Breast Cancer

Female Breast Anatomy

Breasts consist mainly of

fatty tissue & connective

tissue
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 Muscles

Muscles
underneath
Breast has
the breasts
no
separating them
muscle tissue
from the ribs

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 Breast Structure
Breast profile
A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F Pectoralis major muscle
G chest wall/rib cage

Enlargement
A normal duct cells
B basement membrane (duct wall)
C lumen (center of duct)

Illustration © Mary K. Bryson

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 Regional Lymph Nodes for Breast
A: Pectoralis major muscle

B: Axillary lymph nodes level I

C: Axillary lymph nodes level II

D: Axillary lymph nodes level III

E: Supraclavicular lymph nodes

F: Internal mammary lymph nodes

 Breast Cancer - Magnitude

Most common cancer in Indian women.

1 woman is diagnosed in every 4 minutes

1 woman dies with Ca Breast in every 8 minutes

14% of all cancers in Indian women

  spurt  in early thirties and peak at ages 50-64 years.

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 Risk Factors

Family History. (80% vs. 10 – 20%)

Breast lumps.
Dense breast tissue. Diet and lifestyle choices
Age. Radiation Exposure
Obesity
Oestrogen exposure
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Multiple first degree relatives with early onset Ca Breast

Ca breast & Ca Ovary in same family

Male breast cancer

Presence of BRCA 1 & 2
 Tumour suppressor genes Mutations on chromosome 17
 Lifetime risk of 6-7%.
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 Protective factors

Breast feeding - 1 year

Regular moderate physical activity

Maintenance of healthy body weight

Healthy diet
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 Prevention
Early detection

Active surveillance mechanisms

Management of high risk group

Chemoprevention (Tamoxifen)

Prophylactic mastectomy
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 Breast Disorders

 Benign & Malignant

 Benign breast disorders
 Breast pain /mastalgia
 Cyclical / non cyclical. Self resolving.
 Fibro adenomas
 Firm, round, non tender, movable benign tumors. Peak @ 30 yrs.
 Cysts
 Fluid filled sacs develops perimenustually. Estrogen linked.
 Benign proliferative breast disease
 Atypical hyperplasia & LCIS
Malignant Breast Disorders – types
 Ductal carcinoma in situ (DCIS): proliferation of malignant
cells inside the milk ducts. (breast cancer stage 0)
 Invasive cancer:
 Infiltrating ductal carcinoma : 80% of all cases.
 Infiltrating lobular carcinoma: lob. Epithelium, multicentric, bilateral
 Medullary: ↑ women<50 yrs. (5%)
Ductal Carcinoma in situ (DCIS)

Ductal
cancer
cells

Normal
ductal
cell

Illustration © Mary K. Bryson

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Ductal carcinoma
Invasive Lobular Carcinoma (ILC)

Lobular cancer
cells breaking
through the wall
Illustration © Mary K. Bryson 17
 Mucinous carcinoma : 3%, older women. slow growing
 Tubular ductal carcinoma : 2 %, less chance for axillary
metastasis
 Inflammatory carcinoma : 1-2%, Rare, aggressive, Peau
d’orange appearance to locally advanced cases.
 Paget disease: 1%, very rare, scaly, erythematous, pruritic
lesion of nipple,
Peau d’orange appearance
 TNM Staging
 Tumor size
 Tis: in situ
 T1: <2cm
 T2: 2-5cm
 T3: >5cm
 T4: invasion of skin or chest wall
 Node

 N1: 1-3 axillary nodes or internal mammary nodes +

 N2: 4-9 axillary nodes or palpable int mam node
 N3: >10 nodes or combo of axillary and int mam nodes

 Metastasis

(mic micoroscopic posivitiy, mol molecular positivity)

 Coding Grade for Breast

 Histologic grade codes

1 = well differentiated

2 = moderately differentiated
3= poorly differentiated

4= undifferentiated
 Signs and Symptoms

Most common:
lump or
thickening in
breast. Often
painless

Discharge Redness or pitting

or of skin over the
bleeding breast, like the skin
of an orange
Change in size
or contours of Change in color
breast or appearance
of areola 24
 Assessment

Health History

Physical
Assessment.
Diagnostic
Evaluation
Imaging studies
 Mammography

 Breast ultrasound
 Bone scan
 Chest x-ray
 Mammography
 Use a low-dose x-ray system to examine
breasts

 Digital mammography replaces x-ray

film

 Mammography can show changes in the

breast up to two years before it is
palpable.
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Image Source: SEER Training Website
 Prognosis

The two most important

prognostic determinants:
 Tumor size

 lymph nodes involvement

 Management
 Chemotherapy

 Radiation

 Surgery – To gain local control

 Hormonal therapy
 Targeted therapy
 Surgical options
 Breast conservation  Breast conservation +
alone Sentinel lymph node biopsy/
Lumpectomy Axillary lymph node
Quadrantectomy dissection
 Total mastectomy  Total mastectomy +
alone sentinel lymph node biopsy
 Modified Radical mastectomy
 Breast conservation surgeries
 Technique varies..
 Goals
Complete excision of tumor
Obtain clear margins & cosmetic result

 SLNB / ALND for invasive cancers.

Breast conservation surgeries

Breast conserving
surgery:
– Wide local
excision/Lumpectomy
– Quadrantectomy.
 SLNB ALND
 Shorter OR time  Longer OR time (1-2hrs)
 No surg. drain  Surg. Drain +
 LA  GA
 Lymphedema (0-7%)  Lymphedema (0-20%)
 Less neuropathic S/S  Neuropathic S/S +
 ROM  ROM
 Seroma +  Seroma +
 Total / simple mastectomy

– Surgical removal of breast & nipple

areola without ALND.
– In non invasive Ca (DCIS)
– Prophylactically in high risk cases
(…….
 Modified Radical Mastectomy

– Removal of breast tissue

& ALN.
– To treat invasive breast
cancer.
– No removal of pectoral
muscle.
 Radical mastectomy

Not common nowadays.

Most extensive type
Surgical removal of breast, nipple areola, ALND &.Pectoralis
muscles (Major and Minor)
Disadvantages: Scars and deformity. Reduced ROM
Other types
Extended radical mastectomy:

Toilet mastectomy:
– Done in fungating or ulcerative growths.
– Palliative purpose.
 Which procedure?
• Age

• Size of the tumor

• Axillary lymph node status. • Receptor status of the tumor.

• Stage of the malignancy • Multicentricity or multifocality

• Biologic aggressiveness of the tumor

• Menstrual status.

• Size of the breast

• Availability of radiotherapy.

• Patients choice.
• Prophylactic / therapeutic / palliative.
 Pre- Operative Assessment

• Detailed History (Obsteritic & Gynecological h/o)

• Chest assessment & Lung function tests (PFT)

• Stage & grade of cancer, extent of the disease

• Review Surgical details - duration of surgery, incision & details

of the flap used for reconstruction

• Exercise tolerance of the patient.

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 Psychological issues

• Response to illness
• Coping mechanisms
• Support system
• Awareness about the illness..edn needs
 Pre - op. Nsg. Mx

 Deficient knowledge about surgery.

 Anxiety related to the diagnosis of cancer.
 Fear R/T specific treatment & body image changes
 Risk for defensive coping
 Decisional conflict
 Post- operative Assessment

• Chest Assessment

• Examination of Surgical site

• Severity of Pain

• Evaluation Of Posture and mobility

• Lymphoedema Evaluation- Skin changes

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Post - op. Nsg. Diagnoses
 A/c pain & discomfort R/T surg. Procedure.
 Peripheral NV dysfunction R/T nerve irritation
 Disturbed body image
 Risk for ineffective coping
 Self care deficit
 Risk for sexual dysfunction
 Deficient knowledge
 Risk for complications
 Complications
 Lymphedema

 Reduced ROM

 Pain & numbness

 Hematoma

 Infection
 Lymphedema
• Def: Excessive and persistent accumulation of extravascular and
extracellular fluid and protein collection in tissue spaces results in
swelling of the extremity.
Transient edema – common &↑ with ALND.
Accumulation of protein rich fluid in the interstitial space.
R/F: obesity, radiation, age, co-morbidities
Grade I Grade II Grade III

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 Pathophysiology:
Dissection of axillary lymph nodes
causing interrupted lymphatic drainage

Inability to clear protein concentration

from interstitial spaces

Disturbance of fluid- protein concentration across

capillary membrane

Increased fluid into interstitial spaces

Excess load on lymphatic vessels exceeding

capacity
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 Management Strategies:

 Skin Care
 Compression Bandaging
 ROM exercises

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Prevention is vital
 Avoid BP, Injections & blood draws on affected arm.
 Sunscreen lotions & insect repellents.
 Wear gloves & cooking mitt
 Take care while nail trimming
 Avoid heavy lifting & med help if cuts / wounds.
Patient teaching

Hand and arm care

 Exercises after breast surgery

.Range of motion exercies are initial on the 2nd day post op

:Goals of exercises
increase circulation and muscles strength -1
Prevent joint stiffness and contractures -2
Restore full range of motion -3

Exercise done 3 times a day for 20 minutes at a time (4-6 weeks)

 Principles
Check doctor’s order % ensure no contraindications.

3 times a day for 20 minutes at a time.

Let patient shower with warm water prior to exercise.

Administer analgesic 30 minutes prior to exercise.

If graft present, exercises to be introduced gradually.

 Equipments

• Light rope

• Rod\ broom stick

 Rod or broomstick lifting
1. Grasp rod with both hands held about 20 cm apart
2. Keeping arms straight raise the rod over head
3. Bend elbows to lower rod behind the head
4. Reverse maneuver
 Wall hand climbing

1. Stand facing wall with feet apart and toes as close as

possible
2. Arms slightly bent , place palms of the hand on the wall at
shoulders level
3. By flexing fingers works hand up the wall until arm are
fully extended
4. Reverse process, working hands down to starting point.
 Rope turning

1. Tie light rope to doorknob

2. Stand facing the door

3. Take free end of rope in hand on side of surgery

4. Place other hands on hip
 Rope turning

5. With rope holding arm extended and held away from body
(nearly parallel with the floor)

6. Turn the rope , making as wide swings as possible

7. Begin slowly at first ; speed up later

 Pulley tugging

1. Toss light rope over a curtain rod.

2. Stand as nearly under rope as possible.

3. Grasp end in each hand

4. Extend arm straight and away from body

5. Pull the left arm up by tugging down with right arm , continue
in see- sawing motion.
Dr.Nidhi( MPT-Cardio-Vascular &
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Respiratory PT)
Patient teaching

Home care
Home care
 General wound care
 Treatment & follow up
 Lymphedema prevention
 Care of drain
Patient teaching

drainage system care

Care of drain
 Demonstrate how to empty & measure
 Milking of clots
 Reporting of drainage & other S/S. When? (<30ml/24hrs
ready for removal)
 S/S of complications
Breast reconstruction surgeries
 Techniques & timing varies..
Tissue expander breast implants
Flap reconstruction
 Latissimus dorsi flap
 TRAM (transverse rectus abdominis myocutaneous flap)

Prosthesis
TRAM
• Prosthetic implants
• Silicon gel implant
• Tissue expanders
 Augmentation, reduction or mastopexy may be required
after the procedure to ensure symmetry.

Issues
 Graft dysfunction
 Somatosensory loss
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