Al-Esraa University College

Medical Instrumentation Engineering Department

2nd Stage
Anatomy

Breast Cancer

Lecture
Asst.Lec. Mohamad Sareeh

Prepared by:
1)Osama Hayder Ismaeel Khaleel -A-
2)Tabarak Jalal Mousa Azez -A-
3) Aya Nasser Rasheed Saleh -A-
4)Ghufran Adil Hashim Reda -B-
5)Aya Ali Abd-Alrasool Abbas -A-
Introduction:
Breast cancer, the most frequently occurring cancer in women, is a major
public health problem, with 1,384,155 estimated new cases worldwide with
nearly 459,000 related deaths. Breast cancer is highly heterogeneous in its
pathological characteristics, some cases showing slow growth with excellent
prognosis, while others being aggressive tumors. Current predictions and
statistics suggest that both worldwide incidence of breast cancer and related
mortality are on the rise.

Breast cancer is cancer that develops from breast tissue. Signs of breast cancer
may include a lump in the breast, a change in breast shape, dimpling of the
skin, and fluid coming from the nipple, a newly-inverted nipple, or a red or
scaly patch of skin. In those with distant spread of the disease, there may be
bone pain, swollen lymph nodes, shortness of breath, or yellow skin.
Breast cancer most commonly develops in cells from the lining of milk ducts
and the lobules that supply these ducts with milk. And there are more than 18
other sub-types of breast cancer.

According to 2012 GLOBOCAN statistics, nearly 1.7 million women were

diagnosed with breast cancer with 522,000 related deaths—an increase in
breast cancer incidence and related mortality by nearly 18 % from 2008.
According to American Cancer Society, one in eight women in the United
States will develop breast cancer in her lifetime. It has been predicted that the
worldwide incidence of female breast cancer will reach approximately 3.2
million new cases per year by 2050. These numbers reflect the magnitude of
breast cancer incidence, its effect on society worldwide and the need for
urgency for preventive and treatment measures.
Breast Cancer Epidemiology and Risk Factors:
Breast cancer is the most commonly diagnosed cancer among US women, with
an estimated 268,600 newly diagnosed women with invasive disease (48,100
cases of ductal carcinoma in situ [DCIS]) in 2019, accounting for
approximately 15.2%-30% of all new cancer cases among women, depending
on the data sources. (In men, the 2019 estimate is 2,670 new cases of breast
cancer, accounting for < 1% of all new cancer cases among men.) Each year,
nearly 42,000 women die of breast cancer, making it the second-leading cause
of cancer deaths among US women after lung cancer. The lifetime risk of dying
of breast cancer is approximately 2.6%.

Fig 1 Breast cancer epidemiology and risk

factors. 2019 Prevalence of US female breast
cancer relative to other common cancers. Image
from the National Cancer Institute (NCI),
Surveillance, Epidemiology, and End Results
Program (SEER).

Fig 2 Breast cancer epidemiology and risk

factors. These graphs illustrate 2019 US female
breast cancer statistics at glance from the
National Cancer Institute (NCI)'s Surveillance,
Epidemiology, and End Results Program (SEER).
Variation among populations:
The international incidence of female breast cancer varies markedly, being
highest in the United States and Northern Europe, intermediate in Southern and
Eastern Europe and South America, and lowest in Asia. From 1983 to 1987, the
age-adjusted incidence rate of breast cancer varied by factor of about 5 between
countries (see image below). However, incidence rates have been rising in
traditionally low-incidence Asian countries, particularly in Japan, Singapore,
and urban areas of China, as these regions make the transition toward a
Western-style economy and pattern of reproductive behavior.

Fig 3 Breast cancer epidemiology and risk factors. 1982 Average annual breast cancer incidence per 100,000 women
by age in San Francisco, United States, Japan, and China.

Age-incidence curve of breast cancer risk:

Breast cancer incidence rates increase sharply with age, becoming substantial
before age 50 years. During the premenopausal years, the rate of increase in
incidence is common around the world, approximately 8%-9% per year. The
rate of increase in breast cancer incidence continues throughout life but slows
substantially after menopause, to approximately 2%-3% per year. Reproductive
hormones account for this dependence of incidence on menopausal status. (See
below).

Fig 4 Breast cancer epidemiology and risk factors. Percentage of new US cases of female breast cancer by age group
(2012-2016) from the National Cancer Institute (NCI), Surveillance, Epidemiology, and End Results Program (SEER).

Trends in incidence and mortality around the world:

Since the 1950s, breast cancer incidence has been increasing in many of the
lower-risk countries, as well as in high-risk Western countries. Some of the
recent increases in incidence in high-risk populations may be due in part to
greater use of mammography, as in the United States. This appears to be the
case in Sweden and in England and Wales. However, in Norway, a substantial
increase in breast cancer incidence occurred between 1983 and 1993 despite
low use of mammographic screening.
Breast cancer incidence rates have nearly doubled in recent decades in
traditionally low-risk countries such as Japan and Singapore and in the urban
areas of China. Dramatic changes in lifestyle in such regions brought about by
growing economies, increasing affluence, and increases in the proportion of
women in the industrial workforce have affected the population distribution of
established breast cancer risk factors, including age at menarche and fertility
and nutritional status, including height and weight. These changes have resulted
in a convergence toward the risk-factor profile of Western countries.

Signs and symptoms of Breast Cancer:

Breast cancer most commonly presents as a lump that feels different from the
rest of the breast tissue. More than 80% of cases are discovered when a person
detects such a lump with the fingertips. The earliest breast cancers, however,
are detected by a mammogram. Lumps found in lymph nodes located in the
armpits may also indicate breast cancer.
Indications of breast cancer other than a lump may include thickening different
from the other breast tissue, one breast becoming larger or lower, a nipple
changing position or shape or becoming inverted, skin puckering or dimpling, a
rash on or around a nipple, discharge from nipple/s, constant pain in part of the
breast or armpit and swelling beneath the armpit or around the collarbone. Pain
("mastodynia") is an unreliable tool in determining the presence or absence of
breast cancer, but may be indicative of other breast health issues.

According to the American Cancer Society, any of the following unusual

changes in the breast can be a symptom of breast cancer:
 swelling of all or part of the breast
 skin irritation or dimpling
 breast pain
 nipple pain or the nipple turning inward
 redness, scaliness, or thickening of the nipple or breast skin
 a nipple discharge other than breast milk
 a lump in the underarm area
These changes also can be signs of less serious conditions that are not
cancerous, such as an infection or a cyst.
Types of breast cancer:
Breast cancer can develop in the ducts that carry milk to the nipple, the lobules
that produce milk, or the tissue in between. Learn about the different types of
breast cancer, including non-invasive, invasive, and metastatic breast cancers,
and others.

Most known Breast cancers are:

 Ductal Carcinoma In Situ (DCIS)
Ductal carcinoma in situ (DCIS) is non-invasive breast cancer. Ductal
means that the cancer starts inside the milk ducts, carcinoma refers to
any cancer that begins in the skin or other tissues (including breast
tissue) that cover or line the internal organs, and in situ means "in its
original place."
 Invasive Ductal Carcinoma (IDC)
Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal
carcinoma, is the most common type of breast cancer. About 80% of all
breast cancers are invasive ductal carcinomas.
Invasive means that the cancer has “invaded” or spread to the surrounding
breast tissues. Ductal means that the cancer began in the milk ducts, which
are the “pipes” that carry milk from the milk-producing lobules to the
nipple. Carcinoma refers to any cancer that begins in the skin or other tissues
that cover internal organs — such as breast tissue.
 IDC Type: Tubular Carcinoma of the Breast
Tubular carcinoma of the breast is a subtype of invasive ductal
carcinoma (cancer that begins inside the breast's milk duct and spreads
beyond it into healthy tissue). Tubular carcinomas are usually small (about 1
cm or less) and made up of tube-shaped structures called "tubules." These
tumors tend to be low-grade, meaning that their cells look somewhat similar
to normal, healthy cells and tend to grow slowly.
 IDC Type: Medullary Carcinoma of the Breast
 Medullary carcinoma of the breast is a rare subtype of invasive ductal
carcinoma (cancer that begins in the milk duct and spreads beyond it),
accounting for about 3-5% of all cases of breast cancer. It is called
“medullary” carcinoma because the tumor is a soft, fleshy mass that
resembles a part of the brain called the medulla.
 IDC Type: Mucinous Carcinoma of the Breast
Mucinous carcinoma of the breast — sometimes called colloid carcinoma —
is a rare form of invasive ductal carcinoma (cancer that begins in the milk
duct and spreads beyond it into nearby healthy tissue).
 IDC Type: Papillary Carcinoma of the Breast
Invasive papillary carcinomas of the breast are rare, accounting for less than
1-2% of invasive breast cancers. In most cases, these types of tumors are
diagnosed in older women who have already been through menopause. An
invasive papillary carcinoma usually has a well-defined border and is made
up of small, finger-like projections
 IDC Type: Cribriform Carcinoma of the Breast
In invasive cribriform carcinoma, the cancer cells invade the stroma
(connective tissues of the breast) in nestlike formations between the ducts
and lobules. Within the tumor, there are distinctive holes in between the
cancer cells, making it look something like Swiss cheese. Invasive cribriform
carcinoma is usually low grade
 Invasive Lobular Carcinoma (ILC)
sometimes called infiltrating lobular carcinoma, is the second most common
type of breast cancer after invasive ductal carcinoma (cancer that begins in
the milk-carrying ducts and spreads beyond it). According to the American
Cancer Society, more than 180,000 women in the United States find out they
have invasive breast cancer each year. About 10% of all invasive breast
cancers are invasive lobular carcinomas. (About 80% are invasive ductal
carcinomas.)
 Inflammatory Breast Cancer
Inflammatory breast cancer (IBC) is a rare and aggressive form of breast
cancer. According to the American Cancer Society, about 1% of all breast
cancer cases in the United States are inflammatory breast cancers.
 Inflammatory breast cancer usually starts with the reddening and swelling of
the breast instead of a distinct lump. IBC tends to grow and spread quickly,
with symptoms worsening within days or even hours.
 Lobular Carcinoma In Situ (LCIS)
Lobular carcinoma in situ (LCIS) is an area (or areas) of abnormal cell growth
that increases a person’s risk of developing invasive breast cancer later on in
life. Lobular means that the abnormal cells start growing in the lobules, the
milk-producing glands at the end of breast ducts. Carcinoma refers to any
cancer that begins in the skin or other tissues that cover internal organs —
such as breast tissue.
 Male Breast Cancer
Breast cancer in men is a rare disease. Less than 1% of all breast cancers
occur in men. In 2020, about 2,620 men are expected to be diagnosed with
the disease, and an estimated 520 men are expected to die from breast
cancer. For men, the lifetime risk of being diagnosed with breast cancer is
about 1 in 833.
Because breast cancer in men is rare, few cases are available to study. Most
studies of men with breast cancer are very small. But when a number of
these small studies are grouped together, we can learn more from them.
 Molecular Subtypes of Breast Cancer
There are five main intrinsic or molecular subtypes of breast cancer that are
based on the genes a cancer expresses:
I. Luminal A
II. Luminal B
III. Triple-negative/basal-like
IV. HER2-enriched
V. Normal-like
 Paget's Disease of the Nipple
Paget's disease of the nipple is a rare form of breast cancer in which cancer
cells collect in or around the nipple. The cancer usually affects the ducts of
the nipple first (small milk-carrying tubes), then spreads to the nipple surface
and the areola (the dark circle of skin around the nipple). The nipple and
areola often become scaly, red, itchy, and irritated.
  Phyllodes Tumors of the Breast
Phyllodes tumors of the breast are rare, accounting for less than 1% of all
breast tumors,
Phyllodes tumors tend to grow quickly, but they rarely spread outside the
breast, Although most phyllodes tumors are benign (not cancerous), some
are malignant (cancerous) and some are borderline (in between
noncancerous and cancerous). All three kinds of phyllodes tumors tend to
grow quickly, and they require surgery to reduce the risk of a phyllodes tumor
coming back in the breast (local recurrence).
 Metastatic Breast Cancer
Cancer cells can break away from the original tumor in the breast and travel
to other parts of the body through the bloodstream or the lymphatic system,
which is a large network of nodes and vessels that works to remove bacteria,
viruses, and cellular waste products.

Methods of prevent Breast cancer:

LifeStyle:
Women can reduce their risk of breast cancer by maintaining a healthy weight,
reducing alcohol use, increasing physical activity, and breast-feeding. These
modifications might prevent 38% of breast cancers in the US, 42% in the UK,
28% in Brazil, and 20% in China. The benefits with moderate exercise such as
brisk walking are seen at all age groups including postmenopausal women.
High levels of physical activity reduce the risk of breast cancer by about 14%.
Strategies that encourage regular physical activity and reduce obesity could
also have other benefits, such as reduced risks of cardiovascular disease and
diabetes. The American Cancer Society and the American Society of Clinical
Oncology advised in 2016 that people should eat a diet high in vegetables,
fruits, whole grains, and legumes. High intake of citrus fruit has been
associated with a 10% reduction in the risk of breast cancer. Marine omega-3
polyunsaturated fatty acids appear to reduce the risk. High consumption of soy-
based foods may reduce risk.
Pre-emptive surgery:
Removal of both breasts before any cancer has been diagnosed or any
suspicious lump or other lesion has appeared (a procedure known as
"prophylactic bilateral mastectomy" or "risk reducing mastectomy") may be
considered in people with BRCA1 and BRCA2 mutations, which are associated
with a substantially heightened risk for an eventual diagnosis of breast cancer.
Evidence is not strong enough to support this procedure in anyone but those at
the highest risk. BRCA testing is recommended in those with a high family risk
after genetic counseling. It is not recommended routinely. This is because there
are many forms of changes in BRCA genes, ranging from harmless
polymorphisms to obviously dangerous frameshift mutations. The effect of
most of the identifiable changes in the genes is uncertain. Testing in an
average-risk person is particularly likely to return one of these indeterminate,
useless results. Removing the second breast in a person who has breast cancer
(contralateral risk‐reducing mastectomy or CRRM) may reduce the risk of
cancer in the second breast, however, it is unclear if removing the second breast
in those who have breast cancer improves survival.

Medications:
The selective estrogen receptor modulators (such as tamoxifen) reduce the risk
of breast cancer but increase the risk of thromboembolism and endometrial
cancer. There is no overall change in the risk of death. They are thus not
recommended for the prevention of breast cancer in women at average risk but
it is recommended they be offered for those at high risk and over the age of 35.
The benefit of breast cancer reduction continues for at least five years after
stopping a course of treatment with these medications. Aromatase inhibitors
may be more effective than selective estrogen receptor modulators (such as
tamoxifen) at reducing breast cancer risk and they are not associated with an
increased risk of endometrial cancer and thromboembolism.
Stages of breast cancer:
Stage 0
Stage 0 means that the cancer is limited to the inside of the milk duct and is
non-invasive. Treatment for this non-invasive breast tumor is often different
from the treatment of invasive breast cancer.
Ductal carcinoma in situ (DCIS) is a stage 0 breast tumor.
Lobular carcinoma in situ (LCIS) used to be categorized as stage 0, but this has
been changed because it is not cancer. Still, it does indicate a higher risk of
breast cancer.

Stages I-III
Treatment for stages I to III breast cancer usually includes surgery and
radiation therapy, often with chemo or other drug therapies either before
(neoadjuvant) or after (adjuvant) surgery.
Stage I: These breast cancers are still relatively small and either have not
spread to the lymph nodes or have only a tiny area of cancer spread in the
sentinel lymph node (the first lymph node to which cancer is likely to spread).
Stage II: These breast cancers are larger than stage I cancers and/or have
spread to a few nearby lymph nodes.
Stage III: These tumors are larger or are growing into nearby tissues (the skin
over the breast or the muscle underneath), or they have spread to many nearby
lymph nodes.

Stage IV (metastatic breast cancer)

Stage IV cancers have spread beyond the breast and nearby lymph nodes to
other parts of the body. Treatment for stage IV breast cancer is usually a
systemic (drug) therapy.
Recurrent breast cancer
Cancer is called recurrent when it comes back after primary treatment.
Recurrence can be local (in the same breast or in the surgery scar), regional (in
nearby lymph nodes), or in a distant area. Treatment for recurrent breast
cancer depends on where the cancer recurs and what treatments you’ve had
before.

Breast cancer management:

The management of breast cancer depends on various factors, including the
stage of the cancer and the person's age. Treatments are more aggressive when
the cancer is more advanced or there is a higher risk of recurrence of the cancer
following treatment. Breast cancer is usually treated with surgery, which may
be followed by chemotherapy or radiation therapy, or both. A multidisciplinary
approach is preferable. Hormone receptor-positive cancers are often treated
with hormone-blocking therapy over courses of several years. Monoclonal
antibodies, or other immune-modulating treatments, may be administered in
certain cases of metastatic and other advanced stages of breast cancer.
Although this range of treatment is still being studied.

Surgery
Surgery involves the physical removal of the tumor, typically along with some
of the surrounding tissue. One or more lymph nodes may be biopsied during the
surgery; increasingly the lymph node sampling is performed by a sentinel
lymph node biopsy.
Once the tumor has been removed, if the person desires, breast reconstruction
surgery, a type of plastic surgery, may then be performed to improve the
aesthetic appearance of the treated site.
Medication
Medications used after and in addition to surgery are called adjuvant therapy.
Chemotherapy or other types of therapy prior to surgery are called neoadjuvant
therapy. Aspirin may reduce mortality from breast cancer when used with other
treatments.
There are currently three main groups of medications used for adjuvant breast
cancer treatment: hormone-blocking agents, chemotherapy, and monoclonal
antibodies.
 Hormonal therapy
 Chemotherapy
 Monoclonal antibodies

Radiation
Radiotherapy is given after surgery to the region of the tumor bed and regional
lymph nodes, to destroy microscopic tumor cells that may have escaped
surgery. It may also have a beneficial effect on tumor microenvironment.
Radiation therapy can be delivered as external beam radiotherapy or as
brachytherapy (internal radiotherapy). Conventionally radiotherapy is given
after the operation for breast cancer. Radiation can also be given at the time of
operation on the breast cancer. Radiation can reduce the risk of recurrence by
50–66% (1/2 – 2/3 reduction of risk) when delivered in the correct dose and is
considered essential when breast cancer is treated by removing only the lump
(Lumpectomy or Wide local excision). In early breast cancer, partial breast
irradiation does not give the same cancer control in the breast as treating the
whole breast and may cause worse side effects.
Follow-up care
Care after primary breast cancer treatment, otherwise called 'follow-up care',
can be intensive involving regular laboratory tests in asymptomatic people to
try to achieve earlier detection of possible metastases. A review has found that
follow-up programs involving regular physical examinations and yearly
mammography alone are as effective as more intensive programs consisting of
laboratory tests in terms of early detection of recurrence, overall survival and
quality of life. Multidisciplinary rehabilitation programmes, often including
exercise, education and psychological help, may produce short-term
improvements in functional ability, psychosocial adjustment and social
participation in people with breast cancer.
References:
 SpringerLink | Breast Cancer: Epidemiology and Etiology
28 December 2014
https://link.springer.com/article/10.1007/s12013-014-0459-6

 MedScape | Breast Cancer Epidemiology and Risk Factors

26 December 2019
https://emedicine.medscape.com/article/1697353-overview

 Breast Cancer Organization | Symptoms and Diagnosis

https://www.breastcancer.org/symptoms

 American Cancer Society | Treatment of Breast Cancer by Stage

https://www.cancer.org/cancer/breast-cancer/treatment/treatment-of-breast-
cancer-by-stage.html

 Wikipedia | Breast Cancer

Last Edit 20 June 2020
https://en.wikipedia.org/wiki/Breast_cancer

 Wikipedia | Breast Cancer Management

Last Edit 10 June 2020
https://en.wikipedia.org/wiki/Breast_cancer_management