Breast Cancer Dr. Gehan Mohamed

Introduction Most common female cancer. The incidence of breast cancer increases with age. 80% of cases occur in post-menopausal women. Cancer breast most commonly affect upper outer quadrant. Male breast cancer less common (1%) and usually the patient presented with metastasis within pectoralis muscle.

Cancer breast most commonly affect upper outer quadrant

Risk Factors for Breast Cancer 1- Female 2- Aging:After the age of 30 years. 3-Menstrual history :early onset, late menopause 4- Past history of Relative affection (mother or sister) 5-Exogenous Estrogen: Either in the form of Hormonal replacement therapy(HRT) in postmenopausal women or used as Oral Contraceptives. 6-Radiation exposure. 7-Obesity 8-Diet: Fat,Alcohol 9- BRCA1gene,BRCA2 gene have role in familial breast Cancer, ovarian cancer 10-Precancerous breast leisons: e.g Atpyical Hyperplasia

Genetic mutations 1- BRCA-1 gene,BRCA-2 gene mutation specially in the familial type. 2- Gene which code for HER2 (HER2/neu) receptors =human epithelial growth factor receptor: Normal breast cells have HER2 receptors, which help them grow,involved in multiplication, survival, and differentiation of cells. - In about 20 to 30% of breast cancers, cancer cells have too many HER2 receptors. Such cancers tend to be very fast growing.

Types of breast cancer 1- breast carcinoma : arise from epithelial lining of breast ducts and glands 2- Breast sarcoma : arise from stromal cells,blood vessels,fat inside breast e.g angiosarcoma.

Breast carcinoma

Types of Breast carcinoma A- Ductal carcinoma ductal carcinoma in situ (DCIS) Invasive ductal carcinoma a- ductal carcinoma not otherwise specified (NOS) b-Mucinous c-Tubular d- Medullary e-Inflammatory carcinoma f-Paget’s disease B- Lobular carcinoma Lobular carcinoma insitu (LCIS) Invasive

Normal breast lobules

Ductal Carcinoma in situ (DCIS) 11 Illustration © Mary K. Bryson Ductal cancer cells Normal ductal cell

Range of Ductal Carcinoma in situ 12 Illustration © Mary K. Bryson

Invasive Ductal Carcinoma (IDC – 80% of breast cancer ) 13 The cancer has spread to the surrounding tissues Illustration © Mary K. Bryson Ductal cancer cells breaking through the wall

Cancer Can also Invade Lymph or Blood Vessels 14 Illustration © Mary K. Bryson Cancer cells invade lymph duct Cancer cells invade blood vessel

Invasive Lobular Carcinoma (ILC) 15 Illustration © Mary K. Bryson Lobular cancer cells breaking through the wall

Lobular carcinoma

Mucinous carcinoma of the breast: show malignant cells swimming in lakes of bluish mucin

Invasive lobular carcinoma of the breast.

Presentation 1- Breast Signs and Symptoms 2- Abnormal mammogram 3- Axillary lympadenopathy 4- Metastatic disease

Breast Cancer—Signs and Symptoms Initial sign is single, hard, painless nodule  Mass is freely movable in early stage Advanced signs a-Fixed nodule b- Retraction of nipple or discharge from it. c- Dimpling,or puckering of skin d-Change in breast contour Biopsy confirms diagnosis of malignancy

Breast Signs and Symptoms 21 Most common: lump or thickening in breast. Often painless Change in color or appearance of areola Redness or pitting of skin over the breast, like the skin of an orange Discharge or bleeding Change in size or contours of breast

cancer breast showing Skin puckering (Peaud orange) due to infiltration of skin lymphatics leading to their obstruction and accumlation of fluid under skin.

Screening Mammography Mammography routine screening tool  Detect lesions before they become palpable or if they are deep in the breast tissue Recommendations Biannually or annually in y/o Annually in >50 y /o

mammography

Breast Calcifications Calcifications show up as white spots on a mammogram Round well-defined, larger calcifications (left column) are more likely benign Tight cluster of tiny, irregularly shaped calcifications (right column) may indicate cancer 25

Calcification Features 26

Lymphatic drainage of the breast

Staging of Breast Cancer The American Joint Committee on Cancer (AJCC) has designated staging by TNM T= tumor size N = lymph node involvement M = metastasis

Staging Tumor 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 mamary nodes N2: 4-9 axillary nodes or palpable int mam node Metastasis

Treatment of Ductal carcinoma Treatment of DCIS:  Lumpectomy and radiation  Radiation decreases local recurrence by 50%  or Simple Mastectomy  Treatment of advanced cases : Radical Mastectomy. so must remove hormone stimulation  Premenopausal women: ovaries removed  Postmenopausal women: hormone-blocking agent

Types of surgery for cancer breast

Special types of breast cancers Inflammatory carcinoma: there is signs and symptoms of inflammation (as redness,hotness,pain,swelling )due to Carcinoma invading lymphatic ducts but no actual inflammation.

 Paget's disease is a slowly growing cancer of the nipple. In Paget's disease, the tumor starts in the milk ducts of the nipple.  It may be in situ carcinoma, or invasive.

SYMPTOMS  Symptoms: Redness, oozing, and crusting of the nipple and the circular, dark area around the nipple (areola), which causes itching and burning.  erosion on the nipple that will not heal.  These manifestations can be mistaken as skin inflammation or infection, which can delay diagnosis and treatment of paget disease. 

Paget disease: show erosion and ulceration of the nipple

Paget disease: the malignant ductal cells present in the epidermis

Differential diagnosis for breast lump Malignant lump Breast abscess Fibrocystic changes: Lumpiness, thickening and swelling, often associated with a woman’s period Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occuring most in young women Infections: The breast will likely be red, warm, tender and lumpy Trauma: a blow to the breast or a bruise can cause a lump (traumatic fat necrosis)

Case 1 A 41-year-old woman presented with a mass in her left breast. Physical examination:  Revealed a mass, in the left breast.  A single palpable axillary lymph node was also found.  Mammography confirmed the presence of a mass 2.5 cm in diameter.

Mammography Mass

The patient underwent a modified radical mastectomy to remove the mass including axillary lymph node dissection.

Cross-section of breast revealing the mass Mass Retracted nipple Fat

Normal breast tissue

Diagnosis: Malignant tumor of the breast = (ductal Carcinoma of the breast)