East Cancer

Breast Cancer
Axillary Lymph
Nodes
1. Anterior
2. Posterior
3. Medial
4. Lateral
5. Central
6. Apical
Breast Cancer
• Breast cancer is the most common cause of death in middle-aged
women in western countries.
• In 2004 approximately one and a half million new cases were
diagnosed worldwide.
• In England and Wales, 1 in 12 women will develop the disease during
their lifetime.
Aetiological factors
• Geographical
• Carcinoma of the breast occurs commonly in the western world, accounting
for 3–5% of all deaths in women.
• In developing countries it accounts for 1–3% of deaths.
• Age
• Carcinoma of the breast is extremely rare below the age of 20 years but,
thereafter, the incidence steadily rises so that by the age of 90 years nearly
20% of women are affected.
• Genetic
• It occurs more commonly in women with a family history of breast cancer
than in the general population.
• Breast cancer related to a specific mutation accounts for about 5% of breast
cancers
• Diet
• Because breast cancer so commonly affects women in the ‘developed’ world,
dietary factors may play a part in its causation.
• There is some evidence that there is a link with diets low in phytoestrogens.
• A high intake of alcohol is associated with an increased risk of developing
breast cancer.
• Endocrine
• Breast cancer is more common in nulliparous women
• Breastfeeding in particular appears to be protective
• Also protective is having a first child at an early age, especially if associated
with late menarche and early menopause.
• It is known that in postmenopausal women, breast cancer is more common in
the obese.
• Recent studies have clarified the role of exogenous hormones, in particular
the oral contraceptive pill and HRT, in the development of breast cancer.
• Previous Radiation
Pathology
• Breast cancer may arise from the epithelium of the duct system anywhere from
the nipple end of the major lactiferous ducts to the terminal duct unit, which is in
the breast lobule.
• The disease may be entirely in situ, an increasingly common finding with the
advent of breast cancer screening, or may be invasive cancer.
• The degree of differentiation of the tumour is usually described using three
grades: well differentiated, moderately differentiated or poorly differentiated.
Ductal carcinoma is
the most common
variant with lobular
carcinoma occurring
in up to 15% of cases.
• Staining for oestrogen and progesterone receptors is now considered
routine
• as their presence will indicate the use of adjuvant hormonal therapy
with tamoxifen or the newer aromatase inhibitors
• Tumours are also stained for c-erbB2 (a growth factor receptor)
• as patients who are positive can be treated with the monoclonal
antibody trastuzumab (Herceptin), either in the adjuvant or relapse
setting.
• Staining for oestrogen and progesterone receptors is now considered
routine
• as their presence will indicate the use of adjuvant hormonal therapy
with tamoxifen or the newer aromatase inhibitors
• Tumours are also stained for c-erbB2 (a growth factor receptor)
• as patients who are positive can be treated with the monoclonal
antibody trastuzumab (Herceptin), either in the adjuvant or relapse
setting.
Spread of breast cancer
• Local spread
• Lymphatic
• Bloodstream
Clinical Presentation
• Although any portion of the

breast, including the axillary tail,
may be involved, breast cancer
is found most frequently in the
upper outer quadrant
• Most breast cancers will present
as a hard lump, which may be
associated with indrawing of the
nipple
• As the disease advances locally
there may be skin involvement
with peau d’orange
Mammogram
Staging
Treatment
• Achieve local control
• Appropriate surgery
• Wide local excision (clear margins) and radiotherapy, or
• Mastectomy ± radiotherapy (offer reconstruction – immediate or delayed)
• Combined with axillary procedure (see text)
• Await pathology and receptor measurements
• Use risk assessment tool; stage if appropriate
• Treat risk of systemic disease
• Offer chemotherapy if prognostic factors poor; include Herceptin if Her-2 positive
• Radiotherapy as decided above
• Hormone therapy if oestrogen receptor or progesterone receptor positiv
Simple mastectomy
involves removal of only
the breast with no
dissection of the axilla,
except for the region of
the axillary tail of the
breast, which usually has
attached to it a few nodes
low in the anterior group
The radical
Halsted
mastectomy,
which included
excision of the
breast, axillary
lymph nodes and
pectoralis major
and minor
muscles, is no
longer indicated
as it causes
excessive
morbidity with no
survival benefit.
Patey mastectomy The breast
and associated structures are
dissected en bloc and the
excised mass is composed of:
the whole breast
a large portion of skin, the

centre of which overlies the
tumour but which always
includes the nipple
all of the fat, fascia and lymph

nodes of the axilla.
Radiotherapy
• Radiotherapy to the chest wall after mastectomy is indicated in
selected patients in whom the risks of local recurrence are high.
• This includes patients with large tumours and those with large
numbers of positive nodes or extensive lymphovascular invasion.
• There is some evidence that postoperative chest wall radiotherapy
improves survival in women with node-positive breast cancer.
Adjuvant systemic therapy
• Tamoxifen has been the most widely used ‘hormonal’ treatment in
breast cancer.
• The beneficial effects of tamoxifen in reducing the risk of tumours in
the contralateral breast have also been observed, as has its role as a
preventative agent
• Chemotherapy using a first-generation regimen such as a 6-monthly
cycle of cyclophosphamide, methotrexate and 5- fluorouracil (CMF)
will achieve a 25% reduction in the risk of relapse over a 10- to 15-
year period
• CMF is no longerconsidered adequate adjuvant chemotherapy and
modern regimens include an anthracycline (doxorubicin or epirubicin)
and the newer agents such as the taxanes
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Breast Cancer

• Although any portion of the

the whole breast

a large portion of skin, the

all of the fat, fascia and lymph

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