The breast

The breast

By Dr. Imad Wajeh

Objectives of the lectures

To know the basics about the embryology, physiology, and anatomy of the breast. To review congenital anomalies of the breast. What are the presenting symptoms of breast diseases . How to examine the breast clinically. To know the investigations for breast diseases. To have knowledge of the different diseases of the breast. special care about carcinoma of the breast.

Introduction A. Embryologically: belong to integument (skin) B. Functionally: part of reproductive system C. Modified apocrine sweat glands - apex of cell becomes part of secretion and breaks off

Embryology

The mammary milk line

Embryology

At the fifth or sixth week of fetal development, two ventral bands of thickened ectoderm (mammary ridges, milk lines) are evident in the embryo. In most mammals, paired breasts develop along these ridges, which extend from axilla to the inguinal area.

Physiology

The Breast is an apocrine gland modified for the formation of milk under normal physiological circumstances. The breast remains undeveloped in the female until puberty, when it enlarges in response to ovarian estrogen and progesterone, which initiate proliferation of the epithelial and connective tissue elements.



Physiology
The breast at different physiological stages. The central column contains three-dimensional depictions of microscopy structures. A. Adolescence. B. Pregnancy. C. Lactation. D. Post-menopause.

Physiology

Hormonal EffectsEstrogenDevelopment of the breast and lactiferous ducts.ProgesteroneSecretory acinar tissue – lobules.ProlactinLactogenesis.

Breast Anatomy

The breast extends from : clavicle superiorly. Mid-sternal line medially. 7th or 8th rib inferiorly. Anterior axillary line & axilla laterally . Base is circular, either flattened or concave. Separated from pectoralis major muscle by fascia, retromammary space. Axillary tail: prolongation of upper, outer quadrant of the breast in axillary direction.

Breast Anatomy

Breast Anatomy
Nipple: Level at fourth intercostal space Small conical/cylindrical prominence below the center of the breast Surrounded by areola Covered by pigmented skin Thin skinned region lacking hair, sweat glands

Breast Anatomy

Areola: Contains dark pigment that intensifies with pregnancy. Circular and radial smooth muscle fibers, cause nipple erection



Breast Anatomy
Three tissue types:1. Glandular epithelium Alveoli  ductules (10-100 Lobules)  lactiferous ducts (15-20 Lobes)  ampulla2. Fibrous stroma and supporting structures( Cooper ligaments) it is a fibrous continuations of the superficial fascia, which span the parenchyma of the breast to the deep fascial layers.3. Fat surrounds surface, fills spaces between lobes

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy



Breast Anatomy
Arterial supply Internal mammary artery Lateral thoracic artery Venous return Intercostals Axillary vein (primarily) Internal mammary vein

Breast Anatomy

Arterial supply Internal mammary artery Lateral thoracic artery

Breast Anatomy

Breast Anatomy
Lymphatic:- It is primarily to the axilla 75%.There are 6 axillary lymph node groups:(1) the lateral group along axillary vein. (2) the medial group along lat. thoracic vessels.(3) the posterior or subscapular group.(4) the central group, embedded in fat in the centre of the axilla . (5) the subclavicular group (apical).(6) the interpectoral group (Rotter’s).- Only minor portion is to the internal mammary lymph nodes.

Breast Anatomy

Destinations of lymphatic routes in Metastasis
From medial lymphatics to parasternal nodes then to mediastinal nodes Across the sternum then to contralateral breast From subdiaphragmatic lymphatics to nodes in abdomen to liver, ovaries, peritoneum



Subdiaphragmatic Lymph Channels
Channels to Contralateral Breast
Axillary Lymph Channels
Major Routes of Metastasis

Breast Anatomy

Breast Anatomy
Nerves: Long thoracic nerve Thoracodorsal nerve Medial pectoral nerve Lateral pectoral nerve

Congenital abnormalities

Amazia Polymazia Absence of the nipple Supernumerary nipples

Amazia

Polymazia
Relatively commonFound along “milk line”Most identified during pregnancy/lactationMost common in axillaNot dangerous


Polymazia

Supernumerary Nipples

More common than supernumerary breasts Found along milk line May darken during pregnancy Not dangerous

Supernumerary Nipples

Supernumerary Nipples

Presentation

Symptoms: Lump Painful lump or lumpiness Pain Nipple discharge Nipple change Miscellaneous

Examination of the breast

Inspection The surgeon inspects the woman's breast with her arms by her side, with her arms straight up in the air, and with her hands on her hips (with and without pectoral muscle contraction). Inspection- skin, areolas , nipples, discharge – size– Symmetry– Erythema– Ulceration– Edema– Nipple retraction– Scar– Dilated veins

Examination of the breast

Examination of the breast

Examination of the breast
Inspection of the breast with arms at sides. B. Inspection of the breast with arms raised. C. Palpation of the breast with the patient supine. D. Palpation of the axilla.

Examination of the breast

Investigations of the breast
Imaging: Mammography + xerography, Ductogram, Ductoscope Ultrasound Magnetic resonance imaging Histopathology: FNAC, Needle biopsy, tissue biopsy. Triple Assessment: Clinical examination Imaging ( Mammography/ US if < 35years) Histopathology (FNAC,Core needle, biopsy)

Triple Assessment

Mammography



Mammography and xeromammography

Thermogram

Transmission of detectable heat from the breast. In malignant lesions results from the hypervascularity that frequently accompanies carcinoma.

Mammography

Ductogram

Ductogram

Ultrasound

Ultrasound Appearance Breast Masses

Simple Cyst Complex Solid


Breast Cyst

Fibroadenoma--- solid on U/S

MRI

Ductoscope

Histopathology
Biopsy options: Fine needle aspiration Core biopsy Stereotactic biopsy Incisional biopsy Excisional biopsy

Fine needle aspiration

Needle biopsy/cytology, tissue biopsy

Core Needle Biopsy

14-18 gauge spring loaded needle Tissue Multiple

Core Needle Biopsy

Core Needle Biopsy

Stereotactic Core Needle Biopsy

Incisional biopsy

Excisional biopsy

Excisional biopsy

Nipple abnormalities

Congenital abnormalities: Absence of the nipple, Supernumerary nipples. Retraction of the nipples. Cracked nipples. Papilloma of the nipples. Retention cyst of the gland of Montgomery (sebaceous cyst). Chancre of the nipple. Eczema of the nipple. Paget`s disease of the nipple. Abnormal discharge of the nipple.

Nipple abnormalities

Retraction of the nipples: At puberty (remote) : developmental, after mastitis of infancy. At womanhood (recent) : frequently accompanied scirrhous carcinoma

Inverted Nipples at puberty (remote)

Often will evert with stimulation Mostly a cosmetic issue Successful breastfeeding is usually possible.

Inverted Nipples at puberty (remote)

Benign non cancerous inversion of the nipple corrected by day case surgery

Inverted Nipples at womanhood (recent)

Nipple Laceration
Keep clean and dry. Stop breastfeeding that side and allow to heal Antibiotics usually not necessary

Papilloma of the nipple

Montgomery tubercle

Montgomery tubercle

Definition: it is a sebaceous, or oil-producing glands, secrete a lubricating and protective substance, altering the skin's pH and discouraging bacterial growth. These glands also secrete a small amount of milk. This lubrications helps to keep the skin healthy and the areola elastic

Chancre of the nipple

Primary syphilis Primary lesion develops at the site of infection, which heals in 2-6 weeks. Small, painless papule that rapidly forms an ulcer (the chancre). The chancre is usually single, round or oval, painless, surrounded by a bright red margin and indurated with a clean base, and discharging clear serum.

Paget`s disease

Paget Disease of the Nipple


Paget’s Disease Crusty, flaking lesion Gradual onset over months or years Associated with underlying breast malignancy Diagnosis confirmed by needle biopsy

Paget`s disease

Paget`s disease
Eczema
Unilateral
bilateral
Start in the nipple extend to the areola
Start in the areola extend to the nipple
Underlying mass may be present
No mass
Not respond to medical treatment within 2 weeks.
Respond to medical treatment within 2 weeks.

Paget’s disease of the nipple (B&L) Histological appearance

Nipple discharge
Nipple discharge is divided according to the nature of the discharge in to:A clear, serous discharge may be ‘physiological’ in a parous woman or may be associated with a duct papilloma.A milky discharge occurs in Galactorrhea.A blood-stained discharge may be caused by duct ectasia or less commonly a duct papilloma or carcinoma. A black or green discharge is usually due to duct ectasia.Purulent discharge occurs in infection

Nipple discharge

Nipple discharge is divided according to the pathology in to: Benign (common): Physiological causes. Blood stained nipple discharge in Intraductal pailloma. Milky discharge in Galactorrhea. Purulent discharge in mastitis and breast abscess. Black or green discharge is usually due to duct ectasia. Malignant (less common): In situ carcinoma (DCIS) Invasive carcinoma


Nipple discharge
Nipple discharge is divided according to the prognosis into: Physiologic (good prognosis): Age < 40 years Bilateral Clear Multiple ducts Non-spontaneous drainage Occult blood negative, protienaceous material or benign apocrine cells on smear. Pathologic (bad prognosis): Age > 60 years Unilateral Thick, bloody Single duct Spontaneous drainage Associated with a mass, occult blood positive, abnormal cytology.

Nipple discharge

Galactorrhoea

Nipple discharge

nipple discharge of pregnancy

Nipple discharge

A blood-stained discharge may be caused by duct ectasia or less commonly a duct papilloma or carcinoma

Nipple discharge

Duct ectasia



Nipple discharge
Duct ectasia : Generally found in older women. Dilatation of the subareolar ducts fill with a stagnant brown or green secretion associated with periductal inflammation. A palpable retroareolar mass, nipple discharge, or retraction can be present. Treatment involves excision of area.

Duct ectasia

Duct ectasia

Duct ectasia

Nipple discharge
Investigation of Abnormal discharge of the nipple: Prolactin if milky discharge and bilateral. Ultrasound. Mammogram if >35y., Ductogram, Ductoscope. Cytology. Occult blood test.

Ductoscope

Management of spontaneous nipple discharge


Nipple discharge
Treatment: - firstly must be to exclude a carcinoma. - Simple reassurance. - if the discharge is proving intolerable, an operation to remove the affected duct /ducts can be performed (Microdochectomy, Cone excision of the major ducts).

Microductectomy

Cone excision of the major ducts

Breast Diseases

Congenital abnormalities : Amazia, Polymazia. Diffuse hypertrophy. Pendulous breasts (flabby breasts). Under-development of the breast. Injuries of the breasts : haematoma, traumatic fat necrosis. Inflammations : Mastitis, breast abscess. Fibrocystic breasts (ANDI). Breast cysts, galacocele. Benign neoplasms of the breast. Carcinoma of the breast.

Diffuse hypertrophy

Juvenile breast hypertrophy or juvenile gigantomastia is a rare disease characterized with rapid and excessive growth of the breast during adolescence. Although the deformity is benign, it affects patients physically and psychologically. Surgical approach is the primary treatment option, breast-reduction surgery.

Diffuse hypertrophy

Pendulous breasts (flabby breasts)
Surgical treatment by breast-lift surgery

Pendulous breasts (flabby breasts)

Pregnancy, breast feeding, and weight change or gain may all contribute to the breast's sagging more or becoming more pendulous. Surgical treatment by breast-lift surgery or mastopexy.

Under-development of the breast

Surgical treatment by inserting a breast tissue expander beneath the smaller left breast and inflate it over several months in order to stretch the overlying skin so that a suitably sized implant could be inserted

Injuries of the breast

Haematoma, particularly a resolving haematoma, gives rise to a lump which, in the absence of overlying bruising, is difficult to diagnose correctly unless it is aspirated or incised.

Breast haematoma

Breast haematoma

Injuries of the breast

2. Traumatic fat necrosis - acute or chronic. - occurs in stout, middle-aged women. - Following a blow, or even indirect violence (e.g. violent contraction of the pectoralis major). - a lump, often painless, appears. This may mimic a carcinoma, even displaying skin tethering and nipple refraction, and biopsy is required for diagnosis.


Traumatic fat necrosis

Traumatic fat necrosis

Inflammation of the breast (Mastitis)
Mastitis of infants. Mastitis of puberty. Mastitis of mumps. Mastitis from local irritation. Mastitis from milk engorgement. Duct ectasia/ periductal mastitis. Acute bacterial mastitis/ abscess. Chronic abscess. Retromammary abscess. Tuberculosis, actinomycosis, syphilis.

Mastitis of infants

Mastitis of infants is at least as common in boys as in girls. On the third or fourth day of life. if the breast of an infant is pressed lightly, a slight milky secretion, This is popularly known as ‘witch’s milk’.Is seen only in full-term infants. It is caused by stimulation of the fetal breast by prolactin.

Duct ectasia/ periductal mastitis

Duct ectasia/ periductal mastitis
Generally found in older women. Dilatation of the subareolar ducts fill with a stagnant brown or green secretion associated with periductal inflammation. A palpable retroareolar mass, nipple discharge, or retraction can be present. Treatment involves excision of area.

Duct ectasia/ periductal mastitis

Acute bacterial mastitis
Bacterial mastitis is the most common variety of mastitis and is associated with lactation in the majority of cases. Is nearly always commences acutely. Associated with an Infected haematoma, or with periductal mastitis, lactation. Etiology: Staphylncrccsts aureus. Clinical features: a generalized cellulitis with the classic signs of acute inflammation. later on an abscess will form.

Acute bacterial mastitis

Mammary abscess

Acute bacterial mastitis

Treatment :cellulitic stage: - Antibiotics (E.G. Flucloxacillin, amoxyclav) during the cellulitic stage before pus formation. - The infected breast should be emptied of milk using a breast pump. - Support of the breast, local heat and analgesia - The breast should be incised and drained if the infection does not resolve within 48 hours Abscess stage : - The presence of pus can be confirmed with a needle aspiration. - The breast should be incised and drained at the most dependent part of the breast . All loculi that can be felt are entered . - If an antibiotic is used in the presence of undrained pus, an ‘antibioma’ may form. This is a large, sterile, brawny, oedematous swelling which takes many weeks to resolve.

Mammary abscess

Mammary abscess

Tuberculosis of the breast

Tuberculosis of the breast with secondary suppurating axillary lymph nodes


Fibrocystic breastsAberrations of normal development and involution (ANDI)
Synonyms- Mammary dysplasia Cystic disease Cyclic Mastopathy Cystic Hyperplasia Fibroadenosis

Fibrocystic breastsAberrations of normal development and involution (ANDI)

A wide spectrum of clinical and pathologic findings. Pathology: Cyst formation. Cysts are variable in size. Fibrosis. Fat and elastic tissue disappears and is replaced by dense white fibrous trabeculae infiltrated with chronic inflammatory cells. Hyperplasia of epithelium lining the ducts and acini. Papillomatosis. The epithelial hyperplasia results in papillomatous growth within the ducts.

Histopathological sections

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Clinical features: It most commonly affect women between (30-50) years of age. The symptoms of ANDI include an area of lumpiness and/or breast pain (mastalgia). The changes may be cyclical, with an increase in both lumpiness, and often tenderness, before a menstrual period. No consistent association between fibrocystic complex and breast cancer.


Fibrocystic breastsAberrations of normal development and involution (ANDI)

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Aspiration should be attempted when cysts are suspected In the presence of a mass then an excisional biopsy should be done.

Fibrocystic breastsAberrations of normal development and involution (ANDI)

Fibrocystic breastsAberrations of normal development and involution (ANDI)
Treatment: General: Explanation and reassurance are usually effective in reducing anxiety. Limitation of caffeine intake reduce the symptoms of pain and tenderness. Most of the symptoms need little analgesia. Evening primrose oil. Hormonal: Prolactin inhibitor such as danazol 100mg t.d.s. may be given. Anti-estrogen, e.g. tamoxifen Androgenic hormones is effective but it can result in significant side effects and should not be recommended routinely in the therapy of fibrocystic disease. Surgical: Subcutaneous mastectomy and prosthetic implant is the last step in treatment, it should only reserved for very occasional women with severe fibrocystic disease.

Breast Cyst

Smooth, unilateral mass Feels like a cyst Infrequently associated with malignancy Aspirate Watch for reforming of cyst Recurring cysts are more worrisome

Galactocele

Milk-filled cyst Usually follows lactation Firm, tender mass Usually in upper quadrants Diagnostic aspiration often curative



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Galactocele

Galactocele

Benign neoplasms

Classification:•Epithelial (ductal system). - Duct papilloma. - Pure adenoma (very rare).• Connective tissue and adipose tissue. - Neurofibroma - Lipoma• Mixed - Fibroadenoma (including giant fibroadenoma)

Duct papilloma

The majority of these tumors are single. Situated in one of the larger lactiferous ducts. Usually occurs in women between 35 and 50. Bright red blood or, less often, a dark blood-stained discharge from the nipple is the only symptom. On examination, a cystic swelling can sometimes be felt beneath the areola; pressure upon it will cause a discharge from the mouth of the affected duct on the nipple. Treatment by microdochectomy.

Duct papilloma

Duct papilloma



Duct papilloma

Fibroadenoma

Most common benign breast tumor. Usually arise during the 18-25 year age period. Arise from hyperplasia of a single lobule, and usually grow up to 2-3 cm in size. Surrounded by a well-marked capsule. Solid, rubbery, non-tender. Freely mobile, mouse of the breast. Giant fibroadenomas occur occasionally during puberty. They are over 5 cm in diameter and are often rapidly growing.

Fibroadenoma

Fibroadenoma
Common. Benign. Solid, rubbery, non-tender. Freely mobile, mouse of the breast. Round or oval. Rarely grow > 2-3 cm. Diagnosis and Treatment by excisional biopsy. Observe in adolescents.

Fibroadenoma

Phyllodes (meaning leave-like) tumors are rare breast tumors. They account for less than 1% of all breast tumors. This peculiar tumor exhibits a spectrum of behavior, ranging from the benign to the malignant. Usually occur in women over the age of 40 year. They present as a large, sometimes massive tumour. Bosselated surface, mobile on the chest wall, not attached to the skin or the chest wall. Rarely cystic. Rarely develop features of a sarcomatous tumour. May metastasise via the blood stream.

Phyllodes tumour

MRI image of Phyllodes Tumor

Phyllodes tumour

Phyllodes tumour
phyllodes tumours have a myxoid cellular stroma separated by long clefts of (compressed) epithelial tissue. The long clefts are the key feature that differentiates these tumours from the more common fibroadenoma of the breast.

Phyllodes tumour

Treatment for the benign type is enucleation in very young women or wide local excision. Massive tumours, recurrent tumours and those of the malignant type will require mastectomy.

Malignant Diseases of the Breast

The first most common malignant tumor among Iraqi women. A woman has a 1 in 8 chance of developing breast cancer at some point in her life. Breast cancer is the commonest cause of death in middle-aged women in Western countries.


Primary Site No. % 1- Breast 1708 31.33 2- Leukemia 306 5.61 3- N.H. Lymphoma 269 4.94 4- Ovary 216 3.96 5- Skin 211 3.87 6- Bronchus and Lung 181 3.32 7- Stomach 167 3.06 8- Urinary Bladder 160 2.94 9- Thyroid 159 2.92 10-Cervix Uteri 158 2.9 All Sites 5451
Iraqi Cancer Registry [2000]
The commonest ten cancers among Iraqi females

Aetiological factors

Geographical. It occurs commonly in the Western world, accounting for 3-5 per cent of deaths, yet is a rare tumor in Japan. In developing countries it accounts for 1-3 per cent of deaths. Age. Carcinoma of the breast is extremely rare below the age of 20, but thereafter the incidence steadily rises so that by the age of 90 nearly 20 per Cent of women are affected. Gender. Only 1 % of patients with breast cancer are male. Race. White women. Genetic. It occurs more commonly in women with a family history of breast cancer than in the general population. - Two major dominantly inherited genes have been identified are BRCA1 and BRCA2 predisposing to breast cancer. - In addition, P53, ATM, PTEN, MLH1 or MSH2. Diet. rich in saturated fatty acids, high intake of alcohol. Benign breast diseases. Endocrine. - protective factors:- breast feeding, having a first child at an early age. - risk factors:- The duration of exposure to steroid hormones play a vital role. early age of menarche, late menopause, late pregnancy, nulliparity. also oral contraceptive pill and hormone replacement therapy.


Risk Factors for Breast Cancer
Females Early menarche Late menopause Nulliparity or 1st pregnancy >30 y.o.a. White race Old age Family history of breast cancer Genetic predisposition (BRCA 1, BRCA 2, Li Fraumeni Syndrome) Prior personal history of breast cancer Carcinoma in situ Atypical ductal or lobular hyperplasia
Males Testicular Abnormalities Undescended testes Congenital inguinal hernia Orchitis Testicular injury Infertility Positive family history Klinefelter Syndrome Elevated endogenous estrogen Previous irradiation Trauma Jewish ancestry

Age Factor for Breast Cancer

Genetics
Hereditary Breast/Ovarian SyndromeBRCA 1 – chromosome 17BRCA 2 – chromosome 13Li-Fraumeni SyndromeP53 mutation – chromosome 17Cowden SyndromePTEN mutation – chromosome 10Autosomal dominant pattern

BRCA

Account to 25% of early-onset breast cancers 36%-85% lifetime risk of breast CA 16-60% lifetime risk of ovarian CA

Pathology

Types of Breast Cancer: Carcinoma (majority), Sarcoma (rarity) Primary (majority), Secondary (rarity)

Pathology

Breast carcinoma:Ductal (85%): arise from the epithelium of the duct system. – Infiltrating (80%) (schirrhous) or noninfiltrating (5%)Lobular (12%): arise from the terminal duct unit which is in the breast lobule. – Infiltrating (3%) or nonifiltrating (9%)Paget’s disease of the nipple (1%) is a superficial manifestation of an underlying breast carcinoma. Others (1-2%) – Medullary – Colloid – Inflammatory – Tubular carcinoma


Pathology

Invasive duct (schirrhous) carcinoma

Biopsy: Color: grey Cut surface: concave Cutting: gritty sensation

Invasive duct (schirrhous) carcinoma

Inflammatory carcinoma
Inflammatory carcinoma is a fortunately rare, highly aggressive cancer which presents as a painful, swollen breast, which is warm with cutaneous oedema.

Inflammatory carcinoma of the right breast

The spread of breast carcinoma
Local spread: It tends to involve the skin and to penetrate the pectoral muscles, and even the chest wall. Lymphatic metastasis: occurs primarily to the axillaty lymph nodes and to the internal mammary chain of lymph nodes. Bloodstream: It is by this route that skeletal metastases occur (in order of frequency) in the lumbar vertebrae, femurs, thoracic vertebrae, ribs and skull; they are generally osteolytic. Metastases may also occur in the liver, lung and brain, and occasionally the adrenal glands and ovaries.

The spread of breast carcinoma

Clinical presentation

In 33% of breast cancer cases, the woman discovers a lump in her breast. Breast enlargement or asymmetry. Nipple changes, retraction, or discharge. Ulceration or erythema of the skin of the breast. Axillary mass. Musculoskeletal discomfort.

Clinical presentation

breast cancer commences most frequently in the upper, outer quadrant

Quadrants

Breast is divided into quadrants Upper-Outer quadrant has the greatest mass UOQ is the site of about half of all breast cancers

Clinical presentation

Clinical presentation
Most breast cancers will present as a hard lump, which may be associated with indrawing of the nipple.

Clinical presentation

Clinical presentation
skin involvement with Peau d’orange or frank ulceration and fixation to the chest wall or a fungating mass.


Clinical presentation

Clinical presentation

Bilateral carcinoma of the breast

Phenomena resulting from lymphatic obstruction in advanced breast cancer

Peau d’orange is due to cutaneous lymphatic oedema. Late oedema of the arm is a complication of breast cancer treatment, radical axillary dissection and radiotherapy. Cancer-en-cuirasse. The skin of the chest is infiltrated with carcinoma and has been likened to a coat of armour (a cuirasse was the leather or metal breastplate worn by soldiers). Lymphangiosarcoma.

Locally advanced breast cancer

Peau d’orange Nodules of the skin

Clinical presentation

Late oedema of the arm

Clinical presentation

Diagnosis of breast carcinoma

Investigations

Investigations

Breast Cancer Staging

There are two traditional systems of classification for breast carcinoma which predominantly rely on clinical staging of the disease. The manchester system. The International Union Against Cancer TNM (tumour, nodes, rnetastases) staging system.

Breast Cancer Staging

Manchester classification:TIST0 , N0M0. I T1<2 , N0= No nodal metastasesII T22—5 , N1= Mobile axillary nodesllla T3>5 , N2= Fixed axillary nodeslllb T4Any size , N3= Supra clavicular invading ipsilateral nodes skin or chestwallIV M1 Distant metastases

Breast Cancer Staging

TNM classification: T1: <= 2 cm T2:> 2 cm, <= 5 cm T3:> 5 cm T4:Any size, direct extension to chest wall or skin N0:No nodes N1:Ipsilateral axillary nodes (mobile) N2:Ipsilateral axillary nodes (fixed) N3:Ipsilateral internal mammary nodes M0: No evidence of distant metastasis M1: Distant metastases (includes ipsilateral supraclavicular nodes)

Breast Cancer Staging

Staging and Prognosis

Stage Prognosis (5 year surv. Rate) I > 90% II > 70% III < 70% IV < 30%

Prognostic Features

1. Tumor size important prognostic factor - Poor prognostic features of tumor:Presence of edema or ulceration of skin, mass fixed to chest wall or skin, satellite skin nodules, peau d’orange (dermal lymphatic invasion), skin retraction and dimpling, and involvement of medial portion of inner lower quadrant involved.2. Axillary node status:Best source of predicting survival or outcomeN0 has 10 year survival rate of 60%N1 has 10 year survival rate of 50%N2 has 10 year survival rate of 20%If 10 or more nodes are diseased (N3) 10 yr surv. Rate is 14%Poor prognostic feature of nodes:Capsular invasion, extranodal spread, and edema of arm3. Distant metastases is very poor prognostic indicator4. Positive estrogen and progesterone receptor indicates likely response to hormonal treatment and is a positive prognostic indicator

Breast Cancer Treatments

Surgery Chemotheraphy Radiation therapy Hormone theraphy

Treatment of breast cancer by stages

Early = Stages I, II, IIIaThe aims are:‘Cure’ — this will be possible in some patients but recurrence up to 20 years after initial treatment is not uncommon;Control of local disease in the breast and axilla;Conservation of local form and function;Prevention or delay of the occurrence of distant metastases.Achieved through surgery and/or radiotherapy Late = Stages IIIb, IV Pallative surgery Adjuvant radiotherapy Chemotherapy Hormonal therapy.

Surgical treatment

It is indicated in early case (stage I , II, IIIa) when the potential of cure is high. It is recommended in addition to other modalities in stages IIIb & IV when the potential for cue is small.

Surgical Management of Breast Cancer

Extended radical mastectomy (no longer used): – Includes all breast tissue, pec. major & minor, axillary and deep (internal mammary) nodesRadical mastectomy (Halstead; diminished use): – Spares deep nodesModified radical (‘Patey’) mastectomy: – Spares pec. major.Total simple mastectomy: – spares pec. minor.Simple mastectomy & axillary sampling.Simple mastectomy & sentinel lymph node biopsySegmental mastectomy (Segmentectomy ) Quadrantectomy


Surgical Management of Breast Cancer

Surgical Management of Breast Cancer

Breast reconstruction

Breast reconstruction

Rectus muscle flap

Breast reconstruction

Breast reconstruction

Radiotherapy

Radiation therapy is used for all stages of breast cancer. Adjuvant radiation therapy is given to reduce the risk of local recurrence. Increases overall survival rate in most breast cancers Is most effective in: Local chest wall recurrence. Axillary lymph nodes recurrence. Bony metastasis. Brain metastasis.

Radiotherapy

Role of RT in Breast Cancer Preoperative RT. Post-mastectomy RT. Conservative surgery + RT. Palliative RT.

Chemotherapy regimens for breast cancer

Breast Cancer with Node-Negative - CMF - FAC - ACBreast Cancer with Node-Positive - FAC or CEF - AC ± T - A → CMF - CMF - ECA = Adriamycin (doxorubicin); C = cyclophosphamide; E = epirubicin; F = 5-fluorouracil; M = methotrexate; T = Taxol (paclitaxel); → = “followed by.”

Hormones affecting breast cancer

Hormonal Therapy
Hormonal manipulation (alteration of hormonal influences is used in this type of therapy):Premenopausal women- oophorectomy is the procedure of choice (removal of endogenous source of estrogen) or more recently antiestrogens (tamoxifen) might be used in stead of oophorectomy.Post menopausal women – exogenous estrogens , progesterones , androgens , or antiestrogens (tamoxifen).Adrenalectomy is less commonly used.Hypophysectomy is used occasionally to reduce bone pain from metastatic breast cancer regardless of its effect on the disease progression .

Hormonal Therapy

Tamoxifen:Is the most widely used ‘hormonal’ treatment in breast cancer. Given to ER positiveBenefits young and old patients if given to ER positiveAlso improves survival in node negative patients.

Screening for Breast Cancer

Breast screening is a method of detecting breast cancer at a very early age. There are several methods for to screen for breast cancer, and it can begin at a very early age. The simple ways to begin to screen for breast cancer are: Breast Self Examination Mammography Ultrasound*



Breast Self Exam (BSE)

The Male Breast

Gynecomastia Idiopathic: Hypertrophy of the male breast may be unilateral or bilateral. The breasts enlarge at puberty and sometimes present the characteristics of female breasts. Hormonal: - stilbestrol therapy for prostate cancer. - teratoma of the testis, in anorchism and after castration. - ectopic hormonal production in bronchial carcinoma and in adrenal and pituitary disease. - Body builders may use steroids to improve their physique, which may cause gynaecomastia. Some even go so far as to take tamoxifen to mask this symptom. Associated with leprosy: Gynaecomastia is very common in men suffering from leprosy. This is possibly because of bilateral testicular atrophy, which is a frequent accompaniment of leprosy. Associated with liver failure: Gynaecomastia sometimes occurs in patients with cirrhosis as a result of failure of the liver to metabolise oestrogens.

Unilateral gynaecomastia

Gynecomastia
Bilateral gynecomastia

Male breast carcinoma

0.7% of all breast cancers. <1% of male cancers. Average age of diagnosis is 63.6 years old. Painless unilateral mass that is usually subareolar with skin fixation, chest wall fixation,, and ulceration.. Mostly ductal carcinoma. Males generally present at later stage than woman. Overall survival worse in men, however when compared stage for stage the survival rates are similar.

Carcinoma of the male breast.

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