BREAST CANCER

Dr. Frank Enoch Gyamfi

 INTRODUCTION
• The breasts are present in all mammals
• Hall mark of puberty in females
• An organ for infant feeding
• 2/3rd rests on Pect. Major while 1/3rd on serratus anterior
• V 2-6 ribs, H Lat. Sternum to Mid axillary line
• 15 to 20 lobes circularly arranged to form the breast
• Aesthetic and symbolic value in some cultures
• Breast cancer rates are increasing worldwide
 EPIDEMIOLOGY
• Commonest Cancer among women worldwide
• 1 in 8 women in their lifetime
• 2.3 million women diagnosed in 2020
• Half in LMICs
• 25% of cancers in women
• 685, 000 deaths globally in 2020
• 7.8 million alive with breast Ca in 2020
• 58% of mortality in LMIC
American Cancer Society . Global cancer facts and figures. 3 2015
https://www.who.int/news-room/fact-sheets/detail/breast-cancer [ Accessed 23/09/21]
• Ghana- 35/100,000 population
• TNBC 82%
• Breast cancer accounts for 40% of cancers in females
In Ghana
• It forms 15% of all cancers in Ghana.
• 50-70% present with advanced stage of the disease

Thomas AS, Kidwell KM, Oppong JK, et al. Breast Cancer in Ghana: Demonstrating the Need for Population-Based Cancer Registries in Low- and Middle-Income Countries. J Glob Oncol. 2017;3(6):765-772.
 RISK FACTORS
• Non modifiable risk factors
• Modifiable risk factors
Non-modifiable risk factors
• Female sex
• Age
• Family history of breast cancer
• Early menarche
• Late menopause
Modifiable Risk Factors

• First child birth after 30 years

• Smoking
• Alcohol
• Obesity
 • Lack of physical activity
• Fatty diet
 • Hormone replacement therapy
• Oral contraceptive pills
 Other factors
• Previous history of breast cancer, uterus and ovary
• Benign breast diseases (atypical ductal hyperplasia and
papilloma)
• Dense breast
• Radiation
• Exposure to chemical (Parabens and Phthalates)
• Night work and light exposure

Pan S, Yuan C, Tagmount A, et al. Parabens and Human Epidermal Growth Factor Receptor Ligand Cross-Talk in Breast Cancer Cells. Environ Health Perspect. 2016;124(5):563-569. doi:10.1289/ehp.1409200

Zuccarello, P., Oliveri Conti, G., Cavallaro, F., Copat, C., Cristaldi, A., Fiore, M., & Ferrante, M. (2018). Implication of dietary phthalates in breast cancer. A systematic review. Food and Chemical Toxicology, 118, 667–674.
doi:10.1016/j.fct.2018.06.011
 Histopathology
Breast cancer can be invasive or non-invasive according to its
relation to the basement membrane.
• Invasive ductal carcinoma (dense, acellular, fibrous tissue
stroma) 70%
• Invasive lobular carcinoma (diffusely infiltrated with strands of
homogenous small cells )10%
• Medullary carcinoma 5%
• Inflammatory carcinoma 3%
• Mucinous carcinoma 2%
Noninvasive neoplasms:
• Lobular carcinoma in situ (LCIS)
Conformed to the outline of the normal lobule, with
expanded and filled acini
• Ductal carcinoma in situ (DCIS)
2% of symptomatic and 40% of screen detected
50% progress to invasive cancer
 SPREAD
1. Local invasion
Direct infiltration to surrounding tissue
Nipple retraction
Dimpling

2. Lymphatic spread
Axillary LNs and Internal mammary chain
Supraclavicular and Infraclavicular
Peau d’orange
Cancer en cuirasse
3. Haematogenous spread
Spread through the blood stream
resulting in wide spread
dissemination
 CLINICAL PRESENTATION
• Asymptomatic (screen detected)
• Lump in the breast (usually painless)
• Lump in the axilla
• Bloody nipple discharge
• Redness, Scaling, Nipple rash,
Ulceration
• Nipple
retraction
• Nipple
deviation
• Paeu
d’orange
 DIAGNOSIS
Tripple Assessment
• Clinical assessment
History and physical examination
• Imaging (Radiological assessment)
USG: < 35 years. Sensitivity 70-90%
Mammography: > 35 years. Sensitivity of 80-85%. Two views;
Cranio-caudal, Oblique
Mammographic findings
MRI
Microcalcifications Spiculated mass Architectural distortion
• Cytological /Histological assessment
Diagnosis
Immunohistochemistry
+Close biopsy
FNAC, Core needle biopsy
+ Open biopsy
Incision, Excision, Wire loc. Biopsy
+Sterotatatic biopsy
 DIFFERENTIAL DIAGNOSIS
• Traumatic fat Necrosis
• Chronic breast abscess
• Fibroadenoma
• Benign mammary dysplasia (fibroadenosis)
• Duct ectasia
• Intraductal papilloama
• Galactocele
 COMPLICATIONS
• Basically from metastasis
• Lymphedema of arm
• Chest metastasis
• Paraplegia from cord compression
• Pathological fractures
• Cerebral metastasis
Canon balls Malignant pleural effusion Lumbar spine metastasis
with L5 fracture
 TREATMENT
Three main treatment modalities:
1. Loco-regional therapy
a. Surgery
b. Radiotherapy

2. Systemic therapy
a. Cytotoxic chemotherapy
b. Hormonal therapy.

3. Tumour cell-specific therapy/Targeted therapy

Monoclonal antibody therapy for HER2 positive cancer
BAJA Principles and practice of surgery including pathology in the tropics. 4 th Edition
SURGERY
I. Breast conservation surgery: wide local excision
(lumpectomy, quadrantectomy, segmental mastectomy) followed by
radiotherapy
2. Total mastectomy
Axilla investigated/treated with SLND and/or ALND

RADIOTHERAPY
Indicated in:
1. BCS
2. Patient at high risk of recurrence
3. Locally advanced breast cancer
4. Metastatic breast cancer
Watanabe Y,Anan K, The decision to perform or omit sentinel lymph node biopsy during mastectomy for ductal carcinoma in situ should be tailored in accordance with preoperative findings. Breast cancer (Tokyo, Japan). 2018 Oct 16
BAJA Principles and Practice of surgery Including pathology in the tropics. 4 th Edition
CHEMOTHERAPY
Neoadjuvant and Adjuvant
CAF, AC, ACT, TC FEC

HORMONE THERAPY
1. Blocking Ovarian function: Oophorectomy/Radiation/ GnRH
agonist eg Gorserilin (Zoladex)
2. Selective Estrogen Receptor Modulators (SERMs) eg
Tamoxifen, Raloxifen
3. Selective Aromatase Inhibitors
Non Steroidal: Anastrazole (Arimidex)
Steroidal: Exemestane
TARGETTED THERAPY
Monoclonal antibody to bind the extracellular domain of
the HER-2 receptor in HER-2/neu gene expression Eg.
Herceptin (Trastuzumab)

Dieci MV,Vernaci G,Guarneri V, Escalation and de-escalation in HER2 positive early breast cancer. Current opinion in oncology. 2018 Oct 12
 PREVENTION
1. Reduce modifiable risk factors

2. SERM: Tamoxifen for high risk individuals

Side effects: Menopausal symptoms
VTE
Uterine Cancer

Cuzick J, Sestak I, Cawthorn S, et al. Tamoxifen for prevention of breast cancer: extended long-term follow-up of the IBIS-I breast cancer prevention trial. Lancet Oncol. 2015;16(1):67-75. doi:10.1016/S1470-2045(14)71171-4

American Cancer Society, September 2019

 SCREENING
Does not prevent cancer but detects it early
Mammogram
• 40 and 44 years: optional to start screening with a
mammogram every year.

• 45 to 54yeras : should get mammograms every year.

• Women 55 and older can switch to a mammogram every other

year, or they can choose to continue yearly mammograms.
American Cancer Society, March 2020
 • Breast-iTM
• Breast Self Examination(BSE)
• Clinical Breast Examination
(CBE)

Frank Naku Ghartey, David Watmough, Samuel Debrah, Martin Morna, Akwasi Anyanful, "Breast-i Is
an Effective and Reliable Adjunct Screening Tool for Detecting Early Tumour Related Angiogenesis of
Breast Cancers in Low Resource Sub-Saharan Countries", International Journal of Breast Cancer, vol.
2018, Article ID 2539056, 10 pages, 2018.
Breast Self Examination