By Dr. Celine Tey

TECHNIQUE OF BREAST EXAMINATION

Pain --varying with menstrual cycle --independent of menstrual cycle Lump in the breast --Hard lump -- Firm, poorly defined lump or lumpiness --Soft lump Skin changes in the breast --Skin dimpling or tethering --Visible lump --Peau d’orange (kulit limao) --Redness --Ulceration Nipple disorders --Recent inversion or change in shape --“Eczema” (rash involving nipple or areola, or

both) --Nipple discharge Milky Clear Green Blood-stained

NIPPLE DISORDERS --Recent inversion or change in shape suggests a fibrosing underlying lesion such as a carcinoma

or mammary duct ectasia but can be malignancy (refer urgently)

--“Eczema” (rash involving nipple or areola, or both) if unilateral and persistent, this is the classic sign of

Paget’s desease of the nipple, a presentation of breast ca (refer urgently if not responding to treatment)

--Nipple discharge1. Milky—pregnancy of hyperprolactinaemia2. Clear – physiological3. Green –perimenopausal, duct ectasia, fibroadenotic cyst4. Blood-stained –possible carcinoma or intraduct papilloma

(refer urgently)

PAGET’S DISEASE OF THE NIPPLE

SIGNS AND SYMPTOMS

9

Most common: lump or thickening in breast. Often painless

Change in color or appearance of areola

Redness or pitting of skin over the breast, like the skin of an orange

Discharge or bleeding

Change in size or contours of breast

rg

CHARACTERISTIC S&SX OF BREAST CA

1. Skin dimpling2. Visible lump3. Peau d’orange4. Surface erythema5. Surface ulceration6. Recent nipple inversion7. Blood-stained nipple discharge8. ‘eczema’ around nipple (Paget’s

disease)9. Systemic features:weight loss,

anorexia, bone pain, jaundice, malignant pleural and pericardial effusion, anemia

CHARACTERISTIC SIGNS OF BREAST CA

CHARACTERISTIC SIGNS OF BREAST CA

CLINICAL CHARACTERISTICS OF A BREAST LUMP

Solitary or multiple Size – in cm Location – quadrant of breast or clock face Contour – smooth and round/ovoid (likely to be

benign) or firm/ hard (probable malignancy) Mobility – mobile or fixed Associated changes – skin/nipple retraction,

skin tethering, bloody nipple discharge, erythema

Axillary lymphadenopathy – enlarged and mobile or enlarged and fixed

CAUSES1. Inherited

2. Risk Factors

3. Environmental Factors

1.INHERITED BREAST CANCER

Between 5-10% of breast cancer is inherited from a family member.

This means that the majority of women that are diagnosed with breast cancer do not have the genetic mutation.

Research has suggested women who are diagnosed with breast cancer at a young age (less than 45) usually inherited.

This figure shows that one out of every 10 women will obtain breast cancer by inheriting a gene from a

family member.

INHERITED GENES

BRCA1 (Breast Cancer 1)

BRCA2 (Breast Cancer 2)

TP53 gene

ATM gene

BRCA 1 AND BRCA 2Both of these genes code for DNA repair.

If a woman has a mutation on either one of these genes, the risk of her getting breast cancer increases from 10% to 80% in her lifetime.

Mutations in BRCA1 or BRCA2 account for 40-50% of all cases of inherited breast cancer.

These genes are also associated with ovarian cancer in women and prostate cancer in men.

These genes can be inherited either from the mother or the father.

OTHER INHERITED GENES THAT CAUSE CANCER TP53 gene

This gene codes for the tumor suppressor protein p53.

Mutations of this gene cause Li-Fraumeni syndrome, which is a condition that is associated with early onset breast cancer.

ATM geneFemales with one defective copy of the ATM gene and one normal copy of the gene are at increased risk for breast cancer.

2.RISK FACTORS CAUSE BREAST CANCER

Factors that Cannot be Prevented

GenderAging (40-55 y-o)Genetic Risk Factors (inherited)Family HistoryPersonal HistoryMenstrual CycleEstrogen

Lifestyle RisksOral Contraceptive UseNulliparityHormone Replacement TherapyNot Breast FeedingAlcohol UseObesityHigh Fat DietsPhysical InactivitySmoking

3.ENVIRONMENTAL FACTORS

Exposure to irradiationElectromagnetic FieldsXenoestrogensExposure to Chemicals

NORMAL BREAST

Breast profile

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

20

Enlargement

A normal duct cells

B basement membrane (duct wall)

C lumen (center of duct)

Illustration © Mary K. Bryson

DIAGRAM OF THE BREASTThe breast is a glandular organ.

It is made up of a network of mammary ducts.

Each breast has about 15-20 mammary ducts that lead to lobes that are made up of lobules.

The lobules contain cells that secrete milk that are stimulated by estrogen and progesterone which are ovarian hormones.

IN SITU BREAST CANCERIn Situ Breast Cancer remains within the ducts or lobules of the breasts.

This type of cancer is only detected by mammograms – not by a physical examination.

If the cancer is in the duct it is called Ductal Carcinoma in situ.

If the cancer is in the lobule of the breast, it is called Lobular Carcinoma in situ.

This type of cancer is most common among pre-menopausal women.There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other.

DUCTAL CARCINOMA IN SITU (DCIS)

Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs 23

Illustration © Mary K. Bryson

Ductal cancer cells

Normal ductal cell

INVASIVE DUCTAL CARCINOMA (IDC – 80% OF BREAST CANCER)

The cancer has spread to the surrounding tissues

24

Illustration © Mary K. Bryson

Ductal cancer cells breaking through the wall

RANGE OF DUCTAL CARCINOMA IN SITU

25

Illus

trat

ion

© M

ary

K.

Bry

son

INVASIVE LOBULAR CARCINOMA (ILC)

26

Illustration © Mary K. Bryson

Lobular cancer cells breaking

through the wall

CANCER CAN ALSO INVADE LYMPH OR

BLOOD VESSELS

27

Illustration © Mary K. Bryson

Cancer cells invade

lymph duct

Cancer cells invade blood vessel

INFILTRATING BREAST CANCER

Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule.

This type of cancer forms a lump that can eventually be felt by a physical examination.

Breast cancer cells cross the lining of the milk duct or lobule, and begin to invade adjacent tissues. This type of cancer is called "infiltrating cancer." In this picture, you can see the breast cancer cells invading the milk duct.

MORE ON INFILTRATING BREAST CANCER

Infiltrating cancer of the duct

Called “Infiltrating Ductal Carcinoma”

It is the most common type of breast cancer.

Cancer cells that are invading the fatty tissue around the duct, they stimulate the growth of non-cancerous scar like tissue that surrounds the cancer making it easier to spot.

Infiltrating cancer of the lobules

Called “Infiltrating Lobular Carcinoma”

Occurs when cells stream out in a single file into the surrounding breast tissue.

This type of cancer is harder to detect on a mammogram because there is no fibrous growth.

OTHER TYPES OF BREAST CANCER

Cystosarcoma PhyllodesInflammatory Cancer

Accounts for less than one percent of all breast cancers and looks as though the breast is infected.

Breast Cancer During PregnancyPaget’s Disease

COMMON SITE OF SPREAD OF BREAST CA

TNM STAGINGIN BREAST CA

T = Primary TumorTis (T0) = carcinoma in situT1 = less than 2 cm in

diameterT2 = between 2 and 5 cm in

diameterT3 = more than 5 cm in

diameterT4 = any size, but extends to

the skin or chest wall

N = Regional Lymph nodesN0 = no regional node involvementN1 = metastasis to movable same side axillary

nodesN2 = metastasis to fixed same side axillary nodesN3 = metastasis to same side internal mammary

nodes

CLINICAL STAGING  T N M 5-Year Survival

Stage 0 Tis N0 M0 > 95%

Stage I T1 N0 M0 Overall = 85%

Stage II       Overall = 66%

(Stage IIA) T0 N1 M0  

  T1 N1 M0  

  T2 N0 M0  

(Stage IIB) T2 N1 M0  

  T3 N0 M0  

Stage III       Overall = 41%

(Stage IIIA) T0 N2 M0  

  T1 N2 M0  

  T2 N2 M0  

  T3 N1, N2 M0  

(Stage IIIB) T4 Any N M0  

  Any T N3 M0  

Stage IV Any T Any N M1 Overall 10%

THE EFFECT OF TUMOR SIZE ON SURVIVAL

Survival

Tumor Size

As tumor size increases, the

chance of survival decreases.

HOW DO YOU DETECT BREAST CANCER?

Triple assessment 1.Clinical examination 2.Radiological assessment -Mammography usual particularly over age 35y. -Ultrasound sometimes used under age 35

because increased tissue density reduces the sensitivity and specificity of mammography

3.Cytological assessment Fine needle aspiration cytology (FNAC) or

occasionally, core needle biopsy Staging investigations 1. Liver ultrasound 2.Chest X-Ray 3.Bone scan4.Specific investigations for organ-specific

suspected metastases.

Diagnostic tests– all breast lumps or suspected carcinoma

HOW IS THE DIAGNOSIS OF BREAST CANCER MADE?

MAMMOGRAMA Mammogram is a X-ray of the breast that takes pictures of the fat, fibrous tissues, ducts, lobes, and blood vessels.

When should a mammogram be performed?

If a lump has been found during self-examination or by a physicianYounger women who have a strong history of breast cancer in their familyAll women over fortyWomen who have had previous diagnosis of breast cancer.

WHAT MAMMOGRAMS SHOWTwo of the most important mammographic indicators of breat cancers

Masses

Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer.

42

DETECTION OF MALIGNANT MASSES

Malignant masses have a more spiculated appearance

43

malignant

benign

BREAST SELF EXAMINATION

OTHER FORMS OF DETECTION

SonogramThermographyTransilluminationXeromammograpyCat ScanMRIBiopsy

TREATMENTS OF BREAST CANCER

MEDICAL TREATMENT NON- METASTASIS DISEASE Adjuvant to reduce the risk of systemic relapse usually

after primary surgery. Occasionally used as treatment of choise in elderly or

those unfit/inappropriate for surgery

Endocrine Therapy1. Anti-estrogens (e.g tamoxifen, LHRH

antagonists, aromatase inhibitors)2. Most effective in ER +ve tumours

Chemotherapy1. Anthracyclines, cyclophosphamide,5-FU,

methotrexate2. Offered to patients with high risk features (+ve

nodes, poor grade)

MEDICAL TREATMENT METASTASIS DISEASE Palliative to increase survival time

Endocrine TherapyAs above

ChemotherapyAnthracyclines, tanaxest

RadiotherapyTo reduce pain of bony metastases or symptoms from cerebral or liver disease

SURGERYMAINSTAY FOR NON METASTASIS DISEASE

Mastectomy(radical,modified

radical simple)A mastectomy is the surgical removal of the breast, non-protruding breast tissue, the lymph nodes in the armpits and some pectoral muscle.

Breast reconstruction surgery may be conducted after the removal of the breast.

Breast conservation(lumpectomy, wide local

excision, quadrantectomy)

In this surgical procedure, the breast is conserved and the tumor is removed.

Radiation commonly follows a lumpectomy to try to rid the body of any other cancerous cells.

SURGICAL TREATMENT OF BREAST CA

Wide local excision-commenest procedure -breast conserving provided breast is adequate size and

tumour location appropriate (not central/retro-areolar) -usually combined with local radiotherapy Simple mastectomy-best treatment and cosmetic

result Surgical management of regional lymph nodes-Axillary node sampling-Axillary node clearance-Sentinel node biopsy Usually the first axillary node to receive lymphatic

drainage from the tumour. Before operation, a blue dye and a radiotracer are injected into subareolar areas and at operation the sentinel node is identified visually and by using a device to detect radioactivity.

Surgery for metastastic disease: limited to procedures for symptomatic control of local disease (e.g mastectomy to remove fungating tumour)

SELECTION CRITERIA FOR BREAST CONSERVATION SURGERY Single lesion clinically and

mammographically Tumour not larget than 3cm (4cm in larger

breast) No extensive in situ component Tumours more than 2cm away from

nipple/areola Lesion of lower histological grade No extensive nodal involvement

PSYCHOLOGICAL IMPACTS OF BREAST CANCER

WHAT DO PATIENTS GO THROUGH AFTER DIAGNOSIS?

DepressionAnxietyHostilityFearChanges in life patterns due to discomfort and painMarital/sexual disruptions

Reduction of activitiesPanicGuiltDifficulty adapting to illnessOverwhelmedDisappointment

REOCCURRENCES OF BREAST CANCER

ReoccurrencesPersonal ResponsibilityLoss of HopeDenialGrief

TherapiesGroup Therapies

Single session groupsTime limited groupsLong Term groupsTraditional

Single session with psychologists

PREVENTION

FATResearch shows that dietary fat should be 20% or less in order to gain meaningful protection against cancer.

Fat cells make estrogen, which promotes breast cancer.

Diets high in fat are associated with the increasing breast density in mammograms, which makes interpretation more difficult.

FIBERFiber provides protection against breast cancer because it has a mechanism that decreases the amount of estrogen in the body.

The amount of fiber in the diet affects the activities of intestinal bacteria, which affects the amount of reabsorbed estrogens.

ANTIOXIDANT NUTRIENTS

Antioxidants are important in fighting breast cancer because they can disarm cancer-causing substances called free radicals.Vitamin CVitamin EBeta-caroteneVitamin ASelenium

OTHER PREVENTATIVE MEASURES

Early Detection!!!!Exercise

No Smoking!!Good Diet

REFERANCE

Essential surgery 4th edition Oxford handbook of clinical surgery 3rd

edition The National Cancer Institute wedsite