BILATERAL BREAST CANCER

Background
 Breast Cancer :
 comes from ducts or lobes
 29 % of all new malignant disease
 incidents: 170 000 cases per year
 Indonesia: second highest incidence after cervix ca
 patients usually come at an advanced stage
Risk factors
 Sex, 
 Age
 Family history
 Prior breast cancer ~ contralateral breast
 Benign breast disease :Proliferative histologic pattern +
Atypical hyperplasia
 Endogenous endocrine factors
 Age at menarche < 13 y.o.
 Ag at menopause > 55 y.o.
 Parity
 Age at first full-term pregnancy > 35 y.o.
 Exogenous hormone use :Oral contraceptive
 Exposure to ionizing radiation between age 13 and 30
 Obesity & Alcohol consumption
Classification of breast cancer
 Non invasive carcinoma
 Non invasive ductal carcinoma
 Lobular carcinoma in situ
 Invasive carcinoma
 Invasive ductal carcinoma
 Special types
 Paget’s disease
Histological grading
 Gx : can not be assessed
 G1 : low grade
 G2 : intermediate grade
 G3 : high grade
Examination
 Recommended
 Breast US
 X ray
 Whole abdomen US
 Optional
 Bone scan
 CT scan
Therapeutic modalities

 Operation
 Radiation
 Chemotherapy
 hormonal therapy
 Molecular targeting therapy
Bilateral breast cancer
 incidence : 4–20% in patients with primary
operable breast cancer
 The risk factors associated with bilateral
occurrence are:
 familial or hereditary breast cancer,
 young age at primary breast cancer diagnosis,
 lobular invasive carcinoma,
 multicentricity
 radiation exposure
 In bilateral breast cancer, it is important to
know whether contralateral breast lesion is
metastatic or second primary  not easy
 Chaudary et al proposed criteria for the
diagnosis of second primary breast cancer in
1984
Chaudary criteria :
 there must be in situ change in the
contralateral tumor
 the tumor in the second breast is histologically
different from the cancer in the first breast
 the degree of histological differentiation of the
tumor in the second breast is distinctly greater
than that of the lesion in the first breast
 there is no evidence of local, regional,or
distant metastases from the cancer in the
ipsilateral breast
Therapy
 The best management of patients with
bilateral breast cancer (CBC) is still not
known.
 Traditionally, most clinicians have
approached bilateral breast cancer more
aggressively than unilateral disease
 Bilateral / unilateral mastectomy / BCT
 Bilateral / unilateral radiotherapy
 Chemotherapy
 Hormonal therapy
Prognosis

 several studies have shown that the

prognosis of patients with bilateral breast
cancer seems similar to unilateral disease.
 Patients with BBC have a higher rate of
distant metastasis and a worse disease
spesific survival than those with UBC

 Optimal reluts can be obtain by using a

logical multimodality treatment approach for
BBC
CASE REPORT
History of Present Illness
 Women,55 years old with complaints of a lump in the
right breast since 6 years prior admission. First time, the
lump was marble-sized and slowly enlarging.
 three years later appeared a lump in her left breast,size
1x1 cm, no pain
 patient went to the RSCM and had chemotherapy 7x (3x
CAF, 4x paclitaxel/cisplatin)
 no history of trauma, radiation, hormonal drugs, previous
breast surgery
 patient did not complain of bone pain, nausea, coughing,
shortness of breath, headache
 Local status on breast region
 Inspection:
 Right breast :
Looks lump in the right
breast as tennis balls,
redness, no visible
wounds, seemed
nipple retraction, no
ulceration, no peau de
orange
 Left breast :
Looks multiple nodules
with the largest nodule
size of a tennis ball,
redness, no visible
wounds, seemed
nipple retraction, no
ulceration, no peau de
orange
 Local status on breast region
Palpation:
 Right breast :
palpable mass,size
4x3x2 cm, hard
consistency, rough
surface,
defined,mobile,no
nipple discharge,
palpable axillary
lymph nodes
 Left breast :
Palpable multiple
nodules with the
largest size of 5x3x3
cm and the smallest
hard consistency,
rough surface,
defined,mobile,size
0.5 x0, 5x0, 3 cm, no
nipple discharge,
palpable axillary
lymph nodes
X ray (11/10/12)

No abnormalities of
the heart and lungs

Whole abdomen US (11/10/12)

No intra-abdominal organ abnormalities

Breast US (18/1/12)

 Right breast : Skin and subcutaneous good, does not

look thickening, nipple retraction does not seem . Looks
solid heterogeneous lesion in superior quadrant, size 3.7
x 4, 0 x 3, 8 cm. Appear enlarged axillary nodes size 1.2
cm right multiple
 Left breast : skin was not thickened, nipple retracted
invisible, visible lesions hipoechoik,ill defined, irregular
edges in retro areola size 1.0 x 0, 5 cm; appears enlarged
axillary lymph nodes, multiple, biggest size 2.7 x2, 3cm
 Conclusion: Bilateral mammary malignant solid masses,
suggestive of malignant, multiple enlarged lymph nodes
bilateral axillary
Bone scan (2/3/12)

Conclusion :
no bone metastases
 Histopathology (incisional biopsy 20/1/12)

 Ductal carcinoma of the right breast, 2nd grade

Histopathology (incisional biopsy 23/10/12)

 Ductal carcinoma of the left breast, 2nd grade

IHK (7/2/12)

- Estrogen receptor : positif

- Progesterone receptor : positif
- c-erb-B2 : positif
- Ki-67 : positif
- Topo isomerase 2 alfa positif
Diagnosis
 Bilateral ductal carcinoma of the breast
T4bN1M1

Treatment
 Bilateral modified radical mastectomy
Surgery
Histopathology (operatif,20/1/12)

 Bilateral ductal carcinoma of the breast, 2nd

grade 2 (with focal DCIS 5% at right breast)
 the left breast with the nipple Paget's diseases
 Some margin incision contain tumor
 14 limph nodes with 5 positif tumor
THANK YOU