LYMPHATIC DRAINAGE, DIAGNOSIS, TNM CLASSIFICATION OF BREAST CANCER

Dr. KOUSTAV MAZUMDERMD PGT, DEPT of RADIOTHERAPYMEDICAL COLLEGE & HOSPITAL, KOLKATA

• Breast cancer may be one of the oldest known forms of cancerous tumors in humans.

• The oldest description of cancer was discovered in Egypt and dates back to approximately 1600 BC. The Edwin Smith Papyrus describes 8 cases of tumors or ulcers of the breast that were treated by cauterization.

• The French surgeon Jean Louis Petit (1674–1750) and later the Scottish surgeon Benjamin Bell (1749–1806) were the first to remove the lymph nodes, breast tissue, and underlying chest

muscle.• Their successful work was carried on by William Stewart Halsted

who started performing mastectomies in 1882• The first case-controlled study on breast cancer epidemiology was

done by Janet Lane-Claypon, who published a comparative study in 1926 of 500 breast cancer cases and 500 control patients of the same background and lifestyle for the British Ministry of Health

• LYMPHATIC DRAINAGE

• DIAGNOSIS

• TNM CLASSIFICATION

SUPLACLAVICULAR LN

AXILLARY LN

AXILLARY LN

INTERNAL MAMMARY LN

LEVEL III

LEVEL II

LEVEL I

Pectoralis minor

Lateral Thoracic vein

Anterior axillary nodes

Apical axillary nodes

Axillary vein

Central Axillary Nodes

Lateral Axillary Nodes

Posterior Axillary nodes

Subscapular vein

Pectoralis minor

Pectoralis major

Interpectoral node

Internal mammary node

LYMPHTIC DRAINAGE OF BREAST

Draining the PARENCHYMA of BREASTIncluding AREOLA and NIPPLE

Draining the overlying SKIN except AREOLA and NIPPLE

Draining the overlying SKIN except AREOLA and NIPPLE

Anterior abdominal wall

Supraclavicular LNInfraclavicula LN

Internal mammary LN

Axillary LN

Subperitoneal lymphatic plexus

Sub Diaphragmatic node

Hepatic Nodes

Draining the overlying SKIN except AREOLA and NIPPLE

Supraclavicular LNInfraclavicula LN

Internal mammary LN

Axillary LN

Retromammary fat

Lactiferous duct

areola

nipple

lobules

Pectoralis major

Chest wallSubareolar plexus of sappay

Lymphatic Lake of Haller

Draining the PARENCHYMA of BREAST Including AREOLA and NIPPLE

Draining the PARENCHYMA of BREAST Including AREOLA and NIPPLE

Supraclavicular LNInfraclavicula LN

Internal mammary LN

Axillary LN

75%

Draining the PARENCHYMA of BREAST Including AREOLA and NIPPLE

Supraclavicular LNInfraclavicula LN

Internal mammary LN

Axillary LN

•LYMPHATIC DRAINAGE

•DIAGNOSIS

SCREENING• CLINICAL BREAST EXAMINATION

• BREAST AWARENESS

• RADIOLOGICAL INVESTIGATION

MAMMOGRAPHY

BI-RADS (Breast Imaging Reporting And Data System)

PERFORMS=PERsonal perFORmance in

Mammographic Screening

Woman at normal risk

20-39 yrs

•CBE every 1-3 yrs

•Breast awareness

>40 yrs

•Annual CBE

•Breast awareness

•Mammography

Woman at increased risk

•Prior Thoracic irradiation

•>35 yrs

•Lifetime risk >20%

•F/H or genetic predisposition

•LCIS/ Atypical hyperplasia

•H/O Breast Cancer

SCREENING GUIDELINE in NCCN 2012

DIAGNOSIS• HISTORY & CLINICAL EXAMINATION

• RADIOLOGICAL EVALUATION

• BIOPSY

RADIOLOGICAL EVALUATION

• Diagnostic Mammography Spot compression view or magnifiacation view

• Breast ultrasonography woman< 30 yrs of age,

woman>30 yrs age (BIRADS 1-3)

spontaneous nipple discharge/ skin change

BIRADS category 0

• Diagnostic Breast MRI BIRADS 1-3,

IBC

BREAST BIOPSY

• Fine needle aspiration(FNA) Biopsy

• Core needle Biopsy Non palpable lesion

• Excisional Biopsy Atypical hyperplasia, LCIS, mucin producing tumor, Phylloids

• Duct excision(with or without ductography) Non sponteneous discharge from duct with BIRADS 1-3

Guidelines for the basic elements of a pathology report for breast cancer have been established by the College of American Pathologists

• LYMPHATIC DRAINAGE

• DIAGNOSIS

• TNM CLASSIFICATION

• PRIMARY TUMOR (T)

• REGIONAL LYMPH NODE(N)

• DISTANT METASTASES(M)

PRIMARY TUMOR (T)

REGIONAL LYMPH NODE(N)

CLINICAL PATHOLOGICAL

N1

Metastasis to movable ipsilateral level I, II axillary lymph node(s)

N2a

Metastasis in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures

N2b

Metastasis only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary lymph node metastasis

N3a

Metastasis in ipsilateral infraclavicular lymph node(s)

N3b

Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)

N3c

Metastasis in ipsilateral supraclavicular lymph node(s)

pN1a

Metastasis in 1 to 3 axillary lymph nodes(at least one >2 mm)

pN1b

Metastasis in internal mammary nodes with micrometastasis or macrometastasis detected by SLNB but not clinically detected

pN1c

Metastasis in 1 to 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastasis or macrometastasis detected in SLNB but not clinically detected

pN2a

Metastasis in 4 to 9 axillary lymph nodes (at least one tumor deposit greater than 2.0 mm)

pN2b

Metastasis in clinically detected internal mammary lymph nodes in the absence of axillary lymph node metastases

pN3a

Metastasis in 10 or more axillary lymph nodes(at least one tumor deposit >2 mm

pN3a

metastasis to the infraclavicular (level III) lymph nodes

pN3b

>1

Metastases in clinically detected ipsilateral internal mammary lymph nodes in the presence of 1 or more positive axillary lymph nodes

2

more than 3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected

pN3b

pN3c

Metastasis in ipsilateral supraclavicular lymph nodes

• PRIMARY TUMOR (T)

• REGIONAL LYMPH NODE(N)

• DISTANT METASTASES(M)

Distant Metastasis (M)

Stage 0• Tis, N0, M0

Stage IA• T1, N0, M0

Stage IB• T0, N1mi, M0

• T1, N1mi, M0

Stage IIA• T0, N1, M0

• T1, N1, M0

• T2, N0, M0

Stage IIB• T2, N1, M0

• T3, N0, M0

Stage IIIAT0, N2, M0T1, N2, M0T2, N2, M0T3, N2, M0T3, N1, M0

Stage IIIBT4, N0, M0T4, N1, M0T4, N2, M0

Stage IIICAny T, N3, M0

Stage IVAny T, Any N, M1

HISTOLOGIC GRADE (G)

ELSTON- ELLIS modification of SCARFF- BLOOM- RECHARDSON grading system

• TUBULE FORMATION

• NUCLEAR PLEOMORPHISM

• MITOTIC COUNT