BREAST

Maria Salome Fernandez, MD, FPCS, FPSGS

Our Lady of Fatima University
Fatima College of Medicine
Department of Surgery

ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS

Relevant Anatomy
Modified sweat gland of ectodermal origin that lies
cushioned in fat, and is enveloped by superficial
and deep layers of superficial fascia of anterior
chest wall
Each mammary gland consists of 15-20 lobules,
which are drained by lactiferous ducts that open
separately on the nipple
Fibrous septae (Coopers ligaments) interdigitate
the mammary parenchyma and extend from deep
pectoral fascia to the superficial layer of fascia
within the dermis
The skin dimpling in breast cancer is due to
traction on Coopers ligaments.

 The breast frequently extends into axilla as

the axillary tail of Spence.
The breast is also partitioned into 4
quadrants by vertical and horizontal lines
across the nipple:

Upper inner quadrant (UIQ)

Lower inner quadrant (LIQ)
Upper outer quadrant (UOQ)
Lower outer quadrant (LOQ)

Quadrants of the Breast

 Base of the breast

extends from 2nd to 6th
rib
Medial border: lateral
border of sternum
Lateral border:
midaxillary line/
latissimus dorsi
Axillary tail of Spence
pierces the deep fascia
and enters the axilla

LYMPHATIC DRAINAGE
Lymphatic drainage is of importance during
mastectomy and axillary node dissection
The lymphatic drainage of the breast is
important because of its role in the metastasis
of breast cancer.
Axillary Nodes
75% of drainage from the ipsilateral breast
Contains 40-50 nodes
They drain secondarily to supraclavicular and
jugular nodes

Levels of Axillary Lymph Nodes

Level I Lateral to pectoralis minor

1. External mammary nodes/ Humeral/Pectoral nodes
(Anterior)
2. Subscapular nodes/ Scapular (Posterior)
3. Axillary vein nodes/ (Lateral)

Level II Superficial or deep to the pectoralis minor

1. Central group
2. Interpectoral group/ Rotters nodes bet pectoralis mm

Level III Medial to pectoralis minor

Subclavicular/ Infraclavicular group/ Apical nodes

 Level I lateral to pectoralis

minor

1. External mammary nodes/ Humeral/

Pectoral nodes (Anterior)
2. Subscapular nodes/ Scapular
(Posterior)
3. Axillary vein nodes/ (Lateral)

Level II located superficial or

deep to the pectoralis minor

Central group
Interpectoral group/ Rotters nodes

Level III medial to or above the

upper border of pectoralis minor

Subclavicular/ Infraclavicular group/

Apical nodes

 Lymph tends to pass from the

nipple, areola, and lobules of the
gland to the subareolar lymphatic
plexus.
Most lymph (more than 75%),
especially from the lateral
quadrants drain to the axillary
lymph nodes.
Most of the remaining lymph,
particularly from the medial
quadrants, drains to the
parasternal nodes (internal
mammary nodes) or to the
opposite breast, while lymph from
the lower quadrants passes deeply
to the inferior phrenic nodes.

 Internal Mammary
Nodes
Accounts for 20% of
drainage;
Drains the UIQ and LIQ

Abdominal and
paravertebral nodes
Account for 5% of
drainage

Associated Nerves of Surgical Importance

Intercostobrachial Nerve
From chest wall to axilla to supply cutaneous nerve
sensation to upper medial arm
Sacrificing this nerve hyposthesia or anesthesia of
upper medial arm
Long thoracic nerve of Bell
From roots of C5, C6, and C7
Courses close to the chest wall along medial border of
axilla to innervate serratus anterior muscle
Injury results in a winged scapular deformity

 Thoracodorsal Nerve
From the posterior cord of the brachial plexus
C5, C6, C7
Courses along the lateral border of axilla to
innervate latissimus dorsi

Lateral Pectoral Nerve

Arises from the lateral cord of brachial plexus
Innervates both pectoralis major and minor
muscles

Relevant Physiology

Phases of breast development depend on

mammographic effects of pituitary and
ovarian hormones
Estrogen promotes ductal development and
fat deposition
Progesterone promotes lobular-alveolar
development and prepares breast for lactation
Prolactin involved in milk production
Oxytocin involved in milk ejection

Menopause
Cessation of ovarian hormonal stimulation
Results in involution of breast tissue
atrophy of lobules
loss of stroma
Replacement with fatty tissue

HISTORY

1.

2.

Age
Fibroadenoma most common breast lesion in
females younger than 30 years of age
Risk for breast CA increases with increasing age
Over 70% of all cases occur in patients older than 50
years of age
Mass
Determine when first noted, how first noted, tender or
nontender, change in size over time, and relation to
menstrual cycle

3. Nipple discharge - determine nature of discharge,

unilateral or bilateral, from single or multiple duct
orifices, spontaneous or induced, association with
mass.

Bloody
intraductal papilloma or invasive papillary CA
discharge should be sent for cytology

Milky (galactorrhea)
pregnancy, lactation, pituitary adenoma, acromegaly,
hypothyroidism, stress, drugs (oral contraceptives, antihypertensives,
certain psychotropic drugs)
Evaluation may include: urine or serum pregnancy tests, prolactin
levels

 Serous
Normal menses
Oral contraceptives
Fibrocystic change
Early pregnancy

Yellow
Fibrocystic change
Galactocele

Purulent
Superficial or central breast abscess

4. Breast Pain (Mastodynia or Mastalgia)

may be associated with:

Rarely a symptom of breast CA

Tx: NSAIDs (Ibuprofen), Evening primrose oil, OCP, Vitamin
E, avoid caffeine, red wine, chocolate intake
Cyclical breast pain

Menstrual irregularity, as a premenstrual symptom

Administration of exogenous ovarian hormones during or after
menopause
Fibrocystic change is responsible for cyclic pain

Symptoms:
- pain is usually in both breasts
- usually worst in the upper and outer part of the breasts
- usually worst 3-7 days before a period
- relieved by menstruation

5. Gynecologic History
6. Past Medical History

Prior history of benign breast disease, breast cancer, radiation

therapy to the breast or axilla

7. Past Surgical History

Prior history of breast biopsy, lumpectomy, mastectomy, axillary

node dissection, hysterectomy, oophorectomy, adrenalectomy

8. Family History of Breast Disease - in mother, sisters, or

daughters
9. Constitutional Symptoms

Anorexia, weight loss, dyspnea, cough, chest pain, hemoptysis,

bony pain

Physical Examination
Inspection

Patient
Patient
Patient
Patient

seated with arms at her side

seated with arms raised over head
seated with hands on hips
supine

Note:

Breast size, shape, contour

Breast symmetry
Skin coloration
Skin dimpling, edema, erythema, peau de orange
Excoriation
Nipple inversion or retraction
Nipple discharge

 Palpation
Patient in sitting position:
Support patients arm, palpate each axilla to detect axillary
adenopathy
Supraclavicular fossae and cervical region should also be palpated
Note node size and mobility

Patient in supine position with arms stretched above the head

Palpation of breast to identify any masses
4 Ds to distinguish a true lump from a lumpy area:

Dominant
Discrete
Dense
Different

Carcinoma is typically firm, nontender, poorly circumscribed, and

relatively immobile
Palpate nipples to identify any discharge

 Emphasize breast self-examination (BSE)

Should be performed approximately 5 days after
completion of menses in the premenopausal
female and monthly in postmenopausal female

Recommended follow-up
BSE on monthly basis beginning at age 20-25;
majority of breast masses are found by patients
themselves
Physician exam every 1-3 years, depending upon
risk factors

Breast Self-Examination (BSE)

All women should perform a self breast examination

monthly after the menstrual period, when breast swelling
and fibrocystic changes are less likely to interfere with the
detection of a lump or mass.
This is also followed by a yearly clinical breast exam.

HOW TO DO THE EXAM

1. First, lift your right hand and place it behind your head.
2. Keep the first 3 fingers of your hand firmly together.
3. Press the outermost point of your right breast (near armpit) firmly in a
little circular motion with the pads of your fingers. Then continue in a
large circle all around your breast.
4. Move your finger an inch closer to the nipple and feel another circle
around the breast. Continue circling until you have felt every part of the
breast, including the nipple.
5. Squeeze the nipple gently to see if any fluid comes out.
6. Now change hands and repeat the procedure for the other breast.

Breast Self-Examination (BSE)

Breast Self Exam (BSE)

RADIOGRAPHIC STUDIES
Mammograms are the most important tools doctors have
to diagnose and evaluate women who have breast
cancer.
It tends to identify 5 cancers/ 1,000 women
It is 85-90% sensitive
Gives false positives 10%, false negatives 6-8%
Mammograms are more useful in ages >30 secondary to
the large proportion of fibrous tissue in younger womens
breast make more difficult to interpret.
Recommendation for annual mammograms start at the
age of 40; however, women with risk factors for breast
carcinoma should have ~ yearly mammograms at an
earlier age.
The American College of Radiology Diagnostic Code
interprets the mammograms from negative to highly
suggestive of malignancy.

Mammography
Indications for Mammography:
1. Screening ( current American Cancer Society
recommendations)
Baseline mammogram for women ages 35-39 years.
Mammogram every 1-2 years for women ages 40-50
years.
Annual mammogram for women older than 50 years.

2. Metastatic adenocarcinoma without known

primary.
3. Nipple discharge without palpable mass

Mammography
Screening Mammography
Used to detect unexpected breast cancer in
asymptomatic women
Supplements history taking and physical
examination
2 views are obtained:
Craniocaudal (CC) view
Provides better visualization of medial aspect of the breast
and permits greater breast compression
The pectoral muscle is not visualized in this view

Mediolateral oblique (MLO) view

Images the greatest volume of breast tissue, including the UOQ
and the axillary tail of Spence

 Diagnostic Mammography
Used to evaluate women with abnormal findings
such as a breast mass or nipple discharge
Uses different views:
CC view
MLO view
90-degree lateral view
Used along with CC view to triangulate the exact location of
an abnormality

Spot compression view

May be done in any projection by using a small compression
device placed directly over a mammographic abnormality
The compression device minimizes motion artifact, improves
definition, separates overlying tissues, decreases radiation
dose needed to penetrate the breast

Mammography

American College of Radiology

BI-RADS SCORE
BI-RADS is a quality assurance tool designed to
standardize mammography reporting, reduce confusion in
breast imaging interpretations, and facilitate outcome
monitoring.
Results are communicated to the referring physician in a
clear fashion with a final assessment that indicates a
specific course of action.

0:
1:
2:
3:
4:
5:

incomplete assessment, needs additional imaging

negative
benign finding
probably benign recommend short term follow up
suspicious abnormality consider biopsy
highly suggestive of malignancy

Gail Model Risk Assessment

Breast CA risk assessment tool used to determine patients
lifetime risk of developing invasive breast CA
Named after Dr. Mitchell Gail, Senior Investigator in the NCI
Division of Cancer Epidemiology and Genetics
This tool only calculates risk for females > 35 years old
If a woman is at 1.6% 5-year risk for developing cancer, she is
considered HIGH RISK.
A womans risk factor is referred to as her Gail Model Risk
(GMR)


34

Gail Model Risk Assessment

1. Medical history of any breast CA or of DCIS/LCIS
2. Womans age (must be >35y/o)
3. Womans age at the time of first menstrual period
Menarche before age 12 have slightly increased risk of breast CA
Women who start menstruating at a very young age have a slight
increase in breast CA risk (linked to longer lifetime exposure to
estrogen)

4. Womans age at the time of her first live birth of a child

5. How many of womans first-degree relatives mother,
sister, daughter have had breast CA?

35

Gail Model Risk Assessment

6. Has the woman ever had a breast biopsy?
How many breast biopsies (+ or -) has the woman
had?
Has the woman had at least one breast biopsy with
atypical hyperplasia?
7. What is the womans ethnicity or race?

36

Mammographic Findings Suggestive of Malignancy

Solid mass with or without stellate features

Asymmetric localized fibrosis/ thickening of
breast tissues
Clustered microcalcifications
Fine microcalcifications with a linear, branched, or
rod-like pattern, esp. when focal or clustered;
increased likelihood of cancer with increased number
of microcalcifications

Architectural distortion with retraction and

spiculation
Increased vascularity
Altered subareolar duct pattern

Mammogram with Stellate Lesion

Mammogramshowing acluster
ofmicrocalcifications

 An invasive ductal
carcinoma (*) giving a
stellate appearance in
the left breast on MLO
view. There is
associated thickening of
the skin (white arrows)
well appreciated on this
digital mammogram

 Spiculatedmass in
upper breast

Xeromammography
Identical to mammography with the exception
that the image is recorded on a xerography
plate, which provides a positive rather than a
negative image
Details of the breast and the soft tissues of the
chest wall may be recorded with one exposure
Screen film mammography has replaced
xeromammography because it requires a lower
dose of radiation and provides similar image
quality

 Initially, xeromammograms
were produced in the
positive mode with
pathological and anatomical
densities appearing blue
(Image 1)
With increasing concern over
radiation dosage in
mammography, Xerox shifted
its emphasis from
technological development
to the reduction of dose.
By reversing
xeromammograms from the
positive to the negative
mode where densities were
white (Image 2) on a blue
background, the dose could
be further decreased by
about 30%.

Digital Mammography
also called full-field digital mammography
uses computers and specially designed digital detectors to
produce images that are displayed on a high-resolution
computer monitor and stored like other computer files
the procedure is very similar to a conventional screen film
mammogram; Both use compression and x-rays to create
images of the inside of the breast
Unlike film-based mammography however, digital
mammograms produce images that appear on the
technologists monitor in a matter of seconds.
radiologists are able to refine the digital image and
obtain a more detailed and accurate assessment of
certain findings, such as calcifications and subtle masses.
Since theres no waiting for film to develop, theres
usually less time spent in the breast-imaging suite.

Digital vs. Film Mammogram

Digital vs. Screen Film Mammography

Digital mammography (DM) is especially
useful in women with dense breasts and
women <50 years of age
Prospective trials have found that DM and
SFM had similar accuracy, however
DM was more accurate in:
Women <50 years of age
Women with mammographically dense breasts
Premenopausal or perimenopausal women

Ductography
Primary indication: nipple discharge, particularly
when fluid contains blood
Radiopaque contrast media is injected into 1 or
more of the major ducts and mammography is
performed.
A duct is gently enlarged with a dilator and then a
small blunt cannula is inserted under sterile
conditions into the nipple ampulla.
With patient in supine position, 0.1-0.2 ml of
dilute contrast media is injected and CC and MLO
views are obtained without compression.
Intraductal papillomas: small filling defects
surrounded by contrast media.

Normal ductography. Magnified view of the

ductogram with filling of the lobule.

A 42-year-old woman with serous discharge from her left

nipple. Ductography reveals contrast-agent filling defects
approximately 1.5 cm from her nipple. Histopath after
surgery revealed intraductal papilloma

Ductographic Findings in Cancers

Common ductographic findings
included:
complete ductal obstruction
multiple irregular filling defects in
the nondilated peripheral ducts
ductal wall irregularities
periductal contrast extravasation
ductal displacement.

 A 52-year-old woman with

a 2.2 cm ductal carcinoma
in situ with microinvasion
who presented with bloody
nipple discharge.
The mediolateral oblique
ductogram reveals
complete obstruction with
a distal, irregular, motheaten appearance
(arrows), and associated
microcalcifications.

Ultrasound
Ultrasound is frequently used to evaluate breast
abnormalities that are found with screening mammography or
during a physician performed breast examination.
Ultrasound allows significant freedom in obtaining images of the breast
from almost any direction.

However, it is not FDA approved as a screening tool for breast

cancer. Yet, it is used as a first tool in women under 30 years
of age when a breast abnormality is found secondary to the
large amount of fibrous tissue found in women of this age.
Advantages:

They are good for distinguishing between cystic and solid masses
Can assist in therapeutic aspiration
It has excellent contrast resolution

Disadvantages:

It lacks spatial resolution (fine detail)

It cannot detect most calcium deposits on breast tumors
It cannot document how much breast tissue has been imaged
Will not identify lesions <1cm

26 year old woman with 1 year history of breast lump.

Ultrasound showed a 1.5cm nodule at 6 o'clock position about a
cm from the nipple. The nodule is consistent with a fibrodenoma.

Evaluation of Breast Mass

Fine Needle Aspiration Biopsy
Core Needle Biopsy
Vacuum-Assisted Biopsy (Mammatome
or MIBB)
Large Core Surgical (ABBI)
Open Surgical (Excisional or Incisional)

Fine Needle Aspiration Biopsy (FNAB/ FNAC)

For palpable solid masses, especially if clinical suspicion for
malignancy is high, can easily proceed in outpatient setting
A 1.5 in, 22-G needle attached to a 10-ml syringe is used, with or
without local anesthetic
Make multiple passes at different angles through the mass while
aspirating on syringe
Once cellular material is seen on the hub of the needle, the
suction is released and the needle is withdrawn
Immediately air-dried and then fix with 95% ethanol
For palpable cystic lesions:
If serosanguinous or grossly bloody send fluid for cytology
Excisional biopsy is indicated when:
Needle aspiration produces no cyst fluid and solid mass is
diagnosed
Cyst fluid is blood-tinged or grossly bloody
Cyst fluid is withdrawn, but mass fails to resolve completely
Mass reappears in the same area after more than 2 aspirations
Cyst reaccumulates within 2 weeks after initial aspiration

Fine Needle Aspiration Biopsy

Accuracy rates approach 90%
When a breast mass is clinically and mammographically suspicious,
the sensitivity and specificity of FNA biopsy approaches 100%
Advantages:
Fastest and easiest method of biopsy, where the results are easily
available.
It is excellent for confirming breast cysts
Has a low morbidity
Only 1-2% false-positive rate
Disadvantages:
The procedure only removes very small samples of tissues or cells
from breast
If the sample is benign fluid, then the procedure is ideal.
However, if the tissue is solid or a cloudy sample, the small
number of cells removed by FNA only allow for a cytologic
(cell) diagnosis.
False negatives rate up to 10%
May miss deep masses

Fine Needle Biopsy

Core Needle Biopsy

It is also a percutaneous procedure that involves removing small samples
of breast tissue using a hollow core needle.
This procedure is usually for palpable lesions.
It differs from FNA in that is also uses a larger G-14 needle, such as
the Tru-Cut needle
Automated devices are also available
Tissue specimens are placed in formalin and then processed to
paraffin blocks
Advantages:
Core needle biopsy usually allows for a more accurate
assessment of a breast mass than FNA because the larger core
needle usually removes enough tissue for the pathologist to
evaluate abnormal cells.
Disadvantages:
Still a chance of sampling error
Again, like FNA it only removes a sample of the mass and not
the entire area of concern.

Core Needle Biopsy

Quick-Core Biopsy Needle Sets

Vacuum-Assisted Biopsy
This is a relatively new biopsy that is percutaneous procedure that relies on
stereotactic mammography or ultrasound imaging.
Stereotactic mammography involves using computers to pinpoint the exact
location of a breast mass based on mammograms taken from two different
angles.
Vacuum-assisted biopsy is minimally invasive procedure that allows for the
removal of multiple tissue samples.
It has been becoming more common than open surgical biopsies due to its
advantages.
Also called:

Stereotactic (mammographically guided) breast biopsy

Stereotactic core needle biopsy
Stereotactic-guided biopsy
Breast stereotaxy
Mammotome vacuum-assisted biopsy

Advantages:

Minimally invasive
Usually no significant scarring
Does not require stitches
No breast deformity
Procedure takes less than hour
Cost effective

Vacuum-Assisted Biopsy
Through a small incision or cut in
the skin, a special biopsy needle is
inserted into the breast and, using
a vacuum-powered instrument,
several tissue samples are taken.
The vacuum draws tissue into the
centre of the needle and a
rotating cutting device takes the
samples.
The biopsy procedure is
performed under imaging
guidance (mammogram, MRI or
US). In other words, the pictures
or images obtained from scans
allow the radiologist performing
the biopsy to make sure the
needle is correctly positioned.

Finesse Ultra Vaccum-Assisted, handheld, Breast

Biopsy System

Large Core Surgical (ABBI)

Large core breast biopsy (also called ABBI, is a
brand name that stands for Advanced Breast Biopsy
Instrumentation)

It is a surgical technique that involves removing an

entire intact breast lesion under image guidance.
It requires the use of a prone biopsy table and a
stereotactic mammography.
It can remove 5 mm to 20 mm of breast tissue.
However, this technique is not widely accepted
and has bought controversy secondary to that in
large core biopsy it requires the removal of a
significant portion of normal breast tissue just to
reach the lesion.

Large Core Surgical (ABBI)

Open Surgical Biopsy

Traditional open surgical biopsy is the gold standard to
which other methods of breast biopsies are compared.
It tends to require a 1.5 cm to 2 cm incision in the breast.
Excisional Biopsy: The surgeon will attempt to completely remove
the area of concern, often along with the surrounding margin of
normal breast tissue.
Incisional Biopsy: Similar to excisional biopsy except that the
surgeon removes only part of the breast lesion, usually performed
on large lesions.
Advantages:
Yields the largest breast tissue sample of all breast biopsy methods
Gold standard the accuracy is close to 100% for a diagnosis

Disadvantages:
Requires stitches and leaves a scar
Chances of bleeding, infection, or problems with wound healing
Mortality risk associated with anesthesia

Biopsy Methods

Incidence of Breast Lesions

BENIGN BREAST DISEASES

NONPROLIFERATIVE

Fibrocystic changes
Duct ectasia
Fibroadenomas and related lesions
NO INCREASED RISK

PROLIFERATIVE

Sclerosing adenosis
Radial and complex sclerosing lesions
Intraductal papillomas
Ductal epithelial hyperplasia

ATYPICAL PROLIFERATION

ATYPICAL HYPERPLASIA
4-5X INCREASED RISK OF CANCER

BENIGN BREAST DISEASES AND CANCER RISK

ABNORMALITY

RELATIVE RISK

Nonproliferative lesions of breast

No increased risk

Sclerosing adenosis

No increased risk

Intraductal papilloma

No increased risk

Florid hyperplasia

1.5 to 2-fold

Atypical lobular hyperplasia

4-fold

Atypical ductal hyperplasia

4-fold

Ductal involvement by cells of atypical ductal hyperplasia

7-fold

Lobular carcinoma in situ

10-fold

Ductal carcinoma in situ

10-fold

Fibrocystic Change
also called chronic cystic mastitis
May represent an exaggerated response of normal
breast stroma and epithelium to circulating and
normally produced hormones and growth factors
Incidence greatest around age 30-40 years, but
th
may persist into the 8 decade
Breast pain, swelling, tenderness; frequently
bilateral
Not associated with increased risk of breast CA
unless biopsy specimen reveals ductal or lobular
hyperplasia with atypia

Fibrocystic Change
Treatment:
R/O carcinoma by aspiration or excisional biopsy of any discrete
mass that persists without change over several monthly cycles
Frequent breast examinations (BSE and MD)
Baseline mammogram for ages 35-39 and annual mammogram for
women older than 40 to identify any new or changing lesions
Avoid xanthine-containing products (coffee, tea, chocolate, cola
drinks)
Danazol, a weak androgen
50-200 mg po BID for severe symptoms; must be continued to 2-3
months to see a potential effect
50% recurrence within 1 year of discontinuing the drug
S/E: amenorrhea, body fat resistribution, weight gain, acne, hirsutism

Tamoxifen
20 mg po QID for severe symptoms
Anti-estrogenic; binds estrogen receptors
Administer 4-6 wk course, then d/c to assess for continued symptoms

Fibrocystic Change

Fibroadenoma
Fibroadenoma

Most common breast lesion in women under age 30

It is a fibrous stroma that surrounds duct-like epithelium
and forms a benign tumor that is grossly smooth, wellcircumscribed, nontender mass 1-5 cm in diameter
Lesions >5 cm are referred to as giant fibroadenomas,
which must be differentiated from cystosarcoma
phyllodes
This disease is also estrogen-sensitive, which has
increased tenderness during pregnancy.
The breast exam shows smooth, discrete, circular and
mobile mass
Diagnosis: Excisional biopsy to remove the tumor
Treatment: Observation/ may be followed clinically if
static in young patient

Fibroadenoma

Giant Fibroadenoma
Fibroadenomas very rarely turns malignant.
But when it acquires a large size to be called as
giantfibroadenoma, itmay have associated
features of malignancy; and that is the reason
why, it should be subjected
tohistopathologicalstudy after removal.
Removal of giantfibroadenomasmay require
removal of a large chunk of normal breast tissue
and sometimes removal of the whole breast.

78

79

Plan
Reduction mammoplasty with free-nipple graft
Bilateral mastectomy

Procedure
Bilateral mastectomy (March 26, 2013)

Histopathology Report
Bilateral giant fibroadenoma with fibrocystic change
Tubular adenoma, right

Phyllodes Tumors
The nomenclature, presentation and diagnosis of phyllodes
tumors (including cystosarcoma phyllodes) have posed
many problems for surgeons,
Classified as:
Benign
Borderline
Malignant
Borderline tumors have a greater potential for local
recurrence.
Mammographic evidence of calcifications and morphologic
evidence of necrosis do not distinguish between benign,
borderline and malignant phyllodes tumors from the
malignant variant and from fibroadenomas.

Phyllodes Tumors
The breast exam shows large, bulky mass; overlying
skin is red, warm and shiny, with venous engorgement
Medium size of 4-5 cm; characterized by rapid growth
Diagnosis: Biopsy with pathologic evaluation
Treatment:
Small Tumors: Wide local excision with a least a 1
cm margin
Larger Tumors: Simple mastectomy
Axillary dissection is not recommended because
axillary LN metastases rarely occur

86

Cystosarcoma Phyllodes
large, bulky mass;
overlying skin is red,
warm and shiny, with
venous engorgement

Intraductal Papilloma
It is a benign local proliferation of ductal epithelial cells,
that has unilateral serosanguineous or bloody nipple
discharge in premenopausal women.
Patients usually present with subareolar mass and/or
spontaneous nipple discharge.
In examination one must radially compress breast to
determine which lactiferous duct express fluid
Major DDx is between intraductal papilloma and invasive
papillary CA
Diagnosis: Definitive diagnosis by pathologic evaluation
of resected specimen.
Treatment: Excise affected duct after localization by
physical examination

Intraductal Papilloma

Gynecomastia
It is the development of female-like breast tissue in
males, which can either be physiologic or pathologic.
There is at least a 2 cm of excess subareolar breast
tissue present to make the diagnosis.
Physiologic:
Newborns: due to exposure to maternal estrogens
Pubertal (ages 13-17) may be bilateral or unilateral;
regresses with adulthood; treated with reassurance
Senescent (>age 50) due to male menopause with
relative estrogen increase; freq. unilateral; breast
tissue is enlarged, firm and tender; usually
regresses spontaneously in 6-12 months

Gynecomastia
Drug-induced: associated with use of estrogens,
digoxin, thiazides, phenothiazines, phenytoin,
theophylline, cimetidine, reserpine,
spironolactone, methyldopa, diazepam,
tricyclics, antineoplastic drugs, marijuana;
Tx is discontinuation of offending drug.

Pathologic: associated with cirrhosis, renal

failure, malnutrition, hyperthyroidism, adrenal
dysfunction, testicular tumors,
hermaphroditism, hypogonadism (eg.
Klinefelters syndrome)

Treatment: Treat underlying cause if specific

cause identified; any dominant or suspicious
mass should be biopsied to rule out carcinoma,
esp. in the senescent male.

Gynecomastia in Adolescent Before &

After Picture

Sclerosing Adenosis
Sclerosing adenosis (SA)is a benign (non-cancerous) condition
of the breast in which extra tissue develops within the breast
lobules
Its clinical significance lies in its mimicry of cancer; it may be
confused with cancer on PE, mammography, and at gross
pathologic exam.
Excisional biopsy and histologic exam are frequently necessary
to exclude the dx of cancer.
The diagnostic work-up for radial scars and complex sclerosing
lesions frequently involves stereotactic biopsy.
It is usually not possible to differentiate these lesions with
certainty from CA by mammogram, so biopsy is recommended.
The mammogram appearance of a radial scar or SA (mass
density with spiculated margins) will usually lead to an
assessment that the results of core needle biopsy showing
benign disease are incompatible with mammogram; breasts
radiologists therefore often forego image-guided needle biopsy
of a lesion suspicious for radial scar and refer the case directly
to a surgeon for wire localized excision biopsy.

Infectious/Inflammatory
1.

Mastitis:
It is usually caused by S. aureus or S. epidermidis; less commonly
Streptococcus spp.
It commonly occurs during early weeks of breast feeding, in
which there is focal tenderness with erythema and warmth of
overlapping skin.
Most common etiologic agents in nonlactating females: S. aureus
and anaerobes Bacteroides and Peptostreptococcus
Treatment:

Local measures: application of heat, ice packs, or use of mechanical

breast pump on affected side
Broad spectrum antibiotics
Incision and drainage if fluctuant and not improved with antibiotic tx
For recurrent infection: excision of diseased subareolar ducts

Mastitis
Mastitis, which
mainly affects breastfeeding women,
causes redness,
swelling and pain in
one breast.

Infectious/Inflammatory
2. Fat Necrosis
It usually presents as ecchymotic, firm,
irregular mass of varying tenderness, often
accompanied by skin or nipple retraction, with
a history of a local trauma elicited in 50% of
patients.
The exam represents irregular mass with no
discrete borders that may or may not be
tender. Pain is characteristic.
Diagnosis and Treatment: Excisional biopsy to
rule out carcinoma.

Atypical Ductal Hyperplasia

It is the name given to a condition that can occur in the
lining of the milk ducts in the breast.
This typically is benign in both males and females but can
be at risk for developing cancer; hence, further studies are
needed.
In women, this disease rarely proceeds on towards cancer,
and it is not cancer.
In men however, when ADH is diagnosed with a background
of gynecomastia there is a 4-5 times increased risk for the
development of invasive breast carcinoma.
Some may be an under-diagnosed ductal carcinoma in situ.
Diagnosis: Biopsy
Treatment: Observation, or Excisional Biopsy do not need
clear margins

Atypical Ductal Hyperplasia

the duct than would
normally be there, and
some of these cells arenot
typical -- they are
irregular in shape and size.
Usually, a milk ductis
lined with one even layer
In atypical ductal
hyperplasia there are more
cells lining of uniformly
shaped cells, but in ductal
hyperplasia there may be
many layers of cells.

Infectious/Inflammatory Breast
Disease
3. Mondors Disease
Painful, cordlike superficial thrombophlebitis
Thrombophlebitis of superficial veins of the chest
wall (thoracoepigastric vein)
Presents as acute pain over superolateral breast
or axilla, often related to local trauma
Finding of palpable cord is diagnostic.
Treatment: reassurance, heat, analgesics

Mondors Disease

Breast Cancer
It is the second most common cause of cancer
death in women.
It is the main cause of death in women ages 45
to 55.
However, male breast cancer is rare in contrast
to female breast cancer.
Breast cancer is 100 times more common in
females than males.
The median age of onset in males is 65-67 years
of age.

Risk Factors for Breast Cancer

Females

Early menarche
Late menopause
Nulliparity or 1st
pregnancy >30 y.o.a.
White race
Old age
Family history of breast
cancer
Genetic predisposition
(BRCA 1, BRCA 2, Li
Fraumeni Syndrome)
Prior personal history of
breast cancer
DCIS or LCIS
Atypical ductal or lobular
hyperplasia

Males

Testicular Abnormalities

Undescended testes
Congenital inguinal hernia
Orchitis
Testicular injury

Infertility
Positive family history
Klinefelter Syndrome
Elevated endogenous
estrogen
Previous irradiation
Trauma
Jewish ancestry

Screening for Breast Cancer

Breast screening is a method of detecting
breast cancer at a very early age.
There are several methods for to screen for
breast cancer, and it can begin at a very early
age.
The simple ways to begin to screen for breast
cancer are:
Breast Self Examination
Mammography
Ultrasound*

Staging of Breast Cancer

TNM Staging for Breast Cancer

Tx: Cannot assess primary tumor

T0: No evidence of primary tumor
T1: </= 2 cm
T2: </= 5 cm
T3: > 5cm
T4: any size, with direct extension into the chest wall
or with skin edema or ulceration
Nx: Cannot assess lymph nodes
N0: No nodal metastasis
N1: Movable ipsilateral axillary nodes
N2: Fixed ipsilateral axillary nodes
N3: Ipsilateral internal mammary nodes
Mx: Cannot assess metastasis
M0: No metastasis
M1: Distant metastasis or supraclavicular nodes

STAGING SYSTEM FOR BREAST CA

Stage

Tumor Size

Lymph Node
Involvement

Metastasis

0*
DCIS or LCIS

Less than 2 cm

None

None

II

Between 2-5
cm

No or in the
same side of
the breast

No

III

More than 5
cm

Yes, on same
side of breast

No

Not applicable Not applicable

Yes

IV

Treatment of Breast CA
The primary goal of local therapy is to
provide optimal control of the disease
in the breast and regional tissue while
providing the best possible cosmetic
result.
The different types of treatment may
include surgery, radiation therapy,
adjuvant chemotherapy, adjuvant
endocrine therapy, or a combination of
modalities.

Surgical Treatment for Breast CA

The optimal surgical approach is

determined by the following factors:
Disease stage
Tumor size
Tumor location
Breast size and configuration
Number of tumors in the breast

Surgical Treatment of Breast CA

1.
2.
3.
4.
5.

Radical mastectomy: Resection of all breast tissue, axillary nodes, and

pectoralis major and minor muscles.
Modified radical mastectomy: Same as radical mastectomy except
pectoralis muscles left intact.
Simple mastectomy: Resection of all the breast tissue, except
pectoralis muscle left intact and no axillary node dissection.
Lumpectomy and axillary node dissection: Resection of mass with rim
of normal tissue and axillary node dissection good cosmetic result.
Sentinel node biopsy: Recently developed alternative to complete
axillary node dissection.
Lymph nodes are identified on pre-operative scintigraphy and blue
dye is injected in the periareolar area.
Axilla is opened and inspected for blue and/or hot nodes
identified by a gamma probe.
When sentinel node is positive, an axillary dissection is completed.
When sentinel node is negative, axillary dissection is not
performed unless axillary lymphadenopathy identified.

Pre-Malignant Disease
Ductal CA in situ
Proliferation of ductal cells that spread through the ductal
system but lack the ability to invade the basement
membrane. It arises from the inner layer of epithelial cells in
major ducts.
More than the cases occur after menopause, in which there
is a palpable mass some of the times.
Diagnosis: Clustered microcalcifications on mammogram,
malignant epithelial cells in breast duct on biopsy.
Risk of invasive cancer: There is increased risk in ipsilateral
breast, usually same quadrant; where infiltrating ductal
carcinoma is most common histologic type.
Treatment:
If small (< 2 cm): Lumpectomy with either close follow-up or
radiation
If large (> 2 cm): Lumpectomy with 1 cm margins and radiation
If breast diffusely involved: Simple mastectomy

Ductal Carcinoma in Situ

The term 'in situ' refers to
pre-invasive breast
cancer. This is breast
cancer which has not yet
penetrated ('invaded')
through the basement
membrane (the
membrane at the base of
the epithelial lining of
ducts or glands).

Lobular CA in Situ
Originates from cells of the terminal duct-lobular unit,
and develops only in the female breast.
Characterized by distension and distortion of terminal
duct lobular units by cancer cells, which are large but
maintain normal nuclear:cytoplasmic ratio
Cytoplasmic mucoid globules are a distinctive cellular
feature
"Neighborhood calcification" is a feature unique to LCIS.
Calcification occurs in adjacent tissues
The vast majority of the cases occur prior to menopause,
and one usually does not feel a palpable mass.
Diagnosis: Mammogram
Risk of invasive cancer: equally increased risk in either
breast, infiltrating ductal carcinoma; associated with
simultaneous LCIS in the contralateral breast in over
the cases.

Lobular CA in Situ
Treatment Options:
1. Observation
2. Chemoprevention with tamoxifen
3. Bilateral total mastectomy

LCIS is regarded as a marker of increased risk for invasive

breast cancer rather than as an anatomic precursor

Lobular CA in Situ
In lobular carcinoma
in situ (LCIS, the
image to the right),
the lobular cells have
developed the ability
to multiply out of
control - one of the
characteristics of
cancer. The cancerous
cells have not yet
spread beyond the
lining of the lobule.
This is known as LCIS.

Malignant Disease (Invasive)

Infiltrating Ductal Carcinoma

This is the most common invasive cancer in both males

and females (80% of cases).
It is the most common in perimenopausal and
postmenopausal women.

Presentation: A hard, fixed mass, peau d orange overlying the

skin, ulceration of overlying skin, bloody nipple discharge,
inverted or retracted nipple.

The ductal cells tend to invade stroma in various

histologic forms described as scirrhous, medullary,
comedo, colloid, papillary, or tubular.

Medullary: Invasive breast cancer that forms a distinct boundary

between tumor tissue and normal tissue.
Colloid: Formed by mucus producing cancer cells

Can have metastasis to axilla, bones, lungs, liver and

brain.

Invasive
Infiltrating Lobular Carcinoma
It is the second most common type of invasive breast
cancer (10% of cases).
It originates from terminal ducts cells and, like LCIS,
has a high likelihood of being bilateral.
20% of infiltrating lobular carcinoma have simultaneous
contralateral breast cancer.
Tends to present as an ill-defined thickening of the breast.
Like LCIS, does not form microcalcifications and is often multicentric

Tends to metastasize to the axilla, meninges, and

serosal surfaces.

Invasive
Paget Disease (of the Nipple)
It is usually 2% of invasive breast cancers
They are usually associated with underlying
LCIS or ductal carcinoma just beneath the
nipple and areola.
Presentation: Tender, eczematous, itchy nipple with
or without a bloody discharge with or without a
subareolar palpable mass

Treatment: Usually requires a modified

radical mastectomy.

Pagets Disease of the Nipple

Pagets Disease of the Nipple

119

Invasive
Inflammatory Breast Carcinoma (IBC)

Accounts for 1-4% of all breast malignancies

Most rapidly lethal malignancy of the breast
Poorly-differentiated
Char. by dermal lymphatic invasion on pathological exam
PE: diffuse induration, warm, erythematous, peau de
orange skin of the breast, with or without palpable
mass; axillary lymphadenopathy is almost always present
Distant metastases common at time of diagnosis (17-36%)

120

Inflammatory Breast CA

121

Inflammatory Breast CA

122

Inflammatory Breast CA

123

Inflammatory Breast CA

124

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy (SLNB) is used to provide staging information
and to determine the need for axillary lymph node dissection (ALND) in
breast cancer patients.
A properly performed negative SLNB should accurately identify those
patients without axillary node involvement, thereby obviating the need
for a more morbid ALND.
The risk of arm morbidity, particularly lymphedema, is significantly
lower after SLNB than ALND.
SLNB should be performed in most women with clinically node negative
invasive or microinvasive breast cancer.
SLNB can be omitted if the nodal information will not affect adjuvant
treatment decisions. As an example, women 70 years of age who have a
small (<2 cm) estrogen receptor-positive tumor and a clinically
uninvolved axilla may be treated without a SLNB.
SLNB should be performed in women with extensive ductal carcinoma in
situ (DCIS), who are undergoing mastectomy. A SLNB will not be possible
after mastectomy if invasive disease is found on final pathology,
necessitating an axillary dissection for staging purposes.
When a SLNB is not successful or when clinically suspicious nodes are
encountered in the axilla the surgeon should perform an axillary
dissection for staging purposes and to ensure locoregional control
125

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy of the breast. A radioactive
substance and/or blue dye is injected near the tumor
(first panel). The injected material is detected visually
and/or with a probe that detects radioactivity (middle
panel). The sentinel nodes (the first lymph nodes to
take up the material) are removed and checked for
cancer cells (last panel).

126

Sentinel Lymph Node Biopsy

Technique
The patient is prepped and draped in the operating room. The
surgeon injects 3 to 5 mL of blue dye (classically isosulfan blue)
around the tumor periphery, at the palpable edge of the biopsy
cavity or into the subareolar plexus.
It is important not to inject the dye into the tumor itself (because
the lymphatics can be occluded by tumor) or into the seroma
cavity following breast biopsy (as the seroma itself does not
contain lymphatic channels). These errors in technique are likely
to lead to a failure of mapping. Breast massage is then carried out
for about five minutes to dilate breast lymphatics [2,3].
The use of isosulfan blue dyefor SLNB is associated with severe
anaphylactic reactions requiring resuscitation in 0.7 to 1.1 percent
of cases [1,4-6]. Prophylactic treatment with 100 mg of
hydrocortisone(or 20 mg of methylprednisoloneor 4 mg of
dexamethasone), 50 mg of diphenhydramine, and 20 mg of
famotidineintravenously just before or at the induction of
anesthesia appears to decrease the severity but not the incidence
of dye reactions
127

SURGICAL TREATMENT OPTIONS FOR BREAST CA

1. Wide Local Excision (WLE)/

Lumpectomy/ Segmental Mastectomy
2. Subcutaneous Mastectomy
3. Simple Mastectomy/ Total Mastectomy
4. Modified Radical Mastectomy (MRM)
5. Radical Mastectomy (Halsted) (RM)

128

Wide Local Excision (WLE)/ Lumpectomy/

Segmental Mastectomy
Breast-conserving therapy
Major objectives:

Complete excision of the tumor with tumor-free margins

Good cosmetic result

Usually accompanied by axillary node dissection (through

a separate incision) and radiation therapy to the whole
breast post-op.
Eligibility Criteria:

Tumor size 4cm or less

Appropriate tumor size to breast size ratio
No fixation of tumor to underlying muscle or chest wall
No involvement of overlying skin
No multicentric cancer
No fixed or matted axillary nodes

129

Wide Local Excision (WLE)/ Lumpectomy/

Segmental Mastectomy
Complete excision of
tumor with tumor-free
margins
Usually accompanied by
axillary node dissection
(through a separate
incision) and radiation
therapy to the whole
breast post-op.
Curvilinear incision in
upper quadrants, radial
incisions in the lower
quadrants
130

Subcutaneous Mastectomy
Removes breast tissue only, sparing the nipple-areolar complex,
skin and nodes.
Not a cancer operation, leaves 1-2% of breast tissue behind
Rarely, if ever, indicated.
mainly a prophylactic operation, indicated in patients with
premalignant breast disease and in high risk patients with
widespread fibrocystic disease.
A unilateral S.C.M. is indicated in patients who have already had a
mastectomy for carcinoma and whose remaining breast has an
increased risk for also developing a carcinoma.
may be performed according to total mastectomy indications if an
intraoperative frozen section (and the corresponding HE
histopathology) of the tissue next to the nipple-areola skin is free
of tumor.

131

Simple Mastectomy/ Total Mastectomy

Removes the breast
tissue, the nipple-areolar
complex, and skin
No axillary node
dissection /minimal
axillary node dissection
is performed
Often performed for DCIS
or LCIS

132

Modified Radical Mastectomy (MRM)

Removes breast tissue, pectoralis fascia, nipple-areolar
complex, skin, and axillary lymph nodes in continuity;
Spares the pectoralis major muscle.
Patey procedure: preserves the pectoralis major, but
removes the pectoralis minor in order to remove Levels I, II
and III axillary lymph nodes
Auchincloss procedure: preserves both pectoralis major and
pectoralis minor muscles. Preservation of pectoralis minor
limits high axillary node dissection (Level III), but this does
not seem to be clinically significant in most cases.

133

Modified Radical Mastectomy (MRM)

134

Modified Radical Mastectomy (MRM)

135

Simple Mastectomy
and Modified Radical Mastectomy
A simple, or total,
mastectomy (left)
removes the breast
tissue, nipple, areola and
skin, but not all the
lymph nodes. A modified
radical mastectomy
(right) removes the
entire breast, including
the breast tissue, nipple,
areola and skin, and
most of the underarm
(axillary) lymph nodes.
136

Post-operative Care after Mastectomy

137

Radical Mastectomy (Halsted) (RM)

Removes breast tissue, nipple-areolar complex,
skin, pectoralis major and minor, and axillary
lymph nodes in continuity.
Leaves bare chest wall with significant
cosmetic and functional deformity.
Of historical interest only; Clinical trials
comparing MRM with RM reveal no significant
difference in disease-free survival, distant
disease-free survival, or overall survival.
138

Radical Mastectomy (Halsted) (RM)

Removes breast
tissue, nipple-areolar
complex, skin,
pectoralis major and
minor, and axillary
lymph nodes in
continuity.
Leaves bare chest
wall with significant
cosmetic and
functional deformity.
139

Different Types of Mastectomies

140

STAGING SYSTEM FOR BREAST CA

Stage

Tumor Size

Lymph Node
Involvement

Metastasis

0*
DCIS or LCIS

Less than 2 cm

None

None

II

Between 2-5 cm

No or in the
same side of the
breast

No

III

More than 5 cm

Yes, on same
side of breast

No

IV

Not applicable

Not applicable

Yes
141

SURGICAL TREATMENT BY STAGE

Stage 0 In Situ Breast CA
1. DCIS
Total ipsilateral mastectomy vs. WLE plus
radiation therapy (XRT)
General agreement that axillary node
dissection is not required for DCIS
Overall 5-yr survival rate of 95-100%,
independent of whether treated by TM or
WLE plus XRT
142

Stage 0 In Situ Breast CA

2. LCIS
Close observation vs. bilateral TM
Axillary node dissection is not required

3. Clinically occult invasive CA

MRM vs. WLE with axillary node dissection plus
XRT

4. Pagets Disease of the Nipple

TM vs. MRM
143

Stages I and II
Early Breast CA

I
II

Less than 2 cm
Between 2-5 cm

Axillary LN None
No or in the same side of the breast

Approximately 85% of breast CAs

Current tx recommendations: MRM vs. WLE with ALND plus XRT
Clinical trials have shown: WLE + ALND + XRT to be equivalent to MRM in terms
of disease-free survival, distant disease-free survival, and overall survival
WLE with ALND + XRT offers breast conservation with clinical outcome
equivalent to MRM
Tumor-free margins are essential when WLE is performed
Addition of XRT to WLE with ALND improves disease-free survival (localregional recurrence) but does not improve distant disease-free survival or
overall survival in node(-) patients.
Adjuvant chemotherapy is indicated for node(+) patients and high-risk node(-)
patients.



144

Stages I and II
Factors associated with high risk of recurrence:

Age < 35 yrs

Tumor size > 2cm
Poor histologic and nuclear grade
Absence of estrogen and progesterone receptors
Aneuploid DNA content
High proliferative fraction (S-phase)
Overexpression of epidermal growth factor receptor (EGF-2)
Presence of cathepsin D
Amplification of c-erb B-2 oncogene

145

Stages I and II
Lobular CA: use of mirror-image
biopsy or total mastectomy for the
contralateral breast is controversial.
5-year survival rates for Stages I and
II breast CA are approximately 80%
and 60% respectively

146

Stages III and IV

Multi-modality therapy including surgery, radiation
therapy, and systemic therapy is usually employed
Surgical therapy must be individualized based on extent
of tumor and technical ease of resection; Mastectomy
(TM or MRM remains the mainstay of surgical therapy)
Pre-op chemotherapy and local radiation therapy is
under investigation as potential treatment for
inflammatory breast CA
Goal of multimodality therapy is control of local-regional
and distant disease. Even with aggressive therapy,
however, most of these patients will die as a result of
distant metastatic disease.
5-year survival rates for Stages III and IV breast CA are
approximately 20% and 0% respectively.
147

CHEMOTHERAPY AND HORMONAL THERAPY

Surgery and radiation therapy are used to

achieve local regional control.
Chemotherapy and hormonal therapy are
used to achieve systemic control.
Indications for chemotherapy and
hormonal therapy:
Adjuvant therapy for node(+) patients and
high-risk node(-) patients
Palliation for metastatic disease
148

PALLIATION FOR METASTATIC DISEASE

The decision to offer systemic therapy for
metastatic disease should be based on:
Extent and rate of progression of metastatic
disease
Hormone receptor status
Degree and progression of symptoms
Patients ability to tolerate therapy w/o
significant toxixity

149

CHEMOTHERAPY or HORMONAL THERAPY?

Chemotherapy:

tends to have a shorter time to response (4-6 wks vs. 8-12 wks)
Better overall response rate (40-60% vs. 25-35%)
Shorter mean duration of action (8-12 months vs. 14-18 months)
Increased toxicity compared to hormonal therapy
Should be considered for patients with:
Hormone receptor negative tumors
Aggressive metastatic disease
Ability to tolerate side-effects of cytotoxic drugs

Hormonal therapy should be considered for patients

with:
Hormone receptor positive tumors
Relatively indolent metastatic disease

Tamoxifen is the treatment of choice for most of these patients

150

Cytotoxic Chemotherapy
NODES

MENOPAUSAL STATUS

SIZE

THERAPY

Positive

Premenopausal

Any

CMF, CAF, AC,

Positive

Postmenopausal

Any

CMF, CAF, AC

Positive

Postmenopausal

Any

Tamoxifen

Negative

Pre or Postmenopausal

<1 cm

None

Negative

Pre or Postmenopausal

1-2 cm

+/- CMF, CAF, AC

Negative

Pre or Postmenopausal

2 cm

CMF, CAF, AC

Negative

Pre or Postmenopausal

1 cm

Tamoxifen
151

Metastasis
Breast cancer tends to metastasize to
the following places:
Lymph nodes (most common)
Lung/pleura
Liver
Bones
Brain

152

Prognosis
Approximately 50% of patients with operable
breast cancer develop recurrent disease unless
they receive adjuvant chemotherapy or hormone
therapy. Prognostic factors include:

Tumor size: Tumors larger than 5 cm are associated with a

decreased survival rate and increased recurrence rate.
Axillary node status
Histopathology
Hormone receptor status
Oncogenic expression
153

5 Year Survival Rate According to Stage

STAGE

5- YEAR SURVIVAL RATE

92%

II

87%

III

75%

IV

13%

154

SUMMARY
Breast cancer is the most common female cancer, in contrast to male where
it is rare, with a ratio of 100:1.
When performing an initial evaluation of patients with possible breast
disease:
Remember to have a complete medical history, including risk factors,
such as:
Ask when first menarche, first child, any history of breast cancer,
when did menopause happen, how old is the patient, any previous
breast biopsy, etc.
Be sure to inquire about any history of nipple discharge, or any
changes in the size, shape, symmetry, or contour of the breasts.
Remember to inspect and palpate all four quadrants of the breast, the
axillary lymph nodes, and the nipple-areolar complex for any
discharge.
Screening test of choice: Mammogram
Diagnostic Test: Biopsies
Treatments: Surgical, Hormonal, Adjuvant Therapy [Chemotherapy,
Radiation Therapy]
155

Remember,

Thank You !