Breast Cancer evaluation as per NCCN guidelines and investigational tools

1. Clinical Presentation
and Investigations for
Breast carcinoma
Dr.P.Viswakumar,M.S
Assistant professor,
Dept.of General surgery,
PSGIMSR.

2. Embryology and Functional Anatomy
of the Breast
• Two ventral bands of thickened ectoderm
appears at 5th or 6th week _ ‘milk line’.
• Each breast develops when an ingrowth of
ectoderm forms a primary tissue bud in the
mesenchyme.
• The primary bud, in turn, initiates the
development of 15 to 20 secondary buds.
• Major (lactiferous) ducts develop, which open
into a shallow mammary pit.
• During infancy, a proliferation of mesenchyme
transforms the mammary pit into a nipple

3. • The breast remains undeveloped in the female
until puberty, when it enlarges in response to
ovarian estrogen and progesterone, which
initiate proliferation of the epithelial and
connective tissue elements
• However, the breasts remain incompletely
developed until pregnancy occurs.

4. Functional anatomy
• The breast is composed of 15 to 20 lobes which
are each composed of several lobules.
• Fibrous bands of connective tissue travel through
the breast (Cooper's suspensory ligaments), insert
perpendicularly into the dermis, and provide
structural support.
• The upper outer quadrant of the breast contains a
greater volume of tissue than do the other
quadrants.
• The epidermis of the nipple-areola complex is
pigmented and is variably corrugated.

5. Functional anatomy
• The dermal papilla at the tip of the nipple
contains numerous sensory nerve endings and
Meissner's corpuscles.
• This rich sensory innervation is of functional
importance, because the sucking of the infant
initiates a chain of neurohumoral events that
results in milk letdown.

8. Blood supply,Innervation and
Lymphatics
• Arteries (a) perforating branches of the internal
mammary artery; (b) lateral branches of the posterior
intercostal arteries; and (c) branches from the axillary
artery, including the highest thoracic, lateral thoracic,
and pectoral branches of the thoracoacromial artery .
• The three principal groups of veins are (a) perforating
branches of the internal thoracic vein, (b) perforating
branches of the posterior intercostal veins, and (c)
tributaries of the axillary vein.
• Batson's vertebral venous plexus, which invests the
vertebrae and extends from the base of the skull to the
sacrum, may provide a route for breast cancer
metastases to the vertebrae, skull, pelvic bones, and
central nervous system.

9. Blood supply,Innervation and
Lymphatics

10. Blood supply,Innervation and
Lymphatics
• Lateral cutaneous branches of the third
through sixth intercostal nerves provide
sensory innervation of the breast (lateral
mammary branches) and of the anterolateral
chest wall.
• Six axillary lymph node group recognized by
surgeons
1) Lateral 2)Anterior 3) Posterior 4) Central
5) Apical 6) Interpectoral

11. Blood supply,Innervation and
Lymphatics
• Lateral cutaneous branches of the third
through sixth intercostal nerves provide
sensory innervation of the breast (lateral
mammary branches) and of the anterolateral
chest wall.
• Six axillary lymph node group recognized by
surgeons
1) Lateral 2)Anterior 3) Posterior 4) Central
5) Apical 6) Interpectoral

13. Epidemiology and Natural history
• Breast cancer is the most common site-
specific cancer in women and is the
leading cause of death from cancer for
women aged 20 to 59 years.
• Collectively, US, India and China account
for almost one third of the global breast
cancer burden.

16. Indian Data

17. Indian data

18. Age Trend

19. Age Trend

20. Peer Comparision

21. Peer comparision
• For the United States, for the year 2012:
For every 5 or 6 women newly diagnosed
with breast cancer, one lady is dying of it.
• For China, for the year 2012:
For every 4 women newly diagnosed with
breast cancer, one lady is dying of it.
• For India, for the year 2012:
For every 2 women newly diagnosed with
breast cancer, one lady is dying of it.

22. Global Data

23. High Risk groups
• The average lifetime risk of breast cancer for newborn
U.S. females is 12%.
• A recent study of breast cancer risk in India revealed
that 1 in 28 women develop breast cancer during her
lifetime.
• In India the average age of the high risk group is 43-46
years while it is 53-57 years in west.
• Risk assessment tool commonly used now a days is
Modified Gail model.
• It is a computer based model uses Age, race, ethnicity
age@menarche, age@first live birth, no of first degree
relatives with breast cancer, no of previous breast
biopsies and their histological picture for future breast
cancer risk.
• http://bcra.nci.nih.gov/brc

25. High Risk groups
• Increased risk groups are categorized into 6
groups a)Women with prior h/o breast cancer
b) Women >35 years with 5 year risk of invasive
breast ca >= 1.7% as per Gail model
c) Women with lifetime risk of 20 % for invasive
malignancy calculated by models dependent on
family history.
d) Prior therapeutic chest irradiation.
e) Women with LCIS.
f) Women with pedigree suggestive of or with a
genetic predisposition (BRCA1/2,P53,PTEN and
other genetic mutations )

26. Breast Cancer Screening
Breast cancer screening has to address two
groups
1) Normal woman with no inherent risk factors.
2) High risk groups.

27. Breast Cancer Screening
• Screening for Average Risk groups :
i) Women under 25-40 age group complete
breast examination at every 1-3 years.
ii)Breast awareness to be encouraged.
iii)Women aged >40 yrs annual CBE and
Mammogram,breast awareness.
iv)Controversy exist in age groups 50-74 for
interval of screening(annually or every
other year).
v) Mammography detects lesion 2 years
prior to CBE (sojourn period of 2 yrs).

28. High Risk Screening
• Women with increased risk the screening
should start at the age of 35 yrs.
• CBE should done at every 6-12 months.
• Annual mammography
• Women with genetic predisposition screening
should begin by 30 yrs of age.

29. Clinical Presentation
Signs and Symptoms :
 New lump or mass(Most common)- 33%
Other possible signs :
• Swelling of all or part of a breast (even if no
distinct lump is felt),axillary lump.
• A nipple discharge other than breast milk
• Skin dimpling
• Breast or nipple pain
• Nipple retraction (turning inward)
• Redness, scaliness, or thickening of the nipple or
breast skin

30. Complete Breast examination

31. Palpable Mass
How to proceed with palpable mass??

32. Palpable Mass
Palpable mass;Age >30 years
Diagnostic mammogram/USG
Birads 1-3 Birads 4-5
Solid; Simple; Core needle biopsy
complex cyst No abnormality Pathology/Image: concordant/
Short term follow up Observe Discordant: Surgical excision/
Reassessment Excision
Mammo every 6-12 mon
for 2 years

33. Palpable mass
Palpable mass; Age <30 yrs
Low clinical suspicion High clinical suspicion
Observe 1-2 menstrual cycles USG of Breast
No resolution
Solid Simple cyst complex cyst No abnormality

34. Breast Pain
• Mostly it is symptom of benign breast
condition
• But malignancy is detected in 0.4% cases
undergoing mammogram for mastalgia.
• 50 % of operable breast ca reported pain as
one symptom.
• 7% has only pain as their symptom.
• So patient with unilateral breast pain and
age>35 years –mammographic examination is
necessary

35. Nipple Discharge
• Unilateral Single duct spontaneous and persistent
discharge,
• Clear,Serous, Serosanguinous or bloody discharge
are at increased risk of underlying malignancy.
• There is 5.9% to 20.2 % incidence of malignancy in
such pathological discharge.
• Investigation such as USG > Mammogram done
along with history and CBE to R/o underlying
malignancy.
• Cytology of nipple discharge is of less or no value
but can be highly specific but not recommended as
standard of care.

36. Skin Changes
Clinical suspicion of inflammatory breast Ca
1) Paeu-de orange
2) Erythema
Clinical suspicion of Pagets disease or other
manifestation of breast Ca
1) Nipple Excoriation
2) Scaling/ Eczema
3) Skin ulceration

37. Skin Changes
In Both above conditions diagnostic mammogram
with or without USG to be done.
• In BIRADS 1-3 : Punch biopsy of skin/Nipple
biopsy done.
If Benign : a) Clinical reassessment b)
Pathological correlation c) MRI of breast d)
repeat biopsy e) Consultation with breast
specialist
If Malignant : Follow malignancy treatment
protocol.

38. Skin Changes
• In BIRADS 4-5 : Core needle biopsy with or
without punch biopsy of skin or surgical
excision.
• If Benign : Punch/ Nipple biopsy if not done
before benign; follow as said above.
• If Malignant : Follow malignancy treatment
protocol.

39. Breast abscess and malignancy
• Malignancy was reported when the abscess wall cavity
sent for HPE.
• A 10 year retrospective study published in American
journal of Surgery reported the incidence is around 4.4
% (9/206 cases).
• Is it warrant biopsy as routine while doing
I&D ?? Age/lactational status should be considered?
• Since there is no clear guidelines its upto the institution
to decide and warrants well designed study……

40. Investigational Tools
 Mammography
 Ultrasound
 Stereotactic biopsy
 MRI

41. Mammography
• Conventional mammography delivers a radiation
dose of 0.1 cGy per study.
• Screening mammography is used to detect
unexpected breast cancer in asymptomatic women.
• Two views of the breast are obtained, the
craniocaudal (CC) view and the mediolateral oblique
(MLO) view.
• In diagnostic mammogram additional views are
incorporated such as spot compression
technique,etc.
• Solid mass with or without stellate features,
asymmetric thickening of breast tissues, and
clustered microcalcifications.
• The presence of fine, stippled calcium in and around
a suspicious lesion is suggestive of breast cancer.

44. Ultrasonogram
• USG is an important method of resolving equivocal
mammographic findings, defining cystic masses,
and demonstrating the echogenic qualities of
specific solid abnormalities.
• Recommended as initial imaging in women <30yrs
with palpable mass or asymmetric thickening or
nodularity.
• Women >30yrs diagnostic mammogram show
BIRAD 1-3 for palpable mass.
• All age group USG should be considered as adjuvant
to Mammography for women with skin changes
and spontaneous nipple discharge with no mass.
• Lesions <1cm are difficult to diagnose in USG.

46. MRI
• Sensitivity of MRI is higher than mammography
but got low specificity.
• Leads to high false positivity rate.
Annual MRI recommended as screening tool in
i) BRCA mutation.
ii) First degree relative of BRCA carrier but untested
iii) Lifetime risk >=20% defined by risk assesment
tools using family history
Other less evidence in 1)chest irradiation between
10-30 yrs 2) Li fraumeni,cowden and bannayan-Riley-
Ruvalcaba syndrome and first degree relatives.

47. Diagnostic Breast MRI
• To whom we have to recommend MRI of Breast
???
Patient with skin changes with high clinical
suspicion of serious breast disease but skin punch
biopsy and mammographic/USG findings reported
benign MRI should be considered.
Before recommending MRI:
a)Dedicated breast coil available
b)Radiologist experience in MRI breast images.
c)Ability to perform MRI guided procedure to localize
to MRI detected finding.

48. Sterotactic Breast biopsy

49. BI-RADS
• Breast Imaging-Reporting and Data System
• It is a widely accepted risk assessment and quality
assurance tool in mammography, ultrasound or MRI
0 Incomplete assessment; need additional imaging
evaluation
1 Negative; routine mammogram in 1 year recommended
2 Benign finding; routine mammogram in 1 year
recommended
3 Probably benign finding; short-term follow-up
suggested
4 Suspicious abnormality; biopsy should be considered
5 Highly suggestive of malignancy; appropriate action
should be taken

50. Take Home message

51. Take Home message
• Breast cancer becoming leading cancer among
Indian women.
• The incidence ,mortality ratio poor compared to
our peers showing lacunae in management.
• Screening programs still inefficient in our country
due to scarce resources and poor infrastructure.
• So adequate targeting high risk groups with the risk
assessment tools is important.
• Hence every physician should aware of high
screening recommendations.

52. • Palpable mass ,>30yrs first should undergo
mammographic imaging before pathological
evaluation.
• For <30 yrs females USG is recommended as initial
choice of imaging.
• For skin changes and nipple discharge with high
suspicion of underlying breast disease
Mammogram can aided with USG.
• MRI can be used as screening and diagnostic tool
only in certain conditions as described above.
• Stereotactic breast biopsy is excellent tool for
adequately targeting the suspicious lesion that are
not clinically palpable/detectable.

54. Hope You all got our point
Thank you
for your patience