Breast diseases Csaba Kósa M.D.

Symptoms of benign breast disease Breast pain (mastalgia) Cyclical Primary non-cyclical Musculoskeletal Sclerosing adenosis Postoperative Cervical root pain Breast lumps Fibroadenoma Cyclical nodularity Cysts Galactocele Fat necrosis Lipoma Chronic abscess Normal structures (prominent rib, edge of previous breast biopsy, margin of breast tissue, etc.) Disorders of the nipple and periareolar region Discharge Retraction Sepsis Breast infection Lactational Non-lactational

Causes of palpable breast lumps (female)

Causes of gynecomastia

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) Asymptomatic - symptomatic

Lifetime risk of breast cancer Rate of inherited breast cancer

Main risk factors

Percentage of all deaths in women attributable 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

Mammography

MAMMOGRAPHY

Symptomatic Breast Cancer Most frequent symptoms

Triplet Diagnostic Procedure Physical examination (palpation of breast and axilla) Diagnostic imaging (mammography, ultrasound) Biopsy (FNA and/or core biopsy)

TNM

TNM

TNM Mx – distant metastasis has not been assessed M0 – no distant metastasis M1 – distant metastasis veryfied

Site of metastasis of breast cancer -autopsy material

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)

Radical changes, because Mechanical view replaced by a biological aspect based on the biological behaviour of breast tumours Nationally organized breast cancer screening

Invasive epithelial tumours 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

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

Non-invasive epithelial tumours 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 praecursor. Excision and close observation

Division of breast operations by diagnosis (1991-2002)

Division of breast cancer operations by radicality (1991-2002)

TN division of breast tumours in screened and unscreened patients (2002-2003)

Survival in prospective randomized trials comparing surgery and radiation therapy with mastectomy

Prospective randomized trials comparing surgery with and without radiation therapy

Nodal Status and Survival

Survival of patients with breast cancer

Morbidity of axillary block dissection (ABD)

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, T2 or T3 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 (e.g. poidy, S-phase fraction, abscence of EGFR, HER2-neu oncoprotein

Nottingham prognostic index (NPI) Tumor size (cm) x 0,2 + Node negative: 1 point 1-3 nodes involved: 2 points >4 nodes involved: 3 points grade (grade I – 1 point, grade II – 2 points, grade III – 3 points) Prognostic groups based on NPI value: EPG, excellent prognostic group 2 – 2,4 GPG, good prognostic group 2,41 – 3,4 MPG-I, moderate prognostic group I 3,41 – 4,4 MPG-II, moderate prognostic group II 4,41 – 5,4 PPG, poor prognostic group 5,41 – 6,4 VPPG, very poor prognostic group) >6,41

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

Rare appearances of breast cancer II. 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.

BRCA-1 or BRCA-2 positive cases (inherited breast cancer) The risk of developing breast cancer is more than 90%, therefore family planning should be completed ASAP than bilateral mastectomy is suggested with immediate reconstruction.

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

Breast reconstruction after mastectomy

Breast reconstruction after mastectomy

Breast reconstruction after mastectomy

Giant fibroadenoma

Male breast cancer

Inflammatory breast cancer Before chemotherapy After chemotherapy

Duplex carcinoma

Duplex tumor, mastectomy

Infiltrating ductal carcinoma

T4: Infiltration and retraction of mamilla, orange sign

Paget infiltration of nipple

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