Breast cancers is a common cancer in Indian women and most common cancer in some Indian metropolitan cities in women.

Symptoms and Sign

•           Breast lump which is seen in 85% of cases

•           Lump in axilla

•           Change in size/shape of breast

•           Dimpling, puckering of breast

•           Skin induration

•           Redness

•           Nipple discharge

•           Nipple retraction

•           Found on investigation for breast pain

•           No symptoms

Diagnosis

•           Breast self-examination

•           Clinical suspicion

•           Clinical Examination

•           FNAC

•           Biopsy

•           Mammography

•           Breast ultrasound

•           Newer techniques: MR[, nuclear scan.

•           Metastatic workup

The most important, practical and time-tested method of using the available gadgets to come to clinical diagnosis is TRIPLE ASSESSMENT

Triple Assessment- The main components of triple assessment are

•           Clinical examination,

•           Radiological imaging of breasts (mammography and ultrasound breast)

•           Pathological examination of tumor (core biopsy, FNAC)

1.    Breast examination

Early detection of breast cancer significantly reduces the risk of death.

Every woman between the ages of 20 and 49 should have a clinical breast examination by a health professional every one to two years. Those over 50 should be examined annually.

2.    Monthly self-examination

•           Self-examination once a month just after the menstruation, as during this time breast are less engorged.

•           Stand in front of a mirror. Check for changes or redness in the nipple area. Look for changes in the appearance of the skin. With hands on the hips, push the pelvis forward and pull the shoulders back and observe the breasts for irregularities. Repeat the observation with hands behind the head.

•           Lie down on the back with a rolled towel under one shoulder. Palpate the breast with the flat of the finger of the hand for any lump.

•           Examine the nipple area, by gently lifting and squeezing it and checking for discharge.

•           Repeat step 3 in on upright position.

Note: A lump can be any size or shape and can move around or remain fixed. Of special concern are specific or unusual lumps that appear to be different from the normal varying thicknesses in the breast.

3.    Mammography

•           A mammogram is a radiographic examination of the breast, either displayed on a film or on a computer monitor.

•           Images of each breast in the CC (craniocaudal) and MLO (mediolateral oblique) projections are taken.

•           High probability of malignancy occurs in fine linear, branching, pleomorphic, and heterogeneous microcalcifications.

•           Lobulated mass and mass with spiculated margins is also suggestive of carcinoma.

4.    Ultrasound Breast

Malignant sonographic features of solid masses include an irregular or angular shape, more than three lobulations, ill-defined, spiculated or microlobulated margins, width greater than anteroposterior diameter (orientation not parallel to the skin surface or "taller than wide"), markedly hypo echoic (dark) echogenicity; a surrounding thick, echogenic (white) halo, posterior shadowing (black

shadows posterior to the mass), duct extension and associated calcifications.

5.  Biopsy

The various methods of biopsy techniques are

•    FNAC

•    Core needle biopsy

•    Stereotactic biopsy

•    Incisional biopsy

•    Excisional biopsy

Core biopsy is the investigation of choice in the evaluation of breast malignancy. ER/PR/Her 2/Neu tumor status should be determined for all samples of invasive cancer

Treatment

Treatment modalities available are Surgery, Radiation, and combination drug therapy. combination therapy is virtually always required.

The choice is determined by many factors, including the age of the patient and (among women) menopausal status, the kind of cancer (e.g., ductal vs. lobular), its stage, and the tumor hormone receptors status

A.  Surgery

Most commonly performed operation is Modified radical mastectomy (MRM). The entire tissue is removed along with the axillary contents (fatty tissue and lymph nodes). In contrast to a radical mastectomy, the pectoral major muscles are spared.

Breast conservative surgery (BCT) - In this form the patient is left with native breast. Wide local excision is followed by radiotherapy

•           Advantages of BCT

•           Acceptable cosmetic appearance

•           Lower level of psychological morbidity

•           Equivalence in terms of disease outcome for BCT and mastectomy in selected patients

•           Indications of BCT

•           Ti ,T2(<5cm), NO, Nl, MO

•           T2 >5cm in large breasts. More important, however, than the true size of the tumor is the ratio of the tumor size to the breast size.

•           Single clinical and mammographic lesion

•           Absolute contraindications

•           Multicentric disease (tumors in more than one quadrant of the breast),

•           Diffuse malignant-appearing calcifications,

•           Inflammatory breast cancer,

•           Prior radiation to the chest or breast or inability to receive radiation,

•           Persistent positive margins despite appropriate attempts for breast- conserving surgery,

•           Need for radiation during pregnancy.

B.  Chemotherapy

•           Neo-adjuvant chemotherapy is when chemotherapy given prior to surgery. It converts a previously unresectable, locally advanced breast cancer to an operable tumor. Down staging a primarily operable breast cancer results in small increase (7% to 12%) in breast conservation rates.

•           Adjuvant chemotherapy is when chemotherapy is given after surgery. Same regimens can be used in, the neo-adjuvant and adjuvant therapeutically settings. Commonly used chemotherapy regimens are CAF, CEF, CMF and taxanes based in node positive patients.

C.  Adjuvant hormone therapy

•           In hormone positive tumors defined by ER/PR expression on IHC, adjuvant hormone therapy is considered in all positive patients

•           Tamoxifen and aromatase inhibitors (letrozole, anastrazole, exemestane) are used.

•           In HER 2/neu positive tumors trastuzumab is used.

D.  Radiotherapy

Indication for post-mastectomy radiation-

Four or greater than 4 lymph nodes involvement, T3 and 14 tumors, extra capsular invasion, lymph vascular space invasion, close surgical margins, presence of 1-3 lymph node is relative indication.

Radiotherapy is also used after conservative breast surgery, loco-regional recurrence following mastectomy, palliation of bone or brain secondaries including spinal cord compression, fungating and bleeding advanced tumors.

Breast cancer management requires multi-disciplinary approach.