Breast Cancer

Breast CancerAyesha MughalResidentEmbryology:Ectoderm: Epithelial lining of ducts and acini.Mesenchyme: Stroma.Mammary Ridge: Develops from ectoderm, at 5th week, from axilla to groin(Milk Line)Breast Bud: 10 years age.Nipple: 12 years age.Anatomy:Extent:2nd to 6th rib.Sternum to mid-axillary line.Position:Two third over pectoralis major.One third over Serratus AnteriorSuspensory Ligaments:Divide breast into lobules.Connect deep fascia to skin.Lobules:15 to 20 lobues, drain into lactiferous ducts and then lactiferous sinus.Arterial Supply:Internal mammary artery.Axillary Artery.Lateral thoracic artery.Acromioclavicular Artery.Subscapular Artery.Posterior Intercostal Arteries.

Venous Drainage:Internal Thoracic Vein.Axillary Vein.Posterior Intercostal VeinNerve Supply: Cutaneous branches of intercostal nerves T4 to T6. Sympathetic Supply.Lymphatic Drainage: 75% is to Axillary Lymph Nodes. 25% to Internal Mammary Nodes. Sentinel Lymph Node.Epidemiology: One in eight women will develop breast cancer in their lifetime. Second most common cause of cancer death among women overall(lung cancer is number 1). Incidence increases with increasing age. One percent of breast cancers occur in men.PathologyDuctal Carcinoma In SituLobular Carcinoma In SituInvasive Breast CancerInvasive Ductal CarcinomaInvasive Lobular CarcinomaMucoid CarcinomaMedullary CarcinomaPapillary CarcinomaCribiform CarcinomaTubularRisk Factors: Age Early Menarche Late Menopause Nulliparous Not breast-feeding HRT OCP Family History Li-Fraumeni Syndrome History of breast disease Radiation Obesity High alcohol intake.Genetic Predispositon:5 to 10% of all breast cancers.p53: A tumor suppressor gene.Both BRCA1 and BRCA2 function as tumor-suppressor genes.BRCA1 and BRCA2 both are inherited in an autosomal dominant fashion with varying penetrance.BRCA1: On 17q, also associated with ovarian cancer.BRCA2: On chromosome 13q, also associated with male breast cancer.Somatic mutation of p53 in 50% and of Rb in 20% of breast cancers.Clinical Presentation:Breast Lump.Axillary Lump.Asymmetry.Pain(very rare).Skin abnormalities.Nipple abnormalities.Management:Triple AssessmentStagingTreatmentSurgeryRadiotherapySystemic Treatment

Triple Assesment:ClinicalHistoryExaminationRadiologyUltrasoundMammographyPathologyFNACTru Cut biopsyScreening Recommendations:20 to 39 years:BSE: MonthlyClinical Breast Examinaiton: 3 Yearly.

40 years and above:BSE: MonthlyClinical Breast Examination: Annually.Mammography: Annually.GradingGrade I:Well differentiated.Grade II:Moderately differentiated.Grade III:Poorly differentiated. Staging: TNM StagingTumour Size:TisCIST1 5cm in sizeT4Involving skin or chest wallNodes:N0No lymph node involvedN1Palpable mobile ipsilateral axillary nodeN2Fixed involved axillary nodeN3Ipsilateral internal mammary nodeMetastases:M0No distant metastasesM1Distant metastasesUICC(Union Internationale Contrele Centre) Staging SystemI:T1,N0,M0II:T1,N1,M0 or T2,N0-1,M0III:T4,N0-3,M0IV:T1-4,N0-3,M1Prognostic Indicators:Size of primary tumourNodal statusTumour gradeER statusLymphovascular InvasionHER-2Notingham Prognostic Indicator scoring systemSurgical Procedures:Breast Conserving SurgeryWLEQuadrantectomyMastectomySimple MastectomySubcutaneous MastectomyRadical MastectomyModified Radical MastectomyPatey MastectomyPre-Op Preparation:Clinical exmination, Histology and Radiology discussed with MDT.Decision for mastectomy documented.Patient consented and counselled.Side marked.Position: Supine. Ipsilateral arm abducted. Examine breast before incision Arm prepped and wrapped.Incision: Carefully planned Ellipse Upper and lower margins should be of equal length Incision away from obvious tumourProcedure: Incision deepened. Upper and lower skin flaps raised.Adjuvant/Neoadjuvant Therapy:Radiation:Hormonal:Chemotherapy:Prophylactic:Radiation:Decreases risk of local recurrence.Axillary nodal radiation.For high risk of local recurrence.Inoperable locally advanced cancer.MetastasesStage I/II disease

In stage I and II disease, the adjuvant radiotherapy decreases the risk of local recurrence, increase the disease free survival but the effect on overall survival is controversial25Hormonal:ER positive plus node positive or high risk node negative.For palliation of metastases.Tamoxifen.Aromatase Inhibitors.Ovarian Ablation.Progestins.Androgens.Chemotherapy:ER negative plus node positive/high risk node negative.ER positive and young age.Stage I disease at high risk of recurrence.Palliation of metastatic disease.

Axillary Procedure:Axillary lymph node clearance.Sentinel node biopsy.Axillary node sampling.Complications:Chest infection.DVT/PEWound infection.Hematoma.Seroma formation.Skin necrosis.Lymph edema of arm and breast.Shoulder stiffness.Numbness of inner arm.Risk of damage to nerves.Poor cosmesis.Breast Reconstruction:Immediate.Delayed.Prosthesis.Tissue expansion.Myocutaneous flaps.Nipple reconstruction.Reduction mammoplasty or mastopexy of contralateral breast.Adjuvant Therapy:RadiotherapyHormonal TherapyOvarian AblationChemotherapyRadiotherapyTo decrease the incidence of local recurrence.For positive axillary lymph nodes.To treat axillary recurrence.To treat post mastectomy chest wall:Grade III, multifocal.Cancers > 4cm.Presence of lymphovascular invasion.>3 positive axillary lymph nodes.