1.

Significance of age in Fibroadenoma : 15-25 yrs

breast lump Phyllodes tumor : 30-50 yrs
Carcinoma breast : common in middle age anytime after
20 yrs .( Median age - 47yrs)
2. Causes of recent onset Circumferential – Carcinoma breast
nipple retraction Slit Like – Mammary duct
Ectasia with periductal mastitis
Traumatic fat necrosis
Tuberculosis
Previous surgery in breast
3. Types of nipple discharge Blood – Duct papilloma
and causes carcinoma breast

Milk – Lactation, galactocele, mammary fistula

Pus – Breast abscess

Serous/Greenish – duct ectasia

4. Risk factors of CA breast Early menarche

Late menopause

Late childbirth

Nulliparity

Absent breastfeeding

Hormone replacement therapy

Family H/o breast carcinoma

H/o irradiation

5. Genes involved in breast BRAC 1 and BRAC 2

carcinoma HER 2/ neu
6. Features of malignant Ill defined margins.
breast swelling
Hard in consistency.
Uneven surface
Fixed to skin
Peau d ' orange appearance
No Intra mammary mobility

7. Causes of nipple Involvement of lactiferous duts

retraction
8. Causes of skin tethering/ Involvement of coopers ligament
Dimpling
9. PEAU ‘D orange Tumour cells involve and block subdermal lymphatic
appearance and causes cutaneous lymphatic edema.

Skin areas tethered to sweat ducts cannot swell remains

dimpled in between areas of cutaneous lymphatic edema
giving peau d orange appearance

10. Skin involvement STAGING T4 b

Peau d orange appearance
En cuirasse
Ulceration of skin of breast
Satellite nodules
11. Chest wall involvement STAGING T4 a
Chest wall includes:
Ribs
Intercoastal muscles
Serratus anterior but not pectoral muscles
12. Significance of leaning Normal breast falls more forward than the diseased
forward breast suggesting fixity of the lump to chest wall or
pectoralis muscle.
13. Groups of axillary lymph Level 1- Pectoral ,Brachial ,Subscapular
nods Level 2- central group
Level 3- Apical
14. Examination of internal Percussion over Parasternal region 2nd and 3rd space
mammary node
15. Investigations for a Specific investigations:
breast lump FNAC
Trucut biopsy
Incision biopsy- for large lump
Excision biopsy- for small lump
Wedge biopsy- for ulcerated lump
ultrasound
Staging investigations :
X ray chest- pleural effusion
Skeletal bone survey- to look for osteolytic lesions
in ribs, pelvis, spine.
Investigations for secondaries:
USG abdomen- for liver secondaries, krukenberg
tumour, malignant ascites.
Liver function test
CT chest – for mediastinal nodes
Mammogram of opposite breast
FNAC of opposite axillary nodes
Tumour markers:CA-15-3, CEA
PET CT SCAN-recent trend to look for metastasis
based on concept of increased uptake of fluorodeoxy
glucose by the tumour cells
Routine investigations:
urine, blood, blood grouping/ typing, chest x-ray,
ECG
16. Indications of Screening mammography ( more than 40 years with
mammogram family history )
Obese patients
Whenever conservative surgeries are planned
To detect spread or de novo tumor in the opposite breast
Mammography guided biopsy
Evaluation and follow up in breast disease with
malignant potential
Follow up mammography after conservative surgery
Mastalgias
17. Uses of trucut biopsy Differentiate between carcinoma in situ and malignancy
Confirms DCIS ( FNAC does not confirms DCIS
Receptor status of the tumor
18. Hormone status how They are estrogen sensitive receptor present in the breast
it is done and tumor tissue
Tissue for receptor study is sent at low temperature in
ice flasks
Assessed by quantitative analysis
>10U/g of tissue ( ER positive )
<10U/g of tissue ( ER negative)
 ER positive ( prognosis good, hormone therapy
beneficial, respond to treatment is better )
ER negative ( poor prognosis, hormone therapy not very
beneficial, respond to treatment is not good )
19. Investigation for Mammography ( opposite breast )
metastasis Chest X Ray ( pleural effusion, cannon ball secondaries,
mediastinal lymph node, secondaries in rib )
CT chest ( lung secondaries )
USG abdomen ( liver secondaries, ascites, krukenberg
tumor )
X Ray spine ( osteolytic secondaries )
MRI spine/pelvis ( bone secondaries in vertebrae, pelvic
bones )
Radioisotope bone scan
PET scan
Sentinel lymph node biopsy
Axillary sampling
20. TNM staging of breast Tx Primary tumour cannot be assessed (already treated
carcinoma elsewhere without documentation).
T0 – No evidence of primary
Tis – Carcinoma in situ.
Tis (DCIS) Ductal carcinoma in situ.
Tis (LSCIS) Lobular carcinoma in situ.
Tis (Paget’s) – Paget’s disease of the nipple not
associated with
invasive carcinoma or with DCIS/LCIS in the
parenchyma
T1 – Tumour less than 2 cm (20 mm)
T1 mi – Microinvasion 1 mm or less in greatest
dimension
T1a – 1 – 5 mm
T1b – 5 – 10 mm
T1c – 10 – 20 mm
T2 – 20 – 50 mm in greatest dimension
T3 – >50 mm in greatest dimension
T4 – Any size with direct extension to the chest wall or
skin
or both.
T4a – Tumour of any size extending into the chest wall,
not
including only pectoralis muscle invasion/adhesion
(chest wall
means ribs, intercostal muscles and serratus anterior but
not
pectoral muscles).
T4b – Ulceration or ipsilateral satellite nodules and/or
 oedema
including peaud’orange of the skin which do not meet
the
criteria for inflammatory carcinoma.
T4c – T4a and T4b.
T4d – Inflammatory carcinoma.
Nx – Regional nodes cannot be assessed
N0 – No regional nodes involved
N1 – Metastases to mobile ipsilateral level 1 and 2
axillary nodes
N2 –
N2a – Metastases in ipsilateral level 1 and 2 axillary
nodes
which are fxed to one another (matted) or other
structures
N2b – Metastases only in clinically detected ipsilateral
internal
mammary nodes and in the absence of clinically evident
level
1 and 2 axillary nodes
N3 —
N3a – Metastases to ipsilateral infraclavicular lymph
nodes
(level III axillary) with or without level 1 and 2 axillary
lymph node involvement.
N3b – Metastases to ipsilateral internal mammary lymph
nodes
with clinically evident level 1 and 2 axillary lymph
nodes involvement.
N3c – Metastases to ipsilateral supraclavicular lymph
nodes with or without axillary or internal mammary
lymph node involvement
M0—No clinical or radiological evidence of distant
metastases
cM0(i+)–No clinical or radiological evidence of distant
spread
metastases but deposits of molecularly or
microscopically
detected tumour cells in circulating blood, bone marrow
or
other non-regional nodal tissue that are no larger than
0.2 mm
in a patient without symptoms or signs of metastases.
21. Various treatment Surgeries:
options for breast  Total (simple) mastectomy
carcinoma  Total mastectomy with axillary clearance:
  Modifed radical mastectomy [MRM]:
 Patey’s operation
 Scanlon’s operation
 Auchincloss modifed radical mastectomy
 Conservative breast surgeries:
 Wide local excision
 Quadrantectomy
 Toilet mastectomy
 Extended radical mastectomies
 Skin sparing mastectomy (Key hole mastectomy)
 Lumpectomy( wide local excision)
External radiotherapy
™ Total dosage 5000 cGY units
™ 200-cGY units daily 5 days a week for 6 weeks
Hormone therapy
 Tamoxifen - 20mg
 Medroxyprogesteron - 400mg
 Aminoglutethimide - 250mg
 Arimidex , Letrozol, Zoladex,
Diethylstilbestrone, Fluoxymestron
Chemotherapy
 1st line- Anthracyclines
 2nd line-Taxanes
 3rd line- Gemcitabine
22. Indications for hormone ER/PR positive patients in all age group
therapy For prophylaxis against carcinoma of opposite breast
Metastatic breast carcinoma
23. Modified radical Tumour.
mastectomy structures Entire breast, nipple, areola, skin over the tumour with
removed margin.
Pectoralis minor muscles.
Fat, fascia, lymph nodes of axilla.
Few digitations of serratus anterior.

24. Indication for breast Lump <4 cm

conservation surgery
Mammographically detected lesion

Clinically negative axillary nodes

Well-differentiated tumour with low S phase .
Adequate sized breast to allow proper RT to breast
Feasibility of axillary dissection and radiotherapy to
 intact breast
25. Contraindications for Tumour >4 cm
BCS
Positive axillary nodes >N1
Tumour margin is not free of tumour after breast
conservation surgery needs MRM.
Poorly differentiated tumour
Multicentric tumour
Earlier breast irradiation
Tumour/breast size ratio is more (central tumour)
Tumour beneath the nipple
Extensive intraductal carcinoma

Pregnancy

26. Indication for neo In large operable primary tumor to make it amenable for
adjuvant conservative breast surgeries.
chemotherapy

27. Indication for All nodes positive patients

chemotherapy
Primary tumor more than 1 cm in size.
Presence of poor prognostic signs like vascular and
lymphatic invasion.
In advanced carcinoma breast as a palliative procedure.
28. Drugs used in CMF regime (Cyclophosphamide/Methotrexate/ 5-
chemotherapy flourouracil)
Every 21 days for a total of 6 cycles
CAF regime (Cyclophosphamide/Adriamycin/ 5-
flourouracil)
6 cycles
TAC (Taxanes/ Adriamycin/ cyclophosphamide)
29. Side effects of Nausea and vomiting
chemotherapy Alopecia
Myelosuppression
Megaloblastic anemia
Cardiac toxicity (Adriamycin)
Cystitis(cyclophosphamide)
30. Indications of Breast conservation surgery
radiotherapy Extensive in situ carcinoma
More than 4 positive nodes in the axilla or extranodal
 spread
Pectoral fascia involvement
31. Side effects of Skin changes – Redness, irritation
radiotherapy Axillary hair loss
Breast – Mild throbbing pain and swelling
Tightness in the chest/arm
Arm edema

By,
S-03 (117-124)
2015 BATCH