CA BREAST: Clinical Aspects, Investigations, Staging A presentation BY: MOHAMMED SHAKEEBUDDIN KASHIF ESIC MEDICAL COLLEGE, KALABURAGI, KARNATAKA

Clinical presentation HISTORY- Age- >30y usually, Lump in the breast with a short history and rapid growth without any pain, nipple discharge +/- ,Nipple retraction, Loss of weight, Family history of lump in breast.

Examination of breast

Examination Findings:inspection INSPECTION OF BREAST,NIPPLE,AREOLA:- Shrinking and Elevation of breast with nipple retraction made more prominent by raising both the hands above the head. Discharge from nipple +/- Peau d’orange:- Cutaneous lymphatic edema due to blockage of subcuticular lymphatics. INSPECTION OF ARM, THORAX, AXILLA, SUPRACLAVICULAR FOSSA: Multiple Cancerous nodules and thickened infiltrated skin like a coat of armour[Cancer en cuirasse]. Brawny edema of the arm:- extensive neoplastic infiltration of axillary lymph nodes leading to lymphatic blockage and swelling of arms.

PALPATION:- Hard/stony hard lump in Upper outer Q./Tail, usually immobile and fixed to the underlying muscle, uneven in surface, irregular margins. Peau d’orange +/- Advanced cases:- Blood tinged Nipple discharge, Ulceration, Brawny edema.

Retraction of nipple

Peau d’orange

Cancer en cuirasse

Examination of lymph nodes AXILLARY GROUP:- Central, Pectoral, Brachial, Subscapular,, Apical. CERVICAL:- Supraclavicular.

Diagnostic investigations 1. MAMMOGRAPHY- MEDIOLATERAL OBLIQUE VIEW AND CRANIOCAUDAL VIEW. 2. ULTRASOUND SCAN OF BREAST 3. MRI BREAST. 4. FINE NEEDLE ASPIRATION CYTOLOGY AND TRUCUT/CORE NEEDLE BIOPSY 5.IMMUNOHISTOCHEMISTRY 6.TRIPLE ASSESSMENT 7.SENTINAL NODE BIOPSY

MAMMOGRAPHY

mri

mri

FNAC

TRUCUT biopsy

Immunohistochemistry 1.Estrogen receptors[ER], Progesterone receptor[PR] Patients with ER+ve tumor have longer disease free survival after primary treatment All patients may benefit from tamoxifen except Premenopausal ER/PR negative patients. 2.HER-2/neu receptor Receptor tyrosine kinase, 3+ in 25% cases 1+ negative, 2+ equivocal[confirm by FISH], 3+ overexpressed 3.FISH- Fluorescent in situ hybridization. 4.Ki 67- Newer marker for cellular proliferation. SBR[Scarff Bloom Richardson] evaluation- depending upon nuclear pleomorphism, tubule formation and mitotic rate.

Triple assessment

Sentinel lymph node biopsy

Investigations to rule out metastasis 1.Chest X-ray 2.USG Abdomen[with clinical correlation] 3.Bone Scan if Alkaline phosphatase[ALP] increased/Symptomatic