Modified sweat glandModified sweat gland Greater part of gland lies in sup: fasciaGreater part of gland lies in sup: fascia Small part pierces deep fascia i.e. axillary tailSmall part pierces deep fascia i.e. axillary tail It has protuberant part & axillary tailIt has protuberant part & axillary tail Protuberant part extends vertically from 2Protuberant part extends vertically from 2ndnd-6-6th th ribs & ribs &

Horizontally from lat:border of sternum to midaxillary Horizontally from lat:border of sternum to midaxillary lineline

Thin layer of Mammary tissue extends from clavicle Thin layer of Mammary tissue extends from clavicle above to 7above to 7thth – 8 – 8th th rib below and from midline to the rib below and from midline to the edge of L.D post:edge of L.D post:

Axillary tail can be seen pre-menstrualy or during Axillary tail can be seen pre-menstrualy or during lactation.lactation.

Parenchyma of breast consist of 15 to 20 lobesParenchyma of breast consist of 15 to 20 lobes Each lobe is made up of 20-40 lobules Each lobe is made up of 20-40 lobules Lobules are basic structural units of mammary Lobules are basic structural units of mammary

glandsglands consist of variable number of consist of variable number of alveolialveoli 1O to over 1OO lobules empty into lactiferous 1O to over 1OO lobules empty into lactiferous

duct.duct. Each lactiferous duct is provided just prior to its Each lactiferous duct is provided just prior to its

termination a dilated ampulla i.e. reservoir for milk termination a dilated ampulla i.e. reservoir for milk or abn: dischargeor abn: discharge

Breast is supported and attached to chest wall by Breast is supported and attached to chest wall by these ligaments these ligaments

Hollow conical projectionsHollow conical projections

Account for the dimpling of the skin overlying Account for the dimpling of the skin overlying carcinomacarcinoma

Pigmented circular area that surrounds base Pigmented circular area that surrounds base of nippleof nipple

Contains involuntary musclesContains involuntary muscles

Areolar epithelium contains numerous sweat Areolar epithelium contains numerous sweat & sebaceous glands& sebaceous glands

Sebaceous glands enlarge during pregnancy Sebaceous glands enlarge during pregnancy & serve to lubricate nipple during lactation.& serve to lubricate nipple during lactation.

Erectile structure which points outwardErectile structure which points outward

Covered by thick skin with corrugationsCovered by thick skin with corrugations

Near its apex lie the orifices of lactiferous ductsNear its apex lie the orifices of lactiferous ducts

Nipple contains smooth muscle fibers arranged Nipple contains smooth muscle fibers arranged concentrically and longitudinallyconcentrically and longitudinally

Med: by memory branch of int:thoracic Med: by memory branch of int:thoracic arteryartery

Ant:by intercostal branch of int:thoracic Ant:by intercostal branch of int:thoracic arteryartery

Lat:by mammary br of lat thoracic +lat br of Lat:by mammary br of lat thoracic +lat br of 2-5 post:intercostal arteries & thoraco 2-5 post:intercostal arteries & thoraco acromial br of axillary arteryacromial br of axillary artery

Vein follows arteriesVein follows arteries Converge towards the nipple where they form Converge towards the nipple where they form

anastomatic venous circleanastomatic venous circle Sup:veins drain into int: thoracic veinSup:veins drain into int: thoracic vein Deep veins drain into int: thoracic,axillary & post: Deep veins drain into int: thoracic,axillary & post:

intercostal veinintercostal vein

Derived from ant:and lat:cutaneous branches of 2-6 Derived from ant:and lat:cutaneous branches of 2-6 intercostal nervesintercostal nerves

Lymphatics of the breast drain predominantly into axillary Lymphatics of the breast drain predominantly into axillary & internal mammary lymph nodes& internal mammary lymph nodes

Axillary nodes receive approx. 85% of drainageAxillary nodes receive approx. 85% of drainage Ant axillary or pectoral nodes drain lateral quadrant of Ant axillary or pectoral nodes drain lateral quadrant of

breast breast parasternal l.nodes drain lymph from medial quadrantparasternal l.nodes drain lymph from medial quadrant inferior quadrant’s lymph may pass deeply in to inferior quadrant’s lymph may pass deeply in to

abdominal lymph nodesabdominal lymph nodesThe sentinel l.node is defined as first axillary node draining The sentinel l.node is defined as first axillary node draining

the breast.the breast.

Global Carcinoma.Global Carcinoma. Common cause of death in middle aged women in western Common cause of death in middle aged women in western

countries.countries. 200 times more common in females200 times more common in females The disease is fatal in 25 % of the casesThe disease is fatal in 25 % of the cases 2nd most common cause of death (after Ca lung)2nd most common cause of death (after Ca lung) 1 million women newly diagnosed each year 1 million women newly diagnosed each year Less incidence in AsiaLess incidence in Asia

As is the case with all cancers, cause of breast cancer is As is the case with all cancers, cause of breast cancer is also unknownalso unknown

Three sets of influences appear to be importantThree sets of influences appear to be important

mutation in tumor suppressor genes i-eBRCA1&BRCA2mutation in tumor suppressor genes i-eBRCA1&BRCA2

Endogenous estrogen excess or hormonal imbalanceEndogenous estrogen excess or hormonal imbalance

exogenous estrogensexogenous estrogens irradiationirradiation

Common in western world accounting for 3-5%of all deaths in Common in western world accounting for 3-5%of all deaths in womenwomen

In developing countries it accounts <3 per cent of deaths.In developing countries it accounts <3 per cent of deaths.

Extremely rare before 20 yearsExtremely rare before 20 years Risk of ca breast increasing with ageRisk of ca breast increasing with age Decreased incidence after the menopauseDecreased incidence after the menopause

< 1 per cent are males< 1 per cent are males

It occurs more commonly in women with family historyIt occurs more commonly in women with family history

More common in obeseMore common in obese Link between diets low in phyto-oestrogens & Soya is ass: with Link between diets low in phyto-oestrogens & Soya is ass: with

ca ca High saturated fat diet, red meat High saturated fat diet, red meat Inc: alcohol intake – inc: riskInc: alcohol intake – inc: risk

Longer reproductive span inc:risk ( early menarche, late Longer reproductive span inc:risk ( early menarche, late

menopause )menopause ) Nulliparity inc:risk ( higher number of pregnancies is protective )Nulliparity inc:risk ( higher number of pregnancies is protective ) Oral contraceptives inc:riskOral contraceptives inc:risk Prolonged exposure to ex:estrogens postmenopausally i.e. Prolonged exposure to ex:estrogens postmenopausally i.e.

HRT inc riskHRT inc risk Breast feeding is protective Breast feeding is protective

ETIOLOGY OF BREAST CARCINOMAETIOLOGY OF BREAST CARCINOMA

85% of ca arises in ducts, thus ductal ca is most common variant85% of ca arises in ducts, thus ductal ca is most common variant Most frequently upper outer quadrant is involvedMost frequently upper outer quadrant is involved lobular ca occur in up to 15% of caseslobular ca occur in up to 15% of cases Breast cancers are divided in to…Breast cancers are divided in to…

DCISDCIS LCISLCIS

LobularLobular Medullary Medullary ColloidColloid TubularTubular Inflammatory CaInflammatory Ca

In situ carcinoma is pre-invasive caIn situ carcinoma is pre-invasive ca Usually asymptomaticUsually asymptomatic Both i.e. DCIS,LCIS are markers of late development Both i.e. DCIS,LCIS are markers of late development

of invasive caof invasive ca LCIS is usually multifocal and bilateralLCIS is usually multifocal and bilateral Best treatment is for in situ ca is subject of number of Best treatment is for in situ ca is subject of number of

on going clinical trialson going clinical trials

Usually associated with DCISUsually associated with DCIS Ca produce desmoplastic response which replaces normal Ca produce desmoplastic response which replaces normal

breast fat thus forms hard palpable massbreast fat thus forms hard palpable mass Advanced ca may cause i.e. dimpling of skin, retraction of Advanced ca may cause i.e. dimpling of skin, retraction of

nipple, fixation of chest wallnipple, fixation of chest wall

Usually associated with LCISUsually associated with LCIS More frequently metastasize than ductal caMore frequently metastasize than ductal ca Usually multiple and bilateralUsually multiple and bilateral

Comprises of about 2% of casesComprises of about 2% of cases Clinically resemble fibroadenomasClinically resemble fibroadenomas

Rare subtype often present as well circumscribed massRare subtype often present as well circumscribed mass Tumor cells produce abundant quantity of extracellular Tumor cells produce abundant quantity of extracellular

mucinmucin

It rarely present as palpable massIt rarely present as palpable mass Microscopically ca consist of well formed tubulesMicroscopically ca consist of well formed tubules Lymph node metastasis is rareLymph node metastasis is rare Prognosis is excellentPrognosis is excellent

Highly aggressive, mostHighly aggressive, most of tumor have distant metastasis of tumor have distant metastasis Fortunately rareFortunately rare Usually without palpable massUsually without palpable mass Presents as painful, swollen & warm breastPresents as painful, swollen & warm breast May mimic breast abscessMay mimic breast abscess Prognosis is extremely poorPrognosis is extremely poor

Superficial manifestation of an underlying breast CaSuperficial manifestation of an underlying breast Ca

Presents an eczema like condition of nipple or areolaPresents an eczema like condition of nipple or areola

First there is erosion of nippleFirst there is erosion of nipple

Eventually nipple disappearEventually nipple disappear

MICROSCOPICALLY- Loose ovoid cells with clear MICROSCOPICALLY- Loose ovoid cells with clear abundant & pale staining cytoplasmabundant & pale staining cytoplasm

1:1:Fixation to chest wall – cancer –en- Fixation to chest wall – cancer –en- cuirassecuirasse

2:retraction or dimpling of skin2:retraction or dimpling of skin 3:localized lymphedema3:localized lymphedema 4:Peau d’orange(orange peel)4:Peau d’orange(orange peel)

Pt oftenPt often Presents with hard Presents with hard Painless Painless lumplump Nipple may be deviated, displaced, retracted or destroyed.Nipple may be deviated, displaced, retracted or destroyed. Mild aches & Pricking sensationMild aches & Pricking sensation Distortion of shape of breastDistortion of shape of breast General malaise & loss of weightGeneral malaise & loss of weight Change in size of breastChange in size of breast Backache, caused by infiltration & collapse of lumbar Backache, caused by infiltration & collapse of lumbar

vertebrae.vertebrae.

Invades other portion of breast, skin, pectoral muscle and Invades other portion of breast, skin, pectoral muscle and chest wall.chest wall.

Primarily to axillary L.N. & internal mammary chain of Primarily to axillary L.N. & internal mammary chain of lymph nodes lymph nodes

In advanced stage– supra clavicular with contra latera In advanced stage– supra clavicular with contra latera lL.Ns may also be involved.lL.Ns may also be involved.

Through this route metastases occur in skeleton, liver, lungs Through this route metastases occur in skeleton, liver, lungs and brain and brain

SKELETAL

SKELETAL SKELETAL L - Lumber vertebrateL - Lumber vertebrate F - FemurF - Femur T - T.vertebraeT - T.vertebrae R- RIBSR- RIBS S- SkullS- Skull Metastasis may Metastasis may

occur in liver,lungs & occur in liver,lungs & brain brain

Two traditional systems of classificationTwo traditional systems of classification

I. The Manchester systemI. The Manchester system

II.The international union against cancer i.e. II.The international union against cancer i.e. TNM Staging system.TNM Staging system.

Growth confined to breastGrowth confined to breast

Growth confined to breast and affected lymph nodes in ipsilateral axillaGrowth confined to breast and affected lymph nodes in ipsilateral axilla

a) Large skin involvement or peau d’orange but limited to breast a) Large skin involvement or peau d’orange but limited to breast

b) Tumor fixed to pectoral muscles, but not chest wall b) Tumor fixed to pectoral muscles, but not chest wall

c) ipsilateral lymph nodes matted together or fixed to chest wallc) ipsilateral lymph nodes matted together or fixed to chest wall

a) Wide skin involvement of breasta) Wide skin involvement of breast

b) Complete fixation of tumor to chest wallb) Complete fixation of tumor to chest wall

c) Distant metastasisc) Distant metastasis

TIS ca in-situTIS ca in-situ

T1 <2cmT1 <2cm

T2 2-5cmT2 2-5cm

T3 >5cmT3 >5cm

T4 tumour of any sizeT4 tumour of any size

N0 No nodal involvementN0 No nodal involvement

N1 Mobile involved axillary nodesN1 Mobile involved axillary nodes

N2 Fixed involved nodesN2 Fixed involved nodes

N3 Inv ipsilateral supraclavicular nodesN3 Inv ipsilateral supraclavicular nodes

M0 No metastasisM0 No metastasis

M1 +ve distant metastasisM1 +ve distant metastasis

Ca in situ or tumor less than 2 cm in size with no nodal Ca in situ or tumor less than 2 cm in size with no nodal involvementinvolvement

Tumor of less than 2cm in size with mobile involved Tumor of less than 2cm in size with mobile involved lymph nodelymph node

Tumor of 2-5cm in size with fixed involved lymph node Tumor of 2-5cm in size with fixed involved lymph node +no known distant metastasis+no known distant metastasis

Any tumor, any nodal involvement with Known distal Any tumor, any nodal involvement with Known distal metastasismetastasis

Diagnosis should be made by combination ofDiagnosis should be made by combination of1:clinical assessments1:clinical assessments2:radiological imaging2:radiological imaging3:cytological or thru histological analysis3:cytological or thru histological analysis

it own does not exclude breast cait own does not exclude breast ca It is very safe investigationIt is very safe investigation sensitivity of test inc with age as the breast becomes less sensitivity of test inc with age as the breast becomes less

densedense

Useful in young women with dense breast in whom Useful in young women with dense breast in whom mammograms are difficult to interpret mammograms are difficult to interpret

Useful in distinguishing cystic from solid lesions Useful in distinguishing cystic from solid lesions Useful to localized in impalpable lumps Useful to localized in impalpable lumps

Gold standard for imaging the breast of Patients with Gold standard for imaging the breast of Patients with implantsimplants

PT’s with suspected recurrent diseasePT’s with suspected recurrent disease Useful as a screening tool in high risk womenUseful as a screening tool in high risk women

least invasive technique of obtaining cell diagnosisleast invasive technique of obtaining cell diagnosis False negatives do occur thru sampling errorFalse negatives do occur thru sampling error Invasive ca can’t be distinguished from in situ diseaseInvasive ca can’t be distinguished from in situ disease

To reduce the chance of local recurrence To reduce the chance of local recurrence To reduce the risk of metastatic spreadTo reduce the risk of metastatic spread

SurgerySurgery RadiotherapyRadiotherapy Adjuvant systemic therapyAdjuvant systemic therapy

Two Aspects of surgeryTwo Aspects of surgery Mastectomy Mastectomy Conservative breast surgeryConservative breast surgery

INDICATIONS INDICATIONS Large tumor related to size of the breast Large tumor related to size of the breast Central tumor beneath the areola or involving nipple Central tumor beneath the areola or involving nipple Multi focal disease Multi focal disease Local recurrence Local recurrence Patients preference Patients preference

Removal of breast tissue with axillary tail Removal of breast tissue with axillary tail usually attached with few lymph nodes of usually attached with few lymph nodes of anterior axillary groupanterior axillary group

No dissection of axilla No dissection of axilla Simple mastectomy is often followed by Simple mastectomy is often followed by

radiotherapy radiotherapy

It includes It includes Excision of whole breast Excision of whole breast All axillary lymph nodes All axillary lymph nodes All fat and fascia of the anterior chest wall All fat and fascia of the anterior chest wall Excision of pectoralis major and minor muscles.Excision of pectoralis major and minor muscles.

More commonly performedMore commonly performed Excised Mass is composed ofExcised Mass is composed of Whole breast Whole breast Large portion of skin overlies the tumor and nipple Large portion of skin overlies the tumor and nipple All fat, fascia, and lymph nodes of axilla All fat, fascia, and lymph nodes of axilla Pectoralis minor muscle divided or retracted Pectoralis minor muscle divided or retracted With preserving of axillary vein, nerve to serratus anterior & With preserving of axillary vein, nerve to serratus anterior &

lattissimus dorsilattissimus dorsi

Small tumor related to the size of breast Small tumor related to the size of breast Availability of radiotherapy facility Availability of radiotherapy facility Patient preferencePatient preference

Involves removal of lump or tumor with rim of 1cm normal Involves removal of lump or tumor with rim of 1cm normal breast tissue.breast tissue.

Term lumpectomy is reserved for operation in which benign tumour is Term lumpectomy is reserved for operation in which benign tumour is excised and large amount of normal breast is not resectedexcised and large amount of normal breast is not resected

Removing the entire segment of the breast which contain the Removing the entire segment of the breast which contain the tumor.tumor.

Radiotherapy to the remaining breast tissue Radiotherapy to the remaining breast tissue Quadrantectomy, axillary dissection & radiotherapy is known as Quadrantectomy, axillary dissection & radiotherapy is known as

QUARTQUART

INDICATIONINDICATION After mastectomyAfter mastectomy High grade tumourHigh grade tumour Large nodal involvementLarge nodal involvement Multifocal disease Multifocal disease Extensive lymphovascular invasionExtensive lymphovascular invasion

AIM:AIM: To delay the relapse To delay the relapse To prolong the survival To prolong the survival Indications:Indications: Lymph node positive women Lymph node positive women Poor prognosisPoor prognosis Hormonal receptor positive womenHormonal receptor positive women Old patientOld patient

Tamoxifen is widely used hormonal treatmentTamoxifen is widely used hormonal treatment If pat is premenopausal get benefit from 2omg daily of tamoxifenIf pat is premenopausal get benefit from 2omg daily of tamoxifen New aromatase inhibitors i.e.anastrozole,letrozole etc are used if New aromatase inhibitors i.e.anastrozole,letrozole etc are used if

pat is post menopausalpat is post menopausal It reduces risk of cancer in contra lateral breastIt reduces risk of cancer in contra lateral breast Other hormonal agents are being developed i.e. LHRHOther hormonal agents are being developed i.e. LHRH

The aim of this Rx is to shrink tumor to enable breast preserving The aim of this Rx is to shrink tumor to enable breast preserving surgery.surgery.

6 months cycles of cyclophosphamide, methotrexate and 5-FU 6 months cycles of cyclophosphamide, methotrexate and 5-FU achieve 25% reduction in risk of relapseachieve 25% reduction in risk of relapse

Chemotherapy may be considered in node –ve pts if there is hi Chemotherapy may be considered in node –ve pts if there is hi risk of recurrencerisk of recurrence

This Rx is confined to premenopausal women.This Rx is confined to premenopausal women.