Breast

1. Management of Breast cancer and common benign lesions
Moderator: Dr.Chuchu(consultant general surgeon)
Presenter: Dr.Nurhussen M(GSRIII)

2. Outline
•Introduction
•Screening for breast cancer
•Diagnostic modalities
•Staging
•Treatment
•Special considerations
•Benign breast lesions

3. Introduction
Epidemiology
◦ Globally, breast cancer is the most frequently diagnosed
malignancy
◦ Over a million cases each year (23% of total cancer cases)
◦ The second cause of cancer-related mortality in women following
lung cancer.
◦ The most prevalent cancer type in Ethiopia accounting for 32 % of
total cases with more than 20,000 people being diagnosed with
cancer annually.
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4. Screening for breast cancer
Average risk
Age b/n 25-40
◦ Clinical encounter every 3 years
◦ Breast awareness
Age >40
◦ Annual clinical encounter
◦ Annual screening mammography
◦ Annual breast awareness
High risk
Clinical encounter every 6-12 month
Annual mammography
◦ Start 10 years prior than the youngest member’s
diagnosis or 40 years which ever comes first but
not before 30 years.
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5. Diagnosis of breast cancer
Clinical
History
◦ Age, age at menarche & menopause,
pregnancies, history of breast biopsies
◦ Breast Pain or discomfort
◦ Change in breast size or shape, Skin
changes,
◦ Recent nipple inversion or discharge
◦ Axillary lump
◦ Family history of breast, ovarian or
tubal cancer
Physical Examination
◦ Asymmetry with the other breast
◦ Skin color, Edema or peau d’orange
◦ Nipple inversion or discharge, ulceration
◦ Asses breast mass consistency, fixation,
Irregularity
◦ Axillary mass
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6. Imaging Techniques
Mammography
For evaluation of breast mass or nipple discharge
Mammographic features of breast cancer
◦ Solid mass
◦ Asymmetric thickening of breast tissue
◦ Clustered micro-calcifications
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8. Ductography
Radiopaque contrast media is injected into one
or more of the major ducts and mammography is
performed.
Findings
◦ Complete ductal obstruction
◦ Multiple irregular filling defects in
the nondilated peripheral ducts
◦ Ductal wall irregularities
◦ Periductal contrast extravasation
◦ ductal displacement
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9. Ultrasound
Defines cystic masses & echogenic qualities of specific solid abnormalities
Used to guide FNAC, core-needle biopsy
Assess regional lymph nodes
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10. Magnetic Resonance Imaging
Used in younger women because mammographic evaluation is limited due to the increased
breast density
Has high sensitivity low specificity
Indications
◦ In patient who presents with nodal metastasis from breast cancer without an identifiable primary
tumor.
◦ to assess response to therapy in the setting of neoadjuvant systemic treatment;
◦ To select patients for partial breast irradiation techniques.
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11. Biopsy
 Fine Needle Aspiration Biopsy
◦ Rapid
◦ performed using imaging guidance or palpation
◦ experienced cytopathologist -> rare false- positive
result
◦ False-negative results occur in approximately 15% so incase of clinically suspicious lesions do core
biopsy
 Core Needle Biopsy
◦ preferred method of evaluating a suspicious solid mass
◦ able to asses ER, PR & HER2 status
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12. The combination of clinical exam ,diagnostic mammography, ultrasound or stereotactic
localization, and fine-needle aspiration (FNA) biopsy achieves almost 100% accuracy in the
preoperative diagnosis of breast cancer
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13. Receptors in breast cancer
Estrogen receptor (ER)
 Progesterone receptor (PR)
 Human epidermal growth factor receptor (HER2)
-Receptor positivity is an important indicator of hormone responsiveness and identifies tumors
for which endocrine therapy is a valuable therapeutic option
- HER2 status predicts resistance or sensitivity to different types of chemotherapeutic agents
- HER2 positivity may be associated with resistance to endocrine therapies
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14. Staging
Primary tumor (T)
Tx — Primary tumor cannot be assessed
T0 — No evidence of primary tumor
Tis — Carcinoma in situ
T1 — Tumor ≤20 mm in greatest dimension
T2 — Tumor >20 mm but ≤50 mm in greatest dimension
T3 — Tumor >50 mm in greatest dimension
T4 — Tumor of any size with direct extension to the chest wall and/or the skin (ulceration or skin nodules)
◦ T4d — Inflammatory breast cancer
Regional lymph nodes—Clinical (N)
NX - Regional lymph nodes cannot be assessed (e.g., previously removed)
N0 - No regional lymph node metastases
N1 - Metastases to movable ipsilateral level I, II axillary lymph node(s)
N2 - Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted
N3 - Metastasis in ipsilateral infraclavicular (level III) with or without level I, II ALN
Distant metastasis (M)
M0 - No clinical or radiographic evidence of distant metastases
M1 - Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven > 0.2 mm
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15. 15

16. Management of breast cancer
Once a diagnosis is made, the type of therapy offered to a breast cancer patient is determined
by
◦ the stage of the disease
◦ the biologic subtype
◦ the general health status of the individual
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17. Management includes
◦ local treatment with surgery, radiation therapy .
◦ Systemic treatment with chemotherapy, endocrine therapy,
targeted therapy
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18. Principles of surgical axillary staging
Axillary status is important for planning systemic adjuvant treatment and RT.
SLNB Vs. ALND
Indications for SLN mapping then biopsy
◦ Clinically –ve axillary LN
◦ < 2 suspicious LN on imaging
◦ <2 +ve LN(needle biopsy)
If SLNB –ve no ALND.

19. SLNB +ve
NO ALND
if all criteria are met
◦ C T1&T2
◦ No preoperative systemic therapy
◦ Micro metastasis
◦ 1-2 +ve LN
ALND
Do level I and II ALND if all the criteria are not
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20. Principle of radiotherapy
Whole breast radiation (WBRT)
◦ TARGET – the breast at risk
Chest Wall Radiation
◦ Target - ipsilateral chest wall,
mastectomy scar, and drain
sites when indicated
Regional Nodal Radiation
◦ paraclavicular and axillary
nodes
Accelerated Partial Breast Irradiation (APBI)
◦ TARGET-lumpectomy bed plus
a 1-2 cm margin.
◦ Invasive ductal carcinoma (pT1)
with -ve margin of ≥2 mm, no
LVI, and ER-positive
◦ Low/intermediate nuclear
grade, screening-detected DCIS
measuring size ≤2.5 cm with
-ve margin of ≥3 mm.
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21. Principle of endocrine therapy
Goals
◦ Prevent cancer from coming back
◦ Decrease the risk of cancer developing in other breast tissue
◦ Slow or stop the growth of cancer that has spread
◦ Reduce the size of a tumor prior to surgery
Options are
◦ SERM- Tamoxifen
◦ Aromatase inhibitors- Anastrozole , Letrozole and Exemestane
◦ GnRH Agonists- Goserelin or Leuprolide
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22. In situ breast cancer
DCIS
Treatment options can be
BCS + WBRT
◦ BCS + APBI
BCS alone
◦ In low risk DCIS ( low or intermediate grade
DCIS, < 2.5 cm, -ve margin of > 3mm)
Total mastectomy
◦ size > 4 cm or > two quadrants
involvement
Adjuvant endocrine
◦ ER +ve tumors
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24. Early Invasive Breast Cancer (Stage I, IIA, or IIB)
Local treatment
◦ BCS + axillary staging (SLN) and radiation therapy
◦ mastectomy with axillary staging
In patients who present with axillary lymphadenopathy that is confirmed to be metastatic disease on
FNA or core biopsy, SLN dissection is not necessary, and patients can proceed directly to ALND
Adjuvant systemic therapy.
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25. Cont.
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26. Loco regional treatment
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27. Cont…
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28. Systemic treatment
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Consider the use of 21 Gene recurrence score assay

29. Loco regionally Advanced Regional Breast
Cancer (Stage IIIA or IIIB)
Workup
◦ Clinical evaluation
◦ CBC, LFT
◦ Bilateral mammogram & breast ultrasound
◦ Pathology review - ER/PR & HER2 status
◦ Chest imaging
◦ Genetic counseling
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30. Management
 Neoadjuvant Systemic Therapy
◦ HR + ve -> give chemotherapy in the neoadjuvant setting rather than endocrine therapy because chemotherapy is
associated with higher response rates in a shorter time period
◦ HER2-positive -> HER2-directed agent (Trastuzumab) + chemotherapy
◦ Neoadjuvant Endocrine therapy – for postmenopausal patients with ER/PR -positive disease who
are not fit for surgery or chemotherapy (i.e, significant medical comorbidities, advanced age, or poor
performance status)
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31. Cont…
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32. Follow up
Regular history/physical examinations - every 4 to 6 months for the first 5 years then annually
Mammography – Annually
Tamoxifen -> gynecologic follow-up (for possible endometrial cancer)
-> treat hot flashes using SSRI (selective serotonin reuptake inhibitors)
Lymphedema - common complication after axillary surgery, axillary radiation, infection
Birth control methods – Avoid hormonal birth control methods (use intrauterine
devices, barrier methods, tubal ligation)
Osteoporosis – treat it with bisphosphonate
Healthy lifestyle - high fruit and vegetable consumption, physical exercise
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33. Stage IV or metastatic breast cancer
Goal of treatment is not curative but may prolong survival and enhance a patient’s quality of life.
Median survival is 18-24 months
5 years survival is 24.3 %.
Option of treatment
◦ Chemotherapy
◦ HR – ve , visceral crisis , hormone refractory metastasis
◦ Endocrine therapy
◦ HR +ve and no visceral crisis
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34. Cont…
Surgical or radiation therapy
◦ brain metastases, pleural effusion, biliary obstruction, ureteral obstruction,
pathologic fracture of a long bone, spinal cord compression, and painful
bone or soft tissue metastases
HER2-directed therapy(Trastuzumab) – for HER2-positive
Osteoclast inhibitors
◦ For patients with bone metastases
◦ Reduce risk of fractures, spinal cord compression & hypercalcemia of malignancy
◦ Agents - Bisphosphonates or RANK ligand inhibition
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35. Management of Locoregional Recurrence
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Consider
systemic
therapy

36. Monitoring in stage IV disease
Goal is to determine whether
◦ the treatment is providing benefit and that the patient does not have toxicity from an ineffective
therapy.
Results of monitoring are classified as
◦ response/continued response to treatment,
◦ stable disease
◦ uncertainty regarding disease status
◦ progression of disease.
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37. Follow up
History and physical examination
◦ 1–4 times per year as clinically appropriate for 5 y, then annually
Educate, monitor, and refer for lymphedema management
Mammography annually
Patients on Tamoxifen: Age-appropriate gynecologic screening
Lifestyle modification
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38. Summary of oncologic management for
stages I, II, and III disease
Neoadjuvant chemotherapy
◦ Indications for neoadjuvant chemotherapy
◦ Stage IIIA for breast conserving surgery
◦ Inoperable stage IIIA
◦ Stage IIIB
◦ ?Stage IIIC
◦ Benefits of neoadjuvant chemotherapy
◦ Down-staging the tumor (for possible breast conserving surgery)
◦ Cytoreduction making surgery convenient and easy
◦ Assess tumor response to chemotherapy
◦ Rate of response to chemo in chemo naïve tumors
◦ Response: 70%
◦ No response: 15%
◦ Progression: 15%
◦ Treatment of micrometastatic disease
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39. Cont.
Adjuvant chemotherapy
◦ It is of minimal benefit to women with negative nodes and cancers ≤0.5 cm in size and is not recommended
◦ Indications for adjuvant chemotherapy (American Society of Clinical Oncology guidelines)
◦ Tumor >1cm
◦ Tumor 0.5-1cm with:
◦ High histologic grade
◦ ER-negative tumors
◦ Triple negative tumors (10% to 20% of breast cancers)
◦ HER-2/neu overexpression
◦ Lympho-vascular invasion
◦ Node positive
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40. Cont.
Adjuvant radiotherapy
◦ Indications
◦ Stage III disease
◦ Post-breast conserving surgery
◦ Recurrent disease (if not previously irradiated)
◦ Positive tumor margin
◦ Metastatic disease involving ≥4 axillary lymph nodes
◦ Adjuvant radiotherapy decreases the rate of locoregional recurrence by 50% to 70%
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41. Special considerations
1. Inflammatory Breast Cancer
2. Pregnancy-associated Breast Cancer
3. Paget’s Disease of the Breast
4. Breast Cancer In Men
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42. Inflammatory breast cancer
Is a clinical syndrome in patients with invasive breast cancer that is characterized by
◦ Erythema and edema (peau d'orange) of a third or more of the
skin of the breast.
Pathologically, a tumor is typically present in the dermal lymphatic of the involved skin, but
dermal lymphatic involvement is neither required, nor sufficient by itself for a diagnosis of IBC.
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43. IBC con’t…
Work up-
CBC, ER/PR and HER2 status
Bilateral diagnostic mammogram, US Chest ,Abdominal ± pelvic CT Bone scan or FDG-PET/CT ,
Breast MRI (optional)
Treatment
◦ Preoperative systemic therapy (anthracycline + taxane (preferred)
◦ If tumor HER2-positive, HER2-targeted therapy
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44. Breast cancer during pregnancy
occurs in 1 of every 3000 pregnant women
Axillary lymph node metastases are present in up to 75% of these women.
Fewer than 25% of the breast nodules developing during pregnancy and lactation will be
cancerous.
Diagnosis - History & PE ,US with FNAC
Treatment
◦ Avoid radiation endocrine and target therapy in all trimesters
◦ Avoid chemotherapy during first trimester
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46. Paget’s Disease of the Breast
Accounts for only 1 to 3 percent
Underlying breast cancer (in situ or invasive) is present in 85 to 88 %.
Presentation
◦ scaly, raw, vesicular, or ulcerated lesion that begins on the nipple
and then spreads to the areola
◦ Bloody nipple discharge
Workup
◦ History , PE , bilateral mammography , biopsy(full-thickness punch
or wedge biopsy of the nipple)
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48. Breast cancer in Men
Accounts for < 1% of all breast Cancer.
Peak age 6th decade.
20% preceded by gynacomastia.
85% are invasive ductal
carcinoma.
80% are hormone receptor
positive
Risk factors
◦ Radiation exposure
◦ Estrogen therapy
◦ Testicular feminizing
syndromes
◦ Klinefelter’s syndrome (XXY)
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49. Treatment recommendation according to
NCCN
◦ Genetic testing for all males with breast cancer
◦ Breast surgery
◦ Mastectomy
◦ BCS
◦ Chemotherapy, radiation endocrine and target therapy as
indicated (similar to female breast cancer patients)
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50. Fibroadenomas
•Benign solid tumors composed of stromal and epithelial elements
•Most common tumor in < 30 years(late teens and early reproductive
years)
•Firm masses , easily movable (slide easily under the examining
fingers)
•May be lobulated or smooth
•May increase in size over several months
•wax and wane with the menstrual cycle.

51. management
•Reassured, and
•surgical management
• Pt bothered by the mass or
• It continues to grow
• Cryoablation and ultrasound-guided vacuum-assisted treatment lesions
<3 cm.
• Excision : Larger lesions

52. Breast infection(mastitis and abscess)

53. •Mastitis: inflammation of the breast
 with infection : lactational (puerperal) or non-lactational (e.g., duct ectasia)
without infection: foreign material(nipple piercing, breast implant, or silicone)
duct ectasia (peri-ductal mastitis or plasma cell mastitis)
•globally mastitis account 1–10% in LW, first few weeks of postpartum, decreasing
gradually
•LBA 0.1–3% in breastfeeding women(LBA IN 3–11% of those with mastitis)
•NLBA less than 5% of breast abscess cases

54. Etiology
• MC isolated organism in infectious mastitis and breast abscess is S. aurous followed by
streptococcal spp.
•S. aureus isolated are now MRSA .
•40% of BA may be polymicrobial, with aerobes (Staphylococcus, Streptococcus,
E.coli,and Pseudomonas) and anaerobes (Peptostreptococcus, Bacteroides,
Lactobacillus, Clostridium, Fusobacterium).
•smokers more likely to have anaerobes(15%)
•unusual pathogens : TB, Actinomyce, fungi (Candida and Cryptococcus), Bartonella
henselae s, Brucella,Thyphoid. May be the initial presentation of HIV infection

55. •TB mastitis: lymphatic spread, miliary dissemination, or contiguous spread (e.g.,
empyema necessitans ), direct inoculation (via a nipple abrasion)
•Solitary, ill-defined, unilateral hard lump situated in the UOQ. Necrotizing
granulomas
•Granulomatous mastitis : a benign disease once considered idiopathic,
however evidence of an association with corynebacteria infection. non-
necrotizing. painless mass

56. Breast abscess : localized collection of pus within the breast. Classified into
lactational (LBA) and nonlactational breast abscesses (NLBA).
LBA
First pregnancy at maternal age > 30 yrs
 pregnancy > 41 weeks of gestation, and
 mastitis.
Tend to be located in the peripheral breast
Bacteria in the mouth of the infant--- entry via
cracks or fissures in the nipple -- nutrient rich
maternal milk ----- rapid replication.
Early : single segment
late sign: due to px loose parenchyma and
stagnation of milk, extension within the stroma
and through the milk ducts to another segment
NLBA
•premenopausal older woman
•DM , obesity smoking,
•underlying structural breast lesions (duct ectasia)
•chronic course, recurrent obstruction of the ducts
with keratin plugs and have a tendency to form
extensive fistulas
•categorized by location into :
•Central(sub-areolar) : 90% of NLBA.association
with duct ectasia, and periductal mastitis.
Smoking and DM
•Peripheral: diabetes, , steroid , or trauma.

57. Investigation
•CBC
•BREAST ULTRASOUND: abscess -hypoechoic, may be
well circumscribed, macrolobulated, irregular, or ill-
defined with possible septa
•Biopsy:recurrent infection or treatment failure
•Culture:
Hospital-acquired infection
 septic(severe d/se)and unusual case
 recurrent infection
 treatment failure
neonate

58. Management
General measures are :
 Analgesics: Ibuprofen , pcm
 Breast support garment: relaxing the stretched
Cooper’s ligament, reducing the movement of painful
organ and edema.
 Breast emptying and continuation of
breastfeeding
 Antibiotics
Specific measures are :
Aspiration of pus
 Ultrasonography (USG) guided
– Needle aspiration
– Catheter drainage
Incision and drainage

59. Antibiotics
•If MRSA excluded by culture or is not prevalent: beta lactamase-resistant
penicillins- cloxacillin, dicloxacillin, or flucloxacillin.
•But penicillins are acidic, poorly concentrated in human milk, which is also acid.
•They to treat cellulitis well, but they are less effective in eradicating adenitis,
precursor of breast abscess
•Erythromycin, being alkaline, is well concentrated in human milk, best in the
treatment of adenitis of the breast
•cephalexin or clindamycin

60. •If MRSA confirmed by culture or prevalent in the area: a non-beta-lactam antibiotic -Co-
amoxiclav , clindamycin
•I f there is no improvement with oral therapy: IV vancomycin.
•Tetracycline, ciprofloxacin, and chloramphenicol are not suitable to lactating breast infection as
these drugs can enter the breast milk and be harmful to the baby.
•periductal mastitis is almost exclusively associated with tobacco abuse, smoking cessation
advice should be given to these patients .
•Granulomatous mastitis: Medical treatment with corticosteroids provides significant regression
of the inflammatory disease, allowing more conservative surgery

61. Surgical intervention
1. Us guided Needle aspiration : abscesses with a maximum diameter less than 3 cm . Multiple
aspirations over time (daily aspiration for 5 to 7 days) may be necessary for complete
drainage
2. Ultrasound-guided catheter drainage :large abscesses( >3 cm) or which refill rapidly after
aspiration
3. I and D: If skin overlying the abscess is compromised and is thin and shiny or necrotic, us
guide percutaneous drainage fails , large abscesses (>5 cm in diameter)

64. References
National Comprehensive Cancer Network 2022
Schwartz 11th edition
Sabiston 21th edition
Upto-date
Internet
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