It gives a comprehensive summary on infectious, benign and malignant breast diseases for medical students.

1. Breast Diseases
By Ruhama Yoseph (MD)
August, 2021

2. Outline
• Overview of breast anatomy
• Congenital breast malformations
• Infectious and inflammatory malformations of
the breast
• Benign breast conditions
• Carcinoma of the breast
• Paget’s disease of the nipple

3. Objective
• To know the common clinical presentation of
different breast conditions
• To identify different pathologies of the breast
• To discuss the ways to diagnose breast
conditions
• To know the approach to management

4. Anatomy
• Anatomical borders
▫ Extends from clavicle to 7th/ 8th rib,
▫ From midline of the sternum anteriorly to the
anterior border of the latissimus dorsi muscle

5. Anatomy…
• Lobule is the basic structural unit, making about
15-20 lobes
• Each lobe empties into lactiferous ducts

6. Anatomy…
• The lymphatics of the breast drain mainly into the
axillary and internal mammary lymph nodes.
• The axillary nodes receive approximately 85 per cent
of the drainage and are arranged in the following
groups:
▫ lateral, along the axillary vein
▫ anterior, along the lateral thoracic vessels
▫ posterior, along the subscapular vessels
▫ central, embedded in fat in the center of the axilla
▫ Interpectoral (Rotter’s), a few nodes lying between the
pectoralis major and minor muscles;
▫ Apical (subclavicular), which lie above the level of the
pectoralis minor tendon

7. Anatomy…
• The lymph node groups are assigned levels
according to their anatomic relationship to the
pectoralis minor muscle.
• level I lymph nodes, which include the lateral,
anterior and posterior groups.
• level II lymph nodes, which include the central
and interpectoral groups.
• level III lymph nodes, which consist of the
subclavicular /apical group.

8. Anatomy…
• The internal mammary nodes are fewer in
number and lie along the internal mammary
vessels deep to the plane of the costal
cartilages, following the perforating ranches of
internal mammary artery
• They drain the posterior third of the breast
• The sentinel node is defined as the first lymph
node draining the tumor-bearing area of the
breast.

9. Congenital Breast Malformations
• Amastia- congenital absence of the breast
• Polymastia- Accessory breasts
• Polythelia- Accessory nipples

10. Congenital Breast Malformations
• Nipple inversion- a disorder of development of
the major ducts, which prevents normal
protrusion of the nipple.
• Mammary duct fistulas arise when nipple
inversion predisposes to major duct obstruction,
leading to recurrent subareolar abscess and
mammary duct fistula.

11. Infectious and Inflammatory
Disorders of the Breast

12. Bacterial Mastitis and Breast Abscess
• Is associated with lactation in majority of cases.
Cracking and soring of the nipple accompanied
by ascending infections to the ducts is
incriminated
• S. aureaus is commonest etiology
• Women with inverted nipples are also liable, due
to blocking of ducts by debris resulting in stasis
of milk and bacterial proliferation

13. Bacterial Mastitis and Breast Abscess
• Clinically, the patients will present with signs of
breast inflammation
• Treatment:
▫ Supportive
▫ Antibiotics
▫ For breast abscess- Surgical drainage,
continuation of lactaion/milking recommended

14. Tuberculosis of the Breast
• Associated with pulmonary TB and TB of the
lymph nodes
• Common in parous women
• Presents with multiple chronic abscesses and
draining multiple sinuses, with surrounding
bluish attenuated skin
• Treatment:
▫ Anti-TB
▫ Mastectomy reserved for persistent infections

15. Breast Actinomycosis
• Coarse inflammatory nodules developing into
purulent draining fistula
• Discharge contains sulfur granules
• Caused by Actinomyces bacteria
• Treatment:
▫ Antibiotics (penicillin)
▫ Surgical treatment

16. Mondor’s Disease
• A variant of thrombophlebitis that involves the
superficial veins of the anterior chest wall and represents
a thrombosed vein presenting as a tender, cord-like
• Typical presentation pain in the lateral aspect of the
breast or the anterior chest wall. A tender, firm cord is
found to follow the distribution of one of the major
superficial veins.
• Treatment:
▫ liberal use of anti-inflammatory medications and
application of warm compresses along the symptomatic
vein.
▫ When symptoms persist or are refractory to therapy,
excision of the involved vein segment may be considered.

17. Hidradenitis Suppurativa
• A chronic inflammatory condition that originates
within the accessory areolar glands of Montgomery
or within the axillary sebaceous glands of hair
follicles.
• Chronic acne predisposes it
• Formation of abscess, sinuses, keloids with scarring
and foul odor
• Treatment:
▫ Antibiotic therapy with incision and drainage of
fluctuant areas
▫ Excision of the involved areas may be required.

18. Duct Ectasia/Periductal Mastitis
• Painful and tender masses behind the nipple-
areola complex characterized by dilated
subareolar ducts that are palpable and often
associated with thick nipple discharge, greenish
or bloody
• Nipple inversion is common
• Some go on to develop fistulas

19. Duct Ectasia/Periductal Mastitis
• Treatment:
▫ Aspiration of content and subjecting the fluid for
culture
▫ In the absence of pus, antibiotics covering
polymicrobial infections while awaiting the results
of culture.
▫ Repeated ultrasound guided aspiration may be
necessary
▫ surgical treatment is required in selected cases

20. Fat Necrosis
• Etiology is trauma resulting in non-tender peri-
areolar mass with irregular borders
• Skin erythema, retraction, ecchymosis may be
there
• Mammography or U/S- fluid filled oil cysts,
coarse rim calcifications
• Biopsy-fom cells ad multinucleated giant cells
• Treatment - none

21. Benign Breast Conditions

22. Aberrations of Normal Development
and Involution (ANDI)
• The basic principles underlying ANDI
classification of benign breast conditions are the
following:
▫ benign breast disorders and diseases are related to
the normal processes of reproductive life and to
involution
▫ there is a spectrum of breast conditions that
ranges from normal to disorder to disease
▫ ANDI encompasses all aspects of the breast
condition, including pathogenesis and the degree
of abnormality

23. Aberrations of Normal Development and
Involution (ANDI)…

24. Aberrations of Normal Development and
Involution (ANDI)…
• The four features are:
1 Cyst formation
2 Fibrosis
3 Hyperplasia of epithelium in the lining of the
ducts and acini may occur, with or without atypia.
4 Papillomatosis.

26. Fibroadenoma
• Round or ovoid, rubbery, discrete, relatively movable,
nontender mass 1 to 5 cm in diameter.
• Fibroadenomas have abundant stroma with
histologically normal cellular elements.
• Common in young women, age 15 to 25 years
• They lactate during pregnancy and involute in the
postmenopausal period
▫ Small fibroadenomas (≤1 cm in size) are considered normal
▫ Larger fibroadenomas (≤3 cm) are disorders, and
▫ Giant fibroadenomas (>3 cm) are disease
▫ Multiple fibroadenomas (more than five lesions in one
breast) are very uncommon and are considered disease

27. Fibroadenoma
• Treatment
▫ Observation for those less than 1 cm
▫ Cryoablation
▫ Ultrasound-guided vacuum-assisted biopsy for
lesions <3 cm.
▫ Larger lesions are often still best treated by
excision

28. Phyllodes Tumour
• A fibroadenoma-like tumor with cellular stroma
that grows rapidly being well demarcated and
compressing surrounding normal breast tissue
• Cross-section of gross pathology shows leaf like
pattern consisting of monoclonal proliferating
stromal cells
• Classified as benign, borderline and malignant
• If malignant, sarcomatous portion of the tumor
metastasizes to the lungs
• Lymph node metastasis is not expected

29. Phyllodes Tumour
• Treatment:
▫ If benign, by local excision with a margin of
surrounding breast tissue
▫ Malignant, complete removal of the tumor with a
rim of normal tissue avoids recurrence. Because
these tumors may be large, simple mastectomy is
sometimes necessary

30. Intraductal Papillomas
• Arise in the major ducts, usually in premenopausal
women.
• Usually <0.5 cm in diameter but may be as large as 5 cm
• Clinical presentation characterized by nipple discharge,
which may be serous or bloody.
• They rarely undergo malignant transformation, and their
presence does not increase a woman’s risk of developing
breast cancer (unless accompanied by atypia).
• However, multiple intraductal papillomas, which occur
in younger women and are less frequently associated
with nipple discharge, are susceptible to malignant
transformation.

31. Fibrocystic Changes of the Breast
• Benign changes in the breast characterized by the
formation of fibrotic and/or cystic tissues
• Primarily in premenepausl women, 20-50 years of
age
• Subtypes:
▫ Non-proliferative
 Cysts
 Stromal fibrosis
▫ Proliferative
 Sclerosing adenosis
 Ductal epithelial hyperplasia
 Intraductal papilloma

32. Fibrocystic Changes of the Breast
• Clinical presentations:
▫ Premenstrual bilateral multifocal breast pain
▫ Tender/non-tender breast nodules
▫ Nipple discharge

33. Sclerosing Disorders
• It imitates cancer on physical examination,
mammography, and at gross pathologic
examination.
• Excisional biopsy and histologic examination are
frequently necessary to exclude the diagnosis of
cancer usually by way of vacuum-assisted biopsy
or an open surgical excisional biopsy.

34. Sclerosing adenosis
• It is prevalent during the childbearing and
perimenopausal years and has no malignant potential.
• it is charcterized by distorted breast lobules and usually
occurs in the context of multiple microcysts, but
occasionally presents as a palpable mass. Benign
calcifications are often associated
• It can be managed by observation as long as the imaging
features and pathologic finding are concordant
• Lesions up to 1 cm in diameter are called radial scars,
whereas larger lesions are called complex sclerosing
lesions.

35. Galactocele
• A solitary, subareolar cyst containing milk and
always dates from lactation.
• Cyst formed by obstruction of lactiferous duct
resulting in collection of milk and epithelial cells
• In long-standing cases its walls tend to calcify
• Treatment:
▫ Most resolve spontaneously
▫ Repeated aspiration or surgery in symptomatic
cysts

37. Carcinoma of the Breast

38. Epidemiology
• Breast cancer is the most common site-specific
cancer in women and is the leading cause of
death from cancer for women age 20 to 59 years.
• It accounts for 30% of all newly diagnosed
cancers in women and is responsible for 14% of
the cancer-related deaths in women
• In Sub-saharan Africa, it is the second
predominant cancer in women, following
cervical cancer

39. Risk Factors
• Age
• Gender
• Race: Caucasians. But generally it is disease of
westernized and industrialized nations
• Genetic factors
• Family history
• Diet
• Endocrine
• Radiation

40. Risk Factors
• Lifetime risk of breast cancer is lower for
African Americans, yet a paradoxically increased
breast cancer mortality risk also is seen.
• Breast cancer in African Americans and in sub-
Saharan Africa
▫ Starts at younger age
▫ Among men <45 years of age incidence is higher
▫ Lastly , higher incidence rates for estrogen
receptor negative tumors.

41. Risk Factors
• Endocrine risk is related with the exposure to
estrogen, increased exposure to estrogen is
associated with an increased risk for developing
breast cancer
• Thus increased risk with increased number of
menstrual cycles, such as early menarche,
nulliparity, and late menopause
• Moderate levels of exercise and a longer
lactation period, factors that decrease the total
number of menstrual cycles, and are protective

42. Risk Factors
• The terminal differentiation of breast epithelium
associated with a full-term pregnancy is also
protective, so older age at first live birth is
associated with an increased risk of breast
cancer.
• Obesity increases breast cancer risk because the
major source of estrogen in postmenopausal
women is the conversion of androstenedione to
estrone by adipose tissue, thus it is associated
with a long-term increase in estrogen exposure.

43. Risk Factors
• Alcohol consumption is known to increase
serum levels of estradiol.
• Long-term consumption of foods with a high fat
content contributes to an increased risk of breast
cancer by increasing serum estrogen levels

44. BRCA 1& BRCA 2
• Up to 5% of breast cancers are caused by inheritance
of germline mutations such as BRCA1 and BRCA2,
which are inherited in an autosomal dominant
fashion with varying degrees of penetrance
• Female BRCA 1 mutation carriers have been
reported to have up to an 85% lifetime risk (for
some families) for developing breast cancer and up
to a 40% lifetime risk for developing ovarian cancer
▫ BRCA1-associated breast cancers tend to be invasive
ductal carcinomas, are poorly differentiated, are in the
majority triple receptor negative

45. BRCA 1& BRCA 2
• The breast cancer risk for BRCA2 mutation carriers is
close to 85%, and the life time ovarian cancer risk, while
lower than for BRCA1, is estimated to be close to 20%
▫ Men with germline mutations in BRCA2 have an estimated
breast cancer risk of 6%, which represents a 100-fold
increase over the risk in the general male population.
▫ BRCA2-associated breast cancers tend to be invasive ductal
carcinomas, which are more likely to be well differentiated
and to express hormone
▫ Also characterized by early age of onset, a higher prevalence
of bilateral breast cancer, and the presence of associated
cancers in some affected individuals

46. BRCA 1& BRCA 2
• Cancer Prevention for BRCA Mutation Carriers
include the following:
• 1. Risk-reducing mastectomy and reconstruction
• 2. Risk-reducing salpingo-oophorectomy
• 3. Intensive surveillance for breast and ovarian
cancer
• 4. Chemoprevention

47. Pathology
• Nomenclature
▫ Carcinoma-in-situ
 Ductal carcinoma-in-situ
 Lobular carcinoma-in-situ
▫ Invasive carcinoma
 Invasive ductal carcinoma (accounts for 80%)
 special types of breast cancers (10% of total cases)
 Invasive lobular carcinoma
 Mucinous carcinoma
 Medullary carcinoma
 Tubular carcinoma
 Inflammatory carcinoma

48. Carcinoma-in-situ
• A pre-invasive stage relative to the basement
membrane of epithelium
• DCIS is characterized by a proliferation of the
epithelium that lines the minor ducts, resulting
in papillary growths within the duct lumina.
• LCIS is characterized by distention and
distortion of the terminal duct lobular units by
cells that are large but maintain a normal
nuclear to cytoplasmic ratio

49. Carcinoma-in-situ
• Multicentricity and multifocality is prominent
feature of LCIS,
 Multicentricity refers to the occurrence of a second
breast cancer outside the breast quadrant of the
primary cancer (or at least 4 cm away)
 Multifocality refers to the occurrence of a second
cancer within the same breast quadrant as the
primary cancer (or within 4 cm of it).
• LCIS occurs bilaterally in 50% to 70% of cases,
whereas DCIS occurs bilaterally in 10% to 20%
of cases.

50. Invasive Ductal Carcinoma
• Characterized by productive fibrosis and accounts
for 80% of breast cancers
• Presents with macroscopic or microscopic axillary
lymph node metastases in majority of cases
• Occurs most frequently in perimenopausal or
postmenopausal women in the fifth to sixth decades
of life as a solitary, firm mass with poorly defined
margins, and its cut surfaces show a central stellate
configuration with chalky white or yellow streaks
extending into surrounding breast tissues.

51. Lobular Carcinoma
• At presentation, invasive lobular carcinoma is
different in that it replaces the entire breast with
a poorly defined mass.
• It is frequently multifocal, multicentric, and
bilateral.
• Because of its insidious growth pattern and
subtle mammographic features, invasive lobular
carcinoma may be difficult to detect.
• Over 90% of lobular cancers express estrogen
receptor.

52. Medullary Carcinoma
• It accounts for 4% of all invasive breast cancers and
is a frequent phenotype of BRCA1 hereditary breast
cancer.
• Grossly, the cancer is soft and hemorrhagic. A rapid
increase in size may occur secondary to necrosis and
hemorrhage.
• On physical examination, it is bulky and often
positioned deep within the breast. Bilaterality is
reported in 20% of cases.
• It is characterized microscopically by dense
lymphoreticular infilterate.

53. Medullary Carcinoma
• Because of the intense lymphocyte response,
benign or hyperplastic enlargement of the lymph
nodes of the axilla may contribute to erroneous
clinical staging.
• Approximately 50% of these cancers are
associated with DCIS
• <10% demonstrate hormone receptors
• Women with this cancer have a better 5-year
survival rate than those with NST or invasive
lobular carcinoma.

54. Mucinous Carcinoma
• Accounts for 2% of all invasive breast cancers and
typically presents in the older population as a bulky
tumor.
• This cancer is defined by extracellular pools of
mucin, which surround aggregates of low-grade
cancer cells. The cut surface of this cancer is
glistening and gelatinous in quality.
• Over 90% of mucinous carcinomas display hormone
receptors.
• Lymph node metastases occur in 33% of cases, and
5- and 10-year survival rates are 73% and 59%,
respectively.

55. Papillary Carcinoma
• Accounts for 2% of all invasive breast cancers.
• It presents in the seventh decade of life and occurs in a
disproportionate number of nonwhite women.
• Typically, they are small and rarely attain a size of 3 cm
in diameter.
• These cancers are defined by papillae with fibrovascular
stalks and multilayered epithelium.
• 87% of papillary cancers have been reported to express
estrogen receptor.
• These tumors showed a low frequency of axillary lymph
node metastases and had 5- and 10-year survival rates
similar to those for mucinous and tubular carcinoma

56. Tubular Carcinoma
• Accounts for 2% of all invasive breast cancers.
• Usually is diagnosed in the perimenopausal or early
menopausal periods.
• Characterized by haphazardous array of small,
randomly arranged tubular elements.
• 94% of tubular cancers were reported to express
estrogen receptor.
• Approximately 10% of women with tubular
carcinoma will develop axillary lymph node
metastases. Distant metastases are rare in tubular
carcinoma.
• Long-term survival approaches 100%

57. Inflammatory Carcinoma
• Accounts for <3 %
• Shows undifferentiated carcinoma cells.
• It used to be rapidly fatal but with aggressive
chemotherapy and radiotherapy and with salvage
surgery the prognosis has improved considerably
• Presentation is with breast skin changes such as
brawny induration, erythema with a raised edge,
and edema (peau d’orange). It may be mistaken for
bacterial mastitis
• 75% present with palpable axillary LAP, concurrent
metastasis is high possibility

58. Natural History
• Survival depends on the stage at diagnosis, but
mainly on axillary LN status
• Other determining factors for survival are
histologic tumor grade, hormone receptor status
and HER-2 status
• With growth of the cancer and invasion of the
surrounding breast tissues, the accompanying
desmoplastic response entraps and shortens
Cooper’s suspensory ligaments to produce a
characteristic skin retraction.

59. Natural History
• Localized edema (peau d’orange) develops when
drainage of lymph fluid from the skin is
disrupted.
• With continued growth, cancer cells invade the
skin, and eventually ulceration occurs.
• Traditionally the most important prognostic
correlate of disease-free and overall survival was
axillary lymph node status

60. Natural History
• The spread of LN metastasis spreads from level I, to II
and III
• 5 Common sites of distant metastasis in order of
frequency are bone, lung, pleura, soft tissues, and liver.
Brain metastases are less frequent
• At approximately the 20th cell doubling, breast cancers
acquire their own blood supply (neovascularization).
• Then, cancer cells may be shed directly into the systemic
venous blood to seed the pulmonary circulation via the
axillary and intercostal veins or the vertebral column via
Batson’s plexus of veins, which courses the length of the
vertebral column.

61. Clinical Presentation
• Presenting complaints include:
▫ Breast lump (about 30%), usually painless, or
enlargement or asssymetry
▫ nipple discharge, erosion, retraction, enlargement, or
itching of the nipple
▫ redness, generalized hardness, enlargement,
ulceration or shrinking of the breast.
▫ Rarely, an 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.

62. Clinical Presentation
• Physical examination of the breasts:
▫ Inspection
▫ The patient sitting, arms at her sides and then
overhead.
 Abnormal variations in breast size and contour, minimal
nipple retraction, and slight edema, redness, or retraction
of the skin can be identified.
▫ Asymmetry of the breasts and retraction or dimpling
of the skin can often be accentuated by having the
patient raise her arms overhead or press her hands on
her hips to contract the pectoralis muscles

63. Clinical Presentation
• P/E….
▫ Palpation
▫ rotary motion of the examiner's fingers as well as a
horizontal stripping motion has been
recommended.
▫ should be performed with the patient both seated
and supine with the arm abducted
▫ Axillary and supraclavicular areas should be
thoroughly palpated for enlarged nodes

64. Clinical Presentation
• P/E…
▫ Finding usually consists of a non-tender, firm or
hard mass with poorly delineated margins
▫ Slight skin or nipple retraction is an important
sign. Minimal asymmetry of the breast may be
noted
▫ Watery, serous, or bloody discharge from the
nipple is an occasional early sign

65. Clinical Presentation
• P/E…
▫ Ipsilateral supraclavicular or infraclavicular nodes
containing cancer indicate that the tumor is in an
advanced stage
▫ Edema of the ipsilateral arm, commonly caused by
metastatic infiltration of regional lymphatics, is
also a sign of advanced cancer

66. Work-up
• Triple assessment

67. Mammography
• Films taken by exposing the breasts to low voltage
radiation
• Can be diagnostic or screening mammography
• Diagnostic one used for women with abnormal
findings such as a breast mass or nipple discharge
• Here CC, MLO also spot compressions for further
details can be done
• Clues for diagnosis of carcinoma are:
▫ A solid mass with or without stellate
▫ Features, asymmetric thickening of breast tissues
▫ Clustered microcalcifications.

68. Mammography
• Used also for screening also
• Recommended started from 40 onwards
• Only 2 views, CC (craniocaudal) and MLO
(mediolateral oblique)
• Sensitivity increases with decreasing density of the
breast as in age above 50
• Premenopausal breast has dense fibroglandular
pattern thus may be difficult to delineate pathologic
lesions
• Routine use of screening mammography in women
≥50 years of age has been reported to reduce
mortality from breast cancer by 25%

69. Ductography
• The primary indication for ductography is nipple
discharge, particularly when the fluid contains
blood.
• Radiopaque contrast media is injected into one
or more of the major ducts, and mammography
is performed.
• Intraductal papillomas are seen as small filling
defects surrounded by contrast media
• Cancers may appear as irregular masses or as
multiple intraluminal filling defects.

70. Ultrasound
• Ultrasound is particularly useful in young
women with dense breasts in whom
mammograms are difficult to interpret
• It distinguishes cysts from solid lesions
• Ultrasound of the axilla is performed when a
cancer is diagnosed with guided percutaneous
biopsy of any suspicious glands
• It can also be used to guide FNAC, core-needle
biopsy

71. Ultrasound
• On ultrasound examination, breast cysts are well
circumscribed, with smooth margins and an
echo-free center.
• Benign breast masses usually show smooth
contours, round or oval shapes, weak internal
echoes, and well-defined anterior and posterior
margins
• Breast cancer characteristically has irregular
walls

72. MRI
• MRI is an extremely sensitive screening tool that is
not limited by the density of the breast , however, its
specificity is moderate, leading to more false-
positive events and the increased need for biopsy.
• Recommended for BRCA mutation carriers, those
individuals who have a family member with a BRCA
mutation who have not been tested
themselves,individuals who received radiation to the
chest between the ages of 10 and 30 years
• It is less useful than ultrasound in the management
of the axilla in both primary breast cancer and
recurrent disease

73. MRI
• Its use:
▫ To distinguish scar from recurrence in women who
have had previous breast conservation therapy for
cancer
▫ It is becoming the standard of care when a lobular
cancer is diagnosed to assess for multifocality and
multicentricity and can be used to assess the extent of
DCIS (ductal carcinoma in situ).
▫ It is the best imaging modality for the breasts of
women with implants.
▫ It has proven to be useful as a screening tool in high-
risk women (because of family history).

74. Biopsy
• FNAC
• Core needle Biopsy

75. Biopsy
• FNAC
▫ itis obtained using a 21G or 23G needle and 10-mL
syringe with multiple passes through the lump with
negative pressure in the syringe. The aspirate is then
smeared on to a slide.
• False negatives do occur, mainly through sampling
error
• Cannot differentiate invasive cancer from in situ
disease.
• When a breast mass is clinically and
mammographically suspicious, the sensitivity and
specificity of FNA biopsy approaches 100%.

76. Biopsy
• Core needle biopsy
▫ A histological specimen taken by core biopsy
allows a definitive preoperative diagnosis,
differentiates between duct carcinoma in situ and
invasive disease and
▫ Also allows the tumor to be stained for receptor
status.

77. Receptor Testing
• Refers to the determination of receptor overexpression
in biopsy samples
• Hormone Receptors
▫ Immunohistochemical staining used for determination of
estrogen and progesterone receptor positivity
▫ 80% are positive for at least one hormone receptor
• Human epidermal growth factor receptor (HER-2/neu)
▫ 20% of cancer are HER-2 postive
▫ Targeted therapy can be given with trastuzumab with
receptor inhibition in patients who express it
• Triple negative breast cancer
▫ Have worse prognosis

78. Skeletal Isotope Bone Scan
• Shows ‘hot spots’ of metastasis

79. Work-up…
• Other investigations include metastasis workup
like:
▫ CXR
▫ Abdominal U/S
▫ CT scan (Chest and Abd)
▫ MRI of brain
▫ Full body PET-CT- especially for inflammatory ca

80. Staging
• Clinical and pathologic staging
• The clinical stage of breast cancer is determined
primarily through physical examination of the skin,
breast tissue, and regional lymph nodes
• However, clinical determination of axillary lymph node
metastases has an accuracy of only 33%. Ultrasound is
more sensitive than physical examination alone in
determining axillary lymph node involvement during
preliminary staging of breast carcinoma.
• FNA or core biopsy of sonographically indeterminate or
suspicious lymph nodes can provide a more definitive
diagnosis than US alone

81. Staging
• TNM staging
• Tumor Size
▫ Tis- DCIS
▫ T1- less than or equal to 2 cm
▫ T2- 2-5 cm
▫ T3- greater than 5 cm
▫ T4- Tumor of any size with direct extension to the chest wall and/or to
the skin (ulceration or macroscopic nodules)
• Regional Lymph Nodes
▫ cN1- Metastases to movable ipsilateral Level I, II axillary lymph node(s)
▫ cN2- Metastases in ipsilateral Level I, II axillary lymph nodes that are
clinically fixed or matted
▫ cN3- Metastases in ipsilateral infraclavicular (Level III axillary) lymph
node(s) with or without Level I, II axillary lymph node involvement;
• Metastasis

82. Principles of Management
• The modalities
▫ Surgery
▫ Chemotherapy
▫ Radiotherapy
▫ Hormonal therapy

83. Principles of Management
• Surgical options
▫ BCT- type of surgery that focuses on removal of
cancerous breast tissue
▫ Mastectomy – removal of entire breast tissue with
variations on the extent of surrounding tissue removal
 Total mastectomy-entire breast with nipple-areola
complex
 Radical mastectomy-excision of breast together with
axillary LN, Pec major and Pec minor
 MRM (modified radical mastectomy)—excision of breast,
level I&II LN, but spares the Pectoralis muscles

84. Stage specific therapy
• Stage 0 (DCIS)
▫ BCT with radiation, potential SLNB (sentinel LN
biopsy)
▫ Systemic hormonal therapy depending on hormone
receptor status
• Early stage Breast cancer (stage I and II):
▫ BCT with radiation
▫ SNLB or ALND (axillary LN dissection)
▫ Systemic therapy
 Hormonal- depending on hormone receptor positivity
status
 Chemotherapy- depending on size, HER-2 status

85. Stage specific therapy
• Stage III cancers:
▫ Neoadjuvant chemotherapy/radiotherapy
▫ MRM and ALND
▫ Adjuvant therpies
• Stage IV cancers:
▫ Palliative chemotherapy
▫ Palliative surgery

86. Paget’s Disease if the Nipple

87. Paget’s
• It frequently presents as a chronic, eczematous
eruption of the nipple, which may be subtle but
may progress to an ulcerated, weeping lesion.
• A nipple biopsy specimen will show a
pathognomonic features of this cancer which is
the presence of large, pale, vacuolated cells
(Paget cells) in the rete pegs of the epithelium.

88. Paget’s
• A palpable mass may or may not be present.
• It may be confused with superficial spreading
melanoma and eczema.
• Differentiation from melanoma is based on the
presence of S-100 antigen immunostaining in
melanoma and carcinoembryonic antigen
immunostaining in Paget’s disease.
• Surgical therapy for Paget’s disease may involve
lumpectomy or mastectomy, depending on the
extent of involvement of the nipple-areolar complex
and the presence of DCIS or invasive cancer in the
underlying breast parenchyma

89. QUESTIONS?