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Chemotherapy For Breast Cancer
Axillary Node Dissection
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Risk Factors
- Family history - 1st degree relatives
- Contralateral breast carcinoma
- Atypical hyperplasia on previous biopsy
- Nulliparous
- Early menarche
Types
- ductal carcinoma-in-situ
- of duct
- no penetration of basement membrane
- invasive ductal carcinoma
- arises from epithelium of duct
- penetrates basement membrane
- up to 75% of infiltrative breast carcinoma
- stony hard to touch
- histology
- tumour cells arranged in groups, cords and glands
- variable
- lobular carcinoma-in-situ
- arises from epithelium of lobule
- no penetration of basement membrane
- invasive lobular carcinoma
- arises from lobules
- penetrates basement membrane
- 10% of UK invasive breast cancer
- always scirrhous (macroscopic appearance due to dense fibrous
reaction)
- may be multifocal
- histology
- cells small and uniform
- dispersed singly or in columns 1 cell wide
- dense stroma
- infiltrate around existing ducts + acini
- may be signet ring cells
- comedo carcinoma
- high grade ductal carcinoma in situ
- ducts may contain necrotic debris
Spread
- direct
- lymphatic
- giving peau d'orange appearance
- axillary common (40-50% at presentation)
- intramammary
- supraclavicular
- tracheobronchial
- blood
- lung / bone (most frequent)
- liver
- adrenals
- brain
- pleura leading to effusion
- infiltrating lobular carcinoma spreads to more unusual sites due to single
cell spread
History
Presenting Symptoms
- Painless lump in the breast
- Nipple retraction
- Nipple discharge
- Skin dimpling
- Peau d'orange
- Breast assymetry
- Erythema
- Paget's disease of the nipple
- Symptoms of metastasis
- bone pain
- breathlessness
- jaundice
FHx
Examination
Signs suggestive of carcinoma
- Hard irregular mass
- Fixed to skin or deeply
- fixed → infiltration of skin, no mobility, skin cannot be
moved over lump
- tethering → infiltration along ligaments of Astley Cooper,
some mobility, skin dimples at extremes of movement
- Paget's disease
- Peau d'orange
- Axillary nodes (are they mobile, fixed, matted?)
- Supraclavicular nodes
Signs of metastasis
- Liver
- jaundice
- hepatomegaly
- ascites
- Bone
- bone tenderness
- pathological fractures
- Lung
- Pleural effusion
- consolidation
- Brain
- Headache
- fits
- personailty change
- papilloedema
Investigations
- Hb
- LFTs
- Calcium
- Mammography
- CXR
- Bone scan
- USS
- of suspect lesion
- of liver for secondaries
- CT scan of brain
- FNAC
- Trucut biopsy
Staging
TNM
- Tumour
- T0 - no tumour
- T1 - <2cm
- T2 - 2-5 cm
- T3 - >5cm
- T4- extension to skin, chest wall or both
- Nodes
- N0 - no nodes
- N1 - mobile nodes
- N2 - fixed nodes
- N3 - metastases to internal mammary nodes
- Metastases
- M0 - no met
- M1 - mets demonstrable
- MX - mets suspected but not demonstrated
Manchester (modified)
- Stage 0
- Stage I
- T1N0M0
- Definition
- Lump less than 5cm
- Not fixed deeply
- Treatment
- Wide local excision
- Wide local excision + axillary node sampling +/- radiotherapy
- Simple mastectomy + axillary node sampling +/- radiotherapy
- Stage II
- T1-2N1 M0 / T3N0M0
- Definition
- Lump <5cm
- Not fixed deeply
- mobile, ipsilateral axillary nodes
- Treatment
- Modified radical mastectomy +/- radiotherapy
- Stage III
- T1-4N2-3
- Definition
- Lump >5cm
- fixed to skin
- fixed ipsilateral axillary nodes
- supraclavicular nodes
- peau d'orange
- arm oedema
- Treatment
- Modified radical mastectomy/radical mastectomy + radiotherapy
- Radiotherapy +/- chemotherapy
- Stage IV
- M1
- Definition
- Treatment
- Local palliation
- Radiotherapy to localised bony mets
- Aspiration of pleural effusion and instillation of cytotoxic
agents
- Hormonal manipulation
- Tamoxifen
- oopherectomy
- chemotherapy
*Most women, especially those with oestrogen receptor positive tumours given
tamoxifen for 5 years
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