carcinoma breast part 1

1. BREAST CANCER

2. Overview
● Breast cancer is the second most common carcinoma in females.
● Second to lung cancer as a cause of death
● Etiology of vast majority is unknown
● Now, the mortality rate is decreasing owing to early detection
● Surgery is considered as primary treatment for ca breast

3. Risk factors
● More common in developed countries
● More common after middle age, females.
● Attaining early menarche and late menopause.
● Nulliparity
● Late first child birth (>35 years)
● Obesity
● Li- Fraumen’s syndrome (90%), Cowden syndrome (50%)
● Previous therapeutic radiation ( thoracic)
● Hormone replacement therapy more than 5 years
● Alcoholism

4. ● 2-5%cases are familial, majority are sporadic.
● BRCA1 mutation (long arm of chromosome 17)- high risk of breast
carcinoma, commonly shows ER negative status, more aggressive
tumors with poor prognosis.
● BRCA2 mutation (long arm of chromosome 13)- usually shows ER
positive status with good prognosis.
● Both genes are associated with high risk of ovarian cancer.
● Occasionally BRCA3 and p53 suppressor gene is also involved.
● Risk is 3-5 times more if 1st degree relative is having breast cancer.
● Carcinoma in one breast increases the risk of developing carcinoma in
opposite breast by 3-4 times.

6. Protective factors
● Early first child birth
● Breast feeding
● Vitamin C reduces risk

7. Pathology
● Breast carcinoma arising from lactiferous ducts is called as DUCTAL
CARCINOMA.
● Breast carcinoma arising from lobules is called LOBULAR
CARCINOMA.
● IN SITU CARCINOMA is a preinvasive carcinoma which has not
breached the epithelial membrane, INVASIVE CARCINOMA can
occur eventually.
● Invasive carcinoma arises through a series of molecular changes at
cellular level resulting in outgrowth and spread of breast epithelial
cells with immortal features and uncontrolled growth.

9. CLASSIFICATION

10. Ductal carcinoma In Situ (DCIS)
● It is intraductal carcinoma without any invasion into basement membrane.
● High grade- SOLID, COMEDO
● Low grade- CRIBRIFORM, PAPILLARY
● Untreated DCIS becomes invasive in >50% cases
● Invasive ductal carcinoma forms in the same breast and the same quadrant of DCIS unlike LCIS .
● Nipple discharge and small swellings are main presentations.
● Investigations- US assisted FNAC and mammography

12. Management
● FNAC confirms the disease but will not differentiate from DCIS and invasive carcinoma
● Mammography. US breast, MRI breast
● Routine metastatic work up
● Breast conservative surgery with RT to breast and axillary dissection after SLNB (If +ve)
● Hormone therapy (tamoxifen) prevents both local recurrence and development of new
primary breast carcinoma
● Total mastectomy is done in DCIS when-positive margin after wide local excision; two or
more primary tumour (multicentric); when radiation to breast is not possible (collagen
diseases); tumour/breast size ratio is not appropriate for conservative surgery, diffuse
microcalcifications, family history and DCIS in pregnancy.
● Skin sparing mastectomy (SSM) may be ideal in such occasions with immediate
TRAM/LD flap.

13. Types of carcinoma breast
1. Scirrhous carcinoma
2. Medullary carcinoma
3. Inflammatory / lactating / mastitis carcinomatosis
4. Colloid carcinoma
5. Paget’s disease of nipple
6. Atrophic scirrhous carcinoma
7. Lobular carcinoma in situ

14. Biological behaviour and clinical features of
carcinoma breast
PRESENTATIONS:
● Lump in the breast which is hard, painless (most common). At least
tumour should become 1 cm to clinically palpable
● Nipple discharge is the second common presentation
● Ulceration and fungation
● Axillary lymph node enlargement, supraclavicular lymph node
enlargement
● Chest pain and haemoptysis
● Bone pain, tenderness, and pathological fracture
● Pleural effusion, ascites
● Liver secondaries, secondary ovarian tumour
● Pain in the lump in 10% cases

15. ● Most common site is upper outer quadrant
● Cutaneous manifestations:
● Peau d'orange- orange peel appearance due to obstruction of
dermal lymphatics
● Dimpling of skin due to infiltration of ligament of Cooper
Peau d’orange

16. LYMPHATIC SPREAD- occurs through
● Subareolar sappey’s lymphatic plexus
● Cutaneous lymphatics
● Inflammatory lymphatics
Groups 1st and 2nd are commonly involved.
Spread restricted to level1 nodes carry better prognosis.

17. TNM staging of carcinoma breast

20. Stage groups

21. MOLECULAR SUBTYPES

22. INVESTIGATIONS OF CARCINOMA BREAST

23. Clinical examination
1. History
This should include the following elements:
• breast mass
• breast pain
● nipple discharge
• nipple or skin retraction
• axillary mass or pain
• arm swelling
● symptoms of possible metastatic spread

24. 2. Past medical history of breast disease in detail.
3. Family history of breast and other cancers with
emphasis on gynaecological cancers. 4. Reproductive history:
age at menarche
age at first delivery number of pregnancies, children and
miscarriages
age at onset of menopause
history of hormonal viz OCP/HRT
5. Past medical history.

25. 4. Local examination:
• breast mass
- size
-location (specified by clock position and distance from the
edge of the areola)
-shape - consistency
-fixation to skin, pectoral muscle and chest wall
- multiplicity
• skin changes
- erythema (location and extent) - oedema (location and extent)
- dimpling
- infiltration -ulceration - satellite nodules

26. nipple changes
-retraction
- erythema
- erosion and ulceration
-discharge (specify)
• nodal status -axillary nodes on both sides (number, size, location and fixation
to other nodes
or underlying structures) -supraclavicular nodes
.local examination of possible metastatic sites.

27. IMAGING- MAMMOGRAPHY
Mammography is a special type of low-dose (0.1 cGy per study) x-ray imaging used to
create detailed images of the breast.
Mammography can demonstrate microcalcifications smaller than 100 um;
• Reveals a lesion, 1-2 years before it is palpable by BSE.
● Each chest roentgenogram delivers one quarter of this radiation volume
● Not a substitute for biopsy; rather is an adjunctive
● two films are taken- craniocaudal and mediolateral
● INDICATIONS-
1. Screening- beyond 40years age.
2. Diagnostic- to evaluate existing symptoms of breast disease or in patient who had
breast conservative surgery earlier.
3. Obese patients
4. Whenever conservative breast surgeries are planned
5. spread / de novo tumor in opposite breast
6. Mammography guided biopsy
7. Follow up mammography after surgery

28. Findings- mammography
● Mass- size, location, margin
● Microcalcifications
● Microcalcifications
● Spiculations, Duct distortions

29. IMAGING- Ultrasound
INDICATIONS
● Age less than 40 years
● Differentiate between solid and cystic tumors
● Pregnant woman with lump
● Young women with dense breast

30. IMAGING- MRI
INDICATIONS-
● Women with breast implants
● Differentiate between multifocal and multicentric lumps
● Most sensitive for DCIS
Investigation of choice for local scar recurrence
● In a person with suspected ductal lesion and inconclusive USG
● Screening modality for young and high risk patients

32. HISTOPATHOLOGY
● Fine needle aspiration cytology
● Fine needle non aspiration cytology
● Trucut biopsy
● Excisional biopsy

33. MANAGEMENT
1. SURGICAL
2. CHEMOTHERAPY
3. RADIOTHERAPY
4. HORMONOTHERAPY.