KABWE CENTRAL HOSPITAL

KCH
“BREAST CANCER”
Wisdom’s Lecture Notes

Banda Wisdom Chilufya

MBChB (CBU)
 LEARNING OBJECTIVE

• To describe the structure of the Female Breast

system
• Epidemiology
• Risk factors
• Pathophysiology
• Clinical presentation
• Complications
• Investigation
• Treatment modalities.
INTRODUCTION

1. Modified sweat gland

2. Organ of Beauty

3. Provision infant Nutrition

4. Male Breast vs Female Breast

ANATOMY

• Conical in shape

• Extent 2nd rib to 6th rib

• Midaxillary line to lateral parasternal

• Lie deep fascia of the pectoralis major

SPECIAL FEATURES

• Nipple and aerolar

• Montgomeries tubercles

• Extension axilla the tail of Spence

• Held up right by the Ligaments of Astley Cooper

1`111111
 Blood supply
 Internal thoracic artery
 Perforating branches of the intercoastal
artery T4 to T6
 Branches of the Axillary artery
- Superior Thoracic Artery
- Thoracoacromial Artery
- Lateral Thoracic Artery

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 16.32a
 Lymphatic Drainage
 75% Axillary nodes rest –internal
thoracic nodes
 Axillary nodes classified in 2 ways
- Region (Lateral,Medical/Central, Anterior,
Posterior & Apical)
- Levels( In relation to the Pectoralis Minor
Muscle)
level 1 (below Pec Minor),Level 2 (behind)
Level 3 (above)
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 16.33
EPIDEMIOLOGY
- Actual breast cancer incidence not known in
Zambia- about 1 in 100,000 women at risk
- Ranks 2nd women cancers after cervical
cancers
- Ranks 1st in developed countries amongst
women cancers- 1in 10 women at risk
Risk Factors for Breast Cancer
• Females • Being female
– Early menarche
– Late menopause
– Nulliparity or 1st pregnancy
>30 y.o.a.
– White race
– Old age
– Family history of breast
cancer
– Genetic predisposition
(BRCA 1, BRCA 2, Li
Fraumeni Syndrome)
– Prior personal history of
breast cancer
– DCIS or LCIS
– Atypical ductal or lobular
hyperplasia
Classification of breast cancer

• Invasive ductal carcinoma

• Invasive lobular carcinoma
• Papillary carcinoma
• Medullary carcinoma
• Inflammatory carcinoma
• Colloid carcinoma
• Atrophic scirrhous carcinoma
• Paget’s disease
BREAST CANCER

• Triple Assessment
a) Clinical
History, examination
b) Radiological
Ultrasound (below 35yrs)
Mammogram (after 35yrs)
c) Pathological/Histology
FNAC, Biopsy
CLINICAL PRESENTATION
• About 90% of breast masses are discovered by the
patient herself.
• A lump (usually painless) in the breast about 70%
of patients
• Breast pain
• Nipple discharge
• Erosion
• Retraction
• Ulceration
• Enlargement, or itching of the nipple
• Redness,
• Generalized hardness,
• Enlargement, or shrinking of the breast.
• Axillary mass or swelling of the arm may be
the first symptom.

• Back or bone pain, jaundice, or weight loss

may be the result of systemic metastases,
but these symptoms are rarely seen on initial
presentation.

15
Examination

Peau d’ orange

Retraced
nippleted

Puckered
skin

Asymmetry of breasts
SIGNS

• Asymmetry
• Ulceration
• Peau d’ orange
• Nipple deviation or retraction
• Hyperpigmentation
• Hard mass
• Nipple discharge
• Fixation
• Palpable lymph nodes
METASTASIS

• Lymph nodes
• Lung
• Brain
• Liver
• Bone
• Breast was divided
into 5 parts in order
to locate the mass.
• The relative
frequency of
carcinoma in
various anatomic
sites

19
INVESTIGATIONS-RADIOLOGICAL

1. Ultrasound (below 35yrs)

• To differentiate a solid and cystic mass.

2. Mammogram (after 35yrs)

• Cranio-caudal and medial lateral views. Features of
breast cancer includes:
– Irregular mass
– Radio-opaque
– With Speculations
MAMMOGRAPHY
PATHOLOGICAL

• Fine needle aspiration- Cytology

• Core needle biopsy
• Incisional biopsy
• Excision biopsy
Sentinel Node biopsy
Hormone receptor status

• HER2
• ER
• PR
STAGING: Manchester staging
Stage-I
lump <2cm, mobile,

Stage –II

lump 2-5cm, mobile

Stage-III

lump >5cm, fixed, mobile axilla nodes

Stage IV
lump ulcerating, multiple nodes in axilla, lung, bone
metastases
Treatment

• Depends on the stage

- Surgery
- Medical
- Radiation
- Chemotherapy
- Hormonal

26
Surgery

• Stage-1,
- Quadrantectomy + radiotherapy, simple
mastectomy + radiotherapy
- Axilla nodes are absent
- No need of chemotherapy if radiotherapy is
available

27
Surgery

• Stage-2,
-Modified radical + radiation

• Stage –3
-Modified radical + chemotherapy + radiation

• Stage –4
-Palliation ( toilet mastectomy)

28
Surgery-axilla

• Axilla sampling
• Level-I, Level-II, Level-III
• Tendon of pectoralis minor is the determinant
• Level- III clearance associated with lymphoedema

29
• Tamoxifen 20mg daily for at least five years
• Oophorectomy
• Adrenelectomy
5 Year Survival Rate According to
Stage
Stage 5 Year Survival Rate

I 92%

II 87%

III 75%

IV 13%
CONCLUSION

• Self examination
• Surgery main stay of treatment
• Adjuvant radiotherapy or chemotherapy
• All patient especially oestrogen positive should be
given tamoxifen
• Early cancer of breast should be treated
aggressively
• Breast cancer is a systemic disease

32
REFERENCES

• Manipal Manual of surgery. Shenoy R K, Shenoy A

• Surgical Recall
• Rapid surgery
• SRB
“If you don’t know where
• .

you’re going, you may

miss it when you get
there”