RUKMAN MECCA

AETIOLOGY
30 % OF ALL CA S IN FEMALES
AGE- RARE BELOW 20 YRS GENETIC- FAMILY HISTORY-BRCA1,BRCA2

COWDENS SYNDR,LI-FRAUMENS SYN ENDOCRINE-NULLYPAROUS,EARLY MENARCHE LATE MENOPAUSE DIET-LOW IN PHYTOOESTROGENS,ALCOHOL OBESITY OCPS,HRT

PATHOLOGY
DUCTAL CARCINOMA
LOBULAR CARCINOMA DUCTAL CARCINOMA IN SITU(DCIS) LOBULAR CARCINOMA IN SITU(LCIS)

DCIS
PRE INVASIVE CANCER THAT HAS NOT

BREACHED BASEMENT MEMBRANE -SOLID -CRIBRIFORM -PAPILLARY -MICROPAPPILARY

LCIS
PREMENOPAUSAL
MULTIFOCAL AND BILATERAL POOR PROGNOSIS

 DUCTAL CARCINOMA-MOST COMMON TYPE

LOBULAR CARCINOMA-CLASSICAL

-PLEOMORPHIC SCIRRHOUS CARCINOMA-HARD,WHITISH,NON CAPSULATED,CARTILLAGINOUS CONSISTENCY MEDULLARY CARCINOMA-ENCEPALOID TYPE,BRAIN LIKE CONSISTENCY

 INFLAMMATORY CARCINOMA-

-MOST MALIGNANT TYPE -PAINFUL,SWOLLEN BREAST,CUTANEOUS EDEMA -RAPID METS -WORST PROGNOSIS -ALWAYS STAGE 4

GRADING OF TUMOR
1-WELL DIFFERENTIATED
2-MODERATELY DIFFERENTIATED 3-POORLY DIFFERENTIATED

BASED ON -NUCLEAR PLEOMORPHISM -TUBULE FORMATION -MITOTIC RATE

CLINICAL FEATURES
HARD LUMP,COMMON IN UPPER OUTER

QUADRANT. PEAU D ORANGE APPEARANCE NIPPLE RETRACTION-LACT.DUCTS DIMPLING OF SKIN-LIG OF COOPER ULCER,NIPPLE DISCHARGE CANCER EN CUIRASSE-CANCER NODULES FIXITY TO DEEP MUSCLES,CHEST WALL

SPREAD OF BREAST CANCER LYMPHATIC SPREAD

AXILLARY(75%)INT.MAMMARY NODES(POST.1/3)
ANTERIOR-LATERAL THORACIC VESSELS CENTRALPOSTERIOR-SUBSCAPULAR VESSELS LATERAL-AXILLARY VEINS APICAL-RECIEVES FROM ALL GROUPS

INTERPECTORAL (ROTTERS) NODES-RETROGRADE SPREAD SUPRA CLAVICULAR, C/L NODES-ADVANCED Ds LYMPHOEDEMA OF UPPERLIMB IN FIXED NODES

HEMATOGENOUS SPREAD
SKELETEL METS COMMONEST(70%)

LUMBAR VERTEBRAE,FEMUR,THORACIC

VERTEBRAE,RIBS,SKULL
OSTEOLYTIC-PAIN,SWELLING,FRACTURE

LIVER,LUNG,BRAIN,ADRENALS,OVARY

TRANSCOELOMICSPREAD
THROUGH MEDIASTINAL NODES IN TO

PERITONEAL CAVITY-SECONDARIES IN-LIVER, PERITONEUM,OVARY(KRUKENBURG TUMOR)

STAGING

TNM STAGING TX-PRIMARY TUMOR CANT BE ASESSED T0-NO EVIDENCE OF PRIMARY Tis-CARCINOMA INSITU,PAGETS T1-TUMOR LESS THAN 2CM TI MIC-MICROINVASION .1CM OR LESS T1a-UP TO .5cm T1b-UP TO 1 cm T1c-UP TO 2 cm

 T2-2 to 5 cm
T3-MORE THAN 5 cm T4-EXTENSION TO SKIN,CHESTWALL

T4a-EXTENSION TO CHEST WALL

T4b-EXTENSION TO SKIN T4c-BOTH T4a,T4b T4d-INFLAMMATORY CARCINOMA

REGIONAL NODES
NX-CANT BE ASESSED
N0-NO NODES N1-MOBILE IPSILATRAL AXILLARY NODES

N2a-METS IN IPSILATERAL AXILLARY NODES

FIXED TO ONE ANOTHER N2b-ONLY IN INTERNAL MAMMARY NODES ABSENT IN AXILLARY NODES

 N3a-METS IN IPSILATERAL INFRACLAVICULAR

LYMPHNODES N3b-METS IN IPSILATERAL AXILLARY AND INTERNAL MAMMARY NODES N3c-METS IN IPSILATERAL SUPRACLAVICULAR NODES

DISTANT METASTASIS
MX-CANT BE ASESSED
M0-NO METS M1-DISTANT METS

PATHOLOGIC CLASSIFICATION(PN)
BASED ON AXILLARY LYMPHNODE DISSECTION

WITH OR WITHOUT SLNB. pNX-cant be asessed pN0-no lymhnode histologically (i-),(i+),(mol-),(mol+) pN1mi-micromets ,>.2mm or >200 cells,none greater than 2 mm. pN1a-1-3 axillary nodes atleast 1 > 2 mm

 pN1b-mets in int.mammary nodes not clinically

detected pN1c-mets in int.mammary and 1-3 axillary nodes not clinically detected. pN2a-mets in 4-9 axillary nodes pN2b-mets clinically detected int mammary in absence of axillary nodes

 pN3a-mets to 10 or more axillary nodes or

infraclavicular nodes. pN3b-mets clinicaly detected ipsilateral int.mammary with axillary nodes pN3c-mets in ipsilateralsupraclavicular nodes

STAGING
STAGE0 STAGEI A STAGE1B
STAGE IIA STAGEIIB

Tis N0 T1 N0 T0 N1mi T1 N1mi T0,T1 N1 T2 N0 T2 N1 T3 N0

M0 M0 M0 M0 M0 M0 M0 M0

 STAGE IIIA STAGE IIIB STAGE IIIC STAGE IV

Up to T3 Upto N2
ANY T4 ANY T ANY T NO/N1/N2 N3 ANY N

M0
M0 M0 M1

 EARLY BREAST CANCER-STAGE I AND II

LOCALLY ADVANCED BREAST CANCER-STAGE

IIIA & IIIB

METASTATIC CANCER-STAGE IV

INVESTIGATIONS
TRIPLE ASESSMENT CLINICAL ASESSMENT
RADIOLOGICAL IMAGING
CYTOLOGICAL OR HISTOLOGICAL ANALYSIS

FNAC
DONE WITH 23 GAUGE NEEDLE,LESS INVASIVE

FNAC SCORING C0-NO EPITHELIAL CELLS C1-SCANTY EPITHELIAL CELLS,BENIGN C2-BENIGN C3-ATYPICAL CELLS C4-SUSPICIOUS CELLS C5-MALIGNANT CELLS

 CORECUT/TRUECUT BIOPSY-DIFF DCIS AND

INVASIVE DUCTAL CA
FROZEN SECTION EXCISION BIOPSY-FNAC IN CONCLUSIVE AND

FROZEN SECTION NOT POSSIBLE

SENTINAL NODE BIOPSY

FIRST AXILLARY NODE DRAINING THE BREAST DONE IN ALL CASES OF EARLY BREAST CANCER

,T1,T2,WITHOUT CLINICALLY PALPABLE NODES PRE-OP/PER OP-INJ ISOSULFAN VITAL BLUE DYE OR Tc99 RADIOISOTOPE LABELLED COLLOID ALBUMIN NEAR TUMOR DETECTED BY GAMMA CAMERA SKIP LESIONS ONLY IN 3% , AXILLARY DISSECTION IF SLN POSITIVE

IMAGING
MAMMOGRAPHY-LOW VOLTAGE,HIGH

AMPERAGE XRAYS,IN WOMEN >3O YRS ULTRASOUND-USEFUL IN YOUNG WOMEN DIFF SOLID & CYSTIC LESIONS FNA CAN BE DONE UNDER USG GUIDANCE MRI BREAST TUMOR MARKERS CA 15/3

 ESTROGEN RECEPTOR STUDY

VALUE >10- ER POSITIVE-GOOD PROGNOSIS RESPONDS TO TAMOXIFEN CXR-LOOK FOR PLEURAL EFFUSION ,SECONDARIES IN LUNGS CT CHEST XRAY SPINE USG ABDOMEN-KRUKENBURG TUMOR