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mimic breast carcinoma; conversely, many women
presenting with a lump in the breast attribute this to
injury when it is, in fact, cancer.
Clinical features
Fat necrosis commonly presents with a painless,
irregular, firm lump in the breast and there may be a
previous history of trauma. It is often associated
with skin thickening or retraction and as a result is
often difficult to distinguish from carcinoma on
clinical examination. The lump usually decreases in
size with time, but following resolution may leave
an oil cyst within the breast, which is a collection of
liquified fat.
Treatment
Although mammography may demonstrate nonspecific changes, or show a spiculate, dense mass
that mimics carcinoma, ultrasound will often reveal
characteristic features. The diagnosis can be confirmed by core biopsy and the mass should resolve.
In the absence of a firm diagnosis, an open biopsy is
recommended.
Acute inflammation
ofthe breast (mastitis)
There are two common causes of acute breast inflammation in children and adults:
•
Acute bacterial mastitis: may be lactational or
non-
lactational.
Periductal mastitis.
•
Two less common conditions are worthy of mention:
Mondor’s disease: superficial thrombophlebitis in
•
the anterior chest, characterized by the presence
of painful, cord- like lumps.
Post- irradiation oedema: irradiation may be asso-
•
ciated with oedema (peau d’orange), warmth and
a heavy sensation, mimicking inflammation.
Acute bacterial mastitis
It is the most frequent acute inflammation of the
breast; the majority of cases occur during lactation.
Itinitially presents as cellulitis and progresses to an
abscess in 5–10% of cases. A microorganism is
in 60–80% of cases.
Lactational mastitis is more common during the
first months of breastfeeding mainly due to
of the milk or cracking of the nipples. Staphylococcus
aureus is the most common pathogen but methicillin-
resistant S. aureus (MRSA) should be considered in
refractory cases.
lactational (non- puerperal) mastitis and
Nonabscess may be associated with systemic conditions
such as diabetes, steroid therapy and rheumatoid
arthritis. The common organisms include staphylococci, enterococci, α- haemolytic streptococci, proteus
and bacteroides.
isolated
stagnation
Clinical features
Common symptoms include pain, swelling and
tenderness of the breast. The inflammation may be
localized, with erythema and tenderness of a segment
of the breast or may spread to involve the entire
breast. In the later stages, there may be a fluctuant
mass and patients may have signs of sepsis with
pyrexia, tachycardia and leucocytosis.
The possibility of an inflammatory breast cancer
should be considered if the inflammation fails to
resolve on treatment or if there is an associated mass
lesion. In these cases, a core biopsy should be
obtained.
Treatment
Cellulitis
In the early phase of mastitis, appropriate antibiotics
can prevent abscess formation. In lactational mastitis,
suppression of lactation is not required and breastfeeding or pumping should be highly encouraged, as
this will speed up recovery.
Abscess
Patients with clinical or radiological evidence of
pus should have ultrasound performed in addition to appropriate antibiotic
therapy. Repeat aspiration may be necessary and
resolution of the abscess can be monitored
with sequential ultrasound examinations. If the
abscess fails to resolve, or the overlying skin is thin
or necrotic, incision and drainage should be
performed.
guided aspiration
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Severe or refractory infection
Admission for intravenous antibiotic administration
might be required if there is progression on oral antibiotics or in the presence of sepsis. Intraoperative surgical drainage and debridement may be indicated in
advanced stages.
Periductal mastitis
This is an inflammatory process that occurs around
dilated milk ducts near the nipple. Cellular debris and
keratin plugs block the lactiferous ducts, leading to
duct dilation and secondary infection, often with
mixed flora (e.g. staphylococci, enterococci, anaerobic
streptococci and other anaerobes). Occasionally, the
infected ducts may result in a subareolar abscess
beneath the nipple which discharges to form a fistula,
often at the margin of the areola. It is much more
common in smokers, and nipple piercing increases
the risk of infection. It occurs mostly in premenopausal women, in contrast to duct ectasia.
Chronic inflammatory
conditions ofthe breast
There are two uncommon chronic inflammatory
conditions of the breast.
1
Granulomatous mastitis may be secondary to
systemic conditions (sarcoidosis), infections (tuberculosis, fungi), foreign material (silicone) or be idiopathic. Idiopathic mastitis presents with peripheral
masses or abscess and it might take months to
resolve; surgery is avoided due to poor wound healing. Management includes treatment of any organisms cultured and exclusion of malignancy.
Lymphocytic lobulitis occurs in patients with auto-
2
immune diseases, particularly type 1 diabetes
mellitus (diabetic mastopathy), and usually presents with a firm, mass. The diagnosis is made on
core biopsy, with fibrosis and lymphoid infiltrate
on microscopy. No further treatment is required.
Clinical features
Common features include pain and thick, pasty
nipple discharge. There may be cellulitis, nipple
retraction or a mass deep to the nipple. An associated
mammary duct fistula may be present in the periareolar region. Ultrasound may confirm a thickened or
dilated duct or abscess formation.
Treatment
Initial treatment is with appropriate antibiotics and
smoking cessation advice. Nipple rings should be
removed if present. Patients with recurrent periareolar inflammation and ductal discharge should be
treated with total duct excision. A mammary duct fistula is treated by total duct excision combined with
excision of the fistulous track between the duct and
the skin.
Duct ectasia
An involutional change in the ducts associated with
the menopause. The terminal ducts behind the
nipple become dilated (ectasia) and engorged with
secretions. Secondary infection may lead to retroareolar abscess, and fibrosis may result in nipple
inversion.
Benign breast disease
At the start of the menstrual cycle, increasing amounts
of oestrogen stimulate the growth of breast ducts.
After ovulation, increasing amounts of progesterone
stimulate lobular development. When implantation
fails, these changes regress and the levels of progesterone and oestrogen fall, corresponding to the onset
of menstruation. Benign epithelial breast disease is a
consequence of aberrations of these hormonal effects
on the breast; the incidence decreases following the
menopause.
Benign breast disease is characterized by cystic and
solid lesions and is divided into:
•
Nonproliferative (the most common), including
cystic disease and duct ectasia.
• Proliferative, including sclerosing adenosis, radial
scars, fibroadenomas and ductal papillomas.
Cystic disease
Simple cysts are dilations of the ducts and acini, as a
result of the obstruction of the terminal duct- lobular
unit caused by metaplasia of the epithelial lining.
They are more common in women aged 35 to 50 years
old but uncommon after the menopause.
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Clinical features
Cysts often present as a smooth and often tender
lump in the breast. The lump may be fluctuant, but
tense cysts may mimic a solid lump on clinical examination. Cysts may be multiple and/or bilateral. They
appear as wellacteristic halo on mammography, and are clearly
differentiated from a solid lump by ultrasound.
Ultrasound can also identify the presence of internal
debris (complicated and complex cysts) and/or thick
walls (complex cysts).
defined, rounded opacities with char-
Treatment
Newly diagnosed simple cysts do not require aspiration to dryness unless they are symptomatic. If the
fluid is bloodindicated.
Core biopsy or fine(FNAC) is also indicated for complex and complicated cysts, where there is evidence of septae or a
solid area in the cyst wall or if the palpable mass persists following aspiration.
The presence of simple cysts does not increase the
risk of breast cancer. The risk of breast cancer following a complicated or complex cyst depends on the
results of the biopsy.
stained, core biopsy of the cyst wall is
needle aspiration cytology
excision in order to rule out these pathologies.
Ifatypia is found during assessment, then
with mammogram for 5 years is indicated; otherwise
the risk of subsequent malignancy is small.
surveillance
Fibroadenoma
Fibroadenomas are the most common benign breast
tumours and are considered as an aberration of normal
development. Fibroadenomas are proliferative lesions
arising from an entire lobule. There is no increased risk
of malignancy with simple fibroadenomas and about
one- third will decrease in size or resolve over time.
Clinical features
Fibroadenomas are more common in women under
30 years old and are also known as ‘breast mice’. They
usually present as a discrete, firm, mobile lump, or as
multiple or bilateral lumps. Fibroadenomas can grow
rapidly during pregnancy. Apart from ‘simple’,
fibroadenomas can also be:
Complex: when there are other features in pathology,
•
such as sclerosing adenosis or calcifications. These
can slightly increase future breast cancer risk.
Giant: when they measure more than 5cm.
•
•
Juvenile: when found in teenage girls.
Sclerosing adenosis
Sclerosing adenosis is characterized by an increase in
the number of acini in the breast lobules, and is
thought to be the result of an abnormality in breast
involution.
Patients may present with pain or lumpiness in the
breast, or increased density or microcalcifications on
screening mammography which may be indistinguishable from in situ carcinoma. Definitive diagnosis can be made with stereotactic core biopsy. Once
the diagnosis is confirmed, no further treatment or
follow- up is required.
Radial scars
Radial scars are mostly radiological findings, appearing as an area of distortion, which is often difficult to
distinguish from carcinoma, with lines radiating out
from a central scar. A number of radial scars will be
associated with atypical hyperplasia or carcinoma in
situ; thus, a radial scar should be adequately sampled
either with large- gauge core biopsies or diagnostic
Treatment
Like all solid breast lumps, fibroadenomas must be
investigated by triple assessment. In those patients
with multiple fibroadenomas, the largest lump should
undergo core biopsy, as should any lump increasing
in size. Excision is recommended only in large (over
4cm) or symptomatic fibroadenomas.
Intraductal papilloma
A papilloma occurs in the large subareolar ducts and
is a result of epithelial proliferation. They can be single or multiple and may present with intermittent
clear or bloodduct. If the papilloma is large, there may be a palpable
mass in the periareolar area. Multiple papillomas
(papillomatosis) are associated with an increased
lifetime risk of breast cancer. Papillomas can sometimes harbour areas of atypia and rarely DCIS.
In the presence of atypia or nipple discharge, treatment involves surgical excision of the affected duct
(microdochectomy).
stained nipple discharge from a single
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Hamartoma
These rare lesions may present clinically as a breast
lump or may be incidental findings on screening
mammography, when they have the appearance of a
‘breast within a breast’. They have a wellsule and comprise a variable mixture of breast lobules, stroma and fat. Once the diagnosis is confirmed,
no further treatment is necessary.
Gynaecomastia
A benign condition arising from proliferation of
breast tissue in males of all ages. It is caused by an
imbalance of oestrogens and androgens and must be
distinguished from carcinoma of the male breast.
Common causes include:
•
Drugs: digoxin, spironolactone, cimetidine, oes-
trogens or androgens; anabolic steroids or drugs
of abuse (alcohol, methadone, heroin, etc.).
•
Cirrhosis of the liver.
• Renal failure.
• Hypogonadism.
• Adrenal tumours.
• Testicular tumours.
•
Malnutrition.
• Idiopathic.
Clinical features
Gynaecomastia presents as a bilateral or unilateral
diffuse, soft swelling or mass behind the areola. In
patients with any suspicious features (firm or eccentric lump or skin changes), carcinoma must be
excluded. Particular care should be taken not to miss
a testicular tumour in a young man presenting with
otherwise unexplained gynaecomastia.
Treatment
The majority of idiopathic cases will resolve with
no intervention. Secondary gynaecomastia usually
reverses with management of the precipitating factor. A trial of low- dose tamoxifen can be considered in selected cases. Surgery in specialist centres
can be discussed if the gynaecomastia does not
settle, is symptomatic or has significant psychological impact.
defined cap-
Phyllodes tumour
Phyllodes tumour is a rare neoplasm of the breast
that arises from stromal cells. According to its microscopic features it is classified as low, intermediate
or high grade. Although phyllodes
clinical features similar to fibroadenomas, they can
have benign, borderline or malignant behaviour.
Malignant phyllodes tumours rarely metastasize and
can recur locally if inadequately excised. Benign and
borderline phyllodes tumours rarely recur after
complete excision.
7
tumours have
Clinical features
These lesions usually present as a firm, discrete lump
and patients may note a recent increase in size. They
should be investigated by triple assessment to confirm the diagnosis.
Treatment
All phyllodes tumours should be treated by excision
to achieve a clear margin around the tumour. In large
lesions, this may require mastectomy with immediate
reconstruction. Some units might also offer radiotherapy after excision of borderline or malignant
tumours. The role of chemotherapy is still debatable
and it is not routinely indicated.
Carcinoma ofthe breast
Breast cancer is the most common cancer in the UK,
accounting for 15% of all new cancers (2016–2018),
with around 56000 new cases and about 11500
deaths annually. One in eight women will develop
breast cancer during their lifetime. The incidence
has increased by 3% in the last 10 years. Average survival is continuously improving with 5- year survival
being at 90% and 10- year survival at 76%. Less than
1in 10 breast lumps referred to a breast clinic will
prove to be malignant.
7
Phyllodes means ‘leaf- like’, a reference to the lobulated
appearance of the cut surface of the tumour.
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Aetiology
There is an increased incidence of breast cancer with
age and, although any age may be affected, it is
extremely rare below the age of 30 years and 80% of
cases occur in women aged 50 years and over. A previous history of invasive or in situ breast cancer are all
associated with an increased risk of invasive carcinoma. In addition, the following have been identified
as important risk factors.
Hormonal factors
An increase in breast cancer risk mostly correlates
with increased oestrogen exposure:
•
Gender: 99% of breast cancers occur in women,
with fewer than 1% in men.
•
Menarche and menopause: early age at
menarche (under 13 years) and late menopause
(over 50 years) are associated with a twofold
higher risk.
• Parity: nulliparous women have a higher risk than
multiparous women; later age at first pregnancy
also increases the risk. Breastfeeding reduces
overall risk, which is greater with a longer duration
of breastfeeding.
• Hormone replacement therapy (HRT): the risk
of breast cancer is increased while women
take combined oestrogen/progesterone HRT
but reverts 5 years after discontinuation; it is
thought to account for 3 additional cases per
1000women with the risk being proportional to
the length of treatment. There is little or no
change in the risk with oestrogen- only HRT.
Both types of HRT increase the breast density
and can make a breast cancer harder to visualize
on mammograms.
• Oral contraceptive pill (OCP): the combined
oestrogen- containing pill, and for up to 10 years
from discontinuation, is associated with a slight to
no increase in breast cancer risk.
• Obesity in postmenopausal women results in a
twofold increase in breast cancer risk, likely
due to increased oestrogen deriving from the
adipose tissue. In premenopausal women, obesity slightly decreases the risk, for reasons yet
unclear.
• IGF- 1: raised levels of insulin growth factor- 1 are
associated with an increased risk of breast cancer,
though it is not clear why this is the case.
Genetic factors
The majority of breast cancers are sporadic in nature,
with up to 10% being due to genetic predisposition.
•
Family history. The risk increases by twofold with
one firstthreefold with two firstbreast cancer. The risk is higher with younger age
at diagnosis of the affected relative.
•
Gene carriage accounts for 5% of breast cancer
cases. Mutations in the BRCA1 and BRCA2 genes
are the most common. They are autosomal dominant inherited gene mutations and translate to a
50–70% lifetime risk of breast cancer. They also
confer an increased risk of ovarian and other
cancers. Less common mutations in other genes,
such as TP53, PTEN and PALB2, are also associated with an increased susceptibility to breast
cancer.
degree relative (mother or sister) and
degree relatives with
Other factors
• Breast density: when increased, results in four- to
five-
fold increase in breast cancer risk.
• Benign breast disease: history of proliferative
lesions slightly increases breast cancer risk. The
presence of atypia, though, can confer an up to
four-
to five- fold increase.
• Bone mineral density: when increased, increases
breast cancer risk.
Lifestyle factors: increased risk is associated with
•
increased alcohol intake, whereas smoking does
not seem to be related to breast cancer risk. Even
moderate physical activity is known to reduce
breast cancer risk.
•
Radiation exposure: irradiation in adolescence or
early adulthood can markedly increase breast
cancer risk. Young women treated with mantle
radiotherapy for lymphoma have a 1in 3 to 1in 7
risk of breast cancer in the following 25 years.
Classication
1 Primary:
a Ductal carcinoma in situ (DCIS).
b Invasive ductal carcinoma.
c Lobular carcinoma in situ (LCIS).
d Invasive lobular carcinoma.
e Inflammatory carcinoma.
g Paget’s disease of the nipple.
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h Lymphoma.
Sarcoma.
i
2
Secondary:
a
Direct invasion from tumours of the chest wall.
Metastatic deposits, for example from mela-
b
noma or ovarian cancer.
Pathology
Breast cancers arise from the epithelium of the terminal ducttern and not their anatomic location at the ductsystem determines the categorization in ductal and
lobular carcinomas. Carcinomas which have not penetrated through the basement membrane are known
as carcinomas in situ or non- invasive (Figure37.2).
lobular unit. The characteristic growth pat-
lobular
In situ breast cancer
A
Ductal carcinoma in situ
Ductal carcinoma in situ (DCIS) is the most common
type of nonhistologic appearance, it is classified as low, intermediate and high grade, which impacts prognosis. It
usually occurs in localized areas of the breast but may
be extensive; untreated, it will become invasive. DCIS
is generally asymptomatic, appearing as a mammographic finding, usually as microcalcifications.
Because of its malignant potential, treatment is wide
local excision of the disease; extensive disease or
multiple areas of DCIS may necessitate advanced
oncoplastic surgery or mastectomy. Adjuvant radiotherapy is indicated for high- grade DCIS after breast
conservation surgery.
invasive breast cancer. According to its
Invasive breast cancer
C
B
Lobular carcinoma
in situ
(a) (b) (c) (d)
Figure37.2 The different origins of in situ and invasive ductal and lobular carcinomas.
Duct carcinoma
in situ
Invasvive lobular
carcinoma
D
Invasvive ductal
carcinoma
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Lobular carcinoma in situ
Lobular carcinoma in situ (LCIS) is an uncommon entity
not visible on mammography; it is usually an incidental
finding on a biopsy. LCIS is a marker of increased risk
of future breast cancer (approximately 7increase). According to its histologic appearance, it is
classified as classic and nonLCIS on a core biopsy or at the margins of a breast excision requires no further treatment if the findings are
concordant. Annual 5raphy is recommended. Incidental nonshould be excised to clear margins, as it might be
upgraded to DCIS or invasive lobular carcinoma.
classic. Incidental classic
year surveillance with mammog-
to 11- fold
classic LCIS
Invasive ductal carcinoma
This is the most common type of breast cancer, accounting for about 70–80% of all breast cancers. It is often
described as being of ‘no special type’ (NST) to distinguish it from ‘special types’ of cancer such as invasive
lobular cancer or rarer tumours described below.
Invasive lobular carcinoma
Invasive lobular carcinoma accounts for about 8% of
breast cancers. It does not always form a firm lump but
rather an area of thickening, so tends to present late,
and is more likely to be bilateral or multicentric than
ductal carcinoma. Prognosis may be more favourable
for lobular cancers compared to ductal. Mixed ductal/
lobular cancers account for another 7% of breast cancers and have got mixed histologic characteristics.
Rare types ofbreast cancer
There are several less common types accounting for
under 5% of breast cancers. Presentation and management are generally similar to those required for
the more common invasive cancers, such as ductal
carcinoma. These types are named after their distinct
histopathologic characteristics and compared to
ductal carcinoma they can have:
•
Favourable prognosis: usually mucinous, medullary,
tubular, papillary and cystadeno- carcinomas.
• Worse prognosis: mostly associated with metaplastic and micropapillary subtypes.
Spread
• Direct extension. Involvement of skin and subcutaneous tissues leads to skin dimpling, retraction of
the nipple and eventually ulceration. Extension
deeply involves pectoralis major, serratus anterior
and, eventually, the chest wall.
•
Lymphatic. The main lymph channels pass directly
to the axillary– that receive 95% of drainage– and
the internal mammary lymph nodes (Figure37.3).
Later, spread occurs to the supraclavicular and
rarely to contralateral axillary or distant nodes.
Blockage of dermal lymphatics leads to cutaneous
oedema pitted by the orifices of the sweat ducts,
giving the appearance of peau d’orange (orange
peel). Dermal lymphatic invasion produces
daughter skin nodules and if untreated, ‘cancer en
cuirasse’,
mass of tumour tissue.
Bloodstream. Blood- borne spread is most
•
commonly to the bones (at the sites of red bone
marrow, i.e. skull, vertebrae, pelvis, ribs, sternum,
etc.), the lungs, the brain and the liver. Ovaries and
adrenals are also frequent sites of secondary
deposits.
8
the whole chest wall becoming a firm
Prognostic factors
A number of prognostic factors are routinely determined following breast cancer surgery to help predict
the outcome of an individual patient and plan adjuvant systemic therapy.
•
Axillary node spread is a strong and independent
determinant of prognosis; the greater the number
of ipsilateral nodes involved, the worse the
prognosis.
• Tumour size. The size of a tumour has a positive
correlation with the metastatic potential. Larger
tumours are, therefore, more likely to be lymph
node positive and to have a worse survival.
Tumour grade. Breast carcinoma is graded as I, II or
•
III according to the level of differentiation. Grade I
tumours (well differentiated) have a better prognosis than grade III tumours (poorly
and this is an independent prognostic factor.
Additional prognostic factors in invasive breast cancer include:
•
Lymphovascular invasion by the tumour: is an
indicator of poor prognosis, even in the absence of
nodal involvement.
8
A cuirass was an armour breastplate.
differentiated)
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Pectoralis
minor
Axillary
vein
‘Level’ of
lymph node
drainage
• Hormone receptor expression refers to the oestrogen
(ER) and progesterone (PR) receptors. It implies
a less aggressive, hormonePrognosis is worse in singly hormone receptor positive cancers (ER positive and PR negative).
•
Human epidermal growth factor receptor 2 (HER2)
is a protein found in the breast tissue. HER2 is overexpressed in 15–20% of all breast cancers. HER2
positive disease is associated with a more aggressive tumour.
• Histological type: different types have better or
worse prognosis (see earlier in this chapter).
• Genomic assays: analyse different breast cancer
gene expression in breast tumours. These emerging prognostic tools provide valuable information
on the recurrence risk, for suitable patients, that
help guide adjuvant treatments. Most widely used
tools are the Oncotype DX, Prosigna, Mammaprint
and EndoPredict.
•
Risk calculators: different calculators, based on
many of the above factors, have been developed
to assess prognosis. Tools like PREDICT
3
3
2
2
1
1
mammary nodes
responsive tumour.
9
, MD
Internal
Figure37.3 The lymphatic drainage of the
breast.
Anderson Calculators and CancerMath10 are
widely used to estimate benefit from adjuvant
treatments in patients with early breast cancer and
assist in guiding treatment recommendations.
Results should always be used in conjunction with
all other clinical and pathological parameters of
the patient, and in conjunction with discussion at
a local multidisciplinary team (MDT) meeting.
Clinical features
The majority of patients with invasive carcinoma will
present with a lump in the breast. Other features that
warrant urgent investigation include altered breast
contour, recent nipple inversion, blood- stained nipple discharge and unilateral nipple eczema (Paget’s
disease).
The breasts are inspected with the patient both
lying supine and sitting with the arms elevated. The
latter often accentuates any skin tethering or dimpling. Any evidence of nipple inversion or eczema
should be noted.
9
Predict: https://breast.predict.nhs.uk/tool
10
CancerMath http://cancer.lifemath.net/index.html
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Palpation should be with the flat of the hand with
the patient lying flat and the head supported. Both
breasts and both axillae should be examined as well
as the supraclavicular fossae. Any lump should be
carefully examined for evidence of skin or muscle fixation and the clinical size and position in relation to
the nipple noted. Large, firm nodes in the axilla may
suggest metastatic disease. In patients with suspected
tumour, liver palpation and chest auscultation should
also be performed.
Special investigations
Diagnostic investigations
The diagnosis of breast carcinoma is made by triple
assessment comprising clinical examination, imaging
(mammography and/or ultrasound) and biopsy (see
earlier in this chapter). In the vast majority of cases,
the diagnosis has been confirmed prior to surgery.
Staging investigations
Depending on the local extent of the tumour and the
presence of other symptoms, the following investigations may be indicated to assess the potential of distant disease:
•
Full blood count: anaemia and leucopenia suggest
widespread bone marrow involvement.
•
Liver function tests: raised alkaline phosphatase
may signify liver or bone metastases.
Chest X- ray.
•
• Isotope bone scan.
•
Staging CT scan of chest and abdomen +/- pelvis.
• Positron emission tomography- CT (PET- CT): might
be indicated if whole body imaging is required.
Cancers are staged using the TNM classification (see
Chapter 7). The TNM staging for breast cancer is
shown in Table37.1.
Treatment
The treatment of breast cancer involves a multimodality approach comprising the following elements:
1
Surgery.
a
Tumour excision either with breast conserva-
tion surgery or mastectomy.
b Surgery to the axilla according to the nodal
involvement.
Breast reconstruction.
c
Table37.1 Pathologic TNM staging for breast
cancer, AJCC UICC 2010
Stage Description
T Primary tumour.
TX Primary tumour cannot be assessed.
T0 No evidence of primary tumour.
Tis Carcinoma in situ (DCIS, LCIS or Paget’s
T1 Tumour 2cm or less in greatest dimension.
T2
T3 Tumour >5cm in greatest dimension.
T4 Tumour of any size with direct extension to
N Regional lymph nodes.
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis.
N1 Micrometastases or metastases in 1–3
N2 Metastases in 4–9 axillary lymph nodes
N3
M Distant metastasis.
MX Distant metastasis cannot be assessed.
M0 No distant metastasis.
M1 Distant metastasis.
DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma
insitu.
11
for International Cancer Control. ese two organisations
revise staging for cancers. e version in this table was
published in 2010.
disease with no invasive tumour).
Tumour >2cm but <5cm in greatest
dimension.
the chest wall or skin.
T4a– extension to the chest wall, apart
from pectoralis major muscle only.
T4b– extension to the skin (ulceration or
skin nodules or and/or oedema).
T4c– both T4a and T4b.
T4d– inflammatory carcinoma.
(e.g. previously removed).
axillary lymph nodes and/or in internal
mammary nodes but not clinically detected.
or in clinically detectedinternal mammary
lymph nodes in theabsenceof axillary
lymph node metastases.
Metastases in >10 axillary or ipsilateral
infraclavicular (level III) or supraclavicular
lymph nodes or both axillary and clinically
detected internal mammary nodes.
AJCC: American Joint Committee on Cancer; UICC: Union
11
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2 Systemic therapy.
Hormonal therapy.
a
b
Chemotherapy with or without HER2- directed
treatment.
Bisphosphonate treatment.
c
3
Locoregional therapy.
a
Radiotherapy to the breast or chest wall with or
without nodal irradiation.
Some of these treatments are recommended, either
after surgery (adjuvant) or before surgery (neoadjuvant). The order depends on multiple clinicopathological factors discussed later in this chapter.
Surgical management
The aims of surgery are to remove the primary tumour
and any involved lymph nodes, in order to determine
prognosis and plan systemic therapy. Small tumour/
breast ratio is an indication for breastgery (wide local excision). Increased tumour/breast
ratio or multifocal tumours (multiple foci in one
quadrant) might require oncoplastic procedures or
mastectomy. Mastectomy, with or without breast
reconstruction, is also indicated in:
•
Multicentric tumours (multiple foci in more than
one quadrant).
Inflammatory breast cancer.
•
•
Patients with gene mutations, i.e. breast cancer in
BRCA- positive patients.
• When radiotherapy is contraindicated such as during pregnancy or in most circumstances of previous
radiotherapy to the breast or chest wall (previous
breast cancer or previous Hodgkin’s lymphoma).
• Patient preference.
conserving sur-
Tumour excision
Breast- conserving surgery (BCS)
There is good evidence that BCS followed by radiotherapy is equally as effective as mastectomy with
regards both to local control and to survival.
a
Wide local excision. A cylinder of breast tissue is
excised usually from skin down to the pectoral
muscle, in order to achieve complete excision
(‘clear resection margins’).
b Oncoplastic breast surgery. When larger amounts
of breast tissue need to be removed, then oncoplastic techniques can be applied to provide the
optimal cosmetic outcome. These aim to either
reshape the breast (level I and II oncoplasty) or
replace the breast volume with local chest wall
perforator flaps.
Mastectomy
A simple mastectomy involves excision of the breast
tissue, including the nipple, leaving a flat chest wall. If
combined with immediate breast reconstruction,
then a skinshould be performed.
sparing or a nipple- sparing technique
Complications
Common complications after surgery to the breast
include:
Infection.
•
• Seroma.
Haematoma.
•
• Delayed wound healing.
• Pain.
• Numbness.
•
Asymmetry.
These are more common after mastectomy compared
to BCS. Additional risks of BCS include further surgery if margins are involved (ranging from 10 to 20%)
and fat necrosis or nipple complications which
increase with the greater volume of breast tissue that
is removed.
Surgical management ofthe axilla
Axillary node status is an important prognostic indicator in the treatment of invasive breast cancer. As a
result, axillary surgery should be performed on all
patients with invasive operable breast cancer, but is
not generally required for in situ disease.
Negative axillary nodes at
presentation
For patients with negative axillary nodes at presentation, the following is performed:
•
Sentinel lymph node (SLN) biopsy, in which the
first axillary lymph node(s) draining the cancer
field is identified, excised and examined for metastatic tumour. Different techniques can be used to
identify the sentinel node(s) that include a radioisotope, and/or a blue dye injection under the nipple or around the tumour before surgery. New
techniques for SLN localization are also being
developed.
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