Like the playlist in YouTube, in this presentation I have combined three of my presentation into one for the benefit of medical students and surgical trainees. The first presentation regading introduction to breast pathologies, second regarding benign breast lesions and the third one is regarding Carcinoma Breast. Hope you will enjoy this.

1. BREAST
INTRODUCTION
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia

2. Must To Know Core Clinical
Problems

3. BREAST
▪ Surgical Anatomy
▪ Surgical Physiology
▪ Symptomatology
▪ Approach to a patient with breast pathology
▪ Investigations

4. ANATOMY
✓ Breast consists of glandular tissue, ducts,
supporting muscular tissue, fat, blood vessels,
nerves, and lymphatic vessels.
✓ Glandular tissue consists of 15 to 25 lobes,
each of which drains into a separate excretory
duct that terminates in the nipple
✓ Each lobe is subdivided into 50 to 75 lobules,
which drain into a duct that empties into the
excretory duct of the lobe
✓ Each duct dilates as it enters the base of the
nipple to form a milk sinus. This serves as a
reservoir for milk during lactation
✓ Cooper ligaments are the fibrous connections
between the inner side of the breast skin and
the pectoral muscles.

5. ANATOMY

6. PHYSIOLOGY
✓ At birth, branching system of ducts
emptying into a developed nipple
✓ At puberty, glandular tissue begins to
develop beneath the areola.
✓ Major physiologic change related to the
menstrual cycle is engorgement
✓ With pregnancy, neuroendocrine control of
the breasts starts. Suckling produces nerve
impulses that travel to the hypothalamus.
✓ The hypothalamus  anterior pituitary to
secrete prolactin, glandular tissue to
produce milk.
✓ The hypothalamus also posterior pituitary
to produce oxytocin, muscle cells
surrounding the glandular tissue to contract
and force the milk into the ductular system.

7. Breast- Symptoms
▪ Lump or lumpiness
▪ Mastalgia or Mastodynia- Cyclic or Noncyclic
▪ Nipple Discharge

8. Breast- Symptoms
▪ Lump or lumpiness
▪ Benign or Malignant
▪ Triple assessment

9. Breast- Symptoms
▪ Mastalgia or Mastodynia
▪ Cyclical usually associated with menstrual cycle and pain more
during 3 to 5 days before menstruation Ex: fibrocystic disease
▪ Breast is subjected to the influence of Estrogen and progesterone
hormones every month
▪ Noncyclical mastalgia due to inflammatory lesions like mastitis
and breast abscess or chestwall problem like costochondritis

10. Breast- Symptoms
▪ Nipple Discharge
▪ Colour
-Blood Ductal papilloma
&Ductal carcinoma
-PurulentBreast abscess
-Greenish Fibroadenosis &
Ductectasia
-Milky Galactocele,
Prolactenemia
▪ Spontaneous
▪ Segmental expression

11. Breast-Investigations
• Staging Investigations
• Xray Chest
• Abdominal Ultrasound/
CT abdomen
• Radionucleide Bone Scan
• CT Brain
• PET Scan
• Radiological Investigations
• Ultrasonography
• Mammography
• Pathological Investigations
• Fine Needle Aspiration Cytology FNAC
• Core Needle Biopsy Trucut Biopsy
• Needle Localisation Biopsy
• Stereotactic Biopsy
• Open Biopsy Incisional& Excisional
• Sentinel node Biopsy

13. BREAST
Benign Breast Diseases
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical college
Melaka 75150 Malaysia

14. SYMPTOMS

15. Causes for Symptoms

16. Classification of BBD

17. BBD-Benign Breast Diseases
✓Amastia & Athelia
✓Mastalgia- Fibrocystic disease
✓Fibroadenoma & Breast Cysts
✓Fat Necrosis
✓Duct Ectasia
✓Phyllodes tumor
✓Galactocele
✓Mastitis & Breast Abscess
✓Mondor’s disease
✓ Breast is host to a spectrum
of benign and malignant
diseases.
✓ Benign breast conditions are
universal phenomena among
women.
✓ It accounts for 80% of clinical
presentation related to the
breast.

18. BBD- Amastia & Athelia
✓Breast tissue with or without a nipple or
just nipple and areola alone can occur any
where along the milk line
✓The milk line extends from the axilla to
groin
✓ Total lack of breast tissue( amastia) or of
nipple (athlelia) is unusual
✓supernumerary nipples -polythelia &
breast- polymasita are quite common
✓Unilateral amastia is often associated
with absence of the pectoral muscles
Poland’s syndrome
POLAND’S
SYNDROME

19. BBD-Fibrocystic Disease
✓Breast is a dynamic organ undergoing periods of development and
involution throughout a woman’s reproductive life.
✓Affects premenopausal women and is characterized by cyst formation,
hyperplasia of duct epithelium (epitheliosis), enlargement of lobules
(adenosis) and fibrosis, which may vary in extent and degree in any
one breast.
✓This condition is the result of abnormal response to hormonal changes
and can be associated with menstrual irregularities.
✓Ill–defined area of induration or firm swelling, often painful prior to
menstruation. (cyclical mastalgia)

20. BBD-Fibrocystic Disease
✓1. Cyst formation
✓2. Epitheliosis—
Hyperplasia of duct
epithelium
✓3.Adenosis—
Proliferation of
lobular epithelium
✓4. Fibrosis—It
represents
involutional change

21. Fibrocystic Disease- Treatment
✓Reassurance, simple analgesia and a supportive bra often help.
✓Gamma-lineolic acid(evening primerose oil) 3 to 4 Gm/day for 3to4 months
✓Occasionally Danazol- anti gonadotrophin, Tamoxifen- anti estrogen or
Bromocriptine- prolactin inhibitor are required
✓Danazol 200- 300 mgm/day reduced to 100mgm/day from day 14 to 28 days of
menstruation
✓Mammography and ultrasonography typically show normal breast tissue.
✓Despite negative imaging studies, a biopsy should be performed to r/o malignancy

22. Fibroadenoma
✓Fibroadenoma is a benign tumor of breast consisting of glandular and
connective tissue elements.
✓Commonest benign breast tumor. The typical patient is 15 to 35 yrs
✓Well-circumscribed, solid masses represent hyperplastic lobules.
✓Smooth, encapsulated mass that is freely mobile- “breast mouse”-
rubbery in consistency and non-tender.
✓USG shows a mass with smooth margins; Trucut biopsy confirms the
diagnosis
✓Fibroadenomas >2cms size or those with inconclusive biopsy should be
excised

23. Fibroadenoma

24. Fibroadenoma
USG Breast:
Hypoechoic lesion
Smooth partially
lobulated margin
Mammogram:
Popcorn
Calcification in
Involuting
Fibroadenoma

25. BREAST CYSTS
✓Commonly occurs between age 30 to 50
✓Is due to non-integrated involution of stroma &
epithelium
✓Appearance: blue-domed cyst (single/ multiple;
unilateral/ bilateral)
✓Treatment:
✓Fluid aspiration (greenish-yellow; can be sent
fluid cytology)
✓Hemorrhagic fluid and recurrent cysts can be
excised for histological exam to r/o Carcinoma

26. PHYLLODES TUMOR
✓Other names: cystosarcoma phyllodes,
serocystic disease of Brodie
✓Usually occurs in age > 40
✓Presentation: Very large, firm, mobile,
non-tender lump with uneven lobulated
surface.
✓Wide variation in appearance (from
benign to potentially malignant)
✓Treatment: enucleation/ wide excision/
mastectomy
✓Rarely becomes sarcoma
LEAF LIKE

27. DUCT ECTASIA
✓Is a peri-ductal inflammation with duct
dilation
✓Presentations: MARD (mass, abscess,
retraction, discharge)
✓Subareolar mass
✓Slit-like nipple retraction
✓Brown/ green/ blood-stained nipple discharge
✓Abscess & fistula just below & around areola
✓Treatment: Hadfield’s operation, wide excision
of all affected ducts, shave off below nipple

28. DUCTAL PAPILLOMA
✓This benign lesions of the lactiferous duct wall
occur centrally beneath the areola In 75% of
cases.
✓They most commonly produce a bloody nipple
discharge, some times associated with pain
✓They are solitary proliferation of ductal
epithelium
✓Intraductal papillomas should be treated by
excision of a duct as a wedge resection.
✓Treatment: simple excision (microdochectomy)

29. FAT NECROSIS
✓Occurs following blunt injury to breast (may be
acute/ chronic), usually in obese, middle-aged
females
✓Painless, firm, fixed mass with ill-defined
margins
✓May even have skin tethering & nipple retraction
✓This condition is also difficult to clinically
distinguish from Ca (hence, FNAC/ core biopsy is
needed)
✓Treatment: Surgical excision, the excised mass is
an infiltrative yellowish white mass

30. GALACTOCELE
✓Is a solitary sub-areolar cyst filled with
milk during lactation.
✓ Formed by obstruction to a duct in the
puerperium . The milk retained
proximal to the obstruction eventually
becomes cheese-like
✓Appears as a painless lump weeks –
months after cessation of breast feeding
✓Complication Infection
✓Treatment Aspiration or Surgical
Excision

31. CHRONIC MASTITIS
✓Chronic intramammary abscess: Pus
encapsulated by thick-walled fibrous tissues.
Difficult to clinically distinguish from Ca.
✓TB breast: Presents with multiple chronic
abscesses & sinuses. A/w active pulmonary TB/
cervical adenitis. Bacteriological & pathological
confirmation are required. Treatment: anti-TB
drugs
✓Chronic granulomatous mastitis, Actinomycosis
breast

32. ACUTE MASTITIS
BREAST ABSCESS
✓Is usually due to Staph Aureus & a/w lactation
✓Breast mastitis is an infection that commonly affects women who are
breast-feeding (especially during the first two months after
childbirth) but can occur in all women at any time
✓ Sore & cracked/ inverted nipple is the route of infection, the usual
mode of infection is via the nipple, the infection being carried by
suckling infant’s nasopharynx.
✓ Part or all of the breast is intensely: painful, hot, tender, red, and
swollen
✓The breasts are growing more tender, and the fever is becoming more
pronounced.

33. ACUTE MASTITIS
BREAST ABSCESS
✓Ultrasound: used to localize the abscess
✓FNAC: used to exclude underlying carcinoma especially in chronic
Breast abscess where the abscess become encapsulated with a thick
fibrous capsule & the condition can’t be distinguished from a
carcinoma without a biopsy.
✓Needle Aspiration: to confirm presence of pus.
✓Mammogram: to exclude underlying carcinoma.

34. ACUTE MASTITIS
BREAST ABSCESS
✓ MANAGEMENT:
✓ Simple Needle Aspiration: using a wide bore needle under local
anesthesia.
✓Guided drainage: under image control with radiological or ultrasound
techniques a tube drain can be inserted & left until the cavity has
collapsed.
✓Surgical drainage: it is the most certain method, not only can all
loculi be reached, but also dead tissue can be removed. The cavity is
then dressed regularly & left open to heal by secondary intention.

35. ACUTE MASTITIS
BREAST ABSCESS

36. ACUTE MASTITIS
BREAST ABSCESS

37. MONDOR’S DISEASE
✓Superficial thrombophelebitis of vein
over breast & chest– thoracoepigastric
artery
✓Thrombosed subcutaneous cord attached
to skin
✓Self limiting condition
✓Treatment is restricted arm movement

38. BENIGN BREAST DISEASES
✓Benign breast disorders & diseases are common
✓The aetiopathogenesis is complex and not fully understood
✓Lump and pain are the most common complaints
✓Evaluation is done by Triple assessment
✓Histological risk factors for future malignancy are relative and not
absolute risk factors
✓Treatment is based on the natural history of clinical problems
✓Treatment must be tailored to individual needs

39. BENIGN BREAST DISEASES
EMQ

40. BENIGN BREAST DISEASES
EMQ

42. CARCINOMA
BREAST
AN OVERVIEW
AN OVRVIEW
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia

43. OBJECTIVES
• Etiopathogenesis
• Types & Clinical features
• Investigations
• Staging
• Treatment of EBC, LABC&ABC
• Prognosis and Followup

44. Etiopathogenesis
Incidence of Sporadic, Familial, and Hereditary Breast
Cancer
Sporadic breast cancer 65–75%
Familial breast cancer 20–30%
Hereditary breast cancer 5–10%
BRCA1 a 45%
BRCA2 35%
p53 a (Li-Fraumeni syndrome) 1%
STK11/LKB1a (Peutz-Jeghers syndrome) <1%
PTENa (Cowden disease) <1%
MSH2/MLH1a (Muir-Torre syndrome) <1%
ATMa (Ataxia-telangiectasia) <1%
Unknown 20%

45. Risk Factors
Major factors
Gender
Age
Previous breast cancer
Family history and genetic predisposition (BRCA 1 or 2 mutations)
Intermediate factors
Alcohol and diet
Endocrine factors:
Early menarche
Late menopause
Hormone replacement therapy
Nulliparity and elderly primi
Irradiation
Benign proliferative breast disease (e.g. multiple papillomatosis)
Smoking & OCPs not a risk factor

46. TYPES
Classification of Primary Breast Cancer
Noninvasive Epithelial Cancers
Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS)
Invasive Epithelial Cancers (Percentage of Total)
Invasive lobular carcinoma (10%-15%)
Invasive ductal carcinoma
Invasive ductal carcinoma, NOS (50%-70)
Tubular carcinoma (2%-3%)
Mucinous or colloid carcinoma (2%-3%)
Medullary carcinoma (5%)
Invasive cribriform carcinoma (1%-3%)
Invasive papillary carcinoma (1%-2%)
Adenoid cystic carcinoma (1%)
Metaplastic carcinoma (1%)

47. Clinical Presentation
• Paget’s Disease of the Nipple
• Skin
Tethering/dimpling/puckering
• Peau d’Orange
• Skin Ulceration / Fungation
• Visible / Palpable Lump
• Hard Consistency
• Non Tender
• Low mobility
• Axillary Lymphnodes+
• Nipple Retraction
• Nipple Discharge

48. Clinical Presentation
The location of breast cancer is as
follows:
Upper outer quadrant: 60%
Central area: 12%
Lower outer quadrant: 10%
Upper inner quadrant: 12%
Lower inner quadrant: 6%

49. Clinical Presentation

50. Clinical Presentation
Peau d’ orange Appearance

51. Clinical Presentation
Skin dimpling and puckering are
inspectory findings
Tethering is due to infiltration of Astley
cooper’s ligaments and is confirmed by
palpation

52. Clinical Presentation
Nipple retraction- Recent,
Unilateral, circumferential
infiltration and fibrosis of
lactiferous ducts

53. Clinical Presentation
Nipple discharge
suggestive of
malignancy if:
1. Spontaneous
2. Unilateral
3. From single duct
4. Bloody discharge
5. Associated with mass
6. Age > 40 yrs

54. Skin Ulceration

55. Paget’s disease of nipple
✓Eczema like condition
✓Malignant cells in the subdermal layer
✓Red flat ulcer, nipple erosion

56. Paget’s disease of nipple
Paget’s Disease Eczema of Nipple
Unilateral Bilateral
Itching absent Itching present
Absence of oozing Presence of oozing
Scales & Vesicles absent Scales & Vesicles present
Nipple destroyed Nipple intact
Underlying lump may be present No underlying lump present
Edges are distinct Edges are indistinct
No response to treatment Responds to treatment
Occurs at menopaus( old age) Seen in lactating women( young women)

57. Investigations
“The choice of initial diagnostic evaluation
after the detection of a breast lump should be
individualised for each patient according to
the age, perceived cancer risk and
characteristics of the lesion.”

58. Investigations- Triple Assessment

59. Investigations
• Staging Investigations
• Xray Chest
• Abdominal Ultrasound/
CT abdomen
• Radionucleide Bone
Scan
• CT Brain
• Radiological Investigations
• Ultrasonography
• Mammography
• Pathological Investigations
• Fine Needle Aspiration Cytology
FNAC
• Core Needle Biopsy Trucut Biopsy
• Needle Localisation Biopsy
• Stereotactic Biopsy
• Open Biopsy Incisional& Excisional
• Sentinel node Biopsy

60. Investigations- Mammography
• Dense opacity
• Irregular and Ill-
defined margins
• Asymmetry
• Clustered pleomorphic
microcalcification
• Architectural distortion
• Stellate or spiculated
appearance

61. Investigations- Mammography

62. Investigations- Ultrasonography
• High frequency 7MHz probe
is used although 10 to 13MHz
preferable
• Differentiate solid and cystic
lesions
• Malignant appearing masses
1.Irregular margins
2.Hypoechoic
3.Posterior acoustic shadow
4.Vertical growth appearance
(TALLER than wide)
MASS
SHADOW

63. Investigations- FNAC
• 1.5 inch 22 gauge needle attached to
a 10 ml syringe is used
• With or without image guidance
• FNAC-DISADVANTAGES
1. FALSE NEGATIVE rate high
2. Inadequate specimen
3.Requires skilled cytopathologist
4. Cannot differentiate in situ vs
invasive lesions

64. Investigations- Trucut Biopsy
Core Needle Biopsy
• Done using a 14 gauge needle or Tru cut needle
• ADVANTAGES
1. Lower FALSE negative rates
2. Doesn't need specially trained cytopathologist
3. Adequate samples are obtained
4.Can differentiate in situ vs invasive lesions
5.Can confirm-ER/PR/Her 2 neu status

65. Investigations-For Nonpalpable
Lump
Image Guided Biopsies
1.USG guided FNAC or core needle biopsy(if
mass is visualised)
2. Needle localising biopsy
3. STEREOTACTIC needle biopsy
(when no mass present but micro
calcifications seen mammographically)

66. Investigations-Sentinel Node Biopsy
• LYMPHAZURIN BLUE
DYE
• Tch99 SULPHUR
COLLOID
• Accuracy 99%
PORTABLE
GAMMA CAMERA

67. Investigations-Sentinel Node Biopsy
INDICATIONS
• High-risk IN SITU cancer, non-
palpable breast cancer
• T1 or T2 carcinoma and
especially good prognosis
tumors (mucinous, papillary
and adenoid cystic)
CONTRAINDICATIONS
• Altered drainage of breast.eg-
Augmentation surgery
• Recent mammoplasty and
pregnancy
• Allergy to dye or radiocolloid
• Inflammatory Ca
• Axillary mets
Absolute

68. Other Investigations
1.CXR-PA VIEW
2.CT CHEST
3.USG – ABDOMEN AND PELVIS
4.SKELETAL SURVEY/ Tc99 BONE SCAN
5.MRI BREAST- Voluminous breast/ Implant rupture
6.PET SCAN- Follow up to detect residual disease
7.Tumor Marker- CA- 15/3

69. AJCC Staging/TNM Staging
T (Primary Tumor)
Tis Carcinoma in situ (lobular or ductal)
T1 Tumor <2 cm
T2 Tumor >2 cm, <5 cm
T3 Tumor >5 cm
T4 Tumor any size with extension to the chest
wall or skin
N (Nodes)
N0 No regional node involvement
N1 Metastasis to 1-3 axillary nodes
N2 Metastasis to 4-9 axillary nodes
N3 Metastasis to >10 axillary nodes
M (Metastasis)
M0 No distant
metastasis
M1 Distant
metastasis

70. TNM Staging
▪ Stage 1 and stage 2 – EBC
▪ Stage 3 – LABC
▪ 3a- T3, N 1,2,
▪ 3b- T4, ANY N
▪ 3c- N3, ANY T
▪ Stage 4- ABC

71. Management –Multimodality
Treatment
▪ Surgery
▪ Curative
▪ Palliative
▪ Radiotherapy
▪ Chest Wall
▪ Axilla
▪ Supraclavicular
▪ Chemotherapy
▪ Hormonal Therapy

72. Management
•Stage 1 & 2
• Breast conservation
treatment- BCT
✓ Lumpectomy
✓ Wide local excision
✓ Quadrantectomy
✓ Axillary dissection
✓ Radiotherapy
• Modified radical
mastectomy- MRM
EBC
•Stage 3
• MRM+Adjuvant RT+
Adjuvant CT +/- HT
• Neoadjuvant CT+MRM+
Adjuvant RT &CT+/- HT
LABC
•Stage 4
•Toilet Mastectomy
• Adjuvant RT & CT +/-
HT
ABC

73. Management –ECB
RT after BCT

74. Management –LABC
Classification of LABC
•LABC Operable at Presentation
•T3, N1, M0
•LABC Inoperable at Presentation
•T4, Any N, M0
•Any T, N2 or N3, M0
•Inflammatory Carcinoma of Breast
•T4d, N0, M0

75. Management –LABC
Treatment of Operable LABC
1. MRM → Adjuvant Radiotherapy (RT) &
Adjuvant Systemic Chemotherapy (CT) +/-
Hormone Therapy (HT)
2. Neoadjuvant CT→ To attempt to Down-Stage
lesions for Breast Conservation Surgery
Tumor Responding → BCS → CT,RT +/- HT
Non-responders → MRM → CT with RT +/- HT

76. Management –LACB
Treatment of Inoperable LABC
Aim of Treatment: To make the disease operable and
achieve loco – regional control, hence improve patients
quality of life
Neoadjuvant CT → MRM → CT & RT +/- HT
Advantages of Neoadjuvant CT
To make the tumor operable
To assess tumor response to CT

77. PROGNOSTIC FACTORS
1.Axillary nodal status( most important)
2.Tumour size
3.ER/PR Status – Both positive- good prognosis
4.Histological grade of tumour
5.Her 2neu overexpression – aggressive malignancy-
poor prognosis
6.Proliferating rate
1.DNA flow cytometry – aneuploid – poor prognosis
2.S phase fraction – low S phase – good prognosis

78. PROGNOSTIC FACTORS
5 yr survival – Ca Breast
Stage 1 – 90%
Stage 2 – 70%
Stage 3 – 40 %
Stage 4 – 20 %

79. NOTTINGHAM PROGNOSTIC
INDEX- NPI
The index is calculated using the
formula:
NPI = [0.2 x S] + N + G
Where:
S is the size of the index lesion in
centimetres
N is the node status: 0 nodes = 1, 1-4
nodes = 2, >4 nodes = 3
G is the grade of tumour: Grade I =1,
Grade II =2, Grade III =3
NPI Score Prognosis 5yr survival
2 to 2.4 Excellent 93%
2.4 to 3.4 Good 85%
3.4 to 5.4 Moderate 70%
> 5.4 Poor 50%

80. Adjuvant Chemotherapy
To deal with occult metastasis
Always use combination
chemotherapy
More effective in pre-menopausal
CT + HT > CT / HT alone
Drugs used:
Cyclophosphamide
Methotrexate
5 – FU
Anthracyclines: Doxorubicin,
Epirubicin
Taxanes: Paclitaxel, Docitaxel
Schedule used commonly:
CAF q21d x 6cycles
Cyclophosphamide:
500mg/m2 D1
5 – FU: 500mg/m2 D1 &
D8
Doxorubicin: 50mg/m2 D1
Regimen of choice: TAC
Good efficacy irrespective
of ER/PR/HER-2 neu

81. Neo Adjuvant Chemotherapy
CT given before Local Control of disease
It does not provide any survival advantage
Helps decide response of tumor to CT
Indications:
1.To downstage Operable LABC for BCT
2.To downstage Inoperable LABC for operability
3.Inflammatory Breast Cancer
4.In EBC, to improve cosmetic appeal after BCS, for large
tumor in small breast

82. Neo Adjuvant Chemotherapy
▪Usually 2 – 4 cycles are given till maximum shrinkage is
achieved
▪Choice of drugs are the same as for Adjuvant CT – CAF /
TAC
▪If tumor is resistant then non cross resistant drugs can be
used as second line CT

83. Hormone Therapy
▪ER+/PR+ → 80% chance of
favorably response to HT
▪All (pre/post menopausal)
patients with ER/PR+ LABC
should undergo HT for 5yrs.
▪Can be given in combination
with CT
▪Most commonly used agent →
Tamoxifen
Dose: 20mg/day, Oral for 5 Yrs
Side effects: Hot flushes,
sexual dysfunction, endometrial
cancer, thromboembolism
Raloxifene- drug of choice

84. Hormone Therapy
Class Agents
Selective estrogen receptor
modulators (SERMS)
Tamoxifen, Raloxifene,
Toremifene
Aromatase inhibitors Anastrozole, Letrozole,
Exemestane
Pure antiestrogens Fulvestrant
LHRH agonists Goserelin, Leuprolide
Progestational agents Megestrol
Androgens Fluoxymesterone
High-dose estrogens Diethylstilbestrol

85. Hormone Therapy
Trastuzumab or Herceptin
▪Monoclonal antibody that targets the HER-2 neu oncogene
▪Her 2 neu codes for a growth factor that is overexpressed in
25% to 30% of breast cancers
▪Her 2 neu over-expression indicates aggressive nature of
malignancy.
▪Trastuzumab may be used for Her 2 neu positive tumours in
adjuvant or neo adjuvant setting

86. Radiotherapy
Indications for PMRT(Post Mastectomy Radio
Therapy) :
1. >4 Positive axillary nodes
2. Tumour size > 5 cm
3. Positive surgical margins
4. As a part of LABC PROTOCOL

87. Followup
▪ Monthly self examination of the breast
▪ Regular physical examination following mastectomy is necessary
▪ Every 4 months for years 1 and 2,
▪ Every 6 months for years 3 through 5,
▪ Every 12 months thereafter
▪ Contralateral mammogram yearly
▪ Routine bone scans, skeletal surveys, CT of abdomen and brain-
Not necessary, Yield is low

88. Treatment Algorithm
Early Breast Carcinoma

89. Treatment Algorithm
Advanced Breast Carcinoma