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🎓 CARCINOMA BREAST

Complete MS General Surgery Teaching Module

Based on Bailey & Love (28th Ed.) | Schwartz (11th Ed.) | Robbins Pathology | NCCN Guidelines 2025

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1. DEFINITION

Carcinoma of the breast is a malignant epithelial neoplasm arising from the ductal or lobular epithelium of the breast, capable of local invasion, regional lymph node spread, and distant haematogenous metastasis.

• Most common cancer in women worldwide (2.3 million new cases in 2020 - Bailey & Love, 28th Ed.)
• Surpassed lung cancer as the most common cancer globally in 2020 (Robbins Pathology)
• Lifetime risk: 1 in 8 females (to age 90) in USA; 1 in 9 in Western Europe
• In India: incidence rising, now #1 female cancer overtaking cervical cancer in urban areas
• For every 2 women diagnosed in resource-poor countries, 1 dies - reflecting late presentation

• Adenocarcinoma (epithelial origin - ducts and lobules)
• In situ vs. Invasive carcinoma
• ER/PR/HER2 receptor status - "triple negative" (TNBC)
• BRCA1/BRCA2 mutations
• Sentinel lymph node biopsy (SLNB)
• Breast conserving surgery (BCS)
• Nottingham Histological Grade (NHG)

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2. CLASSIFICATION

A. By Stage of Invasion

B. Histological Classification (WHO)

C. Molecular (Intrinsic Subtype) Classification - Robbins / Schwartz

D. DCIS Classification (Schwartz Table 17-9)

Examiner trap: Comedo DCIS = high-grade, worst prognosis among DCIS types. Calcifications on mammography are due to necrosis in comedo DCIS.

E. TNM Staging (AJCC 8th Edition)

Primary Tumor (T)

Regional Lymph Nodes (N) - Pathological

Overall Stage Grouping

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3. SURGICAL ANATOMY

A. Breast Anatomy

UOQ (Upper Outer) | UIQ (Upper Inner)
─────────────────────────────────────
LOQ (Lower Outer) | LIQ (Lower Inner)
             Central/Subareolar

• UOQ = most common site for carcinoma (50%) - examiner's favourite
• Axillary tail of Spence = extension into axilla through foramen in deep fascia

B. Layers from Skin to Chest Wall

1. Skin
2. Subcutaneous fat
3. Cooper's ligaments (suspensory ligaments)
4. Breast parenchyma (15-20 lobes radiating from nipple)
5. Retromammary bursa (plane of surgical dissection)
6. Deep pectoral fascia
7. Pectoralis major

Clinical pearl: Cooper's ligaments attach breast parenchyma to overlying skin - when invaded by carcinoma = skin dimpling/peau d'orange appearance

C. Blood Supply

Key examiner fact: Internal mammary artery = dominant supply = reason medial quadrant tumors have worse prognosis (internal mammary node drainage)

D. Venous Drainage

• Mirrors arterial supply
• Internal mammary veins → brachiocephalic vein → SVC
• Intercostal veins → vertebral venous plexus of Batson → haematogenous spread to spine (most common bone metastasis site)
• Axillary vein tributaries

Batson's plexus - valveless communication between pelvic/breast veins and vertebral venous plexus = explains vertebral and CNS metastases

E. Lymphatic Drainage - CRITICAL FOR EXAM

Level Classification of Axillary Nodes (Berg's Levels):

Level I (lateral) → Level II (behind) → Level III (apical/Halsted's) 
→ Subclavian vein → Thoracic duct/Right lymphatic duct

Other drainage pathways:

• Internal mammary nodes (parasternal) - especially medial quadrant tumors
• Supraclavicular nodes - N3 disease (Stage IIIC)
• Interpectoral (Rotter's) nodes - between pectoralis major and minor
• Cross-drainage to contralateral axilla possible

Examiner trap: "Which nodes are sampled in SLNB?" - Level I axillary nodes and internal mammary nodes (in selected cases)

F. Nerve Supply - Critical for Operative Anatomy

MOST FEARED COMPLICATION in axillary dissection = Injury to Long Thoracic Nerve = Winged Scapula

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4. ETIOLOGY AND RISK FACTORS

A. Risk Factor Table (Bailey & Love - Table 58.3)

Non-Modifiable Risk Factors

Modifiable Risk Factors (Bailey & Love)

Protective Factors

• Breastfeeding >12 months (protective)
• Early first pregnancy (<20 years)
• Physical activity
• Bilateral oophorectomy before age 40
• Tamoxifen/Raloxifene (chemoprevention)

B. Genetic Mutations Summary

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5. PATHOPHYSIOLOGY

Step-by-Step Disease Progression

NORMAL BREAST EPITHELIUM
        ↓
Normal → Hyperplasia (without atypia)
        ↓
Atypical Ductal Hyperplasia (ADH) / Atypical Lobular Hyperplasia (ALH)
        ↓ [RR = 4-5×]
DCIS (Ductal) / LCIS (Lobular) — IN SITU PHASE
        ↓ [DCIS → 30-50% risk; LCIS = 1-2% per year]
INVASIVE CARCINOMA (Basement membrane breached)
        ↓
Local invasion into breast stroma
        ↓
Lymphatic permeation → Regional lymph nodes
   - Level I → Level II → Level III axillary
   - Internal mammary nodes
   - Supraclavicular nodes (N3)
        ↓
Haematogenous spread (Batson's plexus, axillary/internal mammary veins)
        ↓
DISTANT METASTASES
(Bone > Lung > Liver > Brain > Adrenals)

Key Molecular Events

• Estrogen receptor (ER) activation drives proliferation in luminal tumors
• HER2 amplification (chromosome 17q) → tyrosine kinase overexpression → uncontrolled proliferation
• Loss of BRCA1/2 → failure of DNA double-strand break repair
• Epithelial-Mesenchymal Transition (EMT) → invasion and metastasis
• Angiogenesis (VEGF upregulation) → vascular invasion

Skin Changes - Pathophysiological Basis

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6. CLINICAL FEATURES

History

• Painless lump in the breast (most common, ~70%)
• Pain (10-15% have pain as dominant symptom)
• Nipple discharge (blood-stained = red flag)
• Nipple retraction/inversion
• Skin changes (dimpling, peau d'orange, ulceration)
• Axillary lump
• Arm swelling (lymphedema - late)
• Systemic symptoms (weight loss, bone pain, cough, jaundice)

• Duration and progression of lump
• Change in size (especially with menstrual cycle)
• Nipple discharge: character, laterality, number of ducts
• Pain: cyclical vs. non-cyclical
• Family history (BRCA)
• Menstrual history: menarche, menopause, OCP/HRT use
• Obstetric history: pregnancies, breastfeeding
• Previous biopsies / radiation history
• Systemic symptoms (metastasis screen)

Signs

Local Signs

• Lump characteristics: Hard, irregular, ill-defined, fixed
• Skin dimpling / tethering
• Peau d'orange (pitting edema of skin)
• Nipple retraction / deviation
• Nipple discharge (blood-stained)
• Skin ulceration (advanced disease)
• Satellite nodules (T4b)
• Chest wall fixity (T4a)

Regional Signs

• Axillary lymphadenopathy (ipsilateral) - hard, matted, fixed
• Supraclavicular lymphadenopathy (N3)
• Arm edema (axillary node block)

Systemic Signs (Metastatic Disease)

• Bone pain/tenderness (vertebrae, pelvis, ribs, skull)
• Hepatomegaly
• Pleural effusion (dyspnea)
• Neurological signs (brain metastasis)
• Jaundice (liver metastasis)

Red Flag Signs

• ⚠️ Hard, irregular lump > 2 cm
• ⚠️ Skin dimpling or peau d'orange
• ⚠️ Blood-stained nipple discharge (unilateral, single duct)
• ⚠️ Recent nipple inversion (previously normal nipple)
• ⚠️ Hard, fixed axillary nodes
• ⚠️ Supraclavicular nodes
• ⚠️ Paget's disease of nipple
• ⚠️ Inflammatory breast cancer (erythema, warmth, skin induration)
• ⚠️ Bone pain + breast lump
• ⚠️ Arm edema ipsilateral to breast lump

Differential Diagnosis of Breast Lump

Examiner trap - Fat necrosis vs. Carcinoma: Fat necrosis can mimic carcinoma with skin dimpling and irregular hard lump. Always biopsy.

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7. CLINICAL EXAMINATION

Inspection (Patient sitting, arms at side → raised above head → hands on hips)

• Asymmetry of breasts (size, shape, level)
• Skin changes: dimpling, peau d'orange, erythema, ulceration, satellite nodules
• Nipple: retraction, deviation, Paget's changes, discharge
• Dilated veins over breast
• Edema of arm (look from behind)
• Lymphedema of arm

1. Sitting, arms relaxed
2. Arms raised above head (tethering/dimpling becomes visible)
3. Hands pressed on hips (pectoralis contracted - fixity to chest wall)
4. Leaning forward (ptosis, skin tethering)

Palpation

• Examine with flat of fingers, not fingertips
• Systematic: 4 quadrants + subareolar + axillary tail
• Palpate axilla with arm relaxed (patient's arm resting on examiner's forearm)
• Always examine both breasts and both axillae
• Examine supraclavicular fossae

• Site (quadrant, distance from nipple)
• Size (measure in cm)
• Shape (regular/irregular)
• Surface (smooth/nodular/irregular)
• Margin (well/ill-defined)
• Consistency (soft/firm/hard/stony hard)
• Fixity (to skin? to deep fascia? to chest wall?)
• Tenderness
• Transillumination (for cyst - will not transilluminate in carcinoma)
• Pulsatility

Axillary Examination

• Central nodes (Level I - most commonly involved)
• Apical (Level III - infraclavicular)
• Pectoral (anterior - Level I)
• Subscapular (posterior - Level I)
• Lateral (Level I - along axillary vein)

• Examiner's right hand examines patient's right axilla
• Patient's arm supported by examiner's left hand
• Feel along: chest wall, anterior wall, posterior wall, medial wall, axillary vein

• Number, size, consistency, fixity, matting

Special Tests

Clinical Pearls

• "Breast mouse" = mobile fibroadenoma (young woman)
• "Peau d'orange" is NOT pathognomonic for carcinoma - also in mastitis, but with fever
• A lump that disappears after aspiration = cyst; if solid residue remains = suspicious
• Always examine the contralateral breast (10% bilateral carcinoma)
• In Paget's disease: eczematous change that STARTS AT NIPPLE (unlike dermatitis which starts at areola)
• Triple assessment = Clinical + Imaging + Pathology (cytology/biopsy)

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8. INVESTIGATIONS

Triple Assessment (The Gold Standard Diagnostic Framework)

        TRIPLE ASSESSMENT
              │
    ┌─────────┼─────────┐
    │         │         │
Clinical   Imaging    Pathology
 Exam      (USG/      (FNAC/
           Mammo)     Core Biopsy)

• 1 = Normal
• 2 = Benign
• 3 = Uncertain/probably benign
• 4 = Suspicious for malignancy
• 5 = Malignant

Triple Assessment 5/5/5 = Malignant; 1/1/1 = Benign

Routine Investigations

Specific/Imaging Investigations

Mammography

• Best initial imaging in women >35 years
• Screening: 2-view mammography (craniocaudal + mediolateral oblique)
• Features of malignancy on mammography:
  • Irregular/spiculated mass (stellate lesion)
  • Microcalcifications (especially clustered, pleomorphic - pathognomonic of comedo DCIS)
  • Architectural distortion
  • Asymmetric density
  • Skin/nipple retraction
• ACR BI-RADS (Breast Imaging Reporting and Data System):

Ultrasound (USG) Breast

• Best initial imaging in women <35 years and in pregnancy
• Differentiates solid vs. cystic lesions
• Features of malignancy: irregular margins, posterior acoustic shadowing, spiculated
• Guides FNAC/core needle biopsy
• Axillary USG for lymph node assessment

MRI Breast

• Not routine; specific indications:
  • BRCA mutation carriers (annual screening from age 25)
  • Occult primary breast cancer (axillary nodes, no mammographic lesion)
  • Implant integrity
  • Surgical planning for BCS (assess extent/multifocality)
  • Monitoring neoadjuvant chemotherapy response
  • Dense breasts where mammography limited

PET-CT

• Staging of advanced/metastatic disease
• Monitoring treatment response
• Detecting recurrence

Bone Scan

• Suspected bone metastasis
• Routine for Stage III-IV disease

Pathological Investigations

FNAC (Fine Needle Aspiration Cytology)

• Quick, cheap, office procedure
• Graded C1-C5:
  • C1 = Inadequate
  • C2 = Benign
  • C3 = Atypia (probably benign)
  • C4 = Suspicious (probably malignant)
  • C5 = Malignant
• Limitation: Does not distinguish invasive from in situ carcinoma

Core Needle Biopsy (Tru-Cut Biopsy) - GOLD STANDARD

• 14G needle; US-guided
• Gives histology, receptor status (ER/PR/HER2), grade
• Advantages over FNAC: Tissue architecture preserved; can grade; receptor status
• Preferred over FNAC in current practice

Excision Biopsy

• For impalpable lesions (wire-guided/vacuum-assisted)
• For lesion not amenable to core biopsy

IHC (Immunohistochemistry) on Biopsy Specimen

HER2 Testing Algorithm:

IHC 3+ → HER2 POSITIVE (trastuzumab eligible)
IHC 2+ → FISH (fluorescence in situ hybridization) → amplified or not amplified
IHC 0 or 1+ → HER2 NEGATIVE

Nottingham Histological Grade (NHG / Elston-Ellis Grade)

• Total score 3-5 = Grade 1 (well differentiated, best prognosis)
• Total score 6-7 = Grade 2 (moderately differentiated)
• Total score 8-9 = Grade 3 (poorly differentiated, worst prognosis)

Examiner pearl: Nottingham Grade = Elston-Ellis modification of Bloom-Richardson grading

Staging Workup

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9. DIAGNOSTIC ALGORITHM

BREAST LUMP
      │
      ▼
TRIPLE ASSESSMENT
      │
 ┌────┼────┐
 │    │    │
Clin  Img  Path
      │
Age <35 → USG first
Age >35 → Mammogram first
      │
Benign features → Reassure + Follow-up
Indeterminate → Core needle biopsy
Malignant features → Core biopsy + IHC
      │
      ▼
CONFIRMED MALIGNANCY
      │
      ▼
STAGING WORKUP
(CXR, LFTs, ALP, Bone scan if Stage II-III, CT/PET-CT if Stage III-IV)
      │
      ▼
MULTIDISCIPLINARY TEAM (MDT) MEETING
      │
 ┌────┴────┐
 │         │
Early (I-III)  Metastatic (IV)
 │              │
Surgery +       Palliative systemic
Adjuvant Rx     therapy + best
                supportive care

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10. DIFFERENTIAL DIAGNOSIS

Comparison Table

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11. MANAGEMENT

A. Multidisciplinary Team (MDT) Approach

Surgical Oncologist + Medical Oncologist + Radiation Oncologist 
+ Radiologist + Pathologist + Plastic Surgeon + Psychologist
= MDT MEETING (Gold Standard for treatment planning)

B. Initial Resuscitation / Emergency Management

• Inflammatory breast cancer emergency: initiate systemic chemotherapy urgently
• Pathological fracture: orthopaedic stabilization + radiotherapy
• Spinal cord compression (oncological emergency):
  • High-dose dexamethasone immediately
  • Urgent MRI spine
  • Radiotherapy ± surgical decompression
• Hypercalcaemia of malignancy:
  • IV hydration + bisphosphonates (zoledronic acid 4 mg IV)

C. Management Algorithm by Stage

STAGE 0 (DCIS)
      │
BCS + Whole Breast RT (WBRT)
OR Mastectomy ± SLNB
+ Tamoxifen (ER+ DCIS, 5 years)

STAGE I - IIA (Early Breast Cancer)
      │
Surgery: BCS + SLNB  OR  Mastectomy + SLNB
      │
Adjuvant:
  ER+/HER2-: Hormonal therapy ± Chemotherapy (OncotypeDx guided)
  HER2+: Trastuzumab + Chemotherapy
  TNBC: Chemotherapy (AC-T or TC regimen)
  RT: After BCS (mandatory); After mastectomy (if T3/N2-3)

STAGE IIB - IIIA (Locally Advanced, Resectable)
      │
Neoadjuvant Chemotherapy (NACT) first
      │
Reassess → Surgery (BCS if good response OR Mastectomy)
      │
Adjuvant: RT + Hormonal/HER2 targeted therapy

STAGE IIIB-IIIC (Locally Advanced, Unresectable)
      │
NACT → Surgery (usually modified radical mastectomy)
      │
Adjuvant RT + Systemic therapy

STAGE IV (Metastatic)
      │
Palliative intent:
  ER+/HER2-: Endocrine therapy (CDK4/6 inhibitors ± aromatase inhibitor)
  HER2+: Trastuzumab + pertuzumab + chemotherapy
  TNBC: Chemotherapy ± immunotherapy (pembrolizumab if PD-L1+)
  + Bisphosphonates for bone metastases
  + Palliative RT for pain/cord compression

D. Surgical Management

1. Breast Conserving Surgery (BCS) / Wide Local Excision / Lumpectomy

• Single, unifocal tumor
• T1-T2 lesions (up to 4-5 cm relative to breast size)
• Patient preference
• No contraindications to radiotherapy

• Multifocal/multicentric disease
• Previous breast/chest wall irradiation
• Pregnancy (relative if 3rd trimester)
• Inflammatory breast cancer (T4d)
• Diffuse malignant-appearing microcalcifications
• Inability to achieve clear margins after re-excision
• Connective tissue disease (scleroderma, active lupus)
• Large tumor relative to breast size (oncoplastic techniques may help)

• Margin of excision must be clear (≥2 mm per NICE; no tumor on ink per SSO/ASTRO 2014)
• Must always be followed by whole breast radiotherapy (WBRT)
• Oncological equivalence to mastectomy in appropriately selected patients (Milan trials, NSABP B-06)

2. Mastectomy Types

Examiner favourite: "What is the difference between Patey's and Halsted's?" - Patey = pec major preserved; Halsted = pec major removed

MRM is the standard mastectomy for operable breast cancer in India/developing countries

3. Axillary Management

• Indications: Clinically/imaging node-negative (cN0)
• Technique: Patent Blue dye ± Tc-99m labelled nanocolloid (radioisotope)
• Sentinel node = first node to receive lymphatic drainage
• If SLN negative → no further axillary surgery
• If SLN positive → ALND or axillary radiotherapy (per Z0011 trial criteria)

• Indications: Clinically positive axillary nodes (cN1+), positive SLNB (>2 positive SLN, or not meeting Z0011 criteria)
• Standard yield: ≥10 lymph nodes
• Complications: Lymphedema (20-30%), seroma, nerve injury

• SLNB-positive patients with 1-2 positive SLN, T1-T2 tumors, BCS + WBRT can OMIT ALND without compromise in survival

E. Systemic Therapy

Neoadjuvant Chemotherapy (NACT)

• Locally advanced breast cancer (Stage IIIA-IIIC)
• HER2+ or TNBC in early stage (to downstage for BCS)
• Inflammatory breast cancer
• Large tumor relative to breast size (to facilitate BCS)

• AC → T: Doxorubicin + Cyclophosphamide → Paclitaxel/Docetaxel
• FEC → D: 5-FU + Epirubicin + Cyclophosphamide → Docetaxel
• For HER2+: Add pertuzumab + trastuzumab to chemotherapy backbone

• No residual invasive cancer in breast and nodes after NACT
• Best predictor of long-term survival especially in HER2+ and TNBC

Adjuvant Chemotherapy

• ER-/HER2- (TNBC): AC-T regimen; add pembrolizumab (KEYNOTE-522)
• HER2+: Trastuzumab for 1 year; T-DM1 if residual disease after NACT (KATHERINE trial)
• Capecitabine for TNBC with residual disease post-NACT (CREATE-X trial)

Hormonal Therapy

HER2-Targeted Therapy

• Trastuzumab (Herceptin): Anti-HER2 monoclonal antibody (1 year adjuvant)
• Pertuzumab: Anti-HER2 (different epitope); neoadjuvant/metastatic
• T-DM1 (ado-trastuzumab emtansine): Antibody-drug conjugate; residual disease after NACT
• T-DXd (trastuzumab deruxtecan): Second-line metastatic HER2+; also HER2-low tumors
• Lapatinib + Tucatinib: Small molecule TKIs; brain metastases

PARP Inhibitors (BRCA-mutated)

• Olaparib / Talazoparib: Metastatic BRCA-mutated HER2-negative; also adjuvant (OlympiA trial)

F. Radiotherapy

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12. SURGICAL PROCEDURES

A. Modified Radical Mastectomy (MRM) - PATEY'S OPERATION

Indications

• Operable breast cancer not suitable for BCS
• Patient preference
• Locally advanced cancer after NACT

Contraindications

• Stage IV (palliative mastectomy only for toilet/fungating tumor)
• Medically unfit

Patient Positioning

• Supine, arm abducted 90° on arm board
• Shoulder slightly elevated with sandbag
• Arm draped separately for mobility

Anesthesia

• General anesthesia

Incision (Stewart/Greenough transverse ellipse)

     Medial        Lateral
 ←─────────────────────────→
        ELLIPTICAL INCISION
  (encircling nipple-areola complex)
  Upper and lower skin flaps raised

• Transverse ellipse 3 cm above and below breast
• Includes nipple-areola complex
• Extends from parasternal to mid-axillary line

Operative Steps (Stepwise)

• Mark ellipse encompassing nipple; 3 cm clearance from tumor

• Raise upper flap: to clavicle and below pectoralis major
• Raise lower flap: to inframammary fold
• Flap thickness 5-8 mm (preserve subdermal plexus; avoid skin necrosis)

• Elevate breast off pectoralis major fascia (leaving it on specimen)
• From superomedial to inferolateral
• Pectoralis major muscle preserved (distinguishes from Halsted)

• Divide pec minor at coracoid process insertion
• This exposes Level III (apical) nodes
• In Auchincloss-Madden: pec minor retracted, not divided

• Clear from medial to lateral
• Identify and preserve:
  • Long thoracic nerve of Bell (on serratus anterior - medial wall of axilla)
  • Thoracodorsal nerve (on subscapularis - posterior wall)
  • Thoracodorsal vessels (may be ligated if nodal clearance demands)
  • Axillary vein (superior limit of dissection)
• Remove Level I, II, III nodes en bloc with specimen

• Two suction drains (axilla and inferior flap)
• Wound closure in layers (subcutaneous + skin)

Critical Anatomy and Danger Zones

Complications

• Hemorrhage / hematoma
• Seroma (most common - 30-40%)
• Skin flap necrosis
• Infection
• Pneumothorax (rare)

• Lymphedema (20-30% after ALND)
• Shoulder stiffness/dysfunction
• Winged scapula (long thoracic nerve injury)
• Numbness inner arm (intercostobrachial nerve)
• Local recurrence
• Phantom breast sensation

B. Sentinel Lymph Node Biopsy (SLNB)

Technique

1. Peri-tumoral/periareolar injection of:
   • Patent Blue dye (methylene blue) - intraoperative
   • Tc-99m nanocolloid - preoperative (lymphoscintigraphy)
2. Wait 5-10 minutes for dye to migrate
3. Hand-held gamma probe guides identification of hot node
4. Identify blue-stained lymphatic channel → follow to blue/hot node
5. Excise sentinel node(s) → intraoperative frozen section or imprint cytology
6. If negative: no further axillary surgery
7. If positive: ALND OR axillary RT (per ACOSOG Z0011 criteria)

Identification Rates and False Negative Rates

• Identification rate: 95-98%
• False negative rate: 5-10%

C. Breast Conserving Surgery (Wide Local Excision)

Steps

1. Mark lump + 1-2 cm margins on skin
2. Elliptical incision along Langer's lines (cosmetic)
3. Excise specimen with adequate 3D margins (orientate specimen with clips/sutures)
4. Send specimen for margin assessment (intraoperative frozen section OR post-op)
5. If margins positive → re-excision OR conversion to mastectomy
6. Haemostasis + closure
7. Specimen mammogram (if impalpable lesion with wire localization)

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13. COMPLICATIONS

A. Post-Mastectomy / Post-ALND Complications

EARLY COMPLICATIONS                    LATE COMPLICATIONS
─────────────────────                  ─────────────────────
Hemorrhage/Hematoma                    Lymphedema (most common late)
Seroma (most common early)             Shoulder stiffness
Wound infection                        Winged scapula
Skin flap necrosis                     Numbness inner arm
Pneumothorax                           Local recurrence
Deep vein thrombosis                   Tumor-en-cuirasse
Pulmonary embolism                     Stewart-Treves syndrome
                                       (lymphangiosarcoma in chronic lymphedema)

B. Lymphedema Management

• Severity: measured by limb circumference difference
• Prevention: avoid IV lines/blood pressure cuff on affected arm
• Treatment:
  • Complete Decongestive Therapy (CDT)
  • Compression garments
  • Manual lymphatic drainage (MLD)
  • Exercises
  • Surgery (Charles procedure, liposuction) - rarely

C. Seroma Management

• Most common early complication (30-40%)
• Drain with needle aspiration
• Compression bandage
• Drain removal only when <30 mL/day output

D. Stewart-Treves Syndrome

• Lymphangiosarcoma developing in chronic post-mastectomy lymphedema
• Bluish-purple skin lesions on arm
• Very poor prognosis
• Radical excision ± radiotherapy

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14. VIVA DISCUSSION

Rapid-Fire Viva: 40+ Examiner Questions with Model Answers

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15. CASE DISCUSSION

How to Present a Breast Cancer Long Case in the Exam Hall

Case Introduction (1 minute)

"I have examined Mrs. [Name], a [age]-year-old [occupation] female, who presented with a painless lump in the [right/left] breast of [duration] duration. The lump has been [progressive/static]. She also complains of [skin changes/nipple discharge/axillary swelling]."

History Highlights to Cover

• Chief complaint + duration + progression
• Associated symptoms: pain, nipple changes, discharge, skin changes
• Systemic symptoms: weight loss, bone pain, cough, jaundice
• Menstrual/obstetric history (menarche, LMP, pregnancies, breastfeeding, OCP/HRT)
• Family history (breast/ovarian cancer)
• Past history (previous biopsies, radiation)

Examination Findings to Present

1. General: BMI, pallor, jaundice, lymphadenopathy
2. Breast: Inspect + Palpate - all characteristics of the lump
3. Axilla: Palpate all 5 node groups
4. Supraclavicular fossa: both sides
5. Contralateral breast
6. Systemic: Liver, chest, spine (metastasis screen)

Differential Diagnosis Discussion

Investigation Discussion

1. Triple assessment
2. Staging investigations based on suspected stage

Management Discussion

1. MDT referral
2. Staging
3. Stage-specific management plan

Examiner Cross-Questions to Prepare

• "Why did you choose BCS over mastectomy?"
• "What would you do if margins are positive?"
• "How would you manage axillary nodes in this patient?"
• "What systemic therapy would you recommend?"
• "What are the indications for NACT?"
• "If the patient is BRCA positive, how does management change?"

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16. IMPORTANT TABLES

High-Yield Comparison Tables

A. Prognosis by Histological Type

B. Clinical Features Summary Table

C. Operations for Breast Cancer - Evolution

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17. FLOW CHARTS

A. Diagnostic Flowchart

BREAST LUMP
     │
     ▼
CLINICAL ASSESSMENT
(Age, Duration, Features)
     │
 ┌───┴────┐
 │        │
<35 yrs  >35 yrs
 │        │
USG       Mammogram
 │        │
 └───┬────┘
     │
Solid or Indeterminate
     │
     ▼
CORE NEEDLE BIOPSY + IHC
     │
  ┌──┴──┐
 Benign Malignant
  │       │
Discharge Staging
          │
          ▼
    MDT Meeting
          │
    Stage-specific
     Management

B. Axillary Management Flowchart

CLINICALLY NODE NEGATIVE (cN0)
          │
          ▼
    SLNB (intraoperative)
          │
    ┌─────┴─────┐
 SLN-        SLN+
 negative    positive
    │              │
No further   1-2 positive SLN?
axillary         │
surgery      ┌───┴──────┐
             │          │
         BCS +     >2 SLN positive
         WBRT          │
             │        ALND
      Omit ALND     (Levels I-III)
  (Z0011 criteria)

CLINICALLY NODE POSITIVE (cN1+)
          │
          ▼
       Biopsy positive
       axillary node
          │
    NACT → reassess
          │
       Surgery:
    ALND or Axillary RT

C. Staging and Treatment Algorithm

CONFIRMED BREAST CANCER
          │
    STAGING WORKUP
          │
 ┌────────┼────────┬──────────┐
 │        │        │          │
Stage 0  Stage I-IIA  Stage IIB-IIIC  Stage IV
(DCIS)   (Early)  (Locally Adv.)   (Metastatic)
 │        │        │                 │
BCS or   Surgery   NACT first        Palliative
Mastect  first     then surgery      systemic
+ RT     then      + RT              therapy
+Tamox   adjuvant                   ± surgery
         therapy                    (local control)

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18. MIND MAP

                        CARCINOMA BREAST
                               │
         ┌─────────────────────┼──────────────────────┐
         │                     │                      │
    ETIOLOGY              PATHOLOGY              CLINICAL
    ────────              ─────────              ───────
    BRCA1/2              IDC-NST (70%)         Painless lump (UOQ)
    ER exposure          ILC (10%)             Skin dimpling
    Radiation            DCIS/LCIS             Peau d'orange
    HRT                  TNM Stages 0-IV       Nipple retraction
    Nulliparity          Molecular:            Blood discharge
    Age >40              LumA, LumB,           Axillary nodes
    Obesity              HER2, TNBC            Paget's nipple
         │                     │                      │
    INVESTIGATIONS         SURGERY             SYSTEMIC THERAPY
    ────────────           ───────             ───────────────
    Triple Assessment      BCS (+ WBRT)        Chemo (AC-T)
    Mammogram (BI-RADS)    MRM (Patey's)       Hormonal (Tamox/AI)
    USG breast             SLNB / ALND         HER2 (Trastuzumab)
    Core biopsy            Oncoplastic         PARP (Olaparib)
    IHC (ER/PR/HER2)       Nipple-sparing      CDK4/6 inhibitors
    Staging CT/PET         Prophylactic        Immunotherapy (Pemb)

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19. IMAGES AND VISUAL REFERENCES

• Peau d'orange (dermal lymphatic invasion)
• Skin dimpling (Cooper's ligament tethering)
• Paget's disease of nipple (eczematous nipple change)
• Inflammatory breast cancer (erythema + edema)
• Fungating/ulcerating breast mass (T4b)
• Lymphedema of arm post-mastectomy

• Spiculated/stellate mass
• Clustered pleomorphic microcalcifications (comedo DCIS)
• Architectural distortion
• Asymmetric density

• Scirrhous carcinoma - hard, gritty cut surface, stellate appearance
• Medullary carcinoma - soft, fleshy, pushing margins
• Mucinous carcinoma - gelatinous appearance
• DCIS with comedo necrosis - toothpaste-like material expressed from ducts

---

20. INSTRUMENTS

Key Instruments in Breast Surgery

• Show a 14G core biopsy needle: "What is this? What gauge is used? What are its advantages over FNAC?"
• Show a Kopans hookwire: "How is this used preoperatively? What is the purpose?"
• Show a gamma probe: "What is the principle of SLNB? What radioisotope is used? How much radioactivity?"

---

21. SURGICAL PEARLS

Bailey & Love Pearls

• BCS = mastectomy in terms of overall survival (Bailey & Love, 28th Ed.)
• Peau d'orange = dermal lymphatic blockade (NOT inflammatory unless red + warm + ≥1/3 breast affected)
• LCIS = bilateral risk marker, not anatomic precursor
• Internal mammary nodes: important route for medial quadrant tumors; often overlooked

Schwartz Pearls

• In LCIS, up to 65% of subsequent invasive cancers are ductal, not lobular (Schwartz, 11th Ed.)
• ACOSOG Z0011: ALND can be safely omitted in selected SLNB-positive patients
• MRI breast: mandatory for BRCA mutation carriers starting age 25 for annual screening

Operative Pearls (OT)

• Always orient the mastectomy specimen with sutures/clips for the pathologist (superior, medial, lateral, deep margins)
• Raise skin flaps at correct plane (subdermal, 5-8 mm thick) to preserve subdermal plexus and prevent necrosis
• Identify long thoracic nerve early - it lies on the surface of serratus anterior on the medial wall of the axilla
• Thoracodorsal nerve identified by following the thoracodorsal vessels on subscapularis

Emergency Pearls

• Inflammatory breast cancer = NACT first; NEVER take straight to mastectomy
• Spinal cord compression = ONCOLOGICAL EMERGENCY - dexamethasone immediately + urgent MRI
• Hypercalcemia = IV normal saline + furosemide + zoledronic acid
• Pathological fracture = orthopaedic stabilization + RT

Resident Tips

• Always do triple assessment - a single negative result does not exclude malignancy
• Core biopsy > FNAC for treatment planning (receptor status, grade, architecture)
• Always examine the contralateral breast and both axillae
• Ask about family history every single time
• For exam: know Haagensen's criteria of inoperability - frequently asked

---

22. RECENT GUIDELINES (2024-2025)

NCCN Guidelines Version 5.2025 (Key Updates)

Recent PubMed Evidence Updates (2024-2025)

• PMID 39878175 (Int J Surg, 2025): Systematic review - SLNB after NACT in clinically node-positive breast cancer achieves adequate accuracy when ≥3 SLN removed; false-negative rate acceptable
• PMID 38808740 (Asia Pac J Clin Oncol, 2025): BCS vs. mastectomy for metaplastic breast cancer - no significant survival difference; BCS feasible when adequate margins achievable
• PMID 39370318 (Surgery, 2024): Systematic review of surgical treatment in older (≥70 yrs) breast cancer patients - surgery + RT equivalent survival to mastectomy; deescalation strategies valid

---

23. HIGH-YIELD EXAM SECTION

⭐ Frequently Asked MS/DNB Questions

1. Enumerate risk factors for carcinoma breast
2. Describe triple assessment of breast lump
3. Classification of breast carcinoma
4. Discuss management of early breast cancer
5. What is modified radical mastectomy? Describe Patey's operation
6. TNM staging of breast cancer with prognosis
7. Management of axillary lymph nodes in breast cancer
8. Sentinel lymph node biopsy - technique, indications, significance
9. Indications and contraindications of BCS
10. What is DCIS? How is it managed?

⭐ Viva Favourites (One-Liners)

• Most common carcinoma = IDC-NST (70-80%)
• Most common site = Upper outer quadrant (50%)
• Gold standard for diagnosis = Triple Assessment + Core biopsy
• Most important prognostic factor = Axillary lymph node status
• Most common early complication of ALND = Seroma
• Most common late complication = Lymphedema
• Nerve causing winged scapula = Long thoracic nerve of Bell
• BRCA1 site = 17q21; BRCA2 site = 13q12.3
• Inflammatory breast = T4d stage
• Paget's cells = large, pale cells with clear halo in epidermis
• Nottingham grade: tubules + nuclear pleomorphism + mitoses
• Halsted = pec major removed; Patey = pec major preserved

⭐ Examiner's Favourite Traps

• ❌ "Peau d'orange = inflammatory carcinoma" → WRONG. Peau d'orange = dermal lymphatic blockade (any invasive cancer). Inflammatory = erythema + warmth + ≥1/3 breast (T4d)
• ❌ "LCIS is a precursor lesion" → WRONG. LCIS is a RISK MARKER (bilateral, diffuse risk). DCIS is the true precursor
• ❌ "ALND is always needed for positive SLNB" → WRONG after Z0011 trial (1-2 SLN+ with BCS + WBRT can omit ALND)
• ❌ "Inflammatory breast cancer - do emergency mastectomy" → WRONG. NACT first; surgery later
• ❌ "Halsted = Patey" → Halsted removes pec major; Patey preserves pec major but removes pec minor
• ❌ "Fat necrosis is benign, no biopsy needed" → WRONG. Must biopsy to exclude carcinoma

⭐ OSCE Stations

⭐ Mnemonics

• Age >40, Alcohol
• BRCA 1/2, Breast density, Breastfeeding (protective)
• Combined HRT, Contralateral breast cancer
• Dense breast tissue
• Early menarche, Evidence of radiation
• Family history, Fat (obesity)
• HRT use, High estrogen exposure, Hormone contraceptives
• Radiation, Race (Western)
• Late menopause, Late first pregnancy
• Nulliparity
• Ovarian cancer in family

• Subscapular (posterior)
• Central
• Apical (Level III)
• Lateral (axillary vein)
• Pectoral (anterior, Level I)
• External mammary
• Level classification (I, II, III)

---

24. SUMMARY

One-Page Revision Sheet

50 Rapid-Fire Viva Q&A

1. Most common female cancer worldwide? Breast cancer
2. Most common histological type? IDC-NST
3. Best initial investigation in <35 yrs? USG breast
4. Best initial investigation in >35 yrs? Mammography
5. Gold standard tissue diagnosis? Core needle biopsy
6. BI-RADS 4 management? Tissue biopsy
7. Most common site of breast cancer? UOQ (50%)
8. Triple negative = which molecular type? Basal-like / TNBC
9. BRCA1 location? 17q21
10. BRCA2 associated malignancy (male)? Prostate cancer
11. Nottingham grade components? Tubules + Nuclear pleomorphism + Mitoses
12. Grade 1 score? 3-5
13. Haagensen's inoperability - arm edema signifies? N3 axillary nodes
14. T4d = ? Inflammatory breast cancer
15. Inflammatory cancer - initial treatment? Neoadjuvant chemotherapy (NOT surgery)
16. DCIS - true precursor or risk marker? True precursor
17. LCIS - true precursor or risk marker? Risk marker
18. Comedo DCIS - radiological feature? Clustered pleomorphic microcalcifications
19. Peau d'orange mechanism? Dermal lymphatic blockade causing skin edema
20. Paget's disease starts at? Nipple (not areola)
21. Z0011 trial significance? ALND can be omitted in 1-2 positive SLN with BCS+WBRT
22. Most important prognostic factor? Axillary lymph node status
23. Batson's plexus significance? Haematogenous spread to spine without portal circulation
24. Most common bone for breast metastasis? Vertebral column
25. Most common early complication of ALND? Seroma
26. Most common late complication? Lymphedema
27. Nerve causing winged scapula? Long thoracic nerve of Bell
28. Thoracodorsal nerve injury effect? Weak arm adduction/extension
29. Intercostobrachial nerve injury effect? Numbness upper inner arm
30. Halsted mastectomy preserves? Nothing; pec major removed
31. Patey's mastectomy preserves? Pectoralis major
32. Auchincloss-Madden preserves? Both pectoralis muscles
33. Standard yield in ALND? ≥10 lymph nodes
34. SLNB dye? Patent Blue/Methylene Blue + Tc-99m nanocolloid
35. Sentinel node identification rate? 95-98%
36. SLNB false negative rate? 5-10%
37. Indication for MRI in breast? BRCA carriers, occult primary, preoperative planning, neoadjuvant monitoring
38. OncotypeDx - what does it measure? 21-gene recurrence score; guides need for chemotherapy in ER+
39. Trastuzumab target? HER2 extracellular domain
40. Trastuzumab side effect? Cardiotoxicity (cardiomyopathy)
41. PARP inhibitor used in breast cancer? Olaparib (for BRCA-mutated)
42. pCR = ? Pathological complete response (no residual invasive cancer after NACT)
43. Residual disease after NACT in HER2+? T-DM1 adjuvant (KATHERINE trial)
44. Residual disease after NACT in TNBC? Capecitabine (CREATE-X) or Olaparib if BRCA+
45. CDK4/6 inhibitors - example + use? Palbociclib/Ribociclib/Abemaciclib; metastatic ER+/HER2-
46. Stewart-Treves syndrome? Lymphangiosarcoma in chronic post-mastectomy lymphedema
47. Toilet mastectomy? Palliative mastectomy for fungating Stage IV tumor
48. Prophylactic mastectomy reduces risk by? ~90%
49. FAST-Forward trial? 5×5.4 Gy (1 week) equivalent to 40 Gy/15# (3 weeks)
50. ASTRO 2024 APBI criteria (age)? ≥40 years, T1, ER+, node-negative, Grade 1-2, no BRCA

20 MCQs

1. Most common carcinoma of breast: (a) ILC (b) IDC-NST (c) Medullary (d) Mucinous
2. Most important prognostic factor: (a) Tumor size (b) Grade (c) Axillary node status (d) Receptor status
3. BRCA1 chromosome location: (a) 13q12 (b) 17p13 (c) 17q21 (d) 22q12
4. Berg's Level II nodes are: (a) Lateral to pec minor (b) Behind pec minor (c) Medial to pec minor (d) Along axillary vein
5. Sentinel node is identified by: (a) CT scan (b) Bone scan (c) Blue dye + Tc99m probe (d) PET
6. Winged scapula results from injury to: (a) Thoracodorsal (b) Intercostobrachial (c) Long thoracic nerve (d) Lateral pectoral
7. Inflammatory breast cancer stage: (a) T3 (b) T4a (c) T4b (d) T4d
8. ACOSOG Z0011 trial: ALND omission is safe with: (a) Any positive SLN (b) ≥3 positive SLN (c) 1-2 positive SLN + BCS + WBRT (d) All N1 disease
9. Best imaging in a 28-year-old with breast lump: (a) Mammography (b) MRI (c) USG (d) PET-CT
10. Nottingham Grade - best prognosis score: (a) 8-9 (b) 6-7 (c) 3-5 (d) All equal
11. DCIS vs. LCIS - which is a true precursor: (a) DCIS (b) LCIS (c) Both (d) Neither
12. HER2 3+ on IHC means: (a) Negative (b) Equivocal (c) Positive - trastuzumab eligible (d) Requires FISH
13. Paget's disease starts at: (a) Areola (b) Nipple (c) Upper outer quadrant (d) Chest wall
14. Protective factor for breast cancer: (a) Late menopause (b) HRT (c) Early first pregnancy + breastfeeding (d) Radiation
15. Most common site of distant metastasis: (a) Lung (b) Liver (c) Brain (d) Bone
16. Residual disease after NACT in HER2+: (a) Trastuzumab alone (b) Capecitabine (c) T-DM1 (trastuzumab emtansine) (d) Pertuzumab
17. Comedo DCIS characterized by: (a) Low grade (b) High grade + necrosis + microcalcifications (c) Absent necrosis (d) All types equally
18. Patey's operation removes: (a) Pec major only (b) Pec major + minor (c) Breast + axillary LN + pec minor (pec major preserved) (d) Breast only
19. BRCA2 male breast cancer - most common associated malignancy: (a) Pancreatic (b) Prostate cancer (c) Colon (d) Gastric
20. Peau d'orange mechanism: (a) Direct skin invasion (b) Cooper's ligament tethering (c) Dermal lymphatic blockade causing skin edema (d) Tumor ulceration

10 Clinical Scenarios

5 OSCE Stations

---

Top 10 Examiner Take-Home Messages

1. Triple assessment is the cornerstone of breast diagnosis - never rely on clinical examination alone
2. Core biopsy > FNAC - provides histology, grade, receptor status needed for treatment planning
3. BCS = mastectomy in survival outcomes when followed by radiotherapy (Level 1 evidence - NSABP B-06, Milan trials)
4. Axillary lymph node status = most important single prognostic factor
5. LCIS = risk marker (bilateral, 1-2%/year); DCIS = true precursor (must treat)
6. Inflammatory breast cancer - NACT first, mastectomy later; never take to OT initially
7. Z0011 trial changed axillary surgery - 1-2 positive SLN + BCS + WBRT = ALND can be omitted
8. BRCA1 (17q21) = TNBC type; BRCA2 (13q12.3) = multiple organ cancers; prophylactic mastectomy reduces risk by 90%
9. Know your nerve anatomy - long thoracic nerve = winged scapula; thoracodorsal nerve = latissimus dorsi; protect both in ALND
10. Modern breast cancer management is molecular and individualized - receptor status drives every treatment decision; the era of one-size-fits-all surgery is over

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---

🎓 CARCINOMA BREAST

Complete Illustrated Long Question - MS General Surgery Examination Standard

With Real Textbook Images from Bailey & Love (28th Ed.) | Schwartz (11th Ed.) | Sabiston (21st Ed.) | Robbins Pathology (10th Ed.)

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1. DEFINITION

Carcinoma of the breast is a malignant adenocarcinoma arising from the ductal or lobular epithelium of the terminal duct lobular unit (TDLU), capable of local invasion, regional lymphatic spread, and distant haematogenous metastasis.

• #1 cancer in women worldwide - 2.3 million new cases in 2020 (Bailey & Love, 28th Ed.)
• In 2020, breast cancer surpassed lung cancer as the most common cancer overall - Robbins Pathology, 10th Ed.
• Lifetime risk = 1 in 8 females (USA); 1 in 9 (Western Europe)
• 25% of all cancers in women globally
• In India: Age at presentation is ~48 years vs. ~60 years in the West - younger at presentation

---

2. SURGICAL ANATOMY

A. Breast Anatomy (Sabiston Textbook of Surgery, 21st Ed.)

---

Terminal Duct Lobular Unit (TDLU) - Origin of Most Breast Cancers

---

Key Anatomical Points (Viva-Ready):

Blood Supply

Lymphatic Drainage - Berg's Levels (CRITICAL EXAM TOPIC)

Lymphatic flow: 70-80% → Axillary nodes; 20% → Internal mammary nodes (especially medial quadrant tumors); rare → Supraclavicular, contralateral axilla

Nerve Supply - Danger Zones in Axillary Surgery

---

3. ETIOLOGY AND RISK FACTORS

Risk Factor Table (Bailey & Love, 28th Ed. - Table 58.3)

Non-Modifiable Risk Factors

Modifiable Risk Factors

Protective Factors

• Breastfeeding >12 months (protective)
• Early first pregnancy (<20 years)
• Physical activity
• Bilateral oophorectomy before age 40
• Tamoxifen/Raloxifene (chemoprevention, -50% risk)
• Bilateral prophylactic mastectomy (-90% risk) - Robbins, 10th Ed.

---

4. CLASSIFICATION

A. By Invasion Status

BREAST CARCINOMA
        │
   ┌────┴────┐
IN SITU    INVASIVE
(Non-       (Basement
invasive)   membrane
            breached)
   │              │
DCIS   LCIS    IDC-NST (70-80%)
(True  (Risk   ILC (10-15%)
precursor) marker) Special types

B. WHO Histological Classification

C. Molecular (Intrinsic) Subtypes - Robbins Pathology Classification Diagram

Molecular Subtype Table

D. Breast Cancer Incidence by Age and Subtype

---

5. PATHOPHYSIOLOGY AND DISEASE PROGRESSION

Pathway of Carcinogenesis (Robbins, 10th Ed.)

LOW-GRADE PATHWAY (ER-positive)
─────────────────────────────────────────────────────
Normal epithelium → Columnar cell lesion / Flat epithelial atypia
    → Atypical Ductal Hyperplasia (ADH) [Loss of 16q, gain of 1q]
    → Low-grade DCIS
    → Low-grade invasive ER+ carcinoma (Luminal A/B)

HIGH-GRADE PATHWAY (ER-negative or HER2+)
─────────────────────────────────────────────────────
Normal epithelium → High-grade DCIS (TP53 mutation, 17q12 amplification)
    → High-grade invasive carcinoma (TNBC / HER2-enriched)

Mechanisms of Key Clinical Signs

Metastatic Routes

• Lymphatic: Level I → II → III axillary nodes → subclavian vein
• Haematogenous via Batson's plexus: Vertebral venous plexus (valveless) → Bone (most common = lumbar vertebrae > neck of femur > thoracic vertebrae > ribs > skull)
• Direct haematogenous: Axillary/internal mammary veins → Lungs, Liver, Brain, Adrenals
• Intra-epithelial: Paget's disease - along nipple epidermis

Examiner pearl (Bailey & Love): Haematogenous bone deposits occur above the elbow and above the knee in limbs (haematopoietic vascular bone marrow confined to axial skeleton). Order: Lumbar vertebrae > neck of femur > thoracic vertebrae > ribs > skull.

---

6. CLINICAL FEATURES

Clinical Presentation

Key Clinical Signs - Red Flag Features

Sign 1: Skin Dimpling and Tethering

Sign 2: Peau d'Orange

"Peau d'orange is a sign of locally advanced disease due to obstruction of cutaneous lymphatic drainage of the breast, by infiltration of either subdermal lymphatics or axillary lymph nodes by tumour cells." - Bailey & Love, 28th Ed.

Sign 3: Cancer en Cuirasse (Advanced Disease)

---

Sign 4: Inflammatory Breast Carcinoma (T4d - Schwartz, 11th Ed.)

Critical Examiner Trap: Inflammatory breast cancer = NACT first. NEVER take straight to mastectomy. It is classified as T4d (not T4b).

---

Symptoms and Signs - Summary Table

---

7. CLINICAL EXAMINATION

Inspection

• A. Inspection with arms at sides
• B. Inspection with arms raised (accentuates skin tethering/dimpling)
• C. Palpation of the breast with patient supine
• D. Palpation of the axilla (arm supported at elbow by examiner)

---

Breast Examination Record Diagram

---

Positions for Inspection (Schwartz, 11th Ed.)

1. Arms by side - baseline symmetry
2. Arms straight up in air - skin retraction accentuated
3. Hands on hips (with and without pectoral contraction) - chest wall fixity
4. Leaning forward - ptosis, tethering

Palpation Technique (Schwartz)

"The breast is carefully palpated with the patient in the supine position. The clinician gently palpates the breasts, making certain to examine all quadrants from the sternum laterally to the latissimus dorsi muscle and from the clavicle inferiorly to the upper rectus sheath. The examination is performed with the palmar aspects of the fingers, avoiding a grasping or pinching motion."

Clinical Pearls

• Always examine contralateral breast (10% bilateral carcinoma)
• Always examine both axillae and both supraclavicular fossae
• Testing for skin fixity: Pinch skin over lump - fixed = skin involved
• Testing for chest wall fixity: Move lump with pectoralis relaxed, then contracted (hands on hips)
• Triple assessment = Clinical + Imaging + Pathology (each component scored 1-5)

---

8. INVESTIGATIONS

Triple Assessment (The Gold Standard Diagnostic Framework)

TRIPLE ASSESSMENT
(Each component scored 1-5)
         │
  ┌──────┼──────┐
  │      │      │
Clinical Imaging Pathology
(C1-C5) (R1-R5) (B/C1-C5)
         │
  Score 5/5/5 = Malignant
  Score 1/1/1 = Benign
  Any score 3-4 = Needs biopsy

Mammography - Gold Standard Screening Investigation

Schwartz Mammographic Features of Malignancy

• A. Small spiculated mass with skin tethering (CC view) - arrows indicate mass and skin tethering
• B. Mass seen on oblique (MLO) view of right breast
• C. Spot compression mammography - spiculated margins accentuated by compression

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Mammogram - Compression Views

---

Wire Localization for Impalpable Lesions (Schwartz)

---

Specimen Mammography Post-Excision (Schwartz)

---

ACR BI-RADS Classification

HER2 Testing Algorithm (Robbins, 10th Ed.)

HER2 Testing Pathway:

IHC 0 or 1+ → HER2 NEGATIVE
IHC 2+ (equivocal) → FISH testing
   FISH amplified → HER2 POSITIVE
   FISH not amplified → HER2 NEGATIVE
IHC 3+ → HER2 POSITIVE (trastuzumab eligible)

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9. HISTOPATHOLOGY

A. Invasive Carcinoma - No Special Type (IDC-NST) - Macro and Micro

• A. Irregular, radiodense mass on mammographic imaging with haphazard stromal invasion pattern
• B. Gross examination - hard, irregular mass with ill-defined margins
• C. Microscopy - exuberant desmoplastic stromal response (chalky-white gritty cut surface)

Pathology Pearl: When cut or scraped, IDC-NST produces a characteristic grating sound due to areas of chalky-white desmoplastic stroma and occasional foci of calcification.

---

B. Nottingham Histological Grading (Elston-Ellis, 3-component scoring)

• (A, D) Grade 1 (Well-differentiated) - tubules formed of cells with small monomorphic nuclei; only rare mitoses
• (B, E) Grade 2 (Moderately differentiated) - less tubule formation; solid nests; pleomorphic nuclei; occasional mitoses
• (C, F) Grade 3 (Poorly differentiated) - ragged sheets of cells; enlarged pleomorphic nuclei; tumor necrosis; high mitoses

Nottingham Grading Table

---

C. TNM Staging - AJCC 8th Edition (Bailey & Love - Table 58.6)

Primary Tumor (T)

Bailey & Love Summary Box 58.3 Key Points:

• LCIS = high-risk benign lesion, NOT a cancer in the 8th edition
• Inflammatory carcinoma remains classified as inflammatory carcinoma even after pCR from NACT
• Pathological complete response (pCR) = absence of tumor cells in breast AND axillary nodes

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10. MANAGEMENT

A. Multidisciplinary Team (MDT) Approach

"The treatment of breast cancer is multimodal (includes surgery, systemic treatment [chemotherapy, targeted therapy, hormonal therapy] and radiotherapy); hence, specialist breast centres employ a multidisciplinary team (MDT)." - Bailey & Love, 28th Ed.

B. Management Algorithm

CONFIRMED BREAST CANCER (Core Biopsy + IHC)
             │
      STAGING WORKUP
      ─────────────────
      Stage I-IIA: CXR, LFTs, ALP (+ bone scan only if symptomatic)
      Stage IIB-III: CT chest/abdomen/pelvis + Bone scan
      Stage IV: PET-CT ± MRI Brain
             │
      MDT MEETING
             │
   ┌─────────┼──────────────┬──────────────┐
   │         │              │              │
Stage 0  Stage I-IIA  Stage IIB-IIIC  Stage IV
(DCIS)  (Early)      (Locally Adv.)  (Metastatic)
   │         │              │              │
BCS+WBRT  Surgery       NACT first    Palliative
or Mast   first then     then Surgery  systemic Rx
+Tamox    adjuvant Rx   + RT          + best support

C. Surgical Options

1. Breast Conserving Surgery (BCS)

Bailey & Love pearl: "BCS is aimed at removing the tumour along with a 1-cm margin of normal breast tissue. It is important to orient the surgical specimen with sutures: long lateral ('L' for lateral') and short superior ('S' for superior')."

All BCS patients MUST receive adjuvant whole breast radiotherapy (WBRT): BCS + RT = BCT (Breast Conservation Therapy)

2. Mastectomy Types (Evolution of Breast Surgery)

Modified Radical Mastectomy (MRM) = Standard mastectomy for operable breast cancer in India and most developing countries

3. Axillary Management

1. Periareolar/peritumoral injection of Patent Blue dye ± Tc-99m nanocolloid (day before)
2. Lymphoscintigraphy identifies sentinel node location
3. Intraoperatively: hand-held gamma probe identifies "hot" radioactive node; blue lymphatic channel → blue node
4. Excise sentinel node(s) → intraoperative frozen section / imprint cytology / postoperative paraffin
5. If SLN negative → no further axillary surgery (saves patient from ALND morbidity)
6. If SLN positive (1-2 nodes, BCS + WBRT) → may omit ALND (ACOSOG Z0011)
7. If >2 positive SLN / not meeting Z0011 criteria → proceed to ALND (Levels I-III)

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11. NEOADJUVANT CHEMOTHERAPY (NACT)

Indications (Bailey & Love, 28th Ed.)

1. Locally advanced breast cancer (T3, T4 / N2, N3 disease) - to downsize
2. Select early breast cancer: HER2+ tumors; TNBC; premenopausal; axillary node metastasis
3. Large tumor-to-breast ratio (to facilitate BCS)
4. Inflammatory breast cancer (mandatory first-line treatment)

Response Assessment and pCR

• pCR (Pathological Complete Response) = No residual invasive cancer in breast AND axillary nodes
• Best predictor of long-term disease-free survival
• pCR rates: TNBC ~40-50%; HER2+ ~50-60% (with dual HER2 blockade); ER+/HER2- ~15-20%

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12. SYSTEMIC THERAPY OVERVIEW

Chemotherapy Regimens

Hormonal Therapy

---

13. HEREDITARY BREAST CANCER

BRCA Genetics (Bailey & Love, 28th Ed.)

Prophylactic Options

• Bilateral risk-reducing mastectomy → reduces breast cancer risk by ~90%
• Chemoprevention (Tamoxifen/Anastrozole) → reduces risk by ~50%
• Bilateral salpingo-oophorectomy at 35-40 years after completing family (premenopausal)
• Olaparib (PARP inhibitor) adjuvant in high-risk BRCA+ patients - OlympiA trial 2021

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14. SPECIAL SITUATIONS

Mondor's Disease of the Breast

---

Inflammatory Breast Cancer vs. Non-Inflammatory (Schwartz Table 17-15)

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15. COMPLICATIONS OF SURGERY

Early vs Late Complications

---

16. VIVA DISCUSSION - 40 HIGH-YIELD Q&A

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17. CLASSIFICATION FLOWCHART

BREAST LUMP
      │
      ▼
TRIPLE ASSESSMENT
(Clinical + Imaging + Histology)
      │
  ┌───┴───────────┐
Benign          Malignant / Indeterminate
  │                    │
Reassure          Core needle biopsy
+ Follow-up            + IHC (ER/PR/HER2/Ki67)
                       │
              ┌────────┴────────┐
           In Situ           Invasive
              │                  │
         DCIS    LCIS        IDC / ILC / Special
              │                  │
        BCS + WBRT or       Staging + MDT
        Mastectomy          → Stage-specific
        ± Tamoxifen            management

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18. MANAGEMENT ALGORITHM - COMPLETE

CONFIRMED INVASIVE BREAST CANCER
(Core Biopsy: Histology + ER/PR/HER2/Ki67)
                │
        MDT STAGING
                │
   ┌────────────┼────────────┬────────────┐
   │            │            │            │
Stage I-IIA  Stage IIB-IIIA  Stage IIIB-C  Stage IV
(T1-2, N0-1)  (T2-3, N0-2)  (T4 or N3)   (Metastatic)
   │            │            │            │
Surgery        Consider     NACT first   Palliative
(BCS or MRM)   NACT →      (mandatory)  systemic
+ SLNB         then surgery Then surgery therapy
Then adjuvant  + ALND       (MRM+ALND)   ± local
systemic Rx    + RT         + PMRT        palliation
                            + systemic
                            │
   SYSTEMIC THERAPY (ALL STAGES - BASED ON RECEPTOR STATUS):
   ├── ER+/HER2-: Hormonal therapy ± Chemo (OncotypeDx guided)
   ├── HER2+: Trastuzumab ± Pertuzumab ± Chemo
   ├── TNBC: AC-T ± Pembrolizumab; Olaparib if BRCA+
   └── Metastatic ER+: CDK4/6i + AI (1st line); T-DXd (HER2+/HER2-low 2nd line)

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19. HIGH-YIELD EXAM SUMMARY TABLE

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20. RAPID-FIRE VIVA - 30 ONE-LINERS

1. Most common female cancer worldwide = Breast cancer (surpassed lung in 2020)
2. Most common histological type = IDC-NST (70-80%)
3. Most common site = Upper outer quadrant (50%)
4. Gold standard tissue diagnosis = Core needle biopsy (14G) + IHC
5. Most important prognostic factor = Axillary lymph node status
6. Staging system used = AJCC 8th Edition TNM
7. Inflammatory cancer TNM = T4d
8. BRCA1 chromosome = 17q21
9. BRCA2 chromosome = 13q12.3
10. BRCA1 associated carcinoma subtype = TNBC (Triple Negative)
11. Nottingham grade components = Tubules + Nuclear pleomorphism + Mitoses
12. Grade 1 total score = 3-5
13. Peau d'orange mechanism = Dermal lymphatic blockade → skin edema
14. Cooper's ligament invasion → Skin dimpling
15. Winged scapula nerve = Long thoracic nerve of Bell (C5-6-7)
16. Thoracodorsal nerve supplies = Latissimus dorsi
17. Halsted removes = Pec major + pec minor + breast + all axillary LN
18. Patey preserves = Pectoralis major (removes pec minor)
19. Auchincloss preserves = Both pectoralis muscles (Levels I-II ALND)
20. SLNB dye = Patent Blue + Tc-99m nanocolloid
21. Z0011 trial = ALND omittable in 1-2 positive SLN + BCS + WBRT
22. Most common early complication post-ALND = Seroma (30-40%)
23. Most common late complication = Lymphedema (20-30%)
24. Batson's plexus = Valveless vertebral venous plexus; explains vertebral mets
25. Most common bone met site = Lumbar vertebrae
26. Trastuzumab side effect = Cardiotoxicity (cardiomyopathy)
27. T-DM1 used for = Residual HER2+ disease post-NACT (KATHERINE)
28. Pembrolizumab in TNBC = KEYNOTE-522; neoadjuvant + adjuvant
29. Stewart-Treves syndrome = Lymphangiosarcoma in chronic post-mastectomy lymphedema
30. Prophylactic mastectomy reduces risk by = ~90% (Robbins, 10th Ed.)

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21. 20 HIGH-YIELD MCQs

1. Most common breast carcinoma: (B) IDC-NST (a) ILC (b) IDC-NST (c) Mucinous (d) Medullary
2. Most important single prognostic factor: (C) Axillary node status (a) Tumor size (b) Grade (c) Axillary node status (d) ER status
3. BRCA1 chromosome location: (C) 17q21 (a) 13q12 (b) 17p13 (c) 17q21 (d) 22q12
4. Level II axillary nodes (Berg's classification): (B) Behind pectoralis minor (a) Lateral (b) Behind (c) Medial (d) Along axillary vein
5. Sentinel node identified intraoperatively using: (C) Patent blue dye + gamma probe (a) CT scan (b) PET (c) Patent blue + Tc99m probe (d) MRI
6. Winged scapula = injury to: (C) Long thoracic nerve of Bell (a) Thoracodorsal (b) Intercostobrachial (c) Long thoracic (d) Lateral pectoral
7. Inflammatory breast cancer TNM stage: (D) T4d (a) T3 (b) T4a (c) T4b (d) T4d
8. ACOSOG Z0011 - ALND safe to omit with: (C) 1-2 positive SLN + BCS + WBRT (a) Any positive SLN (b) >2 SLN+ (c) 1-2 SLN+ with BCS+WBRT (d) All N1 disease
9. Best imaging in a 28-year-old with a breast lump: (C) Ultrasound (a) Mammography (b) MRI (c) USG (d) PET-CT
10. Nottingham Grade - best prognosis (lowest score): (C) 3-5 = Grade 1 (a) 8-9 (b) 6-7 (c) 3-5 (d) All equal
11. DCIS vs. LCIS - true precursor lesion: (A) DCIS (a) DCIS (b) LCIS (c) Both (d) Neither
12. HER2 IHC 3+ means: (C) Positive - trastuzumab eligible (a) Negative (b) Equivocal (c) Positive - trastuzumab eligible (d) Requires FISH
13. Paget's disease of nipple - eczematous change starts at: (B) Nipple (a) Areola (b) Nipple (c) UOQ (d) Chest wall
14. Most common site of distant metastasis in breast cancer: (D) Bone (a) Lung (b) Liver (c) Brain (d) Bone
15. Residual disease after NACT in HER2+ breast cancer - treatment: (C) T-DM1 (KATHERINE trial) (a) Trastuzumab alone (b) Capecitabine (c) T-DM1 (d) Pertuzumab
16. Peau d'orange mechanism: (C) Dermal lymphatic blockade → skin edema (a) Direct invasion (b) Cooper's ligament tethering (c) Dermal lymphatic blockade (d) Tumor ulceration
17. Patey's MRM preserves: (A) Pectoralis major (a) Pec major (b) Pec minor (c) Both (d) Neither
18. OncotypeDx recurrence score - high risk (add chemotherapy): (C) 26-100 (a) 0-10 (b) 11-25 (c) 26-100 (d) All need chemo
19. Most common early complication of axillary lymph node dissection: (A) Seroma (a) Seroma (b) Lymphedema (c) Winged scapula (d) DVT
20. Bilateral prophylactic mastectomy reduces BRCA cancer risk by: (B) ~90% (a) 50% (b) ~90% (c) 30% (d) 99%

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22. 5 OSCE STATIONS

• Expected: Inspection in 4 positions → Systematic palpation (4 quadrants + subareolar + axillary tail) → Axillary examination (5 node groups) → Supraclavicular examination → Contralateral breast → Structured presentation

• Expected: Spiculated mass = malignant; Microcalcifications = comedo DCIS; Architectural distortion; BI-RADS 5; Management = Core needle biopsy + staging

• Expected: 14G core biopsy needle; USG-guided; gives histology + architecture + grade + receptor status (ER/PR/HER2/Ki67); can distinguish invasive from in situ; FNAC only gives cytology

• Expected: Describe tubule formation, nuclear pleomorphism, mitoses; Score each 1-3; Calculate Nottingham grade; State prognosis implication

• Expected: Explain BCS vs. mastectomy (equivalent survival); Need for radiotherapy after BCS; SLNB; Reconstruction options; MDT approach; Adjuvant therapy; Psychological support

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23. RECENT GUIDELINES UPDATE (NCCN Version 5.2025)

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