Dr.

Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

The Breast
Surgical anatomy:
Extension: 2nd rib to 6th rib (inframammary crease) and lateral border to sternum to
anterior axillary line
Breast parenchyma = ductolobular + supportive tissue
TDLU= terminal ductal lobular unit; 50% located in upper and outer and 20% central
Supportive tissue: ligaments of Cooper, adipose tissue, blood vessel, nerves, lymphatics
Nipple and areola: circular muscle fibers constitute Sappey’s muscle (erection of the
nipple), longitudinal fibers form the Myerholtz muscle (retraction of the nipple)
Lymphatics:
1. Axillary nodes (85%)
a. Lateral: along lower border of axillary vein
b. Anterior/ pectoral: along lateral thoracic vessels
c. Posterior: along subcapsular and thoracodorsal vessels
d. Central/ medial: embedded in fat of center of axilla
e. Interpectoral/ Rotter’s: between pectoralis major and minor
f. Apical: L-III, receives efferent lymphatics from all axillary nodes
2. Internal mammary nodes (drains medial ½ of breast)
** Apical → Supraclavicular → subclavian → great vein (directly/ via thoracic duct/ via
jugular trunk)
Levels of axillary nodes:
• level I, below and lateral to the lateral border of the pectoralis minor muscle (the
majority)
• level II, in front of and behind the pectoralis minor muscle (including Rotter’s
nodes)
• level III, above and medial to the medial border of pectoralis minor
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Assessment for breast symptoms

Tripple assessment-

Ultrasonography-
• Primary imaging modality in young women with dense breast tissue
• USG +/- guided biopsy: performed when cancer is diagnosed
Mammography-
• First investigation in older women who present with breast symptoms
• Low voltage, high amperage X-rays, 1 mGY per film
• Uses with views:
1. Screening (CC, MLO view)
2. Diagnostic (CC, MLO, 90 degree lateral & Spot compression view)
3. Therapeutic (needle localization biopsy)
**CC view (Inner/Outer lesion)
**MLO view (Upper/Lower)
• Skin, S/C fat, parenchyma, retromammary space, pectoralis major, axilla, NAC
• Indication:
1. Screening for asymptomatic high risk
2. Evaluate ill-defined breast lump
3. Occult Ca with axillary mets
4. Screen prior to cosmetic operation
5. Monitoring for previously treated BCS
• Disadvantage: not for young dense breast
• Mammogram of both breast with both axilla
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

MRI- Indications:
1. women with dense breasts or discordant or equivocal findings on mammogram/
ultrasonography
2. To distinguish scar from recurrence in women who have had previous breast
conservation therapy for cancer
3. To assess multifocality and multicentricity and, in lobular cancer, high-grade
ductal carcinoma in situ (DCIS)
4. Women with breast cancer (BRCA) gene or other genetic mutations or a strong
family history
5. Women with breast implants
6. MRI-guided biopsy may be performed for lesions not visible on ultrasonography
or mammogram
PET scan- indications:
1. Staging investigations for T3, T4, N2, N3 cancer
2. Staging investigations for T1, T2, N0, N1 cancer with s/s suggestive of metastasis
Core needle biopsy- 14G for breast tissue and 18G for axillary nodes
Vacuum assisted biopsy: 8G or 11G needle

** BI-RADS
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Benign Breast Disease

Types
Congenital abnormalities Amazia
Polymazia
Mastitis of infants
Macromastia
Acquired abnormalities Disease of the breast (forms of ANDI):
1. Mastalgia
2. Nodular or lumpy breast
3. Discrete lumps of the breast-
a. Breast cyst
b. Galactocele
c. Fibroadenoma
d. Phyllodes tumour
Disease of the nipple:
1. Nipple inversion and retraction
2. Cracked nipple
3. Papilloma
4. Retention cyst of a gland of Montgomery
5. Eczema
Traumatic Haematoma
Traumatic fat necrosis
Inflammatory/ infective Acute- lactational (puerperal) mastitis

Subacute or chronic-
a. Non-lactational mastitis:
a. Periductal mastitis
b. Idiopathic granulomatous mastitis (IGM)
c. Tubercular mastitis
b. Duct ectasia
c. Actinomycosis
d. Mondor’s disease

ANDI
Minor aberrations of the normal process of development, cyclical hormone-related
change and involution: Aberrations of Normal Development and Involution (ANDI)
Etiology: cyclical changes in oestrogen and progesterone in every menstrual cycle, these
hormones act as growth factors on the epithelial and stromal cells of the TDLU
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Pathology:
Phases-
1. Lobule development (15-25 years) → may form fibroadenoma
2. Cyclical changes (15-50 years)
3. Involution (35-55 years) → may form cyst
4 features (B&L- 27th)
↓ • Cyst formation
• Fibrosis
Aberration of above phases • Hyperplasia
↓ • Papillomatosis

Benign conditions, such as-

1. Hyperplasia of epithelium
2. Papilloma
3. Cyst formation
** Nice to know:
Hyperplasia of epithelium:

• Presence of >2 layers of cells in the lining of ducts and acini

• With or without atypia
• With atypia→ atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH)
• DCIS→ ADH of more >2 ducts or lesion >2cm in diameter

Papilloma:

• Composition- central fibrovascular core, papillary projection of epithelium and myoepithelial cells
• Types-
1. Solitary papilloma
2. Papillomatosis: 5 or more papilloma in many ducts
3. Juvenile papillomatosis (Swiss Cheese disease): young, multiple firm palpable nodule, microscopically- multiple
papilloma with or without atypia, apocrine cyst, ductal hyperplasia, sclerosing adenosis

Cyst formation:

• Kinking or narrowing of ductules due to involution of stroma → accumulation of secretion → microcyst→ many join
to form macrocyst

Clinical features:
1. Breast pain: appears around D-14 increasing severity until D-28
2. Benign nodularity: may be cyclical, localized/ diffuse, bilateral, upper outer quad,
1-2 weeks prior mens. and regresses with onset of mens.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Mastalgia (syn. Mastodynia, Mazodynia)

Types: Cyclical and Non-cyclical
Criteria Cyclical mastalgia Non-cyclical mastalgia
Onset D-14 (middle of the cycle) until Any time
D-27 or 28
Site Usually both breast Any location (single or both
breast)
Radiation May radiate to upper arm Well localized (having trigger
spot/ point)
Relieving With onset of menstruation With medication
factor
Underlying Unclear Duct ectasia
cause Periductal mastitis
Tietze’s syndrome
Trauma
Cancer (5% causes pain)
Sclerosing adenosis
Vit-D and Ca deficiency
D/D Angina Angina
Biliary colic
Reflux oesophagitis
Cervical spondylosis
Treatment Anti oestrogen According to cause
LH analogue

Treatment:
1. Assessment: clinical examination and imaging
2. Reassurance
3. Identify- cyclical or non-cyclical mastalgia
4. For non-cyclical mastalgia:
a. Musculoskeletal pain and other referred causes should be excluded
b. Trigger point may be relieved by long-acting corticosteroid inj.
(Triamcinolone) and with Lidocaine (procedure may be repeated)
5. For cyclical mastalgia:
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Nodular or lumpy breasts:

1. Nodularity with pain: Mx as mastalgia
2. Nodularity without pain: Mx-
a. Tripple assessment and objective measurement of nodularity by The
Cardiff-Lucknow nodularity scale
b. No discrete lesion → reassurance; antioestrogen such as Tamoxifen or
Ormeloxifene
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Discrete lumps in the breast:

Causes:

Note:
Evanescent lump: Sometimes a lump appears in the breast and within a few days,
regresses on its own. It is caused by an inflammatory mass of periductal mastitis; the
lump, pain and tenderness all disappear together.
(Sometimes, a cyst or a galactocele may rupture; the lump disappears but pain and tenderness
appear. The cyst fluid or milk leaking in the stroma may induce inflammation, causing pain and
tenderness.)
Breast cysts:
• Age: 35-55 years; painless lump, often multiple and bilateral; mimic malignancy
• Causative factors: contribute as a part of ANDI
o Lobular involution
o Increased secretion
o Ductile obstruction
o Loss of stroma
o Hyperoestrogenaemia and
o Hormone replacement therapy
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

• Types:
o Simple: smooth walled cyst without solid components (BI-RADS 2)
o Complex: presence of solid component in cyst wall (biopsy needed)
o Complicated: intracystic floating debris that moves within the cyst with
change of posture
• Treatment:
o Solitary simple cyst: if associated with pain and inflammation →
aspiration; after aspiration if there is complete resolution and no blood-
stained fluid → no further treatment
o Complex cyst: core or excisional biopsy
o Complicated cyst: if associated with infection → antibiotic
Galactocele
• Solitary subareolar milk-filled cyst seen during or just after lactation.
• It disappears completely and is usually cured by a single aspiration.
• If it recurs, it may be reaspirated or a nylon strand (2/0) may be passed to clear the
blocked duct.
• Complications: non-resolution because of inspissated material and calcification
• Rx: Aspiration; surgical excision is rarely indicated; lactating mothers should be
encouraged to continue breastfeeding.
Fibroadenoma:
• Age: 15-25 years
• Pathology: Hyperplasia of a lobule
• Size: 2-3 cm; giant fibroadenoma: >5cm in diameter; having well defined capsule
• Investigation: USG; if atypical features found (microlobulation)→ biopsy
• Treatment:
o Medical management with antioestrogen: for small fibroadenoma
o Surgical: indications-
▪ Age: >30 years
▪ Suspicious features on imaging (microlobulation)
▪ Atypia on histology
▪ Size: >5cm
▪ Family history of breast cancer
▪ Patient’s preference

**Risk of developing malignancy (lobular carcinoma) in fibroadenoma:

• Epithelial hyperplasia
• Complex fibroadenoma with positive family history
**Excision of fibroadenoma in the elderly should include a rim of normal tissue as it may
contain malignancy or a phyllodes tumour.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Phyllodes tumour (AKA- Cystosarcoma phyllodes)

• Age: >30 years
• Large to massive tumour with unevenly bosselated surface
• Occasionally overlying skin is ulcerated due to pressure necrosis
• Usually mobile on the chest wall and rarely infiltrate the skin until late
• It is a true mixed neoplasm comprising both epithelial and mesenchymal elements
• Rarely metastasize via blood stream
• Subtypes: benign, borderline and malignant
• Treatment:
o Wide local excision (WLE) with a 2-cm margin along with the overlying
skin and underlying pectoralis major muscle because of a high incidence of
local recurrence
o Massive tumours, recurrent tumours and those of the malignant type require
mastectomy
o Recurrent/ malignant → post operative radiotherapy
o Malignant → chemotherapy may be given
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

The Nipple
Nipple inversion: lack of elongation of the major milk ducts leads to failure of the nipple
to protrude.
• Feeding problem
• Source of infection
• Does not predispose to cancer
• Treatment:
o Gently pulling of nipple forward
o Mechanical suction device
o Surgical correction with division of milk ducts (→ loss of nipple sensation)
Nipple retraction: an acquired phenomenon owing to fibrosis in and around the major
milk ducts.
• Long standing retraction → periductal mastitis: transverse slit like or fish mouth
retraction
• May be due to cancer: circumferential retraction
Cracked nipple:
• Found in 10% of nursing mother
• Strong negative suckling force → small blister → small ulcer → colonization of
bacteria and fungi → lactational mastitis
• Treatment:
o Breast rested for 48 hours and should be emptied with a breast pump.
o The sore nipple should be gently washed with warm water and moisturising
soap followed by application of an antimicrobial cream (mupirocin)
Retention cyst of a gland of Montgomery: situated in areola, blockade may form
sebaceous cyst; rarely infected → needs excision
Eczema:
• Often bilateral
• Usually associated with eczema elsewhere in the body
• Treatment: local application of 0.1% betamethasone skin cream, moisturising
soaps; if fails to heal: exclude Paget’s disease
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Paget’s disease:
• Unique type of DCIS arising in the nipple
• Erosion of the nipple that slowly destroys the nipple and encroaches on the areola
• It may become invasive with metastasis to the axillary lymph nodes
• Treatment:
o Paget’s disease without associated underlying malignancy: central core
excision, removing a cone of major milk ducts along with the nipple and
areola down to the pectoralis major muscle, followed by radiotherapy
o With underlying malignancy is treated by mastectomy and evaluation of the
axillary nodal status
Discharge from the nipple:
Discharge from a single duct
• Bloodstained
o Intraduct papilloma
o Intraduct carcinoma
o Duct ectasia
• Serous (sticky translucent fluid)
o Duct papilloma
o Ductal hyperplasia
o Duct ectasia
o Ductal carcinoma (in situ and invasive)
Discharge from more than one duct
• Bloodstained
o Carcinoma
o Duct ectasia
• Black, green or muddy: Duct ectasia
• Purulent: Periductal mastitis
Milk
• Lactation
o Galactorrhoea
o Rare causes: hypothyroidism, pituitary tumour
• Discharge from the surface (not from within nipple)
o Paget’s disease
o Skin diseases (eczema, psoriasis)
o Rare causes (e.g., chancre)
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

**The presence of a Single, Serous, Sanguineous and Spontaneous discharge (‘four

S’) should be considered pathological and triple assessment should be carried out.
*Galactorrhoea: spontaneous milk discharge from several ducts of both nipples unassociated
with childbirth or breastfeeding.

• It may be associated with:

o Prolactin-secreting adenoma of the pituitary gland
o Drugs: haloperidol, chlorpromazine, amitriptyline, metoclopramide and H2
receptor antagonists (cimetidine)
Assessment: triple assessment should be done
Investigation:
• USG
• Ductoscopy
• Ductography (poor diagnostic yield)
Treatment:
• No bloody discharge:
o Reassurance
o If profuse discharge: operation to remove a 1.5- to 2-cm length of the
affected major milk duct (microdochectomy) or ducts (major duct excision)
• Blood or serous discharge:
o <40 years:
▪ Triple assessment
▪ Reassurance
▪ Follow up with annual imaging
o >40 years:
▪ Microdochectomy for single-duct discharge or Hadfield’s major
mammary duct
excision for multiduct discharge
▪ A segment of major milk ducts 5 cm in length from the nipple is
usually removed as most duct papillomas are located up to a distance
of 5 cm from the nipple
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Congenital Abnormalities
Amazia:
• Sometimes associated with Poland’s syndrome:
o Amazia
o Absence of the sternal portion of the pectoralis major
o Short webbed fingers (symbrachydactyly) on the side of the involved breast
• Rx: latissimus dorsi muscle fap and a silicone breast implant
Polymazia:
• Common site: in the axilla (the most frequent site), groin, buttock and thigh
• Associated with other congenital anomalies: vertebral anomalies, cardiac
arrhythmias or renal anomalies
• They may also show the same spectrum of pathological diseases observed in
normal breasts
Macromastia:
• Massive enlargement of one or both breasts disproportionate to the body habitus
• Aetiology: multifactorial-
o Idiopathic
o Associated with obesity
o Presence of excessive endogenous or exogenous hormones
o Increased sensitivity of the breast tissues to the hormones
• Treatment: Reduction mammoplasty or subcutaneous mastectomy along with
breast reconstruction
Injuries to the Breast
Haematoma: may need biopsy
Traumatic fat necrosis:
• Acute or chronic
• Occurs in stout, middle aged woman
• Following a blow, a painless lump appears
• Even skin tethering, nipple retraction may be present- mimic carcinoma
• Biopsy may be required
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Inflammatory conditions
Acute inflammation: lactational (puerperal) mastitis:
• Incidence: 3-20% of lactating mother
• Type: bacterial and non-bacterial
• Pathogenesis:

Bacteria enters Blockade of lactiferous duct

Or, by epithelial debris → stasis
through cracked/
retracted nipple → infection

↓
In the ampulla S. aureus causes clotting of milk
↓
Multiplication within the clot
↓
Cellulites [Cellulitic stage]
↓
Abscess formation [Suppurative stage]
• Abscess formation is common in two stages during lactation-
i. First month after the first childbirth owing to inexperience or inappropriate
and inadequate breastfeeding
ii. At weaning owing to engorgement and trauma to the nipple by the baby’s
teeth
• Clinical features:
o Cellulitic stage- sign of inflammation; suppurative stage- sign of
inflammation, fever, malaise, feeding difficulty, fluctuant lump
o +/- Enlarged axillary LN
o USG: cellulitis (seen as an area of increased echogenicity) and liquefaction
necrosis (pus is seen as a hypoechoic collection with floating debris that
changes with posture)
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

• Treatment:
o Cellulitic stage-
▪ Antibiotic: Cloxacillin/ Flucloxacillin/ Erythromycin
▪ Analgesia
▪ 2-hourly breast feeding followed by emptying
▪ Breast support garment
▪ Cold compression
o Suppurative stage- options
▪ USG guided drainage
▪ Abscess >3cm in diameter and >30ml pus: USG guided insertion of
vacuum suction catheter and irrigation with cold normal saline on
each alternative day + 14 days antibiotic
▪ Incision and drainage (more chance of developing milk fistula)
Subacute and chronic inflammation
Non-lactational mastitis: inflammation of the breast tissue in a nulliparous woman or
occurring after a minimum of 6 months after cessation of lactation. E.g., -
1. Periductal mastitis
2. Idiopathic granulomatous mastitis (IGM)
3. Tubercular mastitis
Periductal mastitis:
• Chronic non-lactational inflammation around the major milk ducts
• Autoimmune
• Common in smoker
• Pathogenesis:
o Inflammatory mass → subareolar abscess → mammary or milk duct fistula
o Sometimes chronic indurated mass formed beneath areola (mimics
carcinoma) and fibrosis around major milk ducts causes nipple retraction
• C/F:
o Central non-cyclical pain
o Pus discharge from nipple
o Subareolar firm tender mass/ abscess/ mammary duct fistula
o Thickened tender major milk duct
o Transverse slit like (fish mouth) nipple retraction
• Investigation:
o USG: thickened major milk ducts with surrounding inflammation or
abscess
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

o Pus for C/S and GeneXpert: common organism- staphylococci, enterococci,

anaerobic streptococci and sometimes Bacteroides and mycobacteria
o Biopsy and histopathological examination
• Treatment:
o A course of antibiotics, combined with needle aspiration of an abscess
o Smoking cessation
o Surgery- major milk duct excision (1.5- to 2-cm length of the ductal cone
should be excised): indication-
▪ Subareolar abscess or sepsis
▪ Mammary duct fistula
Idiopathic granulomatous mastitis:
• Young parous woman, within the first few years after pregnancy
• Association with Corynebacterium kroppenstedtii has been postulated
• C/F:
o Multiple central or peripheral inflammatory breast masses, with or without
abscess formation.
o May be associated with skin ulceration, nipple retraction, sinus formation,
peau d’orange and axillary lymphadenopathy (mimic cancer)
• Investigation:
o Biopsy- non-caseating granuloma with chronic inflammation
o Tissue/ aspirate for Gram staining with C/S, AFB staining, fungal staining
& culture
• D/D: TB, foreign body reaction and sarcoidosis
• Treatment:
o Symptomatic patients with infection: NSAIDs and antibiotics with or
without drainage
o Persistent symptoms with progression: prednisolone (oral or topical) with
or without methotrexate
o Patients with a mammary duct fistula: major milk duct excision
o Patients with recurrence: excision of chronic abscess cavities
Tuberculosis of the breast:
• Uncommon
• Caused by-
o Spread from the axillary or internal mammary lymph nodes or osteitis of
the rib or sternum
o Sometimes from pleural cavity
o Uncommon source- cracked nipple or a haematogenous route
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

• C/F: multiple chronic abscesses and sinuses with a typical bluish discoloration of
the surrounding skin
• Investigation:
o Biopsy and histopathological exam: epithelioid cell granuloma with
caseating necrosis
o AFB staining- occasionally AFB seen in pus/ aspirate from caseation
necrosis
o Ziehl–Neelsen staining, GeneXpert
o CT chest and abdomen: to detect other foci and past TB
o MT test: little value
• Treatment: anti-tuberculous chemotherapy for 6-9 months

Duct ectasia:
• Definition: dilated major milk ducts
• Disorder of involution, as a part of ANDI
• Pathogenesis:
o Dilated ducts filled with debris → irritation → periductal inflammation and
subsequent fibrosis → nipple retraction → brown/ green/ mud coloured
nipple discharge
• D/D: malignancy, mastitis
• Investigation: dilated major milk ducts >3 mm in diameter
• Treatment:
o Tripple assessment
o Antibiotic therapy: Co-amoxiclav/ flucloxacillin/ ciprofloxacin/ cefixime
along with anaerobic coverage- Metronidazole/ tinidazole for 2-3 weeks
o Profuse nipple discharge/ subareolar abscess: major mammary duct
excision
Actinomycosis:
• Caused by Actinomyces bacteria
• The lesions: multiple chronic, pus-discharging, non-healing sinuses over the breast
• The pus demonstrates typical black granules and the specific pathogen on
microbiology
• Treatment: long-term penicillin injections along with curettage of necrotic
granulomas and sinuses
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Mondor’s disease:
• Thrombophlebitis of the superficial veins of the breast and anterior chest wall
• C/F:
o Tender thrombosed subcutaneous cord, usually attached to the skin
o When the skin over the breast is stretched by raising the arm, a narrow,
shallow, subcutaneous groove alongside the cord becomes apparent
• D/D: lymphatic permeation from an occult carcinoma of the breast
• Treatment:
o The only treatment required is to restrict arm movements; the condition
usually subsides within a few months without recurrence, complications or
deformity.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Carcinoma of the Breast

Epidemiology
• 25% of all cancers in women
• In Western Europe 1 in 9 women develop breast cancer
• In resource poor countries 1 in 28 develop breast cancer; 1 in 2 dies
Risk factor
Modifiable risk factors
1. Obesity: BMI >30 ↑ed risk in postmenopausal woman
2. Parity ↑ed risk in nulliparous woman or
pregnancy after 35 years of age
3. Breast feeding Protective (>12 months greater protection)
4. Age at first child birth Early (<20 years): ↓ risk
Late (>35 years): ↑risk
5. Use of HRT Use of >10 years: ↑ risk
6. Tobacco use ↑ risk
7. Alcohol consumption ↑ risk
8. Radiation exposure ↑ risk
Non-modifiable risk factors
1. Age Increasing age is a risk factor
Median age at presentation: 60 years in West
(UK, USA) and 48 years in low-/middle-
income nations
2. Sex Female > male; male only 0.5-1%
3. Ethnicity American white, African American (age
<45 years), Ashkenazi Jew, Parsi in India
4. Family history of breast cancer One first-degree relative (mother, sister or
daughter) with breast cancer: RR = 2;
Two first-degree relatives with Ca breast: RR = 3
5. Genetic predisposition 5–10% of all breast cancers are hereditary;
BRCA1 and BRCA2 mutations: 70% of
hereditary breast cancers
6. Early menarche (<12 years) Risk increases by around 5% for each year
earlier menstruation begins
7. Late menopause (>55 years) Risk increases by about 3% for each year later
menopause begins
8. High risk breast lesions Proliferative conditions without atypia: RR 1.8–2
Complex fibroadenoma: RR = 3
Papillomatosis: RR = 3
Proliferative diseases with atypia: atypical ductal
and lobular hyperplasia: RR = 4–5
Lobular carcinoma in situ: RR = 8–10
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Pathology
• Breast carcinoma arises from the milk ducts in 90% (ductal carcinoma) or from
the lobule in 10% (lobular carcinoma) of patients
• No breach in the basement membrane: in situ ductal or lobular carcinoma
• Infiltration of the surrounding tissue through a breach in the basement membrane:
invasive or infiltrative ductal or lobular carcinoma
• The modified Bloom–Richardson scoring system for tumour grade:
Variables Score Remarks
Tubule formation Score 1>75% of tumour shows tubules
Score 210-75% of tumour shows tubules
Score 3<10% of tumour shows tubules
Nuclear pleomorphism and Score 1Small regular nuclei, similar to normal ductal
size nuclei
Score 2 Intermediate size; 1.5-2 times the size of normal
ductal nuclei
Score 3 High grade nuclei; >2 times the size of normal
ductal nuclei
Number of mitoses/HPF Score 1 0-7 mitoses/10HPF
Score 2 8-14 mitoses/10HPF
Score 3 >15 mitoses/10HPF
Nottingham combined histologic grade:
Score 3-5: Well-differentiated (Grade-1)
Score 6-7: Moderately-differentiated (Grade-II)
Score 8-9: Poorly-differentiated (Grade-III)

• Histological varieties: may be in situ or invasive-

o Colloid
o Mucinous
o Medullary
o Tubular
o Papillary- better prognosis and rarely spreads
o No special type (NST)- invasive one is commonest
**Nice to know: NPI: NOTTINGHAM PROGNOSTIC INDEX
NPI: Tumour size (cm) x 0.2+ Lymph node (1= no node, 2 = one-three node, 3 = for 4/ more node
involved) + Grade (1/2/3)
 Excellent -94 (10yr survival)
 Good-83
 Moderate 1:70
 Moderate 2:51
 Poor -19
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

• Molecular subtypes:
Classification Hormone receptor HER2/neu Others
Luminal A Positive (either or Negative Ki-67 low
both ER/PR)
Luminal B Positive (either or Negative Ki-67 high
both ER/PR)
Basal/ TNBC Negative Negative Ki-67 is usually
high
HER2/neu enriched Negative Positive Ki-67 high
Normal like Positive (either or Negative Ki-67 negative
both ER/PR)
Claudin low Negative Negative Claudin low
**TNBC: more brain mets; ER +ve: bone mets, ER -ve: visceral mets
Spread of cancer
Local spread:
**Tumour cells
1. Adjacent breast parenchyma releases some growth
2. The skin, leading to ulceration and satellite nodules factors: FGF, TGF-α,
3. Pectoralis major TGF-β, VEGF
4. Serratus anterior
5. The chest wall
**FGF induces mitosis of adjacent fibrocytes → convert to fibroblasts & lay down
collagen (desmoplastic reaction) → contraction of collagen → shortening of Cooper’s
ligament → pulling the skin inwards → the telltale signs of dimpling (shortened single
Cooper’s ligament) & puckering or tethering (many Cooper’s ligaments shrunken) or
nipple retraction
Lymphatic metastasis:
1. Mainly to axillary lymph nodes
2. Internal mammary nodes (tumours from the inner half of the breast)
**Involvement of the contralateral lymph nodes in the absence of a contralateral primary
represents metastatic disease
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

** Causes of contralateral axillary lymph node involvement in breast cancer:

1. Haematogenous spread from the contralateral primary
2. Spread of cancer from one breast to another via subdermal lymphatics in front of
the sternum
3. Spread of cancer from one breast to the other via the ipsilateral internal mammary
nodes → interconnecting lymphatics behind the sternum → the contralateral
internal mammary nodes → the other breast → the opposite axillary nodes
4. Tumour developing in an epithelial embryonic cell rest trapped in a lymph node
during embryonic development of a node (rare)
5. Primary tumour of the opposite breast
Haematogenous spread:
1. The skeletal system (osteolytic, osteosclerotic and mixed)- in order of frequency:
a. Lumbar vertebrae **Extensive marrow replacement
**Axial skeleton and
b. Neck of femur limbs (above elbow by tumour cells → immature blast
c. Thoracic vertebrae and above knee) → cells in peripheral blood →
d. Rib and skull marrow involvement leukoerythroblastic anaemia
2. Liver
3. Lungs
4. Brain
5. Adrenal glands
6. Ovaries
**Peripheral blood samples for circulating cell-free tumour DNA (cf-DNA) and
circulating tumour cells are being studied as potential prognostic markers to predict
disease recurrence
Clinical presentation
1. A discrete lump in the breast- upper outer quadrant (50% of TDLUs lie there)
2. Other symptoms:
3. Nipple retraction
4. Nipple discharge (blood or serous)
5. Skin changes such as ulceration, peau d’orange, satellite nodules or
dimpling/tethering
6. Cancer en cuirasse: due to extensive tumour infiltration of the skin of the breast,
chest (in cases of postmastectomy recurrence), upper limb and abdomen
7. Any swelling in the neck or armpit
8. Any symptoms due to distant metastasis- bony pain, cough, breathlessness,
haemoptysis, headache, visual disturbances, neurological deficit, epileptic fits,
abdominal distension, jaundice, anorexia, weakness, weight loss, hypercalcaemia
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

**Peau d’orange is a sign of locally advanced disease due to obstruction of cutaneous

lymphatic drainage of the breast, by infiltration of either subdermal lymphatics or
axillary lymph nodes by tumour cells
**Up to 60% of women still present late in resource poor countries

Staging
Key points of 8th edition of the AJCC TNM staging system:
1. Lobular carcinoma in situ (LCIS) is a high-risk benign lesion not a cancer
2. The T categorisation of multiple synchronous tumours is documented using the
(m) modifier
3. The prefix (y) is used to denote the post-neoadjuvant therapy status
4. Satellite nodules in the skin must be separate from the primary tumour for it to be
categorised as T4b
5. Pathological complete response (pCR) denotes the absence of tumour cells in the
breast and axillary nodes in surgical specimens
6. Inflammatory carcinoma remains classifed as inflammatory carcinoma after
NACT, even after complete remission
7. Microinvasive (T1mi) carcinomas are defined as invasive tumour foci ≤1.0 mm
8. Tumours >1 mm and <2 mm should be reported as rounded to 2 mm
9. Tumour size should be measured to the nearest millimeter

**Nice to know: Anatomical staging-

Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Work-up for metastatic breast cancer

• Contrast-enhanced CT of the chest, abdomen and pelvis and an isotope bone scan
are needed for patients with locally advanced breast cancer (T3, T4 or N2, N3
disease).
• Patients with early breast carcinoma (T1, T2 and N0, N1 disease) need
metastatic evaluation only if they present with symptoms to suggest metastatic
disease or raised serum alkaline phosphatase.
• A PET-CT scan with 18F-fuorodeoxyglucose (18F-FDG) tracer may be used for
metastatic work-up.
**Another reference: Early breast Ca: (up to T2N1 or T3N0); LABC: (T3N1, T4, N2
with any T)
Treatment of breast cancer
• The treatment of breast cancer is multimodal (includes surgery, systemic treatment
[chemotherapy, targeted therapy, hormonal therapy] and radiotherapy)
• Multidisciplinary team (MDT) approach, that should include the surgeon,
radiologist, pathologist, radiation oncologist, medical oncologist, plastic surgeon
and allied health professionals, such as a breast care nurse, psychological
counsellor and preferably a genetic counsellor
• Some patients with low disease burden and low biological aggressiveness can be
treated with surgery followed by adjuvant therapy
• Others require downsizing of disease with neoadjuvant systemic therapy or
primary systemic therapy
**Pragmatic classification of breast cancer (B&L-27th)
Group Approximate Example Treatment
5-year
survival rate
(%)
Very low risk >90 Screen-detected DCIS, Local
primary breast tubular or special types
cancer
Low risk primary 70-90 Node negative with Locoregional with
breast cancer favourable histology or without systemic
High risk primary <70 Node positive with Locoregional with
breast cancer unfavourable histology systemic
Locally advanced <30 Large primary or Primary systemic
inflammatory
Metastatic - - Primary systemic
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Neoadjuvant systemic therapy (NAST)

1. Neoadjuvant chemotherapy (NACT)
2. Targeted therapy
3. Hormonal therapy
Aim: to downsize the disease and enable clinicians to know the in vivo response of the
tumour to therapy.
The indications for NACT are as follows:
1. Locally advanced breast cancer T3, T4/N2, N3 disease, inflammatory carcinoma:
to downsize the tumour.
2. Selected cases of early breast cancer:
a. To downsize the tumour to facilitate breast conservation surgery (BCS)
b. HER2/neu-positive tumours
c. Triple-negative breast cancer (TNBC) (>1/>2 cm tumour)
d. Premenopausal women (age <50 years)
e. Patients with axillary node metastasis
Neoadjuvant targeted therapy (trastuzumab, pertuzumab) is administered for
HER2/neu positive tumours >5 mm in diameter.
Neoadjuvant hormonal therapy is offered to elderly or frail women (with ER and/or -,
PR-positive advanced tumours) who are deemed unfit to receive systemic chemotherapy.
Neoadjuvant hormonal treatment takes longer (around 3–6 months) for the response to
become clinically evident.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Response assessment and timing of surgery:

The patient is examined 3 weeks after administration of the second cycle of NACT.
Response evaluation criteria in solid tumours (RECIST) are used for reporting the
response to NAST.
The four RECIST categories are:
• Complete response (CR) (lesion not detectable on clinical palpation and imaging)
• Partial response (PR) (≥30% reduction in the maximal diameter)
• Stable disease (SD) (<30% reduction in maximal diameter)
• Progressive disease (PD) (≥20% increase in the maximal diameter)

➢ For patients with CR and PR, the entire chemotherapy regimen may be delivered
prior to surgery.
➢ If the patient is being planned for BCS, a radio-opaque clip or magnetic marker
such as Magseed® is placed under image guidance in the epicentre of the tumour
to allow identification at the time of surgery should there be a complete response
to NACT.
➢ If the facility for clip placement is unavailable, in place of the metal clip a 0.5-cm
piece of silicone or a polyvinylchloride (PVC) catheter tip may be inserted through
a small skin incision just anterior to the tumour. This catheter tip remains palpable
even after complete regression of the tumour and helps the surgeon in performing
removal of the index area for BCS, excising 2 cm of tissue all around this catheter.
➢ For patients showing stable or progressive disease, after the initial two cycles of
chemotherapy, the patient should undergo surgery and be given second-line
chemotherapy after surgery.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Surgical management
Aim of surgery: to remove all disease in the breast and axilla with negative margins.
**In patients with DCIS a minimum of 2 mm is considered a safe margin.
Early breast cancer (stage 0, I, II)
Surgery for the breast: mastectomy or BCS
Surgery for the axilla: to stage the patient by SLNB and to treat
disease by ALND for patients with +ve axillary LN

**The aims of treatment of early breast cancer are:

1. Cure: likely in some patients but late recurrence is possible
2. Control of local disease in the breast and axilla
3. Conservation of local form and function
4. Prevention or delay of the occurrence of distant metastases

Algorithm for management of operable breast cancer

1. Achieve local control
2. Appropriate surgery
a. Wide local excision (clear margins) and radiotherapy, or Mastectomy ±
radiotherapy (offer reconstruction – immediate or delayed)
b. Combined with axillary procedure
c. Await final pathology and receptor measurements
d. Use risk assessment tool; stage if appropriate
3. Treat risk of systemic disease
a. Offer chemotherapy if prognostic factors poor; include Herceptin if Her-2 positive
b. Radiotherapy as decided above
c. Hormone therapy if oestrogen receptor or progesterone receptor positive

Surgery for the breast

Mastectomy: Indications-
1. Large tumours (in relation to the size of the breast)
2. Multicentric disease
3. Diffuse microcalcification on a mammogram indicative of DCIS
4. BRCA-positive cancers
5. Local recurrence following BCS
6. The patient’s preference
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Skin- and nipple-sparing mastectomy: Indication-

1. Is an option in DCIS and
2. Early breast cancers where a mastectomy is indicated and the tumour is >1 cm
away from the skin and >2 cm away from the nipple
The breast may then be reconstructed using autologous tissue faps/fat or a silicone breast
implant.
Breast conservation surgery (BCS):
• Is aimed at removing the tumour along with a 1-cm margin of normal breast tissue.
• It is important to orient the surgical specimen with sutures: long lateral (‘L’ for
‘lateral’) and short superior (‘S’ for ‘superior’).
• This is important if one or more margins is positive on histological examination.
Patients with involved margins should have a revision of margins called a ‘cavity
shave’.
• All patients with BCS receive radiotherapy. BCS together with radiotherapy is
called breast conservation therapy (BCT): BCS + RT = BCT.
Contraindication of BCS:
1. Patients with a multicentric tumour
2. Diffuse microcalcifications on a mammogram
3. A large tumour-to-breast ratio
4. Two times positive surgical margins after re-excision
5. A history of previous breast or chest wall radiation
6. Pregnancy
7. SLE or other collagen vascular disease (high risk of a radiation reaction)
8. Ankylosing spondylitis; severe orthopnoea (as pt. cannot lie on radiation table)
Wide local excision (WLE):
• WLE of up to 20% of the breast volume can be achieved by excision of the tumour
with adequate margins and closure of the defect by approximation of the breast
tissue with absorbable sutures.
• Volume loss greater than 20% or an unfavourable breast-to-tumour ratio requires
an oncoplastic procedure to fill the defect so created by mobilising the breast
tissue.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

**Summary: surgical techniques used to treat breast cancer:

 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Note: Mastectomy-
**Specimen removed: removal of the entire breast tissue, including the skin over the
tumour, the nipple–areola complex and the axillary tail.
**The breast tissue usually extends to a point where the anterior premammary fascia
fuses with the posterior pectoral fascia. Therefore, the surgeon should remove the breast
to the point of fusion between these two fasciae.
**Extension:
• Above- to the level of the second rib
• Medially- to the parasternal edge
• Below- to the inframammary crease
• Laterally- to the anterior border of latissimus dorsi
Incisions:
• Stewart elliptical for central tumors,
• Modified Stewart elliptical for inner quadrant tumor,
• Orr oblique incision for upper quadrant tumors,
• Another incision: Gray, Greenough, Kocher’s, Rodman incision
Types:
 Radical/Halsted: Excision of breast, axillary nodes, pectoralis major & minor
muscles
Disadvantage: limitation in movement at the shoulder joint, extensive upper limb
lymphoedema, pain and chest wall deformity
 Extended radical: with excision of internal thoracic & supraclavicular nodes
 Modified radical:
Auchincloss (Most commonly performed, Pectoralis minor muscle neither
removed nor severed at its origin from coracoid process, it preserves Medial
pectoral nerve which traverses in lateral neurovascular bundle)
Pateys (removal of pectoralis minor muscle, so that level 3 nodes properly
exposed & removed)
Scanlons (detaching pectoralis minor muscle at tip of coracoid process for removal
of apical axillary lymph nodes)
 Simple: with axillary tail few nodes low in anterior group
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

 Extended simple: with level-I lymph nodes

 Skin sparing: Removal of whole breast, NAC, 1cm skin around previous scar if it
is excised & Alternative to simple total mastectomy preserving breast skin
envelope for immediate reconstruction.
 Subcutaneous /Risk reduction /Prophylactic: for high genetic risk of breast Ca;
Breast is excised through lateral /submammary incision with breast skin & NAC
preserved
 Nipple sparing: Preserving NAC for no evidence of nipple involvement, indicated
for early-stage tumour located more than 2cm from nipple with clinically negative
axilla
 Complications:
 Intercostobrachial nerve injury leads to localized area of numbness over
medial aspect of upper arm
 Long thoracic nerve injury leads to winging of scapula
 Medial & lateral thoracic nerve injury leads to atrophy of pectoralis major
 Thoracodorsal nerve injury leads to weakened internal rotation/abduction of
shoulder
 Flap necrosis due to excess tension/traction, subdermal vascularity
jeopardized, excess pressure from outside
 Seroma
 Lymphoedema
 Vascular injury
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Surgery for the axilla

Sentinel lymph node biopsy:
Definition of sentinel LN: Sentinel means ‘a guard; the sentinel lymph node refers to the
first echelon lymph node in the axilla draining the breast.
Indication of SLNB: (T1, T2, NO)
1. Impalpable cancer
2. Up to 4 cm tumour
3. Clinically node (-ve) axilla
Contraindications:
1. Palpable nodes
2. T4 disease
3. Multicentric/ multifocal diseases
4. Received prior RT to axilla
5. Previous breast surgery or chest wall surgery
6. IBC (Inflammatory breast carcinoma)
7. Pregnancy
Agents:
1. Blue dye (patent blue or methylene blue)
2. Radioisotope (technetium-99m)-labelled albumin/ sulphur colloid/ antimony
3. The fluorescent dyes: fluorescein or indocyanine green can be used if radioisotope
is not available.
The combination of fluorescein and methylene blue can detect sentinel nodes with >90% identification
Indocyanine green can detect sentinel nodes with 95–100% identification.

Method:
• The dye may be injected into the peritumoral tissue or the periareolar, subareolar
or intradermal plane
• The tracer(s) passes through lymphatics to the sentinel node and is detected
visually as a blue-coloured node and/or a hot node (radioactive) with a handheld
gamma ray detection probe or as a fluorescent node with blue light (480 nm for
fluorescein) or infrared light (780 nm for indocyanine green)
• The ex vivo count of the hot lymph node(s) is noted
• All lymph nodes with >10% of the ex vivo count of the hottest node and blue
lymph nodes are removed and sent for histological confirmation of nodal
metastasis.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

• Histopathological exam done with: frozen-section analysis, touch imprint

cytology or by molecular methods (Gene-Search Breast Lymph Node Assay™)/
OSNA (one step nucleic acid amplification). These methods involve
homogenising the node and detecting a gene expression of cytokeratin 19 or
mammaglobin by RT-PCR.
• Frozen-section evaluation of sentinel nodes has a false negative rate of 10–12%.
Wherever the facility for frozen section is not available, the sentinel node should
be sent for formalin preserved paraffin section processing and haematoxylin and
eosin staining.
Axillary lymph node dissection:
Indication: for staging and local disease control in patients with-
1. Axillary lymph node-positive tumours that are clinically and/or biopsy-proven
non-palpable nodes
2. Three or more sentinel lymph nodes that are positive for macrometastasis.
**Level I and II nodes are routinely removed. Level III axillary dissection is reserved for
patients who have enlarged level I and II lymph nodes.
**ALND requires careful anatomical dissection to protect the axillary vein,
thoracodorsal vessels, medial and lateral pectoral nerves, intercostobrachial nerves and
the long thoracic and thoracodorsal nerves. The intercostobrachial nerve may be divided
in the presence of heavy nodal burden to achieve oncological clearance.
**Nice to know- Targeted axillary dissection: TAD
• Targeted axillary dissection (TAD): SLN dissection & selective targeted excision
of clipped biopsy proven axillary nodes
• Indication (early stage N1 diseases)
• Procedures (Provide USG guided clip to biopsy proven axillary nodes, NACT
given, pCR (pathological complete response) may occur, clipped node localized by
I-125 seed/ wire & per operative dual lymphatic mapping to SLN identification &
targeted excision of clipped node, specimen radiograph taken
• Contraindication: advanced nodal involvement, matted, internal mammary, infra/
supraclavicular nodes
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Breast reconstruction
1. Immediate breast reconstruction:
a. Silicone gel breast implants (pre-pectoral or sub-pectoral)
b. Autologous tissue (LD/ TRAM/ DIEP)
2. Delayed reconstruction: 6–12 months after completion of their adjuvant treatment
**Symmetrisation may be required for opposite breast after breast reconstruction or BCS

**Nice to know: oncoplastic breast surgery

 Oncoplasty is defined as tumour excision with wide margins followed by repair of
the defect by local rearrangement/ replacement of the breast tissue and the nipple–
areola complex to maintain shape and symmetry.
 This may be achieved by volume displacement (level 1), or by volume replacement
using a distant or local fap (level 2).
 In oncoplastic surgery we do activated breast vol scan, ABVS to delineate breast
volume, tumour volume measurement
 Volume displacement (parenchyma, skin, s/c tissue redistribution, if ptotic: Wise
pattern, Tumour adapted mastopexy, Grisotti flap)
 Volume replacement (Myosubcutaneous flap - LD mini after BCS &
Musculocutaneous flap - LD/TRAM after mastectomy, Silicon implant may be
used)
 Level1 oncoplastic (20% maximum excision vol ratio, no mammoplasty needed,
No requirement of skin excision for reshaping)
 Procedure for level 1: skin incision, skin undermining, NAC undermining, full
thickness excision, glandular reapproximating, deepithelialisation & NAC
repositioning
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Algorithm for oncoplastic surgery:

 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Surgical options for locally advanced breast cancers (stages IIIA, IIIB)-

Treatment for the breast:

• NACT then → mastectomy or BCS

• For initial skin involvement/ chest wall involvement/ inflammatory
carcinoma: NACT then → MRM
Treatment for the axilla:

• Patients with cT3N0/ became N0 after NACT → SLNB/ dual tracer SLNB/
targeted SLNB

Adjuvant treatment:
Radiotherapy
Role:
1. Decrease the risk of locoregional and systemic recurrence
2. Improve survival
Indication:
1. Patients with locally advanced breast cancers T3, T4, N1, N2, N3 disease;
2. Following BCS;
3. After mastectomy if:
a. Tumour size ≥5 cm; skin or chest wall involvement; lymphovascular
invasion (LVI), grade III disease
b. Axillary lymph node positive for metastasis
c. Deep margin involvement
Methods:
• In pathologically lymph node-negative tumours, radiotherapy after BCS is given
to the breast only as a dose of 45–50.4 Gy (with or without a boost) delivered in
25 fractions or of 40–42.5 Gy delivered in 15 or 16 fractions (hypofractionation).
• In patients after mastectomy (T3N0M0), chest wall radiotherapy is given if the
sentinel lymph nodes are negative.
• In patients with lymph node-positive disease locoregional radiotherapy is given
covering the chest wall, supraclavicular region, internal mammary nodes and the
axilla.
• The axilla should not be irradiated after axillary node dissection as this increases
the risk of lymphoedema.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Accelerated partial breast irradiation (APBI):

1. Women 50 years or older with -
a. T1 disease
b. Negative resected margins with a margin width of ≥2 mm
c. Invasive ductal carcinoma
d. No LVI
e. ER positive
f. BRCA negative
g. Sentinel node negative
2. Women 50 years or older with
a. Low-risk DCIS (screen detected, low/intermediate nuclear grade, tumour
size ≤2.5 cm, negative resected margin widths ≥3 mm)
The tumour bed is irradiated along with a narrow rim of surrounding tissue so as to avoid the
potentially harmful effects of irradiation on healthy tissue. It is delivered twice daily for 5 days.
Adjuvant systemic therapy
Role:
1. To control putative micrometastases
2. Delay relapse
3. Prolong survival
Benefit of chemotherapy in improving relapse-free survival by approximately 30% and
overall survival by 10% at 15 years.
Chemotherapy: this is the most common systemic treatment for breast cancer
Regimens:
1. Cyclophosphamide (C), Methotrexate (M) and 5-fuorouracil (F) (CMF)
2. Anthracycline-based regimens:
a. CAF (A, Adriamycin [Doxorubicin])
b. CEF (E, Epirubicin)
3. Taxane (docetaxel, paclitaxel)-based regimens.
Indication:
1. All invasive carcinomas >1 cm in diameter
2. Tumours >0.5 cm with poor prognostic factors (presence of LVI, high grade,
HER2/neu positive, TNBC)
3. Node-positive tumours
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Assessment of benefit of chemotherapy:

Gene signature panels help in assessing the benefit of chemotherapy in-
Low-risk tumours, i.e., ER-positive, HER2/neu-negative and node-negative tumours.
The risk of recurrence (ROR) scores:
1. Oncotype Dx® (21-gene recurrence score)
2. Prosigna® PAM-50 (breast cancer prognostic gene signature)
3. MammaPrint® (70-gene breast cancer recurrence assay).
Oncotype Dx®
• Most widely used ROR score
• Measures the expression of 16 cancer-related genes and 5 reference genes on
paraffin-embedded tumour tissue
• The assay classifies the ROR score as-
o Low (<18)
o Moderate (19–30) or
o High (>30).
• In patients with a low ROR score, chemotherapy can be avoided
Chemotherapy can be avoided in:
1. Patients with endocrine-responsive breast cancer
2. With luminal A tumours with a low-risk score on Oncotype Dx® and/or clinical
risk
assessment online tools
Consider chemotherapy in:
High clinical and genomic risk Anthracycline (Epirubicin) or Taxane-
based therapy
Luminal B tumours (greater risk of relapse) Anthracycline and/or Taxane
HER2/neu-positive tumours Trastuzumab + Pertuzumab along with
chemotherapy (Taxane + Anthracycline)
triple negative tumours Taxane + Anthracycline
tumours with aggressive biology Carboplatin-based regimens
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Targeted therapy:
• Trastuzumab (Herceptin®) + Pertuzumab → HER2/neu-positive tumours along
with chemotherapy.
• T-DM1 (Trastuzumab + Emtansine): allow targeted delivery of the chemotherapy
to HER2-positive cells
Hormone therapy:
The selective oestrogen receptor modulator tamoxifen and aromatase inhibitors
(anastrozole, letrozole, exemestane) are used for hormonal therapy in breast cancer.
• In premenopausal patients only Tamoxifen is used:
o For 5 years in low-risk patients
o For 10 years in patients with a high risk of relapse (node positive, tumour
>5 cm, LVI).
• In postmenopausal women, Aromatase inhibitors are used
Other hormonal modalities:
• Gonadotropin analogue (LHRH agonist: goserelin, leuprolide) for
premenopausal receptor +ve
• Newer: Antiprogestine, Pure antiestrogen, Growth factor TKI
• Reversible ovarian ablation by lap. Oophorectomy - premenopausal receptor +ve
• 4 low dose RT to pelvis - for premenopausal receptor +ve
**Side effects of Tamoxifen - loss of libido, vaginal dryness, DVT, stroke, Endometrial Ca, hot flush
**Benefits of Tamoxifen - increases bone density, reducing osteoporosis & cholesterol, Cytochrome P-450
activates it to Endotamoxifen
**Aromatase inhibitors are associated with bone density loss and risk of fracture.
**A bone density scan is advised prior to commencement of treatment with aromatase inhibitors.
**Bisphosphonates with vitamin D and calcium are used to restore bone loss and may also reduce the risk
of recurrence.
**Tamoxifen &AI used as chemoprevention to reduce Ca risk of opposite breast also.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Follow up of operable breast cancer

Follow-up after initial therapy (MRM) routinely includes:
• Clinical examination every 3 months for 2 years, followed by every 6 months for
the next 3 years, thereafter yearly.
• A mammogram is also scheduled yearly.
• Patients with an implant and those with BRCA or other genetic mutations need
contrast breast MRI annually.
• Development of any new symptom or sign during follow-up merits detailed
clinical evaluation and relevant investigation.
• Patients presenting with metastatic disease and those with a local/systemic
recurrence are seen more frequently depending on the clinical condition
After BCS - mammogram after 6 months, then yearly

Metastatic carcinoma of breast

Aim:
1. Palliating symptoms
2. Improving quality of life
3. Preventing potential disabling complications
4. Attempting to prolong life
Treatment:
Systemic chemotherapy Hormone receptor-negative cancers
Hormone-refractory metastases
Patients with visceral crisis
Endocrine therapy Hormone receptor-positive disease with
bony metastasis and limited visceral
metastasis
Palliative radiotherapy + bisphosphonates Patients with bony metastasis in weight-
bearing areas (e.g., vertebra, femur) and
painful bony deposits
Surgical resection of metastatic lesions Solitary visceral metastasis in patients with
good performance status and favourable
tumour biology
Intercostal chest drainage and pleurodesis Pleural effusion
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Management recurrence
• Local, regional, distant
• Local-single spot, multi spot & field change recurrence
• Recurrence in treated breast/chest wall/axilla or even supraclavicular fossa.
• 80% occur in 2 years, mostly within 5 yrs.
• Again, restaging including IHC for ER, PR, HER2
• Whole-body MRI or PET-CT scan should be performed to detect metastasis
• Rx depends on previous treatment, site, operability, receptor status.
• Risk factor: young, high grade, margin involved, BCS without RT, Perineural
invasion & extensive >25% in situ Ca within tumor mass
• Rx: MDT
o Systemic chemotherapy should be followed by surgical excision.
o Most surgeons perform a mastectomy for recurrence; however, second BCS
and re-radiotherapy may be considered
o Systemic antibiotic, charcoal dressing & topical metronidazole gel for
tissue necrosis with infection.
Hereditary and familial breast cancer
• Hereditary breast cancer (HBC) runs in families, affecting several close relatives,
and is associated with an identifiable genetic mutation.
• Familial breast cancer (FBC) affects several members of a family but is not
attributable to any known genetic mutation.
• HBC accounts for 5–10% and FBC for 20–30% of all breast cancers.
• HBCs are more aggressive, present at an earlier age and are more often
multicentric and
bilateral.
• High-penetrance mutations are found in BRCA1, BRCA2, Li–Fraumeni
syndrome, Cowden syndrome, Peutz–Jeghers syndrome and hereditary gastric
cancer syndrome.
• BRCA1 (17q21) is associated with a 50–85% lifetime risk of developing breast
cancer and up to a 40% risk of ovarian cancer.
• The breast cancers in BRCA1 are mostly TNBC.
• BRCA2 (13q12.3) is associated with an up to 50–60% lifetime risk of breast
cancer and a 20% risk of ovarian cancer. It is also associated with cancer of the
prostate, colon, gallbladder, bile duct, stomach and pancreas.
• BRCA mutation is more common in males with breast cancer.
• Genetic risk evaluation should be considered in high-risk individuals
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Rx:
Women with a BRCA mutation-
• Bilateral risk-reducing mastectomy with immediate breast reconstruction (reduces
the risk of breast cancer by 90%)
• Chemoprophylaxis with tamoxifen or anastrozole (reduce the risk to 50%)
• Premenopausal women may be offered bilateral salpingo-oophorectomy after they
have completed their family at around 35–40 years of age
**Nice to know:
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Breast cancer in pregnancy

• Cancer developed during pregnancy, lactation/ during 1st postpartum year.
• Pregnancy is associated with aggressive tumour biology such as TNBC.
• Earlier age, more advanced, ER-ve (young age, relative frequency of nodular
change in breast during pregnancy & increases breast density)
Investigation:
• Ultrasonography of the breast, mammogram and chest radiograph with abdominal
shielding of the fetus may be considered.
• In cases where bone or brain metastasis is suspected or other investigations are
inconclusive, MRI without gadolinium contrast should be used.
• CT and PET-CT should be avoided (high radiation dose).
• Genetic counselling should be offered.
Treatment:
• Surgery can be performed in any trimester. Mastectomy is preferred during the
first and second trimester as the delay in administering radiotherapy until delivery
may be associated with a higher risk of recurrence in the breast.
• SLNB with low-dose technetium-tagged sulphur colloid is considered safe for the
fetus.
• Chemotherapy should not be administered during the first trimester (period of
organogenesis) but can be safely administered during the second and third
trimesters (until 34 weeks to allow haematological recovery at the time of
delivery). Anthracyclines and taxanes remain the preferred agents. 5-
Fluorouracil should be avoided.
• Anti-HER2/neu and endocrine therapy should be given after delivery, as indicated
Carcinoma of male breast
• Less than 0.5% of cases of breast cancer.
• The most common symptom at presentation is a painless subareolar lump.
• Involvement of the nipple–areolar complex and underlying pectoral muscles
occurs early.
• Treatment:
o Mastectomy with a 2-cm margin along with a portion of underlying
pectoralis major muscle followed by radiotherapy.
o SLNB should be performed in node-negative patients.
o Tamoxifen 20 mg daily for 5 years is recommended for those with ER-
positive tumours.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Sarcoma
• Sarcomas, most commonly fibrosarcoma and angiosarcoma, may arise de novo
from the mesenchymal tissues of the breast
• Some genetic conditions (Li–Fraumeni, neurofibromatosis type 1), exposure to
alkylating agents, vinyl chloride or arsenic, prior radiotherapy (e.g., for Hodgkin’s
lymphoma) and chronic lymphoedema are associated with the development of
sarcoma
• Angiosarcoma is the most aggressive of all breast tumours and arises from the
endothelial cell lining of vascular or lymphatic channels
• Angiosarcoma is associated with prior radiotherapy and carries a very poor
prognosis
Screening for breast cancer
• High income countries (UK): population-based mammographic screening (age 50-
70; 3 yearly) achieves very high (90–95%) long-term survival in patients with
screen-detected tumours
• Asian countries clinical breast examination by a trained healthcare professional
along with increasing breast health awareness by breast self-examination is being
encouraged as a mode of screening
** Prognosis of carcinoma breast
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

Short note:
NON INVASIVE CARCINOMA:
Multifocal: (Within same quadrant 2/more foci separated by at least 5 mm)
Multicentric: (Separate discontinuous foci more than 1 quadrant)
DCIS:
Palpable mass/nipple thickening: Dx by mammogram
If impalpable (Stereotactic core needle biopsy, Mammotome/ vacuum assisted biopsy,
Wire/seed localization excisional biopsy)
**Stereotactic biopsy: contraindication
• faint microcalcification on mammogram
• lesion deep in breast &close to chest wall
• obese more than 150kg
• very small breast
• patient who can’t remain prone
• bleeding disorder
• use of anticoagulant.
Rx: VNPI (Van Nuys Prognostic index) low: WLE+RT/Mastectomy; if high score +/-
endocrine therapy
Local recurrence after DCIS: If only BCS previously – Re-excision + RT, If BCS with
RT given- then mastectomy.
LCIS (Rx options-lifelong surveillance, bilateral total mastectomy with immediate
reconstruction for strong family history, pharmacologic risk reduction with antiestrogen
treatment.)

INFLAMMATORY CARCINOMA:
• Dermal lymphatics invasion by skin punch biopsy
• No role of BCS/SLNB due to dermal involvement extend beyond tumour. Initially
NACT(Adriamycin), Targeted therapy if HER2 +ve, then MRM + sadjuvant RT.
 Dr. Towhidul Hasan Nahid, Registrar (Colorectal Surgery), RMCH

GYNAECOMASTIA:
Simon grading
• 1- small but visible breast development with little redundant skin
• 2a - moderate breast development with no redundant skin
• 2b - same with redundant skin
• 3 - marked breast development with much redundant skin
Any male breast lump: benign (adenoma, lipoma, cyst, infection), malignant (carcinoma,
sarcoma, lymphoma), Gynaecomastia, Pseudogynaecomastia
Breast cancer is eccentric within breast, unilateral, whereas gynaecomastia concentric,
subareolar & bilateral
Rx:
• Danazol, Tamoxifen;
• Surgery for Simon 2b & 3, significant asymmetry
o Mastectomy with preservation of areola & nipple
▪ If small: circumareolar incision
▪ If large: Gaillard-Thomas incision

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