1. CA BREAST: Clinical Aspects, Investigations, Staging
A presentation BY:
MOHAMMED SHAKEEBUDDIN KASHIF
ESIC MEDICAL COLLEGE, KALABURAGI, KARNATAKA

2. Clinical presentation
HISTORY- Age- >30y usually, Lump in the breast with a short history and rapid growth without any pain, nipple discharge +/- ,Nipple retraction, Loss of weight, Family history of lump in breast.

3. Examination of breast

5. Examination Findings:inspection
INSPECTION OF BREAST,NIPPLE,AREOLA:-
Shrinking and Elevation of breast with nipple retraction made more prominent by raising both the hands above the head. Discharge from nipple +/-
Peau d’orange:- Cutaneous lymphatic edema due to blockage of subcuticular lymphatics.
INSPECTION OF ARM, THORAX, AXILLA, SUPRACLAVICULAR FOSSA:
Multiple Cancerous nodules and thickened infiltrated skin like a coat of armour[Cancer en cuirasse].
Brawny edema of the arm:- extensive neoplastic infiltration of axillary lymph nodes leading to lymphatic blockage and swelling of arms.

6. PALPATION:-
Hard/stony hard lump in Upper outer Q./Tail, usually immobile and fixed to the underlying muscle, uneven in surface, irregular margins. Peau d’orange +/-
Advanced cases:- Blood tinged Nipple discharge, Ulceration, Brawny edema.

7. Retraction of nipple

10. Peau d’orange

12. Cancer en cuirasse

13. Examination of lymph nodes
AXILLARY GROUP:- Central, Pectoral, Brachial, Subscapular,, Apical.
CERVICAL:- Supraclavicular.

14. Diagnostic investigations
1. MAMMOGRAPHY- MEDIOLATERAL OBLIQUE VIEW AND CRANIOCAUDAL VIEW.
2. ULTRASOUND SCAN OF BREAST
3. MRI BREAST.
4. FINE NEEDLE ASPIRATION CYTOLOGY AND TRUCUT/CORE NEEDLE BIOPSY
5.IMMUNOHISTOCHEMISTRY
6.TRIPLE ASSESSMENT
7.SENTINAL NODE BIOPSY

15. MAMMOGRAPHY

17. mri

18. mri

19. FNAC

20. TRUCUT biopsy

21. Immunohistochemistry
1.Estrogen receptors[ER], Progesterone receptor[PR]
Patients with ER+ve tumor have longer disease free survival after primary treatment
All patients may benefit from tamoxifen except Premenopausal ER/PR negative patients.
2.HER-2/neu receptor
Receptor tyrosine kinase, 3+ in 25% cases
1+ negative, 2+ equivocal[confirm by FISH], 3+ overexpressed
3.FISH- Fluorescent in situ hybridization.
4.Ki 67- Newer marker for cellular proliferation.
SBR[Scarff Bloom Richardson] evaluation- depending upon nuclear pleomorphism, tubule formation and mitotic rate.

22. Triple assessment

23. Sentinel lymph node biopsy

24. Investigations to rule out metastasis
1.Chest X-ray
2.USG Abdomen[with clinical correlation]
3.Bone Scan if Alkaline phosphatase[ALP] increased/Symptomatic