4 1

Chapter-01
Female Breast
Anatomy and Physiology
Embryology
Gross Anatomy
Lymphatic Drainage
Blood Supply & Lactation
FEMALE BREAST - ANATOMY & PHYSIOLOGY 2
Objectives
! To understand the development of the breast and possible abnormalities
occurring during development.
! To understand the anatomical and histological structure of the breast with
possible abnormalities.
! To understand the physiological changes occurring in breast during
menstruation, pregnancy, lactation and menopause.
! To understand the effects of various hormones on the breast.
! To understand various modes of spread of diseases of breast specially
SURGERY - BREAST PROBLEMS 2

FEMALE BREAST
ANATOMY & PHYSIOLOGY
Shuja Tahir, FRCS, FCPS
EMBRYOLOGY
(7TH WEEK) 49TH GESTATIONAL DAY
Breast (mammary gland) is derived
from the ectoderm and becomes Invagination of thoracic mammary bud
apparent in the embryo 4 mm in length (primary bud) into the mesenchyme
as a mammary bud. The mammary bud th
occurs by 49 gestational day.
and surrounding tissue thickens to
become mammary ridge by the time
embryo is 7 mm long.
There is no sign of future breast in the

embryo before first four weeks of
gestational period.
(5TH WEEK) 35TH GESTATIONAL DAY
Epithelial mammary bud appears by

35 th gestational day. Two linear
ectodermal thickenings develop on the
ventro-lateral surface from armpit to
th
groin in the young embryo by 37 day.
These are called milk ridges or milk
lines.
Several mammary glands develop from

these ridges in lower animals. Only two
small buds are seen at future breast
areas and the ridge disappears in
human female. Intrauterine
development of breast is similar in both
sexes. The epithelial cells on the deeper

represents future lactiferous duct. The

epidermal and epithelial buds grow into Areola
the depth on both sides. Site of Depressed

nipple
These are surrounded by the

underlying mesenchyme. The
Lactiferous Ducts
depressed ectodermal thickening is
raised to form nipple. The mammary
glands collectively form the future
breast.
(8TH WEEK)
56TH - 150TH GESTATIONAL DAYS
Nipple formation begins at 56 t h Non development of breast but

gestational day, mammary ducts development of Nipple (Amazia).
develop at 84th gestational day and
canalization occurs by 150th gestational Non development of nipple and breast
day. (Amastia).
Accessary breast tissue present along

DEVELOPMENTAL ANOMALIES
milk line (Polymastia).
Following development anomalies may
Accessary nipple present along milk
occur;

GROSS ANATOMY AT BIRTH

The mesenchymal tissue present
The rudimentary breasts are identical in around growing ductal tissue changes
both sexes at birth and for few years into dense connective tissue dividing
afterwards. the whole breast into 15-25 lobes.
The breast or the mammary glands are There are about 15-25 main mammary
modified skin glands which are ducts in each breast. These open on the
embedded in the fatty tissue. summit of the nipple through separate
openings. Each duct has dilated part
The mammary gland or breast in fact is called ampulla just before its opening
conglomeration of 15 to 25 individual on to the nipple.
and independent glands having
separate lactiferous ducts. Each main duct drains a lobe of the
breast. Each lobe is further divided into
The adult female breasts are paired lobules and acini. Each lobe is
sub-cutaneous organs on the anterior irregularly lobulated.
thorax lying completely within the
superficial and deep layers of Each lobule has a collection of 10-100
superficial pectoral fascia. acini or terminal ductal lobular units. It
consists of extra and intra lobular
Adult female breast is mature breast terminal ductule, alveoli, terminal ductal
and is of different size and shape in lobular units [TDLU]). Some secretions
different women. The size and shape are also present in these ductules.
depends upon genetic, racial and
dietary factors together with age, parity Non lactating breast consists of more
and menopausal status of the women. fibrous tissue and less glandular tissue
The size of the base of the breast is (almost only ducts).
fairly constant in almost all women.
The growth of mammary tissue beneath
nd th
The breast lies in front of 2 to 6 rib in the areola occurs at the age of 10 years.
the mid clavicular line. The breast lies It is called breast bud. True nipple
over the pectoralis major muscle and develops at about 12 years of age
extends to serratus anterior and followed by 2-3 years growth of breast
external oblique muscle of the tissue. Then there is areolar recession
abdomen. and the breast takes a classical shape.
Axillary tail is lateral extension of breast The size of breast in females enlarges
tissue into axilla. Both breasts consist of at puberty by the action of oestrogens.
nipple, areola and breast tissue. The areola becomes recognizable as

The nipple has myoepithelial cells stimulation of stromal and ductal

(erectile tissue ) in its dermis which growth. There is deposition of fat to give
makes the nipple erect on stimulation. mass to adult breast.
Areola has sweat glands, and The additional growth of breasts occur
subaceous glands present in its dermis. during pregnancy when glandular
The sebaceous glands enlarge during tissue develops completely to produce
pregnancy and are called tubercles of milk. It happens due to stimulatory
Montgomery. effects of large quantities of placental
estrogens. These lead to proliferation
Fascia is present beneath the breast and branching of ductal system.
which is the continuation of the fascia of Additional quantities of growth
Scarpa (sub mammary fascia). Sub hormone and prolactin lead to growth
mammary space is present between and branching of ductal system. Gluco-
this fascia and fascia over pectoralis corticoids and insulin also have some
major muscle. The fascia is continuous role in this process of proliferation.
above with superficial cervical fascia Stromal tissue of breast increases and
and below with Camper’s fascia. the deposition of fat also increases
Lymphatic plexus is present in the sub simultaneously.
mammary space.
The large quantities of placental
Young breast has fibrous tissue strands progesterones stimulate growth of
which connect deep fascia with deeper lobules, budding of alveoli and
layers of the dermis. These are called development of secretory
ligaments of Astley Cooper. These keep characteristics of alveolar cells during
the breast protuberant and well shaped. pregnancy.
These strands get atrophic in elderly Both estrogens and progesterones are
women and breasts become essential for the physiological
pendulous. development of breast. Both estrogens
and progesterone hormones have
Peau-de-Orange (like orange peel) inhibitory action on actual secretion of
appearance is produced in carcinoma milk.
and inflammatory conditions of the
breast due to presence of dermal Prolactin, a hormone secreted by the
edema in between these ligaments. anterior pituitary gland promotes
secretion of milk. Prolactin secretion
The development of female breast starts by fifth week of pregnancy and its
begins at puberty stimulated by serum concentration steadily increases
estrogens of monthly cycles. There is till the birth of baby when the hormonal

LATERAL THORACIC ARTERY
It is a branch of axillary artery. It VENOUS DRAINAGE

supplies the superior part of the breast.
Venous drainage is via veins
INTERNAL THORACIC ARTERY accompanying the arteries.
It is a branch of subclavian artery. It LYMPHATIC DRAINAGE OF THE

supplies through its perforating BREAST
branches specially through 2nd and 3rd
intercostal spaces. These branches are Lymph capillaries make network with
large size in adult females. surrounding lymph capillaries,
lymphatics from the opposite breast,
lymphatics from the abdominal wall and
Lateral thoracic vessels neck.
Superficial parts of the breast drain into

subareolar plexus and deeper parts into
Internal thoracic vessels submammary plexus of the lymphatics.
Infra clavicular
lymph glands (Axillary)
Pectoral branches of
Acromio-thoracic vessels Normally both sub areolar
Parasternaland sub
& mediastinal
lymph glands
mammary plexus communicate freely
Inter-costal vessels with each other.
Internal thoracic
Pectoral lymph glands
To opposite breast
Epigastric & peritoneal

INTER COSTAL ARTERIES lymph glands
These supply through their perforating LATERAL MEDIAL

branches. LYMPHATIC DRAINAGE OF BREAST
PECTORAL BRANCHES
These are branches of acromio-

thoracic artery which is a branch of
axillary artery. These supply upper part
of the breast. There are three pathways of lymphatic

AXILLARY GROUP OF LYMPH Medial part of the breast is drained by

GLAND sub mammary plexus of the opposite
breast and also to the lymph glands
These glands are about 35-50 in along the internal thoracic artery and
number. These are placed in five from these to the mediastinal lymph
groups; glands.
1. Anterior or pectoral group. The inferior part of the breast is drained

2. Posterior or subscapular group. by the lymphatics of abdominal wall and
3. Lateral group. to the extra peritoneal lymphatic plexus.
4. Central group.
5. Apical group. All these groups of lymph glands can be
involved in the metastasis of the
The axillary and transpectoral carcinoma breast. Their involvement is
pathways communicate directly and seen in various levels such as;
indirectly with one another through
supra and infra clavicular lymph glands. Level-I
Involvement of axillary node (lateral)
Axillary group of lymph glands drain the below to pectoralis minor muscle.
major part of the breasts. Most of the
regional spread from carcinoma of the Level-II
breast is seen here. Involvement of nodes behind
(posterior) pectoralis minor muscle.
Metastatic deposits can be present in
the other groups of lymph glands but Level-III
these usually appear after the axillary Involvement of nodes above (supro-
involvement. medial) the pectoralis minor muscle.
Most of the lymph from subareolar and LACTATION

submammary plexus is drained to the
anterior or pectoral group of axillary Both estrogens and progesterones are
lymph glands. essential for the physiological
development of breast. Both estrogen
Axillary tail drains into the posterior or and progesterone hormones have
subscapular group of axillary lymph inhibitory action on actual secretion of
glands. milk.
Upper convexity of the breast drains Prolactin, a hormone secreted by the

into infra clavicular group. anterior pituitary gland promotes
secretion of milk. Prolactin secretion

secretion of mother in surges. Growth are surrounded by myofibrils and

hormones, cortico-steroids and smooth muscles.
parathyroid hormone are also involved
in lactation. There is rich capillary and lymphatic
bed surrounding the alveoli binding
There is rapid growth and branching of these with lactating cells.
terminal portions of the gland. There is
some loss of interstitial adipose tissue. The blood supply through the lactating
The visible enlargement of breast is mammary gland is 400-4500 times the
noticed two months after pregnancy. volume of milk secretions. The
increased rate of blood flow increases
The nipples increase in size. The areola the rate of milk secretion.
becomes bigger and pigmented. The
ductal system increase in number and The growth and function of the breast
size during first two trimesters. True depends upon integrated actions of
glandular acini required to produce milk pituitary, ovarian, thyroid and adrenal
appear during early part of 3rd month. glandular hormones. Growth of
The differentiation of acini for secretary mammary ducts depends on estrogen
activity occur during last trimester. synergized by growth hormone,
prolactin and adreno-cortico-steroids.
The enlargement of breasts during last
month of pregnancy is due to The development of lobulo-alveolar
hypertrophy of parenchymal cells of glandular system requires both
alveoli with a hyaline eosinophylic, estrogen and progesterone in the
proteinaceous secretion termed presence of prolactin. Lactogens and
colostrum. About 3 days post partum, milk secretion are regulated by prolactin
the fat content of colostrum increases and corticoids.
suddenly to change it into typical milk
secretion. Ovarian steroid 17a estradiol and
progesterone are essential for
The lactating breast is obvious. The mammary gland development in
nipples project as much as 02 cm females. No breast changes are seen in
beyond aerola. girls with gonadal dysgenesis at
puberty.
There are 15-20 sinuses engorged with
milk which lie beneath the aerola. The Oral contraceptives increase the breast
milk is easily sucked by the baby’s size. The oophorectomy doesn’t affect
gums and lips pressure. Many ductules the size of breast after complete
connect these sinuses with peripheral development.
alveoli. All these alveoli and ductules

Axillary
tail
Edge of
pectoralis
major
deep to
breast
Areola
Nipple
Sebaceous
Possible gland
extensions
of mammary
tissue Circular
(posterior and medical) smooth muscle
Accessory gland
(of Montgomery)
Areola
Lactiferous duct
Lipid
globule
Secretory
protein
Fat
Milk duct
Muscles
Nipple
Areola Milk glands

Myoepithelial
cell process
Ribs
(cross section)
Basal
lamina

Rib
Pectoralis minor
Pectoralis major
Non-lactating
Breast Pectoralis fascia
Suspensory
ligament
Retro-
mammary
space
Deep
Super-
ficial
Adipose
tissue
Secretory
} Layers of
super-
ficial
fascia
lobule
containing 12 weeks I.U.
alveoli
Breast during
lactation
Epithelium
Lactiferous
duct
Secretory
lobule
6 weeks I.U.
Neonate
Mammary Pit
Myoepithelial
Late Fetus cell

Myoepithelial
cell

Chapter-02
Triple Assessment - 1-1

Physical Examination
TRIPLE ASSESSMENT - 1-1 (PHYSICAL EXAMINATION) 2
Objectives
! To detect the breast problems at the earliest stage.
! To differentiate between benign and malignant breast problems.
! To assess the extent of disease (stage of disease).
! To plan effective management & follow up.
! To document the clinical data for audit.
! To counsel the patient and her attendants adequately.
! To learn the skills of examination.

TRIPLE ASSESSMENT - 1-1 (PHYSICAL E AMINATION) 3
TRIPLE ASSESSMENT - 1
PHYSICAL EXAMINATION
TRIPLE ASSESSMENT
The reasons for breast examination
It is a combination of three modalities of training of the students is to learn to
assessment performed to confirm the detect mass in the breast and to
diagnosis and status of breast disease improve the clinical skills2.
specially carcinoma of breast. It
includes following different modalities The objective of clinical breast
to assess the disease process; examination is to differentiate normal
physiological nodularity from discrete
Clinical data breast mass. If a discrete mass is
(Clinical History and examination detected, its evaluation is mandatory in
findings) all cases to exclude breast cancer.
Imaging (Mammography). It is guided by clinical findings, age of

Ultrasound examination the patient and her personal risk
(Sonomammography). status1.
X r a y M a m m o g r a p h y
(Radiomammography). A careful clinical examination is an
Xeromammography. essential part of breast screening in
3
Magnetic resonance imaging (MRI order to reduce false negative results .
mammography).
A standardized system to describe
Cyto-histological examination. clinical breast examination (CBE) alerts
(FNAC, Tru cut or CORE Biopsy or physicians to an increased risk of
Excision Biopsy). delayed diagnosis of breast cancer4.
The diagnostic sensitivity of triple PHYSICAL EXAMINATION OF BREAST

assessment ranges from 85-95%. It
covers all the medico-legal aspects of It is the first part of triple assessment. It
the diagnosis and treatment of breast may be the examination conducted by
malignancy. the doctor (clinical breast examination)

clearly understandable by the patient. therapy with its duration.

The examination room provides
enough comfort and privacy to avoid ALWAYS EXAMINE BOTH BREASTS
embarrassment to the patient. A female
nurse or attendant should always be In supine position.
present when the examining doctor is a In semi recumbent position.
male. The room temperature should be In semi recumbent position with hands
comfortable. The light should be abducted (over head).
adequate and patient should be In semi recumbent patient with hand
completely exposed above the pressing over the hips.
umbilicus. In leaning (dependent) position.
SPECIAL INTERVIEW The patient stands away from the table

and 5rests her hands on the table leaving
5
Certain information such as; age of 1
her breasts 3
hang 3 the findings
freely. All 1
menarche, menstrual history of patient, are recorded on the diagram.
obstetric history, history of lactation and
2 4 4 2
breast feeding, history of breast cancer
and other malignancies in the family is
very carefully noted. History of Right Left
hormonal intake for contraception or as
replacement therapy needs att-ention. Fig-2.1 Diagram of both breast
Following specific questions are asked

before examination is started;
Complaints of lump, nipple discharge,

pain or change in size of breast with
duration.
Pain in back, shoulder or hip areas. INSPECTION
Menstrual cycle and its disturbances.
Age of menarche+Menopause (if Both sides should be examined
elderly). simultaneously.
Number of pregnancies
History of lactation. NIPPLES
Age at first pregnancy.
Relevant family history both in first and Look for;
second degree relatives.
History of contraceptive pill intake. Shape of the nipple.
History of hormone replacement Discharge from the nipple, its amount
and color.

Fig-2.4 Feel the nipples
Fig-2.3 Sitting patient with hands abducted

Color of the skin. PALPATION)
AREOLA The precise palpation of the lump can

be performed between thumb and
Look for; fingers. The palpation is performed
Color of the skin. systematically to avoid missing lump in
Skin pigmentation or de pigmentation. any part of the breast.
Lumps.
Surrounding area. Feel the;
Nipples.
BREAST PROPER Areola.
Breast proper.
Look for;
Size of the breast. Skin temperature is felt over and
Shape of the breast. around the breast. Tenderness and
Color of the skin. point of maximum tenderness is noted.
Puckering of skin.
Symmetry of breast. All observations are marked on the
Visible veins. diagram shown below in patients with
Scars. breast lump.
Signs of inflammation. Note the following points as well;
Lumps.
Peau-de-orange. SITE
Fungating Mass.
Ulceration. Exact site in relation to the quadrants of
the breast should be recorded as;
PALPATION
Upper outer quadrant.
Patient should be asked to point out the Lower outer quadrant.
site of lesion. Upper inner quadrant.
Normal breast should be palpated first. Lower inner quadrant.
Ask about the painful area of the breast. Axillary tail.
It should be examined at the end. Nipple and areolar lesions are noted.
Side of the breast (Right or Left) is
SUPERFICIAL PALPATION always mentioned.
Whole of the breast should be palpated SIZE

with the flat of hand gently. It makes the
lump or tender areas obvious. Exact size of the lump is measured and
D E E P PA L PAT I O N ( P R E C I S E noted in centimeters in two dimensions.


irregular lumps. The measurement of

the largest diameter of the lump is Fixity or mobility in relation to overlying
performed with the help of caliper. It is skin or underlying structures is
essential for the proper staging of the examined. The skin is lifted up between
disease. The speed of increase in size thumb and the index finger. The skin is
is mentioned in the history. rolled over the lump in all directions.
It clearly differentiates the fixity or
SHAPE mobility of the skin. The lumps present
in the skin become obvious as well.
It should be drawn in the diagram of the
breast. The patient is asked to push against
both iliac crests. This puts the pectoralis
CONSISTENCY major muscles into contraction on both
sides.
The lump is palpated between thumb
and the index finger and the The lump is moved over the fixed and
consistency is recorded as; contracted (Hard) pectoralis major
muscles in all directions. It clearly
Soft (similar to touch of cheek). shows the freely mobile or fixed nature
Cystic (similar to touch of water filled of the lump.
balloon).
Firm (similar to touch of tip of nose). FLUCTUATION
Hard (similar to touch of forehead).
It is tested carefully. The lump is fixed
SURFACE between two fingers of one hand and it
is pressed with the index finger of the
It is felt and recorded whether smooth opposite hand. The lift up of the
or nodular. stationary finger is felt. The fluctuation
is tested in two planes at right angle to
MARGINS each other.
Margins of the lump are felt. These can It is positive in cystic (fluid filled) lesions.
be;
TRANSILLUMINATION
Diffuse (Not clearly demarcated).
Clearly demarcated. It is performed in the dark room with a
Regular. powerful pencil torch. Fluid filled lumps
Irregular. (Cysts) become obvious (red glowing
areas) indicating positive
MOBILITY / FIXITY transillumination test.

OTHER FEATURES OF
EXAMINATION
T-3
Jaundice, pallor and edema especially Tumor size 5-10 cm.
of upper limbs is looked for and noted.
Complete examination of liver, lungs T-4
and spine is performed to search for Tumor size more than 10 cm.
distant metastasis. Any size with infiltration or ulceration of
the skin.
CLINICAL STAGING OF THE CARCINOMA Tumor fixed to the chest wall.
BREAST(TNM) Peau-de-orange appearance of the
skin.
T TUMOR
N LYMPH GLANDS (N) STAGES
M METASTASIS
N-x
(T) STAGES Axillary node cannot be assessed.
T-x N-0
Primary tumor cannot be assessed. No palpable axillary lymph glands.
(Post operative patients who were not
staged initially). N-1
Palpable but mobile ipsilateral axillary
T-is lymph glands.
Carcinoma in situ. Incidental finding
showing presence of malignant cells N-2
without invasion of basement Fixed ipsilateral axillary lymph glands.
membrane.
N-3
T-0 Palpable supra clavicular lymph glands
No palpable primary tumor. mobile or fixed.
It is an incidental finding. Edema of the arm.
Involvement of ipsilateral internal
T-1 mammary glands.
Tumor size 2 cm or less.
No fixity. (M) STAGES
No nipple retraction.
M-0
T-2 No metastasis.
Tumor size 2-5 cm.

axilla and supra clavicular lymph mammary node and Supra clavicular
glands. Other distant metastasis. nodes are involved. Edema of the arm
may be present.
STAGE I
STAGE IV
(T0, T1,N0, M0)
This includes growths confined to the (Any T or any N with M1)
breast. Skin involvement extending outside the
breast. Distant metastasis either lymph
Tumor less than 2 cm diameter in size. borne or blood borne. Involvement of
No nodal involvement. opposite breast.
No distant metastasis.
The patient is covered and allowed to
change at the end of clinical
The tumor should not be adherent to the
examination. The examining doctor
pectoral muscles or chest wall.
interacts with the patient very
professionally.
STAGE II
(T0, T1 OR T2 and N1, M0) COUNSELING

Tumor size less than 5 cm in diameter
but there are affected mobile lymph The patient is informed about the
glands in the axilla of the same side. disease status as assessed clinically.
Tumor 5 cms size without lymph node Plan of investigations and possible
involvement. No distant metastasis. modes of treatment are informed and
necessary documenta-tion and
False negative results of clinical appointments are made and recorded.
examination are about 25-30%. Whole of this information is also sent to
the referring doctor.
STAGE III
Then the examining doctor leaves the
(T0, T1, T2, T3, T4, N2 and M0) room after leaving a satisfied patient.
All breast cancers of any size. Skin
involvement or peau-de-orange REFERENCES
present in larger areas than the tumor
1. Freund KM. Rational and technique
itself but these are limited to the breast. of clinical breast examination.
Tumor fixed to pectoral muscles but not Medscape women health 2000 No;
to the chest wall. 5(6):E2.
Axillary lymph nodes, internal 2. Madam Ak, Aliabadi-Wahle S,

KS: Clinical examination (CBE) for CHECK LIST

screening of a symptomatic
women. The importance of CBE for 1. Introduction to the patient.
breast cancer detection. Yonsei 2. Special interview.
Med J. (Korea 2000 Jun: 41
3. Exposure and position.
(3):312-8.
4. Inspection.
4. Goodson WH; Moorl DH: Overall 5. Palpation.
clinical breast examination as a 6. Examination of axilla.
factor in day to day diagnosis of 7. Staging.
breast cancer. Arch Surg 2002 Oct; 8. Covering the patient.
137 (10): 1152-6. 9. Counseling.
10. Follow up appointment.
11. Letter to the referring doctor.

Chapter-0
Triple Assessment - 1-
Sel Examination
TRIPLE ASSESSMENT - 1 SELF EXAMINATION 2
Objectives
! To be aware of the problems of breast.
! To assess the consistency of one’s own breast.
! To assess any change in breast at the earliest stage.
! To be able to seek expert medical help in time.

TRIPLE ASSESSMENT - 1 SELF E AMINATION 3
BREAST SELF EXAMINATION
It is also first part of triple assessment If the patient no longer menstruates,

for breast diseases. she is to choose the same day of each
month to do BSE.
The female patients are advised to
The goal of BSE is to become
conduct their breast examination once
acquainted with how the breasts
a month. It is not performed more often
normally look and feel. Patient s
unless asked by the doctor.
knowledge of the breast texture and
appearance improves as she performs
SETTING BSE. This knowledge helps her to
identify a change more quickly and
The patient should conduct self report it to her doctor.
examination of breast in a room with
comfortable environment and privacy. It INSPECTION
may also be conducted in the bath room
with availability of mirror. Use a mirror.
First, stand in front of a mirror, keeping
The patient should remove her shirt, your arms relaxed at your sides.
vest and Bra to see the breasts, chest,
neck, arms and both axillae clearly. Notice the shape and size of your
breasts. Compare both breasts. It is not
The patient should follow following unusual for one to be larger than the
instructions; other.
Breast self examination (BSE) takes
just a few minutes and the patient only Next look at your skin. Take note of the
needs to do it once a month. texture and color changes. Put your
hands on hips. Look at the breasts with
If the patient is menstruating, she your arms in different positions.
should perform BSE 7 to 10 days after
the first day of period, when the breasts Some of the changes patient should
are least tender. watch for;

further evaluation. fingers over just the width of one finger

and move up again. Continue this up
PALPATION and down pattern until you have
As you do this part of the examination, covered the entire breast self
remember that some lumpiness is examination, from your collar bone to
normal for many women. Self just below your breast.
examination helps you become familiar Relax your arm and examine your
with the normal texture of your breast armpit. Some parts of your breast go up
tissue. into your armpit. Examine this area
To examine your right breast, lie on your again with your arm relaxed at your
back. side. It will feel a little different in this
position. Check for fluid coming from
Place a pillow or a folded towel under your nipple. Gently squeeze your
your right shoulder. Put your right arm nipple. Clear or milky fluid coming from
out, with your elbow at a 90 degree the nipple is more common than blood
angle. stained fluid. All nipple discharges
should be checked by your doctor.
This position flattens and makes it
easier to examine. Feel whole of your Repeat the same steps using your right
breast with your left hand. hand to examine your left breast. You
may conduct the above examination
Use the padded area of your fingers steps while in the shower or bath
and not the tips. Use the pads of three (standing or lying).
or four fingers of your left hand to What to do if you find a lump?
examine your right breast. Move your
fingers in very small circles. Do not panic;
Eighty percent of lumps found are not
For each small circle, change the c a n c e r o u s . S e e y o u r d o c t o r.
amount of pressure so for you can feel Remember Breast cancer can develop
all levels of your breast tissue. Don't lift at any age, but your risk increases as
your fingers from your breast as you you grow older.
move them, you might miss something
that way. You may use lotion to make it Your chancesCHECK LIST
of developing breast
easier for your fingers to slide over your cancer are twice as great at age of 70
1.Exposure.
years than when you are 50 years of
skin.
age.2.Inspection.
Make a pattern of vertical strips 3.Palpation.
examination and cover the self More than 70% ofthe
4.Squeezing all women
nipples with breast
for discharge.
examined area in vertical strips. Start in cancer have no family
5.Feeling the axilla. history of the
your armpit and move down to just disease.
6.CoverEarly diagnosis of breast
yourself.
below your breast. Now move your cancer may save
7.Report to theyour life.
doctor.

Fig-3.1 Stand in front of a mirror normally
Fig-3.3 Feeling the breast while in shower
Fig-3.2 Standing in front of mirror with arms abducted Fig-3.4 Feeling the breast while in bed

Chapter-0
Triple Assessment -
Ima in
Radio Mammography
Sonographic Mammography
Magnetic Imaging Mammography
TRIPLE ASSESSMENT -2 (IMAGING) 2
Objectives
! To accurately diagnose various benign and malignant
lesions of the breast.
! To detect the malignancy at earliest in a female
population.
! To evaluate and monitor the high risk females for
malignancy of breast.
! To assist in evaluation and management of
symptomatic breast problems.
! To detect unsuspected lesions in same or opposite
breast.

IMAGING (MAMMOGRAPHY)
Mammography is visualization of the MAMMOGRAPHY

soft tissue structure of the breast using
various techniques. 1913 (Albert Salomon);
A surgeon, reported the usefulness of
It includes imaging of the breast using radiography of mastectomy specimens
different modalities given below; to reveal the spread of tumor to axillary
lymph nodes.
Radiological examination of the breast
using dedicated machines. 1930 (Stafford L. Warren);
( R a d i o m a m m o g r a p h y, X e r o - He reported the use of stereoscopic
mammography) technique for in vivo mammography.
Ultrasound examination of breast
(Sonomammography) 1940 (Raoul Leborgne);
Magnetic resonance imaging of breast He reported the presence of
(MRI mammography) radiologically visible micro
calcifications in breast cancer. He was
MAMMOGRAPHY one of the first to recognize the
importance of breast compression for
Mammography is the radiological improving the image quality.
visualization of the soft tissue structure
and architecture of the breast at various He emphasized the radiographic
stages of its life. It is used to diagnose difference between benign and
various breast diseases. It is also called malignant calcifications.
screen film mammography. Both
breasts are always examined and 1960 (Robert L. Egan);
compared before this investigation is He described a high mA-low kV
performed. It can be performed on mammographic technique.
symptomatic and asymptomatic
patients. 1963 (Gerald Dodd);
He became the first person to perform
HISTORY EVELOPMENTS IN the needle localization of non palpable,

1965 (Charles Gros (France)); colleagues);

He developed the first "dedicated" They presented the early results of
mammography x-ray unit. screening.
1970 (Dupont, Eastman Kodak 1976 (Howard Frank, Feris Hall &
company); Michael Steer);
The Dupont company produced the first They described a needle hookwire
marketed dedicated screen-film assembly for preoperative localization
mammography system. The Eastman of non-palpable lesions found at
Kodak company followed with its own mammography.
high detail screen-film combination and
introduced the vacuum cassette for 1977 (Edward A. Sickles, Kunio Doi &
mammography. Harry K. Genant);
They published the results of their
1971 (Stephen Gallager & Martin); investigation of magnification
They published their concept of mammography.
"minimal" breast cancer which they
defined as a highly curable lesion. They PHYSIOLOGICAL BASIS FOR
were the first to recognize a focal "new MAMMOGRAPHY
density" in serial mammograms as a
sign of early carcinoma. The breast tissue (mammary gland) is
collection of glands surrounded by
1974 (Myron Moskowitz and his
Adolescent Breast Pregnant Breast Reproductive Breast Menopausal Breast

Fig-4.1 Drawing of mammary gland showing variation and distribution of radiographic density related to
normal life cycle

It is the radiologic differentiating ability

of fat which helps in the diagnosis,
differentiation and study of the internal
structure of the breast tissue. The glands and ducts hypertrophy
during pregnancy, but these are again
The fat content is present between the of water density. The mammographic
glands, lobules, lobes, sub-mammary picture remains homogeneously dense
space and sub cutaneous space. It is and becomes extremely radio-opaque.
usually not present under the nipple
and is minimally present under the The glands and the ducts involute after
areola. delivery and lactation. The
parenchymal involution is followed by
The breast has dense connective tissue some degree of fat deposition. It gives
and normally developed mammary good radiographic differentiation to
glands at puberty. It shows dense breast tissue.
homogenous picture on
mammography. RISKS OF MAMMOGRAPHY
There is always a slight risk of damage
The amount of fat present in and around to cells or tissue from being exposed to
the breast varies from person to person. any radiation, including the low levels of
The increase in glandular content radiation used for this test. However, if
doesn't improve the differentiation of this test is really needed, the risk of
breast tissue as it is also water dense. It damage from the x-rays is very low
is the presence of fat in breast tissue compared with the potential benefits of
which shows the soft tissue the test.
d i f f e r e n t i a t i o n r a d i o l o g i c a l l y.
Newer x-ray techniques have
dramatically reduced radiation
exposure during mammography. The
dose of radiation used for a
mammogram is similar to that used for a
lobules
dental x-ray.
NORMAL MAMMOGRAM
Breast shadow looks normal. No
unusual growth, lumps or other types of
Fig-4.2 Diagram of breast abnormal tissue are seen. The glands
that produce milk for breast feeding and
the tubes (ducts) through which milk
flows appear normal.

Calcifications are most often non examination.

cancerous. Tiny calcifications (micro-
calcifications) often occur in areas The patient is counselled about the
where cells are growing very rapidly procedure briefly and precisely. A
(such as in a cancerous tumor). Larger careful physical examination is
calcifications (macro-calcifications) are conducted and all findings are noted.
usually normal in women over the age Scars, lump, induration, eczematous
of 50. lesion, ulcers and pigmentation is
drawn on the diagram. No feature is
A mammogram is not usually missed, no matter how trivial. Both
performed for a pregnant woman, breasts are examined and compared,
because the radiation could damage findings are recorded for future
her developing fetus. If a mammogram reference.
is absolutely necessary, a lead apron is
placed over the woman’s abdomen. INDICATIONS FOR MAMMOGRAPHY
A mammogram is usually not To screen asymptomatic women.
performed for a woman who is breast To assist in evaluation of symptomatic
feeding, because breast that contains breasts for management decisions.
milk shadow, homogenous opacities To detect the unsuspected lesion in
and diseased area cannot be same and opposite breasts having
differentiated. palpable mass.
To serve as baseline for comparison
Deodorants, perfumes, powders or with subsequent mammography for
ointments on the breast may interfere accurate and early detection.
with the x ray pictures. To evaluate breast status before
starting Hormone Replacement
Breast implants or scar tissue from Therapy (HRT) in menopausal women.
previous breast surgery may make a
mammogram more difficult to interpret MAMMOGRAPHIC EXAMINATION
due to radiographic abnormal shadows.
The patient sits or stands in front of
PREPARATION FOR MAMMOGRAPHY mammography machine and puts her
breast over the movable compression
No special preparation is required other device.
than having the patient dressed in an
open front gown for adequate exposure The compression device has two
of the breast during mammographic plates. One of these is mobile and x-
examination. A female attendant must rays can pass through these. The
accompany the patient throughout the breast is compressed between these

The breast of the patient is compressed irradiation. These machines result in

gently and evenly between two plates of less than 2 rads exposure per
the mammographic equipment. It helps examination.
in uniform differentiation of the internal
structure of the breast. The machines use low kilovolt peak x-
ray technique which enhances the
Compression is one of the most radiographic contrast of fat and water
important aspect of mammography. It content of the breast and give best
helps to achieve; radiographic view of the inside of the
breast.
Good picture resolution as it separates
the overlapping structures. The screen film mammogram gives
A sharp image due to immobilization. maximum information. It can be used to
Exposure under automatic control. put markers at the suspected lesions to
Uniform and smooth resolution. help the surgeon during surgery.
Use of minimum irradiation.
Sometimes radio-opaque dye or
Both breasts are exposed in two or methylene blue is infiltrated in the area
m o r e v i e w s s e p a r a t e l y. T h e of mammographically suspected lesion
mammographic examination is usually to help the surgeon while taking biopsy.
satisfactory in two dimensions; Staining due to methylene blue may not
be very helpful while performing fine
Cranio-caudal1,2,3 needle aspiration cytology or tru-cut
Medio-lateral or oblique medio-lateral needle biopsy. Guide wire can also be
inserted in the lesion
Oblique views and cone views may be mammographically.
required in highly suspicious lesions for
better resolution and detection. The films are examined very carefully
keeping in mind the age of the patient
Each breast is examined separately. and status of the breast. An amplifying
Maximum breast tissue is compressed lens is used for proper examination and
to avoid missing peripheral lesions. interpretation.
Dedicated mammographic machines
have been developed which help to A normal mammogram does not
achieve better resolution and use very guarantee that breast cancer is not
low dose of x-ray irradiation. present.
Structures upto 1 mm size can be Most abnormalities found during

picked up by these machines and mammography are not cancer.
patient is exposed to minimum x-ray However, many women who have

detect breast cancer. plate. Whole of this process is

performed by an automatic processor
MRI can detect suspicious areas in the machine.
breasts, but many suspicious areas
turn out to be normal (false positive The xeromammographic image gives
results). MRI is useful when a diagnosis less overall information than
is difficult to make due to previous radiological mammogram. It definitely
surgery using other methods. MRI is demonstrates the important features
much more expensive than x-ray and resolution is sufficient to show
mammography and is not used very micro calcification.
often to examine the breasts.
DIGITAL MAMMOGRAPHY
Nuclear scanning tests use a
radioactive tracer(called a radionucilide It is a mammographic imaging system
) that is injected into a vein. The tracer that acquires mammograms directly in
travels through the blood vessels and digital form. It has the ability to display
can accumulate in many types of finest details and improve the
tumors. The location of the tracer is performance of mammography.
detected by gamma camera that scans
the body for areas where the tracer has It allows to view different parts of the
accumulated. Nuclear scanning tests breast without taking additional images.
are useful when a diagnosis is difficult to Image from digital mammography can
make using other methods. be magnified and stored electro-nically
more easily than images from standard
Although breast cancer can occur in mammography. Digital mammography
men, it is rare. About 99% of all breast is not yet widely available.
cancer is found in women.
COMPUTER AIDED DETECTION &
ADVANCEMENTS IN MAMMOGRAPHY DIAGNOSIS (CAD)
XEROMAMMOGRAPHY It is a type of digital mammography

which can facilitate computer aided
Xeromammography is a specialized detection and diagnosis which is
radiological processing system using otherwise not easily possible. It helps to
dry electrophotographic technique. A detect lesions which might be missed
charged aluminium plate coated with by the examiner. It, in fact increases the
selenium powder is used instead of detection sensitivity. It can further help
traditional screen film in this in the correct diagnosis due to
investigation. The image is then availability of large data bank for
transferred to the photographic paper comparison and correct diagnosis. It is

images are removed and relevant

structures are preserved and BENIGN LESIONS
interpreted.
Benign calcifications are larger and
DIAGNOSIS
uniform in size and shape.
The mammogram may shows normal
These may be multiple and bilateral.
breast architecture according to the age
Coarse and peripheral calcification is
of the patient or may show benign
usually seen.
lesions such as;
Fibro adenoma.
Cystic lesions.
The mammography may diagnose

malignant lesions such as;
Non invasive carcinoma of breast

DCIS
LCIS
Invasive carcinoma of breast
Fig-4.5 Mammography of normal breast of 15-years old girl

Fig-4.3 Normal mammography of 55-years old women
Fig-4.4 Xeromammography of a normal fullyFig-4.6 Mammography of breast showing calcification

developed adolescent breast of 18-years old girl of lactiferous ducts (DCIS?)

Sometimes well circumscribed mass

can be seen and irregular margins may
not be clear. (Medullary carcinoma) The
masses may be multiple.
Sometimes the mass may not be seen

but calcification may be seen. The
micro calcification clusters are typical of
malignancy. The greater the number of
Fig-4.7 Mammography of breast showing calcification
of lactiferous ducts (DCIS?) clusters, the greater are chances of
malignancy.
Cyst appears as a well circumscribed
mass. Ultrasound scanning helps to
differentiate it from a solid lesion. It
appears as a compressible mass with
smooth back wall and no internal
echoes and hypo-echoic pattern on
ultrasound examination of breast.
BREAST ABSCESS
The clinical picture is usually

suggestive of diagnosis. Radio
mammography is painful and less
helpful. The diagnosis is usuallyFig-4.8 Mammography of 60 years old lady showing
clinically obvious. Ultrasound invasive ductal carcinoma
examination is much fruitful and offers
excellent interpretation.
Sono-mammography is more
acceptable to the patient and helpful in
diagnosis by showing hypo
echoic area of fluid or pus collection.
CARCINOMA OF BREAST
It shows as a spiculated mass. The

irregular margins are very clearly seen.
Fig-4.9 Negative black toner image cranio caudal 29 years
It can be easily diagnosed. old women with history of injury. (Angiosarcoma)

years of age as radio mammography is

less helpful at this age group.
It is being used more often with the

development of better scanners and
probes which are able to see
Fig-4.10 Mammography showing spiculated mass

behind the nipple (carcinoma of breast)
SONO MAMMOGRAPHY
ULTRASOUND SCAN OF THE Fig-4.11 Giant fibroadenoma of breast
BREAST
It is ultrasound examination of the

breast. Ultrasound is helpful in
differentiating between solid and cystic
lesions of breast with a specificity of
almost 100%. Ultrasound is most
helpful initial imaging study1.
It has a sensitivity of 75% and positive

predictive value of 90% in the diagnosis
of breast cancer12.
Ultrasonic mammography is a Fig-4.12 Breast Abscess

completely non invasive investigation.
It can be performed to confirm the
diagnosis of breast abscess which is
very painful on compression during
radio mammography.
It is economical and patient friendly. It is

performed with special probe on 7.5 or
10 MHTZ. It helps to pick up cystic and
fluid containing breast lesion with
almost 100% certainty.
Sono mammography is practically

useful in younger women below 35 Fig-4.13 Collection of fluid (breast abscess)

the finer details of the superficial and Ultrasound examination of breast can
subcutaneous tissues. 7.5-10 MHz be interpreted as;
probe is used for good resolution.
R1 Normal/ benign
R2 Discrete / benign
R3 Intermediate
R4 Suspicious
R5 Malignant
MAGNETIC RESONANCE
IMAGING OF BREAST
(MRI MAMMOGRAPHY)
Magnetic imaging for breast lesion is

Fig-4.14 Cyst of the breast not one of the first line investigation. It is
expensive and not available easily and
The cystic lesions can be diagnosed at all places.
with certainity. These appear as well
circumcised, with a smooth wall and
hypoechoic center (posterior
enhancement is also seen. Ultrasound
guided trucut needle biopsy yields
nearly 100% accurate results and can
in fact replace the excisional biopsy4.
It is useful for guided aspiration of cysts,

needle biopsy of solid tissue lesions
and fine needle aspiration cytology. Its
resolution is less superior for solidFig-4.15 MRI mammography showing normal breast
lesions when compared with radio
mammo-graphy.
As many as 50% of non palpable breast
lesions can be picked up by ultrasound
scan. Intra operative ultrasound can be
used to direct the excision while
i m p r o v i n g m a r g i n n e g a t i v i t y.
Ultrasound guided breast biopsy can It is non invasive. It has great value in
facilitate excision of such masses9. detection of vertebral body metastasis
and musculo-skeletal pathology related

cases, it is used to detect the breast

lesions with improved specificity and
sensitivity5.
Fig-4.16 MRI mammography of patient with nipple discharge

Fig-4.18 MRI mammography (Invasive carcinoma breast)
REFERENCES
1. Tabar L. et al. The control of breast

cancer mammographic screening.
Radiol clinics of N. Am. 25: 993-
1005, 1988
2. Bailar JC. Mammographic screen.

A reappraisal of benefits and risks.
Clin. Obstet Gynaecol 12: 1-14,
1978
3. Kuhl CK. High risk screening: Multi-

modality surveillance of women at
high risk for breast cancer (proven
or suspected carriers of a breast
cancer susceptibility gene) J Exp
clin cancer Res 2002 Sep; 21(3
suppl): 103-6.
Fig-4.17 MRI mammography showing bubble in implant

clinical imaging. second edition Bull. 38: 6-7, 1982

mosby New York 1995; 424-447.
9. American cancer society. Cancer of
5. Bassett LW. Axelrod SA. A breast. Guidelines for cancer
modification of cranio-caudal view r e l a t e d c h e c k u p .
in mammography. Radiology. 132: Recommendations from Rationale
222-4, 1979 CA. 300: 224-32, 1980
6. Logan WW, Janus J. Use of special 10. Alastair M. Thompson and John A.
mammographic views to Dewar. Disorders of the breast.
maximize radiographic information. Essential surgical practice forth
Radiological clinics North Am. 25: edition. Arnold London 69-93,
953-9, 1987 2002.
7. Sickles EA. Practical solutions to 11. Sheybani EO, Sankar R. ATMT: A

common Mammographic telemammography network
p r o b l e m s : Ta i l o r i n g t h e architecture . 1EEE transbroined
examination. Am. J. Roentgenol. Eng 2002 Dec; 49(12): 1438-43.
151: 31-9, 1988.
12. Chinedu I Chainakwalam. Tom
8. American college of radiology. Bates. Diagnosis and management
Guidelines for mammography ACR of a breast lump. Surg international

Chapter-0
Triple Assessment -
Cyto Histolo ical Examination
ore iopsy ru ut eedle

cision iopsy
TRIPLE ASSESSMENT - 3 (CYTO HISTOLOGICAL EXAMINATION) 2
Objectives
! To confirm the diagnosis.
! To differentiate between benign and malignant breast problems.
! To assess the extent of disease (stage of disease).
! To plan effective management & follow up.
! To document the data for audit.
! To counsel the patient and her attendants adequately.

CYTO HISTOLOGICAL EXAMINATION
Cyto histological examination is the finds herself without any lump in the
microscopic examination of cells and breast in few moments after aspiration
tissue after appropriate preparation and of the cyst and gets confirmed
staining. diagnosis within hours.
It includes following tests; These patients must be followed up at

monthly intervals.
FNAC.
Trucut needle biopsy. The lump must be either cytologically
Excision biopsy. examined or excised and sent for
histological examination in case
All these tests are used to confirm the following features are encountered;
diagnosis.
! If aspirated fluid is frankly blood
FINE NEEDLE ASPIRATION stained.
! If the lump does not completely
Fine needle aspiration (FNA) of a disappear on emptying the cyst.
palpable cyst is both diagnostic and ! The cyst refills rapidly or recurs after
therapeutic. two aspirations.
! Aspiration fails.
It is aspiration of cyst and cytological
examination of the cyst fluid. FINE NEEDLE ASPIRATION CYTOLOGY
Normally the aspirated fluid of cyst is FNAC is the first line investigation of
clear, yellow or green but it may be choice for both superficial and deep
blood stained. lesions of the breast and other body
tissues. It is an essential part of triple
The advantage and the pleasure, this assessment for diagnosis in palpable
procedure provides to the patient is breast lumps.
great as a women who seeks medical
advice thinking about cancer breast It can achieve excellent results if efforts

suspicion valuable in the diagnosis of

i n f l a m m a t o r y, i n f e c t i o u s a n d INDICATIONS
degenerative conditions.
Fine Needle Aspiration Cytology is
Intra-operative cytology is valuable used for;
alternative or complement to frozen
section examination. ! Diagnosis of simple cysts.
! Investigation of suspected
FNAC is the last part of (third) Triple recurrence or metastasis in cases of
assessment of breast lesions. Main previously diagnosed cancer.
objective of FNAC is to confirm ! Confirmation of inoperable or locally
carcinoma preoperatively and avoid advanced cancer.
unnecessary surgery in specific benign ! Preoperative confirmation of
conditions.Cytology results can be clinically suspected cancer.
available within 30-60 minutes. ! Investigation of palpable lump
(clinically benign or malignant).
These are described on a five point ! Complementing mammography in
scale; the screening for carcinoma.
! Obtaining tumor cells for special
C1 Inadequate (cellular sample). analysis and research, e.g.
C2 Benign. hormone receptor studies, DNA
C3 Atypical (Probably benign). analysis, immunohistochemistry,
C4 Suspicious of malignancy. cell kinetics and molecular studies.
C5 Malignant. It is also used for nuclear
morphometry, ploidy pattern,
FNAC may be repeated immediately in microspectro-photometry, flow
C1 lesions or immediate core biopsy cytometry and video image
sample may be taken. FNAC is not analysis.
helpful if repeated few days later. ! Indicating prognosis through
cytological grading which correlates
Patients who are pregnant, lactating or with nuclear and histological grade.
on Hormonal Replacement Therapy ! The cytological grading has a
(HRT) may have altered cellular limited independent value as
morphology and patients with previous prognostic indicator.
radiation also show cellular alterations. ! Immuno-histochemical
quantification of Estrogen &
FNAC is not a substitute for tissue Progesterone receptors which is an
biopsy. important development in breast
cancer management.
! Monitoring of the breast cancer

! Low risk of complications.

! No extra staff required. The exact cytological diagnosis is
! Suitable for very ill and debilitated available before definitive surgery is
patients. planned.
! Can be performed any where and in
any department. The immunocytochemical examination
! No difficulties in re-biopsy due to of the aspirate is performed. It helps to
presence of haematoma or other differentiate various conditions of the
complications. breast.
! Immediate diagnosis relieves The benign lesion shows following
anxiety of patient and saves time. features on cytological examination;
! Advance planning of definitive
treatment is possible. It demonstrates uniform groups of
! Staging and metastatic work up can ductal cells, stromal fragments and
be initiated in malignancies. many stripped bipolar nuclei.
! Benign conditions are diagnosed
and mutilating surgery may be The ultra structural examination
avoided. demonstrates ductal cells with
! Hospital facilities are economically surrounding myoepithelial cells resting
used. on a delicate basal lamina with
! Frozen section diagnosis is surrounding bundles of collagen in the
! reduced. interstitial space3.
It is an easy and simple method to The time old belief that carcinoma will
collect the specimen. It does not require spread along the needle puncture has
any special preparation. It is a very been proved to be incorrect.
convenient and minimally invasive
method. The only risk is of missing the early
carcinoma associated with the cyst.
The results are extremely satisfactory This danger can be minimized by
in good hands. The cytological proper follow up and biopsy
examination must be performed in the examination of suspicious cases.
solid lesions. False results may be
encountered occasionally. Most of the
studies have confirmed correct results COMPLICATIONS
in about 96% of the tests which is very
significant. ! Usually uncommon.
! Major haematomas are rare.
An overall correct diagnosis can be ! Pneumothorax is rare but possible
made in 88.67% of cases by FNAC2. in thin patients.

piece of tissue which achieves good (core) of lesion (lump) is removed from
histological diagnosis. the obturator and is fixed in
formaldehyde solution. The specimen
False positive results are less common is sent for histo-pathological
than with other similar procedures. examination.
A number of specimens can be taken
It has ability to give an unequivocal from different parts of the lesion and
diagnosis of invasion and a more examined histopathologically for more
definitive diagnosis of benign lesions. accurate diagnosis.
PREPARATION AND PROCEDURE Early diagnosis can be made with

certainty and definitive surgical
No special preparation is required. It procedure can be planned before
can be performed as an outpatient surgery is under taken.
procedure. Tru-cut needle is required.
Hospitalization is not required as it is an
Skin disinfectant solution such as outpatient procedure.
tincture of iodine, betadine, Povidone,
Chlorhexidene or Savalon may be used It is relatively economical in terms of
to clean the skin over and around the money, time, patient compliance,
lump to the biopsied. hospitalization and surgeon’s efforts. It
avoids complications of open surgery
Few milliliters of local anaesthetic (2% and general anaesthesia.
xylocaine) is infiltrated in the skin over
the lesion. Tru-cut needle biopsy under ultrasound
control achieves even better results.
The lesion is fixed between two fingers
of the left hand and correct size tru-cut In smaller lesions, the actual lesion may
needle is pushed into the lesion when it be missed and examination may be
is closed and the obturator is in the inconclusive.
needle. When the needle has just
entered into the lump to be biopsied, the Haematoma and bruising after biopsy
obturator is pushed ahead into the may be experienced.
whole length of the lump.
It has in fact replaced frozen section
The needle is closed over its obturator biopsy and minimized the use of
by pushing it forwards and whole of the excision biopsy.
needle is pulled out keeping it closed.
It is a very satisfactory substitute for
The needle is opened and the piece surgical biopsy. Automated core needle

The excision of the whole lump with 2-3 predictive value of 21% for the
cm adjoining fat and healthy breast detection of cancer7.
tissue all around the lump is performed.
REFERENCES
FROZEN SECTION BIOPSY
1. Bermen G. Clark RA. Diagnostic
Frozen section biopsy was very popular imaging in cancer primary care
previously. Still many surgeons prefer it. clinics in office practice. [JC: p99]
19(4) 677-713, 1992 Dec.
The patient is kept under anaesthesia.
The suspicious tissue is excised and 2. Patra AK Mallik RN, Dash S. Fine
sent to the laboratory. The frozen needle aspiration as a primary
section is prepared for diagnostic procedure of breast
histopathological examination. The lumps. Indian journal of pathology
biopsy report is received on telephone and microbiology [JC: gkh] 34(4) :
as early as possible usually within 30- 259-64, 1991 Oct.
60 minutes. Further procedure is
carried out according to the histological 3. Siberman JR, Dabba DJ. Gilbert
picture of the lesion. It is less often used CF. Fine needle aspiration cytology
as it increases anaesthetic and of adenosis tumour of the breast
with immunocytochemical and ultra
operation time. It also increases
structural observation acta
number of complications and morbidity. cytological [JC: oli] 33(2) : 181-7,
It has almost been replaced by FNAC 1989 Mar – Apr.
which can provide equally good results
much less invasi-vely. 4. Parker SH. Jole WE. Demnis MA et
al. Ultrasound guided automated
IN VIVO OPTICAL SPECTROSCOPY large core breast biopsy. Radiology
[JC: osh] 187(2) : 507-11, 1993
(INVOS) May.
It is a new technique for evaluating risk 5. Harmus SE. Flamis DO. MR
of breast cancer. It is non ionizing and Imaging of the breast journal of
non imaging. magnetic resource imaging [JC:
beo] 3(1): 277-83, 1993 Jan-Feb.
It evaluates the biochemical
composition of the breast with spectro- 6. Reid AW. Mckellar NJ. Sutterland
photometer to provide a risk number GR. Breast ductography: its role in
related to carcinoma breast. the diagnosis of breast disease.
Scottish medical journal [JC: rik]
34(4): 497-9, 1989 Aug.
It has a sensitivity of 95% but very low
specificity (4% only) and a positive 7. Bosanko CM. Baum JK. Clark K et

Fig-5.1 Skin preparation for fine needle aspiration Fig-5.4 FNAC procedure in progress
Fig-5.2 Fine Needle Aspiration of a cyst in the breast

Fig-5.5 FNAC procedure in progress (preparation of specimen)
Fig-5.3 FNAC procedure in progress (Collection of specimen) Fig-5.6 FNAC procedure in progress

Fig-5.7 FNAC procedure in progress (Preparation of slides)Fig-5.10 FNAC Common benign pattern
Fig-5.11 FNAC Common malignant pattern

Fig-5.8 FNAC procedure in progress (Prepared specimens)
Fig-5.12 FNAC poorly differentiated carcinoma

Fig-5.9 FNAC procedure in progress (Stained specimen)

Fig-5.13 FNAC Fibroadenoma Fig-5.16 FNAC Atypical ductal hyperplasia
Fig-5.14 FNAC Lactating breast Fig-5.17 FNAC (DCIS) Ductal carcinoma in situ
Fig-5.15 FNAC Atypical ductal hyperplasia Fig-5.18 FNAC (DCIS) Ductal carcinoma in situ.

Fig-5.19 FNAC Paget’s disease of nipple Fig-5.22 FNAC Invasive cribriform carcinoma
Fig-5.20 FNAC Paget’s disease of nipple Fig-5.23 FNAC Colloid carcinoma
Fig-5.21 FNAC Tubular carcinoma Fig-5.24 FNAC Medullary carcinoma

Fig-5.25 FNAC Carcinoma breast (Papillary) Fig-5.28 FNAC Infiltrating lobular carcinoma
Fig-5.26 FNAC Carcinoma breast (tubular) Fig-5.29 FNAC Comedo carcinoma with invasion
Fig-5.27 FNAC Infiltrating lobular carcinoma Fig-5.30 FNAC Infiltrating lobular carcinoma

Fig-5.31 Fat necrosis breast (Histopath) Fig-5.34 Intraductal papilloma breast (Histopath)
Fig-5.32 Fibroadenoma breast (Histopath) Fig-5.35 Intraductal carcinoma breast (Histopath)
Fig-5.33 Cystosarcoma phyllodes breast (Histopath) Fig-5.36 Carcinoma in situ breast (Histopath)

Fig-5.37 Paget’s disease of breast Fig-5.40 Infiltrating lobular carcinoma of breast
Fig-5.38 Paget’s disease of breast Fig-5.41 Invasive carcinoma breast
Fig-5.39 Invasive lobular carcinoma of breast Fig-5.42 Lobular carcinoma of breast

Chapter-0
Screenin or
Breast Problems
SCREENING FOR BREAST PROBLEMS 2
Objectives
! To detect the malignancy at earliest stage in a predefined
female population.
! To collect baseline information for future comparison of
breast lesions.
! To evaluate and monitor the high risk females for
malignancy of breast.
! To assist in evaluation and management of symptomatic

SCREENING FOR
BREAST PROBLEMS
Screening for cancer breast, is but mammographically marked lesions

investigating a given population for which are not palpable.
possibility of cancer breast.
SCREENING MAMMOGRAPHY
Screening for carcinoma breast
involves; It is mammography of predefined
female population of predetermined
! Self examination of breast age in a selected locality.
! Clinical examination of breast
! Mammography (ultrasound, Mammography both sonographic and
radiological and MRI). radiological is commonly used for
! Cyto histological examination screening purpose. These are the
investigations which can detect
Self examination and clinical neoplastic lesions at the earliest.
examination have been found
minimally helpful in early detection of M R I mammography is very helpful but
carcinoma of breast which is the it is used in high risk patients as it is
primary objective of screening for expensive and less commonly
cancer breast. available.
Mammography has shown the ability to The general preconditions for

detect breast cancer with high successful screening programme are;
sensitivity and specificity1.
1. Disease should be curable.
It is the only means to detect non- 2. Early detection should increase the
palpable cancers. It is the only effective chances of cure.
investigation which helps in the early 3. Screening procedure (diagnostic
detection of breast lesions. test) should be acceptable to target
population.
Cyto-histological examination is 4. The disease should be sufficiently
performed on palpable or suspicious common to warrant screening.

(WORLD HEALTH ORGANIZATION) prognosis, and are more successfully

PRINCIPLES OF SCREENING treated.
! The condition should pose an It leads to harms in women who

important health problem. undergo biopsy for abnormalities that
! The natural history of disease are not breast cancer, as well as those
should be well understood. who are over treated for ductal
! There should be a recognizable carcinoma in situ (DCIS) that might
early stage. have been non progressive.
! Treatment at an early stage should The benefits of screening should be
be of more benefit than treatment assessed against the “limitations of
started at a later stage. screening and harms associated with
! There should be a suitable test, screening”.
which is acceptable to the
population. Mammography should begin at age 40
! There should be adequate facilities years for women at average risk.
available for the diagnosis and Women in their 20s and 30s should
treatment of abnormalities have clinical breast examination as part
detected. of routine physical examination at least
! Screening should be determined by every three years. At 40 years of age
the natural history of the disease for and thereafter, clinical breast
disease of insidious onset. examination should be done annually.
! The chance of harm to those
screened should be less than the In elderly women, screening should be
chance of benefit. individualized based on potential
! The cost of a screening programme benefits and risks of mammography in
should be balanced against the light of current health and life
3
benefit . expectancy. “As long as a woman is in
reasonably good health and would be
candidate for treatment, she should
GUIDELINES FOR SCREENING continue to be screened with
mammography.”
The underlying premise for breast
cancer screening is that it allows for the
detection of breast cancers before they RISK FACTORS
become palpable.
Following factors help to plan the
Breast cancer is a progressive disease, screening programme.
and small tumors are more likely to be
early stage disease, have a better Age:
The risk of breast cancer increases

A significant number of patients whether a woman has specific genetic

develop cancer before 50 years of age changes known to increase her
and even before 35 years of age3. susceptibility to breast cancer. Doctors
may suggest ways to reduce the risk of
About 50% of all breast cancer patients breast cancer or to improve the
are diagnosed in women aged 65 years detection of breast cancer in women
or older. These patients respond well who have the genetic alterations. Early
with surgery, radiotherapy and standard mammography may be recommended
chemotherapy. for women who carry BRCA1or BRCA2
g e n e m u t a t i o n s .
Older patients should also be included
in screening programmes with Late childbearing:
mammography to detect the carcinoma Women who had their first child after the
at earlier stage7. age of 30 have a greater chance of
developing breast cancer than women
Family medical history: who had their children at a younger age.
Having a first degree relative (or both)
who had breast cancer, increases a Radiation exposure:
woman’s risk of developing breast Women whose breasts were exposed
cancer. If a woman’s family member to significant amounts of radiation at a
developed breast cancer before young age(especially those who were
menopause, her risk is about 3 to 4 treated with radiation for childhood
times greater than another woman of Hodgkin’s disease or thyroid disease)
the same age who does not have a have an increased risk for developing
family history of breast cancer. If the breast cancer. However , the amount of
family member developed breast radiation received from a diagnostic
cancer after menopause, the risk is chest x-ray during childhood is not
about twice as great. significant and does not increase the
risk for developing breast cancer.
It is recommended that screening for
familial breast cancer should start at the Previous breast biopsies:
age of 30 years as it accounts for 10% Two breast biopsies done for a
of all breast cancer. noncancerous (benign) breast disease,
especially for atypical hyperplasia show
Genetic alterations: an increased risk of developing breast
Changes in certain genes(BRCA1, cancer.
BRCA2 and others) make women more
susceptible to breast cancer. In families Hormone replacement therapy:
in which many women have had the The use of daily estrogen 0.625 mg plus
disease, BRCA gene testing can show progestin 2.5 mg for longer than 4 years

definitely warrants diagnosis at the The frequency can be reduced to three

earliest. The disease should be yearly if two consecutive mammograms
detected much before it is palpable. are normal.
CONTROVERSIES IN SCREENING For women in their 20s and 30s, do

clinical breast examination at least
The new guidelines address some every three years.
controversial issues of breast cancer
screening; Asymptomatic women aged 40 years
and older should continue to receive a
What is the efficacy (and potential risk) clinical breast examination as part of a
of breast self-examination? periodic health examination, preferably
annually.
What is the efficacy (and potential risk)
of clinical breast examination? The benefits, limitations, and
implications of breast self-examination
At what age should mammographic (BSE) should be explained to women in
screening begin for women of average their 20s and older. Those opting to
risk and above average risk? perform regular BSE should have their
technique reviewed during their
At what age should mammographic periodic health examination.
screening be discontinued in elderly
women or women with co-morbid Beginning in their 20s, women should
conditions? be told about the benefits and
limitations of breast self-examination
What is the role of new technologies in (BSE), including the importance of
screening practices? prompt reporting of any new breast
symptoms.
The major conclusions are;
Women who choose to do BSE should
For women at average risk: receive instruction and have their
Begin mammography at age 40 years. technique reviewed on the occasion of
a periodic health examination.
Women should have annual or bi-
annually mammography between 40- Women may choose not to do BSE or to
70 years of age depending upon do BSE irregularly. Women should be
physical examination and risk factors. informed about the benefits, limitations
and potential harms associated with
Women should have yearly regular screening.
mammography after 50 years of age.

other than mammography and physical examination or mammography.

examination, such as ultrasound or
magnetic resonance imaging, could be
considered. But the evidence currently The screening mammography is
available is insufficient to justify performed in all women between 40-70
recommendations for any of these years of age to achieve optimal
screening approaches. results2,10.
Patients with mutations in one of the
Pre-menopausal women with strong breast cancer susceptibility gene face
family history should start about 90% life time risk to develop
mammography as early as 35 years of breast cancer.
age or 5 years younger than youngest
affected family member3. 95% screen detected cancers are
smaller in size, better differentiated and
Screening for familial breast cancer node negative when compared with
should start at 30 years of age3. symptomatic cancers5.
Screening of 100% population may not We can anticipate 40% reduction in

always be easily feasible. Breast mortality from breast cancer by
screening program in UK aims to screening women above 50 years of
screen 70% of target population with age and only 5% reduction by
built in quality assurance. screening younger women4.
One of the goals of National Cancer Mammograms must be done regularly

Institute (NCI) to reach more than 80% (every 12 to 18 months) to get the full
of eligible women in mammography benefits of screening and to reduce the
screening by year 2000 yet remains as risk of dying from breast cancer.
a challenge. The failure to achieve this Regular mammograms prevent fewer
goal is due to3; breast cancer deaths in younger
women than they do in elderly women,
! Complex and lengthy examination because breast cancer is more
process. common in elderly women.
! It is not available to majority of
women living in remote areas4. There is 60-80% increase in the
number of women in western world
It has been suggested that average having mammographic screening. It
doubling time for breast cancer growth has resulted in early detection of early
is about 100 days and it takes nearly 6-7 stage carcinoma breast and reduction
years or longer before it becomes in the mortality rate5.
potentially detectable by physical

assessment is essential to provide risk slower growth).

benefit analysis prior to initiating ! Interval cancers: (fast growing
interventions designed to lower breast tumors that surface in between
cancer risk8. screening periods).
The women should be informed about Screening resulted in 25% fewer

the potential benefits and risks of deaths and survival curves began to
screening mammography. They should separate at 1-2 years after initiation of
be helped to make a decision about screening9,10.
their age to join in screening
programme. Some critics don’t get persuaded by the
real value of mammographic screening
The value of screening mammography of women in their 40s. Several factors
is still debatable whether the cost have contributed to this reluctance,
justifies the benefits. The question is including ;
whether any better method of screening
is available? This is the situation after ! A lower cancer incidence in this
nine (9) randomized trials and nineteen group.
(19) meta-analyses to determine the ! Fewer number of women in this age
cost benefit justification9,19. group being screened.
! Dense breasts in younger women
The breast cancer screening is better ! Faster tumor growth rates.
with mammography than without. ! Shorter lead time.
! Higher survival rates in younger
70% of cancers were detected with women in spite of underlying
annual screening as compared to 57% diagnosis.
without screening.
Longer follow-up with younger women
Criticism also includes; may clearly reveal benefits of screening
measures.
! Selection Bias: (some women
volunteered for screening due to An average 18% mortality reduction
fear about breast lump or other was observed with follow up ranging
changes). from 10-13 yearsBreast
Year in women aged
Cancer 40-49.
Decline
! Lead time Bias: (Cancers always This is the reason for supporting
get detected with or without 1987
mammographic screening28.8%
of women of
screening but earlier with 40 years of age11,12,13.
screening). 1992 55.2%
! Length Bias: (certain cancers will be The breast cancer mortality rate has
detected later any way because of 1998
decreased by 1% each 66.9%
year over past

The incidence of breast cancer The ultimate objective is better

detection increased by 36% from 1980- methods of correct early detection of
1999, the rate of mortality dropped by lesions leading to cancer breast19.
17%14,15,16.
REFERENCES
The bulk of mammographically
detected breast cancer has been ductal 1. American college of radiology.
carcinoma in situ (DCIS). The absolute Guidelines for mammography ACR
increase in breast cancer detection Bull. 38: 6-7, 1982.
(9%) exceeds the decline in breast
2. American cancer society. Cancer of
cancer mortality and it implies that breast. Guidelines for cancer
something other than mammography is r e l a t e d c h e c k u p .
at work. It may be treatment of DCIS by Recommendations from Rationale
mastectomy rather than breast CA. 300: 224-32, 1980.
conservation 14,15,16.
3. Rmgash J. Preventive healthcare,
Almost 75% of lesions identified on 2001 update: Screening
mammography ultimately prove to be mammography among women
benign (false positive results)17,18. aged 40-49 years at average risk of
breast cancer. CMAJ 2001 Feb 20;
164(4);469-76.
CONCLUSIONS 4. Alastair M. Thompson and John A.

Dewar. Disorders of the breast.
Following conclusions can be drawn Essential surgical practice fourth
from various studies. edition. Arnold London 69-93,
2002.
Routine mammography can decrease
breast cancer mortality. 5. Sickles EA. Practical solutions to
common mammographic
p r o b l e m s : Ta i l o r i n g t h e
Mammography has significant and examination. Am. J. Roentgenol.
important limitations. 151: 31-9, 1988.
Many new technologies have the 6. Morimoto T, Okazaki M,Endo T.

potential to improve breast cancer Current status and goals of
screening and diagnosis but must be mammographic screening for
tested in clinical trials. breast cancer in Japan. Breast
cancer 2004; 11(1): 73-81.
A greater understanding of breast
tumor biology is needed. 7. Amodeo C; Caglia P; Gandolfo L;
VerousM; Porancto G; Irue A;

9 Baker LH. Breast Cancer Detection 14 Tabar L, Vitak B, Chen HH et al.

Demonstration Project: five year Beyond randomized controlled
summary report. CA Cancer J Clin. trials: organized mammographic
1982; 32: 194-225. screening reduces breast
carcinoma mortality. Cancer 2001;
10. Smart CR, Byrne C, Smith RA et al. 91: 1724-1731.
Twenty year follow up of the breast 15. Duffy SW, Tabar L, Chen HH et al.
cancers diagnosed during the The impact of organized
Breast Cancer Detection mammography service screening
Demonstration Project. CA Cancer on breast carcinoma mortality in
J Clin. 1997; 47: 134-149. seven Swedish countries. Cancer
2002; 94: 458-469.
11. Smart CR, Hendrick RE, Rtledge
JH III et al. Benefit of 16 Gotzsche PC, Olsen O. Is
mammography screening in screening for breast cancer with
women ages 40 to 49 years. mammography justifiable? Lancet.
Current evidence from randomized 2000; 355: 129-134.
controlled trials. Cancer 1995; 75:
1619-1626. Olsen O, Gotzsche PC. Cochrane
review on screening for breast
12. Feig SA. Effect of service screening cancer with mammography. Lancet
mammography on population 2001; 358 : 1340-1342.
mortality from breast carcinoma.
Cancer. 2002; 95: 451-457. 17 Miller AB, Baines CJ. To T et al.
Canadian National Breast
13. Tabar L, Fagerberg G, Chen HH et Screening Study 1: Breast cancer
al. Efficacy of breast cancer detection and death rates among
screening by age. New results from women aged 40-49 years. Can Med
the Swedish Two country trial. Assoc J. 1992; 147: 1459-1476.
Cancer 1995; 75: 2502-2517.
18. Miller AB, To T. Baines CJ et al.

Chapter-0
Breast Feeding
BREAST FEEDING 2
Objectives
! To understand the importance of breast feeding for both
mother & child.
! To understand the normal physiological changes in breast
during pregnancy, lactation and after lactation.
! To understand the preparation and care of the breast before &
during lactation.

BREAST FEEDING 3
BREAST FEE ING

Mahnaaz Roohi, FRCOG
God Almighty is the creator of the whole bonding between the infant and mother
world and is responsible for the bread does not successfully develop without
and butter of all human beings (man, breast feeding. All women have an
animals and plants). The human beings ability to breast feed but there are
are considered as modernized and certain reservations as she requires
civilized mammals. five hundred calories more than the
normal diet.
God has made provision of two breasts
to each woman so that they can breast Breast feeding should start soon after
feed their young ones. There is no need the baby is born even before the
to train the women as breast feeding is umbilical cord is cut, the baby is put to
a natural phenomena and all the the breast. This promotes successful
mammals feed their young ones breast feeding and also helps in
without any training. hen a lady lowering the duration of third stage of
breast feeds a baby, he she will be labor. It is very important that the initial
better equipped in intelligence and milk which is thick and full of calories
psychological behavior and will be colostrum . should be definitely fed to
immune to certain contagious the baby because it provides enough
diseases. calories to the baby for survival and also
contains the antibodies and immune
New parents want to give their baby the factors which prevent diseases in the
very best. As far as nutrition is new born at least for 3 months.
concerned, the best first food for babies
is breast milk1. More than two decades of research
have established that breast milk is
The mothers milk is described as an un- perfectly suited to nourish infants and
equaled food for the baby except in protect them from illness. Breast-fed
special circumstances (hare lip, cleft infants have lower rates of hospital
palate, extreme prematurity). The admissions, ear infections, diarrhoea,
formula milks in no way can give the rashes, allergies, and other medical
same advantage to a new born. The problems than bottle-fed babies.

BREAST FEEDING 4
illnesses, including pneumonia, benefits for the infant as well, creating

botulism, bronchitis, staphylococcal an early attachment between mother
infections, influenza, ear infections, and and child. At birth, infants see only 12 to
German measles. Furthermore, 15 inches, the distance between a
mothers produce antibodies to nursing baby and its mother's face.
whatever disease is present in their Studies have found that infants as
environment, making their milk custom- young as 1 week prefer the smell of
designed to fight the diseases their their own mother's milk. When nursing
babies are exposed to as well. pads soaked with breast milk are
placed in their cribs, they turn their
A breast-fed baby's digestive tract faces toward the one that smells
contains large amounts of Lactobacillus familiar.
bifidus, beneficial bacteria that prevent
the growth of harmful organisms. Many psychologists believe the nursing
Human milk straight from the breast is baby enjoys a sense of security from
always sterile, never contaminated by the warmth and presence of the mother,
polluted water or dirty bottles, which especially when there's skin-to-skin
can also lead to diarrhoea in the infant. contact during feeding. Parents of
bottle-fed babies may be tempted to
Human milk contains at least 100 prop bottles in the baby's mouth, with no
ingredients not found in formula milk. human contact during feeding. But a
No babies are allergic to their mother's nursing mother must cuddle her infant
milk, although they may have a reaction closely many times during the day.
to something the mother eats. If she Nursing becomes more than a way to
eliminates it from her diet, the problem feed a baby; it's a source of warmth and
resolves itself. comfort.
Sucking at the breast promotes good Counseling of a patient for breast

jaw development as well. It's harder feeding should start during the
work to get milk out of a breast than a antenatal period and the patient should
bottle, and the exercise strengthens the be taught how to breast feed and
jaws and encourages the growth of examine their own breasts. If they find a
straight, healthy teeth. The baby at the lump or something else obviously they
breast also can control the flow of milk will consult a surgeon. Other wise the
by sucking and stopping. With a bottle, size of breast is not important for the
the baby must constantly suck or react quantity of milk produced. The common
to the pressure of the nipple placed in problem which women complain of is
the mouth. invertion of nipples. But one should
remember that when breast feeding
Nursing may have psychological starts and the baby sucks this is called

BREAST FEEDING 5
Breast feeding should be on the contraception should be used until the

demand of the child rather than baby is weaned. Breast-feeding is
watching the time on a watch. economical also. Even though a
nursing mother works up a big appetite
BENEFITS TO MOTHERS and consumes extra calories, the extra
food for her is less expensive than
Breast-feeding is good for new mothers buying formula for the baby. Nursing
as well as for their babies. There are no saves money while providing the best
bottles to sterilize and no formula to buy, nourishment possible.
measure and mix. It may be easier for a
nursing mother to lose the pounds of POSSIBLE PROBLEMS
pregnancy as well, since nursing uses
up extra calories. Lactation also For all its health benefits, breast-
stimulates the uterus to contract back to feeding does have some
its original size. disadvantages. In the early weeks, it
can be painful. A woman's nipples may
A nursing mother is forced to get become sore or cracked. She may
needed rest. She must sit down, put her experience engorgement more than a
feet up, and relax every few hours to bottle-feeding mother, when the
nurse. Nursing at night is easy as well. breasts become so full of milk they're
No one has to stumble to the hard and painful. Some nursing women
refrigerator for a bottle and warm it also develop clogged milk ducts, which
while the baby cries. If she's lying down, can lead to mastitis, a painful infection
a mother can doze while she nurses. of the breast. While most nursing
problems can be solved with home
Nursing is also nature's contraceptive-- remedies, mastitis requires prompt
although not a very reliable one. medical care.
Frequent nursing suppresses
ovulation, making it less likely for a Another possible disadvantage of
nursing mother to menstruate, ovulate, nursing is that it affects a woman's
or get pregnant. There are no entire lifestyle. A nursing mother with
guarantees, however. baby-in-tow must wear clothes that
enable her to nurse anywhere, or she'll
Mothers who don't want more children have to find a private place to undress.
right away should use contraception She should eat a balanced diet and she
even while nursing. Hormone injections might need to avoid foods that irritate
and implants are safe during nursing, the baby. She also shouldn't smoke,
as are all barrier methods of birth which can cause vomiting, diarrhea and
control. The labeling on birth control restlessness in the baby, as well as
pills says if possible another form of decreased milk production.

BREAST FEEDING 6
mothers can get away between ! Pre-lacteal feeding is a custom in

feedings if they need a break. our country so it carries on.
Finally, some women just don't feel HARMFUL EFFECTS OF PRE-LACTEAL

comfortable with the idea of nursing. FEEDS
They don't want to handle their breasts,
or they want to think of them as sexual, ! Diarrhea & infections.
not functional. They may be concerned ! Ghurti can act as purgative which
about modesty and the possibility of can lead to early expression of milk.
having to nurse in public. They may ! Cow’s milk is the closest to human
want a break from child care to let milk but it still has many
someone else feed the baby, especially disadvantages.
in the wee hours of the morning. ! Pre-lacteal feed make the new born
nipple conscious as by nature
If a woman is unsure whether she wants humans are lazy and that is easier
to nurse, she can try it for a few weeks for them.
and switch if she doesn't like it. It's very
difficult to switch to breast-feeding after PROPERTIES OF BREAST MILK
bottle-feeding is begun.
It provides enough for that age. It
If she plans to breast-feed, a new contains mild laxative, so constipation
mother should learn as much as is not a problem in these children.
possible about it before the baby is It prevents jaundice.
born. Obstetricians, pediatricians, It contains all the nutrients that the new
childbirth instructors, nurses, and born needs.
midwives can all offer information about There is no reason of giving any
nursing. But perhaps the best ongoing supplement even in the form of water.
support for a nursing mother is
someone who has successfully nursed TIPS FOR BREAST-FEEDING SUCCESS
a baby.
It's helpful for a woman who wants to
There are certain constraint to breast breast-feed to learn as much about it as
feeding. possible before delivery, while she is
not exhausted from caring for an infant
! Either the patient is not motivated around-the-clock. The following tips
herself or cultural and family can help foster successful nursing:
constraints reduce the mobility and
behaviour of the patient. EARLY START
! Inadequate knowledge of the steps Nursing should begin within an hour
to take where breast feeding fails. after delivery if possible, when an infant

BREAST FEEDING 7
NURSE ON DEMAND babies may have allergic reactions to

Newborns need to nurse frequently, at them. Proper positioning at the breast
least every two hours, and not on any can help prevent sore nipples. If the
strict schedule. This will mother's very sore, the baby may not
stimulate the mother's breasts to have the nipple far enough back in his
produce plenty of milk. Later, the baby or her mouth.
can settle into a more predictable
routine. But because breast milk is WATCH FOR INFECTION
more easily digested than formula, Symptoms of breast infection include
breast-fed babies often eat more fever and painful lumps and redness in
frequently than bottle-fed babies. the breast. These require immediate
medical attention.
NO SUPPLEMENTS
Nursing babies don't need sugar, water EXPECT ENGORGEMENT
or formula supplements. These may A new mother usually produces lots of
interfere with their appetite for nursing, milk, making her breasts big, hard and
which can lead to a diminished milk painful for a few days. To relieve this
supply. The more the baby nurses, the engorgement, she should feed the baby
more milk the mother will produce. frequently and on demand until her
body adjusts and produces only what
DELAY ARTIFICIAL NIPPLES the baby needs. In the meantime, the
It's best to wait a week or two before mother can take over-the-counter pain
introducing a pacifier, so that the baby relievers, apply warm, wet compresses
doesn't get confused. Artificial nipples to her breasts, and take warm baths to
require a different sucking action than relieve the pain.
real ones. Sucking at a bottle could also
confuse some babies in the early days. EAT RIGHT, GET REST
They, too, are learning how to breast- To produce plenty of good milk, the
feed. nursing mother needs a balanced diet
that includes 500 extra calories a day
AIR DRY and six to eight glasses of fluid. She
In the early postpartum period or until should also rest as much as possible to
her nipples toughen, the mother should prevent breast infections, which are
air dry them after each nursing to aggravated by fatigue.
prevent them from cracking, which can
lead to infection. If her nipples do crack, EXCLUSIVE BREAST FEEDING
the mother can coat them with breast
milk or other natural moisturizers to Exclusive breast feeding means that
help them heal. Vitamin E oil and lanolin during that time period nothing else (like
are commonly used, although some formula milks or even water) should be

BREAST FEEDING 8
most of the women who breast feed do formula milk and it should be
not ovulate). condemned and its marketing should
be unlawful.
The baby should be fed from both
breasts so that the milk is not wasted Counsel the mothers about the quantity,
from any breast. quality, frequency and consistency of
food for an infant upto 1year of age.
Sore nipple is one of the disadvantages
of sucking but the patient can be given Preferably exclusive breast feeding is
soothing creams and lotions which can for 4-5 months but a women should
solve the problem or if the cracks in the breast feed along with weaning for two
nipple are too many than they can use a years.
nipple sheath.
GUIDELINES OF NORMAL NUTRITION IN
After all, nothing is perfect and some INFANTS
potential problems can arise during
breast feeding such as; ! Give breast milk at least 6 times a
day and none on demand.
! Some people may repeat negative ! Feed semisolid foods three times a
practices such as giving pre-lactel day with a spoon at each feeding
feeds and water. after the age of 4-6 months.
! A Woman may not feel confident
enough and think incapable to Initially a women having a baby for the
breast feed. first time may run into problems and she
! Inadequate maternal feed. needs counseling otherwise she will
! Sore nipples and mastitis develop psychological problems which
are collectively known as “purple
It is important that the patient should be blues”.
explained in the antenatal period about
optimum food intake during pregnancy We keep on using the term confusion of
and lactation. nipple. Now what is meant by it. The
baby has already sucked through a
Counsel the women and her spouse feeder nipple and may have confusion
and family about improving her diet in breast feeding. The mother should
during pregnancy and lactation. keep the baby with her during the day
and night. Isolated nurseries are not
Assess the dietary intake of pregnant required in this modern era.
and lactating women.
Correct positioning of the baby in age
There should be no supplementary more than 4 months, expressed milk or

BREAST FEEDING 9
! If the infant unfortunately dies. at body temperature. So heating

! No contagious disease, even and cooling is not a problem.
hepatitis is not an absolute contra- ! Breast milk is the ideal and enough
indication for breast feeding. food for the baby. This causes less
! Professional mothers do not have stress to the mother and also the
the advantage and facilities to family. Because the mother doesn’t
breast feed on demand remain irritable.
(arrangement at work place should ! It should be remembered, 80% of
be made). our population lives in rural areas.
! When the women herself is poorly Where the usual feed which is given
nourished. to the baby is breast milk. As formula
! When a baby in born with congenital milks are too expensive for them
abnormalities like hare lip and cleft (this is blessing in disguise).
palate.
! Oral thrush; because it also If the animals can breast feed their
contaminate the mother. young ones without any counseling or
! One should not breast feed the baby training. The human beings are much
for 48 hours but obtain the milk of more intelligent and breast feeding is a
the mother every 3 or 4 hour so that natural phenomena which should not
lactating reflex which is initiated by be converted to stop feeding.
prolactin is not terminated in early
onset jaundice which does not clear Breast feeding is associated with
and there is poor excretion of reduction in the incidence of breast
bilirubin. The breast feeding can be cancer in the mother.
resumed later on.
! Early onset fetal (non physiological) It is a natural way of family planning as
jaundice is an absolute contra- ovulation usually does not occur during
indication to breast feed for a limited breast feeding. It should be
period. recommended to stop the marketing
! If the nipple areola complex has and promotion of formula milks. Breast
sores or infection then obviously feeding should be the sole type of
breast feeding should be carried out feeding the new born.
after treating the sores.
MEDICINES AND NURSING MOTHERS
The advantages to the mother and
babies are innumerable. Most medications have not been tested
in nursing women, so no one knows
! Mother can breast feed in which exactly how a given drug will affect a
ever position they like. breast-fed child. Since very few
! The breast milk is always supplied problems have been reported,

BREAST FEEDING 10
! Acetaminophen
! Many antibiotics Bromocriptine (Parlodel):
! Antiepileptics (although one, A drug for Parkinson's disease, it also
Primidone, should be given with decreases a woman's milk supply.
caution)
! Most antihistamines Most Chemotherapy Drugs for Cancer:
! Alcohol in moderation (large Since they kill cells in the mother's body,
amounts of alcohol can cause they may harm the baby as well.
drowsiness, weakness, and
abnormal weight gain in an infant) Ergotamine (for migraine headaches):
! Most antihypertensives Causes vomiting, diarrhea, convulsions
! Aspirin (should be used with in infants.
caution)
! Caffeine (moderate amounts in Lithium (for manic-depressive illness):
drinks or food) Excreted in human milk.
! Codeine
! Decongestants Methotrexate (for arthritis):
! Ibuprofen Can suppress the baby's immune
! Insulin system.
! Quinine
! Thyroid medications Drugs of Abuse:
Some drugs, such as cocaine and PCP,
DRUGS THAT ARE NOT SAFE WHILE can intoxicate the baby. Others, such as
NURSING amphetamines, heroin and marijuana,
can cause a variety of symptoms,
Some drugs can be taken by a nursing including irritability, poor sleeping
mother if she stops breast-feeding for a patterns, tremors, and vomiting. Babies
few days or weeks. She can pump her become addicted to these drugs.
milk and discard it during this time to
keep up her supply, while the baby Tobacco Smoke:
drinks previously frozen milk or formula. Nursing mothers should avoid smoking.
Nicotine can cause vomiting, diarrhea
Radioactive drugs used for some and restlessness for the baby, as well
diagnostic tests like Gallium-69, Iodine- as decreased milk production for the
125, Iodine-131, or Technetium-99m mother. Maternal smoking or passive
can be taken if the woman stops smoke may increase the risk of sudden
nursing temporarily. infant death syndrome (SIDS) and may
increase respiratory and ear infections.
Drugs that should never be taken while
breast-feeding include: REFERENCES

Chapter-0
Presentation o Breast iseases - 1

Breast L mps
PRESENTATION OF BREAST DISEASES-1 (BREAST LUMPS) 2
Objectives
! To find out the presence of lump with its exact site.
! To find out the nature of lump whether inflammatory, benign, malignant or
developmental aberration.
! To stage the lump in cases of malignancy.
! To investigate methodically and appropriately.
! To plan management correctly.
! To follow up the patients adequately.

PRESENTATION OF BREAST DISEASES -1

BREAST LUMPS
The breast diseases present in different prepare for lactation under the
ways. Sometimes the problem of influence of various hormones.
adjacent structures may present as
breast problem. A very careful triple The examination of breast is one of the
assessment helps to reach accurate important parts of diagnosis of
diagnosis and management of such pregnancy or even pervious
patients. These presentations can be pregnancies. The color changes of
of; areola are also typical due to
pregnancy.
1. Breast diseases.
2. Associated diseases. 2. Lactation
BREAST SWELLINGS The breast starts its actual function of

production of milk soon after delivery
These could be swellings of the whole under the influence of various
breast or may be discrete or isolated hormones. The size of breast reduces
lumps. after the baby is fed and increases due
to engorgement of lactiferous ducts due
Breast swellings could be bilateral or to production of milk few times during
unilateral. day and night. The size of breast
reduces and the involution of mammary
BILATERAL BREAST SWELLINGS glands and duct occurs after weaning of
PHYSIOLOGICAL the baby.
These could be seen in following 3. Macromastia / Hypertrophic breasts

conditions;
Macromastia is the massive
1. Pregnancy enlargement of breast unilateral or
bilateral, disproportionate to the growth
The size of breast increases during of remainder of the body.
pregnancy as the mammary glands

Rapid and massive breast hypertrophy commonly seen in males than females.
may occur occasionally at puberty or It is diagnosed clinically. Treatment
during pregnancy or rarely even other decision and plan is simple.
wise. The size of breast eventually Reassurance or subcutaneous
becomes bothersome, or mastectomy can be performed.
incapacitating to the patient2.
Prosthesis of correct size and shape
Pregnancy related breast hypertrophy may be implanted according to female
can be arrested or reversed by reducing patient’s choice for good cosmetic
serum prolactin level with effects.
bromocriptine therapy.
UNILATERAL BREAST SWELLINGS
Extreme tenderness, erythema and
edema of breast can be treated 1. Fibro adenosis of new born.
surgically which may not always be 2. Puberty.
cosmetically acceptable3. 3. Unilateral hypertrophy.
DEVELOPMENTAL SWELLINGS DISCRETE OR ISOLATED LUMP IN

BREAST
The common cause of such swelling is;
These could be malignant or innocent
ANDI (Abnormalities of normal benign in nature.
development and involution).
BENIGN SWELLINGS
Inflammatory breast swellings. FIBROADENOMA
Acute mastitis is a common condition of It is the most common benign tumor of

inflammatory nature. the female breast. It consists of both
fibrous tissue and glandular tissue. It is
Miscellaneous Bilateral Breast common before 30 years of age but no
swellings age is immune. It has a rubbery feel and
moves around easily. It is solid, round
Gynaecomastia or Hypertrophy of and painless. it occurs twice as
breast in males is seen after common in Afro-American females than
stilboesteral therapy for carcinoma American females. It can enlarge
prostate. It is also seen in liver failure as during pregnancy and breast feeding.
the oestrogen levels are raised due to
failure of detoxification in the liver. It is A fibroadenoma can be diagnosed
enlargement of a normal breast. The clinically with fair degree of certainty.
enlargement is uniform. It is more

It may be excised surgically if patient after menstrual periods or develop after

wishes to have it removed or doctor oestrogen replacement therapy1.
advises its excision. It is treated as a
day case surgery. The cyst may demonstrate a thin rim of
calcification on mammographic
The fibroadenomas don’t recur unless examination. The cyst may
e x c i s e d i n c o m p l e t e l y. A n o t h e r occasionally rupture during
fibroadenoma may grow in any one of compression while performing
the breast in future. mammography2.
The giant fibroadenoma grows rapidly A cyst can also be clinically diagnosed
and attains large size. with reasonable confidence. Usually no
edges can be palpable. It is best
confirmed by aspiration. The cyst
It is bigger than 4-5 cm in diameter. The disappears completely after aspiration.
breast is enlarged, nipple may be It can be easily diagnosed
displaced, overlying skin is shiny, veins ultrasonographically.
are dilated. It may be present in one
breast. The patient is followed up every month
for the reappearance of the lump. The
It has higher incidence at two different cyst fluid is cytologically examined and
age groups. It presents at 14-18 years if there is any doubt or the lump does
of age and 45-50 years of age. not disappear completely after
Treatment is cosmetic enucleation. aspiration or reappears within few days,
excision biopsy of the lump is
CYST performed.
Cyst results from the enlargement of The patient is followed up for at least 2-
the breast lobule or lactiferous duct, It is 3 months after aspiration of the cyst for
related to altered hormonal stimulation spontaneous resolution. Excision
and endo-organ response. It enlarges biopsy is performed in young women
and becomes tender before the with residual breast masses3.
menstrual period starts.
There is increasing evidence that
It can occur at any age after puberty but multiple recurrent cysts are associated
commonly presents in the with small but significant increase in
perimenopausal years (35-50 years old
breast cancer risk4.
female).
A.N.D.I.
The cysts can regress spontaneously
FIBROADENOSIS

breast tissue (ducts and glands) to

enlarge and breast to retain fluid. The It is a variety of fibroadenoma which
breast becomes normal after fall in the usually presents in women of age
hormonal levels. Some areas of breast around 35 years as a lobulated mass.
may respond excessively and may
remain enlarged and nodular even after It is giant fibroadenoma and its cut
normalization of hormone levels. sections show leaf like clefts and slits. It
can be benign or locally malignant.
This can be suspected on clinical Occasionally it may be frankly
examination. The lesions may be malignant. 15% may metastasize to
present in both the breasts. The feeling distant sites.
of the breast tissue is nodular. There is
history of variable degree of tenderness It distorts the breast and may lead to
during menstrual cycle. Further ulceration of the overlying skin. It may
confirmation can be done by FNAC, present as a fungating lesion.
trucut needle or excision biopsy.
Microscopically it is more cellular than
GALACTOCELE other fibroadenomas and there is
myxomatous change in the fibrous
It is a rare subareolar cyst presenting in tissue. It shows increased stromal
relation with lactation. It is less common cellularity, anaplasia and high mitotic
problem than thought. activity.
It is commonly seen in women who Malignant change can occur rarely.

have recently stopped breast feeding. Lymph node metastasis is rare as in
Occasionally it may occur during other sarcomas. It was previously
lactation as well. It consists of ducts called cystosarcoma phylloides.
distended with milk.
This should be removed very carefully
Aspiration confirms the diagnosis as it otherwise recurrence can occur.
drains the milk and the lump
disappears. LIPOMA
It is collection of discrete area of fat in
Secondary infection may lead to breast the breast. It can be easily diagnosed
abscess formation. clinically. Treatment is surgical
excision.
FNAC, trucut or excision biopsy must
be performed in doubtful cases. PLASMA CELL MASTITIS (RARE)
It is a rare condition of breast showing
PHYLLOIDES TUMOUR lumpyness.

round and firm lump or lumps. It is more the breast with irregular surface could
common in obese female with large be a malignant lump.
size breast.
It can be mobile or adherent to the
It is due to localized disruption of fat underlying muscle or overlying skin. It
cells following trauma. The fat in may be associated with enlargement of
saponified slowly by the blood and regional lymph glands.
tissue lipases. This is followed by
fibroblast and macrophage reaction All such lesions should have FNAC,
leading to localized hard irregular lump trucut needle biopsy or excision biopsy.
in the breast fat. Further management should be done
according to the histopathological
Necrosis of fat occurs in the breast picture.
tissue. There may be foci of
hemorrhage in the beginning but later Sarcoma (rare)
on there is liquefactive necrosis. Lymphoma (rare)
Mammography must be interpreted Associated diseases

very carefully.
Retro mammary abscess (TB)
FNAC and trucut needle or excision Chondroma of chest wall
biopsy are confirmatory for the Deformities of ribs
diagnosis. Mondor’s disease
Sebaceous cyst over breast
TUBERCULOSIS (RARE).
It may present as a breast lump, cold REFERENCES

abscess or a solitary sinus or multiple
discharging sinuses. History of contact
1. Michael Baum, Breast lumps.
with tuberculous patient is asked. F r e n c h ’s i n d e x o f s u r g i c a l
Standard anti-tuberculous differential diagnosis Harold Ell’s 1st
chemotherapy offers good results. edition 199: 56-62.
Surgery is reserved for residual lumps
or resistant disease. 2. Arscott GD, Gaig HR, Gabay L.
Failure of bromocriptine therapy to
MALIGNANT SWELLINGS control mammary hypertrophy. Br J
(CARCINOMA BREAST) Plast Sug 2001Dec; 54(8): 720-3.
3. O’Hare PM, Friedem IJ. Virginal

Carcinoma of the breast is not so rare in
breast hypertrophy Padiatr
Pakistan as it is thought. A hard lump in

Fig-8.4 Breast lump with nipple retraction
Fig-8.3 Fungating lump breast (Carcinoma breast) Fig-8.5 Breast lump with nipple distortion

Fig-8.8 Breast lump with nipple inversion
Fig-8.9 Breast lump (Carcinoma breast)
Fig-8.10 Breast lump (Giant fibroadenoma left breast)
87
Fig-8.11 Breast cyst (Sonomammography) Fig-8.14 Breast cyst (Sonomammography)
Fig-8.12 Adjacent breast masses on sonomammogrpahyFig-8.15 Large cyst with layered debris and a solid
(A debris filled cyst and a simple cyst) component. (Sonomammography)
Fig-8.16 Ultrasound shows the relationship of the

Fig-8.13 Breast cysts (Sonomammography). dominant cyst to other masses in this patient.

Fig-8.17 Mammography of breast showing

fibroadenoma of left breast. Fig-8.20 Fibroadenoma of breast (Mammography)
Fig.8.18 26 years old lady with left breast lump

fibroadenoma (Mammography) Fig-8.21 Medullary Carcinoma (Mammography)
Fig-8.19 Fibroadenoma of breast (Mammography)

Fig-8.22 Medullary Carcinoma (Mammography)

Chapter-0
Presentation o Breast iseases -

Breast Pain
PRESENTATION OF BREAST DISEASES-2 (BREAST PAIN) 2
Objectives
! To be able to diagnose breast pain.
! To be able to differentiate between various causes of
breast pain.
! To be able to find out the cause of breast pain.
! To be able to manage breast pain properly.

PRESENTATION OF BREAST DISEASES -2

BREAST PAIN
Abid Bashir, FCPS
MASTALGIA 4.7 times) in younger women below the

age of 35 years 2,3.
Mastalgia or Mastodynia can be
defined as “breast pain of sufficient ETIOLOGY & PATHO-PHYSIOLOGY
severity for a women to seek medical
advice”. Some breast pain or The underlying cause of severe
discomfort is experienced by about 2/3rd mastalgia remains unknown. The
of women during the premenstrual traditional surgical view, that pain in the
phase. It may be associated with breast is largely an expression of
increased nodularity1. This pain is mild, psychoneurosis was dismissed in the
lasts for a short time in the premenstrual late 70s by Preece et al4. Similarly
phase but more important, it resolves theory of increased water retention in
with menstruation. It can be considered patients with mastalgia is also
with in the spectrum of “normal”. disproved5. Inflammation, as a cause of
pain has also been postulated but
The development of severe pain and Ramakrishnan et al. compared
nodularity which may last for most of the expression of three inflammatory
menstrual cycle is considered as mediators (IL-6, TNF-a and IL-1a) in
abnormal and may interfere tissues from painful and normal
significantly with patient’s everyday breasts. Even slightly lower levels of IL-
activity. Although two third women have 6 and TNF-a were found in tissues from
some premenstrual discom-fort, about painful breasts. Specimens were also
half of them have severe pain, enough examined for evidence of inflammatory
to consult health care provider. Effect of infiltrate, but no identifiable histological
this severe pain on sexual, physical, correlation was found6.
social and school /workplace activities
has been observed to be 37%, 12% and Recently duct ectasia has been
8% respectively2. described as a major factor associated
with mastalgia. Ultrasonography was
Mastalgia is also a major cause for used in mastalgia patients to
increased use of mammography (2.2 to investigate morphological structure and

postulated in causation of mastalgia for

long time. Recently smoking, caffeine It is often associated with palpable
and perceived stress has been shown nodularity. It is bilateral in 50% patients.
to be associated with mastalgia (O.R = It is also poorly localized and usually
1.52, 1.53 and 1.7 respectively)2. involves upper and outer quadrant,
50% may radiate but usually are
Markedly increased levels of confined to breast tissue
gonadotropin hormones throughout the
cycle has also been observed in Trigger Point Pain: There is no cyclic
patients with mastalgia8. [the use of variation. Usually well localized, it may
gonadotropin inhibitors may be trailed be precipitated or increased by touch. It
in mastalgia patients). These studies is rarely bilateral, 50% radiate usually to
have shown interesting results but merit sub areolar part and inner quadrant. It
further investigations. may have severe burning abscess like
exacerbations. Trigger point pain has a
CLASSIFICATION strong association with clinical,
radiological and histopathological
Classification of mastalgia has also features of duct ectasia/periductal
been confusing and unsatisfactory. It is mastitis complex of disorders; past or
usually classified into two groups. present.
Cyclic and non cyclic mastalgia9. Cyclic
mastalgia account for 67% of cases, Tietze’s syndrome: It is the painful,
usually bilateral, (although may be swollen and tender costo-chondral
unilateral) varies during menstrual junction, usually of the 2nd rib. Because
cycle and is typically worse in the luteal of the vicinity of the female breast to the
phase. It is relieved on the onset of area, pain may be perceived as breast
menopause. Non cyclic pain accounts pain.
for the remaining 33%, being further
divided into true non cyclic pain and Previous trauma: The breast may have
chest wall pain. had abscess, biopsy or injury. The scar
albeit deep in the breast with no
The other classification10 based on cutaneous component can become a
etiology is as follows; source of pain many years after the
initiating injury. Similarly skin incision
Cyclic Mastalgia: Cyclic mastalgia is so specially if across hair lines, may be a
called since patient has obvious source of pain.
menstrual cycle related pattern i.e. pain
increases and decreases with Sclerosing adenitis: It is a benign
menstrual cycle, maximum being condition and usually is histopathology
during luteal phase. of mammographically defined

start of oral contraceptives. History of pain should include onset,

duration, character, severity, site,
Fat necrosis, thrombo phlebitis of the localization, radiation progression,
vessels of the lateral chest wall cyclic changes, relieving and
(Mondor’s disease), and tuberculosis aggravating factors.
are causes of breast pain occasionally. The systemic enquiry should be
performed to rule out causes of referred
The pathognomonic sign of Mondors’s pain. History of dietary habits, smoking,
disease is guttering of the superficial b e h a v i o r, s t r e s s a n d t e n s i o n ,
veins of the breast. occupation and previous surgery
should also be sought.
Tuberculosis presents either as an
abscess or like a malignant tumor, Thorough examination of both breasts
poorly demarcated and with skin is performed in a systematic order.
attachment. Tenderness and/or any localized tender
spot, nodularity or discrete lump is
Fat necrosis may mimic cancer sought carefully. Condition of the nipple
clinically and radiologically. and any discharge is noted. Previous
scar if any is properly assessed. Both
Referred Pain: The pain may be axillae are examined. Systemic
referred from intrathoracic or intra examination to find out intra-thoracic,
abdominal inflammation to the breast intra-abdominal and chest wall
e.g. pain of cholecystitis or pleurisy. pathology is also performed.
Idiopathic: The origin of breast pain Mammography and/or FNAC is advised

remains obscure in some patients, wherever indicated.
although the majority of patients fall into
one of the categories described above. Once malignancy is ruled out, patient is
reassured. Carcinoma breast is less
CLINICAL EVALUATION & MANAGEMENT likely to be a diagnosis in a woman with
breast pain as compared to women who
The main stay of evaluation is triple do not complain of breast pain
assessment. The aims are; regardless of age and other breast
cancer risk factors11. It has also been
To differentiate between cyclic and non noted that majority of these patients
cyclic mastalgia. respond to simple reassurance and
To find out if there is any underlying explanation1.
pathology.
To rule out malignancy. If any other obvious pathology is found,
it is treated on its own merit. Simple

helpful in most of the patients12. Relief of which is balanced against the chance of
pain is seen in 58% patients but 42% response to treatment and risk of side
patients shows adverse effects. Active effects. Patient is reviewed every two to
breast movement on weak suspensory three months. The decision regarding
ligaments may contribute considerably continuation or change of treatment is
to mastalgia. Good external support by made according to patient’s response.
1st Visit
supportive brassiere can relieve most An History,
algorithm for the treatment
examination and investigations if required of
o Breast
f pPain
atients’ symptoms. mastalgia is given in Fig-9.2.
+
Pain chart
Record the degree of breast pain you experience each
day by shading each box as illustrated
Mild Severe
Severe Pain Moderate Pain Mild Pain No Pain
Menstrual bleeding episodes Reassurance Start drug therapy
Record the degree of bleeding you experience each day
by shading each box as illustrated +
Conservative measures
Heavy Average Spotting None (Supporting brassiers, Diet etc)
Month:
Year:
1 2 3 4 5 6 7 8 9 10 11 12 Review (2 months) Review (2 months)
Breast Pain
CBS III, IV CBS III CBS IV
Bleeding
CBS I, II
Continue for
Fig-9.1. Daily Breast Pain Chart CBS I, II 2 months
Discharged CBS I, II CBS III, IV

Table-1. Cardiff breast pain score (CBS)
An excellent response leaving no
CBS I residual pain
Continue for 6 months Change treatment
A substantial response leaving some
CBS II residual pain but considered by patient to
be easily bearable Fig-9.2. Algorithm for treatment of Mastalgia
A poor response leaving substantial
CBS III residual pain
CBS IV No response
DRUG THERAPY
The patient is reviewed after two
months. Pattern of pain is assessed EVENING PRIMROSE OIL
and response is graded according to
Cardiff Breast Pain Score (Table-1). Evening primrose (Oenothera biennis
L) is a North American wild flower that
Specific drug treatment is considered has escaped cultivation and is now

long history among native Americans wish to avoid anti-hormonal therapy

and was transferred to Europe by and remain on oral contraceptive.
colonial settlers13. Addition of an anti oxidant (vitamin E)
might improve the efficacy of evening
The oil expressed from plant’s small primrose oil treatment by reducing its
dark seeds is rich in essential fatty metabolism via lipid peroxidation3. The
acids: approximately 65% Linoleic acid dose is 2 capsules TDS(2-4gm/day
and 8% to 10% gamma linolenic acid14. standardizing to 9% gamma linolenic
These constituents are precursors in acid) and it should be given for at least 3
the manufacturing of prostaglandin E1 months. To obtain full benefit from this
one of the anti-inflammatory regimen it may be necessary to ensure
prostaglandins. Women with mastalgia adequate levels of vitamin B1, B6 and
have abnormal fatty acid profile and Zinc which are co-factors in the
decreased levels of linolenic acid proposed metabolic pathway along with
metabolites15. vitamin C10.
Treatment with evening primrose oil Comparable results has been seen of
improves essential fatty acid profile to fish oil, Corn oil and corn oil with wheat
normal16. Although, it may take upto germ oil with those of evening primrose
three months to provide relief of oil for mastalgia24.
symptoms, its effectiveness has been
proved in placebo controlled trial with DANAZOL
overall response rate of 45% in cyclic
mastalgia and 27% in non cyclic Danazol is a gonadotrophin release
mastalgia with fewer side effects (2% inhibitor. It remains the most effective
for evening primrose oil versus 22% first and second line treatment with its
with danazol and 33% with effectiveness confirmed
Initial dose in controlled
200-300 mg daily
bromocriptine)17,18. 25,26
trials . A useful response to treatment
is observedReduce toin10070%
mg dailyof
afterpatients
1 month with
Evening primrose oil is used as a first cyclic mastalgia and 31% with non
25
line treatment for cyclical cyclic mastalgia Good. Response
mastalgia19,20,21. In a recent survey 13%
to 20% British surgeons recommended Unfortunately, it also100
100 mg daily on days have
mg onhigh ratedayof
every other
evening primrose oil for this use22. 14-18 ofrelated
dose menstrual cycle
side throughout
effects menstrual
(22%) cycle17.
Patients with severe premenstrual Several low dose regimen have been
symptom rate evening primrose oil as Fig-9.3.
developedDanazol therapythe
to reduce lowlikely
dose hood
regimens of
one of the most effective treatment they side effect after remission has been
had ever used23. Evening primrose oil is induced with a full dose of 200 mg
particularly useful in younger women daily27, 28 (Fig-9.3). These regimens may
who may require long term therapy, who also be used in patients who relapse

therefore, adequate contraceptive proven in several clinical trials32,33. A

precautions are required. lower dose of 10 mg daily has been
shown to be as effective in the
BROMOCRIPTINE treatment of mastalgia with a
significantly reduced side effects
Bromocriptine is dopamine agonist compared with 20 mg daily34. The
which has been successfully used for dosage is tailored to individual patient
many years to treat mastalgia. It has requirement and symptom control
been shown to decrease serum balanced against troublesome side
prolactin levels in normal and effects. Better response is observed in
hyperprolactinemic women. Its patients with cyclic mastalgia than in
effectiveness has been confirmed in those with non cyclic mastalgia.
several single center controlled trials29,30 Although yet not licensed for mastalgia
and a large European multicentre treatment in United States, it is used as
study31. 2nd or 3rd line treatment.
Clinical improvement is observed in GOSERLINE

47% of patients with cyclic mastalgia
and 20% with non cyclic mastalgia. Goserline, LHRH analogue has shown
to be effective in both cyclic and non
The side effect profile is the limiting cyclic mastalgia refractory to first line
factor for the more extensive use of this therapy35. It induces reversible ovarian
treatment option. Reported side effects suppression with castrate levels of
include nausea, vomiting, headache, ovarian hormones being attained within
dizziness and fatigue all of which are 72 hours36. Adverse effects (principally
dose related. To minimize these side hot flushes) are common and monthly
effective, an incremental dosing subcutaneous injections does have
regimen is proposed starting with 1.25 compliance problem. It should,
mg at bedtime, increasing by 1.25 mg therefore, be reserved for those
every three to four days until the full patients who fail to respond to other
dose of 2.5 mg twice daily is reached. forms of treatment. It may be used to
Treatment should be continued for 3-6 induce a rapid relief of symptoms to be
months. followed by other therapies as
maintenance.
TAMOXIFEN
MISCELLANEOUS
Tamoxifen an anti oestrogen, has many
uses in the management of breast Lisuride maleate, one tablet of 0.2 mg
disorders. Its effectiveness in the daily for two months has shown to
treatment of breast pain has been significantly reduce prolactin level, and

bilateral. Sometimes it becomes very 1997; 175(1): 126-52.

difficult to differentiate between various
causes of breast pain. 3. Ader DN, South-Paul J, Adera, T
and Deusta, PA. Cyclical mastalgia:
Following conditions present with prevalence and associated health
and behavioral factors. J
unilateral or bilateral breast pain. These Psychosom. Obstet. Gynecol June
can be diagnosed by triple assessment 2 0 0 1 ; 2 2 ( 2 ) : 7 1 - 6 .
and treated effectively.
4. Preece PE, Mansel RE, Hughes
! Mastalgia. LE. Mastalgia: Psychoneurosis or
! Pregnancy. organic disease? Br. Med. J. 1978
! Menstruation (cyclical mastalgia). Jan ; 7: 1 (6104): 29-30.
! Onset of puberty.
! Lactation. 5. Preece PE, Richards AR. Owen
! Cracked nipple. GM, Hughes LE. Mastalgia and
! Inflammation of nipple. total body water Br. Med. J. 1975
(Nov); 29: 4(5995): 498-500.
! Breast cyst.
! Galactocele. 6. Ramakrishnan R, Werbeck J,
! Breast abscess. Khurana KK, Khan S A. Expression
! Sub-mammary abscess. of interleukin 6 and tumor necrosis
! Mastitis, acute mastitis, periductal factor alpha and histopathologic
mastitis. findings in painful and non painful
! Epitheliosis of nipple. breast tissue. Breast J. 2003 Mar-
! T B breast. Apr; 9(2): 91-7.
! Post traumatic.
! Anxiety. 7. Barclay, L. Duct Ectasia linked to
! Angina. mastalgia severity. Obstet Gynecol
2003; 101: 54-60.
! Pain from ribs under the breast.
! Cervical spondylosis. 8. Ecochard R, Marret H, Rabilloud M,
! Herpes zoster. Boehringer H, Mathieu C and
Guerin JF. Gonadotropin Level
REFERENCES abnormalities in women wit cyclic
mastalgia. Eur J Obstet Gynecol
1. Paddler, DL. Mastalgia: evaluation Reprod Biol 2001 Jan; 94(1): 92-6.
and management. Nurse Pract
Form, 2000; 11(4): 213-8. 9. Mansel RE, Fenn NJ, Davies EL.
Benign breast disease and its
2. A d e r D N & B r o w n e M W. management; In Recent Advance
Prevalence and impact of cyclical in Surgery No. 21. Taylor I, Johnson
mastalgia in a U.S. Clinical based CD (Ed), Churchill Livingstone
sample. Am. J. Obstet. Gynecol, Edinburgh, 1988: pp 71-83.

Mastalgia? Breast J 2000 Nov; mastodynia (French-English

6(6): 407-409. Abstract) Revue Medical de la
Suise Romande 1995; 115: 385-90.
13. Grieve M. A Modern Herbal.
London: Cresset Press Book 1973. 21. Gateley CA, Meirs M, Mansel RE.
Drug treatment for mastalgia: 17
14. Oil of Evening Primrose. years experience in the Cardiff
Monograph. Lawrence Review of Mastalgia Clinic. J Roy Soc Med.
Natural Products: Levittown. Pa: 1992; 85:12-5.
Pharmaceutical Information 22. Pain JA, Cahil VJ. Management of
Associates 1993. cyclicalmastalgia. Brit J Clin Pract
1990; 44: 454-6.
15. Horrobin DF, Manku MS, Brush M et
al. Abnormalities in plasma 23. Cambell EM, Peterkin D, O’Grady K
essential fatty acid levels in women et al. Premenstrual symptoms in
with premenstrual syndrome and general practice patients. Practice
with non malignant breast disease. and treatment. J Reprod Med.
Nutr Med. 1991; 2: 259-64. 1997; 42: 637-46.
16. Gateley CA, Maddox PR. Pritchard 24. Blommers J, de LangeDe Klerk ES.
GA et al. Plasma fatty acid profiles Kuik D J. Bezemer PD, Meijer S.
in benign breast disorders. Br J Evening primrose oil and fish oil for
Surg, 1992; 79: 407-9. severe chronic mastalgia: a
randomized, double blind
17. Mansel RE, Pye JK, Hughes LE. controlled trial. Am J Obstet
Effects of essential fatty acids on Gynecol 2002 Nov; 187(5): 1389-
cyclical mastalgia and non cyclical 94.
breast disorders. In: Horrobin DF
(ed) Omega 6 essential fatty acids. 25. Gateley CA, Maddox PR, Mansel
Pathophysiology and roles in R E , H u g h e s L E . M a s ta l g i a
clinical medicine. Wiley-Liss New refractory to drug treatment. Br J
York, 1990; 557-6 Surg 1990; 77: 1110-2.
18. Pye JK, Mansel RE, Hughes LE. 26. Hinton CP, Bishop HM, Holiday HW,
Clinical experience of drug Doyle PJ, Blamey RW. A double
treatments for mastalgia Lancet ii blind controlled trial of danazol and
1985; 373-7. bromocriptine in the management
severe cyclical breast pain. Br J Clin
19. Wetzig NR. Mastalgia. A 3 year Pract 1986; 40: 326-30.
Australian study. Aust N Z J Surg
1994; 64: 329-31. 27. Harrison DJ, Maddox PR, Mansel
RE. Maintenance therapy of
20. Genolet PM, Delaloye JF. DeGrandi cyclical mastalgia using low dose
P. Diagnosis and treatment of danazol. J. R Coll Surg Edinb 1989;

31. Mansel RE, Dogliotti LL. European

multicentre trial of bromocriptine in
cyclical mastalgia. Lancet i 1990;
190-3. 36. Fraser HM, Sandow J. Suppression
of follicular maturation by infusion
32. Fentiman S, Caleffi M, Brame K, of a luteinizing hormone releasing
Chaudary MA, Hayward JL. Double hormone agonist starting during the
blind controlled trial of tamoxifen late luteal phase in the stumptail
therapy for mastalgia. Lancet i M a c a q u e m o n k e y. J C l i n
1986; 287-8. Endocrinol Metab 1985; 60: 579-
584.
33. Fentiman S, Caleffi M, Hamed H,
Chaudary MA, Dosage and 37. Kaleli S, Aydin Y, Erel CT, Colgar U.
duration of tamoxifen for mastalgia. Symptomatic treatment of
A controlled trial. Br J Surg 1988; premenstrual mastalgia in
75: 845-6. premenopausal women with
lisuride maleate. A double blind
34. Faiz O, Fentiman IS. Management placebo controlled randomized
of breast pain. Int J Clin Pract 2000 study. Fertil Steril 2001 Apr; 75(4):
May; 54(4) : 228-32. 718-23.
35. Hamid H, Chaudary MA, Caleffi M, 37. Kaleli S, Aydin Y, Erel CT, Colgar U.
Fentiman IS. LHRH analgue for Symptomatic treatment of
treatment of recurrent and premenstrual mastalgia in
refractory mastalgia. Ann R Coll premenopausal women with
Surg Eng 1990; 72: 221-4. lisuride maleate. A double blind
placebo controlled randomized
study. Fertil Steril 2001 Apr; 75(4):
718-23.

Chapter- 0
Presentation o Breast iseases -

Nipple Problems
PRESENTATION OF BREAST DISEASES -3 (NIPPLE PROBLEMS) 2
Objectives
! To diagnose the problem at the earliest.
! To rule out malignancy.
! To find out the cause of problem.
! To investigate the problem.
! To treat the problem adequately.
! To monitor the effects of treatment during

PRESENTATION OF BREAST DISEASES - 3

NIPPLE PROBLEMS
Tariq Mehmood, FCPS
NIPPLE PROBLEMS treatment either.

The breasts are modified sweat glands
These are the problems/diseases and are derived from ectodermal
related to nipple areola complex. mammary ridge, which extends from
axilla to groin region.
CONGENITAL
! Absence. In many animals breasts develop along
! Supernumery. the whole length of this ridge, but in
! Bifid. human only a pair develop in the
! Inversion. pectoral region. Sometimes
supernumery or only nipple may be
ACQUIRED seen along this line10.
! Inversion.
! Plasma cell mastitis. BIFID NIPPLE
! Mammary duct fistula.
! Duct ectasia. The nipple is divided into two parts
! Retroaerolar carcinoma. usually from the middle congenitally.
! Paget’s disease. The nipple may be inverted or normal. It
! Amazia, Amastia is usually associated with recurrent
infection. It is rare but well defined
Complete absence of the breast and entity. No treatment is required. The
nipple is rare. It may be associated with patient is reassured.
failure of development of pectoralis
muscles (Poland’s syndrome). INVERSION OF NIPPLE
SUPERNUMERY NIPPLE Inversion of nipple is a condition which

is chara-cterized by inward
It is the presence of extra nipple present displacement of the tip of nipple. It leads
in the mammary line. It is neither a to appearance of a slit like opening and
common abnormality nor has any disappearance of almost whole of the
significance. It doesn’t need any nipple.

Congenital failure to protrude nipple is epithelial lining disintege-rates and

also called inversion. Incidence of plugs the dilated lactiferous ducts.
inversion is quite high. About 20% of
females present with this problem. They Multicolored fluid from the nipple is
should be reassured. These patients discharged. Periductal chemical
mostly need no treatment. Sometime mastitis starts. It is infiltrated with
they present with the difficulty is plasma cells and Foreign Body Giant
suckling by the baby. Nipple sheath is cells.
applied to the nipple for helping the
baby to suck easily. It also helps to get A hard indurated mass with overlying
the nipple everted. inflammation may appear at the areolar
margin.
Acquired inversion of nipple is mostly
due to duct ectasia, plasma cell mastitis This inflammation may resolve
or any other inflammatory lesion. Retro automatically or change into periareolar
areolar carcinoma may also lead to abscess. If it is not treated
inversion of nipple. adequately it may lead to mammary
duct fistula. The repeated episodes of
MAMMARY DUCT FISTULA periductal mastitis leads to fibrosis
along ducts which shrink and may lead
Mammary duct fistula is an aftermaths to inversion of nipple.
of periductal mastitis. It presents as a
discharging sinus around the areolar It is commonly seen in postmenopausal
margin. women but it may occur in
premenopausal women. It is often
DUCT ECTASIA / PLASMA CELL bilateral and multiple abscesses and
MASTITIS / fistulae may be seen.
PERIDUCTAL MASTITIS
Treatment is surgery.
This is a common disease process. Its
etiology is not known. It is not clear PAGET’S DISEASE OF BREAST
whether ectasia or inflammation is the
primary problem. No one is clear which Paget’s disease is macroscopic
starts first. Sloughing of ducts initiates a superficial skin manifestation of
process of periductal mastitis. Clinical underlying carcinoma of breast. Usually
features follow the pathological it presents as a unilateral nipple
changes. ulceration. Sometimes whole of nipple
is eroded and it comple-tely
The terminal lactiferous ducts enlarge disappears. The cancer of breast
in size and then dilate grossly. The becomes evident sooner or later if it is

areola complex. cells lie singly or in clusters within the

epidermis.
Paget’s disease of breast is a type of
ductal carcinoma which extends from NIPPLE RETRACTION
the ducts to involve the skin of nipple
and areola. The malignant invasion of It is the inward displacement of
the nipple presents as eczematous whole/part of nipple from its base in the
change of unilateral nipple and areola. direction of disease process. It is
It many present as an encrusted and usually due to malignancy. The lesion
scaby tumor present at nipple and may be present in the breast tissue at
areola. any part. The retraction is due to
involvement of connective tissue Bands
The involved skin is ulcerated, fissured (ligaments of Astley Cooper).
and oozing. It may have surrounding
area of inflammatory hyperaemia and It is acquired problem which could be
edema. Advanced cases show total due to duct ectazia, carcinoma or
ulceration or even loss of nipple and surgical problem. All these problems
areola. There may be superimposed are discussed at length, at some other
infection and suppurative necrosis. Its part of the book.
symptoms include tenderness, itching,
burning and intermittent nipple NIPPLE DISCHARGE
discharge.
Nipple Discharge is a complex
The underlying mass or lump in rarely diagnostic challenge for clinicians. A
palpable. variety of diseases, such as intraductal
papillomas, mammary duct ectazia,
The epidermis is involved by the breast cancer, pituitary adenomas,
malignant cells and these are called. breast absce-sses and infections can
“Pagets cells”. Their origin and nature is manifest as nipple dis-charge1.
unknown. The intraductal lesion is often
multifocal and ducts throughout breast Nipple discharge disorders is a field in
may be dilated due to obstruction of which there has been both increasing
central collecting ducts at the ampula. awareness on part of patients and
advancements in management.
Paget’s cells are large, anaplastic and
hyper-chromatic ovoid cells The nipple discharge can be classified
surrounded by a clear zone or halo. according to its color, cellularity and
These have pale cytoplasm. It is biology. The discharge has to be true,
possibly due to ballooning spontaneous, persistent and non
degeneration. The anaplastic tumor lactational to be significant3.

! Pus discharge.
Cushing’s syndrome
CAUSES OF NIPPLE DISCHARGE Hypothyroidism
LACTATION
LACTATION = Physiological
This is the most common cause of
GALACTORRHOEA nipple discharge and needs no
treatment. This is physiological and milk
It is the discharge of milk from nipple discharge usually stops after cessation
which is unrelated to breast feeding or of breast feeding. In parous women milk
lactation. It can be physiological after can be expressed out even after two
cessation of feeding but continuous years of cessation of lactation.
mechanical stimulus to nipple promotes
milk discharge. Some times pregnant patient can have
blood stained discharge which settles
1. Physiological discharge after on its own. Occasionally neonates may
cessation of lactation. show milk discharge from their nipple if
2. Drug related. luteal or placental hormones get entry
into fetal circulation again it needs no
a. Drugs which reduce production treatment.
of prolactin
Dopamine. PATHOLOGICAL
Trycyclic antidepressants.
Methyl dopa. Intraductal papilloma
Cimetidine. Duct ectazia
Benzodiazipine. Carcinoma
B. Dugs which block dopamine Fibrocystic disease
receptors. Trauma
Phenothiazide. Infection
Metachlopramide.
Hexachlopramide. B L O O D S TA I N E D NIPPLE
Heloperidol. DISCHARGE
c. Oestrogen.
Digitalis. It causes high degree of anxiety in
women because of fear of breast
3. S P O N T A N E O U S cancer. Most frequently it is benign. It is
GALACTORRHEA commonly caused by intra ductal
papilloma, duct ectasia and less
Pituitary adenoma producing prolactin frequently by carcinoma breast2.
Broncho-genic carcinoma.

2
Discharge may be from peri areolar u s e f u l .
breast skin. Which may occur due to
different skin diseases like eczema, A large number of false negative results
psoriasis or chancre. Peri areolar make these tests less productive and
discharge can also be seen in Paget’s histopathological tests are required to
disease and duct ectasia. confirm the diagnosis2.
PAT H O L O G I C A L NIPPLE SERUM PROLACTIN LEVEL

DISCHARGE
When all other investigations are
It is usually spontaneous, unilateral and normal and patient has got
single duct involvement is seen. The amenorrhoea along with visual distur-
discharge may be serous, serosanguis bances, then raised serum prolactin
or blood stained. level may suggest pituitary adenoma.
Sometimes serum prolactin may rise in
TRIPLE ASSESSMENT bronchogenic carcinoma.
Correct diagnosis requires triple IMMUNOLOGICAL TESTS

assessment. Appropriate planning of
management is done after assessment Modern immunological tests can be
of the patient and understanding of performed on cytology smears where
disease process. occurrence of high levels of carcino-
embryonic antigen (CEA) could
CLINICAL EXAMINATION indicate latent malignancy3.
A detailed clinical evaluation by triple IMAGING

assessment is invaluable to determine ULTRASOUND EXAMINATION OF
the pathophysiology and assess risk of BREAST
malignancy1. (SONOMAMMOGRAPHY)
Both breasts and axillae are examined. High resolution ultrasound is helpful in
Nipple is cleaned and breast is visualizing intra ductal abnormality and
squeezed to see nature and site of are becoming a good complimentary
discharge and number of ducts approach if not an alternative to
involved. traditional radiology techniques3.
Hemoccult Test is performed to confirm Ultrasound is more sensitive than

presence of blood in the discharge. galactography in cancer diagnosis. It
G a l a c t o g r a p h y, u l t r a s o u n d also permits guided biopsy and pre
examination, exfoliative cytology are operative localization of impalpable

DUCTOGRAM (GALACTOGRAPHY) Lesions deep within the ductal system

can be identified and removed which
Galactography is the state of art could have been missed by blind duct
approach to investigate patients with excision5.
nipple discharge disorder and this
examination can demonstrate the size, It can be helpful to pick up cells for
location and extent of an intra ductal cytology. Its role is yet controversial
abnormality3.
CYTOLOGICAL EXAMINATION
It may be helpful in diagnosing intra
duct papilloma. Discharge is examined under the
microscope to rule out malignancy but
MR galactography has been shown to false negative reports may confuse the
be of diagnostic value but not as management plan. Ductal lavages in
informative as radio-galactography3. combination with cytology provide
promising results2.
FIBROPTIC DUCTOSCOPY
Cytology smears of discharge material
Early success of image guided excision have helped to classify the cellular
of papilloma and duct endoscopy material, providing information about
promise a significant improvement in normality, atypia and malignancy and
diagnostic accuracy through minimally also about papillary formation3.
invasive procedure.
MANAGEMENT
The most sophisticated investigation
method which can be used Objectives of treatment are to;
therapeutically as well is fibroptic
ductoscopy of the concerned duct in a 1. To rule out malignancy.
breast. 2. To reassure the patient.
3. To offer definitive treatment of
It is a new technique and is expensive. It the causative factors
is a fascinating and promising approach
for visualizing the intra ductal lumina3. SURGERY
Mammary ductoscopy for pathological Indications of surgery;

nipple discharge is a safe, effective
procedure that offers advantages of a. Single duct discharge
high lesion localization rate and intra
operative guidance, therefore, negating i. Blood stained discharge
the need for pre-operative ductogram. ii. Mammography shows

The patients with nipple discharge 2001 Oct; 27(5): 275-82.

should be clearly differentiated from
those who require surgery and who 2. Vargas Hl, Romero L, Chlebowski
don’t need it. Surgically significant RT. Management of blood nipple
nipple discharges are watery, serous discharge. Eur treat option oncol
2002 Apr; 3(2): 157-61.
(yellow), serosanguis or blood stained3.
3. Okazaki A, Hirata K, Okazaki M,
Women presenting with pathologic Svaue G, Azavedo E. Nipple
nipple discharge require duct discharge disorders: Current
exploration regardless of cytologic or diagnostic management and role of
radiologic findings. When discharge is fiber ductoscopy. Eur Radiol 1999;
the result of local extensiveness of 9(4): 583-90.
disease and intra ductal spread, it may
preclude breast conservation in more 4. Bauer RL, Eckhert KH, Nemoto T.
than 60% of cases4. Ductal carcinoma in situ-associated
nipple discharge. A clinical marker
for locally extensive disease. Ann
Nipple discharge in males is very rare surg oncol 1998 Jul-Aug; 5(5): 452-
but once it is there, it should be 5.
regarded with suspicion. There are high
chances of underlying malignancy. 5. Dietz JR, Crome JP, Grundfest S,
Surgical excision of the involved ductal Asrigain S, Kin JAA. Directed duct
system from which the discharge excision by using mammary
emanate. It is the only reliable ductoscopy in patients with
procedure in establishing a certain pathologic nipple discharge.
diagnosis and controlling the blood Surgery 2002 Oct; 132(4): 582-7.
Discussion 587-8
stained discharge2.
6. Cilloti A, Marini C, Marmari A,
Histologically it is an extension of intra Armillot and N. Traumo AC, Falleni
ductal carcinoma or even infiltrating A. Correlation of ultrasound and
ductal carcinoma. 30-40% of these galactography results. Radiol Med
patients have metastasis at the time of (Torino) 1999 Oct; 98(4): 248-54.
surgery and prognosis is less favorable
than simple intra ductal carcinoma 7. Michael Baum, Breast lumps.
which is diagnosed at earlier stage. F r e n c h ’s i n d e x o f s u r g i c a l
differential diagnosis Harold EIIs Ist
edition 1999: 56-62.
REFERENCES
8. Arscott GD, Gaig HR, Gabay L.
1. Sakorafas GH. Nipple discharge: Failure of bromocriptine therapy to
current diagnostic and therapeutic control mammary hypertrophy. Br J
approaches. Cancer treat Rev Plast Surg 2001Dec; 54(8): 720-3.




Chapter-
Beni n iseases o Breast

BENIGN DISEASES OF BREAST 2
Objectives
! To diagnose benign conditions and rule out malignant disease.
! To find out the nature of benign disease. (Inflammatory, ANDI,
Malignancy).
! To plan investigations effectively.
! To plan effective management.

BENIGN ISEASES OF BREAST

Abid Bashir, FCPS
Ata ul Latif, FCPS
The breast is a physiologically dynamic Most of the patients presenting with

organ in which cyclical variations are breast problems have benign condition
superimposed on changes of (over 90 of patients).
development and involution throughout
woman’s life1. Accurate classification of benign breast
diseases depend on relationship
Immature breast is composed mainly of between normal breast morphology
dense fibrous tissue stroma and and the changes that occur throughout
scattered epithelial lined ducts. There is a woman’s reproductive life from breast
an increased deposition of fat at develop-ment through cyclical change
puberty giving the pair of breast a shape to changes during pregnancy and
2,3
and women the sense of feminity . lactation, eventually involution.
New ducts are formed by a process of The quality of investigations and

elongation and lobular units appear, understanding of breast problems has
terminal end buds arise from improved over recent years. Patients
pleuripotent stem cells in the immature demand investigations and treatment
ducts. Growth of breast is controlled by for symptoms. There is question of pre-
many hormones; malignant conditions.
1. Oestrogen. Screening programs present

2. Progesterone. pathologists and clinicians as yet ill-
3. Pituitary hormones. defined clinical entities.
4. Insulin.
5. Thyroxine. The concept first proposed by Hughes
in 1982 has been called Aberrations of
Growth hormone seems to be Normal Development and Involution
responsible for the terminal end duct (ANDI) The concept implies that most
development via production of insulin benign disorders can be regarded as
3
like growth factor 1 (IGF-1). mere aberrations of normal processes .

Classification of the pathogenesis of non malignant breast disease based on the concept of
Aberration of Normal Development and Involution (ANDI)
Physiological state of the Normal Benign disorder Benign disease
breast
Duct development, Nipple inversion
Development Fibroadenoma, Adolescent Mammary fistula,
lobular development,
stromal development hypertrophy Giant fibroadenoma
Cyclical Change Hormonal activity Mastalgia and nodularity

Epithelial activity Benign papilloma
Peri-ductal mastitis with
Pregnancy and lactationEpithelial hyperplasiaBlood stained discharge
Lactation Galactocele suppuration
Involution Duct involution Duct ectasia, nipple Lobular and ductal

retraction hyperplasia with atypia
Lobular involutionCysts, sclerosing adenosis
Involutional epithelial Hyperplasia and
hyperplasia micropapillomatosis
3. Cysts.
4. Galactocele.
contraceptive pill (hormonal). 5. Sclerosing adenosis.
6. Fat necrosis.
PRESENTATIONS OF BENIGN BREAST 7. Lipoma.
PROBLEMS 8. Chronic abscess.
9. Normal structures (prominent
BREAST PAIN (MASTALGIA) rib, edge of previous breast
biopsy, margin of breast tissue,
All women old or young may feel pain in etc).
one or both breasts. It could be;
NIPPLE & PERI AREOLAR REGION
1. Cyclical. DISORDERS
2. Primary non-cyclical.
3. Musculo-skeletal. 1. Discharge.
4. Sclerosing adenosis. 2. Retraction.
5. Post-operative. 3. Sepsis.
6. Cervical root pain.
BREAST INFECTIONS
BREAST LUMPS
1. Lactational.
1. Fibroadenoma. 2. Non-Lactational.
2. Cyclical nodularity.

OBJECTIVES OF ASSESSMENT Inflammation as a cause of pain has

also been postulated6.
The objectives of evaluation of breast
problems are; Recently duct ectasia has been
described as a major factor associated
! To confirm the diagnosis. with mastalgia. Ultrasonography was
! To assess the extent of disease used in mastalgia patients to
process. investigate the location of pain7.
! To form treatment plan.
Hormonal and dietary factors have also
These could be achieved by triple been postulated in causation of
assessment (clinical examination, mastalgia for long time. Recently
imaging and FNAC or core biopsy). smoking, caffeine and perceived stress
has been shown to be associated with
BREAST PAIN (MASTALGIA) mastalgia2.
Mastalgia or mastodynia can be Markedly increased levels of

defined as “breast pain of sufficient gonadotrophin hormones throughout
severity for a women to seek medical the cycle has also been observed in
advice”. patients with mastalgia8. Mastalgia is
usually classified into following groups.
Some breast pain or discomfort is Cyclic and non cyclic mastalgia9.
experienced by about 2/3rd of women
during the premenstrual phase. It may This classification10 is based on etiology
be associated with increased and is as follows;
nodularity1. This pain is felt in the
premenstrual phase but resolves with CYCLICAL MASTALGIA
menstruation.
Cyclic mastalgia is so called because
The development of severe pain and patient has obvious menstrual cycle
nodularity during the menstrual cycle is related pattern.
considered as abnormal and may
interfere significantly with patient’s CYCLICAL NODULARITY
everyday activity2,3,4.
Usually complained by teenagers, lump
ETIOLOGY & PATHO-PHYSIOLOGY varies in size with menstrual cycle and
is located in upper outer quadrant.
The underlying cause of severe
mastalgia remains unknown5. If persistent FNAC is indicated with
mammography in elderly. Younger

mastitis complex of disorders. inflammation to the breast e.g. pain of

cholecystitis or pleurisy.
TIETZE’S SYNDROME
IDIOPATHIC
It is the painful, swollen, tender costo-
chondral junction usually of the 2nd rib. The origin of breast pain remains
Because of the vicinity of the female obscure in some patients.
breast to the area pain may be
perceived as breast pain. History of pain should include onset,
duration, character, severity, site,
PREVIOUS TRAUMA localization, radiation progression,
cyclic changes, relieving and
The breast may have had abscess, aggravating factors. The systemic
biopsy or injury. Similarly skin incision enquiry should be performed to rule out
may be a source of pain. causes of referred pain. History of
dietary habits, smoking, behavior,
SCLEROSING ADENITIS stress and tension, occupation and
previous surgery should also be
It is benign condition diagnosed on sought.
histopathology of suspicious lesion
(microcalcifications) On local examination, thorough
examination of both breasts should be
CARCINOMA performed in a systematic order.
Tenderness and/or any localized tender
Pain does not commonly accompany spot, nodularity or discrete lump should
cancer in the breast. Mastalgia can still be sought carefully. Condition of the
be the presenting symptom of operable nipple and any discharge should be
breast cancer. noted. Previous scar if any should be
properly assessed. Both axillae should
MISCELLANEOUS be examined. Systemic examination to
find out intra-thoracic, intra-abdominal
Occasionally a fibroadenoma or cyst and chest wall pathology should also be
may be painful. Oral contraceptives, performed.
Fat necrosis, thrombo phlebitis of the
vessels of the lateral chest wall Mammography and/or FNAC should be
(Mondor’s disease) and tuberculosis advised wherever indicated.
are causes of breast pain.
Majority of these patients respond to
The pain may be referred from simple reassurance and explanation1.
intrathoracic or intra abdominal

Use of supportive bra specially at night Danazol is a gonadotrophin release

is also very helpful. Good external inhibitor. It remains the most effective
support by sports brassiere can also second line treatment9,13,14,15,16,28.
relieve most of patient’s symptoms.
BROMOCRIPTINE
The patient should be reviewed after
two months. Pattern of pain should be Bromocriptine is dopamine agonist
assessed and response should be which has been successfully used for
graded according to Cardiff Breast Pain many years to treat mastalgia. It has
Score. Specific drug treatment should been shown to decrease serum
be considered which should be prolactin levels in normal and
balanced against the chance of hyperprolactinemic women. Its
response to treatment and risk of side effectiveness has been
effects. confirmed17,18,19,20,21.
Patient should be reviewed every two to TAMOXIFEN

three months. The decision regarding
continuation or change of treatment Tamoxifen an anti oestrogen, has many
should be made according to patient’s uses in the management of breast
response. disorders. Its effectiveness in the
treatment of breast pain is documented
Following drugs are used for treatment 22,23,24
.
of mastalgia;
GOSERLINE
EVENING PRIMROSE OIL
Goserline, LHRH analogue has shown
Women with mastalgia have abnormal to be effective in both cyclic and non
fatty acid profile and decreased levels cyclic mastalgia refractory to first line
of linolenic acid metabolites 1 5 . therapy25,26,27.
Treatment with evening primrose oil
improves essential fatty acid profile to BENIGN BREAST LUMPS
normal8,9,10.
Approximately 40% of the patients
Anti oxidant (vitamin E) might improve attending a breast clinic have a benign
the efficacy of evening primrose oil breast lump. The job of clinician is to
treatment by reducing its metabolism define whether the lump is true
via lipid peroxidation11,12,13,14,15. abnormality and then to exclude
malignancy. Enquiry into its duration,
DANAZOL pain, change in size and relationship to
menstrual cycle is important.

years of age. It is the most common type. Fibrous

! It is common in black and oriental tissue predominates and projects into
women. the lumen of the ducts distorting their
! It commonly occurs in women under shape. It may be occasionally bilateral.
the age of 35 years.
! It constitutes about 75% of all the Cystic and sarcomatous changes
benign breast tumors. sometimes supervene.
! Occasionally it can be associated
with lobular carcinoma. P E R I C A N A L I C U L A R
! Approximately 25% of all discrete FIBROADENOMA
breast lesions are fibroadenomas or
cysts. It is small well encapsulated tumor.
! 10% fibroadenomas are multiple. Both the fibrous and epithelial tissue
! It is benign breast disease with have overgrown in a way that these
epithelial elements and fibrous resemble normal breast lobule.
tissue stroma.
Following investigations help in the
The incidence decreases with age and confirmation of the diagnosis;
specially after menopause.
! Mammography.
It may calcify and be diagnosed easily ! FNAC.
on mammography. It is very mobile but ! Trucut needle biopsy.
with age, the mobility decreases ! Excision biopsy.
(Breast mouse).
FNAC or trucut needle or excision
It is commonly present in the upper and biopsy confirms the diagnosis2.
outer quadrant of the breast. Its size
varies from 1 cm to 15 cm range. TREATMENT
The lesion is usually firm or hard with WOMEN BELOW 25 YEARS OF AGE
well demarcated borders. It is
extremely mobile and slips from the Only symptomatic treatment may be
examining hands easily. It is also called required.
“Breast mouse”. Two histological
variants are described depending upon Reassurance and regular follow up
the predominance of the tissue. clinical examination is enough.
I N T E R C A N A L I C U L A R Surgery may be offered for

FIBROADENOMA psychological or cosmetic reasons
because of presence of the tumor.

and shiny skin on affected side. breast its classic leaflike (Phyllodes)
appearances. The contour may
Bigger fibroadenomas sometimes assume a tear drop configuration7,8.
becomes lobulated and leaf like and is
called Phyllodes tumor which may be Stroma shows hypercellularity, much
benign or malignant. atypia and numerous mitoses.
The giant fibroadenoma can be benign, CLINICAL FEATURES

locally invasive and rarely a malignant
tumor. Clinically they present with features
similar to fibroadenoma but progress
Malignant tumors are called Phyllodes rapidly to a large size, sometimes with
tumors (previous names were ulceration of skin or involvement of
cystosarcoma phyllodes or phyllodes axillary lymph nodes.
sarcoma).
Metastasis occur in less than 5% of the
TREATMENT tumors.
Surgical removal through an TREATMENT

appropriately cosmetic incision is
carried out. Simple enucleation is performed before
the age of 20 years.
The discrepancy in size following
surgical removal settles in a year or two. Elderly patients require wide local
excision with one cm margin, 25%
PHYLLODES TUMORS tumors recur8, these need to be excised
with wide margins.
Previously named as cystosarcoma
phyllodes or phyllodes sarcoma, these Very large tumors or those with
tumors show a wide spectrum of activity aggressive histology merit simple
from completely benign to locally mastectomy and reconstruction.
invasive and occasionally metastatic
tumor. NON PROLIFERATIVE LESIONS
BREAST CYSTS
Histopathologically it harbors a sharp
demarcation from surrounding tissue. Upto 7% women develop a cyst once in
Connective tissue composes bulk of their life. Two distinct populations of
mass. The cystic component is due to cysts appear to exist, simple and
areas of infraction, degeneration and apocrine. These are defined by their
necrosis. These alterations give the microscopic appearance, biochemical

Ultrasound examination of breast and

aspiration confirms diagnosis; SCLEROSING ADENOSIS
TREATMENT It is uncommon cause of breast lump. It

is charact-erized by proliferation of
i. Aspiration. terminal duct lobules, myoepithelial
Ii. Surgical Excision. cells with increased number of acini and
fibrous stromal change. It presents as a
! Aspiration which can be repeated smooth but mobile mass in 30-50 years
for one more occasion. age group. It may have a stellate
! If it does not settle or aspirate is appearance and may calcify thus it may
blood stained, then surgical mimic carcinoma both clinically and
excision is performed. radiologically. The increased cellularity
! Patients with recurrent apocrine can be confused with carcinoma
cysts may benefit from continued histologically. It may be painful. FNAC
mammographic surveillance and no and trucut biopsy is diagnostic.
surgical intervention.
Lump may necessitate excision
GALACTOCELE because of pain or patient’s fear 8,11,25.
It presents as a cyst in women who LIPOMA / ADENOLIPOMA

have recently stopped breast feeding. It
is probably simply cyst filled with milk. Lipomas present as a soft smooth,
mobile lumps quite frequently. These
Aspiration is diagnostic as well as may be having a glandular component-
therapeutic. adenolipoma. These are best excised if
there is any doubt.
FAT NECROSIS
DISORDERS OF NIPPLE AEROLA
Fat necrosis is a frequent cause of COMPLEX
diagnostic difficulty in women. A history NIPPLE DISCHARGE DUCT ECTASIA
of trauma is easily provided. The lump & PERI-DUCTAL MASTITIS
may be hard and confused with
carcinoma. Even mammographic Duct ectasia and peri-ductal mastitis
findings are similar to those of cancer. represent a spectrum of inflammatory
processes where the sub-areolar
FNAC is diagnostic. ectatic, enlarged, ducts are surrounded
by a mild inflammatory infiltrate31.
Lump may have to be excised if the
doubt exists31. PATHOGENESIS

CLINICAL FEATURES breast. The abscess remains contained

in the lobes of breast localized by the
Creamy discharge from multiple, fibrous septa. The induration lasts
bilateral ducts is a feature of duct longer.
ectasia. Periductal mastitis may
present as a mass or an abscess. The abscess typically occurs within first
Repeated inflammation results in few weeks of lactation and breast
retracted slit shaped nipple in contrast feeding.
to retraction seen with an underlying
cancer when it is circumferential. It is most often staphylococcal in
nature. Bacterial invasion of the breast
TREATMENT tissue leads to development of acute
mastitis. The localization of abscess
Antibiotics are to be given for periductal occurs easily. Multi-locular abscess is
mastitis. Abscess necessitates incision typically staph-ylococcal.
and drainage. Sometimes core excision
of major duct system has to be done if it The bacterial access is through the
is referactory to treatment with lactiferous ducts when there is
antibiotics or if the discharge persists32. inspissation of secretions in the ducts or
cracks and fissures in the nipple during
NIPPLE INVERSION & RETRACTION early periods of nursing. These
changes follow dermatitis of nipple.
Inversion describes a congenital failure
of eversion during development and The inflammatory process leads to
retraction is usually due to duct ectasia cellulitis with localized subcutaneous,
or carcinoma. sub-areolar, interlobular, peri-ductal
and retromammary collection of pus.
TREATMENT
Commonly the breast abscess is
For inversion, surgery is usually unilateral, it may be unicentric or multi
unnecessary, it resolves mostly during centric collection. It may be a single
pregnancy and lactation. Cosmetic abscess or multiple abscesses may be
surgery is performed for inversion or present.
retraction due to duct ectasia but it has
drawback of dividing ducts32. Streptococcal infection tends to cause
diffuse spreading infection and involves
BREAST ABSCESS larger areas. It is localized at a later
stage.
It is the collection of pus in the breast.
Commonly it is seen in the lactating The abscess presents with painful

OBJECTIVES OF MANAGEMENT in resolution of inflammatory process.
Objectives of management are; Breast abscess may resolve or be

cured with adequate treatment. It may
1. Assessment of general condition of progress to form chronic or recurrent
the patient. abscess with improper or inadequate
2. Confirmation of diagnosis. treatment.
3. Immediate treatment for relief of Chronic or recurrent abscess is
symptoms. investigated for acid fast bacilli, fungi,
4. Definitive treatment of the cause. aerobic and anaerobic bacteria.
The patient is investigated thoroughly Thorough debridement and use of

for general assessment and appropriate antibiotics for longer period
confirmation of diagnosis. Complete may be used.
urine examination and blood
examination is performed and Simple mastectomy may be required in
ultrasound of the breast is performed. worse cases to treat and avoid the
worse chronic infection.
Fluctuation becomes elicitable at a late
stage. The skin necrosis occurs by the IMMEDIATE TREATMENT
time fluctuation is positive. The breast
abscess is drained at an early period Analgesia can be given both by mouth
when it is still in the induration stage. or parent-erally to relieve the pain.
Focal heat compresses are used.
Surgical drainage of abscess with Parenteral or oral antibiotics against
complete breakage of all loculi is the gram positive cocci are used in
adequate treatment of breast abscess. adequate doses.
Thorough Debridement of the abscess Ultrasound guided aspiration of pus
is required for good cosmetic results collection is performed.
and prevention of recurrent abscess. The conservative treatment is
continued for 2-3 days.
Discontinuation of the lactation by using If the symptomatic relief is obtained, the
anti prolactin drugs (Bromocriptine) treatment may be continued for few
helps to resolve the inflammatory days till complete relief.
process by regression of lactation.
Incomplete drainage leads to healing
Breast suction with the help of breast with fibrosis and scarring. It may
suction pump helps to get rid of the thick occasionally be mistaken as
milk secretion but stimulates further malignancy. It should be completely
lactation and may not be always helpful drained by breaking all the loculi to

mass. Spontaneous resolution is breast demonstrates multiple incisions

common but these may progress to an for drainage of previous abscesses,
abscess. Systemic features are less distortion, nipple retraction, and a
marked. fistula at areolar margins. Basic cause
is duct ectasia/periductal mastitis.
TREATMENT
Treatment is fistulectomy and excision
Treatment is aspiration and obtaining of offending duct. Occasionally major
pus for culture & sensitivity. A duct excision is necessary32.
combination of flucloxacillin and
metronidazole is recommended. MISCELLANEOUS BENIGN BREAST
Repeated aspirations may be helpful. CONDITIONS
Occasionally drainage is required and CRACKED NIPPLE
must be done through smallest possible
incision. It occurs during lactation and is the
forerunner of acute bacterial mastitis.
Definitive treatment is major duct Breast should be rested for 24-48 hours
excision and nipple eversion when and evacuated with breast pump. Then
acute inflammation has settled. It feeding may be resumed.
should be performed under proper
antibiotic cover. PAPILLOMA OF THE NIPPLE
MASTITIS NEONATORUM It has features similar to other

cutaneous papillomas and should be
Breast abscesses can rarely occur in excised with a tiny disc of skin.
neonates due to infection of milk
induced by transplacental passage of SEBACEOUS CYST
maternal hormones.
It results from blockage of duct of gland
Treatment is antibiotics. of Montgomery situated in areola. It
may be excised for cosmetic
Occasionally, surgical drainage is indications.
necessary and may lead to distortion of
breast contour in later life. CHANCRE OF NIPPLE
MAMMARY FISTULA It is very rarely seen. It results from

infection from a syphilitic buccal ulcer of
It may follow spontaneous or surgical the partner.
discharge of an abscess and is found at
areolar margin. Characteristically the Treatment is as for syphilis.

or infection. It occurs occasionally in otherwise

healthy girls at puberty and less often
The veins appear as thrombosed during first pregnancy. Breasts attain
subcutaneous cords attached to skin. A abnormally large size.
groove appear alongside the cord on The enlargement condition is mostly
lifting the skin. It is to be differentiated bilateral. Increased sensitivity to
from lymphatic inflammation from estrogen has been suggested as a
occult carcinoma breast. cause.
TREATMENT Some success has been reported with

treatment with antiestrogens.
Restriction of the arm movements is Otherwise, reduction mammoplasty is
required. It resolves spontaneously the treatment of choice.
within a few months in any case.
GYNAECOMASTIA 26,27,28,29
HAEMATOMA
Gynaecomastia is the abnormal growth
Presents with a lump and history of of breast tissue in males. It is a benign
trauma. Only aspiration or incision is and often reversible condition which
diagnostic as well as therapeutic. affects 3% of the male population once
in a lifetime.
CONGENITAL ABNORMALITIES OF
THE BREAST Mostly it occurs in teenage boys
AMAZIA (pubertal gynaecomastia) and elderly
man (senescent gynaecomastia).
Congenital absence of the nipple may Together these account for 50% of
be unilateral or bilateral. Occasionally it patients.
is accompanied by missing sternal
portion of pectoralis major (Poland’s AETIOLOGY
synd). It is more common in males.
Basically there is disturbance in the
POLYMAZIA estrogen androgen ratio leading to
relative hyperestro-genism. It may be;
Accessory breasts have been recorded
in axilla (most common), groin, buttock i. PHYSIOLOGICAL
and thigh. These function during
lactation only. ! Neonatal.
! Puberty.
DIFFUSE HYPERTROPHY ! Old age.

Lymphomas must be done to rule out carcinoma of

Gastric carcinoma the male breast.
Renal cell carcinoma Reassurance of the patient that this is
purely a benign disease which is
! Systemic Diseases usually reversible will suffice in most of
Chronic liver disease the cases.
Renal failure on dialysis
Thyrotoxicosis If persistent and leading to social
Starvation/Refeeding embarrassment or causing pain, then
surgery has to be performed. Cessation
! Hypogonadal States of drugs should lead to spontaneous
Klinefelter’s syndrome resolution.
Secondary testicular
failure The surgical treatment is subcutaneous
mastectomy using a circumareolar
! Drugs incision. Sub-mammary or a Thomas-
Oestrogens Gallard incision is employed for larger
Androgens breasts .
Cyproterone acetate
Cardiac glycosides e.g. Liposuction has no role in the treatment
Digoxin of gynaeco-mastia as breast tissue is
not fat alone.
H2 Blockers and PPl’s such as
cimetidine, ranitidine and omeprazole REFERENCES
Diuretics e.g.spironolactone. 1. Edwards P & Gateley C. The breast
Tricyclic antidepressants. benign disorders and mastalgia.
Surgery (Quarterly Edition) 2001;
The cause of breast enlargement in 53: 105-8.
hyper androgenic states is peripheral
2. Hughes LE, Mansel RE, Webster
conversion of androgens to estrogens
DTT. Aberrations of Normal
by the enzyme called aromatase development and involution
leading to relative hyperestrogenism. (ANDL); a new prospective on
pathogenesis and nomenclature of
Drugs and metabolic diseases interfere benign breast disease. Lancet
with metabolism of estrogens. 1987; ii: 1316-9.
TREATMENT 3. Authors same as 3: Benign

disorders and diseases of breast.
If unilateral and found in elderly FNAC Concepts and clinical

Obstet. Gynecol June 2001; 22(2): controlled trial. Am J Obstet

71-6. Gynecol 2002 Nov; 187(5): 1389-
94.
6. Chianakawalam CI, Bales T.
Diagnosis and management of a 13. Khan SA, Apkarian AV. Mastalgia
breast lump surgery 2001; 19: 4, and breast cancer: a protective
75. association? Cancer Detect Prev
2002; 26(3): 192.
7. French RE; Fibro-adenoma and
related lesions in page DL, 14. Hadi MS. Sports Brassiere: Is it a
Anderson TJ. Diagnostic Solution for Mastalgia? Breast J
histopathology of the breast. 2000 Nov; 6(6): 407-409.
Edinburgh, Churchill Living stone, 15. Oil of Evening Primrose.
1987: pp 72-88. Monograph. Lawrence Review of
Natural Products: Levittown. Pa:
8. Gateley CA, Maddox PR. Pritchard Pharmaceutical Information
GA et al. Plasma fatty acid profiles Associates 1993.
in benign breast disorders. Br J
Surg, 1992; 79: 407-9. 16. Gateley CA, Maddox PR, Mansel
R E , H u g h e s L E . M a s ta l g i a
9. Mansel RE, Pye JK, Hughes LE. refractory to drug treatment. Br J
Effects of essential a fatty acids on Surg 1990; 77: 1110-2.
cyclical mastalgia and non cyclical
breast disorders. In: Horrobin DF 17. Hinton CP, Bishop HM, Holiday HW,
(ed) Omega 6 essential fatty acids. Doyle PJ, Blamey RW. A double
Pathophysiology and roles in blind controlled trial of danazol and
clinical medicine. Wiley-Liss New bromocriptine in the management
York, 1990; 557-6 severe cyclical breast pain. Br J Clin
Pract 1986; 40: 326-30.
10. Pye JK, Mansel RE, Hughes LE.
Clinical experience of drug 18. Harrison DJ, Maddox PR, Mansel
treatments for mastalgia Lancet ii RE. Maintenance therapy of
1985; 373-7. cyclical mastalgia using low dose
danazol. J. R Coll Surg Edinb 1989;
11. Cuschieri A, Giles G.R, Moossa 34: 79-81.
A.R: P.E Preece; The Breast in
Essential Surgical Practice, 19. Mansel RE, Preece PE, Hughes
Second Edition: P-836-857. LE. A double blind trial of the
prolactin inhibitor bromocriptine in
12. Blommers J, de LangeDe Klerk ES. painful benign breast disease. Br J
Kuik D J. Bezemer PD, Meijer S. Surg 1978; 65: 424-7.
Evening primrose oil and fish oil for
severe chronic mastalgia: a 20. D u r i n g P, S e l l w o o d R A ,
randomized, double blind Bromocriptin in severe cyclical

Advance in Surgery No. 21. Taylor I, 718-23.

Johnson CD (Ed), Churchill
Livingstone Edinburgh, 1988: pp 28. O’Brien PM, Abukhalil IE.
71-83. Randomized controlled trial of the
management of premenstrual
25. Hamid H, Chaudary MA, Caleffi M, syndrome and premenstrual
Fentiman IS. LHRH analogue for mastalgia using luteal phase only
treatment of recurrent and danazol. Am J Obstet Gynecol
refractory mastalgia. Ann R Coll 1999 Jan; 180(1 Pt 1): 18-23.
Surg Eng 1990; 72: 221-4. 29. Michael JG. Benign conditions of
breast. Peter J. Meat. Oxford
26. Fraser HM, Sandow J. Suppression textbook of surgery. Oxford
of follicular maturation by infusion University press London. 789-844
of a luteinizing hormone releasing 1994.
hormone agonist starting during the
late luteal phase in the stumptail 30. Diaxon JM. Cystic disease and
M a c a q u e m o n k e y. J C l i n fibroadenoma of breast: Natural
Endocrinol Metab 1985; 60: 579- history and relation to breast cancer
584. risk. British medical Bulletin [JC:
bog] 47(2) : 258-71, 1991 Apr.
27. Kaleli S, Aydin Y, Erel CT, Colgar U.
Symptomatic treatment of 31. Saunders CM and Baum M. The
premenstrual mastalgia in breast in Baily & Love’s short
premenopausal women with practice of surgery, 23rd ed. Russel
lisuride maleate. A double blind RCG, Williams NS, Bulstrode CJK,
placebo controlled randomized 200 Arnold: pp 749-73.
study. Fertil Steril 2001 Apr; 75(4):


Chapter- 2
Non Invasive Carcinoma

o Breast
uctal arcinoma in Situ IS

obular aracinoma in Situ IS
aget s isease o ipple
NON INVASIVE CARCINOMA OF BREAST 2
Objectives
! To detect the carcinoma breast at a very early stage (non
invasive stage).
! To confirm the diagnosis.
! To plan satisfactory and adequate management.
! To establish an adequate follow up plan.

NON INVASIVE CARCINOMA

OF BREAST
Carcinoma breast is a dreadful

condition. The women feel severely Moderate or florid hyperplasia
depressed even at the thought of Papilloma with fibro vascular core.
suffering from this problem.
MODERATE INCREASED RISK (4-5
Its understanding is improving with the TIMES)
time. The methods to detect the
condition at earliest have been Atypical ductal hyperplasia.
developed and are being further Atypical lobular hyperplasia.
improved.
HIGH RISK (8-10 TIMES)
New methods are being explored. The
patients at risk are identified and Ductal carcinoma in situ (DCIS)
managed to avoid invasive disease. Lobular carcinoma in Situ (LCIS)
Relationship between benign and NON INVASIVE CARCINOMA OF BREAST

malignant disease based on the
consensus statement of the American It includes (Grade I or Type I Non
college of Pathologist is as follow1,5; Metastasizing).
NO INCREASED RISK ! Intra ductal carcinoma of breast,

Ductal caricnoma in situ of breast
Sclerosing adenosis. (DICS).
Aprocrine change. ! Intra ductal carcinoma with Paget’s
Duct ectasia. disease.
Mild hyperplasia. ! Lobular carcinoma in situ (LCIS).
Fibro adenoma.
Apocrine metaplasia. INTRA DUCTAL CARCINOMA
DUCTAL CARCINOMA IN SITU
SLIGHT INCREASED RISK(1.5-2 (DCIS)2
TIMES)

includes heterogenous group of lesions necrotic tumor cells. The number of

with diverse clinical presentations, clusters of microcalcification, branching
histological features and biological or linear calcification are likely to be
potential. associated with malignancy2,7.
Ductal carcinoma in situ is the Its presentations are variable. It

transformation of ductal epithelial cells presents with a mass in breast or nipple
into malignant cells that remain in the discharge. The palpable lesions of
anatomical position and have not yet DCIS are multicentric. These show
broken through the basement occult invasion and overall poor
membrane. prognosis.
It is a local disease which has not It may produce a mass or present as

changed into a systemic or invasive paget’s disease of nipple or as a
disease therefore, it is called carcinoma discharge from nipple.
in situ.
Non Invasive carcinoma of breast is the
The number of patients having DCIS initial stage of breast malignancy. The
have grown 10 times from (2% -20%) special feature is non invasion of
during last twenty years. It represents basement membrane with tumor.
15-20% of breast carcinomas detected
by mammography. It is seen in 95% of These cancers don’t have the ability to
cases of DCIS. Nearly 60% of DCIS metastasize at this stage as these are
cases are solely discovered by confined to the cells.
mammography2,7.
It begins as atypical proliferation of
Intra ductal carcinoma is much more ductal epithelium that eventually
common than lobular carcinoma in situ. completely fills and plugs the ducts with
It is seen in 5% of all symptomatic neoplastic cells. There is marked
breast cancers. dilatation of ducts with solidification. All
these changes may create some
It is usually diagnosed change in consistency of breast
mammographically by detection of substance. The ducts are filled with
micro calcifications. A mass greater necrotic and cheesy material which can
than 1cm at mammography represents be extruded upon slight pressure. It is
malignancy in approx 25% of cases also called comedo carcinoma.
(most of these are invasive lesion).
Histopathological findings are dilated
Calcium deposits in DCIS are ducts filled with neoplastic epithelial
dystrophic calcifications secondary to cells. Some glandular or papillary

HIGH GRADE DCIS Invasion may occur some time later.
It is the easiest to identify. The tumor CRIBRIFORM VARIETY

cells have pleomorphic nuclei, irregular
nuclear contours, prominent nucleoli Histologically the ducts may be more or
and frequent mitosis. Multiple growth less filled with masses of anaplastic
pattern may be seen often with central tumor cells creating small glandular
necrosis and calcification. spaces. It is called cribriform type. It
carries better prognosis than comedo
LOW GRADE DCIS variety.
It shows a uniform group of cells in MICROPAPILLARY VARIETY

cribriform or micropapillary pattern.
There is lack of necrosis or cytologic Some lesions present with ducts filled
Atypia. with solid masses of cells and
sometimes with central areas of
INTERMEDIATTE GRADE DCIS necrosis which may calcify showing as
micro calcification on mammography.
It shows proliferating cells with mild to Sometimes cells grow in papillary
moderate Atypia and variable growth formations. It is called micro-papillary
patterns such as cribriform, variety. It has better prognosis than
micropapillary or solid lesion with comedo variety.
prese-nce of central necrosis.
PAGET’S DISEASE OF NIPPLE
The lesion advances and leads to
invasion of basement membrane and it Rarely anaplastic cancer cells extend
changes to infiltrating ductal carcinoma into the epidermis of nipple and areola
(Invasive carcinoma). to produce Paget’s disease of nipple.
DCIS is the most frequently detected
COMEDO VARIETY abnormality and appears as a cluster of
pleomorphic calcification.
DCIS may not present with clinically
palpable mass. Some times there is It runs 30-50% risk of developing into
palpable cord like thickening. Cheesy invasive carcinoma over 15 years.
material of necrotic tumor extrudes out
on cutting and pressing the cord. It is BIOLOGIC MARKERS OF DICS1
then called comedo carcinoma. It may
be of large size and may have high rate Biologic markers help in the diagnosis
of recurrence. 40% of comedo type intra of intraductal carcinoma. These are as
ductal carcinomas are of high grade. follows;

! There is increase in microvessel reviewing biopsy tissue for some other

density around the ducts involved in lesions. It is more of a marker for
DCIS. development of cancer in future. It may
lead to development of both ductal or
All these markers indicate poor lobular carcinoma.
prognosis after the development of
invasive carcinoma. It is a distinct type arising from terminal
ducts and ductules.
C L I N I C A L F E AT U R E S O F
INTRADUCTAL CARCINOMA These structures get distended with
necrotic anaplastic cells in the center of
The intra ductal carcinoma may present ductule.
with the following features;
There are fibrocystic changes mixed
! Lump. with intra ductal carcinoma even
! Nipple discharge. invasive carcinoma.
! Paget’s disease of breast (It is an
extension of intraductal carcinoma The carcinomatous lesion is usually
to nipple areola complex involving multi focal and bilateral. One third of
its epidermis). LCIS change into invasive carcinoma
! Asymptomatic patient with over a period in the same or opposite
mammographic findings. breast. Many change to ductal
carcinomas. The monitoring or
MAMMOGRAPHIC FINDINGS FOR prophylactic treatment of opposite
DCIS breast is also performed.
! 75% present with calcification PAGET’S DISEASE OF BREAST

(linear, branching, granular or
h e t e r o g e n o u s ) . It is a breast lesion which present as a
! 10% present as soft tissue chronic eczematoid eruption of nipple
mass.(well circumscribed mass, areola complex. It was first described by
architectural distortion and Sir James Paget in 1874. It is seen in
developing density) approximately 02% of patients.
! 12% present as combination of the
above. The specific demonstration of
carcinoembryonic Antigen (CEA) within
LOBULAR CARCINOMA IN SITU the paget cell facilitates in diagnosis
(LCIS) and its differentiation from malignant
melanoma lesions. The origin of paget
It is usually diagnosed incidently while cells is not clear. It may be formed due

Paget’s disease of breast is a type of

ductal carcinoma which extends from It occurs in old age group of patients
the ducts to involve the skin of nipple very rarely it may even present as early
and areola. The malignant invasion of as 20 years of age.
the nipple presents as eczematous
change of unilateral nipple and areola. The epidermis is involved by the
It may present as an encrusted and malignant cells and these are called.
scaby tumor present at nipple and “Paget’s cells”. Their origin and nature
areola. is unknown. The intraductal lesion is
often multifocal and ducts throughout
The involved skin is ulcerated, fissured breast may be dilated due to
and oozing. It may have surrounding obstruction of central collecting ducts at
area of inflammatory hyperaemia and the ampula. Paget’s cells are large,
edema. Advanced cases show total anaplastic and hyper-chromatic ovoid
ulceration or even loss of nipple and cells surrounded by a clear zone or
areola. There may be superimposed halo. These have pale cytoplasm. It is
infection and suppurative necrosis. Its possibly due to ballooning
symptoms include tenderness, itching, degeneration. The anaplastic tumor
burning and intermittent nipple cells lie singly or in clusters within the
discharge. epidermis.
The underlying mass or lump in rarely 30-40% of these patients have

palpable. metastasis at the time of surgery and
prognosis is less favorable than simple
Histologically it is an extension of intra intra ductal carcinoma which is
ductal carcinoma or even infiltrating diagnosed at earlier stage.
ductal carcinoma.
Treatment Outcomes in DCIS: French Experience

Local Therapy Mastectomy
Lumpectomy
Lumpectomy+XRT
No. of Cases 306 403 842
% of local-regional recurrence 1.6% 26% 12.7%
No. of in situ recurrence 0 52 38
No. of invasive recurrence 5 53 65
No. of axillary recurrence 1 9 14
No. of metastatic recurrences 2 5 11
% of metastatic recurrences 0.6% 1.2% 1.3%

The objectives of treatment of non survival is similar to that of mastectomy

invasive carcinoma breast are4,8; patients.
! To prevent the development of It seems to be the most effective

invasive and life threatening breast method of present day treatment. It
carcinoma. provides good, cosmetic results and
! To offer minimum but sufficiently may prevent the psychological trauma.
curative treatment. It has some risk of progress of disease
! To preserve breast if possible. process.
Following options are available; MASTECTOMY
Lumpectomy. Mastectomy provides nearly 100% cure

Lumpectomy with radiation. from this entity. The local recurrence
Lumpectomy, radiation and tamoxifen. rate is approximately 0.75% and
Radiation. mortality rate of 1.7% has been
Radiation with tamoxifen. demonstrated. Ipsilateral mastectomy
Mastectomy. is adequate because overall incidence
Aromatase inhibitors and tamoxifen. of occult disease (10-15%) is equivalent
to the invasive carcinoma breast.
LUMPECTOMY (WIDE EXCISION OF
THE LUMP) It is probably the best treatment but loss
of breast may not be acceptable to all
It is removal of the diseased tissue with women without psychological effects.
some macroscopically healthy tissue
around. The local recurrence and its MASTECTOMY WITH BREAST
development to invasive carcinoma RECONSTRUCTION
breast is seen in about 18% of the
patients after this treatment. It is not a It is an improvement on the mastectomy
good method of treatment even though alone. Reconstruction of breast is a
it conserves the breast. growing speciality which may
incorporate implantation of prosthesis
L U M P E C T O M Y A N D of various materials or reconstruction
RADIOTHERAPY by using myo-cutaneous flap.
It is a good alternate as it gets rid of the Letrozole (Aromatase inhibitor) therapy

disease process and conserves the improves disease free survival in patients
breast. It also minimizes the local with early-stage breast cancer in patients
recurrence and development of after completion of tamoxifen therapy3.
invasive carcinoma. The overall

tamoxifen therapy for early stage with proliferative breast disease

breast cancer. N. Engl J Med 2003; and atypical hyperplasia. Cancer
349: 19. [JC : cIz] 71(4): 1258-65, 1993 Feb
15.
4. Harold J. Burstein. Ductal
carcinoma in Situ: What do we 7. Threatt B. Early detection of breast
know now? Disclosures of 25th cancer. Journal of the American
Annual San Antonio Breast Cancer medical women association [JC :
Symposium. h7r] 47(5): 152-4, 1992 Sep-Oct.
5. Divid L . Page. The women at high 8. Kevin Hughes. Arthur K LE. Ann
risk for breast cancer. Importance of ROLFS. Controversies in the
hyperplasia. Surgical clinics of treatment of ductal carcinoma in
North America Vol. 76 No. 2p 221- situ surgical clinics of North
229, 1996 Apr. America Vol 76 No. 2p 343-265,
1996 Apr.
6. Dupont QD. Parl FF. Hartmann WH
et al. Breast cancer risk associated



Fig-12.9 Invasive Ductal Carcinoma (IDC)

Chapter-
Invasive Carcinoma o Breast
Minimum arcinoma reast

arly arcinoma reast
In asi e arcinoma reast
INVASIVE CARCINOMA OF BREAST 2
Objectives
! To diagnose the lesion correctly.
! To assess the extent of malignancy locally (T-staging).
! To assess the extent of malignancy regionally (N-
staging).
! To assess the extent of malignancy systemically (M-
staging).
! To plan best possible management options.
! To counsel the patient effectively.

INVASIVE CARCINOMA
OF BREAST
Invasive carcinoma of the breast is the

malignant tumor of the breast which has Seven out of every hundred women are
already crossed the basement likely to suffer from carcinoma of the
membrane. It is minimally invasive breast.
when it is less than 1 cm in its greatest
diameter and is node negative (Early It is 2-3 times more common in women
Invasive Carcinoma). It is maximally with family history of carcinoma of
invasive and advanced or metastatic breast.
carcinoma when it is bigger than 10 cm
in its greatest diameter. Females of a family with mutated genes
have 80% risk of developing breast
Carcinoma of the breast is the most cancer by the age of 80 years.
common cancer in the women of the 35-
50 years age group in western society. Male to female ratio is 1 : 100.
In our country exact records are not
available. Occasionally males can also It accounts for 27-32% of all female
suffer from this dreadful disease. malignancies.
Understanding of the fact that breast It is more common in single women than
cancer is not a local problem but in married women.
systemic disease has changed the
methods of treatment of patients with It is more common in nulli-parous
breast carcinoma. women.
INCIDENCE It is rare before 25 years of age.
It is the most common malignancy of It is more common in women with early

women at present. menarche (Before 11 years of age) and
late menopause (after 55 years of age).
Breast cancer is number one killer of
women due to any malignancy. It is more common in jews.

It is common in upper and outer There are many risk factors which are
quadrant. associated with the development of
carcinoma of breast;
Low fat diet is associated with lower
incidence. SEX
Females are 100 time more at risk for
It is more common in obese women the development of breast carcinoma.
than in slimers. Hormonal or genetic factors common in
females may be responsible for its
Second carcinoma breast occurs occurrence.
(second primary tumor SPT) in 4% of
the patients of carcinoma breast. AGE
The risk of breast carcinoma in 20-40
90% carcinomas of breast occur in the years old patient is 0.5% but it is 5% in
ductal epithelium. patients of 50-70 years age group (10
times more). This is the reason for
10% carcinoma occurs in lobules of the patients (Above 50 years) presenting
breast. with carcinoma breast at a higher age.
5-10% of all breast cancers result from The incidence of carcinoma breast
autosomal dominant inheritance of a increases with increase in age
mutated gene1. particularly in women above 50 years of
age.
The incidence is rising. This rise may be
due to better and early diagnosis. HORMONAL EFFECTS
The incidence of breast cancer is six Hormonal influence over a prolonged

times higher in U.S.A., Canada and period may be responsible for greater
Europe than in Asia and Africa. number of cycles of stimulation and
involution breast tissue. The breast
Japan has low incidence. tissue undergoes proliferation and
involution under the prolonged
Carcinoma breast causes nearly hormonal influence.
10,000 to 30,000 deaths every year in
U.S.A only. Greater the number of cycles, greater
the risk of malignancy.
ETIOLOGY
The period between menarche and
The exact cause of breast cancer is still menopause is significant risk. Longer
not known. Its etiology is multi-factorial. period due to early menarche and late

insignificant risk for carcinoma breast. members predisposes to increased

incidence of carcinoma breast.
Bilateral oophorectomy in pre-
menopausal women greatly reduces PARITY
the risk of carcinoma breast.
Single or nulli-parous married ladies
PREVIOUS BREAST CARCINOMA are at a higher risk of carcinoma breast.
The protective effect of full term
The chances of having cancer breast in pregnancy and parity is seen only in
patients who have been successfully younger females (20-30 years age).
treated, are more than normal
population. It may be part of multifocal Independent protective effect of breast
tumor or an entirely new primary feeding has not been confirmed yet.
carcinoma (second primary tumor:
SPT). Its risk is more in younger HEREDITARY
females especially if the first breast
carcinoma is diagnosed before the 40 Hereditary breast cancer is a breast
years of age. cancer in the patients in which it is
related to autosomal dominant
Patients with single breast cancer are at inheritance of a mutated gene2.
risk of having second primary tumor
(SPT). Efforts should be made for early All cancers are genetic at the cellular
detection of cancer breast with the help level in a way that these result from
of triple assessment (clinical accumulation of genetic abnormalities
examination, mammography and leading to genome instability and loss of
FNAC). normal growth regulation.
FAMILY HISTORY There is accumulation of three to six

mutations for the development of
It is a well established risk factor for the sporadic solid tumor. 5%-10% of all
development of carcinoma breast. breast cancers are hereditary.
Familial breast cancer is the one which PATHOLOGY

is seen in first degree relatives (mother,
sister or daughter) and second or higher The carcinoma of the breast arises from
degree relatives (grand mother, aunt, duct epithelium; Terminal duct lobular
cousin). unit (Tdlu).
History of breast, ovarian, prostate and The histological picture is variable.

colonic carcinoma in the family Some are less malignant and retain

feature of histology in carcinoma breast heterogeneous ranging from tumors

is usually an infinite variation in the with well developed tubule formation
pattern of the cancer cells from the and low grade nuclei to anaplastic
atrophic schirrous with much fibrous tumor.
tissue to the most cellular with little or no
fibrous tissue. The tumor margins are irregular but
occasionally may be circumscribed.
While the lump may be obviously Lympho vascular invasion may be
schirrous, deposits in the lymph gland obvious. Dimpling of skin may be seen
may be highly cellular. in advanced carcinoma.
It is possible however to distinguish Retraction of nipple and tumor invasion

between those arising in the nipple into chest wall may be seen
(Paget’s disease) and those arising in histologically. 66% of carcinoma of
the ducts, which are frequently breast may show hormone receptor
papilliferous in form. positivity and nearly 33% may be HER-
2 nem positive.
Those arising in the breast tissue itself
are composed mainly of spheroidal INFLAMMATORY CARCINOMA
cells with varying degrees of fibrous
tissue response. It may present as an enlarged
erythematous breast without discrete
A distinct type is called colloid palpable mass. The underlying
carcinoma where all the neoplastic cells malignancy is diffuse in nature. The
are distended with colloid material. blockage of dermal and lymphatic
This leads to form a large growth but is spaces by malignancy result in such
not as highly malignant as might be appearance.
expected.
Inflammation as such is either minimal
Invasive ductal carcinoma of breast is or not present at all. These tumors are
the most common type of cancer breast usually metastasized and have very
70-80% of carcinomas of breast are poor prognosis.
ductal in origin.
INVASIVE LOBULAR CARCINOMA
The ductal carcinomas produce a
desmoplastic response and replace These tumors are less than 20% of all
normal breast fat forming a hard breast tumors. 66% of these cases are
palpable mass. associated with LCIS. The cellular
invasion is present into the stroma. It is
The microscopic appearance is arranged in strands or chains.

in form of large anaplastic cell sheets GRADING OF THE TUMOR

and have well circumscribed borders.
Clinically these resemble fibro It means the nature (grading) of the
adenomas. There is almost always tumor (whether the tumor is well
pronounced lymphoplasmocytic differentiated or not). Nature of the
infiltration. These are commonly seen in growth affects prognosis of the disease.
women with BRCA1 mutations.
Microscopic variations of histological
COLLOID (MUCINOUS) CARCINOMA picture are classified as different grades
of tumor depending upon the growth
It is also a rare type of tumor. Large pattern. Following features are taken
quantities of extracellular mucin is seen into account while the tumor of the
in the stroma. These tumors present as breast are graded;
circumscribed masses and look similar
to fibro adenomas. The tumor is soft Tubule formation.
and gelatinous. Many of these tumors Irregularity in size, shape and staining
may be hormone receptor positive. of nuclei (pleomorphism).
Number of mitoses.
TUBULAR CARCINOMA
Tumors with glandular or tubular
These are 10% of invasive carcinoma of histological pattern which have marked
less than 1 cm size found by lymphocytic infiltration or elastosis and
mammography. These present as those with high concentration of
irregular densities on mammography. oestrogen receptor proteins have
relatively good prognosis.
Microscopically these present as well
defined tubules with low grade nuclei. Tumors provoking good host reaction
Lymphatic spread is rare and prognosis (regional lymph node hyperplasia) have
is excellent. These are usually hormone good prognosis as well. Histological
receptor positive. types (grades) of carcinoma breast are
following;
Carcinoma of the breast is a disease
which dissemi-nates early but recurs GRADE 1
late. Two main factors affect the TYPE 1 (NON METASTASIZING)
outcome of treatment;
It includes following conditions;
The extent of the disease (staging).
The nature of carcinoma breast Ductal carcinoma in situ (Intra ductal
(grading). carcinoma) (DCIS).
In situ lobular carcinoma (LCIS).

Pure extracellular mucinous or colloid Exact size (in centimeters) and site of
carcinoma. the tumor should be noted preferably on
Medullary cancer with lymphocytic the diagram.
infiltration.
Well differentiated tubular Palpable lymph glands should be noted
adenocarcinoma. and counted. Clinical, biochemical and
Adenoid cystic carcinoma. radiological assessment of the extent of
the disease is essential.
GRADE III
TYPE 3 (MODERATELY One of the great advances in the
METASTASIZING) management of the patients with breast
cancer is the development of the clinical
It includes ; staging system.
Schirrous carcinoma. It establishes criteria to describe the

Ductal carcinoma with stromal extent of disease and enables the
involvement. surgeon to identify the patients with
advanced local or systemic disease. It
GRADE IV helps to estimate the prognosis. It is
TYPE 4 (HIGHLY METASTASIZING) useful for comparing different
treatment results.
This type has worst prognosis and it
includes poorly differentiated There are different staging systems and
carcinoma or anaplastic carcinoma of all assess three elements.
the breast. The prognosis is best in type
I and worst in type 4 carcinoma. The extent of disease at the primary
site.
EXTENT OF THE TUMOR The presence or absence of regional
lymph node metastasis and its extent.
C L I N I C A L S TA G I N G O F T H E Presence of distant metastasis.
CARCINOMA BREAST
TUMOR, NODES, METASTASIS (TNM)
It is physical size of tumors. It is
interpreted as clinical staging of the It is the staging which is mostly
carcinoma breast. If affects the accepted now-a-days. It has been
outcome of the treatment. Careful modified and simplified.
staging of the disease is very important
for adequate treatment and prediction T (TUMOR)
of outcome.
T0

present. No nodal involvement.

No distant metastasis.
N (LYMPH NODES)
The tumor should not be adherent to the
N0 pectoral muscles or chest wall.
No palpably involved lymph nodes.
STAGE II
N1 (TO, T1 OR T2 and N1, MO)
Axillary nodes involved but mobile.
Tumor size less than 5 cm in diameter
N2 but there are affected mobile lymph
Axillary nodes involved and fixed. glands in the axilla of the same side.
N3 Tumor bigger than 5 cms without lymph

Involvement of internal mammary node involvement. No distant
lymph nodes. metastasis.
N 4 STAGE III
Supra clavicular nodes involvement. (To, Tl, T2, T3, T4, N2, N3 and MO)
Edema of the arm present.
All breast cancers of any size.
M (METASTASIS)
Skin involvement or peau-de-orange
M0 present in large areas than the tumor
No distant metastasis. itself but these are limited to the breast.
Tumor fixed to pectoral muscles but not
M1 to the chest wall.
Metastasis present.
Involvement of the skin beyond the Axillarly lymph nodes, internal
breast means distant metastasis. mammary node.
STAGE I No distant metastasis.

(TO, T1, N0, MO)
STAGE IV
This includes growths confined to the (TO, T1, T3 & T4, N1, N2, N3. M1)
breast. The involved skin areas
(adherent or ulcerated) may be present Skin involvement extends outside the
but these are smaller than the periphery beast as well.
of tumor. Supraclavicular nodes are involved.
Tumor less than 2 cm in size. Edema of the army may be present.

Involvement of opposite breast. Sometimes retraction of the nipple may

be congenital and not associated with
CLINICAL FEATURES carcinoma. This is usually bilateral but
could be unilateral.
False negative results of clinical 4. ECZEMA OF NIPPLE
examination are about 25-30%.
This may be the presentation of the
1. LUMP IN THE BREAST Paget’s disease of the breast. Usually
one side is involved. Bilateral nipple
Carcinoma breast usually presents as a eczema can be presentation of some
painless lump in the breast. The extent dermatological lesion.
of fear and psychological upset by the
patient cannot be imagined which is 5. BREAST ULCER
caused by accidental finding of the
lump in the breast. All painless lumps of Fungating mass or ulcer of the breast
the breast are not carcinomas. over a lump may be seen. The ulcer is
usually hard at its base. The surface is
The malignant lump is of variable size. It irregular and margins are everted. Size
is hard in consistency. It may be mobile of the ulcer is variable. The ulcer bleeds
or fixed. Overlying skin of the breast easily and secondary infection may
may be adherent showing peau-de- also be present.
orange or may be freely mobile.
6. METASTATIC FEATURES
2. NIPPLE DISCHARGE
Occasionally the carcinoma of the
Blood stained discharge from the breast presents with features due to
nipple is always pathological. It may or presence of secondaries at distant site
may not be associated with the breast such as backache or paraplegia due to
lump. It may be the only indication of secondaries in the spine.
underlying malignancy.
Pleural effusion or other chest problems
3. INVERTED (RETRACTED) NIPPLE due to secondaries in the chest may be
the presenting symptoms.
Retraction of the nipple is a feature of
carcinoma breast. This occurs due to MANAGEMENT
adherence of skin to the tumor under
the areola and nipple. The logical management of carcinoma
breast has following objectives;
The tumor retraction of one nipple is
often associated with carcinoma. SELECTION

TREATMENT
(To treat the local, loco-regional and RADIO ISOTOPE SCAN
systemic disease).
Bone scintigraphy.
DIAGNOSIS Liver, lung and bone scan (total body
scan).
Simple method for an adequate
diagnosis is called triple assessment; PCR ASSAY
History and clinical examination. It is used to pick up tumor cells causing

Imaging (ultrasonography & occult metastasis in bone marrow cells.
mammography). Several monoclonal antibodies are
Cytohistological examination (FNAC) & used against epithelial mucinous or
Biopsy. cytokeratins on the cell surface. These
cells are not detectable on routine
The investigations helps to; histopathological examination21.
Assess the general condition of patient. ULTRASONOGRAPHY

Assess the associated problems (co-
morbid factors). Ultrasound scan is easily available,
Assess the extent of disease and stage simple and non-invasive investigation.
the disease correctly. It helps in conducting the sonographic
guided FNAC and trucut needle biopsy.
INVESTIGATIONS It picks up the fluid filled lesions of the
breast.
URINE EXAMINATION
It also helps to pick up the metastatic
BLOOD EXAMINATION lesions in the liver and lungs.
Hemoglobin percentage. MAMMOGRAPHY

Total leucocyte count.
Differential leucocyte count. Major advancement in the treatment of
Sedimentation rate (ESR). cancer breast has been widespread
Liver function tests. use of the screening mammography
resulting in mortality reduction7.
RADIOLOGICAL EXAMINATION
Screening by physical examination and
X-Ray chest mammography can decrease the
Skeletal survey mortality rate in women over 50 years of
age by 30%8.

women. EXCISION BIOPSY
MRI SCAN Excision biopsy has been the

conventional method of confirming the
The MRI scan is valuable in selected diagnosis of carcinoma of the breast.
cases of cancer breast as an adjunct to Although less invasive methods have
mammography and ultrasonography10. taken over as first line investigations in
the work up of carcinoma of the breast
It is expensive and not available at yet in doubtful and difficult cases
every center. It is used to assess the excision biopsy is the only choice.
breast lesions in women at high risk.
The immuno-histochemistry is a simple
F I N E N E E D L E A S P I R AT I O N technique offering more accurate
CYTOLOGY definition of nodal involvement than
conventional methods11.
Fine needle aspiration and cytology has
altered the diagnostic methodology for TREATMENT
carcinoma breast. It is the first line
investigation for carcinoma breast Both local and systemic treatment is
these days. required to control the disease
effectively. Local surgical treatment is
It is non-invasive. It is simple. It is essential to get rid of the primary tumor
performed in the out patient’s and related lymph glands.
department. Its sensitivity and
specificity is above 95%. It helps in The histological examination of these
preoperative work up of the patient. lymph glands confirms or excludes their
involvement.
CORE BIOPSY
NEEDLE BIOPSY Various modalities for the treatment of
carcinoma of breast are available;
Trucut needle biopsy and
histopathological examination is Surgery.
confirmatory of the diagnosis. It is an Lymphatic mapping.
alternative to the excision biopsy. It can Radiotherapy.
be perfor-med in the out patient’s Chemotherapy.
department. It can be done under local Hormonal therapy.
anaesthesia. Satisfactory core of the Immunotherapy.
tis-sue can be taken for A combination of these modalities.
histopathological examination.
SURGERY

This operation has two advantages; Morbidity is much less as compared to

radical mastectomy.
Tumor and all lymph glands are
removed and are available for The serious disadvantage is inability to
histological assessment. find out and confirm the lymph node
Postoperative radiotherapy need not to involvement by this procedure.
be given.
SIMPLE MASTECTOMY AND PER
This operation has many OPERATIVE
disadvantages such as; LY M P H AT I C M A P P I N G A N D
SAMPLING
Morbidity is greatly increased.
It is improvement of simple
It has no significant advantage over mastectomy. This procedure includes
less radical surgery as far as life span of simple mastectomy and sampling of the
the patient is concer-ned. pectoral group of lymph glands.
Upper limb edema is a major disability. The enlarged lymph glands in the axilla
are also excised and checked
MODIFIED RADICAL MASTECTOMY histopathologically..
(PATEY’S MASTECTOMY)
Selective radiotherapy may be added
This is more popular method than depending upon lymph node
radical breast surgery. The pectoralis involvement.
major muscle is spared and only
pectoralis minor muscle is resected in L U M P E C T O M Y A N D
this operation. RADIOTHERAPY
Whole of the breast is removed and the It is excision of the breast lump with
axilla is also cleared of all the lymph about 3-5 cms of surrounding and
glands. macroscopically healthy tissue. It also
includes removal of adherent skin. It is
SIMPLE MASTECTOMY followed by appropriate radiotherapy.
This means removal of the breast tissue It is a good alternative as it gets rid of the
and axillary tail. This may or may not be disease process and conserves the
followed by radiotherapy advantages breast. It also minimizes the local
are; recurrence and development of
invasive carcinoma.
Whole of the tumor is removed.

The advantage of this procedure is that Following drugs are commonly used;
patient doesn’t have to loose the breast
but this has higher rate of local Methotrexate.
recurrence. Vincristine.
5fluorouracil.
Radiotherapy is given to minimize local Adriamycin.
and distant spread. The patient should Cyclophosphamide.
be followed up very carefully both CHEMOTHERAPY AND BONE
clinically and with repeated MARROW TRANSPLANT
mammograms.
Navelbine (Vinorelbine or 5-Nor-
RADIOTHERAPY anhydro-vinblastine is relatively less
toxic and has excellent tolerance profile
This is used as an adjuvant to surgery. It can be included in the first line
Rarely it may be used on its own. It has combination chemotherapy for breast
its own side effects which limit its use. cancer20.
This may be used for ovarian ablation
but again oophorectomy is a better High dose chemotherapy and
method of getting rid of the ovarian autologous bone marrow
function. transplantation has been used for
metastatic carcinoma of breast. It has
CHEMOTHERAPY not shown any added advantage over
conventional chemo-therapy19.
Different anti-cancer drugs are used to
treat the micro-metastasis and spread HORMONAL THERAPY
of the tumor. This is also used as an
adjuvant to surgery. These are best used after oestrogen
receptor assay of the excised
Neo adjuvant therapy is use of antic- specimen. Antioesterogen drugs
ancer drugs alone or in combination (tamoxifen, Zitazonium and Nolvadex)
with radiotherapy. It achieves better are being used in patients with cancer
results before undertaking any surgical breast.
procedure. It helps to down stage the
tumor. The evidence has been accumulated
that chances of recurrence of tumor
Different regimens (combination of after hormonal therapy are minimal as
antimitotic drugs) are being used with compared to radiotherapy and
variable results such as quadruple chemotherapy.
therapy.
Tamoxifen currently is the treatment of

Herceptin is a monoclonal antibody early detection of the recurrence. An

against a receptor on the breast cancer earlier recurrence which is noticed by
cell. It is used in stage IV breast cancer. the patient is reported and dealt with
It can be used in combination with earlier.
chemotherapy for improved response.
It binds with the breast cancer cell and Different studies have shown that
stops it from dividing. The antibody routine follow up after potentially
binds to the HER-2/neu receptor of the curative treatment of breast cancer is
breast cells. not so efficient in the detection of
recurrence. But it is highly rated for
FOLLOW UP providing reassurance and reducing
anxiety18.
All patients who have been treated for
breast cancer by any type of surgery are Prolonged survival has been achieved
followed up for rest of their life so that by;
local or distant recurrences is noticed
and treated as early as possible. Evolution of multimodality treatment
planning.
During first post operative year follow Coordinated care.
up is performed at quarter yearly Use of adjunct chemotherapy7.
intervals and during next two years
every six months and afterwards yearly PROGNOSTIC INDICATORS
follow up is sufficient.
The prognostic indicators for breast
Self examination by the patient herself cancer include;
have been found to be more useful in
NOTTINGHAM PROGNOSTIC INDEX (NPI)

Notingham prognostic index (NPI) = (0.2 x tumor size in centimeters) + stage + tumor grade
Involved NodesTumor GradeScore per factorPrognosis NPI ScoreSurvival (15 years)
0 I 1 Good < 3.4 80%

1-3 II 2 Moderate 3.5-5.4 40%
>3 III 3 Poor > 5.4 15%
Example: a 2.5 cm, grade III tumor with 6/12 positive lymph nodes would score NPI 6.5, predicting a poor p

REFERENCES cancer. Journal of the American

medical women association
1. Dlane M Radford. Barbara A. {JCh7r}47(5): 152-4, 1992 Sep-
Zehnbaver. Inherited breast cancer. Oct.
Surgical clinics of North America
Vol. 76 No. 2, p-205-218 1996 Apr. 9. Vogal VG. Early detection,
e p i d e m i o l o g y a n d
2. Robinson F. Rennert G. Rennert prevention of breast cancer.
ITS. Neuont Al. Survival of first and Current opinion in oncology
second primary breast cancer. {JC:alv) 4(6): 107-226, 1992 Dec.
Cancer (JC : xlz}71(1):172-6, 1993
Jan. 10. Klevit HC, Sikhenk AC. Thelissen
GR et al. Magnetic resonance
3. Walker RA. Varley JM. The image appearance of haematoma
molecular pathology of human of breast. Magnetic resonance
breast cancer. Cancer surveys. imaging {JC:mar}11)2)293-8 1993.
{JC:cno}16: 31-57 1993.
11. Hainsworth PJ. Tjandra JJ. Still well
4. David L. Page. The women at high RG. Detection and significance of
risk for breast Cancer. Importance occult metastasis in node negative
of hyperplasia. Surgical clinics of breast cancer. British journal of
North America Vol. 76No. 2p 221- surgery {JC:b34}80(4): 459-63,
229, 1996 Apr. 1993 Apr.
5. Dupont OD. Parl FF, Hatmann WH 12. Cumminos FJ Gray R. Tormev DV.
et.al. Breast cancer risk associated Adjuvant tamoxifen versus placebo
with proliferative breast disease in elderly with node positive breast
and atypical hyperplasia. Cancer cancer. Long term follow up and
{JC:clz 71(4):1258-65, 1993 Feb causes of death Journal of clinical
15. oncology {JC:jco]11(1)29-35, 1993
Jan.
6. Bundred NJ, West RR. Doud JO et
al. Is there increased risk of breast 13. Resso J, Russo lH, The pathology
cancer in women who have had a of breast cancer: staging and
breast cyst aspirated? British prognostic indications. Journal of
journal; of cancer (JC: av4) 64(5): American Women’s Association
953-5, 1991 Nov. [JC:47r]47(5)181-7, 1992 Sep-Oct.
7. Coleman C. The role of 13. Kevin Hughes. Arthur K LE. Ann

comprehensive center. Nurse ROLFS. Controversies in the
practioner forum {JC: bmc}4(2): treatment of ductal carcinoma in
110-4, 1993 Jun. situ surgical. Clinics of North
America vol 76 76No.2p-243-265,
8. Threatt B. Early detection of breast 1996 Apr.

of routine breast cancer follow up jco] 11(7): 1245-52, 1993 Jul.

postgraduate medical journal. 19. Janco F, Novotny J, Vedralova J et
[JC:pfx]68(805):907-7, 1992 Nov. al. PCR, Cas Lek Cesk 2002 Aug
30; 141(17): 546-50.
17. Eddge DM. High dose
chemotherapy with autologous 20. Butitude MF, Fentiman IS. Breast
bone marrow transplantation for the cancer in older women Int J, Clin
treatment of metastatic breast Prac 2002 Oct; 56(8): 588-90.
cancer. Journal of clinical oncology
[JC:jco]10(4)657-70, 1992 Apr. 21. Baldcci L, Bege G. Prevention of
cancer in the older person. Clin.
18. Funoleak Delgado FM Dolozier. Geriatr Med 2002 Aug; 18(3): 505-
Phase II trial of weekly intravenous 28.c
vinorelbine in first line advanced
breast cancer chemotherapy.
Journal of clinical oncology. [JC :


Chapter-
Metastatic Carcinoma o Breast

METASTATIC CARCINOMA OF BREAST 2
Objectives
! To stage the disease.
! To assess the spread of disease with its
clinical effects.
! To plan effective management.

METASTATIC CARCINOMA
OF BREAST
It is the carcinoma of breast which has chondroid or osseous differentiation.

already spread to distant areas. It is These tumors commonly bypass
commonly called as advanced axillary lymph nodes and present as
carcinoma breast. distant metastasis. It poses diagnostic
difficulties at both primary and
Approximately 8% of carcinoma of metastatic site even on FNAC1.
breast patients present with metastatic
disease in the civilized world. The The patients suffering from metastatic
incidence is higher in our part of the carcinoma of breast are incurable at
world and other less developed presentation.
countries.
Work up for metastatic disease is
The metastatic disease is seen in many essential to assess the extent of
patients after treatment for apparently disease process and planning the
localized carcinoma breast with or management.
without nodal involvement.
Median survival after diagnosis of
Metastatic metaplastic carcinoma of the metastatic disease of breast is about 02
breast (MMCB) is well recognized but years but some patients survive upto
uncommon aberrant manifestation of ten year.
poorly differentiated invasive
carcinoma containing both epithelial There are two major patterns of disease
(ductal) and mesenchymal elements as spread in metastatic breast carcinoma
well as a transitional form in between excluding patients with extensive
these. diffuse metastasis.
This hetrogenous tumor The patients with positive ER & PR

characteristically contains ductal tumors tend to develop, bony
carcinoma cells mixed with areas of metastasis and not brain metastasis.
diverse morphologic phenotype,
displaying spindle, squamous, The patients with negative ER & PR

Chest metastasis and pleural effusion survival. The palliative treatment is

present with breathlessness. given to relieve the symptoms.
Lungs may have multiple metastasis MANAGEMENT

leading to cough and haemoptysis.
Breast carcinoma is a systemic
Liver involvement and due to multiple- disease. It must be managed and
peritoneal and hepatic metastasis controlled with effective systemic
presents with ascities. therapy. The patients with metastatic
disease have variable problems and
Brain involvement presents with require multi disciplinary specialist help.
headache, convul-sions and others
neurological symptoms. Every patient with advanced, recurrent
or metastatic cancer breast is treated by
Bony metastasis present with severe breast cancer multi-desciplinary team
pain, fractures, and sometimes even (MDT) which includes oncologist
paraplegia due to spinal cord orthopaedics surgeon and pain relief
compression. specialist as well as special care nurses
for various problems.
Bone marrow involvement presents
with lethargy, myelo suppression, OBJECTIVES
anaemia and infections.
To relieve the symptoms.
The clinico-pathological work up for To improve quality of life of the patient.
metastatic carcinoma is similar to any To control local spread of the disease.
kind of breast cancer. Staging of the To control the disease process.
disease is performed.
TREATMENT
Investigations such as urine C/E, blood
C/E, liver function tests, renal function Appropriate analgesia with or without
tests, x-ray chest, skeletal survey, non-steroidal anti inflammatory drugs
isotope bone scan, liver scan are helpful. Opiates can also be used.
(ultrasound and CT) are performed.
Trans-cutaneous electrical stimulations
Tumor markers such as CEA and CA and other methods of pain control may
15-3 are also assessed for monitoring be used.
the patient during and after treatment.
Immobilization of fractures and
The treatment is planned to improve the mechanical support to the spine is
quality of life and to improve the overall provided to prevent spinal injury and its

tumor is assessed before planning to Patients who did not receive hormonal
prescribe hormonal therapy. therapy initially and are E.R positive
may be given hormonal treatment.
A positive estrogen receptor status is Others may be offered both poly
associated with good response of over chemotherapy and hormonal therapy.
60% and negative estrogen receptor
status is associated with less than 10% Tamoxifen has shown therapeutic
response. advantage when used with
chemotherapy in patients of age group
The metastatic cancer breast patients 50-69 years. It may prolong survival in
with positive receptors may be treated advanced disease as well.
with hormones initially except when
advanced liver metastasis is present as Second line hormonal therapy
the response would be poorer in these response is approximately 50% of the
patients. previous therapy.
If hormonal treatment is used in these A combination of hormones and

patients, the poor and delayed cytotoxic chemotherapy doesn’t
response may compromise patient’s improve the response as such.
survival. These patients should Progesterone or aromatase inhibitors
preferably be managed with are commonly used as 2nd line hormonal
chemotherapy. therapy.
Patients with estrogen negative Aromatase inhibitors are superior in

receptors should be treated with terms of decreasing morbidity and
chemotherapy. Although the response improving survival than progesterone.
is poor but the control may be achieved
for 6-10 months. Letrozole 2.5 mg once daily has proved
to be more potent suppressor of total
Menopausal status and previous body aromatization and plasma
chemo and hormonal therapy help to estrogen levels in post menopausal
determine the type of hormone to be women with metastatic breast cancer3.
used. It takes about 6-8 weeks before
the response of this treatment becomes RADIOTHERAPY
obvious.
Adjuvant radiotherapy is used to relieve
Good response of hormonal treatment the pain from bony metastasis. A single
during first line treatment is a good dose of 7-8 Gy is helpful. Alternate
predictor. analgesia is also required for these
patients.

radiotherapy4. dependent upon the heterogeneity of

cellular population in primary and
CYTOTXIC CHEMOTHERAPY metastatic breast cancer.
It is used in patients with advanced There is prolonged chemotherapy

metastatic disease. It is also used in induced response to E.R positive
estrogen receptor negative patients. It cancer breast patients and those who
is also used after failure of hormone respond favorably to hormonal therapy.
therapy. Median duration of response to
combination poly chemotherapy is 12-
A combination of drugs is better than 18 months.
any single chemotherapeutic agent.
Failure to treatment may be changed
(CMF) Cyclophosphamide, into remission by use of additional
Methotraxate, 5 Fluoro-cil is commonly chemotherapeutic agent.
used combination which is very
effective according to most of the trials Stage-4 cancer breast patients having
all over world. complete remission have a median
survival upto 32 months.
The chemo-therapeutic agents are
selected after assessing the response Dose intensive chemotherapy in
of previous therapy, sites of metastatic combination with transplantation of
disease and side effects of the drugs to normal autologous bone marrow cells
be used. Commonly used combination may show better results and overcome
of poly chemotherapy is the toxicity factor of cytotoxic drugs.
Cyclophosphamide Methotraxate, 5
Fluorocil, vincristine and doxorubicin. Locally advanced disease (T3) can be
The trials have shown 25% response controlled by dose intensive
rate with single agent and 50-60% chemotherapy.
response with combination poly (10 times the normal dose)
chemotherapy.
The tumor cells are killed with larger
Highest response is seen in dose and myelo-suppression can be
combination with the use of treated with autologous marrow
anthracyclines (adriamycin and transplantation. Repeated cycles of
epirubicin). But it doesn’t increase the therapy are required as the adequate
survival rate. It only relieves the tumor population is not eliminated with
symptoms. this therapy.
The therapeutic response is also The use of hematopoitic growth factor

antibody to erb B-2 oncogene

(expressed in 25% of invasive cancer Patho-dynamic therapy of extensive
breast) shows good response. It is used chest wall disease may be helpful.
in patients who are HER-2 Neu positive.
It is cardiotoxic so it must be used with New agents with better response are
care. being developed and evaluated.
Taxanes are new chemotherapeutic
SYMPTOMATIC TREATMENT agents and are helpful against patients
not responding to anthracyclines. The
Breast carcinoma is a systemic response rate is greater than 30%.
disease. It must be managed and Vinorelline also shows significant
controlled with effective systemic response as second line therapy.
therapy. Taxanes (Paclitaxel, doetaxel) and
vinorelline, topoisomerase inhibitors
Patients having pleural effusion due to and new antifolates are also used as
metastatic disease are better relieved second line therapy.
with drainage of effusion. It may be
required regularly. The frequency of re- New hormonal treatment includes
effusion can be reduced by instillation of aromatase inhibitors, Gn RH agonists,
neomycin as anti tumor cytotoxic agent. anti progestin and new antiestrogens.
It may cause pleurodhesis but many Biologic therapy targeting growth
times empyema may follow which factors and growth factor receptors
become troublesome to treat. such as HER-2/neu and epidermal
growth factor receptors have also been
Ascities is drained to relieve the developed.
abdominal symptoms.
REFERENCES
Bisphosphonates help to reduce the
morbidity, pain and reduce the number 1. Catroppo JF, lara JF. Metaplastic
of fractures due to metastatic disease. It Metastatic carcinoma of the breast
can be used as single daily oral dose or (MCB) an uncharacteristic pattern
a monthly intravenous injection. Its use of presentation with clinico
pathologic correlation. Diagn
as a preventive drug against bony
cytopathol 2001 Nov;25(5): 285-91.
metastasis is still to be confirmed.
2. Maki DD, Grossman RI. Pattern of
Surgery for pathological fractures is disease spread in metastatic breast
required. Sometimes surgical fixation is carcinoma. Influence of oestrogen
performed prophylactically to avoid and progesterone receptor status.
pathological fractures and their effects AJNR Am J neur radiol 2000 Jun-
on patients. Jul; 21(6): 1064-6.



Chapter-
Special Types o
Carcinoma Breast
SPECIAL TYPES OF CARCINOMA BREAST 2
Objectives
! To diagnose the carcinoma breast in special situation.
! To understand the tumor biology in such situation.
! To plan effective management in such situation.
! To follow up such patients most economically & effectively.

BREAST CANCER IN YOUNG WOMEN

It is the condition when carcinoma of the breast is more active resulting in cyclic nodularity and
diagnosed in women at or before 40 years of age. thickening.
Breast cancer is very rare in adolescents and very DIAGNOSIS

young women. TRIPLE ASSESSMENT
Less than 1% of all breast cancer cases are seen Triple assessment is performed for adequate
before the 30 years of age. diagnosis.
Young women have more aggressive presentation of The self examination and physical examination is
disease at diagnosis, when compared with pre- more difficult and less helpful in diagnosing breast
menopausal elder patients1. lesions effectively.
A young woman may be very young or pre- Mammography is done less often in younger women
menopausal (40 years old). There is significant rise than in older age group.
in the incidence with increase in age.
Even if it is performed, interpretation may be very
Cancer breast incidence in young women is given in difficult and less conclusive because of increased
the table below. radio-density of the breast tissue.
Incidence/
Age 100,000 women Ultrasound examination of breast is more helpful in
younger women suffering from breast cancer.
Less than 20 years 0.1
The disease is diagnosed at a later stage in younger
20-24 1.4 women than in older women.
25-29 8.1
Breast cancer in young women is more frequently
30-34 24.8 poorly differentiated, oestrogen receptor (E.R)
negative, show high lympho-vascular invasion & high
The young women's breasts are physiologically proliferating fractions 2.

Young women at potentially high risk of developing ! Employment.

breast cancer have germline mutation of BRCA1, ! Insurability.
BRCA2, Tp53, PTEN. These patients require
screening at young age 2. Very young women with endocrine-responsive
tumors have a higher risk of relapse than elder pre-
More aggressive behaviors of cancer breast in menopausal patients with similar tumors.
younger women can be explained by several biologic
factors such as: Invasive breast cancer before 35 years of age has
more aggressive biological behavior associated with
! Higher grade & higher expressions of Ki 67. poor prognosis.
! Higher occurrence of vascular invasiveness.
! Lesser expression of oestrogen and progeste- The local recurrence rate is as high as 35% in
rone receptors1. women of less than 30 years of age after
lumpectomy and radiation while it is about 0% in
MANAGEMENT PROBLEMS women above 50 years of age.
Young women are vulnerable to emotional distress Breast conserving surgery in women under 35 years
and psycho social problems & require support 3. of age is associated with higher risk of local
recurrence.
Psychologically the younger women respond badly
and show higher level of emotional distress and All young women should be considered at moderate-
adjust to the diagnosis with difficulty 2. high risk due to age and should be offered adjuvant
therapy.
Very young women are faced with personal, family,
professional and quality of life issues that further The implications of possible impaired fertility &
complicate the phase of treatment decision making. premature menopause should be considered before
adjuvant therapy3.
The treatment for very young women should be
problem based, specific and focused 1. The adjuvant systemic chemotherapy is more
effective in pre-menopausal than postmenopausal
Breast cancer in young women has special effects of women. Ovarian ablation occurs within few months
cancer breast and its treatment on; of chemotherapy.
! Quality of life. Osteoporosis is a serious effect of premature

! Child care. ovarian ablation caused by chemotherapy.
! Future child bearing.
! Marital relations. Risk of cardiovascular diseases also increases after
! Sexuality. lack of oestrogen.
! Emotional stability.

Impaired fertility after adjuvant therapy is a major 3. Par tridge AH; Gelbers; Peppercorm J;
concern for young breast cancer patients. Sampson E; et al. Web based survey of
fertility issues in young women with breast
Young women may be educated regarding fertility & cancer. Jelin Oncol 2004 Oct 15:22(20) :4174-
other issues & research should be diverted for 83.
preserving fertility in survivors 3. 4. Chia KS; Du WB; Sankaranaryanan R;
Sankila R; Wang H; Lee J; Seow A; Lee HP. Do
Node positive women under the age of 30-35 years younger female breast cancer patients have a
have poor prognosis. proper prognosis? Reports from population
based survival analysis. Int J cancer 2004 feb
Some studies have shown that the younger women 20; 108(5): 761-5.
of less than 35 years of age suffering from cancer
breast show higher survival rates when compared
with older women with breast cancer.
Women over 75 years of age showed highest risk of

excess deaths 4.
TREATMENT
Treatment for breast cancer in young women is

almost similar to treatment given to patients of
cancer breast of any age group.
Follow up is also similar to patients of other age

group.
REFERENCES
1. Curigliano G; Rigo R; Calton I M; Braud FI; Nole
F; et al. Adjuvant therapy for very young women
with breast cancer: response accor ding to
biologic and endocrine features. Clin breast
cancer 2004 June; 5(2):125-30.
2. Shannon C; Smith IE. Breast cancer in

adolescents & young women. Eur J cancer
2003 Dec; 39(18) :2632-42.

BR - 15 - B
PREGNANCY ASSOCIATED
BREAST CANCER (PABC)
Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)
Cancer breast is common and dreadful malignancy # Third trimester

of the females. Women pass through various stages ! Breast carcinoma diagnosed after pregnancy
during their life such as infancy, childhood, during lactation.
menarche, adulthood, pregnancy, lactation and ! Pregnancy occurring in patients already being
menopause. Young women are lucky to have lower treated for carcinoma breast.
incidence of carcinoma breasts than their older There is usually delay in the diagnosis of carcinoma
counterparts. breast in these patients due to physiological
changes in the breast during pregnancy and
Gestational breast cancer or pregnancy associated lactation. It is because breasts are enlarged, lumpy
carcinoma of the breast is an entity which is and tender during pregnancy & lactation. Early
diagnosed during pregnancy or within one year menarche and late menopause are strong negative
risk factors for development of carcinoma breast.
postpartum1,7. It is uncommon but not rare.
Carcinoma breast is seen about once in 3000
Overall menopausal status and age at menopause
pregnancies. Pregnancy associated breast
are significantly associated with breast cancer. A full
carcinoma has poor prognosis. its diagnosis is
term pregnancy and early age at first birth are
usually overlooked during pregnancy. The
associated with decreased breast cancer risk. Post
pregnancy associated breast cancer (PABC) is likely
menopausal women with lactation longer than 48
to increase with rise in educational level and social
months have reduced risk of breast cancer.
status of professional women. More of these
Decreased parity, late age at first birth, early
women are likely to choose childbearing at later
menopause and shorter duration of lactation are
age2. Pregnancy related carcinoma breast presents
important risk factors5. The mammary micro
in following situations;
environment might become tumor promoting after
pregnancy because of the remodeling of the
! Breast carcinoma diagnosed during
pregnancy; mammary gland to its pre-pregnant state. The
remodeling is associated with pro-inflammatory and
# First trimester wound healing mechanisms. It is proposed to
# Second trimester support tumor cell dissemination9.

increased radio density of breast during pregnancy

and lactation3. Mammogram may appear negative in
pregnant women even though the carcinoma si
present. It may show calcification, increased skin
thickening & asymmetric density. Even
mammography of clinically obvious lumps is likely to
be misinterpreted during pregnancy.
CYTOHISTOLOGICAL STUDIES
FNAC or even biopsy is used to assess suspicious
breast mass in a woman during pregnancy &
lactation (II-2A). FNAC may show incorrect results
due to presence of hormonal induced atypia in
DIAGNOSIS these patients. Core needle/excision biopsy is
CLINICAL EXAMINATION performed for correct results.
Triple assessment helps in making an accurate
diagnosis which is relatively difficult in these RECEPTOR STUDIES
patients. All women should be encouraged to Tumor receptor studies for estrogen, progesteron,
practice breast self examination during pregnancy and Her-2-neu receptors
ptor are performed
perf before
and lactation (II-2B). planning the appropriate treatment.
The breast examination during antenatal visits may

help in early detection4. Physicians should screen all
women for cancer breast with thorough clinical
examination during early pregnancy (III-B). The
examination of the breast is also performed during
post partum period, if patient is not breast feeding
or if she presents with breast symptoms (III-B).
IMAGING
Ultrasound examination of breasts is performed as
first line imaging examination in women with
suspected breast lesions. Sonography of solid mass
with posterior acoustic shadow and marked cystic
component may indicate malignancy in pregnant
3
patients .
Mammography is usually less helpful because of

extended periods of breast feeding during

their life time (II-2B).
80% of cancer breast in pregnant women is ! Women with familial risks could potentially
estrogen receptor negative. benefit most from breast feeding (II-2C).
Interruption of lactation is not necessary while ! Breast milk is ideal nutrient for new born
investigating except when nuclear studies are and breast feeding is a modifiable risk
conducted. factor. The women should be encouraged
for breast feeding(II-2A).
Following features are addressed before planning
management of breast cancer during pregnancy MANAGEMENT PLAN2
and lactation; Once breast cancer is diagnosed during pregnancy
! The impact of pregnancy and lactation on or lactation, multi-disciplinary help is used including
risk of breast cancer. obstetrician, surgeon, medical and radiation oncolo-
gist and breast cancer counselors (II-2A).
! The prognosis of breast cancer diagnosed
during pregnancy and lactation. When cancer breast is diagnosed during early
pregnancy, patient is informed about e f f e c t s o f
! The risk of recurrence of breast cancer therapy on fetus and on overall maternal prognosis.
during subsequent pregnancies. It has been shown by many trials that the prognosis
is not altered by termination of pregnancy but it can
! Feasibility and impact of breast feeding on be discussed on its own merits. The patients over 30
prognosis of women with breast cancer. years of age should be informed about pre-mature
These women have tumors with high menopause after treatment with chemotherapeutic
histological grade and low frequency of drugs (II-2C).
hormonal receptors and high expression
of C-erb B-26. No standardized therapeutic interventions have
been reported for patients with breast cancer during
! There is good evidence of transient pregnancy as yet. Various treatment options used
increase in risk of breast cancer in the first presently have not been evaluated for the safety of
3-4 years after delivery of a single baby (II- fetus and efficacy in the mother (the patient).
2B).
! Subsequently their life time risk is lower SURGERY
than the nulliparous women (II-2B). Surgery remains the gold standard of treatment and
modified radical mastectomy and axillary gland
! The risk for pre-menopausal breast cancer dissection is the operation of choice. Breast
is reduced with lactation (II-2A). conserving surgery is not a preferred choice of
operation in these patients.
! This protective effect is best in women with

third trimester of pregnancy.

RADIOTHERAPY
Radiotherapy may be used during first trimester as
the fetus is still in the pelvis and can easily be PROTOCOL OF TREATMENT
shielded. It is not used in second and third trimester The chemotherapy is started after complete
because of danger of irradiation to the fetus. metastatic work up as given below;
! X-Ray chest (with abdominal shielding in
CHEMOTHERAPY pregnancy)
Chemotherapy can be used in these patients with ! PA view and lateral view of both sides.
care. Adjuvant chemotherapy should not be delayed ! Complete blood count.
if required but its effects on fetus and future ! Renal function tests
reproductive capabilities should be informed to the ! Liver functions tests
patient. (II-2B). ! Ultrasonography
The risks and benefits of early delivery during 3rd Counseling is done about the risks of chemotherapy
trimester should be compared with continuation of to the fetus and mother.
pregnancy. Effects of chemotherapy on fetus should
be kept in mind (III-B). Central venous catheter is passed for long term use.
FAC chemotherapy is used
Chemotherapy has teratogenic effects on the fetus
during first trimester of pregnancy. It can still be Day One
used after discussion with the patient about the risks ! Injection cyclophosphamide 500 mg/m2 intra-
to the fetus and mother. Pregnancy may be venously is given as a single dose.
terminated or continued as the prognosis is not
affected by termination of pregnancy or keeping the ! Injection doxorubicin 50mg/m2 is given as
pregnancy. It is definitely affected by delay in the continuous infusion over 72 hours.
required appropriate therapy.
! Injection 5 fluorouracil 500mg/m2 is given as a
Chemotherapy can be used effectively during second bolus intravenous dose.
and third trimester of pregnancy with minimal
complications of labor and delivery. Commonly Day Four
following drugs are used with following doses; ! Bolus dose of injection 5 fluorouracil is given
! 5 - Flurouracil 1000 mg / m2 intravenously.
! Doxorubicin 50 mg / m2
! Cyclophosphomide 500 mg / m2
Three weeks onwards
These drugs are used at 3-4 weeks interval. The risk This course of treatment is repeated after 21 to 28
of intrauterine growth retardation should be kept in days during second and third trimester through 37
mind following chemotherapy during second and weeks of gustation8.

As the recurrence of cancer breast is common in

Patients are monitored with complete blood count, first 2-3 years after diagnosis of cancer breast, the
renal function tests and liver function tests before women should be advised to plan pregnancy after
and during the treatment courses. three Years. These patients must have oncologic
evaluation before such trial. If the patient had cancer
Side effects such as nausea and vomiting are treated breast with positive nodes, she should extend her
with intravenous ondansetron hydrochloride pregnancy free period to five years (III-C).
(zafran) Glaxo. Promethazene or Prochlorperazine
tablets. The breast feeding does not increase the risk of
breast cancer recurrence or development of second
The fetus is looked after for IUGR which is common primary breast cancer (III-B) 2 .
after chemotherapy.
PROGNOSIS
SPECIAL ADVICE2,7 Overall survival is high in both node negative and
Women treated for breast cancer may wish to get node positive patients. Five and ten years survival is
pregnant. Patients successfully treated for breast between 80%-86% and 73%-76%6.
cancer can try pregnancy two years after the
treatment but patients with advanced cancer breast The pregnancy obscures the disease leading to
should be discouraged to get pregnant. All these delay in the diagnosis, hence has poor prognosis.
patients should be informed about possibility of The poor prognosis in these carcinomas is due to
deterioration of prognosis(II-3C). age and not due to pregnancy.
REFERENCES
The women who get pregnant within two years of
treatment of carcinoma breast require careful
1. Tahir S. Carcinoma breast. Surgery Tell me the
management.
answer, 3rd edition. Uroobs Pvt Ltd.,
Faisalabad. Pakistan - 1997; 303-305.
The effects of treatment with high dose
chemotherapy and bone marrow transplant with or 2. Helewa M; Levesque P; Provencher D; Lea RH;
without radiation therapy on later pregnancies are Rosolowich V; Shapiro HM. Breast cancer,
not known. pregnancy and breast feeding. J obstet
Gynaecol can 2004 feb; 24(2) 164-80; quiz
Termination of pregnancy in these patients does not 181-4.
seen to improve mother’s chances of survival and is
not usually a treatment option. It is only considered 3. Ahn BY; Kim HH; Moon WK; Pisano ED; et al,
to avoid teratogenic abnormalities in fetus. It is done Pregnancy & lactation associated
breast c a n c e r : m a m m o g r a p h i c &
with mother’s consent after full counseling. It
sonographic findings. J ultrasound Med
depends upon the age of fetus, stage of disease and 2003 May; 22(5):491-7; quiz 498-9.
the mother’s chance of survival10.

4. Narchant DJ. Diagnosis of breast disease and

the role of the gynaecologist: Current opinions
in obstetrics and gynaecology [JC : a50] 5(1):
67-72, 1993 Feb
5. Oram B; Celik I; Erman E; Baltali E; Zangin N;
Demrikazik F; Tezcan S. Analysis of
menstrual, reproductive and life style SUMMARY
factors for breast cancer risk factors. Med
Oncol 2004; 21(1):31-40. ! Pregnancy associated breast cancer
! Triple assessment
6. Reed W; Hannisdal E; Skovlund E; ! Special problem assessment
Thoresen S; Lilleng P; Nesland JM. ! Risk assessment
Pregnancy and breast cancer: a population ! Management plan
based Study. Virchows Arch 2003 Jul; ! Surgery
443(1):44-50. ! Chemotherapy (treatment protocol)
! Radiotherapy
7. Ives A; Semmens J; Saunders C; Puckridge P. A
growing dilemma - Breast cancer &
! Special advice
Pregnancy. Aus fam physician 2002 Oct; ! Prognosis
31(10):929-32.
8. David L. Berry, Richard L, Theriault, Frankie A

Holmes, Valerie M, Parisi, Aman U Buzdar et. al. POSSIBLE QUESTIONS
Management of breast cancer during
pregnancy using a standardized protocol.
! What is pregnancy associated breast cancer?
Journal of clinical oncology, March 99. Volume
17 No. 3, pp 855-861. ! Discuss diagnosis?
! Discuss management plan?
9. Schedin P. Pregnancy associated breast cancer
and metastasis [NAT review cancer. 2000] Apr;
6(4): 281-91.
10. Breast cancer treatment and pregnancy.

National Cancer Institute, June 20th, 2009.

BREAST CANCER IN ELDERL

ELDERLY WOMEN
It is the presence of cancer breast in women aged 65 factors may worsen the mortality in these patients.
years or more.
Infiltrating ductal carcinoma (IDC) is the most
More than 50% patients of carcinoma breast are common type of carcinoma seen in older women.
above 65 years of age1,6. The old ladies are more likely to have less
aggressive tumors which are oestrogen receptor
A larger proportion presents with a palpable mass. It positive3. It is 68% of all the tumors. In elderly
may be due to less screening of very old women and women it is seen in 77% - 85% of the patients.
failure of early detection of disease.
The cancer breast in elderly women shows favorable
Breast cancer in elderly women is a significant public characteristics such as favorable tumor biology,
health problem. more expression of steroid receptors (estrogen and
progesterone receptors), low proliferative rate,
Elderly women have a 6 fold higher breast cancer good differentiation, normal P53 and low expression
incidence and 8 fold higher mortality when of epidermal growth factor3.
2
compared with non elderly women .
The number of elderly breast cancer patients is likely

to increase in future as the age expectancy
increases2.
The projected increase in number of elderly cancer

breast patient is 72% by 2025 in USA2,3.
The large increase in elderly cancer breast patients

requires need for improved preventive and
treatment strategies for elderly if the cost of
treatment is to be controlled2.
The problems of age & other age related co-morbid

As age increases, the incidence of papillary or as functional independence, co-morbidities and

mucinous carcinoma increases as well. cognitive function of patient along with
determination of her life expectancy and
In women over 70 years of age, estrogen receptor preferences4.
positive cancer breast is more common. It is about
60% - 95%. The treatment decision is made for integerated
conservative surgery, radiotherapy and hormo-
The elderly patients of cancer breast usually have chemotherapy in otherwise healthy elderly women5.
less aggressive investigations and treatment
leading to delay in diagnosis and poor outcome of Surgery alone or surgery and radiotherapy is the
treatment. standard treatment for early cancer breast.
(stage I & II).
Mammographic screening in women aged 65 years
and above should be established to detect the Lump excision under local anaesthesia may be
disease earlier1. performed in very old and unfit patients5,6.
MANAGEMENT Modified radical mastectomy is offered by some

surgeons.
The improvements in outcome may be achieved by
multi-disciplinary management approach involving Use of axillary dissection, chemotherapy and
oncologists, Geriatricians, Surgeons, radio- radiotherapy is likely to improve the outcome of
oncologists, special breast care nurses and social disease in these patients. Radio therapy should also
workers4. be offered when indicated3.
Priorities for breast cancer prevention and control in Elderly women can tolerate breast conserving
elderly should be established2. therapy including radiotherapy well and have
excellent rates of loco-regional control and disease
Geriatric medicine has established Comprehensive specific survival8. Breast conserving surgery with
Geriatric Assessment (CGA) to get important radiotherapy and mastectomy both can be offered
information on elderly patients missed by routine on the preference of the patient7.
clinical examination4.
Hormonal therapy is the most effective adjuvant
The data collected in CGA is of prognostic relevance measure for elderly patients with localized disease.
concerning toxicity of chemotherapy and mortality.
The use of CGA improves functional status and In very old and unfit patients, tamoxifen alone is a
mental health of elderly4. suitable treatment. Chemoprevention can be offered
on individual basis depending upon the risk ; breast
Careful evaluation of biological prognostic factors, ratio9.
performance status and geriatric parameters such

Palliative measures can be suggested to frail 5. Basso U; Brunello A; Pogliani C; Monfardini S.

patients to maximize the balance of benefits and Treatment options for early breast cancer in
toxicities. elderly women. Expert Rev Anti Cancer Ther
2004 Apr; 4(2):197-211.
An objective and problem solving approach to the
6. Butitude MF, Fentiman IS. Breast cancer in older
management is most suitable5. women. Int J Clin Prac 2002 Oct; 56(8): 588-
90.
These women have better 5 years survival rates in
stage I & II carcinomas. There is no age related 7. Warren JL; Brown ML; Fay MP; Schuoler N;
difference in advanced cancer breast. Potosky AL; Riley GF. Costs of treatment for
elderly women with early stage cancer breast in
Elderly women with high bone mineral density (BMD) fee for setting service. J Clin Oncol 2002 Jan 1;
have an increased risk of breast cancer, especially 20(1):307-16.
advanced cancer compared with women with low
BMD. There seems to be association between 8. Cutuli B; Aristei C; Martini C; Perrucci E; Latini P;
Quetin P. Breast-conserving therapy for stage
oesteoprosis and invasive breast cancer, two of the
I-II breast cancer in elderly women. Int J Radiat
most prevalent conditions affecting an older Oncol Biol Phys 2004 Sep1;60(1):71-6.
woman’s health10.
9. Balducci L, Beghe G. Prevention of cancer in
REFERENCES the older person. Clin. Geriatr Med 2002 Aug;
18(3): 505-28.
1. Amodeo C; Caglia P; Gondolfo L; Veroux M;
Brancato G; Imme A. Breast cancer screening in 10. Zmuda JM; Cauley JA; Ljung BM; Bauer DC;
elderly. Tumori 2003 Jul-Aug;89 (4- Cummings SR; Kuller LH. Bone mass and breast
suppl):173-4. cancer risk in older women: differences by
stage at diagnosis. J Natl Cancer Ins 2001 June
2. Alberg AJ; Singh S. Epidemiology of breast 20; 93(12):930-6.
cancer in older women: implication for future
health care. Drugs aging 2001; 18(10):761-
72.
3. Repetto L; Pietropaolo M; Aapro M.

Chemotherapy in the elderly with breast cancer.
Forum (Genova) 2002; 12(1):64-70.
4. Wedding U; Hoffken K. Care of breast cancer in

the elderly women - what does comprehensive
geriatic assessment (CGA) help? Support Care
Cancer 2003 Dec; 11(12):769-74.

BREAST CANCER IN MALES

Male breast carcinoma (MBC) is the malignant tumor distant sites and regional lymph node by the time
of the breast in men. It is seen in men over age of 60 diagnosis is made.
years. Carcinoma breast is very rare in men when
compared with women suffering from same problem. Gender specific incidence trends differ reflective of
The information about this problem is limited1 female-related changes in surveillance and/or
because of less number of patients. reproductive risk factors.
Only 1% cancer breast occurs in men. Its predisposing factors include gynaecomastia and
Male to female ratio is 1:125. increased endogenous or exogenous oestrogen.
There is an association between BRCA2 mutations It presents as a lump or an ulcer over the breast. It is
and male breast cancer specially in those with family most commonly infiltrating ductal carcinoma.
history of breast cancer.
MANAGEMENT
The high prevalence of BRCA2 mutations among
males should be considered when estimating risk for It is similar to female cancer breast. The diagnosis
3
female relatives . and assessment is done by triple assessment.
Male breast cancer has biological differences Wide excision of the diseased area is usually done by
compared with female breast cancer. It occurs late mastectomy.
and has poor prognosis because of early spread of
the disease. Neo-adjuvant chemo-radiation may be given in
advanced cases to down stage the tumor before
The early spread is because of less breast tissue, surgery.
early infiltration to the adjacent tissue in skin and
chest wall. Adjuvant chemo radiation may also be required in
patients with advanced carcinoma breast in males.
The carcinoma in male breast resembles invasive The volume of breast tissue being small, role of
carcinoma breast of females. radio therapy has to be reassessed4.
More than 50% of tumors have already spread to

It responds to hormonal and chemotherapy but

optimal regmines for males are yet undecided due to
limited number of patients and lack of possibility of
controlled trials.
Its prognosis is not statistically different from that of

female invasive ductal carcinoma and invasive
1
lobular carcinoma .
It exhibit same prognosis, stage for stage as in

females2.
REFERENCES
1. Peikarski JH; Jeziorski A. Breast neoplasm in
men & women-prognosis comparison. Wiad Lek
2003; 56(5-6):239-43.
2. Gibson TN. Brady-west D; Williams E; Walters J.

Male Breast Cancer. An analysis of four cases &
review of literature. West Indian Med. J 2001
June; 50(2):165-8.
3. Diez O; Cortes J; Domenech M; Pericay C;

Brunet J; Alonso C; Baiget M. BRCA2 germ-line
mutations in Spanish male breast cancer
patients. Ann Oncol 2000 Jan 11(1):81-4.
4. Gennari R; Curigliano G; Jereczek Fossa BA;

Zurrida S; Renne G; Intra M et al. Male breast
cancer (MBC): a special therapeutic problem.
Anything New? (Review). Int. J Oncol 2004 Mar;
24(3): 663-70.
5. Anderson WF; Althuis MD; Brinton LA; Devesa

SS. Is male breast cancer similar or different
than female breast cancer? Breast Cancer Res
Treat 2004 Jan; 83(1):77-86.

Chapter-
i erential ia nosis o
Breast L mps
DIFFERENTIAL DIAGNOSIS OF BREAST LUMPS 2
Objectives
! To diagnose the lump in breast.
! To differentiate between various types of lumps.
! To plan appropriate investigations for assessment of the
lump.
! To plan adequate management.
! To plan followup for these patients.

DIFFERENTIAL DIAGNOSIS
OF BREAST LUMPS
Breast is a forbidden territory in our Bilateral swelling of whole breast;

religious society, so most of the lumps
are either left undetected or are ! Pregnancy, Lactation.
detected very late. The silly idea in ! ANDI.
general public that any lump in the ! Hypertrophy.
breast is cancer is ill conceived. ! Acute mastitis.
When an adult woman detects a lump in The final diagnosis has to be singled out
her breast, usually she gets very from;
apprehensive about its nature. As soon
as she consults her doctor for help, the Unilateral breast lumps;
doctor has most important duty to
diagnose the lump and its nature ! Fibroadenosis of the newborn.
correctly and then manage it ! Puberty.
adequately. ! Unilateral hypertrophy.
When a patient presents with small The isolated lump in a single breast
lump in the breast, a well organized plan could be;
for early diagnosis and correct
management is formulated. Triple BENIGN
assessment of breast lesion is
performed. It is; ! Fibroadenoma.
! Simple cyst.
1. Clinical history & examination. ! Galactocele.
2. Imaging ! Lipoma.
3. Cyto histological tests ! Plasma cell mastitis.
! Fat necrosis\Tuberculous abscess.
One of the following lesions are to be ! Phylloides tumor.
diagnosed as cause of the problem.
Following swellings of breast are seen; An isolated lump in breast could be;

The lump may not be actually in the A structured and careful examination of
breast tissue but may be in its vicinity both the breasts, axilla and clavicular
such as; regions is under taken. It is performed in
privacy and in the presence of a female
Retro-mammary Abscess (from ribs, attendant or a nurse if the doctor is
chronic osteomyelitis, tuberculosis). male.
If is performed in good light and in
! Empyema. different positions;
! Chondroma of chest wall.
! Rib deformities. The exact site, size in centimeters,
! Mondor's disease. shape, consistency, mobility or fixation
of the lump is noted.
TRIPLE ASSESSMENT Fluctuation and transillumination tests
are performed if indicated. Annual or
It is combination of three sets of biannual physical examination of the
observations (clinical, imaging and breast is very helpful in women at and
cystohistological) which have a very above the age of 40 years1.
high pick up rate in assessment of the
nature and extent of the disease. It is Once it is confirmed by history and
very important in case the malignancy is proper examination that the lump is
suspected. present, it has to be differentiated very
clearly whether the lump is in the chest
Complete history must be written wall underlying the breast or is in the
without forgetting the family history, breast proper.
menstrual history, obstetric history and
history of breast feeding. LUMP BREAST
History of the lump must include Similarly a lump lying in the skin
following information as given by the overlying the breast has to be
patient; differentiated from a lump in the breast
proper. Rarely a lump may be present in
! Duration of the appearance. the accessory breast some where away
! Nature (painful or painless). from the normal breast site.
! Site (four quadrants of the breast).
! Size. If the lump is showing signs and
! Consistency. symptoms of acute inflammation, the
! Surface. diagnosis of breast abscess can be
! Appearance of the surrounding skin. made safely and treatment can be
! Relationship with menstrual cycle. advised accordingly.

URINE EXAMINATION Bacteriological examination of the pus

aspirate is performed in case of breast
Complete urine examination is a simple abscess.
investigation but gives very valuable If signs and symptoms of acute
information. i n fl a m m a ti o n a r e n o t p r e s e n t,
cystohistological examination of the
BLOOD EXAMINATION lump is arranged and diagnosis is
confirmed.
Haemoglobin percentage. Following lesions are commonly
Total leukocyte count. diagnosed in the breast;
Differential leukocyte count.
Sedimentation rate. Lesions arising in large ducts are;
IMAGING 1. Duct ectasia.

2. Papilloma.
Sonographic mammography is 3. Papillary carcinoma.
performed on patients with suspected
breast abscess. Pus (fluid) collection is Lesion arising from terminal duct
picked up on ultrasonography very lobular units are;
clearly and diagnosis is almost
confirmed. 1. Cyst.
2. Adenosis.
It is performed in patients with solid 3. Hyperplasia.
lumps to find out the number and nature 4. Fibro adenoma.
of the solid breast lesions. 5. Carcinoma.
It is helpful in younger patients because DUCT PAPILLOMA

radiomammography is not much helpful
due to inability to differentiate between It is worm like growth that projects into
radio dense nature of breast and these lactiferous ducts near nipple. It is
lesions. another benign lump of the breast
arising from major duct epithelium close
Middle aged and old patients can be to the nipple. It is a papillary neoplastic
better investigated with growth within the duct. It is found in
radiomammography and lesions may principal lactiferous ducts or sinus.
be detected earlier. Usually it is solitary. It may present as
friable, delicate, villous and branching
CYTOHISTOLOGICAL EXAMINATION growth.
FNAC biopsy is performed for lumps. Solitary papillomas usually affect

FNAC, trucut needle or excision biopsy perimenopausal years (35-50 years old
confirms the diagnosis. female).
Complete excision of the duct system is The cysts can regress spontaneously
performed to avoid local recurrence. after menstrual periods or develop after
oestrogen replacement therapy1.
UNILATERAL HYPERTROPHY OF The cyst may demonstrate a thin rim of
THE BREAST calcification on mammographic
UNILATERAL GYNAECOMASTIA examination. The cyst may
occasionally rupture during
It is enlargement of a normal breast. compression while performing
The enlarge-ment is uniform. It is more mammography2.
commonly seen in males than females.
A cyst can also be clinically diagnosed
It is diagnosed clinically. with reasonable confidence. Usually no
edges can be palpated. It is smooth and
Treatment decision and plan is simple. firm. It moves easily and may be tender.
Reassurance or subcutaneous Usually cysts are felt in both breasts
mastectomy can be performed. and sometimes these are seen at more
than one occasion.
Correct size prosthesis may be
implanted on patient's choice for good It can be easily diagnosed by
cosmetic reason. ultrasound exami-nation. It is confirmed
by aspiration. The cyst disappears
CYST completely after aspiration.
A breast cyst is collection of fluid in the The patient is followed up every month
breast. Cyst results from the for the reappearance of the lump. The
enlargement of the breast lobule or cyst fluid is cytologically examined and
lactiferous duct. It is related to altered if there is any doubt or the lump does
hormonal stimulation and end-organ not disappear completely after
response. These often enlarge and aspiration or reappears within few days,
become tender before menstrual period excision biopsy of the lump is
starts. The fluid comes from normal performed.
secretions. The breasts enlarge and
swell towards the end of menstrual The patient is followed up for at least 2-3
cycle. months after aspiration of the cyst for
spontaneous resolution. Excision
It can occur at any age after puberty but biopsy is performed in young women
commonly presents in the with residual breast masses3.

leaf like clefts and slits. It can be benign be performed in doubtful cases.
or locally malignant. Occasionally it
may be frankly malignant. 15% may HAMARTOMA OF BREAST
metastasize to distant sites.
The lump is actually a developmental
It distorts the breast and may lead to aberration and not a true tumour. It
ulceration of the overlying skin. It may presents as a lump in the breast. It
present as a fungating lesion. appears as a discrete mass on
mammography.
Microscopically it is more cellular than
other fibroadenomas and there is The histological picture is variable and
myxomatous change in the fibrous includes;
tissue. It shows increased stromal
cellularity, anaplasia and high mitotic 1. Circumscribed fibro-cysts.
activity. Malignant change can occur 2. Adenolipomas.
rarely. Lymph node metastasis is rare 3. Fibroadenoma
as in other sarcomas. It was previously 4. Fat
called cystosarcoma phylloides. 5. Lobules
6. Cartilage
This is removed very carefully 7. Smooth muscle tissue
otherwise recurrence can occur.
Treatment is excision and biopsy5.
GALACTOCELE
FAT NECROSIS
It is a rare subareolar cyst presenting in
relation with lactation. It is less common It is a very rare condition and the lump is
problem than thought. often attached to the skin. It is a
condition which confuses with
It is commonly seen in women who carcinoma on clinical examination.
have recently stopped breast feeding.
Occasionally it may occur during The external features of injury to breast
lactation as well. It consists of ducts disappear by the time patient presents
distended with milk. for treatment. Sometimes the history of
injury may be just co-incidental and not
Aspiration confirms the diagnosis as it the cause of lump. It is painless, round
drains the milk and the lump and firm lump or lumps. It is more
disappears. Secondary infection may common in obese female with large
lead to breast abscess formation. breast.
FNAC, trucut or excision biopsy must It is due to localized disruption of fat

FNAC and trucut needle or excision

biopsy are confirmatory for the It has higher incidence at two different
diagnosis. age groups. It presents at 14-18 years
of age and 45-50 years of age.
FIBROADENOMA
Treatment is cosmetic enucleation
It is the most common benign tumor of
the female breast. It consists of both FIBROADENOSIS
fibrous tissue and glandular tissue. It is
common before 30 years of age but no Fibroadenosis is the problem in young
age is immune. It has a rubbery feel and women. This can be suspected on
moves around easily. It is solid, round clinical examination. The lesions may
and painless. It occurs twice as be present in both the breasts. The
common in Afro American females than feeling of the breast tissue is nodular.
American females. It can enlarge during There is history of variable degree of
pregnancy and breast feeding. tenderness during menstrual cycle.
Further confirmation can be done by
A fibroadenoma can be diagnosed FNAC, trucut needle or excision biopsy.
clinically with fair degree of certainty.
CARCINOMA BREAST
It may be firm or hard but very mobile
lump (breast mouse) within the breast Carcinoma of the breast is not so rare in
tissue. Its surface is usually smooth and Pakistan as it is thought. A hard lump in
may be lobulated. the breast with irregular surface could
be a malignant lump.
The diagnosis is confirmed by FNAC,
trucut needle or excision biopsy. It can be mobile or adherent to the
underlying muscle or overlying skin. It
Further management is carried out may be associated with enlargement of
according to the cytological or regional lymph glands.
histological picture of the lesion.
All such lesions should have FNAC
The giant fibroadenoma grows rapidly trucut needle biopsy or excision biopsy.
and attains large size.
Further management is performed
It is bigger than 4-5 cm in diameter. The according to the extent of disease and
breast is enlarged, nipple may be histopathological picture.
displaced, overlying skin is shiny, veins
are dilated. It may be present in one REFERENCES
breast.

3. Palmer ML. Tsaugaris TN, Breast 1989 Nov-Dec

biopsy in women 30 years old or
less. American journal of surgery 5. Jones MW. Norris HJ. Wargotz ES,
[JC:3z4]: 165(6): 708-12, 1991 Hematomas of the breast. Surgery,
gynaecology and obstetrics.
4. Hushes LE. Bundred NJ. Breast [JC:vbd] 173(1) : 54-6, 1991 Jul.
macrocysts world journal of
surgery. [JC: x08] 13(6): 711-4,


Chapter-17
Counselling
COUNSELING 2
Objectives
! To understand the disease status of the patient.
! To understand the cognitive status of the patient.
! To understand the socio-economic status of the patient.
! To understand the psychological aspects of patient.
! To inform the patient about provisional diagnosis.
! To inform the patient about suggested investigations, their cost and
benefit in management.
! To inform the patient about treatment options and their cost,
benefits, problems and preference of treating doctor.
! To inform about consequences if not managed properly.
! To inform about the possible complications of treatment.
! To help the patient in making the correct choice.

COUNSELING 3
COUNSELING
Sohail Ali, FCPS (Psychiatry)
Tariq Mehmood, FCPS (surgery)
Abida Kareem, M.Sc (Clinical Psychology)
Breast carcinoma has such a dreadful Interaction between patient and the
reputation socially that most of the treating doctor, surgeon, oncologist,
women are scared to death even if they social worker and psychologist.
suspect or discover a benign or even
inflammatory lump in their breast. Interactive communication among the
health care provider and the female
They are under such a great sufferers.
psychological strain that information Creation of public awareness about the
collection and adequate clinical problems related to breast and its ideal
examination becomes very difficult and management.
sometimes even inadequate.
The process of counseling starts from
Women who are illiterate, less the very first visit of the patient to doctor.
responsible or unaware of the The patient is very nervous and under
consequences may even try to sleep great deal of psychological pressure
over the problem praying for natural and still undiagnosed. Morale of the
relief. patient has fallen immediately after
finding out the problem. Restoration of
C o u n s e l i n g o ff e r s p e o p l e t h e morale helps to improve the
opportunity to relieve their distress & management outcome.
improve the ways to manage their
health issues regarding cancer breast1. The doctor should show concern by
listening with patience and allowing the
Health care providers have to pick up patient to express her feelings. The
the cases of breast malignancy at the patient will feel understood after
earliest possible time for better ventilation of emotions. Further
treatment. counseling should be done after the
patient’s emotional level is back to
Certain steps are required to improve normal 3.
the management scenario;
The treating doctor has following

COUNSELING 4
Answering the questions of the patient disadvantages. A middle way may be

about disease, its treatment, life more acceptable in which, the patient
expectancy, problems related to may be reassured very optimistically
disease and its treatment, sexual, but the facts are given in less harsh and
fertility, pregnancy issues in young less crude manner.
women, discomfort to the patient,
expected cost of treatment, number of One doesn't have to inform the patient
days to be off from work and required that “your are going to die within 02
socio-economic adjustments in the months. Your life can be very miserable.
family. You are going to have lot of pain,
vomiting and difficult end of your life”.
The general policy of counseling varies Same events can be narrated in a
from surgeon to surgeon, department to different way such as;
department and country to country
depending upon the general “You know all about the illness. This
awareness of the disease and status of disease may shorten your life span and
health care and cognitive status of may create unacceptable physical
patients. problems. It is unfortunate but we have
to face the problem with courage and
Some wish to inform the facts very dignity”.
clearly and straight forward rather
bluntly. Some have a diplomatic Structured counseling offers a better
approach. professional touch. It does not miss a
point either and satisfies the patient to
It is important that one person in the maximum extent3.
team should be responsible for
counseling to avoid misunder- It is carried out in five steps;
standings between patient and the
treating team. Same information is 1. C o r r e c t i o n o f myths and
given in the same manner every time misconceptions.
otherwise patient will lose confidence
on the treating team. 2. Counseling is started with an
optimistic and realistic tone. The
Some patients can face up to the disease process may be discussed
realities of life and death. Some just more effectively and information is
break up on any bad news. They wish to imparted that more than 85%
hear only reassuring news whether its patients with early stage carcinoma
true or just a cover up. breast live almost normal life after
adequate treatment. This may be
Both policies have advantages and equal to normal life span of majority.

COUNSELING 5
have better compliance3. psycho-logical status of the person.
A balance of advantages and side The plan of follow up and appearance of

effects is calculated and correct mode complications and their possible
of treatment is selected with patient's treatment and outcome is also
consent. The patients accept side discussed with the patient. Patient
effects of therapy in a better way if they becomes fully aware of her problem
are aware and prepared for such and responds much carefully and in
problems. time.
Bilateral mastectomy is increasingly Patient is also given advice on socio-

considered as a treatment option for economic implications of the disease.
newly diagnosed BRCA1&2 carriers. She is supported and advised to
Patients prefer complete information manage her job, family and friends in
and BRCA 1&2 testing before surgery the best possible manner, one can.
to make a decision2 .
Frequent visits by the social worker,
Counseling differs as the problems doctor, oncologist, psychiatrist and
differ in young, pregnant, lactating and psychologist are very useful in the care
older women and male sufferers of the of patient with cancer breast.
disease.
REFERENCES
Young women sufferers have questions
about their married life, sexual 1. Bowen DJ; Burke W; Mc Tiernam A;
problems, future pregnancies and Yasui Y; Anderson MR. Breast
future fertility issues. cancer risk counseling improves
women’s functioning. Patient educ
Pregnant and lactating women wish to comes 2004 Apr; 53(1):79-86.
ask same questions and more. They
2. Schwartz MD; Lerman C; Brogan B;
wish to know effects of disease and its Peshkin BN; et al. Impact of BRCA
treatment on fetus and their own future. 1/BRCA 2 counseling and testing
on newly diagnosed breast cancer
Older women have questions about patients. J Clin oncol 2004 May 15;
their mobility and quality of life, cost of 22(10):1823-9.
treatment and life expectancy.
3. Shorter oxford textbook of
Male breast cancer sufferers are as psychiatry. 4th edition Gelder M;
worried as their counterpart women. Mayon R; Comen P; Oxford
The effects are usually different on University press 2001.
person to person depending upon the

Chapter-
Treatment Mo alities - 1
S r ery
umpectomy ide local cision

Segmentectomy uaderentectomy emimastectomy
Simple Mastectomy
Radical Mastectomy
Modi ied Radical Mastectomy
TREATMENT MODALITIES -1 (SURGERY) 2
Objectives
! To offer best available means of surgical management.
! To achieve better cosmetic management results.
! To offer better quality of life after treatment.
! To achieve total cure or maximum palliation.
! To achieve complete excision of the diseased tissue (curative
resection).
! To achieve reasonable excision of diseased tissue to relieve
symptoms (palliative resection).
! To choose a cosmetically and functionally acceptable incision.
! To keep the front of chest as normal as possible by maintaining the;
i. Inter breast cleft (cleavage).
ii. Axillary fold.
iii. Lower breast fold.

TREATMENT MODALITIES - 1
SURGERY
Almost 50% of breast cancer is seen in with a cushion of surrounding healthy

women of 65 years or older. It is also tissue. It is performed in a way to leave
suggested that cancer breast may be the breast contour undisturbed and as
more indolent disease in this age group normal shaped as possible.
of patients. INDICATIONS
Presence of co-morbid factors in this 1. Fibroadenoma breast.

age group and refusal of many patients 2. Fibroadenosis breast.
to aggressive treatment for cancer (Doubtful diagnosis)
breast may lead to poor outcome and 3. Early carcinoma of breast.
increased morbidity and mortality. (Breast conserving surgery)
4. Fat necrosis.
Patients treated with tamoxifen and 5. Galactocele.
radiation therapy had significantly
smaller risk of recurrence than those PREPARATION
treated with only lumpectomy or those
with radiation alone. Complete personal and clinical
information and observed data is
This age group of patients is carefully collected such as name, age, sex,
evaluated for adjuvant therapy1. menarche, parity, family history,
hormones intake, history of malignancy,
Surgery is still one of the most favored presence of lump in the breast or nipple
treatment modality for breast problems. discharge.
Following surgical procedures are Baseline investigations for general

commonly used to achieve adequate assessment of the patient such as urine
results; CE, blood CE, sugar, urea, creatinine
and electrolytes, are performed. X-ray
LUMPECTOMY (WIDE LOCAL EXCISION) chest and ECG is also done if indicated.
It is the excision of a lump in the breast Specialized investigations to confirm

simple and benign lump in their breast breast such as;

will never change into dreadful
malignancy. It is only complete removal CIRCUM AREOLAR INCISION
of lump which makes them free of fear.
This incision is selected for lumps near
Lumpectomy is planned depending and around the nipple. It gives minimum
upon its indications for various disease scar which practically disappears within
processes alone or it may be 3-6 months post operatively. The
associated with hormonal, chemo or disadvantages are that it leads to partial
radiation therapy in early carcinoma anesthesia (loss of sensation) of nipple.
breast. But this disadvantage is short lived as
the sensations improve after few
Proper counseling of the patient is done months.
regarding the procedure, post operative
problems, effects of chemotherapy and INFRA MAMMARY INCISION
irradiation and outcome of the surgery.
Skin over the breast to be operated is Hair line/skin crease incision is given
prepared few hours before surgery with over the infra mammary line for inferior
the help of non irritating and non allergic peripheral lump which is not in easy
antiseptic solution for adequate access from circum-areolar incision.
asepsis (pyodine).
GILLIARD THOMAS INCISION
Lumpectomy wound is a clean wound
and it does not require any per The incision is given just lateral to the
operative or post operative antibiotic anterior axillary line. It can also be used
cover. General anaesthesia is selected for lump present in the outer part of the
for better patient compliance, breast.
satisfaction and surgical outcome.
PROCEDURE
INCISIONS
Skin and subcutaneous tissue is
The objectives of incision selection are; incised as near as possible to the lump.
! To achieve adequate exposure. Lump is felt and sharp dissection is

! To achieve minimum scarring. carried out around the lump leaving few
centimeters of healthy tissue. The lump
Incision is selected with great care. It is not held with any tissue forceps or
has to be cosmetically acceptable. dissecting forceps to avoid trauma to
Choice of incisions is available for the lump. The adjacent healthy tissue is
lumps present in different quadrants of held during dissection.

(lump bed) is drained with smallest inflicts great deal of psychological

effective drain to avoid haematoma trauma not only due to loss of breast but
formation. Redivac drain or even because of the fear of the disease
smaller semi tube drain may be used. biology and complications of the
treatment.
The skin may be sutured with finest non
absorbable suture (Prolene 5/0, 4/0) or INDICATIONS
the skin is opposed with the help of steri
strips to achieve minimum scarring. The Carcinoma breast (operable).
sutures or steri strips are removed 7 Early carcinoma breast.
days post operatively. Minimum carcinoma breast.
FOLLOW UP COUNSELING
The patient is followed up for monitoring Counseling is of course different as the

the outcome of the surgery and disease patient is going to loose the breast.
process at regular intervals depending Patient is under psychological pressure
upon the diagnosis. due to understanding of disease
process requiring mastectomy and
COMPLICATIONS associated chemotherapy or
radiotherapy and worries about
Haematoma formation. prognosis, life expectancy, effects and
Infection. complications of the disease and its
Recurrence of lesion. treatment.
SEGMENTECTOMY PREPARATION
QUADERENTECTOMY
Patient is prepared in the same way as
HEMIMASTECTOMY for any other surgical procedure such
as lumpectomy.
It is the excision of a segment or
quadrant of the breast or excision of
Whole of the breast with about 20 cms
almost half of the breast. It is the
surrounding area is painted with non
operation devised for breast
irritating and non allergic antiseptic
conservation. Rest of the procedure is
solution.
similar to wide excision of lump.
Skin over ipsilateral axilla and upper
SIMPLE MASTECTOMY part of arm is also prepared with
antiseptic solution.
It is excision of the whole breast. It

over tumor, nipple and areola of the Axillary sampling/clearance is

breast. The transverse scar is minimally performed if so required.
visible as it is in hair line. The exposure
is adequate. It involves excision of One or two drains are left in the
whole breast and axillary tail. It offers operation site for proper and complete
reasonable exposure for axillary drainage (Radivac drains) through a
clearance if so required. separate incision which are preferred
for better and secure drainage.
Oblique incisions are used occasionally Skin is sutured with silk or prolene or
for upper and outer quadrant tumors closed with the help of steri strips after
when it is not possible to excise the skin adequately opposing the skin.
over tumor with skin crease incision
through a transverse elliptical incision. FOLLOW UP
The cosmetic results are less
acceptable being opposite the hair line. The patient is followed up as per
protocol of follow up for cancer breast
PROCEDURE followed by the surgical oncologist of
the hospital.
Skin and subcutaneous tissue is cut in
the elliptical fashion. Both upper and ADVANTAGES
lower flaps are raised with sharp
dissection over the breast tissue. Axillary dissection may not be required
in early breast carcinoma.
The bleeding points are compressed Sentinel node biopsy (SNB) also keeps
with help of dry surgical swab and the dissection minimum.
further dissection is carried out to Skin loss is minimized.
remove the breast without causing any Healing of wound is quicker and
breach in the fascia over pectoralis suturing is tension free.
major and other muscles in front of the There is greater tolerance to
chest. radiotherapy as chest wall has most of
the muscle layer undisturbed.
Major bleeding vessels are ligated and Radiotherapy can be started earlier
compressed with dry surgical swab. than after radical mastectomy.
The haemostasis is checked, electric SUBCUTANEOUS MASTECTOMY

cauterization, compression and ligation
of bleeding points help to control the It is excision of whole breast
bleeding from bed of the excised subcutaneously leaving the skin over
breast. breast, nipple areola complex
undisturbed.

scissors and blunt dissection upto It is the excision of the breast with
nipple where ducts are cut with overlying skin, underlying muscles and
scissors. The scissors are also used for draining lymph glands all at the same
dissecting the breast over anterior wall time and en-bloc.
of chest.
The classical operation as described by
The breast is brought out of the incision Halstead included following tissues to
after it has been completely separated be removed en-bloc;
anteriorly, posteriorly and peripherally.
The dead space is packed with surgical 1. The breast, skin overlying the tumor
swab for 5-10 minutes to control the including the nipple.
bleeding. Bleeding vessels are either 2. Entire system of lymphatic glands in
diathermized or ligated with fine the axilla with lymphatics with fat
absorbable suture. around them.
3. Sterno-costal part of the pectoralis
Redivac drain is left in the breast bed major muscle, whole of pectoralis
(dead space) for drainage under minor. Upper part of external oblique
vacuum to avoid haematoma or seroma muscle of abdomen, anterior
formation. divisions of serratus anterior
muscle.
The drain is removed 2-3 days later
when drainage has ceased and the INDICATIONS
wound is clean and shows no evidence
of haematoma formation or any other ! Carcinoma breast.
complication. ! Same as for mastectomy.
The skin is sutured with non absorbable INCISION

sutures (silk or prolene). These are
removed on 7th post opera-tive day. The skin and subcutaneous tissue are
cut in the line of elliptical incision. The
COMPLICATIONS skin flaps are raised to expose whole of
pectoralis major, floor of axilla and
Haematoma. inferior border of latissimus Dorsi.
Seroma.
Wound infection. An incision is made along the upper
Flap necrosis. border of fascia covering pectoralis
Local recurrence. major muscle. Sternal fibers are divided
near their attachment and it is retracted
RADICAL MASTECTOMY medially. If required, whole of pectoralis
major fibers are divided. The vessels

and dissection is carried out uptil the 24 fr size tube drain is left to drain the
posterior axillary wall wound adequately. Redivac drain can
muscles(subcapularis, teres major and also be used. Soft dressing with
latissmus dorsi) and serratus anterior reasonable padding is applied to avoid
on the medial wall. All fascial, fatty and chest compression.
glandular tissue are removed. The
nerve to serratus anterior is identified A tight dressing never prevents
and preserved. A hot wet surgical towel haematoma formation, it only causes
is used to compress the dissection area discomfort and respiratory
to control bleeding during surgery. embarrassment.
The skin flaps, fascia fat and the breast The patient is looked after post
with underlying muscles are sharply operatively. The drain is usually
dissected out from above the ribs and removed after drainage has stopped
costal cartilages. and it takes about 4-5 days after surgery
and it takes seven to eight days for the
Perforating branches of internal skin wound to heal. The sutures are
mammary are seen while dissecting removed after that.
sternum. These vessels are identified,
ligated and cut to avoid severe blood COMPLICATIONS
loss. The upper part of rectus sheath is
removed in the line of incision. Sternal 1. Bleeding.
fibers of pectoralis major muscle are 2. Haematoma formation.
raised and deep fascia is divided along 3. Painful limb movements.
with the line of sternal margin on the 4. Upper limb edema.
opposite side.
MODIFIED RADICAL MASTECTOMY
After excision of breast and all tissue en
bloc, the bed of mastectomy is The radical mastectomy was found to
compressed with hot wet towel. Then be a mutilating operation with lot of
any remaining fatty or glandular tissue physical and psychiatric complications.
is looked for and removed. It provided hardly any significant
advantage in the cure of dreadful
Major vessels are carefully ligated. carcinoma of breast when compared
Smaller vessels can be coagulated with with conservative surgical options.
electrical diathermy. The skin flaps are
sutured without any tension. Skin graft The credibility of this aggressive
may be used if complete skin cover is approach was challenged and
not easily possible without tension. modifications were advised. Patey and
others advocated a modified radical

COMPLICATIONS REFERENCES
1. Bleeding. 1. Shah S, Doyle K, Lange EM, Shen
2. Haematoma formation. P, Penrell T, Ferree C, Levine EA,
3. Painful limb movements. Perrier ND. Breast cancer
4. Upper limb edema. recurrences in elderly patients after
l u m p e c t o m y. A m S u r g 2 0 0 2
Aug;68(8): 735-9.


Chapter-
Ra iotherapy
Treatment Mo alities -
eoad u ant Radiotherapy

d u ant Radiotherapy
alliati e Radiotherapy
urati e or Radical Radiotherapy
rachytherapy
TREATMENT MODALITIES -2 (RADIOTHERAPY) 2
Objectives
! To be used as neoadjuvant therapy in malignancy.
! To control the local recurrence after surgical
treatment of malignancy.
! To be used as adjuvant therapy after surgery.
! To be used as palliative treatment for advanced

RADIOTHERAPY
Radiotherapy is a very important fixed target at the end to produce x-

treatment modality for cancer breast. It rays).
involves use of ionizing radiation to kill
the neoplastic cells. High energy electrons can be produced
for treatment in some machines.
Its objective is to deliver a focused and Electrons have the advantage of
measured dose of radiation to the tumor limiting the depth of penetration by
mass to achieve complete or near varying the electronic energy.
complete ablation of tumor tissue and to
avoid damage to the surrounding The use of CT planning and computer
healthy tissue. software technological developments
have improved focused radiation dose
Radiotherapy is being used to treat delivery to the malignant tissue. It has
breast cancer since end of 19th century. also reduced the risk of damage to
Initially the tumor used to regress but surrounding normal tissue.
damage to adjacent healthy tissue used
to be excessive and unacceptable. The radiotherapy can be used alone or
Technical hazards and radiation in combination with other modalities to
damage to the staff were other serious treat cancer breast. It can be used as;
problems.
! Neo-adjuvant radiotherapy.
About half a century ago, megavoltage ! Adjuvant radiotherapy.
radiation delivering machines were ! Palliative radiotherapy.
developed. These help to deposit ! Curative radiotherapy.
radiation in tissues at required depth
and avoid excessive skin necrosis. NEOADJUVANT RADIOTHERAPY
Linear accelerators are now used to It is the use of radiotherapy in cancer
produce high energy x-rays (electrons breast when tumor is inoperable or
are accelerated down a cylindrical when breast conserving surgery is
wave guide and are bombarded at a required. The cancer breast is down

1. To make the tumor resectable by

downsizing the tumor (down staging Indications of adjuvant radiotherapy
the tumor). include;
2. To sterilize the cells pre operatively
so that after surgery they may not be ! Deep margin involvement in tumor.
seeded. ! Skin involvement.
3. To eradicate the lymphatic spread or ! Size of tumor.
subclinical disease outside ! Wide spread lympho vascular
resection margins. involvement.
! 4 or more positive axillary nodes.
The main disadvantages of pre-
operative radiotherapy are; Determination of optimal patient for
adjuvant radiation therapy is highly
1. It interferes with normal healing individualized and had risk adjusted
although it is minimal with doses of approach.
45 – 50 Gy in 2 fractions.
2. Alteration of pathology results may Four issues are considered;
lead to alteration of further
management. ! Evaluation of risk of relapse.
! Concurrence with results of trials.
ADJUVANT RADIOTHERAPY ! Therapeutic ratio.
! Patient preference.
It is the use of radiotherapy alone or in
combination with chemotherapy for the The adjuvant therapy is useful in
treatment of cancer breast after surgery patients diagnosed with invasive breast
has been performed. The cancer of more than 1 cm size in
Outcome of management of carcinoma improving disease-free survival and
breast is improved after adjuvant overall survival.
radiotherapy. It helps to eradicate
possible subclinical residual disease DISADVANTAGE
and reduces the risk of local and distant
recurrence. It requires higher doses of radiation
Accurate post operative localization of Delay in radiotherapy in cases of wound

the radiotherapy area helps to provide infection and poor healing may lead to
better, focused radiotherapy. recurrence of tumor locally.
Adjuvant radiotherapy to chest wall and It has no effect on tumor seeding at the
nodal groups after mastectomy is used time of surgery.
in women of high risk.

is not possible. Radiotherapy is used to particles.

relieve the symptoms by down staging
the tumor. There are some degree of Radiation becomes variable in depth of
side effects of radiotherapy but these penetration and energy emission.
are minimized by controlled dose
delivery of radiation to the tumor. Superficial x rays (10 – 125 Kev)
deposit most of their energy in the skin
CURATIVE OR RADICAL RADIOTHERAPY and subcutaneous tissue. These are
used for skin and subcutaneous tissue
It is the use of radiotherapy for malignancies (recurrence of tumor in
treatment of early lesions of cancer skin).
breast. It is used when there is a
calculated chance of permanent tumor The megavoltage therapy (4 – 24 MV)
control and long term survival after high deposits energy in the deeper tissue
dose radiotherapy. sparing the skin. Deep seated tumors
are treated and overlying skin is spared
Side effects are accepted as the of damage.
ultimate cure is expected.
Electrons are usually used to treat
PHYSICAL PROPERTIES OF superficial tumors because these don’t
penetrate deeply. Their dose falls on
IONIZING RADIATION deep penetration.
The radiation used for radiotherapy can
The radiation dose is described in terms
be electromagnetic or particulate.
of the amount of energy (Joules)
Commonly used x-rays and gamma-
absorbed per unit mass (Kg). It is
rays are part of continuous
measured in grays (J/Kg)
electromagnetic spectrum. These are
supposed to be packs of energy
photons. BIOLOGICAL EFFECTS OF IONIZING
RADIATION
The physical properties of x-rays and
gamma-rays are similar but these are DNA of the neoplastic cells is the target
produced differently. X-rays are of radiation. Ionizing radiation can have
produced electrically in the x-ray tube. direct action on DNA or indirect through
Gamma-rays are emitted from radiation an intermediary. Most of the energy
of substances while these decay. deposited, is absorbed initially in water
which produces free radicals
Particulate radiation includes electrons, (molecules with impaired electrons).
neutrons, protons and heavy charged
These free radicals react with cellular

NORMAL TISSUE RADIATION BIOLOGY

Three dimensional, conventional,
The response of radiation depends on intensity-modulated radiotherapy
the degree of differentiation of the cells. allows smaller volumes to be treated. It
The terminally differentiated cells, such achieves a gain in the therapeutic
as muscles and nerves are more index.
resistant to radiation. It takes months FRACTIONATION
and years to affect slowly proliferating
tissue. A higher local dose can be tolerated by
giving smaller repeated doses of
Bone marrow and reproductive organs radiation than a single larger dose. It
can be damaged by relatively low doses allows normal tissue to repair and
of radiation. The toxicity from repopulate before further radiation.
radiotherapy may have immediate or Higher total doses increase the
late side effects. probability of tumor control.
Immediate effects are seen within days Fractionation describes the number
or few weeks. These effects are severe and size of radiation treatments. The
and seen when treatment is given in standard fractionation schedule is 1.8-2
shorter period. Typical side effects are Gy/day, 5 days a week.
mucositis, skin erythema, and bone
marrow suppression. Unscheduled interruptions in radical
treatment allow repopulation of tumor
Late effects are dependent upon total cells and loss of tumor control. It should
dose of radiation and its fractionation. be avoided.
These effects tend to be dose limiting
factor in treatment schedule. HYPO-FRACTIONATION
These effects include necrosis, fibrosis It is when small number of relatively
and chronic ulceration. Further large fractions are given.
radiation is avoided to the areas
showing these effects as it may cause ACCELERATED FRACTIONATION
excessive toxicity.
It is when a standard dose fraction is
THERAPEUTIC INDEX given over a shorter treatment time
(more than 5 fractions/week).
It is the tumor response for a fixed level
of normal tissue damage. The gain in HYPER FRACTIONATION
local tumor control is balanced against
the rise of normal tissue toxicity.

It depends upon the anatomical site of invasive carcinoma of breast (ductal

the tumor, its histological picture and carcinoma in situ) and invasive
staging. The target volume is defined in carcinoma breast. In early breast
three steps; cancer, shorter radiation schedules are
as efficient for local control and short
! Gross Tumor Volume (GTV). term cosmetic results as traditional
fractionation regimens.
It includes all gross tumor.
Sentinel lymph gland biopsy and
! Clinical Target Volume (CTV). regional radiation is offered to patients
with positive nodes3.
It includes gross tumor volume and
microscopic spread. Low dose-rate implants upto 60 Gy are
well tolerated. The post radiotherapy
! Planning Target Volume (PTV). fibrosis increases upto 25% after
implant dose of 60 Gy. The dose
It includes CTV and margin to allow for calculation requires further studies2.
daily variation in treatment set up.
Indications for boost treatment can
The decision for treatment is made after include;
full consultation with physicist and
dosimeterist. Best distribution is ! Close resection margins (less then
selected to gain homogenecity within 01 cms).
the target volume to reduce toxicity to ! Extensive in situ diseases.
n o r m a l t i s s u e . ! Vascular invasions.
! Grade III tumor histology.
Whole treatment plan is tested or
simulated to ensure correct treatment Survival after breast conservation
area. Marking and immobilization surgery and radiotherapy is
ensures daily treatment volumes. comparable to mastectomy. Adjuvant
radiotherapy reduces local recurrence
Radiotherapy can eradicate the tumor. upto 2/3rd.
Its effectivity depends upon the
vascularity of the tumor. It fails to be Radiation therapy after high dose
effective in hypoxic areas of the tumor. chemotherapy provides excellent local
control rates without excessive toxicity.
COMBINATION THERAPY Delaying the start of radiotherapy until
recovery from high-dose-
Lumpectomy followed by radiotherapy chemotherapy side effects doesn’t
is an effective treatment for non seem to increase local failure rates6.

Estrogen receptor assessment is

valuable for predicting prognosis of 2. Lawenda BD; Taghian AG; Kachnic
early stage breast cancer patients LA et al: Dose-volume analysis of
treated with BCS and radiotherapy4. radiotherapy for T1 N0 invasive
Breast cancer treated by local
excision and partial breast
The benefits of hormonal therapy are
irradiation by low-dose-rate
limited to patients with positive interstitial implant. Int. J Radiat
estrogen receptors. Anthracyclines Oncol Biol Phys 2003 Jul 1:56 (3):
show improvements in patients with 671-80.
positive nodes5. 3. Chow E: Radiation treatment for
Breast cancer. Recent Advances.
BRACHY THERAPY Canfam Physician 2002 June; 48:
1065-9.
It involves intra cavity irradiation using
4. Takei H; Horiguchi J; Maemura M;
radio-active sources placed in the Koibnch Y et al: Predictive volume
tissue cavity near the tumor or of estrogen receptor status as
interstitial radiation using radio-active assessed by ligandbinding assay in
seeds, needles or wires implanted patient with early-stage breast
directly into tumor tissue. cancer treated with Breast
conserving surgery and radiation
Breast conserving treatment leads to therapy. Oncol Rep 2002 Mar-Apr;
excellent long term results in terms of 9(2): 375-8.
local control and marking classical risk
factors. 5. Mincey BA; Palmieri FM; Perez EA.
Adjuvant therapy for breast cancer:
Recommendations for
High dose and large-volume interstitial management based on consensus
brachy-therapy is superior to breast review and recent clinical trials.
conserving treatment without Oncologist 2002; 7(3): 248-50.
brachytherapy7.
6. Moreno M; Azinovic I; Lopez Picazo
REFERENCES JM; Aramendia JM et al;
Radiotherapy after high-dose-
1. Ann Henry; D. Ash. Principles of chemotherapy with peripheral
Cancer Treatment by blood stem cell support for high-risk
R a d i o t h e r a p y. S u r g e r y breast cancer. Am J Clin Oncol.
international. 2001: (53): 66-69. 2002 Aug; 25(4): 347-53.

Chapter-20
Hormonal Therapy
TREATMENT MODALITIES -3 (HORMONAL THERAPY) 2
Objectives
! To understand the effects of various hormones on cancer breast patients.
! To treat the cancer breast patients with hormonal manipulation.
! To use the hormonal therapy as neoadjuvant or adjuvant therapy either alone or
in combination with other therapies for cancer breast.

HORMONAL THERAPY
Hormonal therapy for cancer breast is Receptor proteins for steroid hormones
use of hormones for its treatment. The are present in the cytoplasm and
relationship between hormones and nucleus. Interaction between hormone
various problems of breast has been and its receptor modifies DNA activity,
known for a long time. cell growth and cell division. The events
for the steroids effects on cell
The influence of hormones on tumor proliferation are as;
tissue was discovered over a century
ago. ! Free, non protein bound hormone
crosses the cell membrane.
Sir George Beatson showed regression ! Hormone links to cytoplasmic
of inoperable breast cancer after receptor protein and forms a
oophorectomy during 1896. complex in cytoplasm or nucleus.
! Hormone receptor complex binds to
Surgical ablation remained major form a nuclear protein which controls
of endocrine therapy for next fifty years. DNA activity.
! An increase in RNA polymerase
A rational basis for the use of hormone activity through production of mRNA
manipulation in breast cancer leads to cytoplasmic protein
treatment could not be formed due to production.
lack of knowledge of how hormones or ! DNA synthesis occurs in 24 hours
hormonal antagonists act on cancer followed by cell division.
cells1. ! The production and activation of
hormones can be reduced by
The hormonal therapy became popular surgical, radio therapeutic or
with the understanding of various chemical ablation.
aspects of effects of hormones on their ! The binding of hormone to its
target organs. receptor can be prevented even
when it has entered the cell by
STEROID HORMONES & THEIR RECEPTORS competitive inhibitors or reduction in
production of receptors.

data such as age, menopausal status, f o r o o p h o r e c t o m y. S u r g i c a l

general condition of the patient, grading oophorectomy has a rapid response
and staging of the disease. when compared with radio-therapeutic
or chemical ablation otherwise
The receptors may not be functionally frequency and duration of response are
active even if these are present. same.
All women suffering from carcinoma LHRH is a decapeptide released from

breast must have oestrogen receptor hypothalamus to act on pituitary to
status assessed for adequate produce LH and FSH.
immediate and future management.
LHRH analogues produce medical
Hormonal treatment is used as equivalent of oophorectomy within two
adjuvant in advanced stages of months of administration. These
carcinoma breast. provide response rate similar to
surgical oophorectomy but it has an
All patients with positive oestrogen advantage of being reversible in
receptors receive tamoxifen for five women who wish to stay fertile.
years. This treatment is also given to
patients with advanced carcinoma Its combination with tamoxifen provides
breast and positive oestrogen complete oestrogen block in pre
receptors as palliative treatment. menopausal women thus giving it a
much superior role.
The objective response to initial
hormonal treatment in these patients is ANTI OESTROGENS
65- 75% for 12- 15 months.
Tamoxifen is an anti oestrogen. It is
nd rd
The response to 2 and 3 line effective in both pre and post
hormonal treatment in patients with menopausal women with carcinoma
oestrogen receptor negative patients is breast.
only 5%.
It is used as first line treatment for
OVARIAN ABLATION patients with hormone sensitive
metastatic carcinoma breast. It is
Younger women (less than 35 years of relatively less toxic.
age) with carcinoma breast and
oestrogen receptor positive status It is non steroidal anti oestrogen which
respond to oophorectomy very well. competes with circulating oestrogens
The patients with oestrogen receptor for binding at receptors. The blocking
negative status are not recommended effect leads to some of its anti

The oestrogens are mainly produced by breast cancer or combined hormone

peripheral conversion of adrenal therapy increases the risk of carcinoma
androgens in muscle, liver and fat in breast in females is not supported by
post menopausal women. These are various studies. The long term use of
mediated by aromatase enzymes. these hormones (more than 15 years)
Breast tissue also contains aromatase may increase the risk slightly3.
and can synthesize oestrogen.
Aromatase inhibition can exert anti- Use of HRT does not increase the risk of
tumor effect in carcinoma breast. carcinoma breast recurrence. It does
not shorten life expectancy in women
Aminoglutethamide and anastrozole on treatment for primary invasive
have achieved response rate of about carcinoma breast4.
30% in post menopausal women
progressing on tamoxifen. Anastrozole Approximately half of breast cancers
is used as first line treatment due to occur in women of 65 years or older.
lower toxic effects. The cancer breast may be more
indolent disease in this group of
Progestogens and anabolic steroids patients. It may be as a result of
are relatively less helpful in the comorbid conditions and less
treatment of post menopausal patients aggressive treatment for this age group
with carcinoma breast due to their toxic patients.
effects. Flavopiridol is cyclin dependent
kinase inhibitor. It disrupts the cell cycle The patients treated with tamoxifen and
and is an important therapeutic radiation therapy has significantly
strategy. It causes cell cycle arrest, smaller risk of recurrences than those
induces apoptosis, inhibits treated surgically alone (lumpectomy)
angiogenesis and potentiates effects of or radiation alone5.
chemotherapy2.
HRT use for menopausal symptoms by
HRT AND BREAST CANCER women treated for primary invasive
breast cancer is not associated with an
The menopausal women with increased risk of breast cancer
diagnosed carcinoma breast or without recurrence or shortened life
carcinoma breast require Hormone expectancy.
Replacement Therapy to prevent/
treat/avoid menopausal symptoms and Anastrozole is an effective and well
osteoprosis and associated morbidity tolerated option for the treatment of
and mortality. post menopausal patients with
hormone sensitive early breast cancer.
Estrogen use increases the risk of Longer follow up is required for final

4. Durna EM; Wren BG; Heller GZ; recurrences in elderly patients after
Leader LR; Sjoblom P; Eden JA. lumpectomy. An Surg 2002 Aug; 68
Hormone replacement therapy (8) 738-9.
after a diagnosis of cancer breast;
Cancer recurrence and mortality. 6 Durna EM, Wren BG, Heller GZ,
Med J Aus 2002 Oct 7; 177 (7): Leader LR, Syoblom P, Eden JA.
347-51. Hormone replacement therapy
after a diagnosis of breast cancer.
5. Shah S; Doyle K; Lange EM; Shen Cancer recurrence and mortality.
P; Pennell T; Ferree C; Levine EA; Med J Aust 2002 Oct 7; 177(7): 347-
Perrier ND. Breast Cancer 51,

Chapter-2
Chemotherapy
TREATMENT MODALITIES -4 (CHEMOTHERAPY) 2
Objectives
! To use chemical agents to destroy the malignant cells selectively.
! To use chemical agents to palliate malignancy.
! To use chemical agents to downstage the tumor before surgery (Neo-
adjuvant).
! To use chemical agents after surgical excision of malignancy to
prevent spread (adjuvant).
! To use chemical agents with hormones & radiation to enhance the anti-

CHEMOTHERAPY
Faisal Bilal Lodhi, FCPS
Chemotherapy is the treatment of

breast cancer with various chemical Unfortunately these drugs are
agents commonly used in combination. expensive to the extent that most of the
It is also called anti-cancer public fails to use the drugs due to
chemotherapy or cytotoxic drug economic problems, the cost/benefit
therapy. ratio of these drugs is not always
justifiable to majority of our public.
There have been a great deal of Recent cytotoxic drugs “Taxanes” (taxol
developments in cancer chemotherapy and taxotere) are so expensive (more
over last few years. Very extensive than 100,000 rupees per dose) that it is
research trials have been conducted all difficult to use these with their
over the world to assess the outcome cost/benefit ratio. These may be used
of treatment after use of various as second line therapy for advanced or
combinations of these drugs. recurrent breast carcinoma.
More and more cytotoxic drugs have The chemotherapy is used to destroy
been developed and made available for tumor cells selectively. It is achieved by
human use. Their toxicity has been specific growth characteristics of most
reduced and new techniques have of the tumors.
been developed for the administration
of these drugs. The understanding of cellular cycle is
important to plan the chemotherapy
Better understanding of cancer biology most effectively.
and availability of these drugs have M G0
improved the outcome of breast cancer. CELL CYCLE
Overall survival of breast carcinoma G0 = Resting phase
G1 = Protein and RNA synthesis
patients has improved. Cellular
G2
division Ghas Smultiple phases.
= DNA synthesis
1
Different chemotherapeutic
G2 = RNA synthesis
M = mitosis
agents
Understanding of tumor biology has affect different phase.
helped to target malignant cells S
selectively. G-o is a resting phase outside the cell

cells are in G-o phase and drug

penetration is less reliable. Moreover NON PHASE DEPENDENT DRUGS
the cells in G-o are resistant to effects of
cytotoxic drugs. These are the chemotherapeutic
agents which don’t effect any special
The faster the cells are growing. It is phase of cell division.
more likely that cytotoxic drugs can
“catch” these (kill these). These kill cells exponentially with
increasing dose.
It also accounts for chemotoxicity on These are equally toxic for cell within
rapidly growing normal tissues (e.g the cell cycle or G-o phase.
Gastrointestinal mucosa and Bone
marrow). Examples include;
Large tumors are relatively Alkylating agents.

unresponsive to chemo-therapy due to Cyclophosphamide.
incomplete penetration. Cisplatin.
5-Fluorouracil.
Most drugs kill a fixed proportion of cells Anthracyclines.
rather than fixed number. Different Doxorubicin.
drugs act during different phases of the
cell cycle. Various combinations of PHASE DEPENDENT DRUGS
drugs are more likely to be effective
than single drug and have less toxic These kill cells at a lower dose.
effects. These act within a specific phase of the
cell cycle.
Cell synthesizing DNA go through a
regular cycle with different phases. Example include;
Most of the chemotherapy drugs cause
DNA damage through various i. Methotrexate
processes; ii. Vinca alkaloids – vincristin,
vinblastine
Disruption of cell cycle check points.
Growth factors. Breast carcinoma shows significant
Growth factor receptors. response when treated with
Signal transduction pathways. chemotherapy.
Cell death by apoptosis.
ALKYLATING AGENTS
Chemotherapeutic agents are of
various types; These are chemically reactive drugs.

Carmustine.
Lomustine. Vinca alkaloids bind to tublin and inhibit
Cisplatin the metaphase of mitosis.
TOPOISOMERASE INHIBITORS
Cisplatin inhibits DNA synthesis by
cross linking DNA strands. It is a group of enzymes which allow
unwinding and uncoiling of super coiled
ANTI-METABOLIC AGENTS DNA
These are anti cancer drugs which Topoisomerase-I preferentially binds to

resemble naturally occurring purines , double stranded DNA and causes a
pyramidines and nucleic acids. These single strand break.
inhibit key enzymes involved in DNA
synthesis. Topoisomerase-II binds covalently to
comple-mentary strands of double
Purine analogues. strand DNA cleaving both strands.
Azathioprines.
6 Mercaptopurines. ANTI TUMOR ANTIBIOTICS
Fludardine.
These act differently by DNA cross
Methotraxate is an antifolate drug. It linking and topoisomerase inhibition.
stops DNA synthesis by inhibiting the These lead to alteration of cell
activity of dihydrofolate reductase. It membrane function.
leads to cell death. The biochemical
toxicity can be reversed by restoring PYRAMIDINE ANALOGUES
intracellular folate (by administering
folic acid) and normal tissue may be Gemcitabine.
saved. 5 Fluorouracil.
Capecitabine.
MITOTIC INHIBITORS Methotrexate.
TUBULIN BINDING DRUGS Reltitrexed.
Vincristine.
Tubulin is normal and basic subunit of Vindesine.
microtubules and has many important Vinblastine.
cell functions such as spindle formation Vinorelbine.
and chromosome migration during
cellular division. TAXANES
Vinca alkaloids and taxanes belong to Paclitaxal

this group of drugs. Docetaxel

TOPOISOMERASE II INHIBITORS with other treatment modalities. A

combination of chemo-therapeutic
Etoposide. agents may be used for better results.
Teniposide. No single agent has yet been found out
to cure cancer breast at any stage.
ANTI TUMOR ANTIBIOTICS
Chemotherapy improves cure rate in
Anthracyclines. primary disease of breast. It reduces
Doxorubicin the annual risk of death by 15% and has
It inhibits RNA synthesis by a proven benefit by various trials.
intercalating between DNA base pairs.
The chemotherapy can be used after
Epirubucin. surgery and/or radiotherapy for control
Daunorubacin. of wide spread malignant disease. It
Idarubacin. helps to control the micro-metastasis
not diagnosable by any investigation at
Anthracenediones present.
Mitoxantrone.
Bleomycin Chemotherapy in breast cancer can be
It inhibits DNA polymerase causing given as;
breakage of single stranded DNA.
NEO-ADJUVANT THERAPY
Dactinomycin.
L-asparaginase. Primary systemic therapy prior to loco-
Hydroxyurea. regional treatment.
Procarbazine.
ADJUVANT THERAPY
CHEMOTHERAPY IN BREAST CANCER
It is used following loco-regional
The precise indications for the use of treatment.
cytotoxic drugs become less well (Post operative adjuvant
defined because these improve-ments chemotherapy).
are less dramatic in women over 50
years age group. Treatment decisions The outcome of chemotherapy
are made on individual patients basis. depends primarily on;
Chemotherapy can be used as curative ! Age.

in cases where the tumor is not ! Menopausal status.
advanced and is sensitive to ! Nodal status.
chemotherapy alone or in combination ! Tumor grade.

COMBINATION THERAPY Impact

for of
thechemotherapy onand
node positive breast cancer survival
62 percent for
10 years survival
the node negative patients. .
It is the use of multiple Node Positive Node Negative
chemotherapeutic agents to avoid drug The survival advantage is of a modest
resistance and to achieve optimal Age Less No. Chemo
magnitude Chemo No. ChemoChemo
for women aged 50-69
control of cancer breast. than 50 6%
years. yrs for the node positive and 2 %
42 53 71 78
for the node negative patients.
It is the treatment of choice in almost all 50-69 yrs 46 49 67 69
types of chemotherapy whether
curative, palliative, adjuvant or neo- Fall in death rate% in UK & USA (1987-97)1
adjuvant. Age UK USA
The choice of combination of drugs is 20-49 22 19

determined by following factors; 50-69 22 18
! Effect of drug on target tumor type. 70-79 12 9

! Mode of action of drug on tumor
(alkylating activity, mitotic inhibition
activity).
! Mechanism of drug resistance.
! Dose limiting toxicity.
! Compatible dose schedule.
Combination chemotherapy is more
effective than single drug therapy.
Greatest benefit of chemotherapy is
Most commonly used regimen is CMF seen in pre-menopausal women (where
(cyclophos-phamide, Methotrexate, 5- its effect is likely to be due in part to a
Flurouracil). chemical castration effect) but is being
increasingly offered to post
It is given in six cycles at monthly menopausal women with poor
interval. There is no evidence that more prognosis disease.
than six months treatment is of any
benefit. Other combination regimens used
include;
It has shown to achieve a 30 percent
reduction in the risk of relapse over a (AVM) Adriamycin, Vincristine and
10-15 year period. methotrexate.
The overall 10 years mortality reduction (VCF) Vincristine, Cyclophosphamide

for women under 50 years is 12 percent and 5-Fluorouracil.

combination or with hormones before complete response rates, good

considering surgical treatment. These tolerability in patients of cancer breast5.
are the same drugs which are used after 70% tumors show a clinical response.
surgery. The clinical response is complete in 20-
30%.
Their use before surgery helps to
downstage the tumor. The quality of 80% of these patients still have
surgery improves. The surgery histological evidence of tumor.
becomes less extensive and more Surgery is required even in those with
effective. The spread of malignancy is complete clinical response
minimized. The control of malignancy is
better. Primary systemic therapy has not to
date been shown to improve survival.
It shrinks tumor often allowing breast
conserving surgery rather than ADJUVANT CHEMOTHERAPY
mastectomy (followed by post operative
adjuvant chemotherapy). It is the use of chemotherapeutic drugs
after surgical treatment. It is used in
Chemotherapy or use of anti-cancer patients at intermediate or high risk of
drugs for cancer of breast has a major recurrence. Usually these patients are
role in the control of disease. It prolongs offered 4-8 cycles of multiple agent
life and controls symptoms in advanced (combination) chemotherapy.
cancer breast.
The role of systemic treatment to
Neo adjuvant therapy has become a improve outcome in operable breast
standard treatment in the management cancer is clearly established. It has
of locally advanced breast cancer. been shown that women under 50
years with node positive cancers show
Patients with earlier stage disease may enhanced survival by 25% after
also benefit from neo-adjuvant therapy addition of chemotherapy.
in terms of improved rates of breast
conserving surgery and better quality of Systemic adjuvant treatments include
life. cytotoxic and hormonal therapy.
Gemcitabine is a pyrimidine analogue Tamoxifen has shown similar increase

that has shown activity in a variety of in survival in women above 50 years
solid tumors, a good toxicity profile and age with node positive cancer breast.
non overlapping toxicity with other
chemotherapeutic agents. Preliminary Women with node negative breast
findings demonstrate increased cancer also get benefitted from

figures for node positive and negative research4.

patients of 6% and 2% respectively
(approx 11% relative mortality Patients with risk factors such as high
reduction). grade or large size tumor that for both
node negative and node positive
Anthracycline containing patients also benefit from
chemotherapy combina-tions result in chemotherapy upto 70 years of age.
absolute survival benefit at 5 years of The effect on outcome decreases with
3%. increase in age.
Taxane paclitaxel may further improve RESPONSE RATE(RR)

the survival3.
It is the measurement of
Commonly used chemotherapy chemosensitivity. It is used in palliative
includes Cyclophos-phamide, chemotherapy.
Methotraxate, 5 Fluorouracil,
doxorubacin and epirubicin. A complete tumor response represents
documented resolution of all known
The anthracycline containing regimens disease for at least 4 weeks with no new
are slightly superior and the addition of lesion development.
taxane to an anthracycline containing
regimen may further increase the PARTIAL RESPONSE (PR)
efficacy of adjuvant chemotherapy.
A partial tumor response is a reduction
The patients with metastatic disease in the cross sectional area of
cannot be cured. The objectives of measurable tumor (disease area) by
treatment are to improve the quality of more than 50% with no new lesion
life and prolong survival. Upto 60-80% development.
of these patients experience good
response to first line combination The reduction in tumor size may relieve
chemotherapy. The best results are symptoms subjectively even in the
achieved with 2 n d and 3 r d line presence of disease process.
chemotherapy drugs such as
Capecitabine, Vinorelbine, Emcitabine, Response rate represents survival
5-fluorouracil and variety of its oral pro- benefit correctly as survival benefit is
drugs. restricted to patients with substantial
and durable tumor response.
Combination of chemotherapy with
various response modifiers is a rapidly The potential benefits must be carefully
developing field of clinical cancer balanced against the risks of toxicity.

Interactive consent of patient after benefit.

detailed discussion of various treatment
options. These can be delivered through various
routes;
Outcome monitoring strategies and
record of toxic responses and criteria INTRA THECAL CHEMOTHERAPY
for treatment continuation.
Intra CSF infusion of chemotherapy has
ADMINISTRATION been used for treatment of
leptomeningeal metastatic disease.
The chemotherapy is given to achieve It can also be used for the treatment of
beneficial effects and avoid its severe leukemia and lymphomas.
side effects. The chemotherapy
regimens are scheduled at 3-4 weeks H E PAT I C ARTERY CHEMO
intervals to allow regeneration and EMBOLIZATION
recovery of bone marrow.
Liver metastasis can be palliated by
The cytotoxic drugs are given in c h e m o - e m b o l i z a t i o n o f l i v e r.
intravenous bolus doses over 1-2 hours Chemotherapy via intra arterial
or long infusions over 24-48 hours to injections has hardly shown any
improve efficacy and reduce toxicity. advantage in the treatment of liver
Infusion pump may be more helpful for metastasis.
the continuous infusion of drugs like 5
fluoro-uracil. GENERAL SIDE EFFECTS
Vinca alkaloids can cause severe skin Following side effects occur with most
necrosis and loss due to extra-vasation. of the cytotoxic agent;
Skin grafting may be required to
achieve adequate healing. ! Nausea and vomiting.
! Bone marrow toxicity
REGIONAL CHEMOTHERAPY (Suppression).
! Gastrointestinal toxicity.
Chemotherapy can be used regionally ! Alopecia.
for local treatment of tumors. High ! Gonadal effects.
doses of chemotherapy are delivered to ! Hyperuricaemia.
the tumor locally to show greater effect
and low systemic toxicity. SPECIFIC SIDE EFFECTS
High dose chemotherapy with stem cell Some side effects are specific to
rescue produces no overall survival certain agents.

particular drugs. The toxic effects vary against myelo-suppression. This

with the dose and type of drugs and treatment is only cost effective in
schedule of administration; patients requiring intensive treatment
with curative intentions.
FATIGUE
HAIR LOSS (ALOPECIA)
It may be profound and disturbing. It
may effect patient compliance for next It is a common complication of cytotoxic
cycle. The patient must be counseled chemo-therapy. Alopecia may be
about it and measures should be taken complete within few weeks after starting
to relieve it. chemotherapy. The hair loss can be
prevented by using a cool cap over the
All types of side effects must be head at the beginning of chemotherapy.
informed to the patient before starting The cool cap is a hat or cap which is
the treatment. cooled gel filled in a freezer prior to use.
70% of patients can be protected from
BONE MARROW SUPPRESSION having hair loss. The patients with liver
secondaries usually have no effect with
It is the most serious side effect of this cap and loose hair anyway.
chemotherapy. Myelo-suppression is
usually at its maximum 10-14 days after NAUSEA AND VOMITING
treatment. It may lead to life threatening
neutropenia related infections. The These are common with cisplastin and
patient may end up in septicaemia and other alkylating agents. Anti emetics are
septic shock. All patients on used with initial treatment in these
chemotherapy, when feel unwell and patients. It can be relieved by
have fever must be treated actively for granisterion, metoclopramide and
septicaemia. domperidone for few days after
chemotherapy. Delayed vomiting may
Thrombocytopenia occurs and be treated with corticosteroids.
presents with bruising, petechia and Intractable vomiting is uncommon but
epistaxis. Prophylactic platelets may be treated with pheno-thiazines
transfusion is considered to avoid the (levomepromazine).
risk of post chemotherapy hemorrhage.
Most of the acute adverse effects of
Anaemia is quite common and is seen chemotherapy are transient. The late
few weeks after chemotherapy. It can adverse effects are irreversible such as
be treated with blood transfusion. cardiomyopathy associated with
Haemopoitic growth factors after anthracyclines. Infertility may occurs
alternate to transfusion and protection due to premature menopause of

collaboration groups: 5. Sanchaz-Rovira P,JaenA, Duenas

Lancet1998;353:930-42. R, Porras I et al. Neo-adjuvant
gemcitabine therapy for cancer
3. Bergh J, Jonsson PE, Glimelius B, breast. Clin breast cancer 2002
Nygren P. A systemic over view of May; 3 Suppl 1 : 39-44.
chemotherapy effects in breast
cancer. Acta oncol 2001;40(2-3):
253-81.
4. Current treads in pharmacotherapy

of breast cancer. Orv Hetil 2002
April 7; 143(14): 725-30.

Chapter-22
Imm notherapy
TREATMENT MODALITIES -5 (IMMUNOTHERAPY) 2
Objectives
! To understand the immunological aspects in breast carcinoma
patients.
! To evaluate the effects of Immunological therapy on breast cancer
patients.
! To find out new immunotherapeutic agents for more effective

IMMUNOTHERAPY
It is the treatment of carcinoma of modality for the treatment of carcinoma

breast through immune response as a breast.
part of body's natural defense or
following artificial stimulation of The immune system can clearly
immune system against carcinomatous recognize the cancer cells. There is little
tissue. evidence that it does so to any effective
consequence in patients with advanced
The concept of immunotherapy of breast cancer.
cancer was evoked more than a century
ago by W. Coley. Recent understanding The challenge for the clinician is to find
of molecularly defined therapeutic ways to enhance the ability of a
approaches and efforts required to patient's own immune system to
place immunotherapy beside surgery, recognize and effectively target
chemotherapy and radiotherapy as 4th malignant cells. There is no shortage of
option target antigens for immune cell
recognition of breast cancer.
Its two aspects are being focused;
It is still not clear whether successful
! Active therapeutic vaccination outcome depends upon enhanced
! Active vaccination with allogenic recognition of an individual target or a
bone marrow cell transplantation. more general route to enhance immune
cell activation2
Immunotherapy is likely to be very
powerful and less harmful modality than A variety of specific and non specific
conventional therapies4. It is still in early immuno stimulatory strategies have
stages of development. been applied with only modest clinical
success.
There is relatively minor role of
immunotherapy in carcinoma breast at The molecular characterization of novel
present but future holds a very human tumor antigen and improved
significant and positive role of this understanding of immunological

rejection antigens. Identification of immune response.

antigen specific T and B cells will be
helpful in clinical and diagnostic Histological examination of regressing
immunotherapy3. lesion show significant T-cell infiltration.
There is increasing evidence that Spontaneous regression after

tumors express putative target resection of primary tumor is seen in
molecules for therapeutic immune renal cell carcinomas and melanomas
reaction. The identification of possibly due to immunological
immunogenic tumor associated response of the body against cancer.
antigens may allow new modes of
vaccination with a hope to add a new Acquired immune deficiency or
and powerful modality for treatment of dysfunction is related with increased
cancer breast13. incidence of malignancies.
Adjuvant chemotherapy has achieved Two clear components of immune

significant result but the control of system are noticed in cleaning the
minimal residual cancer breast is still a foreign matter (cancer tissue and
challenge for treating clinicians. microbes);
Immunotherapy holds promise for ! Non specific immune response

future modes of treatment. This anti (phagocytosis and inflammation).
cancer strategy aims at triggering a ! Specific recognition by humoral
highly specific endogenous killing and/or cellular immunity.
machine against tumor cells14.
T-cells differentiate in thymus and
Many clinical observations are mediate cellular response.
suggestive of immunological
recognition of human cancer such as; B-lymphocytes produce
immunoglobulins in response to foreign
The tumors of breast are recognized by antigens. The immunoglobulin-antigen
the body as foreign to the host. combinations trigger cellular and
molecular response.
The halo naevus a surrounding area
with prominent lymphocytic infiltrate Macrophages, mononuclear
suggesting endogenous immune phagocytes and dendritic cells are the
response. antigen presenting cells.
Spontaneous regression of cancers is Lymphocytes are natural killers. These

also suggestive of striking endogenous destroy tumor cells coated with

few clinical responses. Some 3. T-cell therapy12.

chemotherapeutic agents may
enhance the immune effects of INTERFERON
genetically modified tumor vaccines6.
There are three classes of interferon a,
Tumor vaccines are based on weakly b and g. These pose wide spectrum of
immunogenic specific tumor antigens activities. These are antiviral,
admixed with adjuvants in order to elicit, stimulatory to immune system (macro-
restore, augment anti tumor immune phage phagocytosis, natural killer cells
responses against residual or and direct cytotoxic effects). These
metastatic tumor cells. Cellular change cell membrane characterisitics
cytotoxity plays major role in killing of the tumor cells.
tumor cells.
These function by binding to cell
It requires three synergistic signals; surface receptors interacting with
specific gene sites in normal and
1. Presentation of specific tumor neoplastic cells.
antigen.
2. C o s t i m u l a t o r y s i g n a l ( B - 7 INTER LEUKINS
molecules).
3. Propagation signal cytokines. These are peptides which act as
modulators of immune and
Vaccines produce specific immune inflammatory response. Interleukin 2
response and objective clinical (IL-2) is a natural product secreted by
responses with minimal toxicity. activated CD4-positive T-lymphocytes.
Advances in gene transfer technology, IL-2 stimulates production of interferon

tumor immunology and better methods g and tumor necrosis factor (TNF) it
of monitoring specific anti tumor activates natural killer cells,
response promise a hope for future lymphocyte activated killer cells (LAK).
development of tumor vaccine for These kill tumor cells.
7
appropriate clinical use .
HERCEPTIN
The major immunotherapeutic
strategies have potential to enhance or It is a recombinant, humanized
generate an anti breast cancer T-cell monoclonal antibody. It is an immune
immune response; therapeutic agent which has attracted
significant attention because of its
1. Cytokine therapy. efficiency and moderate toxicity.
2. Cancer vaccines.

Herceptin given in combination with cells. These can be grown under

chemotherapy for advanced breast various culture conditions which
cancer has a higher response rate and influence the phenotypical and
longer disease free survival than functional properties immune response
chemotherapy alone in women with m a i n l y e x e c u t e d b y T- c e l l s .
HER-2/neu positive tumors (survival Administration of dendritic cells cause
advantage). tumoricidal T-Cell based immune
response5.
Local and systemic treatment for
cancer breast such as surgery, REFERENCES
radiation therapy, hormonal therapy
and chemotherapy are effective against 1. Samneen. 1 Ahmed Bary W
primary and metastatic disease but far Hancock, Principals of cancer
from achieving cure and survival of treatment by immunotherapy.
patients. It may be due to emergence of Surgery international, (53) 58-61,
drug resistant tumor cells. 2001.
2. Cameeron DA. Breast cancer

Gene therapy offers a useful approach
vaccines: current research and
to breast cancer therapy. These future prospects. Expert Rev
approaches are; vaccines, 2002 Jun: 1(1):29-34.
Altering the metabolic or signaling 3. Geissler M, Weth R.

response within the breast cancer. Immunotherapy, rew in sights
schweiz Rudsch Med Prax 2002
Designed to enhance the immune Dec 91(51-52): 2236-46.
response to tumor cells (immunogene
therapy) 4. Zoller N, Matzku S. Active
vaccination after allogenic bone
marrow cell transplantaion. A new
Using the drug resistant gene with
option in the immunotherapy of
chemotherapy. cancer. Arch immunol there Exp
(Warsz) 2002; 50(3): 197-224.
The systemic treatments are more
important. It is hopeful to over come the 5. Remhard G. Marten A, Kiske SM,
difficulties like heterogenicity and low Fel F, Bieber T, Schmidt Wolf IG.
immunogenicity of breast cancer cells11. Generation of dendritic cell based
vaccines for cancer therapy, Br J
DENDRITIC CELLS cancer 2002 May 20 20; 86 (10):
1529-33.
Dendritic cells play a major role in the
6. A r m s t r o n g T D , J o ff e e E M .
generation of immunity against tumor
Cytokyne modified tumor vaccines.

breast. Genetic immuno therapy. boil Neoplasia 1999 Oct; 4(4): 353-
Breast cancer Res 2002;2(1):51- 65.
21. 13. Zoller M, Matzku S. Cancer therapy,
new concepts on active
11. Takeda Y, Eriguchi M. Gene therapy immunization. Immuno-biology
for breast cancer. Nippon Rinsho 1999 Sep, 201(1): 1-21.
2001 Jan; 59(1): 110-8.
14. Mocellin S. Rossi CR, Lise M.
12. Knutson KL, Schiffman K, Rinn K, Marincola FM. Adjuvant immuno
Disis ML Immuno therapeutic therapy for solid tumors. From
approaches for the treatment of Promise to clinical application.
breast cancer. J mammary gland Cancer immunol immuno ther 2002

Chapter-2
Pro nosis in
Cancer Breast
PROGNOSIS IN CANCER BREAST 2
Objectives
! To understand the tumor biology.
! To understand the natural behavior of tumor.
! To understand the outcome of various treatments.
! To plan preventive measures to improve the quality of
life.
! To plan psycho-social aspects of patient.
! To counsel the patient adequately.

PROGNOSIS IN CANCER BREAST

Prognosis is a forecast as to the lesion.

probable outcome of an attack of ! Growth rate of tumor (doubling time
disease. It is also the prospect as to the or mitosis).
recovery from a disease as indicated by ! Histologic type of tumor.
the nature and symptoms of the patient. ! Tumor differentiation (histologic
nuclear grading).
Prognosis in breast cancer is the ! Extent of lymphocytic infiltration.
assessment of quality and quantity of ! Mucin secretion.
life after the diagnosis and / or ! Lipid content.
treatment for cancer of the breast. ! Tumor necrosis.
Prognosis depends upon; ! Lymphatic invasion.
! Blood vascular invasion.
1. D y n a m i c i n t e r p l a y b e t w e e n
anatomical extent of tumor and its ANATOMICAL EXTENT OF CANCER
g r o w t h p o t e n t i a l
(virulence/aggressiveness) Assessment of extent of tumor is
2. Degree of Immuno competence of performed by staging the disease.
the host (host defence mechanism Staging of carcinoma breast is
). performed with great care. It is based
3. Appropriate and timely treatment. on the fact that carcinoma breast starts
locally, spreads locally and regionally to
There are many factors, which help to lymph glands and distant metastasis is
predict the prognosis and estimate seen as the systemic spread occurs .
survival in patients with breast cancer; Most but not all patients show direct
relationship to the stage of disease at
! Anatomical extent of cancer the time of diagnosis and length of
! Number of axillary nodes involved survival.
with tumor.
! Histopathological features of lymph The earlier the cancer is detected, the
nodes. better is the prognosis.
! Size and / or contour of primary

cancer patients is only 25%. 10 years survival 33%.
10 year survival rate in cancer breast. In clinically positive group of nodes ;

Description 5 year 10 year
survival survival
Node free cancer breast 75% 5 years survival 58%.
Pathologically
10 negative
years survival 38%. nodes
84% 70%
Node positive cancer breast 25%
Clinically negative nodes 74% 58%
It is not only the involvement of nodes
but their number, level of involvement Pathologically positive nodes
52% 33%
and extension through capsule.
Determination of micro or macro Clinically positive nodes 58% 38%
metastasis are important prognostic
factors.
There is 33% difference in involvement

of nodes between clinical and
histological assessments. The number of axillary nodes involved
in cancer is inversely proportionate to
The false evaluation of axillary nodes patient’s survival. More number of
on clinical examination varies between. nodes involved, worse is the prognosis.
(false positive : false negative 24%-
39%) Ten years survival ranges between 38-
Overall error in clinical staging is about 54% when one to three nodes are
32%. involved but it drops to 13% when more
35 % of clinically negative nodes have than three nodes are involved,
metastasis on histopathology.
87% clinically positive nodes have 5 years Five year survival
survival in nodeLevelpositive
wise
metastasis on histopathology. patients is about 49%. It is not only the
Level-I involvement
number but the level of 65% nodal
In pathologically negative nodes; involvement as well which affects
5 years survival 84%. Level-II involvement
prognosis signifi-cantly. 45%
10 years survival 70%.
Level-III involvement 28%
In clinically negative nodes ;
In pathologically positive nodes ;


contained within capsule has 30% configuration) affects prognosis. The

recurrence rate after same period. rounded tumour has better 10 years
survival and tumors with irregular
Lymph node morphology has variable margins have poor prognosis.
prognosis (10 years survival) such as;
SITE OF CANCER
10 years survival (lymph gland morphology)
Cancer of breast present in the outer
Lymphocyte predominance 75% quadrants has better prognosis than if
present in the inner quadrants.
Germinal center predominance 54%
5 years survival in medial quadrant
Lymphocyte depletion 33% tumours is 70%.
And 5 year survival in lateral quadrant
Un stimulated 37% tumour is 84%.
It seems to be due to involvement of
The prognosis (5 years survival) is internal mammary lymph glands which
decreased as the size of carcinoma affect the prognosis significantly.
increases, (local spread, T-staging).
The lymph gland involvement (N The prognosis is poor when tumours
staging regional spread) affects the are located in the middle vertical
prognosis badly. segment of the breast or are diffuse.
Smaller the cancer, better the survival. There are different types of cancer
breast. Some lesions have less
Non invasive carcinoma of breast virulence and rarely change to
(lobular carcinoma and intra ductal metastatic disease. Some are very
carcinoma) and early invasive cancers virulent and change into metastatic
(minimal cancers) upto 0.5 cm diameter disease early. These two groups have
have an estimated ten year or more marked difference in the prognosis and
survival over 90%. mortality.
Cancers less than 01 cm size are 40% of accurately diagnosed patients

termed as minimal cancers. These of carcinoma breast die at a rate of 25%
show 20 years survival rate of about per year (Aggressive tumors). 60% of
93% and 10 years survival rate of 95%. patients die at the rate of 2.5% per year
(less aggressive tumors).
SHAPE OF CANCER BREAST
The patients with local breast cancer
Cancer margins (contour or and no lymph node involvement have

situ (LCIS) and intra ductal carcinoma

in situ (DCIS) have excellent prognosis Prominent nucleoli.
(100%) 5 years survival. Chromatin clamming.
Numerous mitotic figures.
These patients usually do not have any
recurrence when treated with simple It is considered to be undifferentiated.
mastectomy and axillary sampling.
NUCLEAR GRADE II (NG-2)
Following histologic types of invasive
carcinoma of breast have better It is intermediate grade between NG -1
prognosis ; and NG-3. The nuclear changes are
moderately differentiated.
Adenocystic carcinoma.
Colloid carcinoma. NUCLEAR GRADE III (NG-3)
Comedo carcinoma with minimal
stromal invasion. The nuclei are quite similar in size and
Medullary carcinoma with lymphoid shape to normal breast cell nuclei.
infiltrate . These are well differentiated with
Papillary carcinoma. minimal malignant change.
Tubular carcinoma.
TUMOR GROWTH AND
Histologic grading is measurement of AGGRESSIVENESS
5 year survival in cancer breast
normal histologic and cytologic
differentiation and general or nuclear The doubling time of breast cancer cells
Quadrant
grading. vary between 23-209 days with an
Medial (Inner) average of 100 days.
70%
Lateral (outer) 84% A tumor with 23 days doubling time

takes about 2 years to attain 1 cm size.
A tumor with 200 days doubling time

takes 17 years to achieve size of 1 cm.
Majority of patients show inverse

NUCLEAR GRADING I (NG-I) relationship of survival to the size of
tumor at time of diagnosis but in some
There is definite association between cases post operative survival of
nuclear grading and survival of the patients with large size tumor is
patient. It shows marked variation in prolonged while of those with small size
size and shape; tumor is minimized with disseminating

TUMOR NECROSIS patients (within 18 months).
Tumor necrosis is associated with Although it is not confirmed yet,

greater rate of regional (axillary elastosis present in the tumor bed is a
metastasis). It has higher mortality. favourable sign and has better 5 year
survival. It is a sign of slow growth of
Tumors with necrosis and infiltrated tumor.
border are more aggressive and have Mucinous or colloid carcinoma of breast
75% rate of axillary metastasis. It is has favourable prognosis but
associated with 29% 10 years survival. intracellular mucin (signet ring cell)
carcinoma does not have better
Tumors with smoothly circumscribed survival.
borders and no necrosis have 30% rate
of axillary metastasis and 61% 10 years Good host defense response to cancer
survival. is indicative of better survival.
Tumor necrosis is an independent LYMPHO-RETICULOENDOTHELIAL

variable predicting treatment failure. RESPONSE
SPREAD OF TUMOR The fatal behavior of carcinoma of

breast is determined by the interaction
Blood vessel invasion by tumor has a of growth potential of tumor nuclear
negative effect on survival time. Blood grade or relating to host inhibitory or
vessel invasion is more likely to be resistance factors that represent an
associated with a severe cell reaction in immunological response of
the tumor, lymphatics, invasive reticuloendothelial system.
metastasis, four or more axillary nodes,
necrosis and NG I grading. These include the degree of lymphoid
infiltrate around the tumor, the degree
Lymphatic invasion is an unfavourable of perivenous infiltrate in section cut
pathologic finding for patients survival. through the tumor, number of
There is an association of early tumor histiocytes in the sinusoids of regional
recurrence at 6-18 months. lymph nodes (sinus histiocytes).
Tumors with perineural space invasion These tests are graded 0-4 with better
are more likely to be associated with survival in higher grades and worst in
lymphatic invasion, nipple involvement lower grades.
and axillary metastasis.
IMMUNO COMPETENCE OF
Tumor recurrence is seen early in these PATIENT

shorter the time of disease free interval, breast cancer death1.

greater is the number of sites of
recurrence, poorer is the survival. Breast cancer comprises 22% of all
cancers occurring in females but only
Recurrence in liver and brain has 2% of cases occur in women aged 35
extremely poor prognosis while years or less2.
recurrence in bones have less poor Breast cancer in young (<or=35 years)
prognosis. Untreated patients of breast women is biologically aggressive
cancer have a 5 year survival of 18% compared with older women. Factors
and 10 years survival of 4%. Any Form predicting survival and overall survival
of treatment is likely to improve survival. are comparable with those of old
women.
The primary objective of the treatment
of carcinoma breast is cure. Although Difference between 5 year survival rate
cosmetic appearance and functional is observed according to length of
results are very important, no 5 years interval between
survival recognizing
rate depending the of
upon length
procedure is selected to compromise interval
primarybetween diagnosis
lesion and and recurrence.
recurrence.
cure of the cancer.
Shorterwith
Patients thaninterval;
24 months 14%
Earlier the diagnosis is confirmed,
24-60 months 64.3%
better is the cure and long term survival. Shorter than 24 months has survival
rate 14.3%.
More than 60 months 41.7%
Early diagnosis offers better cure, less Between 24-60 months survival rate
extensive surgery, better cosmetic 64.3%.
results, less adjuvant therapy and Longer than 60 months had 41.7%3.
better functional results.
The morphometrical grading system

helps in efficient prediction of prognosis
of cancer breast by dividing patients
into;
Favourable (grade I).

Intermediate (grade II).
Unfavorable (grade III). Patients treated with surgical excision
and chemoradiation have better
Morphological grading is efficient in prognosis about 53.9% than patients
identifying patients with most who could not have surgical excision.
unfavorable outcome. Morphometrical
grade III patients have a 5.4 fold risk of REFERENCES

3. Showronek J, Piotronski T. Loco-

regional recurrence of breast
cancer: a metrospective
comparison of treatment methods.
Neoplasma 2002; 49(6): 426-3.

Chapter-24
Primary Care for

Survivors of Breast Cancer
PRIMARY CARE FOR SURVIVORS OF BREAST CANCER 2
Objectives
! To evaluate the outcome of treatment in breast cancer patient.
! To look after the breast cancer patient adequately.
! To look after the psycho-psychiatric aspect of the patient.
! To look after the socio-economic aspects of the patient.
! To look after and manage the complication of disease or its
treatment appropriately.

PRIMAR CARE FOR SURVIVORS

PRIMARY
OF BREAST CANCER
Faisal Bilal Lodhi, FCPS
Screening programs have increased wall.

the number of women in whom invasive ! Adenopathy (axillary and other).
or noninvasive breast cancer has been ! Weight loss.
diagnosed. Earlier detection and better ! Persistent cough.
treatment have led to improved ! Cardio-pulmonary symptoms.
prognosis. ! Musculo-skeletal pain.
! Headache and vertigo.
Women with breast cancer have
several unique health issues. They These symptoms are non specific and
require regular follow-up to detect even in survivors of cancer, are
recurrences of their breast cancer at the frequently attributable to benign
earliest. They may have long lasting conditions. Many long term follow-up
side effects of treatment including studies have shown that more than 75
premature menopause. Survivors of percent of recurrences are heralded by
cancer may have questions regarding symptoms or by findings on physical
childbearing, the use of hormone examination. The symptoms should be
replacement therapy, psychological carefully evaluated1,2.
and social aspects of survival.
Physicians may detect local or regional
ME ICAL EVALUATION recurrences in the breast, chest wall or
lymph nodes on physical examination.
Women with a history of breast cancer Laboratory tests, chest roentgeno-
are at risk for recurrence for the rest of graphy and bone scanning. They rarely
their lives,. Most of these are detected identify metastatic disease in
within 5 years, but recurrences can asymptomatic patients.
occur 5 to 10 years after diagnosis and
later recurrences are not uncommon. Even with intensive surveillance,
Symptoms suggestive of recurrence asymptomatic recurrences constitute
include; only a fraction (15 to 25%) of all cases of
metastatic disease3.
! Changes in the breast or chest

Modeling studies suggest that patients and radiation treatment.

with node-negative breast cancer who
are known to carry a BRCA1 or BRCA2 Because it requires less extensive
mutation may have gains in life axillary surgery, sentinel-lymph node
expectancy from prophylactic contra biopsy is likely to be associated with a
lateral mastectomy. In addition, the lower risk of lymph edema than
family members of affected patients standard axillary dissection.
may want to consider intensive
surveillance or prophylactic surgery. Obesity, weight gain and infection in the
arm are additional risk factors for lymph
L O C A L C O M P L I C AT I O N S O F edema. In most patients, lymph edema
THERAPY FOR BREAST responds to conservative
CANCER management, including arm elevation
and the use of compression gloves or
Local complications are worse with sleeves. Appropriate physical therapy
more extensive surgery, more may relieve lymph edema that does not
extensive radiation or both and may be respond to conservative treatment. It is
aggravated by adjuvant chemotherapy. reasonable to protect the ipsilateral arm
from infection, compression,
Breast reconstruction with implants or venipuncture, exposure to intense heat
tissue flaps is an option for most women and abrasion to minimize chance of
after mastectomy. The reconstructed lymph edema.
breast should be examined for nodular,
erythematous or rash like changes in L AT E C O M P L I C AT I O N S OF
the skin or subcutaneous tissues that CHEMOTHERAPY
might indicate recurrence.
Chemotherapy for breast cancer have
Women who are candidates for many adverse effects, most of which
radiation therapy after mastectomy resolve after treatment has been
may wish to consider reconstruction completed. The most serious, even life
with autogenous tissue or delay threatening, late sequelae are
reconstruction. Radiation therapy secondary leukemia and cardiac
contributes to complications and impairment, both of which are rare.
impairs cosmoses after construction, Clinically significant congestive heart
particularly when implants are used8. failure develops in 0.5 to 1.0% of
women treated with standard
Lymph edema rates of 10 to 25% are anthracycline based chemotherapy
still reported, although most cases are regimens.
mild. The risk of lymph edema is directly
related to the extent of axillary surgery Risk factors for cardiac toxicity include

-phamide, methotrexate and the more gradual lowering of estrogen

fluorouracil or anthracycline adjuvant levels that occurs with normal aging.
chemotherapy.
EFFECTS OF TAMOXIFEN ON
G Y N E C O L O G I C A N D GYNECOLOGIC
REPRODUCTIVE COMPLICATIONS FUNCTION AND FERTILITY
OF THERAPY Tamoxifen is a mixed estrogen against
and antagonist that has a variety of
A M E N O R R H E A R E L AT E D T O effects on gynecologic functions.
CHEMOTHERAPY Among both younger and older women,
Adjuvant chemotherapy is frequently tamoxifen therapy can cause hot
associated with either temporary or flushes, night sweats, vaginal
permanent amenorrhea resulting from discharge, itching or dryness. Over half
direct toxicity to the ovary. The of all women taking tamoxifen report
incidence of chemotherapy induced such symptoms, although in most
ovarian failure depends on; cases they are mild. Tamoxifen may
contribute to dyspareunia and can
The chemotherapy regimen. diminish sexual interest and
The cumulative dose. satisfaction.
(particularly the dose of alkylating
agents such as cyclophosphamide). Menstrual function may be either
The age of the patient. normal or disrupted during tamoxifen
Younger women are much less likely to therapy. Women who have menstrual
have chemotherapy induced dysfunction while taking tamoxifen may
amenorrhea. On the other hand, resume normal menses after drug
ovarian failure is common in women therapy is stopped.
over 40 years of age who are receiving
chemotherapy. Women who wishes to become
pregnant should discontinue tamoxifen
Chemotherapy induced ovarian failure therapy several months before trying to
is characterized by diminished conceive.
circulating levels of estrogen and
progesterone and elevated levels of Tamoxifen increases the risk of
follicle-stimulating hormone and endometrial cancer, owing to its
luteinizing hormone. These changes proestrogenic effects on the
are similar to the changes seen in endometrium . The risk is more
10
natural menopause and have the same pronounced among postmenopausal

effects. Because of the rapid change in women, obese women, and women
menopausal status, symptoms can be who have had hormone replacement
more severe than those associated with therapy. Endometrial cancer develops

become pregnant after a diagnosis of pregnancy resulting in asymmetric

breast cancer have a worse outcome breast enlargement.
then those who do not become
pregnant. Some women (25 to 30%) are able to
lactate after breast conserving surgery
Self selection of patients with a more and irradiation, but the majority of these
favorable prognosis on the basis of patients continue to report difficult and
tumor features or natural history may inadequate lactation in the affected
introduce bias into studies of pregnancy breast.
after a diagnosis of breast cancer. HORMONE REPLACEMENT THERAPY
According to the limited available Surveys suggest that a minority of
reports, previous chemotherapy does survivors of breast cancer (20 to 30%)
not appear to have teratogenic effect11. are interested in hormone replacement
therapy and that these are mainly
The studies to date offer reassurance women with severe menopausal
for women who wish to become symptoms or a great fear of heart
pregnant after treatment for breast disease or osteoporosis.
cancer, but they do not exclude the
possibility that, for a given patient, Hormone replacement therapy is
pregnancy may increase the risks of generally not recommended for
recurrence. survivors of breast cancer, partly
because of the possible risk that such
Traditionally, patients have been therapy will exacerbate breast cancer
advised to wait two years after and partly because any potential
diagnosis before becoming pregnant, benefits of such therapy are diminished
because of the higher rate of by the risk of death from breast cancer
recurrence of breast cancer in the first in these women.
several years.
Furthermore, Hormone replacement
The extent and nature of breast therapy can impair both the sensitivity
conserving surgery affect the likelihood and the specificity of mammography
of successful lactation. Resection of potentially impeding the timely
centrally located tumors is more likely to detection of a new contra lateral breast
impair lactation, as is breast irradiation cancer or an ipsilateral recurrence.
which causes fibrosis of the lobules.
Consideration of Hormone
A breast that has been treated by breast replacement therapy seems most
conserving surgery and irradiation may reasonable in the small subgroups of
not undergo hypertrophy during survivors of breast cancer including;

months) is likely to be safer than they do in the general population of

extended use8. postmenopausal women.
O S T E O P O R O S I S & Survivors of breast cancer may benefit

CARDIOVASCULAR RISK FACTORS from other strategies to minimize the
risk of osteoporosis, such as smoking
survivors of breast cancer may be at cessation, treatment of any metabolic
lower risk for osteoporosis than the or endocrine disorders, weight bearing
general population because of the role exercise and adequate intake of
of estrogen in both preserving bone calcium (1000 to 1500 mg/day) and
mineral density and increasing the risk vitamin D (400 to 800 IU/day).
of breast cancer. However clinical trials There is concern that prolonged
have demonstrated that amenorrhea estrogen deprivation may put survivors
caused by adjuvant chemotherapy is of breast cancer at greater risk for heart
accompanied by a loss of bone mineral disease. As yet, there are no data on the
density of 2 to 7%, a loss similar to that clinical importance of estrogen
which occurs during natural deprivation in such women.
menopause. As with normal
menopause, trabecular bone (such as Aggressive and appropriate
the lumbar spine) is affected more than management of known risk factors for
cortical bone (such as the femoral cardiovascular disease, such as
neck). hypertension, diabetes, and elevated
lipid, as well as the encouragement of
Specific interventions may alter the risk smoking cessation is clearly warranted
of osteoporosis in survivors of breast with modern techniques of radiation
cancer. therapy. The risk of cardiac disease due
to irradiation of the left side of the chest
Tamoxifen preserves bone density in appears to be minimal. Women treated
postmenopausal women by its according to older radiation protocols
proestrogenic effects10 and may reduce and with older equipment may have a
the incidence of osteoporotic fractures slightly increased long term risk of
of the hip, spine and radius. In cardiac complications from irradiation
premenopausal women, however, of the breast or chest wall.
tamoxifen therapy has been associated
with varying degrees of loss of bone Tamoxifen therapy is associated with
mineral density. Bisphosphonates, an increased risk of thromboembolic
given either during or just after adjuvant events, including deep venous
chemotherapy, may prevent the loss of thrombosis, pulmonary embolism and
bone mineral density associated with stroke. The absolute risk is small (these
chemotherapy induced menopause, as events occur in 0.5 % of patients) but is

dyspareunia, incontinence and vaginal Negative body image.

dryness. Estrogen rings appear to be Treatment related side effects (e.g.
associated with less systemic menopause, limb edema etc10.
absorption of estrogen than oral or
topical estrogen, but the safety of Most of these impairments resolve with
locally applied estrogen in survivors of time and adequate psychological
breast cancer is not known. support by the treating clinician.
PSYCHO SOCIAL ISSUES Survivors of breast cancer identify

many positive aspects of life after
The diagnosis and treatment of breast diagnosis of cancer, including an
cancer is life altering event with optimistic outlook on life and a renewed
significant psychological impact on sense of confidence, purpose and
patients, families and friends. vitality.
Specific treatments for cancer and the CHANGES IN LIFESTYLE

experience of having a serious illness
contribute to psychosocial difficulties. Obesity and weight gain, a lower level
Clinicians should inquire about mood of exercise and physical activity and
disorders, fatigue, anxiety, impaired greater alcohol consumption are all
cognitive performance and sexual associated with a higher risk of breast
dysfunction, since these problems are cancer. It is not known whether
prevalent among survivors of breast modifications in lifestyle or diet after a
cancer. diagnosis of breast cancer improve
survival.
Psycho social distress and problems
with adjustment are most intense Women who are treated with adjuvant
during the first year after diagnosis and chemotherapy particularly those who
therapy and they tend to improve over go through early menopause often
time. gain weight. Tamoxifen does not appear
to contribute to weight gain.
Risk factors for more pronounced
psychological and social distress Multi disciplinary efforts, including
include; nutritional advice, counseling and
exercise, can help survivors of breast
Preexisting psycho-social, family or cancer lose weight. Moderate exercise
marital stress. programs have been shown to lessen
Intense initial response to diagnosis fatigue, as well as the symptoms of
and treatment. depression and anxiety among
Young age. survivors of breast cancer.

REFERENCES 271:1593-1597.
1. W i n c h e s t e r D P, S e n e r S F, 6. Clinical practice guidelines for the

Khandekar JD, et al. use of tumor markers in breast and
Symptomatology as an indicator of colorectal cancer. J Clin Oncol
recurrent or metastatic breast 1996: 14: 2843-2877.
cancer. 1979: 43: 956-960.
7. Mellink WAM, Zholland R, Hendriks
2. Pandya kj, McFadden ET, Kalish JHCL, Peeters PHM, Rutgers EJT
LA, Tomey DC, Taylor SG IV, and van WAJ. The contribution of
Falkson G. A retrospective study of routine follow up mammography to
earliest indicators of recurrence in an early detection of asynchronous
patients on Eastern Cooperative. contralateral beast cancer 1991;
Oncology Group adjuvant 67:1844-1848.
chemotherapy trials for breast
cancer: 1 preliminary report. 8. Schuster RH, Kuske RR, Young VL
Cancer 1985;55:202-205. and Fineberg B. Breast
reconstruction in women treated
3. Schapira DV, Urban N. A minimalist with radiation therapy for breast
policy for breast cancer cancer. Cosmetics, complications
surveillance. JAMA, 1991: and tumor control. Plast Reconstr
265:380-382. Surg 1992; 90: 445-452.
4. The GIVIO Investigators. Impact of 9. Valagussa P, Zambetti M. Biasi S,

follow up testing on survival and Moliterni A, Zucali R and
health related quality of life in breast Bonadonna G. Cardiac effects
cancer patient; a multicenter following adjuvant chemotherapy
randomized controlled trial. JAMA and breast irradiation in operable
1994; 271:1587-1592. b r e a s t c a n c e r. A n n O n c o l
1994;5:209-216.
5. Roselli Del Turco M, Palli D, Cariddi
A, Ciatto S, Pacini P and Distante V. 10. Osbome CK. Tamoxifen in the
Intensive diagnostic follow up after treatment of breast cancer. N Engl J
treatment of primary breast cancer: Med 1998; 339: 1609-1618.
a randomized trial, JAMA 1994;

Chapter-2
Epi emiolo y Biostatistics

in Cancer Breast
EPIDEMIOLOGY AND BIOSTATISTICS IN CANCER BREAST 2
Objectives
! To understand various scientific and statistical
definitions.
! To be able to analyze various health conditions.
! To compare the local scientific data with data from other
parts of the world.

EPIDEMIOLOGY AND BIOSTATISTICS IN CANCER BREAST 3
EPIDEMIOLOGY & BIOSTATISTICS

IN CANCER BREAST
INCIDENCE
It is expressed as rate / number of
It is the number of new cases of cancer population / year.
breast in a defined population during a MORBIDITY
given period (defined period) of time. It
is expressed as rate / number of Morbidity is defined as a change,
population / year. subjective or objective from
phsiological well being. It can be
It is calculated by the formula; measured in;
Number of persons who were ill.
Number of new cases of cancer breast Spells / Periods of illness experienced
in a given time period by persons.
x 1000 Duration of these illnesses.
Population at risk during that period
ENDEMIC DISEASES
SUSCEPTIBILITY
It refers to the constant presence of a
Susceptibility means a likelihood of a disease within a given geographic area
person getting a disease. or population group without
importation.
PREVALENCE
It also refers to the usual or expected
It is the total number of cancer breast frequency of the disease with such area
patients present in a defined population or population group.
during a given period of time.
SPORADIC DISEASES
MORTALITY
It refers to the disease process which is
It is the number of deaths due to cancer scattered. The cases occur irregularly,
breast in a defined population during a haphazardly from time to time. These
given period of time. cases are few in number and separated

BREAST PAIN PRESENTATION OF BREAST DISEASES-2 4
examinations or other procedures in common in women. There is 3%

apparently healthy individuals who are increase in the incidence annually. The
not seeking help from health care. It incidence, mortality and survival trends
could be mass screening, high risk in breast cancer have changed after the
screening, selective screening or use of mammographic screening.
multiphasic screening. There is clear difference in the
behaviour of pre and post menopausal
Screening tests are not intended to be cancer breast.
diagnostic. These help in picking up the
positive case for further diagnostic work The cancer breast arises from ductal or
up. The time gained by screening for lobular epithelial cells with many
early detection of cancer breast is histological sub groups. There is
called lead time. marked variation in incidence between
races, geographical areas and socio-
LEAD TIME economic groups.
Lead Time is the period between The rates are almost double in north
diagnosis by early detection America and Israeel when compared
(screening) and diagnosis by other with Eastern Europe, Singapore &
means. Philippines & three times when
compared with China, Japan, India &
EPIDEMIOLOGY OF BREAST Pakistan.
CANCER
40% of families with increased cases of
It is the presence and behavior of cancer breast and more than 80% of
carcinoma breast in a defined families with breast and ovarian cancer
population during the defined period are due to genetic mutation & BRCA I
which can be mentioned and compared gene. These account for 4% of all
in relation to the characteristics of that breast cancers.
population.
MAJOR RISK FACTORS
It is used to explore factors related to
cancer breast etiology and risk factors ! Early menarche.
by virtue of race, exposure to known ! Late menopause.
genetic, environmental & cultural risk ! Late first birth.
factors. ! Single women.
EPIDEMIOLOGICAL SIGNIFICANCE MINOR RISK FACTOR

Cancer of breast is rare in men but most ! Post menopausal obesity.

SENSITIVITY POSITIVE PREDICTIVE VALUE
It is ability to identify effected individuals It is the ratio of true positive to the total
in screened population. of true positive and false positive.
It is the ability of a test to identify
correctly or to pick up correct diagnosis. TP
It is the ratio of true positive (TP) to the total of true
= -----------X 100
TP+FP
positive and false negative (FN) patients.
NEGATIVE PREDICTIVE VALUE
TP
Sensitivity =
-----------X 100
TP+FN It is the ratio of true negative to the total
SPECIFICITY of true negative plus false negative.
It is the degree of correlation of positive TN

test to the presence of disease. = -----------X 100
TN+FN
It is the ability to differentiate disease
process correctly. FALSE POSITIVE RATE = 1 0 0 % -
It is the identification of those who truly specificity
do not have the disease. FALSE NEGATIVE RATE = 1 0 0 % -
sensitivity
This is the ratio of true negative (TN) to
the total of true negative and false PROGNOSTIC INDEX
positive (FP).
TN It is an index or %age or a figure which
Specificity =-----------X 100
TN+FP predicts prognosis
It is calculated by the formula;

ACCURACY (Efficiency or Validity)
(PI) = (0.2 x size of tumor in cms) +
It is the percentage of correct pick up or (stage)+(grade)
identi-fication.
It is the ratio of true positive and true Prognosis of breast carcinoma
negative to total patients.
It is the ratio of true positive (TP) plus NOTINGHAM PROGNOSTIC INDEX
true negative (TN) results to the total (NPI)
number of patients subjected to the
test. NPI = (tumor size in cms x 0.2) + Lymph
Accuracy TP+TN node stage + tumor grade.
(Validity)= ----------- X 100
Total number of patients

2= 1-3 positive nodes. CASE CONTROL STUDY

3= 4 or more positive nodes.
3= 4 or more positive nodes. It is the study of patients and control
group. It reflects some kind of
Tumor grade incompatibility.
1= Well differentiated.
2= Moderately differentiated. COHORT STUDY
3= Poorly differentiated.
It is an observation or analytical study of
Prognostic Prognostic 5 years cases. It helps to obtain additional
groups Index survival
evidence in favour or against the
Good Less than 3.1 88% existing knowledge.
Moderate Bet 3.4-5.4 69%
It is also called prospective study,
Poor More than 5.4 25%
longitudinal study or incidence study.
NOTINGHAM PROGNOSTIC INDEX

(NPI) RETROSPECTIVE STUDY
Prognostic GroupsN.P.I 10 yrs survival %
1- Excellent Upto 2.4 94 Retrospective study or retrospective
2- Good Upto 3.4 83
cohort study is one in which the
outcomes have all occurred before the
3- Moderate - I Upto 4.4 70 start of investigations.
4- Moderate - II Upto 5.4 51
5- Poor > 5.4 19 REFERENCES
1. Mohammad Ilyas: Community

Medicine and Public Health,
Epidemiology. 5th Edition. 2001;
197-236.
2. J.E Park: Park’s Text Book of

Preventive and Social Medicine.
22nd Edition. Principals of
Epidemiology 2002; 45-71.

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What are the major stages of breast development during embryogenesis?

What are the major stages of breast development during embryogenesis?

What are some potential abnormalities that can occur during breast development?

What are some potential abnormalities that can occur during breast development?

Chapter-01

SURGERY - BREAST PROBLEMS 2

There is no sign of future breast in the

(5TH WEEK) 35TH GESTATIONAL DAY

Epithelial mammary bud appears by

Several mammary glands develop from

SURGERY - BREAST PROBLEMS 3

represents future lactiferous duct. The

the depth on both sides. Site of Depressed

These are surrounded by the

Nipple formation begins at 56 t h Non development of breast but

Accessary breast tissue present along

SURGERY - BREAST PROBLEMS 4

GROSS ANATOMY AT BIRTH

SURGERY - BREAST PROBLEMS 5

The nipple has myoepithelial cells stimulation of stromal and ductal

SURGERY - BREAST PROBLEMS 6

LATERAL THORACIC ARTERY

It is a branch of axillary artery. It VENOUS DRAINAGE

It is a branch of subclavian artery. It LYMPHATIC DRAINAGE OF THE

Superficial parts of the breast drain into

Epigastric & peritoneal

These supply through their perforating LATERAL MEDIAL

These are branches of acromio-

SURGERY - BREAST PROBLEMS 7

AXILLARY GROUP OF LYMPH Medial part of the breast is drained by

1. Anterior or pectoral group. The inferior part of the breast is drained

Most of the lymph from subareolar and LACTATION

Upper convexity of the breast drains Prolactin, a hormone secreted by the

SURGERY - BREAST PROBLEMS 8

secretion of mother in surges. Growth are surrounded by myofibrils and

SURGERY - BREAST PROBLEMS 9

Areola Milk glands

SURGERY - BREAST PROBLEMS 10

SURGERY - BREAST PROBLEMS 11

SURGERY - BREAST PROBLEMS 12

Triple Assessment - 1-1

SURGERY - BREAST PROBLEMS 14

Imaging (Mammography). It is guided by clinical findings, age of

The diagnostic sensitivity of triple PHYSICAL EXAMINATION OF BREAST

SURGERY - BREAST PROBLEMS 15

clearly understandable by the patient. therapy with its duration.

SPECIAL INTERVIEW The patient stands away from the table

Following specific questions are asked

Complaints of lump, nipple discharge,

SURGERY - BREAST PROBLEMS 16

Fig-2.4 Feel the nipples

Fig-2.3 Sitting patient with hands abducted

SURGERY - BREAST PROBLEMS 17

Color of the skin. PALPATION)

AREOLA The precise palpation of the lump can

Whole of the breast should be palpated SIZE

SURGERY - BREAST PROBLEMS 18

SURGERY - BREAST PROBLEMS 19