Breast Flashcards
Symptoms of benign breast disease
Breast pain (mastalgia)
Breast lumps
Disorders of the nipple and periareolar region
Breast infection
Causes of palpable breast lumps (female)
- Cancer (older age)
- Benign breast change (middle age)
- Fibroadenoma (young adult)
- Cysts
- Abscess (rare
Causes of gynecomastia
- Puberty
- Idiopathic
- Drugs (cimentidine, digoxin, spironolactone, androgens or antiestrogens)
- Cirrhosis or malnutrition
- Primary hypogonadism
- Testicular tumor
- Secondary hypogonadism
- Hyperthyroidism
- Renal disease
Breast cancer
Lifetime risk: 10-12% (1 in 8-10 women) Incidence: 1. (6500 per year in Hungary) Mortality: 2. (2200 per year in Hungary) Main risks: - Family history (x2-5) - Precocious puberty (x1.7-2) - Late menopause (x1.3-2) - Nuliparty (x1.3-2) Abount 20% of all deaths in women around 45 years of age is due to breast cancer
Asymptomatic breast cancer: screening
- Mammography between age 45-65 every 2 years
- Sensitivity 91-97% (false negative)
- Specificity 87-97% (false positive)
- 100 in 1000 screening are „not negative”
- 3-4 in this 100 prooves to be cancer
Symptomatic Breast Cancer
Most frequent symptoms
- Lumb (76%)
- Swelling (8%)
- Pain
- Paget’s disease
- Nipple retraction and/or discharge
Triplet Diagnostic Procedure
- Physical examination (palpation of breast and axilla)
- Diagnostic imaging (mammography, ultrasound)
- Biopsy (FNA and/or core biopsy)
Pathological Classification of Invasive Epithelial Tumours
- Invasive ductal carcinoma (70-75%)
- Invasive lobular carcinoma (8-10%)
- Medullary carcinoma (3-5%)
- Mucinous carcinoma (2-3%)
Surgical treatment of early breast cancer - Past and Present
Anatomically determined mechanical view –sometimes ended in ultraradical surgery
- Biological view - reduced radical surgery (ablation + axillay block dissection)
- Breast preserving surgery (wide tumour excision + sentinel node biopsy/axillary block dissection)
- Breast Conserving Surgery + SNB/ABD:
Tumour size is less than 40 mm
- Excision with satisfactory safety zone - Rest mammal tissue is esthetically acceptable - tumour is not centrally located - Multicentrical, but in the same quadrant and radiotherapy accessible - In case of lobular hystology mammography excluded multicentricity - Radiotherapy is available
Contraindications for BCT for invasive carcinoma
- two or more primary tumors in separate quadrants of the breast
- Persistent positive margins after surgical attempts
- Pregnancy (except perhaps in 3rd trimester)
- History of previous therapeutic irradiation to the breast
- History of scleroderma or active SLE
Advanced Breast Cancer
- In case of advanced breast cancer – without distant metastasis – better to start with chemo-radio-hormontherapy and operate after required regression
- Advanced breast cancer – with distant metastasis and/or exulceration – can not be treated curatively but ablation is considerable for hygienic reasons
DCIS
ABD is not neccessary because the probability of occult metastasis is 1-2 %
- stereotaxical biopsy in case of unpalpability
- Size is more than 4 cm or multicentrical: ablation
- Size between 2.5-4 cm: wide excision or ablation
- Size less than 2.5 cm: wide excision
LCIS
increased risk of invasive tumour(6-18x) but not obligate precursor. Excision and close observation
Sentinel Lymph Node Biopsy
- Peritumoural injection of Technecium isotope
- Subareolar injection of Patent blue solution to visualize lymph nodes and vessels
- Localisation of first (sentinel) lymph node with gamma camera (GPS locator) and excision
- With this double marking technique the sentinel lymph node detection is successful in 96-98 % of cases.
- Axillary block dissection should only be performed if intraoperative histology confirmes metastatic lymph nodes
- Applicable if T1 or T2 less than 30 mm and preoperative nodal status is negative
- If performed correctly and routinely clinical value is equal to ABD
Risk factors other than nodal status for survival
- tumor size
- tumor grade
- estrogen receptor status
- Presence of lymphatic/vascular invasion
- Biological markers
Rare appearances of breast cancer I
- Inflammatory BC: first treatment is non-surgical, after neoadjuvant therapy and regression palliative ablatio+ABD possible
- Pregnancy and BC: poor prognosis. In st. I-II. surgery then postop. therapy considering foetus. Advanced BC - chemo-radiotherapy.
- Male BC: mastectomy and ABD
- Occult cancer with axillary metastasis: ABD and chemo-radio-hormone therapy and observation.
- Paget carcinoma: if only mamilla is involved - mamillectomy and central excision of ducts (cone excision). If invasive component is also present – mastectomy and SNB/ABD.
Reconstruction after Breast Cancer Surgery
Primary reconstruction: at the time of tumour removal
Delayed primary reconstruction: after tumour removal and histological results together with definitive surgery
Secondary reconstruction: 1-2 years after definitive surgery and adjuvant therapy if no recurrence is detectable.
Methods: prostesis, TRAM-, LD-flap, free fasciocutan flap
