CASE REPORT

BREAST TUMOR

WRITTEN BY
Tarathya Bunga Dharmasaputra
NIM 030.11.284

SUPERVISOR
Dr. W. Setiawan, Sp.B

DEPARTMENT OF SURGERY
FACULTY MEDICINE OF TRISAKTI UNIVERSITY
TNI AL Dr. MINTOHARDJO HOSPITAL
PERIOD 16 MAY -22 JULY 2016

CHAPTER 1
CASE REPORT

I.

PATIENT IDENTITY
Name

: Mrs. D.S.

Date of birth

: 10 October 1958

Age

: 57 years old

Gender

: Female

Address

: Pembangunan Street V No. 26 RT 05/002,Gambir, Central Jakarta

Occupation

: Housewife

Religion

: Islam

Race

:Sumatera

Marital status

: Married (Widow)

Education

: High School Graduate

Date of consultation : 24 May 2016

II.

Date of admission

: 30 May 2016, at 17.00

Medical Record

: 157440

ANAMNESIS
Autoanamnesis was done with the patient on May 24th, 2016 at the Outpatient Care Unit, at
11.00, and May 30th 2016 at Pulau Sibatik ward at 18.00 in Angkatan Laut Mintohardjo
Hospital.
Chief Complaint :
Mass on the right breast since 1 year before consultation.
Additional Complaint :
Recurrent uncomfortable dull pain is felt on the mass
Recent Medical History :
Patient came to the Outpatient Care Unit because she felt a mass on the right breast since 1
year ago. The size was about the finger tip of the fifth hand. Patient stated she did not feel
any pain along with the mass back then. There was no occurance of weight loss, signs of
inflammation on the mass, fluid excreted from the nipple, fever, nausea and vomitting at the
2

time. As time goes by, about 7 months later after the first occurance, the patient stated the
mass has grown larger in size and change of color on the mass was present. The color is red
at first. Then, about 1,5 months after that, the patient started to feel uncomfortable dull,
sometimes palpating pain occuring on the mass, especially at night. The sleeping position is
supine with both hands at the side of the body, not raised above the head. Although, fluid
excreted from both nipples were never present until this time. The skin around the breast
was also not ulcerated, nipples werent retracted inward, and there was no dimpling on the
skin either. There was never any weight loss, fever, nausea and vomitting.
Past Medical History :
Patient has a history of hypertension since 5 years ago. The patient was given Captopryl a
long time ago, but felt the drug given makes her heart beats faster. So she has stopped the
medication and decided to take herbal medicine. Since then, her blood pressure are
uncontrolled and resulted in an unstable blood pressure. Because of the planned operation of
the tumor, she had cheked with a Cardiovascular Specialist and were given Amlodipine 5
mg/day. She has no history of Diabetes Mellitus, kidney disease, heart disease, allergic, lung
disease, operation, tumor, or any given radiation (-)
Family History :
Patients father has a history of hypertension, but patient denies cancer or tumor history or
any other medical history from the 1st and 2nd degree family.
Obstetric dan Gynekology History :
Patient got her period the first time when she was about 16 years old. Patient got married at
20 years old, has 5 kids. Each kid was breastfed for at least 2 years. She had used injection
contraceptive method every 3 months. Patient menopaused since she was 50 years old.
Behavioural History :
Patient has never smoked , but her husband had smoked in front of her when he was still
alive. Patient never consumed alcohol either. Patient admitted she used to eat a lot of fat
containing food because back then she just ate what was there at home due to
socioeconomic problem. At home, patient is a housewife, and she usually cooks at home.

III.

PHYSICAL EXAMINATION
General condition

: Moderately ill

Consciousness

: GCS =15 (E4V5M6)

Vital sign

: Blood pressure
Heart rate

: 80 x/minute

Respiration rate

: 20 x/minute

Temperature

: 36,5 C

Body Weight

: 45 kg

Body Height

: 150 cm

Nutritional status

: 130/80 mmHg

: Body Mass Index = 20 (normal)1

GENERALIZED STATUS
- Head

: normocephalic

- Eyes

: anemic conjungtiva -/-, icteric sclera -/-, palpebral swelling -/-

- Ear

: normotia, discharge -/-, serumen +/+.

- Nose

: septum deviation -, discharge -

- Mouth

: good oral hygiene , caries -

- Neck

; enlarged thyroid -, normal JVP, tracheal deviation -

- Regional lymph node

- Thorax

: not enlarged

Lung

Inspection : simetrical, thoraco-abdominal breathing

Palpation : vocal fremitus equally palpated in both hemithorax

Percussion : sonor in both hemithorax

Auscultation : vesicular breathing, ronchi -/-, wheezing -/-

Heart
Inspection

: ictus cordis not clearly seen

Palpation

: pulsating ictus cordis at ICS V, 1 cm lateral from

left midclavicular line

Auscultation

: regular heart beat (S1S2 regular) , gallop (-),murmur (-)

- Abdomen

Inspection

: no vein distention

Palpation

: liver and spleen not palpable, no pain during palpation through all

abdominal region, ballottement -/

Percussion

Auscultation : bowel sound 3x/minute

: tympanic sound at all abdominal region

- Ekstremities
Inspection

: no deformity, no swelling in four extremities

Palpation

: capillary refill time < 2 seconds, no swelling in four extremities.

LOCAL STATUS (MAMMAE REGION)

- Mammae dextra :
Inspection

: asimetrical (slightly higher than the left breast) , mass (+) on the right upper
outer quadrant of the breast, irregular border, round shaped, reddish purpleish
mass, skin erythematous(-), ulcus (-), dimpling (-) , peau de orange (-),
nipple discharge (-),nipple inverted (-), nipple retraction (-) , normal
overlying skin, absent of skin retraction.

Palpation

: mass (+), size 8x 6x5 cm, oval shaped, irregular border, well delimited,
solid and hard mass, smooth outer surface of the mass , immobile,fixed, pain
during palpation on mass (-), warm to touch (-), nipple discharge (-), no
tenderness.

- Mammae sinistra :
Inpection

: asimterical (right breast slightly higher than left breast), absent of mass,
normal overlying skin, absent of dimpling, nipple retraction, discharge, skin
retraction.

Palpation

: normal, no enlarged lymph nodes, no mass

- Lymphatic nodes

: External mammary nodes, scapular nodes, central nodes, interpectoral

nodes, axillary nodes, subclavicular nodes, drainase internal thoracic nodes,
are all not palpable.

IV.

PEMERIKSAAN PENUNJANG
Laboratorium examination pre-operation on 24 May 2016
Laboratorium
Leukosit
Hematokrit
Hemoglobin
Eritrosit
Trombosit
Laju Endap Darah
Differential Count
Basofil
Eosinofil
Neutrofil batang
Neutrofil segmen
Limfosit
Monosit
Hemostasis
PT
APTT
Kimia klinik
Blood Glucose
Renal Function
Ureum
Creatinine

V.

Result
9.600
44*
14.5*
4.87
339.000
22*

Normal range
5.000-10.000 /ul
37 - 42%
12 - 14 g/dl
4,2 5,4 million /L
150.000 450.000 /mm3
<20 mm/hour

0
5*
0*
67
22
6

0-1 %
1-3 %
2-6 %
50-70 %
20-40 %
2-8 %

14,5
49,6*

14-21 second
17,3- 49,3 second

98

<200 mg/dl

30
0,8

17-43 mg/dl
0,6 1,1 mg/dl

RESUME
Patient, Mrs. D.S, 57 years old, a widow, a mother of 5 children, came to the Outpatient
Care Unit with a mass on the right breast since 1 year ago. The size has grown larger from
the size of a finger tip of the fifth hand to the size of a hens egg. About 7 months later after
7

the first occurance, the mass has changed color from red to purplish color. 1,5 months after
that, patient started to feel an uncomfortable dull, sometimes palpating pain occuring on the
mass.
The patient has a history of hypertension since 5 years ago. the first time Patients first
period is when she was about 16 years old. Patient got married at 20 years old, has 5 kids.
Each kid was breastfed for at least 2 years. She had used injection contraceptive method
every 3 months. The patient menopaused when she was 50 years old. Patient used to eat a
lot of fat containing food
Local breast examination shows an assimetrical of two breasts, which the right breast is
slightly higher than the left breast. A single, hens egg shaped, red purplish mass is seen on
the upper outer quadrant of the right breast with a size of 8 x6 x 5 cm , immobile, solid, free
of palpable pain. The area around the mass shown no abnormality.
VI.

WORKING DIAGNOSIS
Tumor Mammae Dextra suspect Malignant

VII.

THERAPY PLAN
- Operation: Excision of tumor mammae dekstra
Pre-operative procedure:
-

Laboratory check (blood count, hemostasis , renal function, blood glucose level)
listed above

Radiology check up (Chest X-Ray) Heart and Lung in a normal condition, CTR <
50%

ECG Normal Sinus Rhythm

Consultation with a Cardiologist Patient has Hypertension grade II (160/110 mmHg),

so the operation is adviced to be done when systolic blood pressure is under 140 mmHg.
Therefore, patient was given Amlodipine 1x 5 mg.

Consultation with an Anaesthesiologist Patient is categorized in ASA II due to

Hypertension grade II and patient must fast for 8 hours before operation. The rest
follows Cardiologist instruction until the day of operation.
8

Intra-operative procedure:
The operative procedure was done on May 31st 2016 at 7.10 a.m 7.50 a.m. The duration of
operation was about 40 minutes.
Type of Anaesthesia: General Anaesthesia (LMA)
Patients position during surgery: supine
Operative method:
-

Incision and excision around tumor

Tumor was separated from healthy tissue around it

Tumor was taken out and bleeding management was done

Excised wound is cleaned and irrigated

Operation has finished

Post-Operation Instruction:
a.

General medication
-

Vital sign observation and consciousness

IVFD RL 20 drip per minute stop and aff when IVFD empty

After patient is awake, start mobilization and patient may eat and drink

After one day of surgery, patient are allowed to be discharged from the hospital and
control to the outpatient care unit on next Tuesday, June 7th 2016.

b.

The excised area must not be in contact with water just yet.

The excised tumor must be sent to the Histopathology Unit for further assessment

Medication
-

Inj Ceftriaxone

2 x 1 gr (iv)

Inj Tramadol

2 x 100 mg (drip)

Continue with oral medications:

-

Cefadroxil

3 x 500 mg

Asam mefenamat

3 x 500 mg

FOLLOW UP POST OP H+1 (June 1st, 2016)

Subjective:

patient has no complaint other than pain on post op area.

Objective:

General condition

: Moderately ill

Conciousness

: GCS 15

Blood pressure

: 130/70 mmHg

Heart Rate

: 86x per minute

Temperature

: 36,7 oC

Respiration rate

: 20x per minute

General Examination
Eyes

: conjunctiva anemis -/-

ENT

: normal

Neck

: no enlargement

Thorax

: Lung: vesicular breathing, wheezing -/-, ronchi -/10

Heart: S1S2 regular, murmur -, gallop

Abdomen

: bowel sound +, pain when palpable

Extremities

: capillary refill test < 2 seconds, oedem -

Local Status Mammae Region

Inspection

: post incision wound post operative on the right breast region which
was closed with a sterile dressing, blood was not seen outside the
outer dressing.

Palpation

: Pain when palpated (+) on the incision area

Asessment

: Post excision wound post-operative Tumor Mammae Dextra

Planning

: Patient is discharged from the hospital

- Medications to continue at home :
Cefadroxil

3 x 500 mg

Asam mefenamat

3 x 500 mg

- Control to the doctor 1 week post-operation and analyze the histopathology result
VIII. PROGNOSIS
Ad vitam

: dubia ad bonam

Ad sanationam

: dubia ad malam

Ad fungsionam

: dubia ad malam

11

Histopathology Result

Macroscopic : brown mass , consisting the skin

Size : 9 x 6 x 5 cm
Microscopic : Mass sample from the right breast,consisting cancerous epithelial mass which
invades the tissue around it. Proliferative tumor cell, creating a solid and skirrus
structure. The nucleus is round to pleomorphic, the chromatin seems rough, and
mitosis was found.
Conclusion

: Histologic imaging resembles Invasive Breast Carcinoma, NOS

Outpatient Follow-up Care:

June 7th, 2016
Patient came for a follow up to the Outpatient Care Unit, and was given a post operative
check up. Patient was explained of the result of the histopathology result and must go back
to the Outpatient Care Unit, on June 14 th, 2016, for future assessment and plan toward her
illness.
June 14th, 2016
The patient will have to do another follow up after Ramadhan.

12

CHAPTER 2
LITERATURE REVIEW
2.1. Basic Anatomy
a. Anatomy

Figure 1. Anatomy of the Breast2

The breast consists glandular tissue, ducts, muscular tissue, fat, blood vessels,
nerves, and lymphatic vessels. The breast extends from from the sternal edge to the anterior
axillary line. The thickest area is usually the tail of the breast which extends into the axilla;
which is the upper outer quadrant. This quadrant contains the greatest bulk of mammary
tissue and about 60% neoplasia occur at this site. There are about 15 to 25 lobes in the
glandular tissue, each drains into a separate excretory duct and terminates in the nipple.
Each lobe consists of 50 to 75 lobules, which drain into a duct which empties into the
excretory duct of the lobe. The nipple and areola contain smooth muscle to contract, which
makes the nipple erect and firm and empties the milk sinuses. The skin of the nipple and
areola is deeply pigmented. Although, the areola contain hair follicles and Montgomerys
tubercles; the sebaceous glands on the areolar surface. The ligaments in the breast is called
the Coopers ligaments which projects the breast tissue as suspensory structures. The
nodularity, density, and fullness of the adult breast depend on several factors; such as the

13

presence of excess adipose tissue, body mass index, and aging factors relating to
menopause.3
b. Lymphatic system

Figure 2. Lymphatic drainage of the breast3

Figure 3. Lymph node levels4

The breast has an extensive network of venous and lymphatic drainage. Most of
the lymphatic drainage empties into the nodes in the axilla. Other nodes lie beneath the
lateral margin of the pectoralis major muscle, along the medial side of the axilla, and in
the subclavicular region.3 The axillary lymph node groups are the lateral axillary vein
group, the external mammary group or anterior or pectoral group, the scapular group or
posterior or subscapular, the central axillary group, the subclavicular group , the
supraclavicular, the internal mammary group, and the interpectoral group (Rotters
lymph nodes). The lymph node groups are assigned levels according to their anatomic
relationship to the pectoralis minor muscle. Level I lymph nodes are lymph nodes
located lateral to or below the lower border of the pectoralis minor muscle. Level II
lymph nodes are lymph nodes located superficial or deep to the pectoralis minor muscle.
Level III lymph nodes are lymph nodes located medial to or above the upper border of
the pectoralis minor muscle.4
c. Vascular
The blood supply to the breast is carried by perforating branches of the internal
mammary artery, lateral branches of the posterior intercostal arteries, and branches from
the axillary artery, including the highest thoracic, lateral thoracic, and pectoral branches
of the thoracoacromial artery. The second, third, and fourth anterior intercostal
perforators and branches of the internal mammary artery form branches in the breast as
14

the medial mammary arteries. The lateral thoracic artery gives off branches to the
serratus anterior, pectoralis major and pectoralis minor, and subscapularis muscles. It
also gives rise to lateral mammary branches. The veins of the breast and chest wall
follow the course of the arteries, with venous drainage being toward the axilla. The three
groups of veins are perforating branches of the internal thoracic vein, perforating
branches of the posterior intercostal veins, and tributaries of the axillary vein.3,4
d. Innervation
Lateral cutaneous (mammary) branches of the third through sixth intercostal nerves
provide sensory innervation of the breast and of the anterolateral chest wall. The anterior
branches of the supraclavicular nerve, supply the upper portion of the breast. The
intercostobrachial nerve is the lateral cutaneous branch of the second intercostal nerve
supply the medial aspect of the upper arm. Batsons vertebral venous plexus, extends from
the base of the skull to the sacrum through vertebrae, facilitate the possible route for breast
cancer metastases to the vertebrae, skull, pelvic bones, and central nervous system.4

2.2. Physiology

15

Figure 4. Neuroendocrine control of the breast develompment and function4

Breast development and function are initiated by a variety of hormonal stimuli, including
estrogen, progesterone, prolactin, oxytocin, thyroid hormone, cortisol, and growth hormone.
Estrogen, progesterone, and prolactin especially have profound trophic effects that are essential to
normal breast development and function. Estrogen initiates ductal development. Progesterone
initiates differentiation of epithelium and lobular development. Prolactin is the primary hormonal
stimulus for lactogenesis in late pregnancy and the postpartum period, by upregulating hormone
receptors and stimulating epithelial development. The secretion of neurotrophic hormones from the
hypothalamus of the anterior pituitary is responsible for regulation of the secretion of the hormones
that affect the breast tissues, such as Gonadotropin-releasing Hormone (GnRH) which releases
Luteinizing Hormone (LH) and Follicle-stimulating Hormone (FSH) to regulate the release of
estrogen and progesterone from the ovaries with positive and negative feedback effects. These
hormones are responsible for the development, function, and maintenance of breast tissues.4

2.3. Tumor

16

Tumor is a mass of abnormal tissue. There are two types of breast tumor; benign or noncancerous and malignant or cancerous.
2.3.1 Benign Breast Tumor
a. Classification
There are two classification of benign breast disease; Aberrations of Normal
Development and Involution (ANDI) and the original classification of benign breast
disorder. The basic principles of ANDI classification of benign breast conditions
consist of the relation between the normal processes of reproductive life and
involution to benign breast disorders and diseases. On the other hand, the original
classification system developed by the various types of benign breast disorders and
diseases that are divided to three clinically relevant groups: nonproliferative
disorders, proliferative disorders without atypia, and proliferative disorders with
atypia.4

Figure 5. ANDI Classification of Benign Breast Disorder4

17

Figure 6. Classification of Benign Breast Disorder4

Non- proliferative /Fibrocystic Disease

Nonproliferative disorders of the breast account for 70% of benign breast conditions
and carry no increased risk for the development of breast cancer. Non-proliferative
Disorder includes duct ectasia, cysts and apocrine metaplasia, mild ductal
hyperplasia, adenosis, and fibroadenoma without complex features.3,4

Proliferative Disorders Without Atypia

Proliferative breast disorders without atypia include sclerosing adenosis, radial scars,
complex sclerosing lesions, ductal epithelial hyperplasia, and intraductal
papillomas.4
- Sclerosing adenosis is prevalent during the childbearing and perimenopausal years.
It has no malignant potential. It is characterized by distorted breast lobules and
usually occurs as multiple microcysts, presents as a palpable mass.
- Radial and complex sclerosing lesions are usually up to 1 cm in diameter (radial
scars. Larger lesions are called complex sclerosing lesions. Radial scars originate at
sites of terminal duct branching where the characteristic histologic changes radiate
from a central area of fibrosis.
- Moderate / Florid ductal epithelial hyperplasia is characterized by the presence of
five or more cell layers above the basement membrane. It occupies at least 70% of a
minor duct lumen. It can be solid or papillary, and the cancer risk is increased.
18

- Intraductal papillomas usually occur in the major ducts, usually in premenopausal

women. The diameter is about <0.5 cm to 5 cm. A serous or bloddy nipple discharge
is a common symptom. It rarely transforms into malignancy, except in younger
women.

Atypical Proliferative Diseases

This classification includes Atypical ductal hyperplasia (ADH) and Atypical Lobular
Hyperplasia (ALH).4
- Atypical ductal hyperplasia (ADH) appears similar to low grade ductal carcinoma
in situ (DCIS) histologically. It is composed of monotonous round, cuboidal, or
polygonal cells enclosed by basement membrane with rare mitoses. ADH lesion is up
to 2 or 3 mm in size; if larger would be called DCIS People diagnosed with ADH
have increased risk for development of breast cancer.
- Atypical Lobular Hyperplasia (ALH) is a spectrum of disorders which may range to
lobular carcinoma in situ (LCIS). ALH results in minimal distention of lobular units
with cells that are similar to LCIS. The diagnosis of LCIS is made when small
monomorphic cells that distend the terminal ductal lobular unit are present.

2.3.2 Malignant Breast Tumor / Breast Cancer

a. Epidemiology
Breast cancer is the most common type of cancer in women and also the leading
cause of death for women in their 20s to 50s. The increase in breast cancer
incidence occurred primarily in women 55 years. Women living in lessindustrialized nations tend to have a lower incidence of breast cancer than
women living in industrialized countries, although Japan is an exception. Breast
cancer incidence has decreased related to decrease use of hormon replacement
therapy. In general, both breast cancer incidence and mortality are relatively
lower among the female populations of Asia and Africa, relatively
underdeveloped nations, and nations that have not adopted the Westernized
reproductive and dietary patterns.6
b. Classification

19

Figure 7. Classification of Primary Breast Cancer6

Noninvasive Breast Cancer

Noninvasive breast cancer are LCIS and DCIS. 6,7
o LCIS is a risk factor for the development of breast cancer. LCIS is recognized by
its conformity to the outline of the normal lobule.
o DCIS is a more heterogeneous lesion and consist of four categoriespapillary,
cribriform, solid, and comedo types. The four categories are usually seen as
mixed lesions. The papillary and cribriform types of DCIS are generally of lower
grade and may take a longer period of time to transform to invasive cancer. The
solid and comedo types of DCIS are generally higher grade lesions. The
mammogram shows typical calcifications called segmental calcifications.

Invasive Breast Cancer

Invasive breast cancers have lack of overall architecture, infiltration of cells into a
variable amount of stroma, or continuous and monotonous sheets formation cells.
This type is divided into lobular and ductal histologic types.6,7
o Invasive lobular cancer tends to permeate the breast in a single nature, which
explains why it remains clinically occult and often escapes detection on
mammography or physical examination until the extent of the disease is large.
Invasive lobular carcinoma accounts for up to 10% of breast cancers
o Invasive ductal cancer, also known as infiltrating ductal carcinoma, is the most
common (50%-70%) form of invasive breast cancers. Ductal cancers tend to
grow as a more cohesive mass; form discrete abnormalities on mammograms and
are often palpable as a discrete lump in the breast at a smaller size compared with
lobular cancers. When this cancer does not take on special features, it is called
infiltrating ductal carcinoma. When infiltrating ductal carcinomas take on
differentiated features, they are named according to the features that they display,
20

such as infiltrating tubulare and mucinous or colloid tumors. Infiltrating ductal

carcinoma, not otherwise specifed (NOS), is the most common form of breast
cancer. Both tubular and mucinous tumors are usually low grade (grade I) lesions
and represent about 2% or 3% each of invasive breast carcinomas. In contrast,
bizarre invasive cells with high-grade nuclear features, many mitoses, and lack of
an in situ component characterize medullary cancer.

Other Tumors of the Breast / Mixed Connective Epithelial Tumor

Mixed connective epithelium tumor consist of groups of unusual primary breast
tumors, such as Phylloides, Carcinosarcoma, Angiosarcoma, and Adenosarcoma.
Metastases from malignant tumors occur via hematogenous spread, and the common
sites usually invade the lung, bone, abdominal viscera, and mediastinum. Phyllodes
tumors contain a biphasic proliferation of stroma and mammary epithelium. While,
angiosarcoma is a vascular tumor in the breast or within the dermis of the breast after
irradiation for breast cancer. The irradiated skin is seen as purplish vascular
proliferations. Histologically, the tumor is composed of an anastomosing tangle of
blood vessels in the dermis and superficial subcutaneous fat. Clinically, radiationinduced angiosarcoma is identified as a reddish brown to purple raised rash within
the radiation portals and on the skin of the breast.6,7
c. Risk Factors
There has been many risk factors for breast cancer including age, family
history or genetic factors, hormonal factors, proliferative breast disease, irradiation
of the breast at an early age, personal history of malignancy, and lifestyle factors.6,7,8
- Age
Breast cancer is rare in people under 20 years old and the incidence increases
from 30 years old and greatly increased by 80 years old.
- Gender
Majority of breast cancers occur in women. Women have an average risk of
12.2% of being diagnosed with breast cancer at some time during their lives.
Although, breast cancer also occur in men, however, male breast are more likely to
be benign and the result of gynecomastia.

21

- Personal history of breast cancer

A history of mammary cancer in one breast increases the likelihood of a
second primary cancer in the contralateral breast.
- Histologic risk factors
Histologic abnormalities diagnosed by breast biopsy represent an important
category of breast cancer risk factors. About 40% of the carcinomas that developed
were pure from in situ lesions, the invasive cancers that developed were
predominantly ductal and not lobular in histology.
- Family history and Genetic risk Factors
First-degree relatives of patients with breast cancer have 2 to 3 times risk for
developing breast cancer. The risk is also increased if a first-degree relatives had
premenopausal onset and bilateral breast cancer. Genetic factors are estimated to be
responsible for 5% to 10% of all breast cancer cases, but they may account for 25%
of cases in women younger than 30 years. The BRCA1 and BRCA2 gene mutation
increases to 40% of familial breast cancers.
- Reproductive risk factors
Reproductive risk factors correlates with the increase of estrogen exposure
during womens lives. These include onset of menarche before 12 years of age, first
live childbirth after age 30, nulliparity, and menopause after age 55 years.
Breastfeeding has also been reported to reduce breast cancer risk.
- Exogenous hormone
The use of exogenous hormone such as therapeutic or supplemental estrogen
and progesterone increases the risk of breast cancer by 20% (5 years use of
combination HRT). Although, women who take estrogen-only formulations do not
appear to show an increased incidence of breast cancer.
- Diet and lifestyle
Women who drink alcohol and has a habit of smoking increases the risk of
breast cancer. Diet with a low phyto-estrogen also have a predisposising factor of
developing breast cancer.8

d. Clinical Manifestation

22

Figure 8. Signs of breast cancer (from upper left to lower right: peau de orange,
ulceration and erythema, nipple retraction,8 asymmetry of the breasts4)
Breast cancer is found most frequently in the upper outer quadrant, as
explained in the anatomy section of this paper. In 30% of cases, the woman discovers
a hard lump in her breast. Other less frequent presenting signs and symptoms of
breast cancer include breast enlargement or asymmetry of the breasts, nipple
retraction, nippe discharge, dimpling, ulceration or erythema of the skin of the
breast, an axillary mass, and musculoskeletal discomfort. However, up to 50% of
women presenting with breast complaints have no physical signs of breast pathology.
Breast pain usually is associated with benign disease.4 Edema of the skin produces a
clinical sign known as peau dorange. Direct involvement may result in retraction of
the nipple. Flattening or inversion of the nipple can be caused by fibrosis in certain
benign conditions, especially subareolar duct ectasia. Centrally located tumors that
go undetected for a long period of time may directly invade and ulcerate the skin of
the areola or nipple. Peripheral tumors may distort the normal symmetry of the
nipples by traction on Coopers ligaments. A condition of the nipple that is
commonly associated with an underlying breast cancer is Pagets disease. Pagets
disease has histologically distinct changes within the dermis of the nipple.8

23

Figure 9. Differences of Breast Masses3

Clinical manifestations may vary when the cancer has spread. Breast cancer
usually can spread through local spread, lymphatic metastasis, and hematogen
metastasis through blood vessels.8
o Local spread
The tumour increases in size and invades other portions of the breast.
If diagnosed late,the invasion might involve the skin and penetrate the
pectoral muscles and chest wall.
o Lymphatic metastasis
Lymphatic metastasis occurs primarily to the axillary and the internal
mammary lymph nodes. Tumours in the posterior one-third of the breast are
more likely to drain to the internal mammary nodes. It represents not only an
evolutional event in the spread of the carcinoma but is also a marker for the
metastatic potential of that tumour. Involvement of supraclavicular nodes and of
any contralateral lymph nodes represents advanced disease.
o Hematogen metastasis
Hematogen metastasis occur via bloodstream and create skeletal
metastases, although the initial spread may be via the lymphatic system. The
lumbar vertebrae, femur, thoracic vertebrae, rib and skull are usually affected.
Other metastases may also occur in the liver, lungs, brain, adrenal glands, and
ovaries.

e. Physical Examination

24

Inspection
The examination are done with a careful visual inspection for masses and other signs
of breast tumor benign or malignant as it has already been written on clinical
manifestation section. The breast examination involve many positions, such as
upright sitting positionm, arm stretched high above the head so the pectoral muscle
are tensed which may provoke the visuality of asymmetries and dimpling.4,6

Palpation
Palpation of the breast tissue and regional lymph nodes follows visual inspection.
While the patient is still in the sitting position, the examiner supports the patients
arm and palpates each axilla to detect the presence of enlarged axillary lymph nodes.
The supraclavicular and infraclavicular spaces are similarly palpated for enlarged
nodes. Palpation of the breast is always done with the patient lying supine on a solid
examining surface, with the arm stretched above the head. Palpation of the breast
while the patient is sitting is often inaccurate because the overlapping breast tissue
may feel like a mass or a mass may go undetected within the breast tissue. The breast
is best examined with compression of the tissue toward the chest wall, with palpation
of each quadrant and the tissue under the nipple-areolar complex. Palpable masses
are characterized according to their size, shape, consistency, and location and
whether they are xed to the skin or underlying musculature. Benign tumors, such as
broadenomas and cysts, can be as firm as carcinoma; usually, these benign entities
are distinct, well circumscribed, and movable. Carcinoma is typically firm but less
circumscribed, and moving it produces a drag of adjacent tissue. Cysts changes can
be tender with palpation of the breast. Most palpable masses are self-discovered by
patients during casual or intentional self-examination. 4,6

f. Tumor Staging
Classical staging of breast cancer with the TNM (tumour nodemetastasis) system.
These classifications have made it clear that these factors influence outcome and treatment
of breast cancer.6,8

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Figure 10. TNM Classification for Breast Staging6

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Figure 11. Stage groupings for Breast Cancer6

g. Diagnosis
Diagnosis is made with a thorough anamnesis, physical examination, advanced
techniques , such as biopsy and breast imaging to support the diagnosis of breast cancer. 6,8

Biopsy
o Fine-Needle Aspiration Biopsy (FNAB)
FNAB is used for the diagnosis of breast masses. The aspirate must be
examined cytologically to differentiate solid mass from cystic masses, but
FNAB has been replaced with a non-invasive by ultrasonography. With a
mammographically identifed mass or a palpable mass, ultrasonography can
quickly discriminate solid from cystic masses. If the mass is solid and the
clinical situation is consistent with carcinoma, cytologic examination of the
aspirated material is performed.
o Core Needle Biopsy
Core needle biopsy is the method of choice for nonpalpable mass and imagedetected breast abnormalities. Core needle biopsy can be performed under
mammographic, ultrasonographic, or magnetic resonance imaging (MRI)
guidance.
o Excisional Biopsy

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Surgical excision are required if the lesion cannot be adequately sampled by

core biopsy approaches, or if there is discordance between the imaging
abnormality and pathologic findings.

Breast Imaging
Breast imaging techniques are used to detect small, nonpalpable breast
abnormalities, evaluate clinical findings, and guide diagnostic procedures.
o Mammography
Mammography is the primary imaging modality for screening asymptomatic
women. Two views of each breast are obtained on a screening mammogram,
mediolateral oblique and craniocaudal. Mammographic sensitivity is limited
by breast density. Breast tissue in women under 30 years old is dense with
stroma and epithelium, while older womens the breast tissue involutes
replaced by fatty tissue.
o Ultrasonography
Ultrasonography is useful in determining whether a lesion detected by
mammography is solid or cystic. Ultrasonography can be useful for
discriminating lesions in the patient with dense breasts. However, the use of
ultrasonography resulted in more false-positive events and required more
call-backs and biopsies.
o Magnetic Resonance Imaging
MRI is increasingly being used for the evaluation of breast abnormalities. It
is useful for identifying the primary tumor in the breast in patients who
present with axillary lymph node metastases.The sensitivity of MRI for
invasive cancer is higher than 90%, but is only 60% or less for DCIS. The
MRI has a moderate specificity, with significant overlap between the
appearance of benign and malignant lesions.

h. Therapy
The two basic principles of breast cancer treatment are to reduce the chance of local
recurrence and the risk of metastatic spread. Treatment of early breast cancer will usually
involve surgery with or without radiotherapy. Systemic therapy such as chemotherapy or
hormone therapy is added if there are adverse prognostic factors such as lymph node
involvement, indicating a high likelihood of metastatic relapse. At the other end of the
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spectrum, locally advanced or metastatic disease is usually treated by systemic therapy to

palliate symptoms, with surgery playing a much smaller role. A multidisciplinary team
approach between surgeon, medical oncologist, radiotherapists and allied health
proffesionals is needed to treat cancer patients. A good communication between doctor and
patients plays a big role. Participation of the patient in choosing the best therapeutic options
is important.

Figure 12. Algorithm management of operable breast cancer

Local treatment of early breast cancer is achieved through surgery and/or
radiotherapy
o Surgery
Surgery plays a big role for breast cancer management. There are two types of
surgery approach; radical (mastectomy) and conservative surgery by doing a local excision
followed by radiotherapy. Each approach has many controversial outcome, such as
mastectomy alleviate psychological morbidity associated with breast cancer, but recent
studies have shown about 30 % of women develop significant anxiety and depression
following both radical and conservative surgery because of the recurrence possibility.
Mastectomy is indicated for large tumours. There are several types of mastectomy; the
radical Halsted mastectomy, the modified radical (Patey) mastectomy, and simple
mastectomy.
-

Simple mastectomy concentrates on the breast tissue itself by removing only the breast
with no dissection of the axillary lymph nodes, however lymph nodes are taken when the
tumor is located within the breast tissue.

The radical mastectomy is the most extensive type of mastectomy which the entire
breast is removed by excision of the breast, level I, II, and III of the underarm lymph
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nodes are removed and the chest wall muscles under the breast (pectoralis major and
minor muscles) are also removed.
-

The modified radical (Patey) mastectomy involves the removal of breast tissue and
lymph nodes. Axillary lymph node (lymph node level I,II of underarm) dissection is
performed and no muscle are removed from beneath the breast.

Conservative breast cancer surgery involves minimal surgery of the tumor itself
accompanied by conservative therapy afterwards. There are many types of conservative surgery,
such as lumpectomy, wide local excision,and quadrantectomy.
- Lumpectomy is a procedure of excising the tumor but normal breast tissue is not resected
- A wide local excision is a method which removes the tumour and about 1 cm of normal
breast tissue within tumor area.
- A quadrantectomy removes the entire segment of the breast that contains the tumour.
There are two types of conservative therapy, adjuvant and neoadjuvant. Adjuvant therapy is
done after conservative surgery, while neoadjuvant therapy is done in high grades inoperable
cancer, where conservative therapy is done to shrink the tumor before conservative surgery or
mastectomy. Types of conservative therapies include radiotherapy, chemotherapy, and hormone
therapy.
- Radiotherapy after mastectomy is indicated in patients with a high risk of local recurrence,
patients with large tumours, and patients with nodes invasion or extensive lymphovascular
invasion.
- Hormone therapy, has reduced the rate of recurrence by 25%, and reduction of death by
17%. Tamoxifen has been the most widely used hormonal treatment in breast cancer.
Other hormonal agents used as hormonal therapy are LHRH agonists, and the oral
aromatase inhibitors (AIs) for postmenopausal women.
- Chemotherapy, is a systemic therapy with the use a first-generation regimen such as a sixmonthly cycle of cyclophosphamide, methotrexate and 5-fluorouracil (CMF). By the use of
those regimen, chemotherapy has shown 25% reduction of relapse risk over 10 to 15
years.

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i. Prevention and Early Detection

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picture.

Figure 13. Breast Self Examination9

The first step of breast examination is to look at the breasts in the mirror with
shoulders in straight position and the arms on both hips. The second step would be to raise
both arms and look for any abnormal findings on both breasts. The third step is to look for
further fluid discharge from the nipples. The fourth step is to feel the breasts in a lie down
position, with the right hand to feel the left breast and the left hand to feel the right breast.
The method is to use the firm finger pads of the hand and do a circular motion. Palpate the
breasts slowly and make sure to examine the entire breasts from top to bottom, side to side,
and thoroughly from the collarbone to the top of the abdomen, and from the armpit to the
cleavage. The examination can be started from the nipple, moving larger and larger in circles
to the outer edge of breast. The other way is to do an up-and- down approach around the
breast. The amount of pressure given varies due to the location; light pressure for the skin
and tissue beneath; medium pressure for the tissue in the middle part; and firm pressure for
the deep tissue; rib cage is usually palpable. This breast self examination is usually done by
many woman in the shower because it makes the skin wet and slippery.9
j. Prognosis
Prognosis in breast tumor is depending on the type of tumor, benign or malignant,
TNM classification, metastatic potential.8

The 5-year survival rate for patients with

localized disease is is 98.6%; for patients with regional disease is 84.4%; and for patients
with distant metastatic disease is 24.3%. Breast cancer survival has significantly increased
over the past two decades due to improvements in screening and local and systemic
therapies.4 For those free of metastatic disease at initial evaluation, the median time to
recurrence after mastectomy is 8 months and the median survival is 2 years.6

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3. Swartz M. Textbook of physical diagnosis. Philadelphia, PA: Saunders/Elsevier; 2010. P 455-475
4. Brunicardi F. Schwartz's principles of surgery. 10th ed. New York: McGraw-Hill Education
Medical; 2016. P. 497-557
5. Sherwood L. Human Physiology: From Cells to Systems. 9 th ed. Boston, MA: Cengage Learning;
2016. P 649
6. Sabiston. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19 th ed.
Philadelphia, PA: Saunders/ Elsevier; 2012. P 823-866
7. Kumar et al. Robbins and Cotrans Pathologic Basis of Disease. 8th ed. Chicago,IL: Saunders/
Elsevier. 2010
8. Williams NS. Bailey and Loves Short Practice of Surgery. 26 th ed. Boca Raton, FL: CRC Press;
2013. P 798-819
9. Breast Cancer. The Five Steps of Breast Self-Examination. Accessed on June 17,2016. Available
on http://www.breastcancer.org/symptoms/testing/types/self_exam/bse_steps

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