CARCINOMA BREAST

Breast cancer is cancer that develops in breast cells. Typically, the cancer
forms in either the lobules or the ducts of the breast.

AETIOLOGY
 Carcinoma breast is more common in developed, western countries.
 It is second most common carcinoma in females. Incidence is 19-34%.
Median age is 47 years.
 Carcinoma in one breast increases the risk of developing carcinoma on
opposite breast by 3-4 times. Incidence of bilateral carcinoma is 2%.
 Mutation of tumour suppressor genes BRCA1/ BRCA2 is thought to be
involved with high risk of breast carcinoma. BRCA1 mutation is having
more risk (35-45%) than BRCA2 mutation. It is located in long arm of
chromosome 17, whereas BRCA2 is located in long arm of chromosome
13.
 It is more common in nulliparous woman. Attaining early menarche and
late menopause have high risk of breast malignancy.
 Early child bearing and breast feeding reduces the chances of
malignancy.
 It is more common in obese individuals.
 In males, occasionally gynaecomastia turns into carcinoma.
 A benign breast disease with atypia, hyperplasia and epitheliosis has got
higher risk in a patient with family history.
 It is more common in individuals who are on oral contraceptive pills and
hormone replacement therapy (HRT) for more than 5 years.

PATHOLOGY
 Breast carcinoma arising from lactiferous ducts is called as ductal
carcinoma.
 Breast carcinoma arising from lobules is called as lobular carcinoma. It
is 10% common.
 In-situ carcinoma is preinvasive carcinoma which has not breached the
epithelial basement membrane.
 It may be
- Ductal in situ carcinoma (Ductal Carcinoma In Situ, DCIS) or
- Lobular in situ carcinoma (Lobular Carcinoma In Situ, LCIS).

 Invasive carcinoma can occur eventually.

CLASSIFICATION
I. Ductal carcinoma.
Lobular carcinoma.
II. (a) In situ carcinoma

• DCIS (Ductal carcinoma in situ).

• LCIS (Lobular carcinoma in situ).

(b) Invasive.

• Invasive ductal carcinoma.

• Invasive lobular carcinoma. It is commonly multifocal and often
bilateral.

III. Unilateral.
Bilateral—2-5% common.

.IV. Unifocal.
Multifocal--tumour tissues within the same quadrant at multiple foci.
Multicentric--tumour tissues within the same breast but in different
quadrant.

DCIS (Duct carcinoma in situ)

 It is intraductal carcinoma (proliferation of malignant mammary ducal
epithelial cells) without any invasion into the basement membrane.
 It is 5%-20% common.
 It can be—
– Solid.
– Comedo with necrosis is high grade with increased chances of
microinvasion.
– Cribriform.
– Papillary.
– Micropapillary.
 Nipple discharge and often small swelling are main presentations.
 Risk of lymph node spread in DCIS is less than 4%. So axillary dissection
is not necessary.
Types:

i. Scirrhous carcinoma: It is 60% common. It is hard, whitish, or whitish

yellow, noncapsulated, irregular, with cartilaginous consistency. It
contains malignant cells with fibrous stroma.
ii. Medullary carcinoma: Also called as ‘encephaloid type’ because of its
brain like consistency. It contains malignant cells with dispersed
lymphocytes.
iii. Inflammatory carcinoma/Lactating carcinoma/Mastitis carcinomatosis:
Most malignant type of carcinoma breast. It is 2% common.
iv. Paget’s disease of the nipple: It is superficial manifestation of an
intraductal carcinoma. The malignancy spreads within the duct up to the
skin of the nipple and down into the substance of the breast. It mimics
eczema of nipple and areola.
v. Tubular, papillary, cribriform are other types of duct carcinomas.
vi. Atrophic scirrhous carcinoma: Seen in elderly females. It is a slow
growing tumour which has got better prognosis. FNAC is diagnostic. It is
curable.
vii. Lobular carcinoma in situ: Predominantly premenopausal. Need not be
detected by mammography, as it does not provoke calcification. It has
poor prognosis due to bilateral, multifocal nature and difficulty in
identifying it.
viii. Disease of Reclus: It is a rare intracystic papilliferous carcinoma of breast
presenting as a cystic swelling with bloody discharge from the nipple.
ix. Colloid carcinoma: It produces abundant mucin.

GRADING OF TUMOR
 It is based on nuclear pleomorphism; tubule formation; mitotic rate.
 It can be – well-differentiated (grade 1); moderately differentiated (grade
2) and poorly differentiated (grade 3).

CLINICAL FEATURES AND PRESENTATION

• Lump in the breast which is hard, painless (commonest)
• Nipple discharge is the second common presentation
• Ulceration and fungation
• Axillary lymph node enlargement; Supraclavicular lymph node enlargement
• Chest pain and haemoptysis
• Bone pain, tenderness, and pathological fracture
• Pleural effusion, ascites
• Liver secondaries, secondary ovarian tumour
• Pain in the lump in 10% cases

 Common sites of distant spread in carcinoma breast

• Bones—70% - (lumbar vertebrae, pelvic bones, long bones)
• Lungs and pleura—20-30%
• Soft tissues—5-15%
• Liver—10-12%
• Brain—2-5%
• Adrenals—2-5%

DIFFRENTIAL DIAGNOSIS
 Fibroadenosis
 Traumatic fat necrosis
 Tuberculosis of breast
 Blood good cyst
 Filariasis breast
 Mastitis
 Antibioma
 Galactocele
 Mondor’s disease
 Cystosarcoma phylloides

INVESTIGATIONS
 Mammography:
Findings
• Size and location of mass lesion
• Microcalcifications signify malignancy
• Soft tissue shadow is irregular
• Spiculations
 Ultrasound of breast: To find out whether the lesion is solid or cystic.
 FNAC: It is very useful in diagnosing the carcinoma breast. U/S guided
FNAC is also used. But negative results are difficult to interpret because it
may be due to sampling errors and so requires further diagnostic methods.
 FNAC of opposite breast, lymph nodes, opposite axillary lymph nodes are
also often required.
 Frozen section biopsy: If FNAC fails even after two trials or in cases of
negative FNAC, then on table frozen section biopsy is done for diagnosis.
 Corecut/Trucut biopsy is done under local anaesthesia.
 Excision biopsy is done only when FNAC is inconclusive and a facility for
frozen section is not available.
 Chest X-ray: To look for pleural effusion, cannon ball secondaries in lungs,
mediastinal lymph nodes, secondaries in rib.
 CT chest is more reliable method to see lung secondaries.
 Ultrasound abdomen: To look for liver secondaries, ascites, and
‘Krukenberg’ tumour.
 X-ray spine shows osteolytic secondaries.
 MRI of breast:
– To differentiate scar from recurrence.
– To image breasts of women with implants.
– To evaluate the management of axilla and recurrent disease.
 Tumour markers: CA 15/3 (normal value < 40 U/ ml of serum) are used
mainly during follow-up period.
 Edge biopsy: Done only when there is ulceration and fungation. Diathermy
should be avoided in incision biopsy as it may distort the histology of tumor
and study of hormone receptor status may not be possible.
 Axillary sampling: It is often done with an adequate axillary incision. 10-15
nodes are removed for sampling.
 Ductography: It is contrast study of ducts of breast in case of unilateral
nipple discharge.
 Thermography: It is not very sensitive test (50%). Malignant tumours are
hypervascular and so transmitted temperature is detected through different
thermographic methods.

TREATMENT
It is usually through a combined approach.
• Surgery
• Radiotherapy
• Hormone therapy
• Chemotherapy

A. Surgeries
 • Total (simple) mastectomy: Along with the tumour, entire breast, areola,
nipple, skin over the breast, including axillary tail are removed.
• Total mastectomy with axillary clearance: Commonly used procedure.
Total mastectomy is done along with removal of axillary fat, fascia and
lymph nodes.
• Halsted Radical Mastectomy.* (Complete Halsted)(R M)
• Conservative breast surgeries: Tumour is removed with a rim of 1 cm of
normal tissue.
• Toilet mastectomy: In locally advanced tumour, tumour with breast tissue
and whatever possible is removed to prevent further fungation.
• Skin sparing mastectomy (SSM/Key hole mastectomy) is becoming
popular with different approaches.
• Lumpectomy word is presently used only for removal of benign diseases
of breast; not for malignant disease.

 Complications of MRM/mastectomy
• Injury/thrombosis of axillary vein
• Seroma—50-70%
• Shoulder dysfunction 10%
• Pain (30%) and numbness (70%)
• Flap necrosis/infection
• Lymphoedema (15%) and its problems
• Axillary hyperaesthesia (0.5-1%)
• Winged scapula

B. Radiotherapy in carcinoma breast

To chest wall:
 T3 tumour > 5 cm
 Residual disease-LABC
 Positive margin/close surgical margin of < 2 cm
 After conservative surgery
 Inflammatory carcinoma

To axilla:

 4 or more nodes positive

 Extranodal spread
 Axillary status not known
 RT is a must after conservation of breast
  Local as well as to axilla
 Internal mammary and supraclavicular area may be included in
radiation field
C. Hormone therapy in carcinoma breast
Principles
• It is used in ER/PR positive patients in all age groups (earlier it is used
in perimenopausal age groups).
• It is relatively safe, easy to administer.
• It gives prophylaxis against carcinoma of opposite breast.
• It is useful in metastatic breast carcinoma.

Includes
• Oestrogen receptor antagonists—Tamoxifen.
• Ovarian ablation by surgery (Bilateral oophorectomy) or by radiation.
• LHRH agonists (Medical oophorectomy).
• Oral aromatase inhibitors for postmenopausal women.
• Adrenalectomy or pituitary ablation.
• Progesterone receptor antagonist.
• Androgens—Inj Testosterone propionate 100 mg IM three times a
week.
• Aminoglutethimide—blocks the synthesis of steroids by inhibiting
conversion of cholesterol to pregnenolone— Medical adrenalectomy.
• Progestogens, e.g. Medroxyprogesterone acetate.

D. Chemotherapy in Carcinoma Breast

Indications
• In advanced carcinoma breast as a palliative procedure.
• In postoperative period after simple mastectomy in stage III carcinoma
breast with fixed axillary nodes.
• In inflammatory carcinoma of breast.
• In stage IV carcinoma breast with secondaries in bone, lungs, liver.
• In premenopausal age group with poorly differentiated
tumours.

Toxic effects are: Alopecia, bone marrow suppression, cystitis,

megaloblastic anaemia, GIT disturbances, nephritis.

Drugs Used
1. CMF regime
Cyclophosphamide
Methotrexate
 5-Fluorouracil
2. CAF regime
Cyclophosphamide
Adriamycin
5-Fluorouracil
3. MMM regime
Methotrexate
Mitomycin-C
Mitozantrone