It contains details about breast carcinoma-pathology,investigations and diagnosis,NACT,surgery and adjuvant therapy. Hope you will find it helpful.....

1. BREAST CARCINOMA
by
Students of
MEDICAL COLLEGE KOLKATA
(batch 2011)
1

2. INTRODUCTION
• Breast cancer is the second most common cancer in India.
• The incidence of breast cancer is increasing in the developing world
due to increase life expectancy, increase urbanization and adoption of
western lifestyles.
• Although some risk reduction might be achieved with prevention,
these strategies cannot eliminate the majority of breast cancers that
develop in low- and middle-income countries where breast cancer is
diagnosed in very late stages.
• Therefore, early detection in order to improve breast cancer outcome
and survival remains the cornerstone of breast cancer control.
2

3. Pathology of breast carcinoma
BY
AMIYA GOPAL RANJA
& RAJARSHI BANERJEE
3

4. RISK FACTORS
Age: peak at 75-80 years
Age at menarche:20% more risk in women reaching menarche <11 years of age compared to
menarche at >14 years of age
Age at first live birth: more risk of nulliparous women or women >35 years of age at their first birth
First degree relatives with breast cancer: 13% women with breast cancer have one affected first
degree relative, and 1% have two or more
Atypical hyperplasia in prior breast biopsies
Oestrogen exposure: postmenopausal women having HRT have 1.2 -1.7 fold greater risk, adding
progesterone increase it even further
Breast density
Radiation exposure: women having radiation in their teens and early 20s have 20%-30% more risk of
developing carcinoma
Obesity: decreased risk in obese women <40 years but more in case of post menopausal obese
Carcinoma of contralateral breast
Race/Ethnicity
4

5. AETIOLOGY AND PATHOGENESIS
• Major risk factors for development of breast cancers are hormonal
and genetic
• It can be therefore divided into
 Hereditary carcinoma-Associated with germline mutations
 Sporadic carcinoma-probably related to hormonal exposure
5

6. MOST COMMON SINGLE GENE MUTATIONS ASSOCIATED WITH HEREDITARY
SUSCEPTIBILITY TO BREAST CANCER
GENE(LOCATION)
AND SYNDROME
% OF SINGLE GENE
HEREDITARY CANCERS
BREAST CANCER RISK
BY AGE 70
FUNCTIONS COMMENTS
BRCA1(17q21)
Familial breast and
ovarian carcinoma
52% 40-90% Tumour suppressor
Transcriptional
regulation
Repair of ds DNA breaks
Carcinomas are poorly
differentiated and triple
negative with p53
mutation
BRCA2(13q12-13)
Familial breast and
ovarian carcinoma
32% 30-90% Tumour suppressor
Transcriptional
regulation
Repair of ds DNA breaks
Biallelic germline
mutations cause a rare
form of Fanconi
anaemia
P53(17p13.1)
Li Fraumeni
3% >90% Tumour suppression
with critical roles in cell
cycle control, DNA
replication, repair and
apoptosis
Most commonly
mutated gene in
sporadic breast
carcinoma
CHEK2(22q12.1)
Li Fraumeni
5% 10-20% Cell cycle checkpoint
kinase, activates BRCA1
and p53,repair of DNA
damage
May increase risk after
radiation exposure
6

7. SPORADIC BREAST CANCER
• The major risk factors for sporadic breast cancer are related to
 Hormone exposure
 Gender
 Age at menarche and menopause
 Breast feeding
 Exogenous oestrogens
• The majority of sporadic cancer occur in postmenopausal women and
are ER positive.
7

8. PRECANCEROUS LESIONS
Pathologic lesion Relative risk Absolute lifetime risk
NON PROLIFERATIVE BREAST CHANGES
(FIBROCYSTIC CHANGES)
1.0% 3%
PROLIFERATIVE DISEASE WITH ATYPIA
Atypical ductal hyperplasia(ADH)
Atypical lobular hyperplasia (ALH)
4-5% 13-17%
CARCINOMA IN SITU
Ductal carcinoma in situ
Lobular carcinoma in situ
8-10% 25-30%
8

9. DISTRIBUTION OF HISTOLOGIC TYPES OF BREAST
CANCER
TOTAL CANCERS PERCENTAGE
CARCINOMA IN SITU
 Ductal carcinoma in situ (DCIS)
 Lobular carcinoma in situ (LCIS)
15-30
 80
 20
INVASIVE CARCINOMA
 No special type carcinoma
 Lobular carcinoma
 Tubular carcinoma
 Mucinous carcinoma
 Medullary carcinoma
 Papillary carcinoma
 Metaplastic carcinoma
70-85
 79
 10
 6
 2
 2
 1
 <1
9

10. DUCTAL CARCINOMA IN SITU (DCIS)
• Among mammographically
detected carcinomas almost half
are DCIS
• DCIS consists of a malignant
clonal population of cells limited
to ducts and lobules by
basement membrane
• DCIS can spread throughout
ducts producing extensive
lesions involving an entire sector
of breast
10

11. Histologically DCIS have been divided into 4 architectural subtypes…
• Solid pattern-filling and plugging of the ductal lumina with tumour cells.
• Comedo pattern-centrally placed necrotic debris surrounded by neoplastic
cells in the duct.
• Papillary pattern-has formation of intraductal papillary projections of
tumour cells which lack a fibrovascular stalk.
• Cribriform pattern-recognised by neat punch out fenestrations in the
intraductal tumour.

12. LOBULAR CARCINOMA IN SITU (LCIS)
• It is always an accidental finding
as it is not associated with
calcification or stromal reactions
• The cells are identical to invasive
lobular carcinoma and share
genetic abnormalities like loss of
E-Cadherin expression
• LCIS almost always expresses ER
and PR but overexpression of
HER2/neu is not observed
12

13. 13
LCIS DCIS
Age (years) 44 to 77 54 to 58
Incidence 2 to 5% 5 to 10%
Clinical signs nil Mass,pain.discharge
Mammographic signs nil calcification
Multicentricity 60 to 90% 40 to 80%
Bilaterality 50 to 70% 10 to 20%
Subsequent carcinoma:
Invasive type 25 to 35% 25 to 70%
Histology of invasive Ductal Ductal
(Thus the subsequent invasive
carcinoma
that develops is 65 percent ductal
origin and not lobular type)

14. TREATMENT OF CIS
oLCIS: observation with or without tamoxifen
oDCIS:
 Limited disease : lumpectomy + radiotherapy
 ≥ 2 quadrants involved : Mastectomy
14

15. INVASIVE CARCINOMA ,NO SPECIAL
TYPE
• This includes the majority of carcinomas and can be divided into five
major types on the basis of Gene Expression Profiling. They are
 Luminal A (40-50% of NST cancer): ER positive and
HER2/neu negative
 Luminal B (15-20% of NST cancer): triple positive cancers
 Normal breast like (6-10%):ER positive, HER2/neu negative
with gene expression pattern similar to normal tissue
 Basal like (13-25%):Absence of ER,PR and HER2/neu i.e.
triple negative
 HER2 positive (7-12%):ER negative but HER2/neu positive
15

16. INVASIVE CARCINOMA ,NO SPECIAL
TYPE
Mastectomy specimen containing a very large invasive
ductal carcinoma of the breast. To the right, the nipple
can be seen on the pink skin, while in the centre of the
picture a large blue and pink swelling or tumour can be
seen. At the edges of this surgical specimen fat tissue
(orange/red) can be observed.
Typical macroscopic (gross) appearance of the cut surface
of a mastectomy specimen containing an invasive ductal
carcinoma of the breast (pale area at the centre).
16

17. RISK ASSESSMENT AND RISK
PREVENTION
By
RAMIJ RAJA
17

18. INTRODUCTION
The breast cancer risk assessment tool is an interactive tool designed
by scientists at NATIONAL CANCER INSTITUTE (NCI) and THE NATIONAL
SURGICAL ADJUVANT BREAST AND BOWEL PROJECT (NSABP) to
estimate a women's risk of developing invasive breast cancer
18

19. RISK ASSESSMENT MODELS
GAIL MODEL CLAUS MODEL
Data derived from Breast Cancer Detection
Demonstration Project study
Cancer and Steroid Hormone Study
Family history characteristics FDR with breast cancer • FDR or SDR with breast cancer
• Age of onset in relatives
Other characteristics • Current age
• Age at menarche
• Age at first live birth
• Number of breast biopsies
• Atypical hyperplasia in biopsies
• Race
Current age
Strength Incorporates
Risk factors other than family history
Incorporates
• Paternal and maternal history
• Age of onset
• Familial history of ovarian
carcinoma
19

20. RISK ASSESSMENT MODELS
GAIL MODEL CLAUS MODEL
Limitations • Underestimates risk in hereditary
families
• Number of breast biopsies without
atypical hyperplasia may cause
inflated risk estimates
Does not incorporate
• Paternal family history of breast
cancer or any family history of
ovarian cancer
• Age at onset of breast cancer in
relatives
• All known risk factors for breast
cancer
• May underestimate risk in hereditary
families
• May not be applicable to all
combinations of affected relatives
Best application • For individuals with no family history
of breast cancer or one FDR with
breast cancer, aged ≥50 y
• For determining eligibility for
chemoprevention studies
For individuals with no more than two
FDRs or SDRs with breast cancer
20

21. RISK PREVENTION
Screening mammography
o Routine use of Screening mammography of >50 year old
female decreases mortality by 33%
o Recommendation-Baseline mammography at the age of 35
and from 40 year annually
21

22. RISK PREVENTION
SERMs therapy-by Tamoxifen , Raloxifen
o Should be given if relative risk is > 1.7
o Both drugs reduce the risk of developing breast cancer by
approx. 50%
o After a mean follow up period of 4 years, the incidence of
breast cancer was reduced by 49%
22

23. RISK PREVENTION
Prophylactic mastectomy
o Reduces the risk >90%
o The benefit of Prophylactic mastectomy differed
substantially according to breast cancer risk conferred by
mutations
o For women with an estimated life time risk of 40%
Prophylactic mastectomy adds 3 years of life whereas for
women with an estimated life time risk of 85% Prophylactic
mastectomy adds >5 years of life
23

24. INVESTIGATIONS AND
PROGNOSTIC FACTORS
BY
AMBITA MONDAL
& SUDIPTO SAHA
24

25. Triple assessment
• Breast self examination
• Mammography
• FNAC
25

26. INVESTIGATIONS
• For confirmation of diagnosis
 Imaging
 Mammography
 USG
 MRI
 Biopsy
 FNAC
 Tru cut biopsy
26

27. INVESTIGATIONS
• To stage the disease-metastatic workup
 CT scan chest
 X-ray chest
 Whole body bone scan
 Upper abdominal USG
 LFT
 Sentinel node biopsy
• To know the general condition
 Complete haemogram
 Serum albumin, sugar, urea, creatinine
 ECG,Echo and Pulmonary function test for elder patients
27

28. Mammography
Most frequently done investigation
• Procedure
A selenium coated x-ray plate is used directly in contact with the breast
which is exposed to low voltage& high amperage x-ray
• Two views-Medio-lateral & cranio-caudal
28

29. Mammography
Indications
• For screening of women >40 years or earlier in a young women with
strong family history
• To characterize breast lump
• To exclude multicentricity if BCS planned
• Specimen mammography to assess completeness of surgery
• Mastalgia
29

30. Mammography
Findings
• Benign lesions- round ,punctate ,
popcorn like etc.
• Highly suspicious lesions-
Pleomorphic, heterogeneous
Solid mass with irregular edges,
spiculation
Long tentacles- tentaculation
Fine scattered calcification- micro
calcification
Distortion of architectural pattern of the
breast
Asymmetrical thickening of breast tissue 30

31. Mammography
Advantages
• Non invasive
• Minimum hazards of radiation
Disadvantage
• 10% false positive rate and 7% false
negative rate in mammography.
Hence, biopsy is a must.
• LCIS may be missed in mammography
• Mammography is inconclusive in
women under 35 due to dense breast
tissue.
BI RADS (Breast Imaging-Reporting And Data
System) category:
Score Assessment Follow up
0 Incomplete assessment Needs additional imaging
1 Negative Continue regular
screening(>40 yrs.)
2 Benign findings Same as above
3 Probably benign Follow up study after 6
month
4 Suspicious of carcinoma Core biopsy may be
required
5 Highly suggestive of
carcinoma
Core biopsy is must
6 Known biopsy proven
carcinoma
Biopsy confirms presence of
cancer before treatment
begins 31

32. USG
• In premenopausal women with dense breast tissue , USG is a better
imaging modality to detect breast lesion than mammography
• USG can detect the mass as solid or cystic
• No radiation(done in Pregnancy) , cheap, easily available
• USG guided aspiration of breast may be done
• May demonstrate solid lesion in breast but cannot detect lesion less
than 1 mm in diameter.
32

33. MRI
INDICATIONS
• To differentiate scar from recurrence
• To image breasts of women with implants
• To evaluate the management of axilla and recurrent disease
• Lesion indeterminate by ultrasonography and mammography.
• To screen breasts of young women with strong family history or
carrying known genetic mutation
33

34. Trucut biopsy
• Core needle biopsy has become the standard of care for biopsy of breast
lesion(may be USG or mammography guided if not palpable)
• A histological diagnosis of invasive or non invasive carcinoma may be
made
• The tumour grade and any lymphovascular invasion may be assessed
• The ER/PR and Her2-neu status may also be assessed
• TECHNIQUE
After antiseptic cleaning & draping , local anaesthesia with inj.
2%lignocaine hydrochloride is given
A small stab incision in skin and a 11gauge core needle biopsy needle is
inserted into the lesion to obtain sample. 34

35. FNAC
• It is done with 23gauge needle and material is collected on a slide ; a
smear is made using 100% alcohol
• Minimum 6 aspirations are done
• Giemsa , pap, H&E stains are used
FNAC Mammography
Sensitivity 90-98% 90%
Specificity 98-100% 90%
False negative 2-10% 7%
False positive Near 1-5% 10%
FNAC Scoring
Co No epithelial cells
C1 Scanty epithelial cells , benign
C2 Benign cells
C3 Atypical cells
C4 Suspicious cells
C5 Malignant cells
35

36. TNM Classification
Primary Tumour (T)
• TX Primary tumour cannot be assessed
• T0 No evidence of primary tumour
• Tis Carcinoma in situ
• Tis (DCIS) Ductal carcinoma in situ
• Tis (LCIS) Lobular carcinoma in situ
• Tis (Paget’s) Paget’s disease of the nipple NOT associated with invasive
carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying
breast parenchyma. Carcinomas in the breast parenchyma associated
with Paget’s disease are categorized based on the size and characteristics
of the parenchymal disease, although the presence of Paget’s disease
should still be noted
36

37. TNM Classification
Primary Tumour (T)
• T1 tumour ≤ 20 mm in greatest dimension
• T1mi tumour ≤ 1 mm in greatest dimension
• T1a Tumour > 1 mm but ≤ 5 mm in greatest dimension
• T1b Tumour > 5 mm but ≤ 10 mm in greatest dimension
• T1c Tumour > 10 mm but ≤ 20 mm in greatest dimension
• T2 Tumour > 20 mm but ≤ 50 mm in greatest dimension
• T3 tumour > 50 mm in greatest dimension
37

38. TNM Classification
Primary Tumour (T)
• T4 Tumour of any size with direct extension to the chest wall and/or to the
skin (ulceration or skin nodules)
• Note: Invasion of the dermis alone does not qualify as T4
• T4a Extension to the chest wall, not including only Pectoralis muscle
adherence/invasion
• T4b Ulceration and/or ipsilateral satellite nodules and/or oedema
(including peau d’orange) of the skin, which do not meet the criteria for
inflammatory carcinoma
• T4c Both T4a and T4b
• T4d Inflammatory carcinoma
38

39. TNM Classification
Regional Lymph Nodes (N)
• NX Regional lymph nodes cannot be assessed (for example, previously removed)
• N0 No regional lymph node metastases
• N1 Metastases to movable ipsilateral level I, II axillary lymph node(s)
• N2 Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed
or matted; or in clinically detected ipsilateral internal mammary nodes in the
absence of clinically evident axillary lymph node metastases
• N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another
(matted) or to other structures
• N2b Metastases only in clinically detected ipsilateral internal mammary nodes
and in the absence of clinically evident level I, II axillary lymph node metastases
39

40. TNM Classification
Regional Lymph Nodes (N)
• N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s)
with or without level I, II axillary lymph node involvement; or in clinically
detected ipsilateral internal mammary lymph node(s) with clinically evident
level I, II axillary lymph node metastases; or metastases in ipsilateral
supraclavicular lymph node(s) with or without axillary or internal
mammary lymph node involvement
• N3a Metastases in ipsilateral infraclavicular lymph node(s)
• N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary
lymph node(s)
• N3c Metastases in ipsilateral supraclavicular lymph node(s)
40

41. TNM Classification
Distant Metastases (M)
• Mx-Metastases cannot be assessed
• Mo-No metastasis
• M1-Distant metastasis
41

42. Staging
Stage 0
Stage I
Stage IIA
Stage IIB
Tis N0 M0
T1 N0 M0
T0 N1 M0
T1 N1 M0
T2 N0 M0
T2 N1 M0
T3 N0 M0
T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
T4 N0 M0
T4 N1 M0
T4 N2 M0
Any T N3 M0
Any T Any N M1
Stage IIIA
Stage IIIB
Stage IIIC
Stage IV

43. PROGNOSTIC FACTORS
Major Prognostic Factors
 Invasive vs In-situ
 Distant metastases
 Lymph node metastases
 Tumour size
 Locally advanced disease
 Inflammatory carcinoma
Minor prognostic factors
 Histologic subtype
 Histologic grade(Scarff-
Bloom-Richardson)
 ER & PR
 HER2/neu receptor
 Lymphovascular invasion
 Proliferative rate
 DNA content
 Respond to neoadjuvant
therapy
 Gene expression profiling 43

44. NEOADJUVANT THERAPY
IN CA BREAST
BY
ANAND KUMAR
44

45. What is Neoadjuvant Therapy?
Neoadjuvant therapy involves giving chemotherapy or hormonal
therapy before surgery to patients with non metastatic primary breast
cancer which is potentially inoperable.

46. Origin
• The use of neoadjuvant chemotherapy has its origins in the
management of inoperable locally advanced breast cancer.
• Preoperative chemotherapy was initially introduced to downsize
patients and enable successful local treatment.

47. Advantages
• It changes the timing of treatment and can change surgical options.
• It can shrink a tumour enough so that lumpectomy plus radiation
therapy becomes an option to mastectomy.

48. Disadvantages
• Neoadjuvant therapy does not increase survival (compared to
adjuvant therapy).
• No increase in Overall Survival (OS) of the patient compared to
adjuvant chemotherapy.

49. Factors to Consider
• Will it convert requirement of a mastectomy to a lumpectomy?
• Whether there is nodal involvement?
• Whether there is distant metastasis?

50. Results of Neoadjuvant
Therapy

51. Clinical Response
Clinical response measures how
much of the tumour reduces in size
from its original that can be assessed
clinically. If it disappears completely
then it is termed a Complete Clinical
Response (cCR).
• Its grades are -
Size of tumour after therapy
to initial
Response
0% to 25% Complete responder
25% to 75% Partial responder
75% to 100% Resistant disease
> 100% Progressive disease

52. Pathologic Response
• Pathologic response describes how much of the tumour is left in the
breast and lymph nodes after neoadjuvant therapy.
• Pathological complete response (pCR) is defined as the absence of
residual invasive cancer on hematoxylin and eosin evaluation of the
complete resected breast specimen and all sampled regional lymph
nodes following completion of neoadjuvant systemic therapy.

53. Treatment Response Assessment
A specialized MRI software has been used to mark the
improvement in a breast cancer patient on neoadjuvant
therapy.

54. Neoadjuvant Hormone Therapies
• Some breast cancer cells need oestrogen and/or progesterone to
grow.
• All tumours are checked for hormone receptors. The receptor
status is checked by testing the tumour tissue removed during a
biopsy.
• Most breast cancers are hormone-receptor positive. Hormone
therapies are only used to treat hormone receptor-positive
breast cancers.

55. Neoadjuvant Hormone Therapies
• It may also have a role in the treatment of women who are not
candidates for chemotherapy due to other health problems or
advanced age.
• It may also be an option for women with low grade tumors and
invasive lobular breast cancer.
• Most young women with large tumors are treated with
chemotherapy rather than hormone therapy, even if their tumors
are ER-positive.
55

56. Drugs Used in Hormone Therapy

57. Regimen of Neoadjuvant chemotherapy
CMF REGIMEN
Cyclophosphamide – 100 mg/m2 oral (14 days)
Methotrexate – 40 mg/m2 i.v. (1, 8th day)
5-Fluorouracil – 400 mg/m2 i.v. (1, 8th day)
* For 3 cycles
* Each cycle being 28 days
More decrease in recurrence is seen on substituting anthracyclines
(Adriamycin or Epirubicin), i.e. FAC or FEC regimens.
57

58. Neoadjuvant Therapy For Her2-neu positive Breast
Cancers
Trastuzumab
Pertuzumab
• If one gets neoadjuvant trastuzumab, she will likely also have
trastuzumab after surgery (adjuvant trastuzumab).
• Trastuzumab is not usually given at the same time as
anthracycline-based chemotherapy, neither in the
neoadjuvant nor the adjuvant setting.
• Pertuzumab is only used as a neoadjuvant therapy and is not
given after surgery.
58

59. After The Neoadjuvant Therapy
To check the response to neoadjuvant therapy, several tests are done ,
including-
 a clinical breast exam,
a mammogram,
a breast MRI , and/or
 an ultrasound.
Some surgeon plan the surgery in the much same way as if there was
no neoadjuvant therapy(they ignore initial staging),but the trend
should be – always plan surgery before giving neoadjuvant therapy.
59

60. After the Neoadjuvant Therapy
• Before neoadjuvant therapy is started the area of the initial breast
lump is delineated with radio opaque clips.
• This is important as neoadjuvant therapy shrinks the original tumour
but some cancerous cells remain embedded in the fibrous tissue
surrounding the shrunken tumour and need to be resected during
surgery.

61. Clipping

62. Technique of Lumpectomy after Neoadjuvant
Therapy
After completion of neoadjuvant therapy the lumpectomy is
done keeping in mind the clips inserted.
An area covering the entire lump originally present along with
tissue 1 cm away from the clips is resected out.

63. Sentinel Node Biopsy & Neoadjuvant Therapy
• A sentinel node biopsy will be done either before neoadjuvant
therapy begins or after neoadjuvant therapy, at the time of
breast surgery.
• The sentinel node biopsy checks for cancer in the lymph nodes in
the axilla.
• It is unclear whether it is better to have a sentinel node biopsy
before or after neoadjuvant therapy. There are pros and cons to
each and the best timing is still under study. .
63

64. BY
PURNENDU MUKHERJEE
SURGERY FOR CA
BREAST
64

65. DIFFERENT MODES OF
SURGERY
Breast(Primary)
1. Breast Conservation Surgery
2. Simple mastectomy
3. Modified radical mastectomy
4. Radical Mastectomy
Axillary
1. Sentinel lymph node biopsy
2. Axillary lymph node dissection
65

66. Conservative Breast Cancer Surgery
A) Wide local excision/Lumpectomy
INDICATIONS:
 Early breast carcinoma(stage I & II) where tumour size < 4 cm
and well differentiated cytology
 Breast tumour ratio is very important criteria.

67. Contraindications
Absolute
• Multicentric tumour
• History of previous breast
irradiation
• Pregnancy
• Persistent positive
margins after reasonable
surgical attempts.
• Centrally located tumour
Relative
1.Collagen vascular disease
2.Poor socioeconomic
strata(follow up?)
3.Size >4 cm
4.Family history positive

68. Conservative breast cancer surgery
Salient points:
• It is removal of unicentric tumour with 1 cm clearance margin.
• The placement of surgical clips at lumpectomy enables visualization of
lumpectomy cavity.
• Specimen is marked after placing in orientation grid and
mammography is done followed by frozen section biopsy to look for
margin clearance .At least 2 mm clearance is needed for adequacy.

69. Conservative breast surgery
• If margin remains positive after biopsy, cavity brushing is done .After
a maximum of 2 cavity brushing ,if margin is still positive mastectomy
is required.
• In addition to being equivalent to oncologic safety ,lumpectomy
appears to offer advantage with regard to asthetic outcomes and
quality of life.

70. Specimen mammography
The specimen mammogram
contains suspicious mass seen
on peroperative image.

71. CONSERVATIVE BREAST SURGERY
B)Quadrantectomy:
It is done as a part of QUART(quadrantectomy, axillary
dissection, and radiotherapy)therapy(by Veronesi from Italy ).
• It includes removal of entire segment /quadrant with 2-3 cm
normal breast tissue clearance along with axillary dissection
(level I and II)and radiotherapy to breast area.
• It is not advocated now a days as there is no outcome
benefit.

72. CONSERVATIVE BREAST SURGERY
DISADVANTAGES:
1. Higher rate of local recurrence .
2. Needs radiotherapy after surgery.
3. It needs strict surveillance of post
operative patient.

73. MASTECTOMY
Mastectomy What is it? Indications Comment
Simple Mastectomy Surgical removal of the
whole of breast tissue
superficial to the
pectoral fascia
Advanced Breast
Carcinoma(M1), also
called Toilet Mastectomy
Often followed by
radiotherapy to axilla as
no pathological staging of
axilla is performed.
Radical Halsted
Mastectomy
Surgical removal of the
whole of breast tissue
including the pectoral
fascia, both pectoralis
muscles and axillary
lymph nodes
Now it is obsolete, but
few surgeons prefer it for
male breast tumour
Causes excessive
morbidity with no
survival benefit, not
performed nowadays.
Modified Radical
Mastectomy
Surgical removal of the
whole of breast tissue
including the pectoral
fascia and level I, II
&/or level III axillary
lymph nodes
Locally Advanced Breast
Carcinoma(T3,T4,N2)
Most widely practised
surgery.
73

74. MODIFIED RADICAL MASTECTOMY:
• Most acceptable and most widely practised surgery.
• Advantages over radical mastectomy:
o Good postoperative cosmetic appearance
o Maintain motor activity in the arm
o Low rate of postoperative arm oedema
o Easy postoperative breast reconstruction
74

75. MODIFIED RADICAL MASTECTOMY:
• It is of 3 types:
1. Patey’s Modified Radical Mastectomy :- Pectoralis
major muscle is preserved and Pectoralis minor
removed
2. Scanlon’s Modified Radical Mastectomy :– Pectoralis
minor muscle is divided but not removed.
3. Auchincloss’ Modified Radical Mastectomy :– Pectoralis
minor is retraced but not divided.
Auchincloss’ Modified Radical Mastectomy is widely practiced
nowadays.
75

76. MODIFIED RADICAL MASTECTOMY:
INCISION
Two transverse elliptical incisions,
including the nipple areola
complex and skin overlying the
tumour together with skin
margins that lie 1-2 cm from the
cephalic and caudal extents of the
tumour.
76

77. MODIFIED RADICAL MASTECTOMY:
• Anatomical boundaries of MRM:
 Lateral - anterior margin of latissimus dorsi muscle
 Medial - sternal border
 Superior - clavicle
 Inferior – up to upper ¼ th of rectus sheath.
77

78. MODIFIED RADICAL MASTECTOMY:
78

79. MODIFIED RADICAL MASTECTOMY:
• Three important structures should be preserved:
1. Axillary vein
2. Bell’s nerve(long thoracic nerve)
3. Cephalic vein
79

80. MODIFIED RADICAL MASTECTOMY:
• A complete axillary block dissection should include node clearance up
to level III:
Level I:located lateral to Pectoralis minor muscle.
Level II:located beneath the Pectoralis minor muscle.
Level III:located medial to Pectoralis minor muscle.
80

81. MODIFIED RADICAL MASTECTOMY:
• Complications of MRM:
PEROPERATIVE
oAnesthetic complications
oHemorrhage
oInjury to nearby nerves & muscles
POSTOPERATIVE
Early:
oSeroma/lymph collection(30-50%)
oSecondary infection
81

82. MODIFIED RADICAL MASTECTOMY:
oFlap necrosis
oPain & numbness
oShoulder dysfunction
oWinging of scapula
Late:
oLymphedema
oLymphangiosarcoma
(Stewart treve’s syndrome)
3-5 yr after lymphedema development
Ipsilateral limb
Multiple subcutaneous nodule
Require amputation
82

83. AXILLARY SURGERY
• Role of axillary surgery in CA breast is debated, but it is accepted that
presence of metastatic disease within axillary lymph nodes is still the
best single marker for prognosis.
• In early breast carcinoma, if there is no clinically apparent nodes and
the disease is not multicentric, then sentinel node biopsy is
considered.
• Otherwise Complete Axillary Dissection is done.
83

84. AXILLARY SURGERY
SENTINEL NODE BIOPSY:
• Sentinel means guard. Sentinel node is the first lymph node to get
enlarged in malignancies.
• Indication:
Early breast cancer with clinically node negative axilla.
• Procedure:
 On the day prior to surgery, the radioactive colloid
(Technetium 99m sulfur or radioalbumin) is injected using a
tuberculin syringe into three to four separate sites at the
cancer area or subdermally proximal to cancer; the node
biopsied using hand-held gamma camera peroperatively.
 Alternatively during surgery methylene blue is injected into
the tumor and the sentinel node identified and sent for frozen
section biopsy. 84

85. AXILLARY SURGERY
SENTINEL NODE BIOPSY:
• Interpretation:
1. If –ve: no axillary block dissection is required.
2. If +ve: axillary block dissection is done.
• Fallacy of sentinel lymph node biopsy: 3% show skip malignancy
85

86. Reconstruction surgery
Goal of reconstructive surgery after mastectomy are wound closure
and breast reconstruction.
Methods of reconstruction
Insertion of breast implants or expanders -best for small breast
Flap reconstruction if a more radical removal of skin and
subcutaneous tissue has been done
o Latissimus dorsi musculocutaneous flap (LD flap )
o Transversus abdominis muscle flap (TRAM flap )
Flap with implant or expanders
Nipple is created using nipple sharing from contralateral nipple
using composite graft .

87. Reconstruction surgery
Latissimus dorsi flap
In original position In new location
location

88. Breast implants
• Technically simple
• Achieves symmetry easily
• Implant in submuscular plane is better whenever muscle is not
removed during surgery
• Subcutaneous implant is placed in case of radical mastectomy.
• Silicon gel implants or saline implants are used.

89. Adjuvant THERAPY for carcinoma of breast
BY
ADITYA SARKAR
& SANJOY MONDAL
89

90. Adjuvant therapy for breast cancer is any treatment given after
primary therapy to increase the chance of long-term disease free
survival.
What is adjuvant therapy for breast
cancer?
90

91. ADJUVANT THERAPY
Radiotherapy Systemic therapy
Chemotherapy
Hormonal therapy
91

92. RADIOTHERAPY IN CA
BREAST
To the Chest Wall To the Axilla
• T3,T4 tumour >5cm
• Residual disease-LABC
• Positive margin
• After conservative surgery
• Higher risk group
• Inflammatory carcinoma
• 4 or more nodes positive
• Extranodal spread
• Axillary status not
known(inadequate
sample)
INDICATIONS:
92

93. RADIOTHERAPY IN CA BREAST
Accelerated Partial Breast Irradiation (APBI)
• Only to the lumpectomy bed
• By increasing the radiation fraction size and
decreasing the target volume in a shorter
period.
• APBI is generally defined as radiation therapy
that uses daily fraction doses greater than 2
cGy delivered in less than 5 weeks
93

94. RADIOTHERAPY IN CA
BREASTBrachytherapy in Breast Cancer- It refers to use of radiation
sources in or close to the tumour.
External Radiotherapy –
• Sites: breast area, axilla (in selected patients like if axillary
dissection is not done or more than 4 positive axillary
nodes) internal mammary and supraclavicular area
• Total dosage 5000 cGY units
200-cGY units daily 5 days a week for 6 weeks.
94

95. RADIOTHERAPY IN CA BREAST
A. Comprehensive chest wall
and regional lymph node
radiation therapy.
B.cross-sectional view showing the tangential field.
95

96. ADJUVANT HORMONAL
THERAPYPrinciples:
 It is used in ER/PR positive patient in all age groups
 It gives Prophylaxis against carcinoma of opposite Breast
 It is not used in ER negative Patients
The Drugs are Categorised as follows:
1st line- Anti oestrogen Tamoxifen
2nd line- Aromatase inhibitor ,Prevent the synthesis of oestrogen by blocking aromatase
inhibitor enzyme which converts androstenedione to oestradiol on adrenals.
1st generation: Aminoglutathemaide
2nd generation: Anastrozole, Letrozole,
3rd line: Progestogens-megestrol acetate 400mg per day
4th line: Androgen fluoxymesterone 30 mg daily
96

97. Tamoxifen:
Oestrogen Receptor Antagonist
20mg once daily for 5 years
Half life is 7 days
Used commonly in Premenopausal women
Adverse Effects: Flushing, tachycardia, Sweating, vaginal atrophy, itching, bone pain
Advantages: Reduces recurrence rate by 25%
Equally effective in male breast carcinoma
Cheap easily available less toxic
Advantage of AHT:
It is relatively safe easy to administer
Used in metastatic carcinoma of breast
ADJUVANT HORMONAL
THERAPY
97

98. Indications:
• Tumour size >1cm
• Tumour size <1cm with ER negative,HER-2
Positive, high grade
• Lymphovascular or perinural invasion
ADJUVANT CHEMOTHERAPY
98

99. ADJUVANT CHEMOTHERAPY
• Adjuvant Chemotherapy refers to administration of cytotoxic drugs to women after
breast cancer surgery to eliminate undetectable distant spread.
• 1st line drugs used-
• 2nd line drugs- Taxanes Paclitaxel docetaxel
• 3rd line drugs- Gemiticabine
CMF regime CAF regime MMM regime
Cyclophosphamide Cyclophosphamide Methotrexate
Methotrexate Adriamycin Mitomycin-C
5-Fluorouracil 5-Fluorouracil Mitozantrone
99

100. ADJUVANT
CHEMOTHERAPY
100

101. Adjuvant Trastuzumab therapy:
Transtuzumab: A monoclonal antibody against tyrosine kinase receptor(HER-
2) is administrated in patients with HER-2 +ve Patients to improve Disease
Free Survival(DFS)
Dose: Loading 4mg/kg
Maintenance: 2mg/kg for 9 weeks
ADJUVANT CHEMOTHERAPY
101

102. Chemotherapy: Infections and bruise or bleed easily, less energy loss of
appetite, nausea, vomiting, diarrhoea, or mouth sores.
Chemotherapy drugs, Anthracyclines can increase the risk of heart problems.
Trastuzumab: Trastuzumab can induce nausea, vomiting, hot flashes, and joint pain.
Trastuzumab can also increase the risk of heart problems.
Radiation therapy:Skin in the area treated by radiation may become red,
dry, tender, and itchy, and the breast may feel heavy and tight.
SIDE EFFECTS OF ADJUVANT THERAPY
102

103. Hormonal therapy: Hot flushes, vaginal discharge, and nausea.
Tamoxifen also increases the risk of cataract development .
Aromatase inhibitors: Hot flashes, vaginal dryness, and other symptoms of
menopause joint pain (arthralgia) or muscle pain (myalgia) during treatment
SIDE EFFECTS OF ADJUVANT
THERAPY
103

104. • Adjuvant chemotherapy is given orally (by mouth) or by injection
into a blood vessel. It is given in cycles, consisting of a treatment period
followed by a recovery period. The number of cycles depends on the
types of drugs used. Adjuvant chemotherapy usually does not last for
much more than 6 months.
Trastuzumab is given by infusion into a blood vessel every 1 to 3
weeks for a year.
How is adjuvant therapy given, and
for how long?
104

105. • Hormonal therapyis usually given orally, as a pill.
 Most women who undergo hormonal therapy take tamoxifen every day
for 5 years.
 Some women may take an aromatase inhibitor every day for 5 years
instead of tamoxifen.
 Some women may receive additional treatment with an aromatase
inhibitor after 5 years of tamoxifen.
• Radiation therapy is given after mastectomy is divided into small
doses given once a day over the course of several weeks.
How is adjuvant therapy given, and
for how long?
105

106. SUMMARY OF MANAGEMENT OF BREAST CA
• Early breast carcinoma(T1,T2,N0,N1):
o BCS + sentinel node biopsy/Axillary LN dissection(as indicated) +
adjuvant radiotherapy and chemotherapy(as
indicated)………RECENT TREND
• Locally Advanced Breast Carcinoma(T3,T4,N2):
o NACT(to know to response of drugs that will be given as
adjuvant) + MRM(BCS if possible) + Adjuvant therapy
• Advanced breast carcinoma:
o Hormone therapy as toxicity less;chemotherapy if given,with one
drug;Toilet mastectomy if needed.
106

107. THANK YOU
107