Understanding the pathophysiology of carcinoma of breast is essential for deciding the optimum treatment for this lethal disease. The bilogical behaviour of the disease should guide radical treatment of the disease. Radical surgery is still the gold standard for treatment. Chemotherapy,radiotherapy and hormonal manipulation are useful adjuncts to surgery.

1. CARCINOMA OF BREAST
Dr. Ketan Vagholkar
MS., DNB., MRCS., FACS .
Professor of Surgery
&
Consultant General Surgeon.

2. Risk Factors
• Family history • Breast feeding has
• Chronic cystic mastitis protective effect
• Previous h/o contralateral • Nulliparity is associated
breast cancer with high incidence
• High socioeconomic • Obesity
status • Women having wet
• Individuals staying in the cerumen have higher risk
western hemisphere of breast cancer
• Risk is lowest if the first • Estrogen compounds
pregnancy is at 23 yrs of have variable effect in
age experimental animals

3. Etiology
• Estrogen window hypothesis
– First window opens at menarche leading to
unopposed estrogen exposure
– Second window opens at menopause
– Early menarche with late menopause
• Bittner factor
– Seen in sucking mice
– Similar factor seen in Parsi women in India
who have a high incidence of breast cancer

4. Pathology
• Ductal • Lobular
– In situ – In situ
– Invasive – invasive
• Medullaryca with • Mixed
lymphoid stroma
• Mucoid • Carcinosarcoma
• Tubular • Unclassified
• Sqamous
• Adenoid cystic
• Inflammatory
• Paget’s disease

5. Lobular Carcinoma
• Gross
– Rubbery in consistency
• Microscopy
– Infiltration of fibroblastic stroma by single cells or lines
of cells arranged in single files giving the appearance
of ‘ Indian File Pattern’
– Single files disposed in concentric circles around the
breast ducts giving rise to ‘targetoid’ lesions
– Lobular ca are estrogen receptor positive
– Areas of lobular ca in situ may be seen in the same
breast

6. Ductal Carcinoma
• Gross • Microscopy
– Majority are infiltrating – Variation in the type of
ductal type epithelial component and
– Types stroma
– Cicumscibed – Several patterns seen in
• Less common the same tumour
• Well defined margins • Variants of ductal ca
• Better pronosis – Medullary (encephaloid)
– Stillete – Mucoid
• Stillete type with typical – Tubular
features cancer
– Inflammatory
• No capsule
• Hard in consistency – Paget’s disease of the
(scirrhous) nipple
• Gritty to cut

7. Morphology of carcinoma of breast

8. TNM Staging
• T STATUS
• Tis-Ca in situ
• To-no evidence of primary tumour
• T1-size<2cms
• T2-size 2-5 cms
• T3-size>5cms
• T4-extension to chest wall or skin
• N STATUS
• No-no nodes palpable
• N1-mobile axillary LN
• N2-fixed axillary LN
• N3-palpable supraclavicular LN
• M STATUS
• Mo-no distant mets.
• M1- distant mets

9. Manchester staging
• StageI
– Tumor confined to the breast, not adherent to pectoral muscles
or chest wall, if adherence this must be smaller than the size of
the tumour.
• StageII
– Primary tumour as in stage I with additional mobile ipsilateral
lymph nodes
• StageIII
– Skin involvement larger than the tumour, tumour fixed to pectoral
muscles but not to the chest wall, fixed nodes in axilla.
• StageIV
– Distant spread either blood ,lymph, invasion of skin beyond
supraclavicular nodes,involvement of opposite breast, bone
brain, lung & liver involvement.

10. Hormone receptors
• Types (present on breast epithelial cells)
– ER-estrogen receptors
– PgR-progesterone receptors
• Mechanisms
– Estrogen binds with ER, resultant complex enters the cell nucleus and
binds to areas of chromatin called acceptor sites resulting in production
of mRNA by transcription.
– mRNA enters cytoplasm and produces various enzymes and proteins
one of which is PgR.
– The estrogen ER complex induces DNA synthesis and cell growth.
• Application
– Presence of receptors on tumor tissue suggests good differentiation and
hence better prognosis
– Patients with receptor positive tumors respond well to hormonal
manipulation
– Detection of receptors on metastatic deposits will help detect the
primary in the breast.

11. Clinical features
• HISTORY • PHYSICAL EXAMINATION
• Chief complaints(odp) • General
• h/ocomplications(trauma,pain,relation examination(pallor,jaundice,scars of
to menses,pus,ulceration,nipple previous surgery)
retraction,wt loss axillary • Local examination (privacy,expose
swellings,pbone pains,abd lump) both breasts,chaporone)
• h/o • INSPECTION
etiology(trauma,fever,pain,malignancy • Site,size,nipple
in first degree relative,lactation,breast deviation,retraction,tethering of
feeding after pregnancy,similar skin,axillary fullness(demontrated by
swelling in opposite breast) a.sitting position with hands by the
• h/o treatment taken for the lesion side,hands elevated above the head,&
bending forwards)
• PALPATION
• Cosistency,mobility over underlying
structures and overlying skin
• Avillary LN palpation
• Supraclavicular LN palpation
• OTHER SYSTEMS
• Chest, abdomen ,PV<PR.

12. Final diagnosis
• Type of lesion –benign/malignant
• Extent of spread with reference to axillary
lymph nodes, supraclavicular LN,
abdomen, bone, opposite breast
• Staging- TNM/Manchester

13. Clinical appearances

14. Clinical appearances

15. Clinical appearances

16. Screening for Breast Cancer

17. Investigations
MAMMOGRAPHY
• Applications
– Screening of patients
– Assesing the opposite breast
– Support the clinical impression
of no malignancy
• Findings
– Asymmetry
– Skin thickening
– Irregular masses
– Architectural distortions
– Clustered pleomorphic
microcalcifications

18. Mammographic findings in
malignancy

19. Mammography

20. Investigations
• USG
• To determine whether
or not a mass is solid
or cystic

21. Investigations
BIOPSY • METASTATIC WORK
• FNAC UP
• Excision biopsy • Chest x ray
• Wedge biopsy • USG/CT abdomen
LAB INV. • CT scan of brain in
• CBC suspected brain mets.
• LFT • Bone scan for
detecting bony mets.
• Alkaline phosphatase

22. Bone Scan

23. Treatment
• Surgery
• Chemotherapy
• Hormonal therapy
• Radiotherapy

24. Surgical Principles
• Criteria for inoperability • Principles of surgery
– Extensive edema of breast – Removal of entire breast
– Satellite nodules of due to multicentricity
carcinoma – Removal of axillary lymph
– Inflammatory carcinoma nodes to accurately stage
– Parasternal tumour the disease
– Supraclavicular mets
– Arm edema
– Distant mets

25. Surgical options
(principles,technique,complications)
• Modified radical
mastectomy with
axillary clearance
• Radical mastectomy
• Quadrantectomy
• Toilet mastectomy

26. Adjuvant therapy
• Chemotherapy • Radiotherapy
– Indications – Indications
– Selection of patients – Complications
– Regimes used – Quart therapy
– Precautions
– Complications • Hormonal therapy
– Indications
– Patient selection
– Medications

27. Follow up care
• Every 3 months in the • Recurrent disease
first year followed by – Loco regional
every 6 months – Second primary breast
thereafter ca
• Annual – Distant mets
mammography
• Chest x ray
• LFT

28. Prognosis
• Lymph Node status
– 5 yr survival
• 1 node involved-48%
• 4 nodes involved-38%
• 5 nodes involved-29%
• Tumour size
– Larger the tumour size ,worst is the prognosis
• Stromal reaction
– Good prognosis in medullary ca with lymphoid stroma due to better
immunological host reaction
• Hormonal status
– Best prognosis if both receptors are positive (ER, PgR)
• Histological grade
– Grade I- 81% (5 yr survival rate)
– Grade II- 54% (5 yr survival rate)
– Grade III-34% (5 yr survival rate)

29. Overview of benign breast
diseases
• Fibroadenoma
• Fibroadenosis
• Fibrocystic disease of the breast
• Cystosarcoma phyllodes