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Breast Cancer

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Fayad J.rashid

on 14 January 2014

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Transcript of Breast Cancer

tumors is the most important lesions of the female breast
may arise from either connective tissue or epithelial structures
Clinical picture
Group VI
Breast Cancer
Breast cancer: is a type of cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas , while those originating from lobules are known as lobular carcinomas . Breast cancer occurs in humans and other mammales . While the overwhelming majority of human cases occur in women, male breast cancer can also occur.

Worldwide, breast cancer accounts for 22.9% of all cancers (excluding non-melanoma skin cancer) in women. In 2008, breast cancer caused 458,503 deaths worldwide (13.7% of cancer deaths in women). Breast cancer is more than 100 times more common in women than in men, although men tend to have poorer outcomes due to delays in diagnosis.
Prognosis and survival rates for breast cancer vary greatly depending on the cancer type, stage, treatment, and geographical location of the patient. Survival rates in the western world are high; for example, more than 8 out of 10 women (84%) in England diagnosed with breast cancer survive for at least 5 years. In developing countries, however, survival rates are much poorer.
The probability of its occurrence increases throughout life
The mean age of affection is 60 years
The exact aetiology of breast cancer is not known,but there are some eveidacne shows that:
may have a role in develop the disease

* Genetic
*Endocrinal or hormonal
*Benign breast disease
*Environmental factors
The majority of breast cancer are sporadic in nature, with up to10% due to genetic predisposition
Family history .apremenopausal first-degree relative (mother or sister) with breast cancer confers alifetime risk of 25%, which reduces to 14% if the same ralatives is postmenopausal , if both mather and sister develop premenopausal breast cancer the risk is 33%
Gene carriage. Two inhereted susceptibility genes have been identified, BRCA1 and BRCA2. these are autosomal dominant genes with variable penetrance of 80-90%. An individual whose mother carries a mutation in one of these genes have a50% chance of inhereting that mutation, which will confer alifetime risk of 80-90%. The carriage rate for the BRCA1 mutation is 1-300 women

Number of hormonal factors lead to minor increases in breast cancer risk ,most correlate with increase exposure to estrogers.
Menarch and menopause: early age of menarch (11years and under) and late menopause(50years and over) are associated with high risk.
Parity: mulliparous women have high risk than multiparous women.
Also late age at first pregnancy increse risk compared with younger age . Breast feeding may contribute to reducing overall risk.
Hormone replacement therapy may slightly increase the incidence of breast cancer ,with the risk proportional to the length of treatment.
A number of benign breast conditons are known to carry an increased risk of breast cancer. The presence of atypical lobular or ductal hyperplasia confers afour-to five fold increase risk.
Exposure to ionizing radiation in adolescence or early adulthood can cause marked increases in breast cancer risk
Obesity and high intake of saturated fatty acids are associated with increased risk. Steroid hormone are converted to oestradiol in fatty tissues.
Risk factors
Non modifiable risk factor

Lifestyle related risk factor

Controversial risk factor

Genetic Risk factors
Family history
Personal history
Dense breast tissue
Menstrual periods
Previous exposure to radiation
mulliparity, or having babies later in life
Recent oral contraceptive use
Hormone replacement therapy
Not breast feeding
Excessive alcohol consumption
Being overweight
Lack of physical activity

High fat diets
Breast implants
Tobacco, smoke

Follow up & prognosis
Personal Data

Chief Complaint

H.C.C : when and how first noticed, Pain, tenderness, change in size over time and with menstruation.
Triple assessment
Clinical examination .

Imaging ( mammography , ultrasonography , … ) .

Needle biopsy .

Physical examination
– Inspection, Palpation
Skin changes: Edema, Dimpling, Redness, Retraction, Ulceration.
Nipple: Bloody Discharge, Crusting, Ulceration, Inversion.
Prominent Veins
palpable axillary/supraclavicular lymph nodes
Arm Edema
1- Mammography
Position and Attachment:
neurovascular bundle
Histology of the breast
Thank you
Arterial supply
derived from thoracic branches of three pairs of arteries
. Axillary arteries
. Internal mammary (thoracic) arteries:
. Intercostal arteries:
Venous derange
a. form a ring around the base of the nipple (“circulus venosus”)
b. Large veins pass from circulus venosus to circumference of mammary gland, then to
c. External mammary v to axillary v
d. Internal mammary v to subclavian v
a. anterior & lateral cutaneous nerves of thorax
b. spinal segments T3 – T6
Lymphatic deranage
a. Glandular lymphatics drain into anterior axillary (pectoral) nodes central axillary nodes apical nodes deep cervical nodes subclavicular (subclavian) nodes

b. Medial quadrants drain into parasternal nodes

c. Superficial regions of skin, areola, nipples:
-form large channels & drain into pectoral nodes

d. NOTE: axillary nodes also drain lymph from arm

1. Lateral aspect of pectoral region
2. Located between ribs 3 and 6/7
3. Extend form sternum to axilla
4. Surrounded by superficial fascia
5. Rest on deep fascia
6. Fixed to skin & underlying fascia
7. Left breast is usually slightly larger
8. Separated from pectoralis major muscle by fascia, retromammary space

3- Magnetic resonance imaging
4-Needle biopsy and cytology
Minimum degree of invasiveness and discomfort to the patient .
Because the more invasive investigations tend to be the most expensive , this approach is considered the most economical
very safe investigation {The radiation dose very low ( 0.1 Gy )} .
Used for both : screening and diagnosis .
Sensitivity increase with age ( breast become less dense ) .
A normal mammogram does not exclude the presence of carcinoma
Useful in young women with dense breast .
Distinguishing between cysts and solid lesion .
Can be used to localize impalpable areas of the breast .
Not a useful screening tool .
Provide useful information regarding the staging of the axilla .
Also it is useful in the guidance of biopsies and therapeutic procedures .

.Recent advances is digital mammography :
- Allow images to be recorded and stored .
- Images can be magnified to improve evaluation .
- Can be transmitted electronically :
1) Decreasing the time to second opinion .
2) No risk of losing the film .
- Ductogram : Helpful In determining the cause of nipple discharge .

It can be useful to distinguish scar from recurrence in women who have had previous breast conservation therapy for cancer .
It is the best imaging modality for the breasts of women with implants.
It has proven to be useful as a screening tool in high-risk women (because of family history).
It is less useful than ultrasound in the management of the axilla in both primary breast cancer and recurrent disease.
Indication for MRI :
Lesion that is indeterminate after a full assessment .
Detection off occult breast carcinoma in a patient with a carcinoma in an axillar lymph node .
Evaluation of suspected multifocal or bilateral tumor .
Monitoring of the response of neoadjuvant chemotherapy .
Detection of recurrent breast cancer .
Contraindication :
Contraindication to gadolinium – based contrast media ( allergy or pregnancy ) .
Patient inability to lie prone .
Marked obesity .
Extremely large breasts .
Relative contraindiction :
Cancer phobic patient .
Assessment of mammographically detected microcalcification .

Fine-needle aspiration cytology (FNAC) is the least invasive technique of obtaining a cell diagnosis rapidly .
False negative do occur ( sampling error ) , and invasive cancer can't be distinguished from in situ disease .
Histological specimen taken by core biopsy allows a definitive preoperative diagnosis , differentiates between duct carcinoma in situ DCIS and invasive disease and allows the tumor to be stained for receptor status .
The aims of evaluation of a breast lesion are to judge whether surgery is required and , if so , to plan the most appropriate surgery .
The ultimate goal of surgery is to achieve the most appropriate degree of breast conservation while minimizing the need for reoperation .
1.Outer surface convex, skin covered
3. Areola
4.Each breast consists of ~ 20 lobes of secretory tissue
5.axillary tail
6.Fatty Tissue
a. At fourth intercostal space
b. Small conical/cylindrical prominence below center
c. Surrounded by areola: pigmented ring of skin

d. Thin skinned region lacking hair, sweat glands

contains dark pigment that intensifies with pregnancy

a. Circular and radial smooth muscle fibers

b. Cause nipple erection

a. Each lobe has one lactiferous duct
b. Lobes (and ducts) arranged radially
c. Embedded in connective tissue & adipose of superficial fascia
d. Lobes composed of lobules
a. prolongation of upper, outer quadrant in axillary direction

b. Passes under axillary fascia

c. May be mistaken for axillary lymph nodes
surrounds surface, fills spaces between lobes

a. Determines form & size of breast

b. No fatty deposit under nipple & areola

Important things to ask about :

Mastalgia : Cyclic Vs. Non- Cyclic

Skin Changes : Redness, Warmth, Tenderness

Nipple Inversion : Benign Vs. Malignant
Nipple Discharge
- Clear, Yellow, White, Green
- Blood Stained or Dark
- Purulent Discharge
- Galactorrhoea

Gynaecomastia ( Males ).

Family History : Especially in first degree relatives.

Constitutional Features :
- Anorexia
- weight loss
- Respiratory Symptoms
- Bone Pain

Examination of the breast
In later stages, changes in the skin, distortion of the skin and nipple retraction may be apparent.
Features of malignancy is a hard, irregular lump which may be fixed to the underlying chest wall or overlying skin in later stages
The axillary lymph nodes and supraclavicular lymph nodes should be carefully evaluated
A significant nipple discharge is blood-stained and from one duct
Paget’s disease of the nipple is ulceration which starts at the nipple not the areola.
All the findings on physical examination must be recorded.
In early breast cancer, it is impossible to decide whether a lump is malignant or not just on physical examination alone.
The age of the patient is important – a breast lump in a 20 year old is not likely to be malignant as opposed to a breast lump in a 60 year old.
All breast lumps must be investigated further with a radiological assessment (mammogram or ultrasound), followed by a biopsy to confirm whether it is benign or malignant, whatever the age of the patient.
The Manchester system of staging breast carcinoma was devised originally in 1940. It is an anatomical system.
The stages are: 
stage I:breast onlymobile tumour less than 5cm in diameter with or without local skin involvement
stage II:tumour confined to breastnodes thought to be involved but not fixed - palpable, mobile and ipsilateral
stage III:locally advanced disease in breast or nodestumour greater than 5cm diameter with involvement of:underlying muscle orskin wide of the tumour oraxillary node fixation
stage IV:distant metastases other than the axillary nodes orsatellite nodules on breast orsupraclavicular nodal involvement
Stage 1
Stage 2
Stage 3
Stage 4
Examination of the breast
Nipple retraction
Ulceration of the skin
Skin retraction / dimpling left breast
Skin retraction accentuated by raising the arms

Composition ( Fluctuant, Hard, Rubbery )
Fixation to underlying tissue or skin

Characteristics of a Breast mass
*Differential Diagnosis of a Breast Lump
The two basic principles of treatment are to: reduce the chance of local recurrence.
and the risk of metastatic spread.
Members of multidisciplinary care team
Modalities of treatment

Radiation therapy

Treatment depends on stage of cancer.
More than one treatment may be used.
Multidisciplinary approach
Types of surgery:
Conservative surgery
 an operation to remove the cancer but not the breast itself, includes the following:
Lumpectomy: Surgery to remove a tumor (lump) and a small amount of normal tissue around it.
Partial mastectomy: Surgery to remove the part of the breast that has cancer and some normal tissue around it. The lining over the chest muscles below the cancer may also be removed. This procedure is also called a segmental mastectomy.
done at the time of the mastectomy or at a future time
Tow procedures are available:
1) A synthetic implant; may be inserted behind the pectoralis major muscle and is inflated gradually until it attains the desired size.
2) A myocutaneous flap;TRAM

Breast reconstruction
The use of high-energy x-rays or other particles to destroy cancer cells

Usually used to treat breast cancer after surgery

:Different methods of delivery

External-beam: outside the body
Internal: uses implants inside the body

Side effects may include: fatigue, swelling, and skin changes
drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.eg;
Positive axillary nodes.
Metastatic disease;response 60%_80%.
P.t below 70years.
Tumor more than 1cm.
Hormone receptor negative and HER2 positive tumor.
Side effects
Acute, reversible: nausea, vomiting, fatigue, anemia, neutrocitopenia, hair loss, etc.

Long-term: Acute leukemia (<1%), cardiac toxicity (1% anthracyclines), cognitive deficits “chemo brain”, psychological effects.

Used to manage tumors that test positive for either estrogen or progesterone receptors.
Reduce recurrence by 40%.
Estrogen receptor blocker (tamoxifen).
Aromatase inhibitor(anastrazole).

After ttt patients are reviewed at regular. intervals :
3_monthly for the first 2 years.
4_monthly for the next 3 years.
And annually thereafter.
fallow up
Depends on following factors:
1) Type of the tumor.
2) stage of the primary tumor
3) Number,size,mobility of L.N involved
8)Measurement of tumor proliferation by thymidine labelling index &measurement of oncogene products.

4) Presence of distant metastases.
5) Hormone receptor status.
6) Site of the tumor.
7) Male ca breast.
Primary care physician
Surgical oncologist
Medical oncologist
Radiation oncologist
Rehabilitation specialists
Oncology nurse
Oncology pharmacist
Family members \ patient advocates
Early childbirth, breast feed
Exercise 3-7 hours / week
Maintain normal body weight
Minimize alcohol
Avoid long term HT, especially progestins
Low fat diet
Estimated 30-80% reduction in ris
Consider tamoxifen or raloxifene for high risk women.
Assess familial risk:
BRCA carriers. Consider prophylactic surgery for
Treatment designed to target cancer cells while minimizing damage to healthy cells
For HER2 positive cases.
Its amonoclonal antibodies agenst HER2 resptor.

An accurate history and clinical examination are important methods of detecting breast disease .
Breast cancer is found most frequently in the outer upper quadrant of the breast
The majority of breast cancers will present with:
– Painless or slightly tender hard lump .
Patients with more advanced tumours:
– breast tenderness, skin changes (with peau d’orange,) bloody nipple discharge, frank ulceration and fixation to the chest wall) or occasionally change in the shape and size of the breast .
Rarely patients may present with axillary
lymphadenopathy (which occasionally may be
painful) or distant metastasis .
A. Breast Duct System
B. Lobules
C. Breast Duct System
D. Nipple
E. Fat
F. Chest Muscle
G. Ribs

A. Cells lining duct
B. Basement membrane
C. Open central duct

Normal Breast

2-phyllodes tumor
3-intraductal papilloma
types of breast cancer
phyllodes tumor
is by far the most common benign neoplasm of the female breast. An absolute or relative increase in estrogen activity is thought to contribute to its development and indeed similar lesions may appear with fibrocystic changes ( fibroadenomatoid changes)
usually appear in young women ; the peak incidence is in third decade of life
this is a neoplastic growth within a duct
most lesions are solitary, found within the principal lactiferous ducts or sinuses
they present clinically as a result of
1) the appearance of serous or bloody nipple discharge.
2) the presence of a small subareolar tumor few millimeters in diameter
3) rarely nipple retraction
intraductal papilloma
Premalignant change
Turn out to be cancer in ongoing years

Not a premalignent change
A sign, which indicate risk of breast ca


Hormone therapy
Targeted therapy
how to do BSE
Male:female 1:100
Death: 31 in every 100,00
Incidence higher in high socioeconomic status, left breast, upper outer quadrant
1.3 million diagnosed annually.
465,000 die annually worldwide
The lifetime probability of developing breast cancer in developed countries is about 4.8%.
In developing countries, The lifetime probability of developing breast cancer is about 1.8%.
34% of cancer in Sudan

less common than fibroadenomas
arise from periductal stroma
some become lobulated and cystic
he most ominous change is the appearance of increased stroma cellularity with anaplsia and high mitotic activity , accompanied by rapid increase in size, usually with invasion of adjacent breast tissue by malignant stroma.
the carcenoma is two types:
1)ductal carcenoma in situ ( DCIS )

2) lodular carcenoma in situ ( LCIS )
1) invasive ductal carcenoma

2) invasive lobular carcenoma

3) medullary carcenoma

4) colloid carcenoma

5) tubular carsenoma
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