MALIGNANT BREAST Diseases

DR. GEORGE W. O. MUGENYA

MBChB, MMed, FCS (ECSA)

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Learning Objectives

• Identify common malignant breast lesions.

• ŠUnderstand staging evaluation of breast carcinoma.
• ŠOutline management principle of breast carcinoma.
• Understand principles of breast cancer screening.
Breast Cancer Epidemiology

• There is remarkable variation in the incidence of breast cancer between different

countries and regions.
• Breast cancer is a major and important form of malignant disease in Kenya (1st in
Kenya).
• Breast cancer affects 1:12 women in UK (3 - 5% worldwide and 1 - 3% in developing
world)

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Breast Cancer

• Definition:
– Malignant lesion of (predominantly) the female breast.
• Can arise from the nipple, lobules or ducts.
• Can be infiltrating or non-infiltrating (ie. invasive or non-invasive).
• Epidemiology
– Male/female ratio 1 : 100.
– Any age (usually > 30 years).
– High incidence in western world and in white people more than black people.

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 Cancer Burden In Kenya

WOMEN MEN COMBINED

1 Breast Oesophagus Breast
2 Cervix Prostate Cervix Uteri
3 Oesophagus Stomach Prostate
4 Ovary Liver Oesophagus
5 Stomach Kaposis Stomach
6 Liver Leukemia Liver
7 Colorectal Colorectal Ovary
8 Non-Hodgkins lympoma Non-Hodgkins lymphoma Kaposis
9 Corpus Uteri Lung Colorectal
10 Kaposis Sarcoma Pancreas Non-Hodgkins lymphoma

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Risk Factors For Breast Cancer

• Major factors:
–Female gender: (M:F is 1:100)
–Age: Rare in < 20 years and 20 % in > 90 years.
–Previous breast cancer
–Family history and genetic predisposition (BRCA 1 or BRCA 2
mutations)

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…Risk Factors For Breast Cancer

• Intermediate factors:
– Alcohol and diet
– Endocrine factors:
• Early menarche.
• Late menopause.
• Oral contraceptive and hormone replacement therapy.
• Nulliparity.
– Irradiation.
– Benign proliferative breast disease (e.g. multiple Papillomatosis).
– Benign breast disease (e.g. hyperplasia with moderate or severe atypia).

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…Risk Factors For Breast Cancer

• Minor or controversial factors:

–Body size
–Stress
–Benign breast disease (e.g. hyperplasia with moderate or mild atypia)
Pathology

• Histology:
– Adenocarcinomas arising from the glandular epithelium.
• Common types are invasive ductal or lobular carcinoma.
• Paget’s disease is ductal carcinoma involving the nipple.
• Spread:
– Lymphatics, vascular invasion, direct extension spreads to lung, liver, bone,
brain, adrenal, ovary
• Staging:
– TNM classification important for treatment & prognosis.

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Cancer Of The Breast—Cell Types

WHO Classification of breast cancer:

1. Epithelial
• Non-invasive
–Ductal carcinoma in situ (DCIS)
–Lobular carcinoma in situ (LCIS)
• Invasive
–Ductal (85%), Lobular (1%) , Mucinous (5%)
Papillary (<5%), Medullary (<5%)
2. Mixed Connective tissue and Epithelial
3. Miscellaneous:- Sarcomas, Lymphomas,
Metastatic, etc.
.

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Clinical Features

• Palpable, hard, irregular, fixed breast lump, usually painless.

• Nipple retraction and skin dimpling.
• Nipple eczema in Paget’s disease.
• Peau d’orange (cutaneous oedema secondary to lymphatic obstruction).
• Palpable axillary nodes.

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13
.

Differential
Diagnosis of
Inflamed
Breast and
Nipple.

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Investigations

• Triple assessment: clinical, radiological, cytological

• Radiological assessment:
– Mammography (ultrasound in young women with dense or large breasts).
– Features on mammography: - irregular, spiculated, radiopaque mass with
microcalcification
• Cytological assessment:
– Fine-needle aspiration cytology
• Breast biopsy:
– Core biopsy
– Excision biopsy occasionally required for diagnosis
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…Investigations

• Staging investigations for proven cancer:

– All: chest X-ray, full blood count, serum alkaline phosphatase, γ-glutamyl transferase, serum
calcium (suggest liver or bone metastases)
• If clinically indicated: isotope bone scan, ultrasound scan of liver, brain CT scan.
• Breast tissue for hormone receptor status (oestrogen receptor +/–): important for
treatment and prognosis

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TNM Staging

T - Primary Tumour –T1—Tumour less than 2 cm in

TX. Primary tumour cannot be diameter.
assessed –T2—Tumour 2 to 5 cm in
T0. No evidence of primary diameter.
tumour –T3—Tumour greater than 5 cm
Tis. Carcinoma in situ in diameter.
T1, T2, T3, T4. –T4—Tumour fixation to chest
 Increasing size and/or local wall or skin.
extent of the primary tumour

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…TNM Staging

• N - Regional L Nodes
• M - Distant Metastasis
–NX: Regional L N
–MX: Distant metastasis cannot
cannot be assessed.
be assessed.
–N0: No regional L N
–M0: No distant metastasis.
metastasis.
–M1: Distant metastasis.
– N1: Mobile involved
axillary LN
–N2: Fixed axillary
lymphnodes.
– N3: Supraclavicular L N
involvement or arm
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swelling.
…TNM Clinical Staging

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Sentinel Node Biopsy

• Aims to accurately stage the axilla without the morbidity of axillary clearance.
• Technique used to identify the first nodes that tumour drains to.
• Can be located following the injection of either:
–Radioisotope.
–Blue dye.
–Combination of isotope and blue dye.
• Can be injected in peri-tumoural, subdermal or subareolar site.
• Allows more detailed examination of nodes removed.

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 …Sentinel Lymph Node Biopsy

1. Radioactive substance and/or blue dye is

injected near the tumor.
2. Injected material is located visually and/or
with a device that detects radioactivity.
3. Sentinel node(s) (the first lymph node(s) to
take up the material) is (are) removed and
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checked for cancer cells.
Treatment

• Treatment options are determined by the stage of the disease:

– Early breast cancer(stage I and II)=> Cure
– Late (advanced) breast cancer (stage III and IV)=> Palliate
• Surgery is usually the mainstay of treatment and may be followed by radiotherapy,
chemotherapy, or hormonal therapy as adjuvant therapy.
• Often, a combination of these treatments is used.
Surgery
• Aims of breast cancer surgery are:-
– To achieve cure if excised before metastatic spread has occurred.
– To prevent unpleasant sequelae of local recurrence.

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…Treatment

…Surgery
• Surgical options for the breast cancer:
–Breast Conserving Surgery (BCS) + Radiotherapy
=>BCS is regarded as either wide local excision, quadrantectomy or
segmentectomy
–Simple mastectomy
=>With axillary clearance (Patey’s mastectomy).
=>With axillary sampling
–Modified radical mastectomy
–Radical mastectomy => Obsolete
–Mastectomy + reconstruction (immediate or delayed)

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…Treatment

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…Treatment

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…Treatment

…Surgery
• Tumours suitable for breast conservation:
–Small single tumours in a large breast.
–Peripheral location.
–No local advancement or extensive nodal involvement.
–For tumours that are suitable for breast conservation there is no
difference in local recurrence or overall survival when BCS +
radiotherapy is compared to mastectomy.

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Chemotherapy In Breast Cancer

Chemotherapy can be given as:

 Primary systemic therapy prior to loco-regional treatment
(neoadjuvant).
 Adjuvant therapy following loco-regional treatment.
 Post-operative adjuvant chemotherapy depends primarily on:
 Age / menopausal status
 Nodal status
 Tumour grade

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…Chemotherapy In Breast Cancer

• Combination chemotherapy is more effective than single drug.

• Most commonly used regimen = CMF (Cyclophosphamide,
Methotrexate, 5-Flurouracil).
• Given as six cycles at monthly intervals.
• No evidence that more than 6 months treatment is of benefit.
• Greatest benefit is seen in premenopausal women.
• High -dose chemotherapy with stem cell rescue produces no overall
survival benefit.

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Endocrine Therapy In Breast Cancer

• Tamoxifen:
– Tamoxifen is an oral anti-oestrogen.
– Effective in both the adjuvant setting and in advanced disease.
– 20 mg per day is as effective as higher doses.
– 5 years treatment is better than 2 years.
– Value of treatment beyond 5 years is unknown.
– Risk of contralateral breast cancer reduced by 40%.
– Greater benefit seen in oestrogen receptor rich tumours.
– Little benefit seen in oestrogen receptor negative tumours.
– Benefit observed in both pre and post menopausal women.

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…Endocrine Therapy In Breast Cancer

• Aromatase inhibitors:-
– Several new endocrine therapies are available (anastrozole,
letrozole).
– Reduced the peripheral conversion of androgens to
oestrogens.
– Only effective in post menopausal women.
– May be superior to tamoxifen in high risk women.
– To date have not been shown to have survival benefit
compared with tamoxifen.
• LHRH agonists:- Cause reversible ovarian
suppression.
• Biological therapy (Herceptin [Trastuzumab]):- 31
.

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 Male Breast Cancer

1% of all breast cancers occur in men.

Pathologically, the disease is similar to that which occurs in women.
The principles of treatment are the same.
The proportion of men undergoing mastectomy is higher.
Adjuvant therapy is the same as for women.

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…Male Breast Cancer

• Factors that increase the risk of male breast cancer include:

–Older age. Breast cancer is most common in men ages 60 to 70.
–Exposure to estrogen.
–Family history of breast cancer.
–Klinefelter's syndrome.
–Liver disease.
–Obesity.
–Radiation exposure.

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Breast Cancer Screening

• WHO principles for any cancer screening:

– The condition should pose important health problem.
– The natural history should be understood well.
– There should be a recognisable early stage, and treatment
at that stage should be of more benefit than treatment
started at a later stage.
– There should be a suitable test that is acceptable to the
population.
– There must be adequate facilities for diagnosis and
treatment of any abnormalities detected.
– The chance of harm to those screened should be less than
the chance of benefit.
– Screening programme cost should balance against benefit.
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…Breast Cancer Screening

Mammography is the most effective breast cancer screening tool used

today.
 However, the benefits of mammography vary by age.
Yearly mammograms are recommended starting at age 40 and
continuing for as long as a woman is in good health.
Clinical breast exam (CBE):
Every 3 years for women in their 20s and 30s
Every year for women 40 and over.

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…Breast Cancer Screening

Women should know how their breasts normally look and feel and report
any breast change promptly to their health care provider.
Breast Self Examination (BSE) is an option for women starting in their
20s.
Some women – because of their family history, a genetic tendency, or
certain other factors – should be screened with MRI in addition to
mammograms.

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BREAST SELF-EXAMINATION FOR MEN

Things to look for:

– Lumps in the breast
– Soreness or discharge from the nipple
– Retraction of the nipple
– Ulcerations on the breast tissue
• Method:
– Use your right hand to examine your left breast, pressing firmly.
– Massage the breast in a circular motion, being extra cognizant of the center.
– Squeeze the nipples to check for discharge.
– Repeat using your left hand on your right breast.
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THANK YOU

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