Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Carcinoma of the breast
A etiological factors
Geographical more common in the west
Age rare before the age of 20 & it increases with age
Genetic – occur commonly in patients with family history
Diet
Endocrine – late menarche- early mean pose
Early 1st child- Breast feeding
All protective.
- Post menopausal –obese
- oral contraceptive pill –small risk
Pathology
Arise from the epithelium of ducts – ducal carcinoma
May arise from the epithelium of lobules – lobular carcinoma
Can be well differentiated -moderate diff --poorly diff
The most common histological type is adeno carcinoma
Rare histological types colloid – medullary – tubular
Ductal carcinoma in situ – DCTS pre invasive
Lobular carcinoma in situ – LCIS preinvasive –multifocal and bilateral
CIS is detected by mammography –screening pick up 20%
Treat of CIS is not same as invasive carcinoma
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Inflamatory carcinoma
– highly aggressive – Biopsy give diag
Pagets disease of the nipple
Superficial manifestation of underlying carcinoma
Lesion in the nipple and aerola look like eczema
Biopsy will give the final diagnosis
Spread of mammary carcinoma
Local spread –in breast tissue –skin -pectoral muscle –chest wall
Lymphatic spread –axillary --and internal mammary lymph nodes
Lymph node involvement is a marker for the metastatic potential of the cancer
Supraclavicular lymph nodes and contralateral nodes can be involved
Blood stream spread – bones – lumbar vertebrae –Thoracic vertebrae – femur
Osteolytic . Lung –liver –ovary –suprarenal.
How does the patient present clinically
Common site upper outer quadrant
Hard lump in the breast
There may be nipple retraction
There may be skin involvement Peau –d –orange – ulceration
Tumor may be fixed to chest wall – Cancer –en –cuirasse
Advanced breast cancer (skin manifestation)
Skin –Peau-d-orange –cutaneous lymphatic odema due to skin infiltration by the
tumor --the pitting is due to opening of sweat ducts which cannot swell –can be
seen in chronic abscess
Late odema of the arm after Radical surgery to the axilla ---or Radiotherapy can
occur months or years later may indicate neoplastic infiltration
Arm swollen and painful ---Bacterial infection can add to the problem
Cancer –en –cuirasse- skin feels like a leather coat due to the neoplastic
infiltration
It can also be seen after DXRAY of the area
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Lymphangiosarcoma
Is a rare complication of lymphatic odema
Appear with multiple nodules in subcutaneous tissue
Surgery may be required – Forequarter amputation
Staging of breast cancer
Two systems – Manchester system and International TNM system
Manchester classification
Stage I –mobile lump in the breast no palpable axillary LN
Stage II mobile lump in the breast +palpable mobile LN
Stage III fixed lump (skin and chest wall)+ - palpable LN
Stage IV --Distant metastasis
International union against cancer TNM
Tis not palpable No- no nodal metastasis Mo – metastasis
I T1 -- <2cm No
II T2---2—5cm N1 mobile LN
IIIa T3 –more than 5cm N2 fixed LN
IIIb T4 -any size+ skin or chest wall invasion N3 –Ipsilat supraclavicular
IV Distant Metastasis M1 Distant metastasis
Treatment for breast cancer depend on the stage
Stage of the disease also indicate its prognosis
Nottingham Prognostic Index includes tumor size+Lymph node + grade
Treatment of breast cancer
Early breast cancer
Aim
Cure (but recurrence after 20 years is possible)
Control of local form and function
Prevention or delay of the distant metastasis
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Local control
Surgery alone Surgery + Radotherapy
Surgery
Mastectomy -very small breast –central tumor –multifocal – patient preference
Wide local excision + Radiotherapy
One third of patients develop significant anxiety and depression after both treat
Radical mastectomy =Halstead mastectomy –excision of the breast, axillary LN,
pectoralis major and minor (No survival benefit –excessive morbidity)
Modified Radical mastectomy = Patey mastectomy
Involves removal of the breast +axillary fat and facia and the LN
Pectoral muscles are not removed
Conservative breast cancer surgery ( wide local excision +DXT
Lumpectomy—Removal of tumor + 1cm of surrounding normal tissue
Quadranectomy –Removal of entire segment containing the tumor
Lumpectomy+ axillary surgery
Quadrantectomy+axillary surgery
Axillary surgery—separate incision—sample LN in axilla—or full clearance of
axillary nodes
Quadrantectomy+axillary clearance + Radiotherapy =QUART
Results
--- Long term survival did not change
Local recurrence rate is somewhat higher
Presence of metastasis in lymph nodes
Indicate the metastatic potential of the disease
There removal will not affect long term survival
There presence is a bad prognostic factor
There presence make the use of chemotherapy needed
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
The complete clearance of the axilla should not be followed by DXT
Sentinal lymph node biopsy—1
st
node involved by tumour, can be detected by Dye
injection near tumour , or use of Radio Active labeled Albumin near tumour , such
LN
Is sent for Frozen section if negative no further axillary dissection is needed
Radiotherapy
Mastectomy to be followed by DXT has been abandoned
Conservative surgery + DXT is still used
Radiotherapy is used for Advanced breast cancer with infiltration of chest wall
Adjuvant systemic therapy
Includes chemotherapy and hormonal therapy
Their role is to target the micrometastasis and results in reduction of the recurrence
rate
And it increases the survival rate .
Chemotherapy to be used in ;
Premenapausal women with LN +ve patients
Premenapausal women with LN –ve (high risk) poor prognosis ( high grade
tumour)
Postmenapausal
Cyclophosphamide
Methotrexate
5-Flurouracil
6monthly cycle of CMF -----30% reduction in relapse—10 –15 years .
New Adjuvant chemotherapy—aim is to shrink large tumours
Hormonal therapy
Tamaxofin anti oestrogen 20 mg /day givento premenaposal patient with estrogen
receptor +ve
Premenaposal with estrogen receptor –ve less benefit
Premenaposal with estrogen receptor +ve is beneficial
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Use of hormonal therapy
Reduce annual rate of recurrence by 25%
Reduce annual rate of death by 17%
Other hormones
LHRH Agonists—Ovarian suppression in premenaposal
Aromatase inhibitor for postmenapausal women
Treatment of Advanced breast cancer
Present with no evidence of primary (occult) metastatic
Treat is hormonal ----No surgery
Locally advanced inoperable ca –Treat chemotherapy or hormonal
Toilet mastectomy or Radiotherapy to control fungating tumour .
Treatment metastatic carcinoma of the breast
Palliative systemic therapy
Homone manipulation –bony metastasis
Cytotoxic therapy
Radiotherapy for painful bony deposits
Prognosis of breast cancer
Indicators of prognosis in breast cancer are tumour size and lymph node status
It is the invasivenes and the metastatic potential of the tumour that determines the
prognosis .
Prognostic factors include, grade, hormone receptor, growth factor, oncogene, S
phase fraction , thymidine labeling index
Breast Reconstruction
Immediate or delayed reconstruction of the breast
Most commonly used is silicon gel implant under the pectoralis Muscle
Prior tissue expansion –use of expandable saline prosthesis
If skin at previous operation site is poor then other procedures used
Musculocutanous Flap --Lattisimus Dorsi ( LD Flap)
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Musculocutanous flap –Transverses Abdominis muscle (TRAM) flap
Other breast may need reduction or augmentation
External breast prosthesis can be used within the bra
Screening for breast cancer
Use of mammography for women between ages of 50-64
It has great value in early detection of breast cancer
When the disease is picked up at early stage –mortality less than 30%
Every 6months for 3 years
Costly program, benefit is more than disadvantage
Familial breast cancer
Breast cancer predisposition genes BRCA1, BRCA2 and TP35
The above genes can be inherited in families
Gene carriers can have breast screening and ovarian screening
Gene +ve women have 80%risk to develop breast cancer
Prophylactic mastectomy may be considered
Women with family history of breast cancer but do not carry the gene need follow
up
Carcinoma of the breast occurring during pregnancy
Usually present late –need mastectomy
No Radiotherapy –No Chemotherapy –No Hormonal treatment
Allow pregnancy after 2 years of diagnosis of breast cancer
Male Breast
Gynaecomastia
Idiopathic –unilat or bilateral during puberty
Hormonal –use of hormones stilbestrol therapy for prostatic cancer
Teratoma of the testis
Ectopic hormonal production in bronchial carcinoma
Adrenal and pituitary disease
Leprosy --testicular atrophy
Liver failure – failure to metabolise estrogens
Drugs –cimetidine interfere with hepatic metabolism of estrogen –digitalis
spironolactone
Surgery
Diseases of the Breast 2
Dr. Salim Al-Sarraf
Lec. 25
Treatment
Reassurance Mastectomy
Carcinoma of male breast -rare
Predisposing causes –gynaecomastia
Excess endogenous or exogenous estrogen
Present as a lump
Same stage and same treatment depend on stage
mastectomy