Breast DR Banez
Breast DR Banez
Breast DR Banez
Treatment:
- plastic surgery
Malignant Lesions of the Breast
One of the leading cause of death from CA
Etiology: - multifactorial
1. Sex: male : female ratio (1 : 100)
2. Age: almost unknown for pre-pubertal age
20 40 y/o steady increase incidence
40 50 y/o (menopausal) plateau
> 50 y/o higher incidence
3. Genetic:
Mother with carcinoma ---> (2 3x) daughter
(+) family history ----> younger, bilateral
4. Dietary influence:
Increase in developed countries (except) Japan
Increase in upper class society
Dietary: Increase in animal fat
Malignant Lesions of the Breast
5. Hormonal Usage:
Oral contraceptive has adverse effect if taken for
prolonged time at early age or when before the 1st full
term pregnancy
No effect if taken 25 39y/o
Slight increase risk if estrogen usage by peri-
menopausal for hormonal replacement
6. Physical Stature:
Obesity ---> increase fat cells ----> increase tissue
concentration
Malignant Lesions of the Breast
6. Multiple primary neoplasm:
Hx of primary breast CA ---> 4x fold increase of
primary CA
Hx of primary CA of uterus and ovary ----> 1-1.5 risk
7. Irradiation:
Multiple exposure
Had radiotherapy for breast CA of contralateral breast
Malignant Lesions of the Breast
8. Other factors
a. 1st pregnancy due to estrogen
b. Age of menopause
Late menopause (55y/o) higher risk
c. Infertility
Higher risk
Established Risk factors For Breast cancer in Females:
Risk factor High risk Low risk Relative risk
Age old young >4.0
Socioeconomic status high low 2.0 4.0
Marital status Never married Ever married 1.1 1.9
Place of residence urban rural 1.1 1.9
Race > 45 years white black 1.1 1.9
< 40 years black white 1.1 1.9
Nulliparity yes no 1.1 1.9
Age of first full-term pregnancy > 30 y/o < 20 y/o 2.0 4.0
Oophorectomy premenopausally no yes 2.0 4.0
Age at menopause late early 1.1 1.9
Age at menarchy early late 1.1 - 1.9
Weight, postmenopausal women heavy thin 1.1 1.9
Hx of benign or cancer in one breast yes no 2.0 4.0
Hx of breast Ca 1st degree relative yes no 2.0 4.0
Mother or sister w/ hx. Of breast CA yes no > 4.0
Hx. Of primary ovarian or endometrial yes no 1.1 9.0
CA
Mammographic parenchymal patterns Dysplastic Normal parenchyma 2.0 4.0
parenchyma
Radiation to chest Large doses Minimal doses 2.0 4.0
Malignant Lesions of the Breast
Natural history (Schirrhous adenocarcinoma)
Doubling time (2-9mos)
1 cell ---> 30DT/5 yrs ---> 1cm. Mass/20DT
---> increase size & fibrosis ----> dimpling
(retraction) ---> invade the lymphatics --->
edema ----> invade regional LN/venous ---->
systemic.
Successful implantation depends on:
1. Number of cells
2. Character of cell
3. Host resistance
Histological Classification of Breast Cancer
Cancers of the Mammary Gland can be Classified:
1. Histogenesis duct, lobule (acini)
2. Histologic Characteristic adenocarecinoma, epidermoid CA, etc.
3. Gross Characteristic Scirrhous, colloid, medullary, papillary, tubular
4. Invasive Criteria Infiltrating, in-situ
3. Medullary carcinoma:
2-15%
Large round cancer cells arranged in broad plexiform mass
surrounded by lymphocytes and lymphatic follicles
Soft, bulky and large tumors w/ necrotic areas
5 year survival = 85 90%
Good prognosis
Histological Classification of Breast Cancer
4. Mucinous (Colloid) carcinoma:
2%
Soft, bulky w/ ill defined borders
Cancer cells floats in large mucinous lakes
Cut surface is glistening, glaring and gelatinous
5. Tubular carcinoma
Well differentiated
Ducts lined by a single layer of well differentiated cancer cells
Absence of myoepithelial w/ well defined basement membrane
Common in premenopausal and detected w/ mammography
5 yr survival ---> 100% if the CA contain 90% or more of tubular
components
Histological Classification of Breast Cancer
6. Papillary carcinoma:
2 %; present in 7th decade
Thrown into papilla w/ well defined fibrovascular stalks and
multilayered epithelium
Has the lowest frequency of axillary nodal involvement;
has the best 5 and 10 yrs survival rates
Even if w/ axillary metastases, it is still indolent and slowly
progressive disease than the common adenocarcinoma
9. Squamous Carcinoma:
Metaplasia w/in the lactiferous duct system
Similar to epidermoid CA of the skin
Metastasize thru the lymphatic
Histological Classification of Breast Cancer
10. Sarcoma of the Breast: (Fibrosarcoma,
liposarcom, leiomyosarcoma, malignant fibrous
histiocytoma, etc.)
Large, painless breast mass w/ rapid growth
Mammography ---> false (-)
Grossly: --> it lacks the cut gabbage surface of
phyllodes
Histologically:
Spindle cell neoplasm that grows expansile and its
margin either pushes or infiltrate adjacent
structures
It invades the fat and tend to intervene between
the glandular aspect of the breast parenchyma and
expands the lobules and intralobular spaces
Treatment: --> total mastectomy
Histological Classification of Breast Cancer
11. Lymphoma of the Breast:
Similar to other malignant lymphoma
Mastectomy w/ axillary LN sampling
Tx: radiotherapy / chemotherapy
Stage Grouping:
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T0 N1 M0
T1 N1a M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 T2 N2 M0
T3 N1-2 M0
Medullary 4 44 63 50
Comedo 5 32 73 58
Colloid 3 32 73 59
Papillary 1 17 83 56
Treatment:
1. Benign: hormonal, surgery (excision biopsy), antibiotics
2. Malignant:
Selection of patients a. stage of lesion
b. medical condition of pt
Criteria of Inoperability / Incurability (Haangensen)
a) extensive edema of the skin over the breast
b) satellite nodule in the skin over the breast
c) inflammatory carcinoma of the breast
d) parasternal tumor nodule
e) supraclavicular metastasis
f) edema of the arm
g) distant metastasis
h) Any 2 or more of the following locally advances cancer
i. ulceration of skin
ii. Edema of skin less 1/3
iii. Solid fixation of tumor to the chest wall
iv. Axillary LN 2 cm or more
v. Fixation of axillary LN to skin and dep structure
Surgical Management:
1. Radical Mastectomy (Willi Meyer, Halsted)
Stage III, IV
2. Extended Radical Mastectomy
Hardley 21% of outer quadrant and 44% inner quadrant
tumor has (+) internal mammary nodal involvement.
1. Wangesteen (Classical RM + Internal mammary mediastinal
and supraclavicular LN)
2. Urban (CRM + ipsilateral half of sternum, part of 2nd to 5th rib
and pleura and internal mammary LN)
3. Modified Radical Mastectomy:
1. Patey preserved pectoralis major
2. Madden / Auchincloss preserved both the pectoralis major
and minor
4. Total mastectomy w/ or w/o radiation:
1. Crile Total mastectomy
2. Mc Whirter Total mastectomy and radiation (Axilla,
supraclavicular and internal mammary nodes)
Surgical Management:
5. Subcutaneous Mastectomy:
Nipple is retained / for T1s
6. Quandrantectomy, axillary, radiotherapy (QUART)
Quadrant of the breast that has the CA is resected
(quadrant of breast tissue, skin and superficial pectoralis fascia)
Unacceptable cosmetic result
7. Partial Mastectomy and Radiation:
Lumpectomy, segmental resection or tylectomy
Histologically free margin of breast CA (1cm)
Advent of supervoltage radiotherapy with skin sparing effect
Frozen section evaluation of margin
To determine adjuvant chemotherapy adequate sampling of axillary LN (level
I), curvilinear incision should be done
If LN (+) ----> adjuvant chemotherapy
Chemotherapy:
CMF, CAF, CA, AV, doxorubicin
Side effect: nausea, vomiting, myelosuppression, alopecia,
thrombocytopenia, exercise intolerance
Hormonal Therapy:
Receptor Assay (ER/PR):
1 gm of fresh tissue obtained by using cold scalpel and should be
determined w/in 20-30 min.
ER (-) < 10% respond to endocrine ablation or exogenous estrogen
ER (+) > 60% responds
premenopausal 30% (only due to masking effect of endogenous estrogen)
Menopausal 60%
PR (+) 15% of premenopausal benefit from 15%
Hormonal Therapy:
1. Ablation:
Oophorectomy, adrenalectomy, hypophysectomy
Replaced by medical adrenelectomy, etc.
2. Anti-estrogen:
a. Tamoxifen a non-steroidal anti-estrogenic
compound that compete w/ estrogen at receptor site.
Estrogen receptor assay should be determined; if negative
chance of success is very low
b. Aromasin
c. Aminogluthethimide it interferes with conversion
of androstinedione to estrone and estradiol in the
peripheral tissue and inhibit the conversion of
cholesterol to pregnanolone
Hydrocortisone should be added
Hormonal Therapy:
A. Carcinoma in Situ:
1. DCIS:
a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifen
b. Total mastectomy w/ or w/o tamoxifen
c. Breast-conserving surgery w/o radiation therapy
Palliative Mastectomy
Chemotherapy/Hormonal/ Chemotherapy/Radiotherapy
Radiotherapy
Therapeutic Approach for Breast Cancer
4. Inflammatory Breast Carcinoma:
3 5% 5 year survival
Main role of surgery is in the diagnosis
Primary therapy is chemotherapy and radiotherapy and if possible
surgery (mastectomy).
CAF ----- regression ------> extended mastectomy (level I) ---------->
irradiation of axillary and skin flap (30% - 5 yr survival)