CARCINOMA BREAST

2. CARCINOMA BREAST

3. CARCINOMA BREAST Most common cause of death in middle age women in western world. In 2004 one in half million new cases diagnosed world wide. In england and wales 1 in 12 women well develop the disease during there life time.

4. Risk Factors • Geographic Influences • Genetic • Age • Gender • Diet • Endocrine Length of reproductive life Parity Increase age at first child Exogenous estrogen Obesity • Radiation

5. Classification • Arising in ducts 90% • Non-infiltrating a) DCIS b)Intraductal carcinoma(comedo ca) c)Intraductal papillary ca • Infiltrating a)invasive ductal ca (NOS ) b)medullary ca c)colloid(mucinous)ca d)tubular ca e)paget’s disease • Arising in lobules 10% 1. Non infiltrating (LCIS) 2. Infiltrating (lobular ca)

6. PATHOLOGYSITE 1. Side: left side more affected and 4 to 10% bilateral 2. Quardant: a) UOQ – 60% b) CP - 12% c) UIQ -12% d) LOQ – 10% e) LIQ - 6%

7. MACRO AND MICROSCOPIC FEATURES • Intraductal carcinoma 5% 70% becomes invasive • Macroscopic features: . Presents as mass upto 5cm in diameter, or as ropy cords within breast . Ducts bcms filled with cheesy necrotic tissues can be extruded with slight pressure when ducts are transected. • Microscopic features: . Neoplastic cells may initially assume a glandular pattern or pile up with in ducts to create irregular excrescences. . Continued replication fills the ducts with compressed tumor cells untill architectural detail is lost.

8. MACRO AND MICROSCOPIC FEATURES 2) Invasive ductal carcinoma 75% • Macroscopic features: . Mass 3 to 4cm in dia of stony hard consistency. . On cut section tumor is infiltrative and retracted below the surrounding fibrofatty tissues and has a gritty texture that produces a grating sound when scraped with a knife. • Microscopic features: . Dense fibrous stroma in which are foung scattered nests and cords of tumor cells.

9. MACRO AND MICROSCOPIC FEATURES 3) MEDULLARY CARCINOMA 5% • Macroscopic features: . Soft and fleshy upto 10cm . On cut section tumor bulges above the surrounding tissue. • Microscopic features: . Scanty stroma . Tumor cells grow in large, irregular sheets and occasionaly in well differentiated glandular pattern.

10. MACRO AND MICROSCOPIC FEATURES 4) COLLOID CARCINOMA 2% • Macroscopic features: . Soft ,bulky, grey blue masses with the consistency of gelatin. . Central cystic softening and hemorrhage. • Microscopic features: . 1st pattern: tumor cells are seen in small islands floating in a large lake of basophilic mucin. . 2nd pattern: tumor cells grow in well defined glandular pattern, the lumen of which contain mucin.

11. MACRO AND MICROSCOPIC FEATURES 5) INFILTRATING DUCTAL CARCINOMA • Macroscopic features: . Poorly circumscribed and usually rubbery in consistency . . Sometimes it is hard in scirrhous. • Microscopic features: . Strands of tumor cells often one cell in width, found loosely disperesed in fibrous stroma. . Occasionally they surround normal appearing acini or ducts called bull’s eye pattern.

12. MACRO AND MICROSCOPIC FEATURES 6) INFLAMATORY CARCINOMA . Highly aggressive and fortunately rare . Present as painful swollen breast which is warm with cutaneous edema bcz of blockage of subdermal lymphatics by carcinoma cells. . Involves 1/3 of breast and mimic breast abscess. . Biopsy confirm the diagnosis and show undifferentiated ca cell.

14. LOCAL MORPHOLOGICAL FEATURES • Adherence and fixation to pectoral muscles and deep fascia of chest wall. • Adherence to to overlying skin with retraction and dimpling of skin or nipple. • Infiltration into the skin of chest results in cancer-en-cuirasse • Involvement of lymphatic pathway may cause localized lymphedema. • Inflammatory esp in pregnancy, tumor spreads so rapidly that it excites an acute inflammatory reaction with swelling,redness and tenderness

16. SPREAD • Local a) skin b) pectoral msls c) chest wall • Lymphatics a) early axillary and internal mammary nodes b) later supraclavicular , opposite breast and mediastinumbcms involved • Blood borne a) bones: lumbar vertebrae, femur,thoracic vertebrae, ribs, and skull. b) liver c)lungs d) brain e) adrenal and ovaries

19. STAGING • MANCHESTER SYSTEM I: growth confined to breast II: a. confined to breast b. affected mobile l.n in ipsilateralaxilla III: a. skin involvement or peau d orange larger than tumor but still limited to breast. b. tumor fixed to pectoral msl but not to chest wall. c. ipsilateralaxillary lymph nodes matted together or fixed to chest wall or ipsilateralsupraclavicular nodes mobile or fixed or edema of arm. IV: a. skin involvement wide of breast b. complete fixation of tumor to chest wall c. distant mets

20. TNM Staging • Primary tumor (T) • Tis no palpable tumor (ca in situ) • T1  <2cm • T2  2-5 cm • T3  >5cm • T4  tumor of any size invading skin or chest wall • Nodal involvement (N) • No  no nodal mets • N1  mobile involved axillary nodes • N2  fixed involved axillary nodes • N3  involved ipsilateralsupraclavicular nodes • Distant mets (M) • Mo  no known distant mets • M1  known distant mets

21. TNM staging •  Tis or T1, No & Mo •  T2 , N1 , Mo •  T3 or T4, N2 or N3, Mo •  Any T, Any N & M1

22. Clinical features • Age & sex • Symptoms: • Painless lump • Mild aches & pricking sensations & subsequently a lump when feel the painful area • Distortion of shape & size of breast • Nipple deviated, displaced, retracted or destroyed • Lump in axilla • Swelling of arm • Backache • General malaise & loss of weight • Dyspnea or pleuritic pain • Nodules in skin • Jaundice • Mental changes & fits • Pathological fractures

24. Clinical features • Signs • Local  lump • Site  60% in UOQ • Shape  begin as roughly spherical & can grow into any shape • Size  variable • Surface  indistinct • Color  initially reddish purple but once the skin is completely infiltered, it becomes less vascular & looks yellow or pearly white • Temp.  normal in non-vascular carcinoma e.g scirrhous ca

25. Clinical features • Consistency • Stony hard • Soft • Extremely soft • Rubbery sometimes hard • Relation with surrounding structures • Tethered or fixed to skin or deep structures • Orange peel appearance • Lymph nodes  axillary & supraclavicular nodes

26. Clinical features • General signs • Skeleton  reduced spine & hip movements, pathological fractures • Lungs  pulmonary consolidation & collapse & pleural effusion • Liver  hepatomegally, jaundice & ascites • Skin  multiple hard nodules • Brain  motor, sensory & psychological defects

27. Diagnosis • Mammography • Crab like shape • Microcalcifications • Thickening of the skin • Needle biopsy for histopathology • Ultrasonography • Aspiration • Thermography • Chest x-ray • Bone x-ray • Bone scan • Liver scan • CT scan • Biochemical studies

34. Prognosis of breast ca • Depends on tumor size & lymph node status • On invasiveness & metastatic potential • Agressiveness of tumor & early systemic therapy depends upon • Histological grade of tumor • Hormone receptor status • Measure of tumor proliferation such as S phase fraction • Growth factors analysis • Oncogene products measurements

35. Treatment • Treatment of early breast cancer • Cure likely in some patients but late recurrence is possible • Control of local disease in breast & axilla • Conservation of local forms & function • Prevention or delay of the occurrence of distant mets • Stage I & II  A) surgical treatment • Indications • Large tumor • Central tumor beneath or involving the nipple • Multifocal disease • Local recurrence • Patient preference

36. Operative choices • Radical (Halstead) mastectomy • Modified radical mastectomy • Simple mastectomy • Conservative surgery • Wide local excision • Lumpectomy • Quardentectomy • Sentinel node biopsy • Radiotherapy

42. Breast reconstruction • 50% females undergo mastectomy so to improve the quality of their life breast reconstruction is done either by implanting silicone gel under the pectoralis major muscle. It may be combined with prior tissue expansion using an expandable saline prosthesis first or a combined device which creates some ptosis of new breast. • If skin at the site is poor or if large volume of tissue is required then musculocutaneous flap can be used either using LD flap or TRAM flap.

43. Breast reconstruction • Timing  immediate / delayed • Immediate  impediments to it are • Insufficient theatre time • Lack of experienced surgeons • Incase of radiotherapy capsular contracture can occur • Nipple reconstruction  simple, under LA, many types but majority lose height with time. Prosthetic nipples can be used. • For symmetry opposite breast may require cosmetic procedures such as reduction/augmentation , mamoplasty or mastopexy.

44. Breast reconstruction • External breast prosthesis that fit within the bra are most common methods of restoring volume fill & should be available for all woman who do not have immediate reconstruction.

48. Follow up • For life long to detect recurrence & dissemination. • Yearly or 2yearly mammography of treated & contra lateral breast.

49. Lymphatic obstruction • Peau d orange • Cutaneous lymphatic edema • Infiltered skin is tethered by sweat duct which cant swell • Late edema of arm is troublesome complication • Neoplastic infiltration of axilla can cause arm swelling because of lymphatic & venous blockage • Painful because of brachial plexuses involvement. • Limb is susceptible to bacterial infection due to minor trauma & require antibiotic therapy. • Treatment • Limb elevation • Elastic arm stocking • Pnuematic compression devices