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BREAST CANCER
The Breast
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A ducts
B lobules
C dilated section of duct to
hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage
Enlargement:
A normal duct cells
B basement membrane
C lumen (center of duct)
Breast Carcinoma Incidence
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20% of all cancers in
women
Commonest cause of
death - 35-55y
In UK 1 in 10-12 chances
1 in 8 women in US
Less incidence in Asia
Majority of cancers arise in
the ducts.
Very rare before age 25
Risk Factors:
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Female sex..!, Age, Obesity, high fat diet
Maternal relative with breast cancer.
Longer reproductive span.
Nulliparity, Oral contraceptives
Later age at first pregnancy.
Atypical epithelial hyperplasia.
Previous breast cancer/Endometrial Ca.
Geographic factors - country
BRCA1 and BRCA2 genes
Breast Cancer Risk Factors
that cannot be changed
Age
Family/Personal
History
Race
Treatment with
DES
GENDER - All
women are
at risk
Reproductive
History
Menstrual
History
Radiation
Genetic
Factors
Breast Cancer Risk Factors
that can be controlled
Obesity
All
women are
at risk
Exercise
Exercise
Breastfeeding
Breastfeeding
Alcohol
Hormone
Replacement
Replacement
Therapy
Not
Not having
having
children
children
Birth Control
Control
Birth
Pills
Pathology ( WHO classification)
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Epithelial (mammary tissue)
 Non invasive
 DCIS
 LCIS
 Invasive
 Ductal 85 %
 Lobular 9 %
 Mucinous 5 %
 Papillary < 5 %
 Medullary < 5 %
Mixed Ct & epithelial
Miscellaneous
 Paget’s disease
 IBC
Pathology (Foot& Stewart
classification)
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Neoplasm of mammary tissue proper
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Neoplasm of lobular epithelium 9- 10 %
 LCIS 50 %
 Lobular carcinoma invasive 50 %
Neoplasm of ductal epithelium 85 %
 DCIS
 Ductal carcinoma Invasive ( IDC)
 NOS ( simple type)
 Special types ( scirrhous, medullary, mucinous,
papillary, cribriform, comedo, tubular, secretory
with metaplasia)
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Unusual presentations
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Paget’s disease
IBC
Pathology (Foot& Stewart
classification)
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Malignant mesenchymal neoplasm
 Sarcoma
 Lymphomas
 Myeloid leukemia
Miscellaneous malignancies
 Skin
 SCC
 BCC
 Skin adenxa ( carcinoma of sweat glands or
sebaceous glands)
Undifferentiated carcinoma
Metastatic
 Female ( other breast, lung, MM)
 Male (prostate)
Carcinoma in situ
It is a spectrum of pre invasive neoplastic changes
in the breast includes;
 DCIS 4 % symptomatic 25 % screen detected
 LCIS <1 % symptomatic 1% screen detected
 Hyper plastic appearance ( ductal or lobular)
Ductal Carcinoma in Situ
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It is the group of
neoplasm arising from
ductal epithelium &
confined by basement
membrane
Ducts expanded by
large irregular cells
with lage irregular
nuclei
Malignant cells are
confined by basement
membrane
Ductal Carcinoma in Situ
(classification)
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Comedo DCIS
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High grade cytology
Extensive necrosis
Branched
calcification
Non Comedo DCIS
•Low grade cytology
•Lack necrosis
•Lack calcification
• Cribribriform
• Solid
• micropapillary
Intermediate histology
Ductal Carcinoma in Situ
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Clinical presentation
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Asymptomatic > 50 % in screening programs
as abnormal mamographic finding
Nipple discharge
Paget’s disease
Risk of invasive BC is 40 % over 30 y
Multicentricity in 50 %
Ductal Carcinoma in Situ
(Diagnosis)
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Sterotactic CNB
U/S guided CNB
Wire or ink guided excisional biopsy which is a
must if;
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Atypical ductal hyperplasia
Radial scar
Non specific diagnosis
Lack correlation with mammogram
Wedge biopsy if paget’s
Ductal Carcinoma in Situ
(Treatment)
Depend on Van Nuys Prognostic Index
which classify patients into 3 groups
Depending on 3 factors
1- Tumor size
2- Histological grade
3- Surgical free margin
Low risk
Wide local excision
(BCS)
Intermediate risk
BCS & irradiation
High risk
Mastectomy
SSM
Lobular Carcinoma In Situ
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It constitute 25 % of CIS
The risk of invasive cancer is 20 – 30 % life time
and bilateral
It is multicentric in 80 %
Never palpable mass
Treatment
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Follow up by
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C/E every 4 months
Mammography yearly
Chemoprevention by Tamoxafen or raloxifene
Mastectomy which is rarely used
Non Invasive (Carcinoma in Situ)
Feature
DCIS
LCIS
Incidence
Risk of invasive
cancer
Multi-centric
Palpable
75 % of CIS
30-40 %, mostly in
location of DCIS
50 %
Rarely
25% of CIS
20 % lifetime,
bilateral
80 %
Never
Mammography
Mass or
microcalcifications
Occult
Invasive Breast Cancer
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Epithelial Invasive BC
Ductal 85 %
 Lobular 9 %
 Mucinous 5 %
 Papillary < 5 %
 Medullary < 5 %
Mixed Ct & epithelial
Miscellaneous
 Paget’s disease
 IBC
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Infiltrating Duct Carcinoma: small hard
(Atrophic scirrhous)
5%
post menopausal with
shriveled breast
NEA
 Small size
 Irregular in shape
 Very hard in consistency
MP
 ++++ FT
 + islads of malignant
spheroidal cells
 Infrequant mititic figures
Very slowly progress 10 Y
Very late metastases
Best prognosis
Infiltrating Duct Carcinoma: Fibrosis
(Scirrhous)
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75 %
Middle aged 40 – 60 Y
NEA
 Small size
 Irregular in shape
 hard in consistency
MP
 +++ FT
 ++ scanty as finger like
processes
slowly progress
late metastases
Good prognosis
Medullary Carcinoma: Large soft
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3- 5 %
Well developed breast of young
woman
NEA
 Largr fleshy in size
 Brain like cut section in
shape
with hge & necrosis
 Soft in consistency
MP
 ++ delicate FT
 ++ + highly malignant cells
Rapidly progress
Moderate metastases
Good prognosis
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Rapid increase lead to early
presentation
Fungate more than infilttrate
Late LN affection dt large cell
size
Mucoid or Colloid Carcinoma
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It form a bulky mass with mucoid
degeneration & necrosis
It grow slowly & disseminate late & may
reach huge sizes so have good prognosis
after surgery
Signet ring shaped cells dt mucoid
materials
Lobular Carcinoma
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It constitute 9 %
Arise in the terminal
lobules
It could take different
presentation as ductal
carcinoma
Paget’s Disease
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It is a chronic eczematoid
malignant eruption of the
nipple
1 % in middle aged and old
woman
Etiology
 Old theory ( skin tumor
with secondary breast
mass
 New theory ( tumor in
terminal ducts as in situ
cancer then spread
 Outward to nipple
and skin
 Inward breast mass
Paget’s Disease
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Hyper plastic changes
in all layers of
epidermis (epidermal
hypertrophy)
Characteristic paget’s
cells
 Large vaculated cells
 Deeply stained
eccentric nucleus
Subdermal round cell
infiltration
Paget’s Disease
( Clinical picture)
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Persistent eczema like
condition that affect old
female 50 Y which does
not respond to topical
treatment
Unilateral erosion of the
nipple which is red,
thick, scaly & crusted
without vesicles or
itching
Serosangious discharge
Mass in the breast in 2
Years
Paget’s
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Menopause
Unilateral
No vesicles or
itching
Sub areolar mass
after 2 years
Not respond to
topical treatment
Biopsy paget cells
Eczema
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Lactation
Bilateral
Vesicles and
itching
No mass
Respond to topical
treatment
No paget cells
Paget’s Disease
Diagnosis
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Mammography is a must
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Detect sub clinical mass
Detect micro calcification
Detect multi centricity
Biopsy ( full thickness nipple biopsy) is
diagnostic where there are 3 different types
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Paget’s disease with DCIS ( high grade comedo)
Paget’s disease with invasive cancer ( commonest)
Paget’s disease confined to epidermis of nipple &
areola ( rarest)
Paget’s Disease
( Treatment)
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The standard treatment is mastectomy
Recently BCS is used with segmentectomy of nipple &
areola & radiotherapy
Paget’s disease
Paget’s disease
with mass or with
with no mass
invasive cancer
Or with DCIS
Segmentectomy
Of N & A
-Ve margins
-No multicentric
Radiotherapy
Segmentectomy
Of N & A
& Axillary dissection
+ Ve margins
multicentric
Mastectomy
Paget’s Disease
( Treatment)
Use of chemotherapy based on 5 prognostic
indication of chemotherapy
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2.
3.
4.
5.
Age < 35 year
Tumor > 1 cm
Tumor high grade
+ ve LN
- ve ER
IBC( Inflammatory breast cancer
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Very rare
Well developed breast of
young woman during
pregnancy and lactation
should be DD of abscess
NEA
 Diffuse swollen, hot on
palpation ,with dilated
vein
 Soft in consistency
MP
 + very little FT
 ++ + + highly
malignant anaplastic
cells
Rapidly progress
Very early metastases
IBC( Inflammatory breast cancer
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It is very similar to acute breast abscess
with the following differences
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It is a diffuse lesion
No pyrexia
LN not tender
Progressive in nature
No lecucytosis
No respond to antibiotic
Spread of Breast Carcinoma:
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Methods of spread
 Direct
 Lymphatic
 Blood
 Trans- celomic
Theories of spread
 Loco-regional
theory
 Systemic theory
TNM Staging
Tumor
 Tx
primary tumor can not be assessed
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Tis In situ carcinoma & paget’s disease
T0 no palpable mass
T1 tumor < or = 2 cm
 T1a < or = 0.5 cm no deep fixation
 T2b
0.5 – 1 cm + deep fixation
 T3c
1 – 2 cm + deep fixation
T2 tumor 2 – 5 cm
 T2a
no deep fixation
 T2b
deep fixation
T3 tumor 5 – 10 cm
 T3a no deep fixation
 T3b deep fixation
T4 tumor of any size
 T4a
direct chest extension
 T4b skin ( Peau d’orange, skin nodule & ulceration)
 T4c T 4a + T4b
 T4d inflammatory breast cnacer
Nodes
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N
N
N
N
N
TNM Staging
x can not be assessed
0 not palpable LN
1 palpable homo-lateral axillary LN and mobile
2 palpable homo-lateral axillary LN and fixed
3 ipsilateral internal mammary LN
Metastases
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M X can not be assessed
M 0 no known metastases
M 1 distant metastases including supra-clavicular LN
TNM staging
T0
N0
T1
T2
Stage I T1 N0 M0
N1
N2
N3
Stage II a T1 N1, T2 N0, T0 N1
Stage II b T2 N1, T3 N0
T3
T4
TNM staging
T0
T1
T2
T3
N0
N1
N2
N3
Stage III a
any N2 any T3 except T3 N0
Stage III b any N3 any T4
T4
St
ag
Definition
5-year
Surv (%)
7-year
Surv (%)
I
Tumor 2 cm or less without spread
96
92
II
Tumor 2-5cm with regional lymph
node involvement but without distant
metastases, OR > 5 cm in diameter
without spread
81
71
52
39
18
11
Any size with skin/chest wall fixation,
& axillary or internal mammary
III
nodal involvement, without distant
metastases
Tumor of any size with or without
IV regional spread but with evidence of
distant metastases
Manchester classification
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Stage I ( 85%)
 Mobile tumor
 Free axilla
 Paget’s
Stage II ( 66 %)
 Mobile tumor
 Mobile axillary LN
Stage III ( 41 %)
 Tumor fixed
 LN fixed
Stage IV ( 10%)
 Wide dissemination
 suprac;lavicular LN
Prognosis
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Clinical factors
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Pathological factors
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Age
Sex
Site
Stage
Grade
Pregnancy
Tumor type
Grade
Axillary LN
Biological factors
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Receptors ER, Pg R
Tumor markers
DNA ploidy
S phase fraction
Nottingham Prognostic Index (NPI)
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Axillary LN involvement
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1 no node
2 1-3 node
3 4 or more node
Grade (1, 2, 3)
Tumor size in cm x 0.2
Prognostic group
NPI
10 Y survival
Excellent
< or = 2.4
94
Good
< or = 3.4
83
Moderate I
< or = 4.4
70
Moderate II
< or = 5.4
31
Poor
> 5.4
20
Breast self examination for early
detection
Clinical Features: (symptoms)
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Main symptoms
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Lump
Discharge ( blood stained)
Pain ( late)
Symptoms of spread
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Direct ( skin, nipple, Areola)
Lymphatic LN
Blood
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Lung ( respiratory distress & hemoptsis)
Bone ( aches & patholgical fracture)
Malignant ascites
Met static nodules any where
Clinical Features: (signs)
1.
Breast a whole
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Examination while
sitting ( puckered or
displaced
Raising the arms
above the head
(pulled upward)
Patient leaning
forward ( not
protrude freely)
Clinical Features: (signs)
2.
Nipple changes
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Recent retraction
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dt neoplastic fibrosis &
lactiferous ducts invasion
Should be DD from
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Congenital
Chronic inflammation
Nipple erosion (should be
DD of eczema)
Discharge which could be
serous or bloody
Clinical Features: (signs)
3.
Skin manifestations
1.
2.
3.
Peau d’ orange dt
obstruction of skin
lymphatic
Cancerous nodule or
satellites
Ulceration or fungation dt
skin invasion
Clinical Features: (signs)
Clinical Features: (signs)
Clinical Features: (signs)
Clinical Features: (signs)
4.
5.
6.
7.
8.
9.
Dimpling and
puckering dt pull on
cooper ligaments
Dilated veins
Skin lymphoedema
Tumor fixation to the
skin
Inflammatory signs
as in IBC
Nipple and areola
changes
Clinical Features: (signs)
10.
Cancer en cuirasse
1.
2.
3.
4.
5.
Atrophic breast
Hard
Pigmented
Fixed to chest wall
Studded with nodules
Clinical Features: (signs)
4.
Breast lump
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5.
Mostly in UOQ in 60 %
Irregular in shape
Hard in consistancy
Ill deined borders
Fixed within the breast
my be fixed to skin or
chest wall
Opposite breast
examined first before
the diseased one to
exclude metastases
Clinical Features: (signs)
6- lymph nodes should be examined
Central and apical groups
Pectoral or anterior group
Lateral or brachial groups
Clinical Features: (signs)
Posterior or subscapular group
Supraclavicular group
Clinical Features: (signs)
7- general examination
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Chest effusion, deposites , mediastinal
LN
Abdomen ascites, hepatomegally
Pelvis by PR and PV
Krukenberg
 Plummer shelf
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Bones tenderness , weakness,
deformity and fractures
Diagnosis:
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Laboratory
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General
Liver function
Kidney function
Cytological examination of nipple discharge
Tumor markers
Radiological
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Plain x ray
Breast imaging
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Mammography
Thermo graphy
Galactography
Ultrasound
CT
MRI
Light spectroscopy
Radioactive isotope scanning of LN
Diagnosis:
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Biopsy
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Fine Needle Aspiration Biopsy
Core Biopsy
Excision Biopsy
Frozen section
Drill biopsy
Sentinal node biopsy
Immunoperoxidase,
Molecular techniques – Gene detection.
History of Mammography
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Used in clinical practice since
1927 in diagnosis of breast
abnormalities.
In the 50’s and 60’s it was
developed to the point that
benign and malignant tumors
could be differentiated.
1963-1967 screening program
for the detection of breast
cancer conducted by the
Health Insurance Plan of New
York (60,000 women
screened).
1973 Breast Cancer Detection
Demonstration Project
(B.C.D.D.P.) – 15 annual
screenings of 270,000 women.
Low Dose X-rays
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Electrons originating
at the cathode are
accelerated towards
the rotating anode.
Upon contact the
kinetic energy of the
electron is converted
into x-rays and heat
(0.5% x-rays)
Collimator system,
composed of lead for
complete absorption,
focuses the x-ray
beam
X-ray/ Breast Interaction
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As with most x-ray images greater contrast
occurs when there is a large difference in
attenuation between tissues.
The breast is compressed and the x-ray beam is
applied.
Contrast is best seen between fatty tissue and
functional glandular tissue, but contrast is poor
between glandular tissue and cancerous tissues.
Thus, in older women, post-menopause, the
reduction in functional glandular tissue provides
for a distinct contrast between cancerous
masses and fatty tissues.
Two Types of Mammograms
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A screening mammogram is an x-ray examination of
the breast in a woman who has no breast complaints
(asymptomatic). The goal of screening
mammography is to find cancer when it is still too
small to be felt by her doctor or the woman.
A screening mammogram usually takes 2 x-ray
pictures (views) of each breast.
A diagnostic mammogram is an x-ray examination of
the breast in a woman who either has a breast
complaint (for example, a breast mass, nipple
discharge, etc.) or has had an abnormality found
during a screening mammogram. During a diagnostic
mammogram, more pictures will be taken to carefully
study the breast condition.
Two Methods of Mammograms
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Ordinary film
Xero or zeno
mammography
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over selinium plates gave
different colors blue and
white
Mammogram Equipment
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A mammography unit is a
rectangular box that
houses a tube in which xrays are produced.
Attached to the unit is a
device that holds and
compresses the breast
and positions it so images
can be obtained at
different angles.
Modern technique uses a
special machine
exclusively for breast xrays to produce studies
that are high quality but
have a low radiation dose
(usually about 0.1 to 0.2
rad dose per picture).
Mammogram Equipment Cont.
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A mammogram device
has special accessories
that allow only the breast
to be exposed to the xrays.
x-rays do not penetrate
tissue as easily as the xray used for routine chest
films or x-rays of the arms
or legs.
Mammogram Procedure
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1)
2)
3)
4)
5)
The breast is first placed on a platform
and squeezed between 2 plates
Breast compression is necessary to:
even out the breast thickness so all
tissue can be visualized
spread out tissue so small
abnormalities won't be obscured by
overlying breast tissue
allow the use of a lower x-ray dose
since a thinner amount of breast
tissue is being imaged
hold the breast still to eliminate
blurring of image caused by motion
reduce x-ray scatter to increase
sharpness of picture.
Indications of Mammography
4- Evaluation of
contralateral breast
1- Breast with mass
2- Breast with discharge
3- Follow up of
breast lesions
5 - Screening of BC
Follow up is needed in the following
6 - breast that is difficult to
be examined
Premalignant lesions, papillomatoso
cystic lesions ,
atypia, lobular neoplasia
7 – work up of met static
Aden carcinoma
Patient at high risk of cancer
breast
Patients with previous BC
Reading the Mammogram
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Best if read by radiologist specializing in mammography
Important to recognize even the smallest abnormalities
Multiple films and angles are often necessary
Sometimes two physicians will read the same film for the most
thorough assessment
Computer based digital mammography is used to get
maximum information from each mammogram taken
Comparison with older films is also extremely useful
Mammography
Average-size lump found by woman practicing
occasional breast self-exam (BSE)
Average-size lump found by woman practicing
regular breast self-exam (BSE)
Average-size lump found by first
mammogram
Average-size lump found by getting regular
mammograms
Abnormal Mammographic findings
Micro calcifications
Circumscribed
lesion
Speculated
lesion
Satellite
lesion
Rounded
Linear
branching punctuate
Mammographic signs of malignancy
1. Breast lump
2. Linear or branching micrcalcification
3. Skin or nipple thickening
4. Mammary duct distortion or asymmetry
Ultrasound
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It is the intial
investigation in a
woman < 35 yeaers
DD solid and cystic
lesions
Positive predictive
value is 92 % with
palpable mass
Sentinel Node Biopsy
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An evolving technique to
identify node status
without formal axillary
dissection
A radioactive tracer
and/or blue dye is
identified in the first
draining node
Potentially gives accurate
staging with decreased
morbidity
Sensitivity exceeds 90%
and accuracy exceeds
95% for experienced
surgeons
Breast Cancer Treatment
Treatment of early BC
( stage I& II a)
Treatment of advanced BC
•(stage II b, III& IV)
•Metastatic disease
•Local recuurence
Neoadjuvant chemotherapy
Surgery&
observation
Surgery&
Adjuvant therapy
Surgery either Mastectomy or BCS
+ or - Radiotherapy
+ or - Chemotherapy
Treatment of early BC
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Surgery & Observation
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Indication
T1 N0
 ER + ve
 Patient under willing close observation
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Surgery
MRM
 MRM + breast reconstruction
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Observation
Monthly C/ E
 Chest x ray, U/S abdomen every 6 months
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Treatment of early BC
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Surgery & Adjuvant therapy
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Why use of adjuvant therapy
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Decrease local recurrence ( Radiotherapy)
Decrease distant metastases as Radiotherapy) micro
metastases are present in 50 % of cases at diagnosis
(chemotherapy)
Good response to adjuvant therapy
Types of adjuvant therapy



Radiotherapy
Chemotherapy
Hormonal treatment
Breast Cancer Treatment (Surgery)

Old operation that lost popularity (Radical Mastectomy)
 Remove the whole breast, P Major & minor, axillary LN and wide
margin of skin & soft tissue
 Its rationale is loco regional theory of spread

Obsolete operations
 Extended Radical Mastectomy ( RM + internal mammary LN
removal)
Used with medial lesions, +ve Axillary Ln & M0
 Supra Radical Mastectomy ( RM + clavicle excision and
supaclavicular LN removal)
Operations that recently gained popularity
 Modified Radical Mastectomy
70 % in USA
 Simple mastectomy (Total Mastectomy) 70 % in UK
Breast Conservative procedures
 Lumpectomy
 Partial Mastectomy (Quadrantectomy)
 Segmental mastectomy
 Tylectomy
 QUART (Quadrantectomy +Axillary clearance + RT)


Conservation Therapy (BCT)
1.
2.
3.
4.
5.
Indications for Use:
Tumor size

2 cm in small breast

4 cm in large breast
Tumor location favorable for good aesthetic
result (peripheral location)
Unifocal single tumor with negative margins
Patient’s preference for breast conservation
Patient’s inability to tolerate general anesthesia
Advantages of BCS
• Better cosmetics
• Not affect survival
• Not affect local recuurence which if occur not in the chest
wall and MRM could be done
Contraindications to Conservation
1.
2.
3.
4.
5.
6.
Tumor size > 5 cm
Tumor multi centric (Two or more primary
tumors in separate quadrants)
Diffuse tumors ( Diffuse malignant appearing
micro calcifications)
High grade tumors
Distant metastases
Any contraindication to irradiation

Previous breast irradiation

Pregnancy (unless radiation is provided
after delivery)

Collagen vascular disease (relative
contraindication)

Large breast size
Standard Axillary Dissection
Method
Levels I and II axillary
dissection
Aim of axillary surgery
 Provides staging
information
 Provides local control if
node positive
 Provide prognostic
information
 No reliable imaging
technique
Complications
 Wound infection
 Arm lymphoedema
 Arm morbidity
Sentinel Lymph Node Biopsy (SLNB)
Surgical Treatment Options



Procedure is still under investigation to
determine if patients’ survival will not be
affected if lymph nodes that may have cancer in
them are left behind and untreated
Not the standard of care for breast cancer at this
point
Success rate of about 92 %
Indications of MRM






Tumor size > 5 cm
Tumor multi centric (Two or more primary
tumors in separate quadrants)
Diffuse tumors ( Diffuse malignant appearing
micro calcifications)
High grade tumors
Distant metastases
Any contraindication to irradiation
 Previous breast irradiation
 Pregnancy (unless radiation is provided
after delivery)
 Collagen vascular disease (relative
contraindication)
 Large breast size
Ductal Carcinoma in Situ
(Treatment)
Depend on Van Nuys Prognostic Index
which classify patients into 3 groups
Depending on 3 factors
1- Tumor size
2- Histological grade
3- Surgical free margin
Low risk
Wide local excision
(BCS)
Intermediate risk
BCS & irradiation
High risk
Mastectomy
SSM
Lobular Carcinoma In Situ





It constitute 25 % of CIS
The risk of invasive cancer is 20 – 30 % life time
and bilateral
It is multicentric in 80 %
Never palpable mass
Treatment

Follow up by




C/E every 4 months
Mammography yearly
Chemoprevention by Tamoxafen or raloxifene
Mastectomy which is rarely used
Paget’s Disease
( Treatment)


The standard treatment is mastectomy
Recently BCS is used with segmentectomy of nipple &
areola & radiotherapy
Paget’s disease
Paget’s disease
with mass or with
with no mass
invasive cancer
Or with DCIS
Segmentectomy
Of N & A
-Ve margins
-No multicentric
Radiotherapy
Segmentectomy
Of N & A
& Axillary dissection
+ Ve margins
multicentric
Mastectomy
Paget’s Disease
( Treatment)
Use of chemotherapy based on 5 prognostic
indication of chemotherapy
1.
2.
3.
4.
5.
Age < 35 year
Tumor > 1 cm
Tumor high grade
+ ve LN
- ve ER
Post-Treatment Follow-up of the Patient
with Early Stage (I and II) Breast Cancer
Study
Year 1-2
Year 3-5
Year > 5
Exam
3-6 mos.
6 mos.
12 mos.
Mammo
6-12 mos.
6-12 mos.
12 mos.
CXR
prn
prn
prn
CT, bone
scan
prn
prn
prn
Infiltrating Cancer
Surgical treatment Options
Breast Conservation (followed by RT)
and Axillary Lymph Node Dissection


Modified Radical Mastectomy
(with/without reconstruction)
Long Term Side Effects of
Surgery for Breast Cancer





Loss of part or of the whole the breastchange of self image and sexuality
Nerve Function Deficits/Neuropathy
Lymphedema
Motor (Muscle) Function Deficits
Pain
Breast Reconstruction




Indicated in women undergoing
mastectomy who desire reconstruction
Radiation after reconstruction may
produce less desirable results
Autogenous tissue vs. prosthetic
vs.
combination
Immediate vs. delayed- no survival
difference
Prosthetic Silicon implants
Latissmus Dorsi Mycutaneus flap
TRAM Flap
TRAM Flap



Most women with breast cancer may be
treated with breast conservation if they so
desire
Most women requiring/choosing
mastectomy may undergo immediate
breast reconstruction
Optimal treatment involves multimodality
therapy provided by multidisciplinary
teams
Radiotherapy


Aim to destruction of local micro metastases to
decrease local recurrence
Indications
Radiotherapy to breast area
After all BCS
Radiotherapy to Axilla
After mastectomy
1. 4 or more + ve LN
2. Extracapsular invasion
3. + ve or close margin
T3 , T4 & pectoral fascia affection
All ABC
Used only if
1. 4 or more + ve
Axillary LN
2. Extra capsular
invasion
Radiotherapy

When ?


Dose


1.
2.
3.
4.
2- 3 weeks after mastectomy
40 – 50 Gy delivered at 15 –
25 fraction
Complications
T1 N0 it decrease 5 y survival
Lymphatic destruction
Increase cancer in contralateral breast
Local complications




Skin burn
Arm lymph-oedema
Interfere with breast
reconstruction
Increase interstitial
pulmonary fibrosis
Hormonal therapy

Anti-estrogen (Tamoxifen) First line

Mechanism



Advantages






Decrease annual recurrence by 25 %
Decrease annual mortality by 17%
Decrease risk of CB in contra-lateral breast by 40 %
Benefits observed in pre & post menopausal
Great benefit in ER + ve but also in ER – ve
Dose


Decrease estrogen uptake by tissue
Increase TGF inhibitor
20 mg/ day for 2- 5 years
Side effects




Hyper-calcemia
Bone pains
Hot flashs
phlebitis
Hormonal therapy

Aromatase Inhibitor Second line


Progestin Third line


It block conversion of androgen to
estrogen
Megestrol acetate 40 mg 4 times daily
LHRH agonists

Reversible ovarian suppression in premenopausal female
Chemotherapy

Aim to


Indications 5 major






killing of malignant micro-metastases any where in
the body
Age < 35 years
Tumor > 1 cm
Tumor high grade
ER + ve
LN + ve of metastases
Methods

given 6 cycles post operative in early CB
Chemotherapy
Classic
CMF
CMF CA
Cyclophosphamide
100
600
Methotrexate
40
40
5 FU
600
600
A ( Doxorubicin)
Cyclic frequency
4 weeks
3w
600
FAC
400-500
(day 1)
400-500
60
40-50
3w
4 weeks
Breast Cancer Treatment
Treatment of early BC
( stage I& II a)
Treatment of advanced BC
•(stage II b, III& IV)
•Metastatic disease
•Local recuurence
Neoadjuvant chemotherapy
Surgery&
observation
Surgery&
Adjuvant therapy
Surgery either Mastectomy or BCS
+ or - Radiotherapy
+ or - Chemotherapy
Neo-adjuvant Chemotherapy

Advantages
1.
2.
Assessment of tumor response
70 % of tumors show clinical response



3.
4.

20- 30 % complete response
80% still have histological evidence of the tumor
Surgery is required even with complete response
Increase incidence of BCS
Improve cosmetic results
Disadvantages
1.
2.
3.
Delayed local treatment
Loss of prognostic information of LN and tumor size
Induction of drug resistance
Neo-adjuvant Chemotherapy

What to give




When to give



CMF
VAP
CHOP
SE






3 months pre-operative
9 months post-operative
BM suppression
Alopecia
Cystitis
Cardio-toxic
Neuro-toxic
GIT disturbance
Treatment of ABC
Neo-adjuvant chemotherapy
No response
Change
Partial response
Stop treat
RT until
regimen the tumor
Is operable
MRM
+/- RT
+ Chemo
Complete response
Radio alone then
Chemo for a year
BCS with PALND
Then Radio
Then Chemo for a year
Treatment of ABC

Hormonal treatment



used in all patients regardless age
Given continuously until relapse occur
Postoperative chemotherapy

Life threatening disease
Rapidly growing tumor
 Liver metastases
 Lung metastases



ER – ve
Failure of hormonal treatment
Treatment of ABC
Radiotherapy
If No response
RT until
the tumor
Is operable
Partial response
MRM
+/- RT
+ Chemo
Complete response
Radio alone then
Chemo for a year
BCS with PALND
Then Radio
Then Chemo for a year
Treatment of ABC

Palliative Radiotherapy



Single brain metastases
Chest wall recurrence
Multiple metastases
Bone
 Spinal cord
 Liver
 Brachial plexus

Male BC






4 quadrant from the
start
Absent pad of fat
Lymphatic spread in 4
directions
Rapid blood spread
Radical surgery is
difficult due to lack of
soft tissue
Recently male and
females are equal
except male with + ve
LN