BREAST CANCER

Issah J. kiswagala

(M.B.B.S)

MWEMASITE.COM

DEFITION

• Breast cancer is defined as malignant neoplasm of the breast arising from the epithelial lining of the lobule, ducts and the nipple

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SURGICAL ANATOMY

1. Position
1. The human breast is a modified sweat gland located on the anterior aspect of the chest wall
2. It is rudimentary in males but develops to variable proportions in the female
3. The human breasts are usually two in number on either side of the sternum

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2. Shape
1. Dome –shaped which is round and hemispherical
2. The nipple (which is directed downwards and laterally) forms the apex of the dome
3. The nipple is surrounded by areola which has several elevations known as tubercles of Montgomery (sebaceous glands)
4. About 15-20 small openings for the underlying lactiferous (milk) ducts are seen at the nipple

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3. Structure
1. Breast composed of:
• Glandular tissue
• Fibrous tissue
• Adipose tissue
2. 15-20 lobes, each lobe is divided into lobules
• Acini (alveolus) → lobule → lobe
3. Lobules are separated by Cooper’s ligaments
4. Each lobe pours secretion in a lactiferous duct

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4. Boundaries
1. Superiorly: 2nd rib
2. Inferiorly: 6th rib
3. Medially: lateral border of the sternum
4. Laterally: mid-axillary line
• Axillary tail of Spence projects from its upper and lateral part and extends through a foramen of Langer in the deep fascia to enter the axilla

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5. Relations
1. The base of the mammary gland lies over the pectoralis major (2/3), serratus anterior and external oblique aponeurosis (1/3)

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ANATOMICAL QUADRANTS

• Divided into 4 quadrants and a tail
• The quadrants are:-
• Upper outer quadrant
• Upper inner quadrant
• Lower outer quadrant
• Lower inner quadrant
• The upper outer quadrant contains the most glandular tissue
• Breast tissue extends from the upper outer quadrant into the axilla, forming the tail of Spence
• Tail of Spence (axillary tail) extends along the inferolateral edge of the pectoralis major muscle and enters a hiatus of Langer in the deep fascia of the medial axillary wall

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EPIDEMIOLOGY

1. Incidence
• Incidence rates are higher in the developed countries than in the developing countries and Japan
• Incidence rates are also higher in urban areas than in the rural areas
• In Africa, Breast Cancer has overtaken cervical cancer as the commonest malignancy affecting women and the incidence rates appear to be rising
• Breast cancer is the third most common cancer among women in Tanzania, after cervical cancer and HIV-related Kaposi's sarcoma

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2. Morbidity/mortality
• Overall breast cancer mortality rates have declined in recent years, attributable to the increased use of screening mammography and the aggressive use of adjuvant therapies
• Worldwide, breast cancer is the fifth most common cause of cancer death
• Mortality rates are highest in the very young (less than age 35) and the very old (greater than age 75)
3. Age
• As for other epithelial cancers the incidence of breast cancer increases with age

4. Gender
• Breast cancer is 100 times more common in women than in men
5. Race
• White women are slightly more likely to develop breast cancer than are black women
• Black women are more likely to die of this cancer
• The reasons for this are not known

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ETIOLOGY/RISK FACTORS

• Etiology unknown, but several risk factors have been identified. These are
• Hereditary factors:
• Genetic predisposition - The mutated genes BRCA 1 and BRCA 2 are responsible for 30-40% of inherited breast cancer
• And Family history of beast cancer is associated with an increased risk of the disease
• Dietary factors
• Diets rich in fat especially saturated fat raises the risk of developing breast cancer

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• Hormonal factors
• Prolonged exposure to and higher concentrations of endogenous estrogen increase the risk of breast cancer
• Early age at menarche [≤ 12 years]
• Late age at first pregnancy [>30 years ]
• Late menopause [≥55years]
• Nulliparity at the age of 40 years
• Note: prolonged lactation/breast feeding is protective
• Exogenous estrogens e.g. oral contraceptive drugs have been shown to increase the risk of developing breast cancer

• Lifestyle factors
• Weight gain
• Obesity is associated with a twofold increase in the risk of breast cancer in postmenopausal women whereas among premenopausal women it is associated with a reduced incidence
• Alcohol intake
• Some studies have shown a link between alcohol consumption and incidence of breast cancer, but the relation is inconsistent and the association may be with other dietary factors rather than alcohol
• Smoking
• Smoking is of no importance in the etiology of breast cancer

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• Factors related to breast conditions
• Individuals who have a prior history of breast disease have an increased risk of developing breast cancer
• Women with atypical ductal or lobular hyperplasia have a four to five times higher risk of developing breast cancer
• Proliferative lesions without atypia, such as moderate hyperplasia and sclerosing adenosis, are associated with a slightly increased risk
• Other common non-proliferative changes such as palpable cysts, fibroadenomas and duct papillomas are not associated with a significantly increased risk

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• Environmental factors
• Exposure to ionizing irradiation increases the risk of developing breast cancer
• Environmental exposures to organic chlorines and other environmental/synthetic estrogens like cosmetics and phytoestrogens found in food have also been postulated to increase the risk

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PATHOPHYSIOLOGY

• Breast cancer may arise from the epithelium of the duct system anywhere from the nipple end of major lactiferous ducts to the terminal duct unit which is in the breast lobule
• It is more common in the upper outer quadrant

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CLASSIFICATION

• Classified as:-
• Non-invasive
• Lobular carcinoma in situ [LCIS]
• Ductal carcinoma in situ [DCIS]
• Paget's disease of the nipple
• Invasive
• Lobular carcinoma
• Ductal carcinoma
• Mucinous / colloid carcinoma
• Medullary carcinoma

SPREAD OF BREAST CANCER

1. Direct (local) spread to the:-
• Skin over the breast
• Pectoral muscles
• Chest wall
2. Lymphatic spread by Permeation and/or Embolization
• 75% to the axillary lymph nodes arranged in 3 levels (I, II and III)
• The remaining to the internal mammary lymph nodes
3. Blood (hematogenous) spread to distant sites via blood vessels eg lungs, liver, bones, brain etc
4. Transcoelomic implantation - dropping of cancer cells by gravity from metastases to the liver to the pelvic cavity causing metastases to the ovary

CLINICAL PRESENTATION

• History
• Physical examination

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HISTORY

• Symptoms referring to the breast
• Breast lump
• Nipple discharge
• Nipple or skin changes
• Axillary mass or pain
• Arm swelling

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BREAST LUMP

• Duration
• Short duration- traumatic, Inflammatory, abscess, ? malignancy
• Long duration- benign conditions
• Mode of onset
• Sudden onset- traumatic, Inflammatory, abscess
• Gradual onset- benign conditions
• Progression
• Fast growing- malignancy
• Slow growing- benign conditions

• Is it painful?
• Painful- traumatic, Inflammatory, abscess
• Painless- neoplastic conditions
• Initially painless then painful → malignancy

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NIPPLE DISCHARGE

• Character & quantity
• Bloody discharge- intra-ductal Papilloma or carcinoma
• Pus discharge- abscess
• Milky discharge- galactocele
• Serous or greenish discharge- fibroadenosis or mammary ductal ectasia

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NIPPLE OR SKIN CHANGES

• Nipple- rétraction, ulcérations, inversion, Dimpling
• Skin - rétraction, ulcération, Peau d’orange, Fungating

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Why the skin of the breast looks like an orange peel (Peau d’Orange)?

ANS: Due to obstruction of the superficial lymphatics of the breast

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AXILLARY MASS OR PAIN

• May be involvement of the axillary tail or axillary lymphnodes

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• Symptoms with reference to possible metastatic disease
• Cough, chest pain, SOB – lung involvement
• Jaundice- liver metastasis
• Bone pain – bone metastasis
• Features of brain metastasis
• Past medical history of breast disease
• Family history of breast cancer

PHYSICAL EXAMINATION

• General examination
• Local examination
• Systemic examination

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GENERAL EXAMINATION

• Weight, Height & surface area
• Wasting
• Jaundice
• Dyspnea
• Anemia

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LOCAL EXAMINATION

• Examination should be carried out in both sitting and supine position includes:-
• Inspection
• Palpation
• Lymph node examination

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INSPECTION

• Position
• With the arms by the side of the body- to assess the level of the nipples
• With the arms raised straight above her head- lumps or dimple will be more marked
• With the hands pressing on her hip- abnormal movement of the nipple or exaggeration of the dimples will be evident
• With the patient bending forward so that the breast fall away from the body- failure of one nipple to fall away indicates abnormal fibrosis behind the nipple
• Inspect systematically starting with the normal breast

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• Nipple
• Position - compare levels on both sides, elevation → cancer or inflammatory swelling due fibrosis
• Size & shape → prominent: underlying cyst or swelling

→ retracted: malignant, fibrosis

• Surface → look for cracks, ulceration, fissure or eczema
• Discharge
• Areola - look for Cracks, Ulceration, Fissure, Eczema, Discharge

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PALPATION

• Position: sitting initially then in recumbent position
• Look for:-
• Local temperature & tenderness
• Location [which quadrant]
• Size & shape
• Margin
• Consistency
• Fixity to skin, breast tissue, pectoral muscles & chest wall

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LYMPH NODE EXAMINATION

• Includes:-
• Axillary lymph nodes
• Supraclavicular lymph nodes
• Note:-
• Number
• Size
• Location
• Fixation to other nodes or underlying structures
• Clinically suspicious or benign

SYSTEMIC EXAMINATION

• Respiratory examination R/O lung involvement
• Abdominal examination R/O liver involvement
• Rectal/Vaginal examination R/o Krukenberg’s tumor of the ovary
• CNS examination R/O brain metastasis
• MSS examination R/O bone metastasis

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INVESTIGATIONS

• Full blood count
• Serum urea and creatinine [RFT]
• Liver Function Test [LFT]
• Fine needle aspiration cytology
• Has high degree of accuracy and when a diagnostic sample of malignant cells is obtained, definitive surgery may go ahead without need for open biopsy
• Can be done with or without mammography or US- guided
• Core Biopsy
• Done when FNAC is inconclusive, can be done under US guidance

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• Open biopsy
• Excisional biopsy
• For small lesions
• Impalpable lesions may require mammographic localization
• Incisional biopsy
• For big lesions

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IMAGING

• Mammography
• Imaging technique of first choice in symptomatic patients aged ≥ 30 years
• Breast ultrasound
• Is complimentary to mammography
• Provides added information e.g. solid / cystic mass, true size of lesions
• It may be the technique of first choice in the breast lumps of young women
• Galactography
• A discharging duct is cannulated and contrast medium injected
• Radiographs are then taken
• It is useful in localization of intraductal growth

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• Pneumocystography
• Air is injected into a cyst after aspiration of fluid to detect intra-cystic growth
• Chest X-ray R/O lung metastasis
• Abdominal (liver) US R/O liver metastasis
• Skeletal survey R/O bone metastasis
• Bone scan
• CT scan
• MRI

STAGING

• Aim
• To assess the extent of the disease
• To assess the prognosis of the disease
• To plan for treatment modality
• Criteria
• TNM system
• Manchester system
• Columbia system

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TNM SYSTEM (2002 VERSION)

• First described in 1959 by the international Union Against Cancer which was organized by the American College of Surgeon
• The system is described as follows:-

T= Primary tumor

N=Regional lymph nodes

M=Distant metastasis

• By far the TNM classification has achieved widespread acceptance

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T-STATUS

Tx - Primary tumor cannot be assessed

To - No evidence of primary tumor

Tis - Carcinoma in situ:

• Ductal carcinoma in situ [DCIS]
• Lobular carcinoma in situ [LCIS]

T1 - Tumor ≤ 2cm in greater dimension

T2 - Tumor > 2cm and < 5cm in dimension

T3 - Tumor > 5cm in dimension

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T4 - Tumor of any size with direct extension to the chest wall or skin

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T4a - Extension to chest wall

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T4b - Edema (including peau d’orange), ulceration of the skin of the breast, or satellite nodules confined to the same breast

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T4c - Both 4a and 4b, above

T4d Inflammatory carcinoma

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N-STATUS

• N x - Regional lymph nodes cannot be assessed
• N0 - No regional lymph node metastases
• N1 - Metastases to movable ipsilateral axillary nodes
• N2 - Metastases to fixed ipsilateral axillary nodes
• N3 - Metastases to ipsilateral internal mammary nodes

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M-STATUS

• M0 No distant metastases
• M1 Distant metastases present (including to supraclavicular LN)

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TREATMENT

• Surgery
• Breast conserving surgery - surgical excision of the tumor + with surrounding margins (lumpectomy)
• Mastectomy (surgical removal of the affected breast) - Simple or Modified
• Surgery of the RLN
• Axillary lymph node dissection [ALND]
• Sentinel lymph node biopsy [SLNB]
• Radiotherapy
• Chemotherapy
• Immunotherapy

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• Hormonal therapy
• Can be given as an adjuvant therapy after surgery or as treatment for systemic disease
• Classified as:

1st line treatment

• Antiestrogen e.g. Tamoxifen 20mg daily for 2-5 years

2nd line treatment

• Aromatase inhibitor e.g Anastrozole 1mg daily
• Medroxyprogesterone acetate 0.4-1.5g daily

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FOLLOW UP

• Follow up involves the following:-
• Palliative care team [Hospice] & Other health workers
• To provide psychological care
• To provide symptomatic care
• Pain management
• Vomiting
• Mammography
• Patients who had mastectomy should have mammography of the opposite breast every 2 years
• For patients who had BCS both breasts should have mammography every 2 years
• TCA
• Patients should be seen at 3 and 6 months following radiotheraphy and then once every year for life

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PREVENTION

• Primary prevention
• Modification of risk factors
• Health education → ↑ awareness of the risk factors
• Secondary prevention
• BSE
• Clinical breast examination
• Mammography screening
• Tertiary prevention
• rehabilitation

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