BREAST CANCER

Dr. Farhanul Huda

Associate Professor &Acting HOD
Dept. of Surgery
EPIDEMIOLOGY
• Collectively, US, India and China account for almost one third of
the global breast cancer burden.
• India has a long way to go!
• See the images below and listen to the discussion and you will
understand why.
 ?
• Why is the mortality so high?
• more patients turn up in later stages.

• What are the reasons for late presentations?

• lack of awareness,
• shyness on part of patients,
• social stigma,
• ignorance of doctors
So what do we learn today?
WHO prediction for breast cancer in India

• For the years 2015, there will be an estimated 1,55,000 new cases of
breast cancer and about 76000 women in India are expected to die of
the disease. The gap only seems to be widening, which means, we
need to work aggressively on early detection.
RISK FACTORS
• Three main groups:
• Major
• Intermediate and
• Minor
Major risk factors
• Gender
100 times more common in women than in men.
• Age
Very rare before the age of 20 and rare below 30 years.
The incidence of breast cancer doubles every 10 years until the
menopause.
• Previous breast cancer
• Family history and genetic predisposition
Intermediate risk factors
• Diet and alcohol intake
• Endocrine factors
Increased duration of exposure to endogenous estrogens.
Early age of menarche (age< 12), late age of menopause (>
55), and late age at first pregnancy (> 30),nulliparity,HRT,OCPs.
Lifetime number of menstrual cycles.
• Irradiation
Minor and controversial risk
factors
• Body size
• Stress
Genetics of breast cancer
BRCA 1
BRCA 2
• BRCA-1 is located on chromosome 17q.
• BRCA-1–associated breast cancers are invasive ductal carcinomas, are
poorly differentiated, and are hormone receptor–negative.
• BRCA-2 is located on chromosome 13q .
• BRCA-2–associated breast cancers are invasive ductal carcinomas, are
well differentiated and express hormone receptors.
PATHOLOGY
Why?
• Paramount importance in establishing the diagnosis of the tumour.
• It also helps determine the patient's prognosis
• There are many methods of pathologically classifying breast cancer;
most are based on whether the tumour is invasive or non-invasive
and whether it is derived from the duct system or the lobule.
Ductal carcinoma of the
breast
Most common form of breast cancer accounting for 85 to 90 per cent of all cases.
Lobular carcinoma of the
breast
subdivided into in situ and invasive forms
Clinical scenarios
• A 38 years old lady (with a history of breast cancer in her sister) presented with a 4 cm lump
in her right breast which turned out to be a cancer and had a few enlarged axillary nodes.
She had noticed the lump only a few months back. However, on evaluating all past records,
doctor found one mammogram done 2 years back (was advised by her gynecologist), just for
screening; she did not have any lump or other symptom then. In that mammogram, there
was a small area of stippled microcalcification, which was very suspicious (Stippled
microcalcifications are pathognomonic for cancer) . The radiologist had also mentioned it in
the report. But since there was no palpable lump, her gynecologist told her, not to worry. She
didn't do anything for that for the next 2 years, and finally, was detected with cancer in the
same site, in a minimum of clinical stage 2B. Finally after surgery, 5 (out of 27) nodes were
positive for cancer and this placed her in stage 3A. So please understand here, the
gynecologist advised the mammogram, but did not not know how to interpret or act, and the
lady, who would have otherwise been detected with cancer of stage 1 and would have had
more than 90% chance of 10 years survival, now ended up with stage 3A and will have
about 60% chance of 5 year survival. So two years of wait have definitely decreased her life
by 5 years.
• A 32 years old lady presented with a history of heaviness in breast before the periods as
well as pain in the breast for a few days before the periods. On clinical examination, breasts
were normal, except for slightly engorged. Again here, her family doctor had advised her
mammography (I wouldn't have advised her mammography, if at all needed, I would have
gone for an ultrasound of the breast first). On the ultrasound which was done with the
mammogram, there were multiple cysts of varying sizes in both the breasts, from few
millimetres to 8 to 9 millimetres. She was overtly worried about cancer, and had already
taken opinion from one surgeon and one gynecologist. One had advised surgery (!!) and the
other had given some non specific medications. All the doctor did was to reassure her, that
this was nothing to worry about (She was visibly more worried about the cancer than the
symptoms of pain and heaviness she had). The doctor assured her that this was not cancer,
this did not require surgery, this occurs in many women of her age - some have more
symptoms while some have less symptoms, and that over a period of time, it will all settle.
Gave her some symptomatic medications and some vitamin supplements and believe me,
after three months, she was almost settled of symptoms and was very happy. Not that
medications worked or something, but it was the re assurance that worked.
CLINICAL FEATURES
• A lump
• Changes in the skin may be the sole presenting symptom.
• Puckering .
• Peu d'orange .
• Ulceration .
• Nipple distortion and inversion .
• A unifocal or bloodstained nipple discharge.
Diagnosis
• Fine-needle aspiration cytology
• Core biopsy
• Mammography
 TNM definitions
Primary Tumour

• Tx – Primary tumour cannot be assessed

• To – No evidence of primary tumor
• Tis – Carcinoma in situ
• T1 – Tumor 2 cm or less
• T2 – 2 – 5 cm tumor
• T3 – Tumor 5 cm and above
• T4 – Extn. to chest wall / skin
Regional lymph node involvement -
clinical
NX – Regional lymph nodes cannot be
assessed.
No – No regional lymph nodes.
N1 – Movable ipsilateral axillary nodes.
N2 – Fixed ipsilateral axillary nodes.s
N3 – Ipsilateral internal mammary nodes
 Regional lymph node involvement -
pathological
• pNX – Regional lymph nodes cannot be assessed.
• pNo – No regional lymph node metastasis.
• pN1 – Movable ipsilateral axillary node metastasis.
• pN1a – Micrometastases (< 0.2 cm )
• pN1b – Metastases ( > 0.2 cm )
• i) 1 – 3 nodes
• ii) 4 or more nodes
• iii) extending beyond the capsule (< 2 cm)
• iv)Metastases to nodes ( > 2 cm )
• pN2 - Fixed ipsilateral axillary nodes
• pN3 – Ipsilateral internal mammary nodes
Distant Metastases

• Mx – Distant metastases cannot be

assessed.
• Mo – No distant metastases.

• M1 – Distant metastases ( ipsilateral

supraclavicular lymph nodes )
AJCC / UICC Stage
grouping
• St 0 - Tis No Mo

• St 1 – T1 No Mo

• St 2a
To N1 Mo
T1 N1 Mo
T2 No Mo
• St 2b
T2 N1 Mo
AJCC / UICC Stage
grouping
• St 3a
To N2 Mo
T1 N2 Mo
T2 N2 Mo
T3 N1 Mo
T3 N2 Mo
• St 3b
T4 any N Mo
any T N3 Mo
• St 4
any T any N M1
STAGING
• The Manchester system (1940)
• Stage I. Tumour confined to breast. Any skin involvement covers an
area less than the size of the tumour.
• Stage II. Tumour confined to breast. Palpable, mobile axillary nodes.
• Stage III. Tumour extends beyond the breast tissue because of skin
fixation in an area greater than the size of the tumour or because of
ulceration. Tumour fixity underlying fascia.
• Stage IV. Fixed axillary nodes, supraclavicular nodal involvement,
satellite nodules or distant metastases.
MANAGEMENT
Management of non-
invasive
breast cancer
Stage 0
LCIS
• Because LCIS is considered a marker for increased risk rather than an
inevitable precursor of invasive disease, the current treatment of LCIS
is observation with or without tamoxifen.
• The goal of treatment is to prevent or detect at an early stage the
invasive cancer.
• There is no benefit to excising LCIS, as the disease diffusely involves
both breasts and the risk of invasive cancer is equal for both breasts.
The use of tamoxifen as a risk-reduction strategy should be
considered in women with a diagnosis of LCIS.
DCIS
• Women with DCIS and evidence of widespread disease (two or more
quadrants) require mastectomy.
• For women with limited disease, lumpectomy and radiation therapy
are recommended.
• Low-grade DCIS of the solid, cribriform, or papillary subtype, which is
less than 0.5 cm in diameter, may be managed by lumpectomy alone.
• Adjuvant tamoxifen therapy is considered for all DCIS patients.
• Simple mastectomy
• 95% cure rate
• Rarely relapse, due to micro-invasive cancer
• No need for axillary dissection
• Wide excision alone—30% recurrence at 5 years
• Wide excision + radiotherapy—15% recurrence at 5 years
Early Invasive Breast
Cancer
Stage I, IIa, or IIb
T1–3, N0–1 tumors.
• Treatment of the breast and axilla
• Pathological staging to direct adjuvant therapy
• Adjuvant therapy—endocrine, chemotherapy, radiotherapy
• Follow-up
Breast surgery
• Quadrantectomy removes the primary cancer with a margin of 2.0 cm
of normal breast tissue.
• Lumpectomy is the removal of the tumour mass with a limited
portion of normal tissue (1 cm).
• MRM
INDICATIONS OF BCS
• T1,T2lesions, N0/N1,M0 disease.
• Tumor>4cm in a large breast.
• Single clinical and mammographic lesion.
• Patient should be willing tomaccept the chances of recurrence.
CONTRA INDICATIONS OF BCS
• T4,N2 Lesions
• Patients choice
• Multifocal/Multicentric disease
• Tumor size high as compared to breast size.
• Extensive calcification on mammography
• Pregnancy
• Persistent positive margins
• Patient’s contraindication to radiotherapy.
Treatment of the axilla
• Surgery
• —sentinel node biopsy:
• —removal of first node which contains secondary deposit
• —use either blue dye or 99MTc colloid
• —negative sentinel node avoids clearance
Loco-regional radiotherapy
• Reduce the risk of local recurrence after BCS
• Irradiation of axilla—not required if clearance performed
• Radiation to axilla may cause lymphodema and brachial neuropathy
Adjuvant endocrine therapy
• 60% of breast cancers are oestrogen receptor positive
• Ovarian ablation
• Side-effects of tamoxifen—menopausal symptoms
• —endometrial cancer, 4-fold increase in risk
• LHRH agonists
Adjuvant chemotherapy

• CMF (cyclophosphamide, methotrexate, 5FU)

• Anthracycline regimes may be better
• Taxanes based regimes
Management of locally
advanced
breast cancer
Stage IIIa or IIIb
• The probability of metastatic disease is high (>70%).
• A combination of neoadjuvant chemotherapy, surgery and
radiotherapy is commonly used.
Management of metastatic
breast cancer
• Aim is palliation
• If hormone-sensitive, bony disease—may survive years .
• Visceral, ER-negative disease has bad prognosis
• Usual sites—lung, liver, bone, brain
• Rare sites—choroid, pituitary
• Combination of endocrine therapy, chemotherapy, radiotherapy and
symptomatic tt is given.
SENTINAL LYMPH NODE
BIOPSY
SENTINEL NODE CONCEPT

Based on the hypothesis lymph flow is orderly,

predictable & tumor cells spread sequentially

Sentinel node is the first node encountered by

the tumour cells

The sentinel node is in the direct pathway of

the primary tumour
Advantages of sentinel node biopsy
• Minimally Invasive
• Low Cost
• low morbidity
• Nodal metastasis outside axilla detected
• obviates the need for ALND without compromising staging &
local control
 Disadvantages of Sentinel
node Biopsy
• Has a False negative rate of 6% (ALND3%)
• Not useful in clinically involved axilla
• Not useful in pregnancy & lactation
• Cannot be done in multifocal / multicentric breast carcinomas
• Cannot be done in patients with previous breast surgery on the
same side
Technique

Blue dye isosulfan blue (or)

technitium labelled colloidal albumin with
gamma camera and probe can be used
Sub dermal injection
A single dose of 0.2 ml of the dye is
injected at the tumour site sub-dermally
one day prior to surgery
Peri tumour injection
Dye injected at four sites.
Larger volumes are given
Removal of dye or tracer is slower due to
scanty lymph supply of breast
parenchyma
imaged 1 to 2 hrs after injection
SENTINEL LYMPH NODE DISSECTION
WITH DYE TECHNIQUE
Blue lymphatics leading to SLN are traced

Discolouration of breast and blue urine

ISOTOPE TECHNIQUE
Probe guided surgery is superior
Useful for intra-operative localisation
After removal of SLN probe is reapplied to
site and radioactivity measured for
confirmation
PIT FALLS IN SENTINEL NODE
DISSECTION
• 6% FALSE NEGATIVE
• SKIP PHENOMENON & CHANGED FLOW
DIRECTION
• INFILTRATION BY CARCINOMA
• FATTY DEGENERATION
• UPPER OUTER QUADRANT -CLOSE
PROXIMITY TO SENTINEL NODE. SHINE
THROUGH PHENOMENON-Breast to be
retracted when probing
Special problems
SPECIAL PROBLEMS IN BREAST
CANCER – PAGETS DISEASE
Rare before 30 years, peak between
50 & 60
Can occur in the male
Erythematous exudative or scaly lesion
appears first on the nipple spreads to
areola
Does not involve surrounding skin
Nipple retraction & nipple pigmentation
& mass
D D for Pagets disease
Chronic Eczema
Malignant melanoma
Syphilitic chancre
Bowens disease
Mammary ductectasia
Mammography
Mass , sub areolar micro calcification
or only thickening of nipple areola
complex
Biopsy
Full thickness nipple biopsy or
exfoliative scrape cytology
PAGETS TREATMENT
1) with palpable mass-
segmentectomy with 1.5 cm margin
with ALND with PO-RT
2)if resection margins positive or muticentric or
solid or comedo type or high grade with
necrosis
completion mastectomy is done
Pagets without palpable mass
Biopsy of nipple areola complex positive
first step: On mammo no occult mass.no
microcalcification—do segmentectomy of nipple
areola complex +RT without axillary dissection
Mammography + ve
Stereotactic needle localisation of occult mass
or microcalcification with frozen section biopsy
and proceed
Tamoxifen
BREAST CANCER IN PREGNANCY&
LACTATION
DELAY IN DIAGNOSIS
1) firm ,nodular &hypertrophied breast
2) small tumours can be missed
3) present at advanced stage
4) high proportion of ER-ve
5) bad prognosis
BREAST CANCER IN
PREGNANCY
Mammography

FALSE NEGATIVE rate is high

due to high radiographic density of
pregnant breast
BREAST CANCER IN PREGNANCY
Alkaline phosphatase is elevated in
pregnancy
Chest X-ray is allowed with proper
shielding
Bone scan
A) Stage 1 & 2-Bone mets
uncommon
scan not done
B)Stage 3 Especially with bone pain
Bone scan done in later stages of
pregnancy or after pregnancy
BREAST CANCER IN
PREGNANCY
Treatment
Modified Radical Mastectomy is the
choice irrespective of the trimester
In the first & second trimester breast
conservation with radiotherapy should not
be
done due to radiation induced anomalies
in foetus
Study questions
• A 57-year-old woman undergoes core-needle biopsy of a breast mass.
The pathologic diagnosis is infiltrating ductal carcinoma of the breast.
• How will you stage this cancer?
• What are the important prognostic factors?
A 49-year-old woman presents with a breast mass. You are examining the affected
breast.
◆ How would the following clinical findings affect the woman’s prognosis?
1. Red edematous breast with an underlying mass
2. Edema of the skin overlying the mass
3. Puckering of the skin overlying the mass
4. Retraction of the nipple
5. A 1.5-cm mass fi xed to the deeper tissues
6. A lymph node palpable in the supraclavicular area
7. A hard, fi xed lymph node in the ipsilateral axilla
8. Arm edema
• A 60-year-old woman has breast cancer and undergoes preliminary
staging. The lesion is 1.5 cm in diameter, and no axillary nodes are
palpable. A metastatic workup is negative.
• What stage is this woman’s cancer?
• What are this woman’s surgical options, both for sampling the
lymph nodes and treating the primary tumor?
• A 38-year-old woman is scheduled for a mastectomy and sentinel
node biopsy. She is concerned about her appearance and would like
to know her options for breast reconstruction.
• What options should you offer?
• A 38-year-old woman presents with a 3-month history of a progressively
enlarging breast mass. At the time she sees you, she has a 6- 7-cm fi xed
mass, with erythema and edema on the upper, outer aspect of her right
breast. Clinically, her axilla is positive with enlarged, firm lymph nodes.
• What is the suspected diagnosis?
• What histologic features are typical of this condition?
• The surgeon confirms the physical findings and obtains a punch biopsy
of the mass. Pathology reveals inflammatory carcinoma. Estrogen and
progesterone receptors are negative.
• What is the recommended treatment?
• A 55-year-old woman has a modified radical mastectomy for a stage II
carcinoma of the breast.
• A small, 0.5-cm nodule in the suture line 5 years after surgery.
• A mammographic abnormality in the opposite breast
• Elevated liver function studies
• A fracture of the femur