Carcinoma Of The Breast

Nur Zulaikha

Breast Cancer

NonEpithelium

Epithelium

Angiosarcoma

Ductal

Malignant
phyllodes
tumour

Lobular

Others: Medullary, Tubular,

Inffammatory carcinoma

 65-80% Invasive ductal carcinoma arises from the

epithelium of the breast ducts.
03-14% Lobar carcinoma Invasive lobular carcinoma
arises from the acini of breast lobules.
02-08% Tubular carcinoma
Less than 1% of invasive breast cancers are
sarcomatous or other mesenchymal origin.

1. History of lump
Site of the lump?
Single or multiple?
When & Why was it first noticed? (Pain, self-examination, etc)?
Painful or painless?

HISTORY

Overlying skin changes noted:

- Erythema, warmth,
- Dimpling (more prominent hair follicles 2o to dermal oedema from
blocked lymphatics)
- Swelling?
- Any general asymmetry of the breasts noticed?
Duration since first noticed
Any increase in size from first noticed to now?
Any changes in the nipple e.g. retraction
Nipple discharge? If present, what is the colour and
consistency?
Any other lumps elsewhere other breast? Axilla? Neck?

2. Oestrogen exposure history

Increased risk:
- Age of menarche
- Age of menopause
- Use of HRT and/or Oestrogen based OCP?

HISTORY

Protective factors:
- How many children?
- Age at which first child was born
- Whether patient breastfed her children, and if so, for how long
3. Other risk factors for cancer
Family history of breast cancer or ovarian cancer in paternal (BRCA2)
and maternal side (BRCA 1&2), especially if cancer occurs in:
- first degree relative below the age of 40,
- in bilateral breasts
Previous breast disease:
- Treated cancer
Previous biopsy showing atypical ductal hyperplasia or LCIS
Exposure to ionising radiation (esp. RT for previous breast disease)
Daily Alcohol intake, especially before age of 30
4.

Systemic review
- LOA, LOW (constitutional)
- Fever (infective cause)
- Bone pain, SOB (metastasis)

PHYSICAL EXAMINATION

Inspection
General appearance
any asymmetry
skin changes (peau dorange, erythema, puckering, dimpling)
any scars of previous operation or procedure e.g. punch biopsy
nipple changes
Discolouration ,scaly, erythematous nipple
Discharge (Blood stained)
Depression (retraction)
Palpation
Painless lump, Single lump, lump at upper outer quadrant ( 2/3 of the pt)
Hard, irregular surface,Diffuse margin, Fix to chest wall, ulceration
Lymph node extension (axilla, supraclavicular/ cervical LN)
Systemic Examination :
Lungs : Pleural Effusion
Spine: Bony tenderness
Hepatomegaly

RISK FACTOR

Previous hx of breast cancer

Previous radiation to the breast

Hx of primary cancer of ovary or endometrium

Geographic variation: developed countries
Diet :staple diet containing red meat, saturated fat & alcohol
Family history
- in first degree relative
- 2 to 3 folds higher
Increasing age : doubling every 10 years until menopause
Age at first full pregnancy
- first child in early 40s (late pregnancy) highest risk
Nulliparity at the age of 40
Early menarche : aged 12
Late menopause : aged 55
Obesity : particularly in postmenopausal women
Evidence of specific genetic susceptibility - carriage BRCA1, BRCA2
or BRCA3
Hormone replacement therapy
Oral contraceptive pills

Investigation

Mammogram
Asymptomatic > 40 y / Symptomatic 35y :
screening procedure
Microcalcification (<0.5mm):
-pleomorphic microcals,
- heterogeneous appearance; segmental
-closely grouped or arranged in a linear pattern (ductal
distribution),
Spiculated mass / Stellate lesion/ comet tail sx
U/S:
-Screening procedure: <35y
-Evaluate consistency: solid/ cyst, margin
Biopsy :
Fine needle aspiration
Core needle biopsy
Incisional / excisional open biopsy

infiltrative ductal carcinoma.

Spiculated mass in upper breast

indicating infiltrative ductal
carcinoma.

Irregular clustered microcalcifications

Investigation

Baseline investigation
detection of metastatic disease:

liver function tests

serum calcium
chest radiograph
isotope bone scan
liver ultrasound scan
CT brain

- in cases where suspicion is great clinically

TNM STAGING

Stage I
: T1 N0 M0
Stage II A : T1 N1 M0 / T2 N0 M0
Stage II B : T2 N1 M0 / T3 N0 M0
Stage III A : T1 N2 M0 / T2 N2 M0 /
T3 N1 M0 / T3 N2 M0
Stage III B : T4 any N M0 / any T N3 M0
Stage IV : any T any N M1

Manchester staging of breast

carcinoma

stage I:
Confined to breast only
mobile tumour < 5cm in diameter with or without
local skin involvement
stage II:
tumour confined to breast
nodes thought to be involved but not fixed - palpable,
mobile and ipsilateral
stage III:
locally advanced disease in breast or nodes
tumour greater than 5cm diameter with involvement
of:
underlying muscle or
skin wide of the tumour or
axillary node fixation
stage IV:
distant metastases other than the axillary nodes or
satellite nodules on breast or
supraclavicular nodal involvement