MALIGNANT NEOPLASMS OF

THE BREAST

Presented By-
DR. Esha Bhatia
1st year Jr
Malignant neoplasm
of the breast is
broadly classified
into –

Breast Carcinoma
Breast Sarcoma
BREAST CARCINOMA
AETIOLOGY
1. AGE-

 Incidence of breast cancer increases with age.

 Risk of developing breast cancer is only 0.3% between the age of 20 and 40
years but it is more than 5% between 50 and 70 years.
 So, majority of patients presenting with breast cancer are over the age of 50
years.

2. GENETIC FACTORS-

 Family history of breast cancer shown an increased incidence in the same family.
 The risk is greatest in patients with 1st degree relatives[ mother, sister] affected.
 Two genes has been identified [i.e. BRCA1 and BRCA2] on the long arm of
chromosome no. 17 and 13 which is concerned with the development of
breast cancer.
 BRCA 1 predisposes to both breast and ovarian cancer in families, BRCA 2
appears to be restricted to breast cancer, even male breast cancer.
 Together BRCA 1 and BRCA 2 accounts for approximately 75% of all
hereditary breast cancers.

3. CHILD BEARING & FERTILITY-

 Single and nulliparous married women have a increased risk of breast cancer
as compared to multiparous women.
4. AGE OF MENARCHE & MENOPAUSE-

 The girls whose menarche occurs before the age of 12 years have a high risk of
developing breast cancer compared to those whose menses started after 12
years.
 Reduction in the age of menarche over last few decades due to improved
nutrition and general health may be an important cause of higher incidence of
breast cancer.
 Women in whom menopause occurs after the age of 55 years have twice the risk
of developing the disease compared to women whose menopause started before
the age of 45 years.
 Artificially induced surgical menopause appears to be protective for breast
cancer.
5. GEOGRAPHICAL FACTORS-

 Breast cancer is commonly seen in western countries. It is still a rare tumour

in Japan.

6. ENDOCRINE FACTORS-

 The women who takes oral contraceptive pills from long time have a high risk
of developing breast cancer.
 In post menopausal women, breast cancer is more common in obese. It may be
due to increased conversion of steroid hormone to oestradiol in the body fat.
7. DIET-

 Diet rich in saturated fatty acids may influence the risk of developing breast
cancer.
 Cancer of the National Academy of Science concluded that fried and high fat
foods can increase the risk of developing cancer approximately 2 folds.
 High intake of alcohol is also associated with increase risk of breast cancer.
 Vitamin C seems to have some protective action.

8. BENIGN DUCT DISEASE-

 Some pathological entities like multiple papillomatosis, gross atypia with

hyperplasia are associated with increased risk of breast cancer.
PATHOLOGY

 Approximately 50% of breast cancers arise in the upper and outer

quadrant, 12-15% in the upper and inner quadrant, 6-10% in lower and outer
quadrant, 3 to 5% in the lower and inner quadrant and 20% in the central or
subareolar region.
 Breast carcinoma is mainly unilateral condition, but in 1-2% of cases it
shows bilateral presentation.
 Over 90% of breast cancers arise in the ductal epithelium and only 10% in
the mammary lobules.
CLASSIFICATION- BREAST
CARCINOMA
A. DUCTAL CARCINOMA OF THE BREAST

 Ductal carcinoma in situ

 Invasive ductal carcinoma-
i. Infiltrating ductal carcinoma with productive fibrosis [ Scirrhous Carcinoma ]
ii. Medullary carcinoma
iii. Tubular carcinoma
iv. Mucinous [Colloid] Carcinoma
v. Papillary Carcinoma
vi. Adenoid Cystic Carcinoma
B. LOBULAR CARCINOMA OF THE BREAST

 Lobular carcinoma in situ

 Invasive lobular carcinoma

C. PAGET’S DISEASE OF THE NIPPLE

DUCTAL CARCINOMA OF THE
BREAST
This is the most common form of breast cancer accounting for
85% to 90% of all cases.

Classification
1. Ductal carcinoma in situ
2. Invasive ductal carcinoma
DUCTAL CARCINOMA IN SITU

 It is characterized by proliferation of malignant breast epithelial cells

confined to the duct system and does not invade the basement
membrane or surrounding tissues.
 It accounts for 5% of all cases of breast carcinoma.
 30 to 50% of cases shows invasive cancer in the same quadrant after an
interval of 10-15 years.
It is further divided into two histological types-
i. Solid or Comedo type- most common and most virulent.
ii. Papillary or Cribriform type- characterized by papillary projections of
tumour cells into ductal lumen.
DUCTAL CARCINOMA IN INVASIVE DUCTAL
SITU CARCINOMA
INVASIVE DUCTAL CARCINOMA

 Once intraductal carcinoma has invaded the basement membrane of

the duct, it has now the ability to infiltrate into the surrounding
breast tissue and is called invasive ductal carcinoma.
 It is further divided into-
i. Scirrhous Carcinoma
ii. Medullary Carcinoma
iii. Tubular Carcinoma
iv. Mucinous Carcinoma
v. Papillary Carcinoma
vi. Adenoid Cystic Carcinoma
SCIRRHOUS CARCINOMA

 It accounts for 70% of all invasive mammary cancers.

 This tumour originates from the ductal epithelium.
 This is presented in peri or post menopausal women in the 6th decade as
solitary, non tender, firm and ill defined mass.
 This tumour possess a poorly defined border which is better defined by
palpation than inspection.
 Cut surface looks as a central radiating stellate tumour with chalky
white or yellow streaks extending into surrounding parenchyma.
MEDULLARY CARCINOMA

 This cancer represents 2 to 15% of all breast cancers.

 Grossly, the tumour is soft, well circumscribed, bulky, haemorrhagic
and has uniform consistency.
 The lesion is deeply placed within the breast and it is mobile.
 In less than 1/5th of cases, it is bilateral.
 In less than 10% of cases, these neoplasms contain detectable
oestrogen or progesterone receptors.
 Lymph node metastasis is rare, hence it is having better prognosis.
 5 year survival rate is better than other invasive ductal and lobular
carcinomas.
TUBULAR CARCINOMA

 This type of breast cancer represents only 3%of all breast cancers.
 Grossly, this cancer is small about 1 cm in diameter and scirrhous.
Most commonly, this lesion is seen in perimenopausal or early
menopausal women.
 It is more diagnosed mammographically and has been reported in as
many as 1/5th of women whose cancers are detected by screening
only.
 Only 10% of patients develop axillary metastasis and it is confined to
only small numbers in low axillary nodes [level 1].
 This carcinoma has a good prognosis and 10 years survival rate is more
than 75%.
MUCINOUS [COLLOID] CARCINOMA

 This type is uncommon and constitutes only 2% of all breast cancers.

 It is typically bulky, mucinous and largely confined to elder women.
 The cut surface looks glistening, glaring and gelatinous. Fibrosis is
variable and when abundant, it imparts a firm consistency to the
tumour. The mucin is secreted by the carcinoma cells.
 About 2/3rd of these tumours contain detectable ER receptors.
 Approximately 1/3rd of cases are having axillary metastasis and 5 year
survival rate is more than 70%.
PAPILLARY CARCINOMA

 This carcinoma accounts for less than 2% of all breast carcinomas and are
generally seen in old women [around 70 years].
 Typically, this tumour is a small one and rarely attains a size more than 2to
3 cm in diameter.
 Histologically, there are papillae with well defined fibrovascular stalks and
multilayers epithelium with pleomorphic cells.
 This tumour has the lowest frequency of axillary nodal involvement and has
the best 5 year survival rate.
ADENOID CYSTIC CARCINOMA

 This lesion is very rare- less than 0.1% of all types of breast cancer.
 These cancers present as small lesions- 1 to 3cm in diameter.
 These are characteristically well circumscribed with well defined
margins. The tumour contains dense mucoid material with glandular
spaces.
 Axillary metastasis are rare with this type of carcinoma, but distant
metastasis like pulmonary metastasis are not uncommon.
LOBULAR CARCINOMA OF THE
BREAST
 This can be divided into in-situ and invasive forms depending
upon whether the basement membrane of the lobule has been
invaded by tumour or not.
 Histologically, it is a proliferation of small round epithelial cells
within the lumens of multiple breast acini.
 So, it presents as multiple clusters of epithelial cells forming
islands of neoplastic cells maintaining lobular architecture.
LOBULAR CARCINOMA IN SITU INVASIVE LOBULAR CARCINOMA
LOBULAR CARCINOMA IN SITU

 This accounts for 3% of all breast cancers.

 It is a condition in which abnormal cells are present in the lobules of
the breast.
 In practice, this lesion is only discovered by chance in biopsy
specimen taken for some another reason.
 It never forms a palpable mass and thus missed in physical
examination. There is no typical mammographic finding.
 Lobular carcinoma is characterized by bilaterality, multicentricity and
multifocality.
INVASIVE LOBULAR CARCINOMA

 This accounts for 10% of all breast cancers.

 Grossly, this lesion varies from clinically inapparent microscopic
tumour to a poorly defined firm mass.
 This tumour is particularly known for bilaterality, multicentricity and
multifocality.
 Examination of the contralateral breast shows lesions in nearly 40% of
cases.
 Microscopic evidence of preinvasive tumour cells in clusters within
the acini in a lobule is the only diagnostic finding.
 The prognosis of invasive lobular carcinoma is better than that of
invasive ductal carcinoma.
PAGET’S DISEASE

PATHOLOGY-
Paget’s disease constitutes
approximately 1% of the histologic
types of breast cancer. It is almost
always associated with an underlying
intraductal or invasive carcinoma.
It begins as a eczematous lesion of the
nipple which becomes red and
thickened.
The areola and surrounding skin may be
involved as well. In the beginning, no
mass can be felt but gradually a
swelling will develop beneath the
nipple in most of the cases.
CAUSE-
 This condition arises from an underlying carcinoma of the mammary
duct, which gradually grows towards the nipple and invades the skin
around the nipple.
 Any eczematous lesion of the nipple in a postmenopausal women should
be biopsied to exclude paget’s disease.

HISTOLOGY-
 Presence of paget cell is most diagnostic evidence.
 These cells are large, clear and vacuolated with small dark nuclei.
 These cells are seen in clusters in the deeper layers of epidermis.
CLINICAL FEATURES- The symptoms of the paget disease of the breast
are often mistaken for those of some benign skin conditions, such as
dermatitis or eczema. The symptoms include the following-

 Itching, tingling or redness in the nipple or areola.

 Flaking, crusty or thick skin on or around the nipple.
 A flattened nipple
 Discharge from the nipple that may be yellowish or bloody.
 Physical finding identify a palpable mass in subareolar area.
 1/4th to 1/3rd of patients are having axillary node metastasis.
SPREAD OF CARCINOMA

Carcinoma of the breast spread through following routes-

 Local spread
 Intraductal spread
 Lymphatic spread
 Spread by blood
 Intracoelomic spread
1. Local Spread

Carcinoma of the breast spreads into the surrounding tissues by

infiltration and invasion. Scirrhous carcinoma is particularly notorious for
local spread. Invasion of the skin causes dimpling of the skin. Invasion
into the major periductal tissue causes retraction of the nipple.
Through the local spread breast carcinoma gradually invades the pectoral
fascia, pectoral muscle and ultimately the chest wall.

2. Intraductal Spread

Carcinomatous cells in the breast spread through the ducts and ductules.
Examples are Paget’s disease, lobular carcinoma, tubular carcinoma etc.
This explains the phenomenon of multifocal nature of breast cancer.
3. Lymphatic Spread

 Breast carcinoma spread through this route by Emboli and

Permeation. Emboli are clusters of carcinoma cells which are swept
along the lymphatic vessels to the regional lymph nodes. By
permeation it means that columns of cancer cells grows along the
lumen of the lymphatic channel and gradually proceed to the regional
lymph nodes.
 Lymphatic spread is early in the scirrhous carcinoma of the breast.
The pectoral group of axillary lymph nodes is the first to be involved
in majority of cases.
 Due to involvement of regional lymph nodes and blockage of the
lymphatics there is oedema of the whole breast. In case of oedema of
the breast, there is multiple pin-point depressions at the site of
attachment of hair follicles.
 This looks like peel of an orange and called as “peau de orange.”
4. Spread by Blood

 This spread occurs later than lymphatic spread in case of carcinoma of

the breast. Cancer cells detach as emboli into venules and are drifted
through the venous blood to the lungs first.
 If they cross the capillaries of the lungs they reach the left atrium and
hence to the systemic circulation.

5. Intracoelomic Spread

 Cancer cells spread into the peritoneal cavity from breast cancer. This is
through lymphatic spread which involves the subdiaphragmatic and
retroperitoneal lymph plexus. Cancer cells thus reach the peritoneum
and peritoneal dissemination may occur.
CLINICAL FEATURES
OF BREAST CANCER
 Age group affected- After 40 Years
 Patient presents with a painless lump in the
breast, most commonly in the upper and outer
quadrant.
 Discharge through nipple is not usual. Though
blood discharge is common in ductal
carcinoma.
 Retraction of nipple
 Sometimes patient complains of metastatic
symptoms like backache, chest pain,
haemoptysis, dyspnoea, enlarged axillary or
supraclavicular lymph nodes.

A lump in the breast should always be

suspected as a carcinoma unless proved
otherwise.
 LOCAL EXAMINATION
ON INSPECTION-
 Retraction of nipple or dimpling of skin
 Peau de orange may be seen due to cutaneous lymphatic oedema.
 Red eczematous lesion is seen in Paget’s disease.
 Bloody nipple discharge is seen in ductal carcinoma.
ON PALPATION-
 Breast lump is best palpated by flat of the hand.
 Lump has irregular surface, harder in consistency and it is fixed to
the overlying skin or pectoral fascia. In late stages, the growth has
been fixed to the chest wall.
 Axillary lymph nodes are enlarged and they are palpable.
 The opposite breast should always be palpated to find out if there is
any distant metastasis.
CLINICAL STAGING

There are 3 methods of clinical staging in use at present. These are-

1. Manchester System
2. The Columbia System
3. The TNM [ tumours, nodes, metastases ] system.

By far, the TNM system has achieved widespread acceptance.

MANCHESTER SYSTEM

Stage 1- The growth is confined to the breast.

Stage 2- The growth is confined to the breast but palpable and mobile
lumph nodes are present in the axilla.
Stage 3- The growth extends beyond the mammary parenchyma as shown
by-
a) Skin invasion or fixation over an area larger than the size of breast or skin
ulceration.
b) Tumour fixation to the underlying muscle or fascia- Axillary lymph nodes, if
enlarged are mobile.

Stage 4- The growth extends beyond the breast area; Fixation of the
tumour to the chest wall; Fixation or matting of the axillary lymph nodes,
Supraclavicular lymph nodes involvement; Distant metastasis.
COLUMBIA SYSTEM

Stage A- No skin oedema, ulceration or fixation of the tumour to the chest

wall. Axillary lymph nodes are not clinically involved.
Stage B- No skin oedema, ulceration, or fixation of the tumour to the
chest wall. Axillary lymph nodes are clinically involved but less than 2.5cm
in transverse diameter and are not fixed to the overlying skin or deeper
structures of the axilla.
Stage C- Presence of oedema of the skin, skin ulceration, fixity to the
chest wall, massive involvement of axillary lymph nodes (more than 2.5cm
in transverse diameter) and fixation of the axillary nodes to the overlying
skin or deeper structures.
Stage D- All those present in Stage C + there is extensive oedema of the
skin, clinically supraclavicular lymph node involvement, parasternal
metastasis, oedema of the ipsilateral arm and distant metastasis.
TNM SYSTEM

It is based on Clinical Observation related to the tumour(T), regional

lymph nodes(N) and distant metastasis(M).
Tumour(T)-
T0 – No demonstrable tumour in the breast.
T1S- Preinvasive Carcinoma (Carcinoma in situ)
T1- Tumour of 2cm or less; skin is not involved or involved locally in
Paget’s disease.
T2- Tumour size 2 to 5cm
T3- Tumour is greater than 5cm in size.
T4- Tumour of any size with any of the following-
Skin infiltration, ulceration, skin oedema, Peau d orange, pectoral muscle
or chest wall attachment.
Regional lymph nodes(N)
N0- No clinically palpable axillary lymph nodes.
N1- Clinically palpable axillary nodes (N1a- metastasis not suspected, N1b-
metastasis suspected)
N2- Clinically palpable, fixed axillary nodes (metastasis suspected)
N3- Homolateral supra-or infraclavicular nodes considered to contain
metastasis, oedema of the arm.

Distant Metastasis(M)-
M0- No distant metastasis
M1- Clinical and radiologic evidence of metastasis except those to
homolateral axillary or infraclavicular lymph nodes; includes skin
involvement beyond the breast.
STAGING-

Stage 1- T1, N0 or Na, M0

Stage 2- T1, N1b, M0; T2, N0, M0 or T0, N1b, M0; T2, N1a, M0 or T2, N1b,
M0
Stage 3- T3, N2, M0 or T4, N2, M0
Stage 4- Any T, Any N with M1.
INVESTIGATIONS FOR
BREAST CANCER
1. Mammography- This is the X ray examination the breast. In case of
swelling of a breast whose clinical diagnosis has not been certain,
mammography has a very definite role to play.
2. Ultrasound- Ultrasonic examination of the breast is useful only in
differentiation between solid and cystic swellings greater than 2.5cm in
diameter.
3. Magnetic Resonance Imaging(MRI) of the breast
4. Fine Needle Aspiration Cytology(FNAC)- It has become an almost a routine
practice in the investigation of breast lump. A 22-gauge needle and an
appropriate size syringe is required. This method has the advantage that it
can be performed as an outpatient procedure. It cannot differentiate
between in-situ and invasive cancer but it differentiates ductal from
lobular carcinoma.
INVESTIGATIONS FOR DISTANT METASTASIS

1. Chest X-ray
2. Bone X- ray- The common type of osseous metastasis is the osteolytic
lesion which destroys bone mineral and produces an irregular lytic lesion
on x ray. The pelvis and the spine are the most frequently involved sites.
The lumbar spine is the common site in the spine followed by thoracic
spine, sacrum and cervical spine.
3. Liver Scan
4. Biochemical Studies-
 Elevated alkaline phosphatase and gamma glutamyl transaminase
levels are estimates of liver metastasis.
 Serum Carcinoembryonic Antigen(CEA)- It is a valuable indicator in
association with liver scan to detect liver metastasis. If the defects in
the liver scan are associated with CEA levels greater than 5mg/ml,
liver metastasis are considered to be present.
 TREATMENT OF EARLY BREAST
CANCERS (STAGE 1 AND STAGE 2)
 The traditional surgical treatment for breast cancer involves total removal
of the breast.
 Upto early 1970s breast cancer was treated by total mastectomy, the most
commonly performed operation was Halsted’s radical mastectomy.
 Later on, more conservative operations came into play e.g. tumourectomy,
lumpectomy, tylectomy, segmental mastectomy and quadrantectomy in
which the primary tumour is removed and the breast is preserved.
 The terms ‘lumpectomy’, ‘tumourectomy’ and ‘tylectomy’ implies removal
of tumour with a minimal margin of the normal breast tissue around it.
 ‘Segmental Mastectomy’ implies excision of tumour with a rim of associated
normal breast tissue.
 The term ‘quadrantectomy’ denotes removal of a breast quadrant and
involves wider excision of normal breast tissue than segmental mastectomy.
SARCOMA OF THE BREAST
 There are various sarcomas which can be found in the breast such as
liposarcoma, fibrosarcoma, haemangiosarcoma and lymphosarcoma but
these are rare.
 Cystosarcoma is the most common sarcoma found in the breast.
CLINICAL FEATURES
 Age group affected- 40 to 50 years.
 Slowly growing tumour present as a large lobular mass in the breast.
 On inspection- Huge mass can be seen in the breast. Overlying skin is
tense, red with dilated veins.
 On palpation- tumour is having soft consistency.
 Axillary lymph nodes involvement is late.
Spread of carcinoma-
1. Mainly through blood.
2. Local infiltration is next type of spread.
3. Lymph spread is rare and very late.

Treatment – Wide local excision in the form of total mastectomy followed

by radiotherapy is the treatment of choice.

Prognosis- Prognosis of all sarcomas of the breast are relatively good than
other sarcomas in the body.