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BREAST CANCERBREAST CANCER
Dr Phillip L.Chalya Dr Phillip L.Chalya
M.D. [Dar]; M.MED surg M.D. [Dar]; M.MED surg [Mak] [Mak]
Surgeon Specialist – Surgeon Specialist – Bugando Medical Bugando Medical Centre Centre
OUTLINEOUTLINE Definition Definition Surgical Anatomy of the breastSurgical Anatomy of the breast EpidemiologyEpidemiology Aetiological/Risk factorsAetiological/Risk factors PathophysiologyPathophysiology Clinical presentationClinical presentation Work upWork up Triple assessmentTriple assessment StagingStaging Management Management PrognosisPrognosis Prevention Prevention
DEFINITIONDEFINITION
Breast cancer is defined as Breast cancer is defined as malignant neoplasm of the breast malignant neoplasm of the breast arising from the arising from the epithelial lining epithelial lining of the lobule, ducts and the nippleof the lobule, ducts and the nipple
Breast cancer is the third most Breast cancer is the third most common cancer worldwide and is common cancer worldwide and is the most common cancer in the most common cancer in women women
Surgical anatomy cont….Surgical anatomy cont….
Position : Position : is situated on the anterior is situated on the anterior aspect of the chest and they are two aspect of the chest and they are two in number on each side.in number on each side.
Shape: Shape: it is dome in shape with the it is dome in shape with the nipple at the apex of the dome and nipple at the apex of the dome and the nipple is surrounded by areola. the nipple is surrounded by areola. The shape is maintained by The shape is maintained by suspensory ligament.suspensory ligament.
Surgical anatomy cont….Surgical anatomy cont….
Structure: Structure: the parenchyma is made the parenchyma is made up of:-up of:-
glandular tissueglandular tissue Adipose tissueAdipose tissue Fibrous tissueFibrous tissue
NB; the functional unit of the breast is NB; the functional unit of the breast is ACINACIN
Boundaries: Boundaries: Superior: Superior: second ribsecond rib Inferior: Inferior: sixth rib sixth rib Medially: Medially: lateral border of the sternumlateral border of the sternum Laterally: Laterally: mid axillary linemid axillary line
Surgical anatomy cont…Surgical anatomy cont…
Reletion: Reletion: pectoralis majorpectoralis major
-seratus anterior-seratus anterior
-external oblique-external oblique Quadrants: Quadrants: it has 4 quadrants which areit has 4 quadrants which are
-upper outer quadrant-upper outer quadrant
--lower outer quadrantlower outer quadrant
-upper inner quadrant-upper inner quadrant
--lower inner quadrantlower inner quadrant
Cont…Cont…
Blod supply: Blod supply: lateral thoracic lateral thoracic and and thoracoacromial artery thoracoacromial artery which are branches which are branches from axillary atery supply the medial aspect from axillary atery supply the medial aspect of the breast.of the breast.
internal thoracic artery internal thoracic artery a branch from a branch from subclavian artery supply the superior part of subclavian artery supply the superior part of the breast.the breast.
Posterior intercostal artery Posterior intercostal artery a branch of the a branch of the thoracic aorta in the 2thoracic aorta in the 2ndnd,3,3rdrd and 4 and 4thth intrecostal space supply the inferior and intrecostal space supply the inferior and lateral aspect of the breast.lateral aspect of the breast.
Cont…Cont…
Lymph drainage: Lymph drainage: axillary axillary lymph75% which has 5 groups:-lymph75% which has 5 groups:- Apical groupApical group Central groupCentral group Lateral group(brachial)Lateral group(brachial) Pectoral group(anterior)Pectoral group(anterior) Subscapular group(posterior)Subscapular group(posterior)
Cont…Cont…
Internal mammary lympnodes 20-Internal mammary lympnodes 20-25%25%
Intercostal lymph <5%Intercostal lymph <5% Upper and lower outer quadrants Upper and lower outer quadrants
and nipple,its and nipple,its lymph drainage join lymph drainage join the apical, pectoral and central the apical, pectoral and central group (APC group) then go in group (APC group) then go in retrograde way to the lateral and retrograde way to the lateral and subscapular group.subscapular group.
Cont..Cont..
The inner upper quadrant lymph The inner upper quadrant lymph go go to the intermammary lymph node up to to the intermammary lymph node up to the neighbour breast.the neighbour breast.
The inner lower quadrant lymph The inner lower quadrant lymph go to go to the abdomen and meet with subpectoral the abdomen and meet with subpectoral lymph group. It can drop up to the bare lymph group. It can drop up to the bare space of the liver. It can go in space of the liver. It can go in transcelomic way to the pelvic organs transcelomic way to the pelvic organs where it can cause where it can cause krugenberg tumor krugenberg tumor in female and in female and blummer tumor blummer tumor in male.in male.
Cont…Cont…
Surgically lymp drainage are divided Surgically lymp drainage are divided in to three groups:-in to three groups:-
Level I- below the pectoralis minorLevel I- below the pectoralis minor Level II-under the pectoralis minorLevel II-under the pectoralis minor Level III-above the pectoralis minorLevel III-above the pectoralis minor
Surgical anatomy of the Surgical anatomy of the breast [cont]breast [cont] AA ducts ducts
BB lobules lobules CC dilated section of dilated section of
duct to hold milkduct to hold milk DD nipple nipple EE fat fat FF pectoralis major pectoralis major
musclemuscle GG chest wall/rib cage chest wall/rib cage Enlargement of the Enlargement of the
ductal lumenductal lumen AA normal duct cells normal duct cells BB basement membrane basement membrane CC lumen (center of duct) lumen (center of duct)
Surgical anatomy of the Surgical anatomy of the breast [cont]breast [cont]
Lymph node areas Lymph node areas adjacent to breast area.adjacent to breast area. AA pectoralis major muscle pectoralis major muscle Axillary LN are divided Axillary LN are divided
into 3 levels in relation into 3 levels in relation to PMnto PMn
BB axillary lymph nodes: axillary lymph nodes: levels I – lateral to PMnlevels I – lateral to PMn
CC axillary lymph nodes: axillary lymph nodes: levels II – posterior to levels II – posterior to PMnPMn
DD axillary lymph nodes: axillary lymph nodes: levels III- medial to PMnlevels III- medial to PMn
EE supraclavicular lymph supraclavicular lymph nodesnodes
FF internal mammary internal mammary lymph nodeslymph nodes
EPIDEMIOLOGYEPIDEMIOLOGY
IncidenceIncidence Mortality/ MorbidityMortality/ Morbidity AgeAge SexSex RaceRace
IncidenceIncidence There is remarkable variation in the There is remarkable variation in the
incidence of breast cancer between incidence of breast cancer between different countriesdifferent countries
The rates in the United States and The rates in the United States and Canada are six times higher than those Canada are six times higher than those in Asia or black Africa in Asia or black Africa
Japan has a low incidence of breast Japan has a low incidence of breast cancer, although it is becoming more cancer, although it is becoming more commoncommon
Mortality/ MorbidityMortality/ Morbidity
Overall breast cancer mortality rates have Overall breast cancer mortality rates have declined in recent years, attributable to the declined in recent years, attributable to the increased use of screening mammography increased use of screening mammography and the aggressive use of adjuvant therapies and the aggressive use of adjuvant therapies
Worldwide, breast cancer is the fifth most Worldwide, breast cancer is the fifth most common cause of cancer death common cause of cancer death
Mortality rates are highest in the very young Mortality rates are highest in the very young (less than age 35) and the very old (greater (less than age 35) and the very old (greater than age 75)than age 75)
AgeAge
As for other epithelial cancers the As for other epithelial cancers the incidence of breast cancer increases with incidence of breast cancer increases with ageage
Breast carcinoma is only occasionally Breast carcinoma is only occasionally seen in the late teens but thereafter seen in the late teens but thereafter there is a rapid rise in age-specific rates there is a rapid rise in age-specific rates
SexSex
Being a woman is the main risk factor Being a woman is the main risk factor for developing breast cancerfor developing breast cancer
Breast cancer is 100 times more Breast cancer is 100 times more common in women than in mencommon in women than in men
In strict epidemiological terms, In strict epidemiological terms, therefore, female sex is a major risk therefore, female sex is a major risk factor for breast cancer, although it is factor for breast cancer, although it is often forgotten as such. often forgotten as such.
RaceRace
White women are slightly more likely to White women are slightly more likely to develop breast cancer than are black develop breast cancer than are black womenwomen
Black women are more likely to die of Black women are more likely to die of this cancerthis cancer
The reasons for this are not knownThe reasons for this are not known
AETIOLOGICAL/RISK AETIOLOGICAL/RISK FACTORSFACTORS
Etiology is not known but there are Etiology is not known but there are some etiological risk factors which some etiological risk factors which are as follow:-are as follow:-
Socio-demographic risk factorsSocio-demographic risk factors Hereditary factorsHereditary factors Hormonal factorsHormonal factors Dietary factorsDietary factors Factors related to breast conditionsFactors related to breast conditions Environmental factors Environmental factors
Socio-demographic risk Socio-demographic risk factorsfactors
GenderGender Breast cancer occurs one hundred times Breast cancer occurs one hundred times
more frequently in women than in menmore frequently in women than in men AgeAge
Incidence rates rise very sharply with age Incidence rates rise very sharply with age until about the age of 45 to 50 when the until about the age of 45 to 50 when the rise is less steeprise is less steep
This change in slope probably reflects the This change in slope probably reflects the impact of hormonal change (menopause) impact of hormonal change (menopause) that occurs about this timethat occurs about this time
At age 75 to 80, the curve flattens and At age 75 to 80, the curve flattens and decreases slightly thereafter decreases slightly thereafter
Socio-demographic risk Socio-demographic risk factors [cont]factors [cont]
Socioeconomic status Socioeconomic status Women of higher SES are at greater risk for Women of higher SES are at greater risk for
breast cancer [2-fold] breast cancer [2-fold] The influence of socioeconomic status are The influence of socioeconomic status are
thought to be mediated by differing thought to be mediated by differing reproductive patterns with respect to parity, reproductive patterns with respect to parity, age at first birth, and age at menarcheage at first birth, and age at menarche
Area of residence Area of residence Higher incidence in developed countries than Higher incidence in developed countries than
in developing in developing These differences are thought to be accounted These differences are thought to be accounted
for by differences in parity and age at first live for by differences in parity and age at first live birth, at menarche, and at menopause birth, at menarche, and at menopause
Socio-demographic risk Socio-demographic risk factors [contfactors [cont]]
RaceRace Whites > BlacksWhites > Blacks Most of these racial difference are Most of these racial difference are
attributable to factors associated with attributable to factors associated with lifestyle and socioeconomic status, which lifestyle and socioeconomic status, which also appear to explain disparities in also appear to explain disparities in treatment and survival that are often treatment and survival that are often attributed solely to race attributed solely to race
Hereditary factorsHereditary factors
Genetic predispositionGenetic predisposition The mutated genes BRCA 1 and BRCA 2 are The mutated genes BRCA 1 and BRCA 2 are
responsible for responsible for 30-40% of inherited breast 30-40% of inherited breast cancercancer
Family history of beast cancerFamily history of beast cancer A family history of breast cancer is associated A family history of breast cancer is associated
with an increased risk of the diseasewith an increased risk of the disease The risk is greatest in patients with first-The risk is greatest in patients with first-
degree relatives (mother or sister) affected, degree relatives (mother or sister) affected, especially if under the age of 50 when the especially if under the age of 50 when the disease developed disease developed
Hormonal factorsHormonal factors Prolonged exposure to and higher Prolonged exposure to and higher
concentrations of endogenous estrogen concentrations of endogenous estrogen increase the risk of breast cancerincrease the risk of breast cancer Early age at menarche [Early age at menarche [≤ ≤ 12 years12 years]] Late age at first pregnancy [>30 Late age at first pregnancy [>30 yyears ]ears ] Late menopause [Late menopause [55years]55years] Nulliparity at the age of 40 years Nulliparity at the age of 40 years
Exogenous estrogens eg oral Exogenous estrogens eg oral contraceptive drugs have been shown to contraceptive drugs have been shown to risk of developing breast cancer risk of developing breast cancer
Dietary factorsDietary factors Weight Weight
Obesity is associated with a twofold increase in Obesity is associated with a twofold increase in the risk of breast cancer in postmenopausal the risk of breast cancer in postmenopausal women whereas among premenopausal women women whereas among premenopausal women it is associated with a reduced incidenceit is associated with a reduced incidence
Alcohol intake Alcohol intake Some studies have shown a link between Some studies have shown a link between
alcohol consumption and incidence of breast alcohol consumption and incidence of breast cancer, but the relation is inconsistent and the cancer, but the relation is inconsistent and the association may be with other dietary factors association may be with other dietary factors rather than alcoholrather than alcohol
Smoking Smoking Smoking is of no importance in the aetiology of Smoking is of no importance in the aetiology of
breast cancer. breast cancer.
Environmental factorsEnvironmental factors
Previous exposure to radiationsPrevious exposure to radiations
PATHOPHYSIOLOGYPATHOPHYSIOLOGY
SiteSite Macroscopic /gross appearanceMacroscopic /gross appearance Microscopic /histopathological Microscopic /histopathological
appearanceappearance Spread Spread
SiteSite
Upper outer Upper outer quadrant – quadrant – commonest site for commonest site for cancer due to cancer due to precence of lots of precence of lots of glandular tissue.glandular tissue.
Lower outer Lower outer quadrantquadrant
Upper inner quadrantUpper inner quadrant Lower inner quadrantLower inner quadrant Nipple Nipple
MacroscopicallyMacroscopically UlceratingUlcerating infiltratinginfiltrating Satellite nodulesSatellite nodules RetractionRetraction Dimpling Dimpling Peau d’orange due to lymphatic Peau d’orange due to lymphatic
obstruction which lead to edema of the obstruction which lead to edema of the subcutaneous tissue.subcutaneous tissue.
FungatingFungating Solid massSolid mass
MicroscopicallyMicroscopically Classified as:-Classified as:-
Non-invasiveNon-invasive Lobular carcinoma in situ [LCIS]Lobular carcinoma in situ [LCIS] Ductal carcinoma in situ [DCIS]Ductal carcinoma in situ [DCIS] Paget disease of the nipplePaget disease of the nipple
Invasive Invasive Lobular carcinomaLobular carcinoma Ductal carcinomaDuctal carcinoma Mucinous / colloid carcinomaMucinous / colloid carcinoma Medullary carcinomaMedullary carcinoma Mixed connective /epithelial tumorsMixed connective /epithelial tumors
Phylloides tumor-benign/malignant, Carcinosarcoma, Phylloides tumor-benign/malignant, Carcinosarcoma, AngiosarcomaAngiosarcoma
SpreadSpread
DirectDirect LymphaticLymphatic Blood Blood Transcoelomic implantation Transcoelomic implantation
DirectDirect
To the:-To the:- Skin over the breastSkin over the breast Pectoral muscles Pectoral muscles Chest wallChest wall
Lymphatic spreadLymphatic spread By:-By:-
PermiationPermiation Embolization Embolization
75% to the axillary lymphnodes 75% to the axillary lymphnodes [pectoral/anterior, brachial/lateral, [pectoral/anterior, brachial/lateral, subscapular/posterior, central and subscapular/posterior, central and apical]- arranged in 3 levels (I, II and III)apical]- arranged in 3 levels (I, II and III)
Internal mammary LNodesInternal mammary LNodes
Blood spreadBlood spread To distant sites via blood vessels eg To distant sites via blood vessels eg
lungs, liver, bones, brain etclungs, liver, bones, brain etc In the bone it produce osteolytic lesionIn the bone it produce osteolytic lesion
Transcoelomic Transcoelomic implantationimplantation
Dropping of cancer cells by gravity Dropping of cancer cells by gravity from metastases to the liver to the from metastases to the liver to the pelvic cavity causing metastases to the pelvic cavity causing metastases to the ovaryovary
CLINICAL CLINICAL PRESENTATIONPRESENTATION
History /SymptomsHistory /Symptoms Physical examination/SignsPhysical examination/Signs
General examinationGeneral examination Local examination Local examination Systemic examinationSystemic examination
HistoryHistory
Symptoms referring to the breast:Symptoms referring to the breast: Breast lumpBreast lump Nipple discharge Nipple discharge Nipple or skin retractionNipple or skin retraction Axillary mass or pain Axillary mass or pain Arm swellingArm swelling Loss of hair / development of beardsLoss of hair / development of beards
History [cont]History [cont]
Symptoms with reference to possible Symptoms with reference to possible metastatic disease metastatic disease Cough, chest pain, SOB – lung Cough, chest pain, SOB – lung
onvolvementonvolvement Jaundice- liver metastasisJaundice- liver metastasis Bone pain – bone metastasisBone pain – bone metastasis Features of brain metastasisFeatures of brain metastasis
History [cont]History [cont] Past medical history of breast diseasePast medical history of breast disease Family history of breast cancerFamily history of breast cancer Reproductive HistoryReproductive History
Age at menarche Age at menarche Menstrual historyMenstrual history Age at first pregnancy Age at first pregnancy Age of onset of menopauseAge of onset of menopause Number of pregnancies, and abortions Number of pregnancies, and abortions
(including criminal abortions)(including criminal abortions) Duration of breast-feedingDuration of breast-feeding History of hormone use including History of hormone use including
contraceptivecontraceptive pills pills
Physical examinationPhysical examination
General examinationGeneral examination Weight, Height & surface areaWeight, Height & surface area WastingWasting Jaundice Jaundice DyspnoeaDyspnoea Anemia Anemia
Local examinationLocal examination Examination should be carried out in both Examination should be carried out in both
sitting and supine position; sitting and supine position; Both breasts and glandular areas should be Both breasts and glandular areas should be
examined.examined.
a) Breast massa) Breast mass SizeSize Shape Shape ConsistencyConsistency Location (specified by quadrants and the Location (specified by quadrants and the
distance from the edge of the areola)distance from the edge of the areola) Fixation to skin, pectoral muscle or chest wallFixation to skin, pectoral muscle or chest wall
Local examination [cont]Local examination [cont]b) Skin changesb) Skin changes
Erythema Erythema InfiltrationInfiltration Ulceration Ulceration Satellite nodulesSatellite nodules Dimpling ( peau d'orange) – vidimpo kama Dimpling ( peau d'orange) – vidimpo kama
ganda la chungwaganda la chungwa
c) Nipple changesc) Nipple changes Retraction – when ligaments of cooper are Retraction – when ligaments of cooper are
involved involved ReddeningReddening Erosion and Ulceration Erosion and Ulceration Discharge (specify)Discharge (specify)
Local examination [cont]Local examination [cont]
d) Nodal statusd) Nodal status Axillary nodesAxillary nodes
NumberNumber SizeSize LocationLocation Fixation to other nodes or underlying Fixation to other nodes or underlying
structuresstructures Clinically suspicious or benignClinically suspicious or benign
Supraclavicular nodes Supraclavicular nodes
Local examination [cont]Local examination [cont]
e) Arme) Arm Swelling Swelling Neurological assessmentNeurological assessment
Systemic examinationSystemic examination
Respiratory examination R/O lung Respiratory examination R/O lung involvement involvement
Abdominal examination R/O liver Abdominal examination R/O liver involvementinvolvement Rectal/Vaginal examination R/o Rectal/Vaginal examination R/o
Krukenberg’s tumor of the ovaryKrukenberg’s tumor of the ovary CNS examination R/O brain metastasisCNS examination R/O brain metastasis MSS examination R/O bone metastasisMSS examination R/O bone metastasis etcetc
WORK UPWORK UP
Divided into two main categories:-Divided into two main categories:- Diagnostic investigationsDiagnostic investigations Staging investigationsStaging investigations
Aim:-Aim:- To assess the general condition of the To assess the general condition of the
patientpatient To assess the extend of the diseaseTo assess the extend of the disease To confirm diagnosisTo confirm diagnosis To plan for treatment To plan for treatment
A. Diagnostic A. Diagnostic investigationsinvestigations Breast imagingBreast imaging
Mammography – radiography of the breastMammography – radiography of the breast Breast ultrasoundBreast ultrasound Galactography – radiagraphy of the breast ducts Galactography – radiagraphy of the breast ducts
after injection of a radio-opaque material into the after injection of a radio-opaque material into the duct systemduct system
Pneumocystography- cystography (radiography of Pneumocystography- cystography (radiography of the urinary bladder) after injecting air or gas into the urinary bladder) after injecting air or gas into the bladder the bladder
Pathological Pathological Fine Needle Aspiration Cytology [FNAC]Fine Needle Aspiration Cytology [FNAC] Core Biopsy Core Biopsy Open Biopsy Open Biopsy
Breast imagingBreast imaging MammographyMammography
Imaging technique of first choice in symptomatic Imaging technique of first choice in symptomatic patients aged ≥ 30 yearspatients aged ≥ 30 years
Breast ultrasoundBreast ultrasound Is complimentary to mammographyIs complimentary to mammography Provides added information e.g. solid / cystic mass, Provides added information e.g. solid / cystic mass,
true size of lesionstrue size of lesions It may be the technique of first choice in the breast It may be the technique of first choice in the breast
lumps of young womenlumps of young women GalactographyGalactography
A discharging duct is cannulated and contrast A discharging duct is cannulated and contrast medium injectedmedium injected
Radiographs are then takenRadiographs are then taken It is useful in localization of intraductal growthIt is useful in localization of intraductal growth
PneumocystographyPneumocystography Air is injected into a cyst after aspiration of fluid to Air is injected into a cyst after aspiration of fluid to
detect intra-cystic growthdetect intra-cystic growth
Pathological Pathological investigationsinvestigations
Fine needle aspiration cytologyFine needle aspiration cytology Has high degree of accuracy and when a Has high degree of accuracy and when a
diagnostic sample of malignant cells is diagnostic sample of malignant cells is obtained, definitive surgery may go ahead obtained, definitive surgery may go ahead without need for open biopsywithout need for open biopsy
Can be done with or without mammography Can be done with or without mammography or US- guidedor US- guided
Core BiopsyCore Biopsy Done when FNAC is inconclusive, can be Done when FNAC is inconclusive, can be
done under US guidancedone under US guidance
Pathological Pathological investigations [cont]investigations [cont]
Open biopsyOpen biopsy Excisional biopsyExcisional biopsy
For small lesionsFor small lesions Impalpable lesions may require mammographic Impalpable lesions may require mammographic
locarizationlocarization Incisional biopsy Incisional biopsy
For big lesionsFor big lesions
B. Staging investigationsB. Staging investigations
Laboratory investigationsLaboratory investigations Imaging investigationsImaging investigations
Laboratory investigationsLaboratory investigations
Full blood countFull blood count Serum urea and creatinine [RFT]Serum urea and creatinine [RFT] Liver Function Test [LFT]Liver Function Test [LFT]
ImagingImaging
Chest X-ray R/O lung metastasisChest X-ray R/O lung metastasis Abdominal (liver) US R/O liver metastasisAbdominal (liver) US R/O liver metastasis Skeletal survey R/O bone metastasisSkeletal survey R/O bone metastasis Bone scan Bone scan CT scanCT scan MRIMRI
TRIPLE ASSESSMENTTRIPLE ASSESSMENT
A pre-operative diagnosis using triple A pre-operative diagnosis using triple assessment is essential before treatment assessment is essential before treatment is undertakenis undertaken
This involves:-This involves:- Clinical evaluationClinical evaluation Breast imagingBreast imaging Pathological examinationPathological examination
a. Clinical evaluationa. Clinical evaluation
This involves:-This involves:- Thorough historyThorough history Local and systemic clinical examination as Local and systemic clinical examination as
aboveabove
b. Breast imagingb. Breast imaging
Patients are divided into three categories;-Patients are divided into three categories;- Symptomatic patients, those with breast pain, Symptomatic patients, those with breast pain,
breast lump, nipple discharge, skin and areola breast lump, nipple discharge, skin and areola changes, nipple retraction etcchanges, nipple retraction etc
Patients for screening, these include those Patients for screening, these include those with family history of breast cancer, history of with family history of breast cancer, history of benign disease, after surgery being followed benign disease, after surgery being followed up, and those more than 45 years of ageup, and those more than 45 years of age
Patients for image guided interventional Patients for image guided interventional proceduresprocedures
Breast imaging [cont]Breast imaging [cont]
Imaging procedures offered include:-Imaging procedures offered include:- Mammography Mammography Breast ultrasoundBreast ultrasound GalactographyGalactography PneumocystographyPneumocystography
c. Pathological c. Pathological examinationexamination
This include:-This include:- Fine needle aspiration cytologyFine needle aspiration cytology Core biopsyCore biopsy Open biopsyOpen biopsy
Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy
STAGINGSTAGING
Aim Aim To assess the To assess the extentextent of the disease of the disease To assess the To assess the prognosisprognosis of the disease of the disease To To planplan for treatment modality for treatment modality
Criteria Criteria TNM classificationTNM classification
TNM classification of breast TNM classification of breast cancercancer
T= Primary T= Primary TUMORTUMOR N=Regional lymph N=Regional lymph NODESNODES M=Distant M=Distant METASTASISMETASTASIS
T-statusT-status
Tx Primary tumor cannot be assessedTx Primary tumor cannot be assessed To No evidence of primary tumorTo No evidence of primary tumor Tis Carcinoma in situ:Tis Carcinoma in situ:
Ductal carcinoma in situ [DCIS]Ductal carcinoma in situ [DCIS] Lobular carcinoma in situ [LCIS]Lobular carcinoma in situ [LCIS] Paget’s disease of the nipplePaget’s disease of the nipple
T1 Tumor ≤ 2cm in greater T1 Tumor ≤ 2cm in greater dimensiondimension
T2 Tumor > 2cm and < 5cm in T2 Tumor > 2cm and < 5cm in dimensiondimension
T3 Tumor > 5cm in dimensionT3 Tumor > 5cm in dimension
T-status [cont]T-status [cont]
T4 Tumor of any size with direct T4 Tumor of any size with direct extension to the chest wall or skinextension to the chest wall or skin T4a Extension to chest wallT4a Extension to chest wall T4b Oedema (including peau d’orange), T4b Oedema (including peau d’orange),
ulceration of the skin of the breast, or ulceration of the skin of the breast, or satellite nodules confined to the same satellite nodules confined to the same breastbreast
T4c Both 4a and 4b, aboveT4c Both 4a and 4b, above T4d Inflammatory carcinomaT4d Inflammatory carcinoma
N-statusN-status
Nx Regional lymph nodes cannot Nx Regional lymph nodes cannot be assessedbe assessed
N0 No regional lymph node N0 No regional lymph node metastasesmetastases
N1 Metastases to movable N1 Metastases to movable ipsilateral axillary nodesipsilateral axillary nodes
N2 Metastases to fixed ipsilateral N2 Metastases to fixed ipsilateral axillary nodesaxillary nodes
N3 Metastases to ipsilateral N3 Metastases to ipsilateral internal mammary nodesinternal mammary nodes
M-statusM-status
Mx metastasis cannot be assesedMx metastasis cannot be assesed M0 No distant metastasesM0 No distant metastases M1 Distant metastases present M1 Distant metastases present
(including to supraclavicular lymph (including to supraclavicular lymph nodesnodes
G- Histopathological G- Histopathological GradingGrading
G1 Well differentiatedG1 Well differentiated G2 Moderately differentiatedG2 Moderately differentiated G3 Poorly differentiatedG3 Poorly differentiated
AJCC stage groupingAJCC stage grouping
Stage 0 Tis,N0,M0Stage 0 Tis,N0,M0 Stage 1 T1,N0,M0Stage 1 T1,N0,M0 Stage IIA T0-Stage IIA T0-
1,N1,M01,N1,M0
T2,N0,M0T2,N0,M0 Stage IIB T2,N1,M0Stage IIB T2,N1,M0
T3,N0,M0T3,N0,M0
Stage IIIA T0-2,N2,M0Stage IIIA T0-2,N2,M0
T3,N1-2,M0T3,N1-2,M0 Stage IIIB T4,N0-2,M0Stage IIIB T4,N0-2,M0 Stage IIIC any T,N3,M0Stage IIIC any T,N3,M0 Stage IV any T, any Stage IV any T, any
N,M1N,M1
AJCC stage grouping AJCC stage grouping [cont][cont]
Stage I : Early breast cancerStage I : Early breast cancer Tumor confined to the breastTumor confined to the breast No nodal involvementNo nodal involvement
Stage II: Early breast cancerStage II: Early breast cancer Tumor spread to movable ipsilateral axillary nodesTumor spread to movable ipsilateral axillary nodes
Stage III: Locally advanced breast cancerStage III: Locally advanced breast cancer Tumor spread to superficial structures of the chest wallTumor spread to superficial structures of the chest wall Involvement of ipsilateral fixed axillary/internal mammary Involvement of ipsilateral fixed axillary/internal mammary
nodesnodes Stage IV: Advanced/metastatic breast cancerStage IV: Advanced/metastatic breast cancer
Presence of distant metastases eg lung, liver, bone, brain Presence of distant metastases eg lung, liver, bone, brain etcetc
Involvement of supraclavicular nodesInvolvement of supraclavicular nodes
MANAGEMENTMANAGEMENT
Goals of TreatmentGoals of Treatment CureCure Extend Survival/improve quality of lifeExtend Survival/improve quality of life PalliationPalliation
Treatment optionsTreatment options
Counseling Counseling SurgerySurgery RadiotherapyRadiotherapy ChemotherapyChemotherapy Homonal therapyHomonal therapy Immunotherapy Immunotherapy
CounselingCounseling Like in all cancers the diagnosis of breast Like in all cancers the diagnosis of breast
cancer is frightening and exposes the patient cancer is frightening and exposes the patient and her family to psychological tortureand her family to psychological torture
Proper counseling should be part and parcel of Proper counseling should be part and parcel of the entire management strategythe entire management strategy
Good counseling enables the patient and her Good counseling enables the patient and her family to cope with the stress that is part and family to cope with the stress that is part and parcel of cancer and adjust to their life stylesparcel of cancer and adjust to their life styles
Counseling should continue during treatment Counseling should continue during treatment and during follow upand during follow up
SurgerySurgery Breast conserving surgeryBreast conserving surgery
surgical excision of the tumor + with surgical excision of the tumor + with surrounding margins (lumpectomy)surrounding margins (lumpectomy)
Mastectomy (surgical removal of the Mastectomy (surgical removal of the affected breast)affected breast) Simple Simple Modified Modified Toilet Toilet
Surgery of the RLNSurgery of the RLN Axillary lymph node dissection[ALND]Axillary lymph node dissection[ALND] Sentinel lymph node biopsy [SLNB]Sentinel lymph node biopsy [SLNB]
RadiotherapyRadiotherapy
Use of high-energy rays to stop breast Use of high-energy rays to stop breast cancer cells from growing and dividingcancer cells from growing and dividing
Can be given as part of the primary Can be given as part of the primary treatment or as palliativetreatment or as palliative
Can be given after surgery [adjuvant] or Can be given after surgery [adjuvant] or before surgery [neo-adjuvant]before surgery [neo-adjuvant]
Given as an external beam radiotherapy to Given as an external beam radiotherapy to the breast, axilla and supraclavicular the breast, axilla and supraclavicular nodesnodes
Chemotherapy Chemotherapy
Use of anticancer drugs to kill Use of anticancer drugs to kill breast cancer cellsbreast cancer cells
Can be used as an adjuvant or neo-Can be used as an adjuvant or neo-adjuvant therapyadjuvant therapy
Regimes include:-Regimes include:-1.1. CMF every 3 weeks for 6 cyclesCMF every 3 weeks for 6 cycles
C= Cyclophosphamide 600mg/m2 i.v.C= Cyclophosphamide 600mg/m2 i.v. M=Methotrexate 40mg/m2 i.v.M=Methotrexate 40mg/m2 i.v. F=5-Fluorouracil 600mg/m2 i.v. F=5-Fluorouracil 600mg/m2 i.v.
Chemotherapy [cont]Chemotherapy [cont]
2. CAF every 3 weeks for 6 cycles2. CAF every 3 weeks for 6 cycles C= Cyclophosphamide 600mg/m2 i.v.C= Cyclophosphamide 600mg/m2 i.v. A=Adriamycin 50mg/m2 i.v.A=Adriamycin 50mg/m2 i.v. F=5-Fluorouracil 600mg/m2 i.v. F=5-Fluorouracil 600mg/m2 i.v.
Hormonal therapyHormonal therapy
Can be given as an adjuvant therapy Can be given as an adjuvant therapy after surgery or as treatment for after surgery or as treatment for systemic diseasesystemic disease
First-line therapyFirst-line therapy Antiestrogen eg Tamoxifen 20mg daily for 2-Antiestrogen eg Tamoxifen 20mg daily for 2-
5 years5 years Second-line therapySecond-line therapy
Aromatase inhibitor eg Anastrozole 1mg Aromatase inhibitor eg Anastrozole 1mg dailydaily
Medroxyprogesterone acetate 0.4-1.5g dailyMedroxyprogesterone acetate 0.4-1.5g daily
ImmunotherapyImmunotherapy
Use of monoclonal antibodies Use of monoclonal antibodies directed against breast cancer cellsdirected against breast cancer cells
Still under investigationStill under investigation Include: Include:
Trastuzumab Trastuzumab
Modes of treatmentModes of treatment Depends on a variety of factors including:-Depends on a variety of factors including:-
The size of the breast tumorThe size of the breast tumor Location of the tumorLocation of the tumor The stage of the cancerThe stage of the cancer Hormonal receptor status eg ER or PRHormonal receptor status eg ER or PR
Divided into 4 main categories according to Divided into 4 main categories according to the stage:-the stage:- Management of early breast cancerManagement of early breast cancer Management of locally advanced breast cancerManagement of locally advanced breast cancer Management of metastatic and locally recuring Management of metastatic and locally recuring
breast cancerbreast cancer Management of breast cancer occurring during Management of breast cancer occurring during
pregnancypregnancy
A. Management of early A. Management of early breast cancer [Stage I & II ]breast cancer [Stage I & II ]
Treatment optionsTreatment options Counseling Counseling SurgerySurgery
Breast conserving surgery- only for stage I Breast conserving surgery- only for stage I [T1N0M0, T2N0M0) tumor size < 3cm[T1N0M0, T2N0M0) tumor size < 3cm
Mastectomy – for stage II and stage I for Mastectomy – for stage II and stage I for multifocal ,central or tumor > 3cm multifocal ,central or tumor > 3cm
Adjuvant RadiotherapyAdjuvant Radiotherapy Done after BCS or mastectomyDone after BCS or mastectomy To reduce risk of local recurrenceTo reduce risk of local recurrence To plan for ease radiotherapyTo plan for ease radiotherapy
Incision should be short and transverse Incision should be short and transverse Physiotherapy of the contra-lateral shoulder joint Physiotherapy of the contra-lateral shoulder joint
should start on day 1 Post-operativeshould start on day 1 Post-operative
Adjuvant systemic [chemotherapy and Adjuvant systemic [chemotherapy and hormonal] therapyhormonal] therapy
Neo-adjuvant systemic therapy may be Neo-adjuvant systemic therapy may be given to down stage the cancergiven to down stage the cancer
Follow up after treatment Follow up after treatment for early breast cancerfor early breast cancer
Aims:-Aims:- To detect recurrence at an early stage To detect recurrence at an early stage
and thus early treatmentand thus early treatment To detect and manage treatment To detect and manage treatment
related toxicity related toxicity To screen for new primary in the To screen for new primary in the
contra-lateral breastcontra-lateral breast To provide psychological supportTo provide psychological support
Follow up involves the following:-Follow up involves the following:- Palliative care team [Hospice] & Other health Palliative care team [Hospice] & Other health
workersworkers To provide psychological careTo provide psychological care To provide symptomatic care To provide symptomatic care
Pain management Pain management Vomiting Vomiting
Mammography Mammography Patients who had mastectomy should have Patients who had mastectomy should have
mammography of the opposite breast every 2 yearsmammography of the opposite breast every 2 years For patients who had BCS both breasts should For patients who had BCS both breasts should
have mammography every 2 yearshave mammography every 2 years TCA TCA
Patients should be seen at 3 and 6 months Patients should be seen at 3 and 6 months following radiotheraphy and then once every year following radiotheraphy and then once every year for lifefor life
B.Management of locally B.Management of locally advanced breast cancer advanced breast cancer
[stage III][stage III] Aim of treatment: Aim of treatment: Palliative Palliative CounselingCounseling Multimodalities of treatmentMultimodalities of treatment Surgery:Surgery:
Toilet mastectomy should be able to close the Toilet mastectomy should be able to close the surgical flap, otherwise neo-adjuvant systemic surgical flap, otherwise neo-adjuvant systemic therapy should be done to down stage the diseasetherapy should be done to down stage the disease
Radiotherapy Radiotherapy Can be given as palliative, neo-adjuvant or Can be given as palliative, neo-adjuvant or
adjuvant adjuvant
Chemotherapy Chemotherapy Can also be given if the patient can Can also be given if the patient can
tolerate ittolerate it Can be given as adjuvant, neo-adjuvant Can be given as adjuvant, neo-adjuvant
or palliative therapyor palliative therapy Hormonal therapyHormonal therapy
C. Management of C. Management of metastatic and locally metastatic and locally
recurring breast cancerrecurring breast cancer The treatment of metastatic and locally The treatment of metastatic and locally
recurring breast cancer are the samerecurring breast cancer are the same Aim:Aim:
Palliation depending on individual patientPalliation depending on individual patient ModalitiesModalities
Surgery:Surgery: Chest wall involvement Chest wall involvement →→re-excision and flap re-excision and flap
reconstructionreconstruction Recurrence after BCSRecurrence after BCS→ mastectomy→ mastectomy Chest wall RTChest wall RT± Surgery± Surgery
Chemotherapy who can tolerate itChemotherapy who can tolerate it For extensive metastases For extensive metastases → C→ Chemotherapy hemotherapy
± hormonal therapy or both± hormonal therapy or both In elderly or unfit patient, it is better to In elderly or unfit patient, it is better to
start with start with hormonal therapyhormonal therapy Bone involvement, spinal cord Bone involvement, spinal cord
compression and superior vena cava compression and superior vena cava obstruction syndrome obstruction syndrome →RT→RT
Pathological fracturesPathological fractures→ splintage→ splintage Pleural effusionPleural effusion→UWSD +→UWSD + intra-pleural intra-pleural
bleomycin or tetracycline instillationbleomycin or tetracycline instillation Hypercalaemia Hypercalaemia → i.v. rehydration, → i.v. rehydration, if failsif fails→ →
bisphosphanates bisphosphanates
D. Management of Breast D. Management of Breast cancer occurring during cancer occurring during
pregnancypregnancy Multi-disciplinary approach involving the Multi-disciplinary approach involving the
surgeons, medical and radiation surgeons, medical and radiation oncologists, obstetricians is neededoncologists, obstetricians is needed
Termination of pregnancy is not necessary Termination of pregnancy is not necessary and does and does notnot improve survival improve survival
11stst / 2 / 2ndnd trimester: trimester: Radiotherapy and chemotherapy should be Radiotherapy and chemotherapy should be
delayed until deliverydelayed until delivery Mastectomy and axillary clearance is the Mastectomy and axillary clearance is the
treatment of choicetreatment of choice
33rdrd trimester trimester Ideally treatment should be delayed until Ideally treatment should be delayed until
after delivery at about 32/40 after delivery at about 32/40 →→ treatment as treatment as for non-pregnant patientfor non-pregnant patient
Hormonal therapy should be avoided Hormonal therapy should be avoided Lactation Lactation
Patients receiving chemotherapy should not Patients receiving chemotherapy should not be allowed to breastfeed as some of drugs be allowed to breastfeed as some of drugs [eg cyclophosphamide and methotrexate ] [eg cyclophosphamide and methotrexate ] are secreted in breast milk and could be are secreted in breast milk and could be harmful to the childharmful to the child
Palliative care in Breast Palliative care in Breast cancercancer
Definition Definition Active total care of patients whose disease Active total care of patients whose disease
is not responsive to curative treatmentis not responsive to curative treatment Involves control of pain and other symptoms Involves control of pain and other symptoms
related to the disease or treatment related to the disease or treatment modalitiesmodalities
Also deals with psychological , social and Also deals with psychological , social and spiritual problems of the patientspiritual problems of the patient
Palliative care team [Hospice]Palliative care team [Hospice] Is multi-disciplinary team of doctors, nurses, social Is multi-disciplinary team of doctors, nurses, social
workers, support staff and volunteers of various workers, support staff and volunteers of various categoriescategories
Palliative care options include:-Palliative care options include:- Pain control using the WHO criteria for analgesia Pain control using the WHO criteria for analgesia
for somatic painfor somatic pain Step 1: NSAIDs + ParacetamolStep 1: NSAIDs + Paracetamol Step 2: NSAIDs + Paracetamol + Weak opioid [Codeine]Step 2: NSAIDs + Paracetamol + Weak opioid [Codeine] Step 3: NSAIDs + Paracetamol + Strong opioid [Morphine]Step 3: NSAIDs + Paracetamol + Strong opioid [Morphine]
Control of infectionsControl of infections→ crushed metranidazole → crushed metranidazole for for fungating lesionsfungating lesions
Control of nausea / vomitingControl of nausea / vomiting→steroids + anti-emetics→steroids + anti-emetics Appetite stimulants Appetite stimulants → Corticosteroids→ Corticosteroids Counseling / Social supportCounseling / Social support
PROGNOSISPROGNOSIS With modern treatment, the 5-year With modern treatment, the 5-year
survival rate for:-survival rate for:- Stage I patients is 94%Stage I patients is 94% Stage IIa patients, 85%Stage IIa patients, 85% Stage IIb patients, 70%Stage IIb patients, 70% Stage IIIa patients is 52%Stage IIIa patients is 52% Stage IIIb patients, 48%Stage IIIb patients, 48% Stage IV patients, 18%.Stage IV patients, 18%.
Prognostic IndicatorsPrognostic Indicators
Age: the younger the pt the poor the prognosisAge: the younger the pt the poor the prognosis Sex: M>F early fixation to the chest wallSex: M>F early fixation to the chest wall Site: ILQ early metastasis to the mediastinum Site: ILQ early metastasis to the mediastinum
+abdomen+abdomen Nature of growth; inflammatory ca> medullaryNature of growth; inflammatory ca> medullary Axillary nodal statusAxillary nodal status Tumor sizeTumor size Histological gradeHistological grade Tumor stageTumor stage Hormonal receptor statusHormonal receptor status Metastasis Metastasis
PREVENTIONPREVENTION
Primary preventionPrimary prevention Difficulty Difficulty Modification of risk factorsModification of risk factors Health education Health education → ↑ awareness of the risk → ↑ awareness of the risk
factorsfactors Secondary preventionSecondary prevention
BSEBSE Clinical breast examinationClinical breast examination Mammography screeningMammography screening
Tertiary preventionTertiary prevention rehabilitationrehabilitation
