surgical and Non-Surgical
SURGERY
Mastectomy
Indications:
• Large tumors (in relation to the size of breast)
• Central tumors beneath or involving the nipple
• Multifocal disease ( tumors are lying in same quadrant)
• Local recurrence
• Patient preference
Simple mastectomy – removal of only the breast with no dissection of
axilla, except for the region of axillary tail of the breast.
Radical Halsted mastectomy- excision of the breast, axillary LN,
pectoralis major and minor; no longer indicated
Modified radical (Patey) mastectomy-more commonly performed
Patey mastectomy
The breast and associated structures are dissected en
bloc and the excised mass is composed of:
• The whole breast
• A large portion of skin, the centre of which overlies the
tumour but which always includes the nipple;
• All of the fat, fascia and lymph nodes of axilla.
Conservative breast cancer surgery
• This is aimed at removing the tumour plus a rom of at least 1cm of normal breast
tissue.
• This is commonly referred to as a wide local excision.
It is done by :
Lumpectomy: benign tumour is excised and large amount of normal breast tissue is
not resected.
Quadrantectomy: removing of the entire segment of the breast that contains the
tumour.
• Both of these operations are usually combined with axillary surgery, ( to stage the
patient and to treat the axilla) usually via a separate incision in the axilla.
Options that can be used in axilla include:
• Sentinel node biopsy
• Sampling
• Removal of the nodes behind and lateral to the pectoralis minor
(level II)
• Full axillary dissection ( level III)
Radiotherapy
Indication after mastectomy:
• Patients with large tumour
• Large number of positive nodes
• Extensive lymphovascular invasion
Hormone therapy
Tamoxifen- preventative agent
reduces the risk of tumours in contralateral breast
Optimal duration of treatment preferable is five years.
Others: LHRH agonists - in premenopausal receptor+ve women
oral aromastase inhibitors (Ais) – for postmenopausal
women
Chemotherapy
• Using first-generation regimen such as a six monthly
cycle of cyclophosphamide, methotrexate and 5-
fluorouracil will achieve a 25% reduction in the risk of
relapse over a 10 to 15 year period.
• In node negative patients if poor prognostic factors,
such a tumour grade, imply a high risk of recurrence.
Follow up
• 6 months for first 2 years
• then every year
Yearly or two-yearly mammography.
THANKYOU!!
