eMentorSurgery

Dear students, Thisis only for your revision and NOT A FULL TEXT.

Carcinoma breast

Ø      Commonest

Ø       7 to 8 % women            

 AETIOLOGY

Ø     Age and Sex

Ø     Diet  and environ.factors

Ø      Japanese < Europeans

Ø      Fat intake increases risk

Ø      Higher social class

Ø      Early menarche and late menopause

Ø      Nulliparity increases  risk

Ø      Breast feeding protects

Ø      Positive family history

Ø     A high intake of alcohol is associated

Ø     a link between diets low in phyto-oestrogens.

 Genetics:

 Ø      BRCA 1, 

          Chromosome 17

Ø      BRCA 2,

          Chromosome  13

 Pathology   :

-may arise from theepithelium of the duct system anywhere from the nipple end of major lactiferousducts to the terminal duct unit which is in the breast lobule.

-may be entirely in situ —an increasingly common phenom­enon with the advent of breast cancer screening

- or may be invasive cancer.

-by three grades — welldifferentiated, moderately or poorly differentiated.

 - Ductal carcinoma is the most common variant,

-lobular carcinoma occurs inup to 10 per cent of cases, although this may be mixed. -colloid carcinoma-abundant mucin, and medullary carcinoma-with solid sheets of large

Inflammatorycarcinoma

-        fortunately rare,

-        highly aggressive cancer which presents as a painful, swollen breast, which is warm with cutaneous oedema.

-        mimic abreast abscess.

Paget’s disease of thenipple

-a superficial manifestationof an underlying breast carcinoma.

 -an eczema-like condition of the nipple andareola .

-The nipple is eroded slowlyand eventually disappears.

-biopsied –Microscopically -bythe presence of large, ovoid cells with abundant, clear, pale-stainingcytoplasm in the Malpighian layer of the epidermis.

Types(Pathalogical)

•        Ductal Carcinoma  90%

•        Lobular Carcinoma 10%

 Non infiltrating

•       Intraductal

•       Lobular

•       Comedo

 Infiltrating

•         Scirrhous

•          Atrophic Scirrhous

•         Colloid

•         Medullary

•         Inflammatory (mastitiscarcinomatosa)

•         Pagets disease of the nipple

 CLINICAL FEATURES

•         Upper outer quadrant

•          Hard ,irregular lump

•          Nipple retraction

•          Dimpling ,puckering of skin

•         Peau d orange

•          Skin nodules/ulceration

•          Nipple discharge

•         Fixation to pectoralis

•         Bony metastasis

 SPREAD

v    DIRECT

v     LYMPHATICS

v     BLOOD STREAM

 Phenomena resulting from lymphatic obstruction in Staging of breast cancer

advanced breast cancer

Peau d’orange is due tocutaneous lymphatic oedema. Where the infiltrated skin is tethered by the sweatducts it cannot swell, leading to an appearance like orange skin. Occasionallythe same phenomenon is seen over a chronic abscess.

Late oedema of the arm is a troublesome complication

-radicalaxillary dissection

-radiotherapy are rarely combined..

An oedematous limb is susceptible to bacterial infections

-.Treatment of late oedema is difficult but limb elevation, elastic arm stockingsand pneumatic compression devices can be useful.

Cancer-en-cuirasse.The skin of the chest is infiltrated with carcinoma and has been likened to a coat.

Lymphangiosarcoma- a rare complication of lymphoedema with an onset many years following the original treatment.

-        multiplesubcutaneous nodules in the upper limb and must be distinguished from recurrentcarcinoma of the breast.

-        -Theprognosis is poor but some cases respond to cytotoxic therapy or irradiation.

-        Interscapulothoracic(forequarter) amputation is sometimes indicated.

Diagnosis

•         Haemogram

•         Chest X ray

•         Ultrasound

•          FNAC

•          Mammography

•          Biopsy

•         Clinical examination

Mammography (Carcinoma –breast)

 Spiculated border

 Calcification

   TNM classification

       Primary tumour =T                    

 TX:  Not assessable

TIS:  Carcinoma-in-situ

TI :  2 cm or less ( No fixation ortethering )   

T2:  2 cm - 5 cms                 

T3 :   >5 cm

T4: Involving skin / chest wall / nodules / odema

T4    Any size withchest  wall or skin extension                        

 T4a   Chest wall                         

T4b   Oedema/ulceration/nodules 

T4c   Both 4a and 4b                 

T4d   Inflammatory cancer

NO   No node metastasis          

NI    Axillary (mobile)                                   

N2   Axillary (fixed)  

N3   Supraclavicular/odema

M0 : No distant metastases

MI : Distant metastases present

Staging systems

            TNM               Manchester                  Columbia

 •        TO – T1                       Stage 1               StageA

            NO – N1a

•        T2                                StageII                     Stage B

            N1B                                                    

•        T3 – T4                        Stage III                    StageC

            N2 – N3

•        MI                               StageIV                       Stage D

Treatmentof cancer of the breast

-largely depend uponclinical stage of the disease at presentation including not only classical TMNstaging but often other tumour characteristics such as tumour grade.

-with or without radiotherapy.

-Systemic therapy such aschemotherapy or hormone

The multidisciplinary team approach

As in all branches of medicine good doctor

-        breast counsellor and also to have available advice on breast prostheses,psychological support and physiotherapy,

-        -as ajoint venture between the surgeon, medical oncologist, radiotherapist andallied health professionals such as the clinical nurse specialist.

Local treatment of earlybreast cancer

Local control is achievedthrough surgery and/or radiotherapy.

Surgery

-equal efficacy between mastectomy and local excision followed by radiotherapy..

Mastectomy is now only strictly indicated for large tumours (in relation to the size ofthe breast), central tumours

-The radical Halstead mastectomy which included excision of the breast, axillary lymph nodes, pectoralis major and minor muscles is no longer indicated as it causes excessive morbidity with no survival benefit.

-Modified radical (‘Patey’ mastectomy is more commonly performed

Simplemastectomy involves removal of the breast only with no dissection of the axilla, except for the region of the axillary tail of the breast which usuallyhas attached to it a few nodes low in the anterior group. Because no pathological staging of the axilla is performed with a simple mastectomy, it isoften followed by radio therapy to the axilla.

  Patey’ mastectomy.

• the whole breast;

• a large portion of skin, the centre of whichoverlies the tumour, but always includes the nipple;

• all of the fat, fascia and lymph nodes of theaxilla. The pectoralis minor muscle is either divided or removed to gain accessto the upper two-thirds of the axilla. The axillary vein and nerves to serratusanterior and latissimus dorsi should be preserved.

The wound is drained using awide-bore suction tube.

 Early mobilisation of the arm is encouraged and physiotherapy

Radiotherapy

Radiotherapy to the chestwall after mastectomy has been largely abandoned except in cases of extensivelocal disease with infiltration of the chest wall.

-adjuvant radiotherapy,

Adjuvant systemic therapy

-treat­mentare predetermined by the extent of micrometastatic

Hormone therapy

Tamoxifen is the most widelyused ‘hormonal’ treatment in breast cancer.

-suggest that 5 years oftreatment may be preferable to 2 years.

.Chemotherapy

Chemotherapy using a regimensuch as a 6-monthly cycle of cyclophosphamide, methotraxate and 5-fluorouracil(CMF)

-adjuvantchemotherapy

Breast reconstruction

- immediate or delayedreconstruction of the breast

The mostcommon type of reconstruction is using a silicone gel implant under thepectoralis major muscle.

-largervolume of tissue is required, a musculocutanous flap can be constructed fromeither the latissimus dorsi muscle (an LD flap) or the contralateraltransversus abdominis muscle (a TRAM )