Have well defined borders compared to malignant

diseases.

• Fibrcystic disease
Surgery (Dr. Salcedo)
o softer
• Fibroadenoma
Breast
o painful before menstruation
Breast is composed of adipose tissue with ducts
Breast Cancer
and lobules where cancer may arise.
Can be hereditary or sporadic.
Blood Supply
Risk Factors
1. Perforating branches of the internal mammary
artery.
Hormonal: Estrogen
2. Lateral branches of the posterior intercostals
arteries.
1. Early menarche
3. Branches of the axillary artery.
2. Late menopause
a. Highest thoracic
3. Nulliparity
b. Lateral thoracic
4. Late FT pregnancy
c. Pectoral branches of the thoracoacromial
5. Obesity
artery
6. HRT (Hormone replacement therapy
Anatomy
Estrogen most common cause of hormonal breast
cancer.
Male carcinoma is a more aggressive type.
The longer the ‘estrogen window’, the higher the risk.
(1 and 2)

Non Hormonal

1. Radiation exposure
2. Alcohol
3. Fatty foods

Others

1. BRCA 1 and BRCA 2

Lymphatics
The older you get, the more chances you are to have
Level 1 cancer.
• Axillary Vein (lateral)
• External mammary (anterior) BRCA
• Scapular (posterior)

Level 2 BRCA1 BRCA2

• Central
• Interpectoral (Rotter’s) Lifetime risk of 90% 85%
Breast CA
Level 3 Ovarian CA 40% 20%
• Subclavicular
Pathology Invasive ductal Invasive ductal
CA CA

Differentiation Poorly Well

differentiated differentiated
Receptor Status Hormone Hormone
receptor (-) receptor (+)

Other features Bilateral breast Male breast CA

CA

Benign Breast Diseases

 Associated CA Ovarian, Colon, Ovarian, Colon,
Prostate Prostate,
Pancreas, GB,
Skin dimpling
Bile ducts,
Stomach,
Melanoma

Risk Management

Breast Exam
• Monthly SBE (5-7 days after menstruation)
• CBE (Clinical Breast Examination)

Mammogram
• Baseline mammogram at age 35 years
• Annual mammogram starting at age 25 years
Can catch small lesions in its’ in situ stage.
Dimpling of the skn over a carcinoma is caused by
the involvement and retraction of the suspensory
(Cooper’s) ligament.

Tamoxifen (Estrogen antagonist)

BRCA Carriers

1. Prophylactic mastectomy and reconstruction

2. Prophylactic oophorectomy and hormone
replacement therapy
3. Intensive surveillance for breast and ovarian CA
4. Chemoprevention

Lump Nipple retraction

- Carcinoma involving the mammary ducts.

Skin Ulceration

- most common complaint

- painless

Orange Peel
Satellite Nodules

Involvement and obstruction of subcutaneous

lymphatic by tumor result in lymphatic dilatation and
lymph accumulation in the skin. Resultant edema creates
“orange peel” appearance due to prominence of skin
gland orifices.

- metastasis to nodes
Diagnosis

Breast Exam

Primary indication of ductography is

nipple discharge, particularly when the fluid
contains blood.
Imaging Studies
2. Ultrasound
• Cystic vs. Solid
1. Mammography
• MLO and CC view • Used to guide FNAB, core-needle biopsy,
• Solid mass with or without satellite and needle localization of breast lesions.
• Not reliably detect lesions that are <1cm
features
• Asymmetric thickening of breast tissue in diameter.
• Clustered microcalcifications
• Yearly mammogram 3. Sonomammogram

Mammogram

Ductography

4. MRI
 • For high risk women
• Newly diagnosed breast CA
• Detects lesions not detected by UTZ and
Mammogram
- Bigger mass tumors, lesser survival. Lymph nodes are
affected.
Primary Breast Tumor
• Fibrosis of epithelium and stromal tissues
• Shortens Cooper’s ligament
• Subdermal lymphatics
• Skin
• Surrounding skin – satellite nodules
• Size=DFS and overall survival rate, axillary lymph
node involvement

Breast Biopsy

1. FNA

Axillary lymph node metastasis

• Lymphatic spread
• Soft, ill-defined! firm or hard
• Matted! involves contiguous areas
• Sequential involvement
• Most important prognostic factor of DFS and OS
o Node (-) <30% RR
2. Core Needle o Node (+) >75% RR

- gets tissue samples

Distant Metastasis
3. Incision • Neovascularization
• >0.5 cm tumor may metastasize
4. Excision • Pulmonary circulation – axillary and intercostals
vv
• Vertebral colun – Batson’s plexus
• Bone, lung, pleura, soft tissues, liver

Histopathology

In situ
• Basement membrane is intact
• DCIS vs. LCIS
• Multicentric, multifocal

Invasive carcinoma
• Lobular vs. Ductal CA
• NST vs. Special type

5. Image-guided non-palpable lesion

Natural History
LCIS vs. DCIS

Lobar CA In situ (LCIS)

TNM Classification

T0 Carcinoma in situ or
microinvasion

T1 Tumor <2cm
Stage 1A Breast Cancer
T2 Tumor 2-5cm

T3 Tumor >5cm
T4 Overlying skin or
underlying muscle
attachment

N0 No axillary nodal
involvement
N1 Free axillary nodes
(histologically less than
three involved nodes)

N2 More than 3 involved nodes

or fixed axillary nodes
N3 Supraclavicular nodes Stage 1B Breast Cancer
involved

M0 No metastases
M1 Metastatic disease present

Ductal CA In situ (DCIS)

 - skin changes are evident

Stage IIA Breast Cancer

Stage IIIC Breast Cancer

Stage IIB Breast Cancer

- lymph nodes are already involved, regardless the size of

tumor

Stage IV Breast Cancer

Stage IIIB Breast Cancer


- signs of metastasis.
Treatment Options
1. Surgery
• Excision biopsy with or without needle
localization
• Breast conservation therapy
o Lumpectomy
o Segmental mastectomy
o Quadrantectomy
o 2mm margin of normal tissue
• Sentinel Node biopsy
- if negative on one lymph node, probably
negative on other nodes.
• Axillary dissection
o Combined with BCT if sentinel
node is positive
- not done in In situ carcinoma
• Mastectomy
o Total/Simple mastectomy
o MRM (Modified Radical
Mastectomy)
- whole breast is removed to
axillary disection
o Radical mastectomy
- pectoralis muscles is removed
Long thoracic and thoracodorsal nerve should be
preserved.
2. Radiation
3. Chemotherapy
• Neoadjuvant (before surgery) – Stage III
• Adjuvant (after surgery)
4. Hormonal
• Tamoxifen
• Aromatase Inhibitors