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Management of Breast

Disease
Supervisor: Ms. Vysa
Presenters:
Dr. Neoh Ping Sern
Dr. Vikkineshwaran Siva Subramaniam
Dr. Nadzirah Afiqah
Contents
• Benign Breast Diseases
• Breast Abscess
• Mastitis
• Fibroadenoma
• Nipple discharge
• Breast Cancer
• Diagnosis
• Risk factors
• Staging
• Management
• Screening
Benign Breast Diseases
Topics
• Mastitis
• Breast abscess
• Nipple discharge
• Fibroadenoma
Mastitis
• Inflammation of breast -> If complicates with a
localized collection of pus = Breast abscess
• May or may not be associated with infection

• Most common organism : Staphylococcus aureus

• Nonpuerperal mastitis is commonly associated with


breast cyst

• May occur spontaneously or during lactation


(commonly first 6-8 weeks postpartum)

• Incidence : 2-10% in lactating mothers, <1% in


nonpuerperal mothers
Aetiology
• Infective in origin:
• S. aureus
• Streptococci
• E.coli
• Candida if symptoms of burning nipple pain or radiating
breast pain

• Noninfective in origin:
• Breast cyst

• Features of malignancy?
• Consider breast carcinoma
Risk factors
• Incomplete breast drainage (difficulty
in attachment, infrequent feedings,
cleft palate)
• Engorgement/ oversupply of milk
• Blocked nipple/milk ducts
• Trauma to breast or nipples, cracked
or excoriated nipples
• History taking :
• Acute presentation
• Fever
• Preceded by inflammation/breast tenderness
• Painful lump
• Lactation?
• Recent surgical procedure (breast injection?)
• Constitutional symptoms

• Firm, erythematous, tender and swollen area


• Skin appears shiny with tight red streaks
• Fever
• Axillary pain/ reactive lymphadenopathy
• Any overlying skin changes
• Erythema, warmth
• Swelling
• Skin cracks -> Pus or blood discharge?
• Dimpling?
• Breast asymmetry
• Examine for lump(s)

• Fever + breast lump in puerperal patients


• Consider breast abscess -> ultrasound to visualize abscess collection
Management
• Reassure breastfeeding is safe

• Frequent expression of breast milk, apply warm compress prior to feeding to aid milk let-down

• Cold compress after milk feeding to reduce pain and edema

• Education regarding proper positioning and attachment

• Symptomatic relieve
• Analgesia for pain (paracetamol)
• Topical mupirocin in cases of traumatized nipples (cracked/fissured during breastfeeding) for superficial skin infection
• Remove and reapply after each feeding

• Antibiotic treatement for 10-14 days


• First generation Cephalosporins
• Clindamycin for patients allergic to penicillin
• MRSA -> Flucloxacillin, Dicloxacillin
Breast Abscess
• Abscess – Localized collection of pus built up within tissue

• Any age group

• Risk factors :
• Diabetes mellitus
• Smoking
• Lactation, progress from puerperal mastitis
• History of injection?

• History taking :
• Acute presentation
• Fever
• Preceded by inflammation/breast tenderness
• Painful lump
• Lactation?
• Recent surgical procedure (breast injection?)
• Constitutional symptoms
• History of the lump
• Site
• Single or multiple?
• How was it noticed? (sudden pain?)
• Any overlying skin changes
• Erythema, warmth
• Swelling
• Skin cracks -> Pus or blood discharge?
• Dimpling?
• Breast asymmetry?
• Duration since 1st noticed
• Nipple retraction?
• Nipple discharge?
• Well defined, fluctuant lump

• Correlate with lumps elsewhere


• Axilla, neck?
• Lymph nodes
Management
• Surgical
• Surgical incision, digital disruption of septa, evacuation of contents
• Ultrasound guided percutaneous aspiration (to allow continuation of
breast feeding)
• Antibiotics
• Pain relief
• Advice on expression of milk, and breast care
Nipple discharge
• Discharge can occur from 1 or more lactiferous duct

• Clear/serous discharge can be physiological in parous


woman

• Breast lump in patients breast feeding -> milk, give


reassurance to continue breast feeding

• Blood stained
• Carcinoma? Correlate with history and clinical findings
• Ductal ectasia?

• Black/green discharge : Ductal ectasia


Fibroadenoma
• Fibroadenoma is a smooth discrete breast lump, consisting of
fibrous and adenomatous (glandular) tissue
• Arise from lobule of terminal duct lobular unit
• Proliferation of both glandular and stromal elements

• Firm, mobile -> breast mouse

• Common benign tumour, age <30 years old

• Single lump, smooth surface

• 10-15% women may have several lumps, affecting both


breasts
• Risk factors :
• Use of OCP, Hormonal therapy (Estrogen)
• Premenopausal or pregnant women
• Postmenopausal women on Hormone Replacement Therapy
• Menstrual cycle causing changing hormone levels

• History taking -> Family history of breast cancer, details on menstrual history

• Age 15-30 years old


• 10% of all women
• 10% disappear over time
• 20% recur
• Usually stop growing after 2-3 cm if they don’t disappear
• Incidental finding when self examining
• Firm, rounded
• Smooth, rubbery
• Mobile
• Tender during period (Estrogen levels change)

• Usually 1-5cm

• Giant fibroadenomas can be up to 15cm, bosselated


surface
• After a physical examination :
• Breast ultrasound
• Women > 35 years old, with risk of breast cancer -> Mammogram

• Women in teens or early 20s may not need a biopsy if lump goes
away on its own (lump <1cm)
• If lump is doesn’t disappear and has increased in size..
• USG guided FNAC for definite diagnosis -> Histopathology examination
• Fibroadenomas are benign

• If small, painless, same size, biopsy shows


normal tissue -> Follow up ultrasounds (usually
for patients with lump <1cm)

• If large (> 2cm), painful, growing, biopsy


atypical cells -> Lumpectomy

• Advocate regular BSE (Breast Self Examination)


• Done once a month, few days after end of period
(day 10-15 from day of menses)
• Post menopausal women should do BSE on the
same date every month
References
• https://specialty.mims.com/mastitis/references?channel=obstetrics-
gynaecology

• https://www.researchgate.net/publication/6470168_Aspiration_of_B
reast_Abscess_Under_Ultrasound_Guidance_Outcome_Obtained_an
d_Factors_Affecting_Success

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900741/

• http://www.myhealth.gov.my/en/fibroadenoma-2/
Breast Cancer
Risk factors
Diagnosis
Staging
Management
Screening
Risk Factors
• Gender- Female has higher risk.
• 42.6 per 100,000 women years vs 1.15 per 100,000 men years

• Age- increases from 40 y/o (pre menopausal) & 50 y/o (post menopausal)

• History of Neoplastic disease of the breast


• Prior history of breast cancer
• Person with breast carcinoma in situ (LCIS/DCIS)
• Person with breast tissue biopsy showing proliferative disease with and without
atypical cells
• Family history
• Independent risk factor
• Among young first degree relatives
• Sister carries more risk than mother
• Carriers of BRCA1 and BRCA2 genetic mutation
• Radiation Exposure
• Multiple exposures of therapeutic radiation to the chest for cancer at an early age
(less than 20 years old)
• Exposures of high dose radiation used during radiotherapy for breast cancer
• Patients with Hodgkin’s disease receiving radiotherapy at high doses
* Screening using mammography HAS NOT been shown to affect the breast cancer
status
• Breast Density- Higher breast density from mammography

• Lifestyle
• A BMI > 25 has an increase risk to develop breast cancer with higher death rate
• Small waist and waist-hip ratio (WHR) give a significant protection (pre-
menopausal)
• Reproductive Factors
• First full-term pregnancy >30 years old
• Nulliparity
• OCP use poses a mild increase of risk if it is used before the first full term
pregnancy and lower with low dose preparation
• Unopposed estrogen use in hysterectomised women mildly increases the risk of
breast cancer and only after longer term use (>15 years)
• Combination hormone replacement therapy has a mild risk for breast cancer
• Age at menopause of more than 55 years old
• Age at menarche less than 12 years old
• Breastfeeding for a duration >12 months is protective of breast cancer
Stratifications of Risk Factors
Low Risk (RR 1.0-1.4) Moderate Risk (RR 1.5-2.0) High Risk (RR>2.0)

 Alcohol consumption  Increasing age from 40 years old  Personal history of invasive breast cancer

 Reproductive factors:  Reproductive factors:  Lobular Carcinoma In Situ (LCIS) and


o Increasing age at first full term o Early menarche (< 12 year old) (RR Ductal Carcinoma In Situ (DCIS)
pregnancy > 30 year 1.02)
o Hormone replacement therapy o Late menopause (> 55 year old)
o Oral contraceptive pill usage (OR 2.4)
o Nulliparity

 Obesity  Benign breast disease with proliferation  Benign breast disease with atypical
without atypia hyperplasia
 Dense breast  Ionising radiation from treatment of
breast cancer, Hodgkin’s disease, etc.

 Carrier of BRCA1 and 2 genetic mutation

 Significant family history (refer to Familial


Breast Cancer section)
Which of the following statements
best describe the risk factors of
Breast Cancer?
1 Breast feeding as a protective factor T F

2 The usage of oral contraceptive pills poses high risk T F


3 Benign breast disease poses low risk T F


4 Obesity poses high risk T F



ASSESSMENT/DIAGNOSIS
IN SPECIALIST CLINIC
Triple Assessment

• Is an established method for the diagnosis of breast


cancer
• Consist of:
1. Clinical assessment
2. Imaging (ultrasound and / or mammography)
3. Pathology (cytology and /or histology)

54. NICE guidelines 2009; 55. KCE Belgian guideline, 2007


31
Triple Assessment

• All patients presenting with breast symptom should


have a full clinical examination

• If a localised abnormality is present, patients should


have mammography and /or ultrasound examination
followed by core and /or FNAC depending on the
clinician’s, radiologist’s and pathologist’s experience.

55. Belgian Guideline 2007 32


Triple Assessment

• Where possible histological confirmation should be


obtained before any definitive surgical procedure

• In young women (< 40 years old), ultrasound should be


the initial imaging modality as part of the triple
assessment

55. Belgian Guideline 2007

33
Triple Assessment

• In most cases whether symptomatic or screen detected,


the diagnosis of breast cancer is made by triple
assessment

54. NICE guidelines 2009 34


Accuracy of Triple Assessment

• Ghimere et .al. 2008


• N = 50, age > 35
• Triple assessment ( clinical, MMG and FNAC)
• Results:
• Accuracy = 98%
• Sensitivity = 100%
• Specificity = 95.2%
• PPV = 96.7%
• FP = 3.3%

56. Ghimire et al. J Nepal Med Assoc. 2008 35


Diagnostic Accuracy of
Ultrasound
• Adjunct ultrasound to mammography improves the
diagnostic yield of breast cancer

• US screening of MMG negative dense breast


(n=25,572) contributed an additional 20% cancer
detection rate in asymptomatic women compared to
MMG alone with higher contribution among women <50

36
57. Corsetti et al. Eur J of Ca. 2008
Diagnostic Accuracy of Ultrasound

• In another cross –sectional study (n = 999


symptomatic women) on complementary role of US to
MMG, adjunct US was found to be significantly more
sensitive in cancer detection compared to MMG alone (p
< 0.001)

• There was no significant difference in specificity of


adjunct US vs MMG alone

58. McCavert et.al., Int J Clin Proct. 2009


37
Utrasound is a useful adjunct to mammogrphy in
the assessment of breast tumours in all patients

58. McCavert et al. Int J Clin Pract.2009 38


Recommendation

• Patients presenting with a breast symptom should be


evaluated with a full clinical examination, mammography
and/or ultrasound followed by biopsy, either fine needle
and/or core biopsy.

• Adjunctive ultrasound assessment improves breast cancer


detection in women of all ages and where possible should
be offered to all symptomatic breast patients

• In young women ( < 35 year old), ultrasound should be


used as the initial imaging modality as part of the triple
assessment
39
Regarding triple assessment
1 Consist of clinical assessment, imaging ( ultrasound and / T F
mammography) and pathology ( cytology and /or histology) ✔

2 Triple assessment is an established method to diagnosed breast T F


cancer ✔

3 Ultrasound is a sensitive modality to detect breast cancer T F


4 In young women ( < 35 of age), ultrasound is the preferred initial T F



imaging modality as part of the triple assessment
5 Adjunct ultrasound improves breast cancer detection by about T F

25% compared to mammography alone
41
Pre- operative MRI in Early
Breast Cancer
• Effective assessment prior to primary
treatment ensures appropriate treatment
• MRI is a sensitive procedure for the
diagnosis of breast cancer ( sensitivity 86 –
98%)
• However the low quality of evidence does
not advocate the routine use of MRI for the
diagnosis and staging of breast cancer

42

55. Belgian Guideline, 2007


Pre- operative MRI in Early
Breast Cancer
• MRI demonstrates some benefits in accuracy
over conventional imaging modalities

• May lead to change in surgical management


with more extensive tissue removal although
subsequent pathology may not always justify
the MRI results

• NZ Guidelines recommend that MRI should be


considered in clinical situations where other
imaging modalities are unreliable or
inconclusive 43

61. New Zealand Guideline, 2009


Pre- operative MRI in Early
Breast Cancer
• Recent prospective cohort (n = 349) women
with breast cancer eligible for BCT
• Pre-operative MRI breast detect:
• larger extent of breast cancer in 19 women (11%),
• leading to treatment change
• mastectomy( 8.7%)
• wider excision (2.3%)
• Conc:
• pre-operative MRI did not significantly affect the
overall rate of incomplete tumour excision (p =
0.17)
• Women with IDC, pre-operative MRI yielded
significantly lower rates of incompletely excisions
(p = 0.02) 44

62. Pengel et.al., Breast Ca Res Treat. 2009


Pre- operative MRI in Early
Breast Cancer
• Retrospective study (n = 349) women with
operable breast cancer (stages Tis to T4)
• Result:
• 30 additional cases (18.75%) were
diagnosed correctly using pre-operative MRI
• 14 cases (8.75%) were false positive
• Conclusion: pre-operative breast MRI detects
additional invasive carcinoma and changes
surgical management of operable breast cancer

45

63. Braun et.al., Breast Ca Res Treat. 2008


Recommendation
• MRI should not be routinely performed in the pre-operative
assessment of patients with biopsy proven invasive breast
cancer or DCIS (Grade B)

• MRI may be considered in clinical situations where other


imaging modalities are unreliable or inconclusive which
include:
• Invasive lobular cancer
• Suspicion of multicentricity
• Genetic high risk (BRCA1 or BRCA2)
• Patients with T0 N+ disease
• Patients with breast implants/foreign bodies
• Diagnosis of recurrence
• Follow up of after neo-adjuvant treatment
• Women with dense breasts
(Grade B) 46
STAGING BASED ON AMERICAN JOINT
COMMITTEE ON CANCER (AJCC) CANCER
STAGING MANUAL (7th EDITION)

47
Early Breast Cancer

Definition:
• Cancer that has not spread beyond the
breast or axillary lymph nodes
• Includes ductal carcinoma in situ, stage 1,
stage IIA and stage IIB

48
Early Breast Cancer

• Belgian guidelines 2007 - No good evidence


to support routine screening for metastases
for patients with early breast cancer who
are asymptomatic with negative clinical
findings

55. Belgian Guidelines, 2007


49
Early Breast Cancer
• New Zealand guidelines 2009 –
• Imaging investigations including CXR, bone scan,
liver US and CT have low diagnostic and should
be used only when clinically indicated such as
symptoms of lung disease, a palpable liver,
abnormal liver function test , bone pain or bony
tenderness
• Patient at high risk of harbouring distant
metastases ( triple negative and young patients
< 35 years old) should be staged aggressively

50

61. New Zealand Guidelines Group (NZGG), 2009


Early Breast Cancer
• Routine bone scintigraphy is not
recommended for patients presenting with
metastatic disease if CT scan of thorax,
abdomen and pelvis had been performed

• Bone scintigraphy is indicated for patients


with symptoms suggestive of bone
metastasis at sites not imaged by CT scan
and had plain radiograph of the affected
sites negative

• There is insufficient evidence to determine 51

whether
61. NZGG, 2009
FDG-PET or bone scintigraphy is
superior in detecting bone metastases from
Early Breast Cancer
• Another retrospective study (n = 221)
with operable breast cancer
• Result :
• Routine pre-operative staging with bone scan and
liver ultrasound were not helpful
• Bone scan has a 12 % FP and 19 % PPV
• Liver ultrasound has 3% FP and 33% PPV
• Conclusion:
• These investigations should be reserved for
patients with symptoms suggestive of metastases,
abnormal blood test and high risk patients

52

65. Kasem .et.al., Breast J. 2006


Recommendation
• In patients with early asymptomatic operable
breast cancer, intraductal tumour and
pathological stage I, screening (CXR, liver
ultrasound, CT scan and bone scintigraphy)
for metastasis should not routinely be
performed (Grade C)

• In patients presenting with symptoms


suggestive of bone metastases, bone
scintigraphy should be used if CT of the
thorax, abdomen and pelvis or plain
radiograph of the symptomatic site are 53

negative (Grade C)
Advanced Breast Cancer

Definition:
Locally advanced breast cancer (LABC)
includes cancers with large primary
tumours > 5 cm or those with skin and /or
chest wall involvement with or without
regional node involvement ( Stage 3a, 3b
and 3c)

54
Advanced Breast Cancer
• If advanced breast cancer is suspected
either clinically or on imaging, the routine
practice is to confirm the diagnosis and
assess the extent of the metastatic disease
with more imaging (staging)

• This includes plain X-Ray, US, bone


scintigraphy, CT scan, MRI and PET or
PET/CT

• MRI and FDG-PET were equal to or better


than scintigraphy in visualising osteolytic
bone metastases rather than osteoblastic 55

lesions
54. NICE guidelines, 2009
Advanced Breast Cancer

• There is insufficient evidence to


support the choice of one imaging
over another

• The choice of the modality will


depend on the availability

56
54. NICE guideline, 2009
Recommendation
• In patients presenting with clinically advanced
breast cancer, further imaging modalities such
as chest x-ray, liver ultrasound, and/or CT scan
should be offered to assess the extent of disease
depending on the available resources. (Grade
C)

• CT (with bone window) or MR or bone


scintigraphy may be offered to assess presence
and extent of metastases in the axial skeleton.
(Grade C)

• The risk of pathological fracture in the


extremities may be assessed using bone
scintigraphy and/or plain radiography. (Grade 57

C)
Positron Emission Tomography
(PET) or PET/CT in Staging
• FDG labelled with positron emitting flourine
provides functional information

• Most malignant tumours have higher


glucose metabolism than normal tissue and
take up more FDG-PET

• Show up as areas of increased activity


• PET/CT allows anatomical localization of
the functional information 58
Positron Emission Tomography
(PET) or PET/CT in Staging
NICE guidelines:

PET/CT should only be used to make


new diagnosis of metastases for patients
with breast cancer whose imaging is
suspicious but not diagnostic of
metastatic disease

59
54. NICE guidelines, 2009
Positron Emission Tomography (PET) or
PET/CT in Staging
New Zealand guidelines:

Recommend PET scan as a confirmatory


test in diagnosing bony metastases as PET
scan had a higher specificity compared to
bone scintigraphy

60
61. NZGG, 2009
Positron Emission Tomography (PET) or
PET/CT in Staging
Belgian guidelines:
• PET scan is not indicated in the diagnosis of
breast cancer, axillary staging and in the
follow-up of breast cancer.

• PET can be useful for the evaluation of


metastatic disease in invasive breast cancer

61
55. Belgian guidelines , 2007
Positron Emission
Tomography (PET) or
PET/CT in Staging
Other studies:
• Diagnostic accuracy of FDG-PET/CT nearly
equal to AUS in detecting axillary lymph node
metastases primary operable breast cancer 67,
level III

• FDG-PET could not replaced staging with


SLNB in patients with breast cancer 68, level II-3
• The positive detection rate on FDG-PET/ CT
was insufficient to determine the indication
for SLNB 69, level III
62

67. Ueda et.al., BMC Cancer, 2008; 68. Kumar et. al., Nucl Med Commun. 2006; 69. Taira N et. al.,
Jpn J Clin Oncol. 2008
Positron Emission Tomography
(PET) or PET/CT in Staging
Other studies:
• PET/CT is superior to PET or CT alone for
the diagnosis of tumour recurrence and
for the definition of extent of disease 70, level
III, 71, level III

• PET/CT exam resulted in increased patient


radiation exposure compared to stand
alone PET or CT exam 74, level III
63
70. Radan et.al. Cancer. 2006; 71. Haug et.al., J Comput Assist Temogr. 2007; 74.
Huang et. al., Radiology. 2009
Recommendation
• PET or PET/CT scan should not be
offered to make the diagnosis of
malignancy in breast tumours or for
axillary staging or in the follow up of
breast cancer patients. (Grade C)

• PET/CT scan may be used in patients


whose imaging is suspicious but not
diagnostic of metastic cancer (Grade
C) 64
65
Laboratory
Diagnosis

Clinical Practice Guidelines


Management of Breast Cancer
Development Group

66
Fine Needle Aspiration
Cytology

Fine needle aspiration cytology may be


considered as the initial method of
pathological assessment for palpable
breast lumps where facility and
expertise are available

67
Core Biopsy (CB)

• Core biopsy may be used as a


complement for pathological diagnosis if
the fine needle aspiration cytology is
equivocal

68
Core Biopsy (CB) in
combination with Fine Needle
Aspiration Cytology (FNAC)

Core biopsy in combination with FNAC


may be used where facility and
expertise are available

69
RECOMMENDATION
• Fine needle aspiration cytology may be
considered as the initial method of
pathological assessment for palpable breast
lumps where facility and expertise are
available. (Grade C)

• Core biopsy may be used as a complement for


pathological diagnosis if the fine needle
aspiration cytology is equivocal. (Grade C)

• Core biopsy in combination with FNAC may be


used where facility and expertise are
available. (Grade C)

70
Human Epidermal Growth
Factor Receptor 2 (HER-2)
Testing In Breast Cancer

May be performed by various methods


including:
• Immunohistochemistry (IHC),
• Fluorescent in-situ hybridisation (FISH)
• Chromogenic in-situ hybridisation (CISH)
• Silver-enhanced in-situ hybrid (SISH).

71
IMMUNOHISTOCHEMISTRY
• A technology review based on 10 studies
looking at Human Epidermal Growth Factor
Receptor 2 (HER-2) testing showed that
the most cost-effective testing strategy is
to screen all breast cancer cases with IHC,
followed by FISH or CISH or SISH for
Immunohistochemistry( of 2+ and 3+) 81, level
III

81.Noormah MD. Technology review, 2008


72
Fluorescent in-situ
hybridisation (FISH)

• FISH testing was more objective and


predictive of response to anti-HER-2
therapy and had been advocated to
confirm some or all positive
immunohistochemistry results 81, level III

81. Noormah MD. Technology review, 2008


73
Chromogenic in-situ
hybridisation (CISH)

• CISH is another promising and practical


alternative to FISH that can be used in
conjunction with IHC81, level III
• Thus, it may represent an important
addition to the HER-2 testing algorithm

81.Noormah MD. Technology review, 2008


74
Chromogenic in-situ
hybridisation (CISH)
• Pederson et al, dual CISH (using probe for HER-2
and centromere of chromosome 17) was shown to
have 98.6% concordance and a correlation
coefficient of 0.95 with FISH.
• The author concluded that further evaluation of its
accuracy is still required before adopting into routine
practice 82 , level III

82. Pedersen M et. al., 2009

75
Silver-enhanced in-situ
hybridization (SISH).

• SISH was found to be an alternative for


HER-2 testing.
• It had 96% concordance with CISH 83, level
III

83. Francis GD et. al., 2009

76
RECOMMENDATION

• HER-2 test using


immunohistochemistry should be
performed for all invasive breast
cancer cases (Grade C)

• Fluorescent in-situ hybridisation,


silver-enhanced in-situ hybrid or
chromogenic in-situ hybridisation
should be used for confirmation
when the immuno-histochemistry
score is 2+ or 3+ (Grade C)
77
Pathology Reporting for Breast Cancer

An adequate pathology report for breast


cancer must have the following minimum
parameters: modified from 84, level III

• Location (side and quadrant), maximum diameter, multifocality


• Tumour type (histology)
• Histological grade
• Lymph node involvement and total number of nodes examined
• Resection margins
• Lymphovascular invasion
• Non-neoplastic breast changes
• Hormone receptor status [estrogen-receptor/progesterone
receptor (ER/PR)]
• HER-2 assessment

84. Austin R et. al., 2009 78


LOCALLY ADVANCED BREAST CANCER
• 45 years old Malay female, presented with fungating and ulcerated left breast
tumour for the past 1 month. It was started with small lump of ping pong ball size
a year ago before progressively enlarged and fungating. It was painless and no
other related symptoms.
• She is premenopause, para 5 with the youngest child age 8 years old. She breast
fed all her children and not taking any OCP. She has no co-morbid. No family
history of breast cancer.
• On physical examination, patient was slight pallor and distress. The vital signs
were normal. Half of left breast at outer quadrant was occupied by fungating and
ulcerated growth with smell. It was fixed to the chest wall. The rest of skin was
edematous. On the ipsilateral axilla, matted lymph nodes palpable. No lymph
nodes palpable superior and inferior clavicle. The right breast and axilla were
normal.
• The other systems were unremarkable.
What are you going to do?
• Counseling the patient regarding possibility of cancer and the need
for further investigation to confirm it.
• Core biopsy of the tumor
• Mammogram on right breast
• CT thorax, abdomen and pelvis, bone scan
• Dressing the ulcerated tumor
She was confirmed with left breast cancer on
pathology report, what is the clinical stage now?
• Stage IIIb ( T4c N2 Mx)
Core biopsy: infiltrating ductal carcinoma, grade 2,
ER negative, PR negative and cerbB2 positive on
FISH test. Mammogram of right breast was
normal.
After staging investigations, there was no evidence
of distant metastases, what is your next plan?

• Start neoadjuvant chemotherapy


• Review the response after 3-4 cycles
After 4 cycles of neoadjuvant chemotherapy, the
tumor shrunk more than half, ulcer healed and no
more fungated growth. The axillary lymph nodes
no more palpable. What is the next plan and why?
• Left mastectomy + axillary dissection
• Left mastectomy – for better local control as BCS following
neoadjuvant chemotherapy in LABC has significant higher local
recurrence rate.
• Axillary dissection – for regional control of cancer, proper staging of
cancer (pathological staging) and prognosis of the disease.
One month after the uneventful operation, she came to
the clinic. The wound has healed. The HPE: tumour
infiltrating ductal carcinoma 2x2x1cm, grade 2, ER, PR
and cerbB2 receptors not done.
What are other parameters required from the HPE
report?
What is your next plan as oncologist?
• HPE report: margin clearance, lymphovascular infiltration, no. of lymph nodes
harvested and no. of metastasis.
• To complete another 2 cycles of chemotherapy followed with external beam
radiotherapy. Finishing that, to complete trastuzumab every 3 weeks for a year.
• Follow up the patient in clinic every 3 months
What is your long term follow up plan for this
patient?
• 3 monthly follow up to check for local-regional recurrence and
contralateral breast lump
• Monitor long term effect of surgery such as lympedema
• Yearly mammogram on right breast for early detection of breast
cancer
18 months after the operation, she noticed 2 cm
size skin nodule at lateral aspect of the scar. FNA
showed malignant cells. What are you going to do?

• Restaging of the cancer – CT thorax, abdomen and bone scan


On Bone scan showed evidence of metastasis
at pelvic bone. What is the advice to patient?
• Wide excision of skin lesion followed with second line chemotherapy
and IV Zolendronic acid 4 mg every month for 1 year.
SCREENING
• IN GENERAL POPULATION
• HIGH RISK GROUP
MAMMOGRAPHY
• To detect cancer at early stage or before it physically evident. So that patient are cured more
easily possible at less expenses.
• Screening may be considered in high risk women below the age of 40 years.
• The value of mammographic screening should be explained to those asymptomatic
women, aged 40-49 years, who have expressed their wish to be screened.
• In patients on postmenopausal HRT, a screening mammogram should be performed
before therapy is started to establish a baseline, as well as to ascertain the absence of
any malignancy or other lesions.
• Annual or biennial screening if the patient has been on HRT for more than 5 years
• High resolution ultrasound is the first diagnostic imaging method in women less than
35 years for symptomatic women
• In screening mammography, ultrasound is a useful adjunct and is recommended
in the assessment of a patient with dense parenchymal pattern on
mammograms. It is most useful in differentiating cysts from solid masses,
thereby avoiding unnecessary biopsies
GENERAL POPULATION
HIGH RISK GROUP
MANAGEMENT
SURGICAL MANAGEMENT FOR WOMEN WITH
EARLY BREAST CANCER
• SURGERY IS THE MAINSTAY OF TREATMENT FOR EARLY BREAST CANCER
AND CONSISTS OF EITHER BREAST CONSERVING SURGERY OR
MASTECTOMY AND ASSESSMENT OF AXILLARY LYMPH NODE.
• BREAT CONSERVING SURGERY- BCS (LUMPECTOMY)
• Operation to remove the cancer while leaving as much as normal breast as
possible. Some surrounding healthy tissue and lymph nodes are usually
also removed.
• Breast-conserving surgery is sometimes called as lumpectomy,
quadrantectomy, partial mastectomy, or segmental mastectomy.
• Its often an option for a woman with early-stage-cancer, and allows her to
keep most of her breast.
CONTRAINDICATIONS OF BREAST
CONSERVING SURGERY (BCS)
• The ratio of the size of the tumour to the size of the breast and
location of the tumour would not result in acceptable cosmesis

• Presence of multifocal/multicentric disease clinically or radiologically

• Conditions where local radiotherapy is contraindicated (such as


previous radiotherapy at the site, connective tissue disease and
pregnancy)
TUMOUR FREE MARGIN IN BREAST
CONSERVING SURGERY
If the surgical margin is less than 2 mm, several factors should be
considered in
determining whether re-excision is required. These includes:

• Age
• Tumour histology (lymphovascular invasion, grade, extensive in-situ
component and tumour type such as lobular carcinoma)
• Which margin is approximated by tumour (smaller margins may be
acceptable for deep and superfcial margins)
• Extent of cancer approaching the margin
AXILLARY SURGERY IN EARLY BREAST CANCER
• Axillary lymph node dissection (ALND) comprises of removal of one,
two or three level of nodes relative to the pectoralis minor muscle.
Typically 10 - 15 lymph nodes are retrieved and at least one section
from each assessed by standard haematoxylin and
eosin (H&E).

• The assessment should be undertaken for most early invasive breast


cancers in order to stage the disease, minimise the risk of loco-
regional recurrence and assist in planning of adjuvant therapy
INDICATIONS FOR SENTINEL LYMPH NODE
BIOPSY (SLNB) IN BREAST CANCER
• SLNB was an appropriate method of staging the axilla as there was no
difference in axillary recurrence or overall survival.

AXILARY SURGERY
INDICATIONS FOR SENTINEL LN BIOPSY (SLNB) IN BREAST CANCER
1. Women with tumors > 3cm
2. Women with multicentric / multifocal tumors
3. Women with clinically positive nodes
4. Pregnant or breastfeeding women
5. Women with known allergies to radioisotopes or blue dye
6. Women with previously treated breast cancer or axillary surgery
on the affected side
MANAGEMENT OF LOCALLY ADVANCED
BREAST CANCER
• Locally advanced breast cancer is invasive breast cancer that has one
or more of the following features:
• large (typically bigger than 5 cm)
• spread to several lymph nodes in the axilla or other areas near the
breast
• spread to several lymph nodes in the axilla such as the skin, muscle
or ribs.
However, there are no signs that the cancer has spread beyond the
breast region or
to other parts of the body.
SURGICAL MANAGEMENT IN EARLY BREAST
CANCER
MASTECTOMY
• REMOVAL OF THE WHOLE
BREAST.
1. ‘SIMPLE’ OR ‘TOTAL’
MASTECTOMY
2. MODIFIED RADICAL
MASTECTOMY
3. RADICAL MASTECTOMY
4. PARTIAL MASTECTOMY
5. SUBCUTANEOUS (NIPPLE
SPARING) MASTECTOMY
FOUR BOUNDARIES FOR A MASTECTOMY
• Clavicle- superior boundary
• Inframammary fold (above
rectus sheath)- inferior
boundary
• Sternum (midline)- medial
boundary
• Latissimus dorsi (anterior
border)- lateral boundary
MASTECTOMY + BREAST RECONSTRUCTION
• IMMEDIATE OR DELAYED RECONSTRUCTION
• According to NICE guideline, there is no difference in recurrence and
survival following
mastectomy with immediate reconstruction compared to mastectomy
with no reconstruction.
• The aim of immediate breast reconstruction is to improve well-being
and quality of life for women undergoing mastectomy for breast
cancer.
CHEMOTHERAPY
Treatement with cancer-killing drugs that may be given intravenously
(injected into vein) or by mouth. Occasionally, chemo may be given
directly into spinal fluid which surrounds the brain and spinal cord.
NEO-ADJUVANT CHEMOTHERAPY IN LOCALLY
ADVANCED BREAST CANCER
• neo-adjuvant chemotherapy can be given to downsize the tumour
in an attempt for BCS or enable subsequent surgery for initially
inoperable breast cancer.
• The most common drugs used for adjuvant and neo adjuvant
chemo include:
1. Anthracyclines, such as doxorubicin (Adriamycin) and epirubicin
(Ellence)
2. Taxanes, such as paclitaxel (Taxol) and docetaxel (Taxotere)
3. 5-fluorouracil (5-FU)
4. Cyclophosphamide (Cytoxan)
5. Carboplatin (Paraplatin)
• Most often, combination of 2-3 of these drugs are used
POST MASTECTOMY RADIOTHERAPY
• Radiotherapy is a treatment for cancer that uses carefully measured and
controlled
high energy x-rays.
• In primary breast cancer it aims to destroy any cancer cells that may be
left behind in the breast area after surgery.
• Radiotherapy has the greatest effect on cancer cells but also affects
healthy tissue in the area being treated – however, this is generally able to
recover and repair itself.
• In high risk patients who have had mastectomy, there is a significant risk of
loco-regional relapse. Radiotherapy has been shown to improve loco-
regional control but controversy existed regarding the survival benefit until
recently.
FOLLOW UP
• Minimum 3 years
• First year: every 3 months
• Next 5 years : 6-monthly
• Subsequent years: annual review
• Annual mammography and regular physical examination were
recommended