Ch 35 BREAST CANCER 부산백병원 산부인과 R1 서 영 진 R1 서 영 진

1/3 of all cancers in women 1/3 of all cancers in women 2 nd only to lung cancer as the leading cause of 2 nd only to lung cancer as the leading cause of cancer deaths in women cancer deaths in women Incidence: increased significantly Incidence: increased significantly one in every eight women in U.S.A one in every eight women in U.S.A But, mortality rate actually declined But, mortality rate actually declined -increased success in earlier diagnosis & treatment -increased success in earlier diagnosis & treatment

PREDISPOSING FACTOR 25 세 미만 : less than 1% 25 세 미만 : less than 1% 30 세 이후 : a sharp increase 30 세 이후 : a sharp increase 45 세 -50 세 : short plateau 45 세 -50 세 : short plateau 이후 : increases steadily with age 이후 : increases steadily with age

PREDISPOSING FACTOR Family hystory Family hystory -only 20%: family hystory -only 20%: family hystory -mother & sister : breast cancer after menopause -mother & sister : breast cancer after menopause -> risk is not increased -> risk is not increased bilateral premenopausally bilateral premenopausally -> at least 40%~50% -> at least 40%~50% unilateral premenopausally unilateral premenopausally -> 30% -> 30% -inherited oncogenes: BRCA 1 (chromosome 17q 21) -inherited oncogenes: BRCA 1 (chromosome 17q 21) BRCA 2 (chromosome 13q 12-13) BRCA 2 (chromosome 13q 12-13)

PREDISPOSING FACTOR Diet, obesity, and alcohol Diet, obesity, and alcohol - high-fat diet, obesity, alcohol :risk factor - high-fat diet, obesity, alcohol :risk factor - but, not clear - but, not clear

PREDISPOSING FACTOR Reproductive and hormonal factors Reproductive and hormonal factors - the risk of breast ca increases with the length of a - the risk of breast ca increases with the length of a women’s reproductive phase women’s reproductive phase - menarche is lower - menarche is lower early menopause early menopause artificial menopause (oophorectomy) artificial menopause (oophorectomy) -> the risk is decreased -> the risk is decreased -> but, no clear association with irregularity & -> but, no clear association with irregularity & duration of menses duration of menses

-lactation does not affect the breast cancer -lactation does not affect the breast cancer ->but, risk is high : never pregnant > multiparous ->but, risk is high : never pregnant > multiparous -primigravida: older > younger (high incidence) -primigravida: older > younger (high incidence) -although short-term estrogen treatment for -although short-term estrogen treatment for menopausal symptoms prebably does not increase menopausal symptoms prebably does not increase the risk of breast ca, prolonged use or higher dosages the risk of breast ca, prolonged use or higher dosages of estrogen may increase the risk of estrogen may increase the risk -> low dose or combination with progestin -> low dose or combination with progestin -> but, benbefits in preventing osteoporosis and -> but, benbefits in preventing osteoporosis and heart problem heart problem

HISTORY OF CANCER Endometrial carcinoma, ovarian carcinoma, or colon Endometrial carcinoma, ovarian carcinoma, or colon cancer has also been associated with an increased cancer has also been associated with an increased risk of breast cancer risk of breast cancer

DIAGNOSIS most commonly in the upper outer quadrant most commonly in the upper outer quadrant (there is more beast tissue) (there is more beast tissue) mammography and physical examination, the standard mammography and physical examination, the standard screening modalities, are complementary screening modalities, are complementary -10% to 50 % of cancers detectred mammographically -10% to 50 % of cancers detectred mammographically are not palpable, physocal exam detects 10% to 20% are not palpable, physocal exam detects 10% to 20% of cancers not seen on mammography of cancers not seen on mammography All women unfergo screening mammography starting at All women unfergo screening mammography starting at age 40, along with clinical or self breast examination age 40, along with clinical or self breast examination

DIAGNOSIS USG, MRI, CT, PET, sestamibiscans, serum blood USG, MRI, CT, PET, sestamibiscans, serum blood marker: be used only when indicated marker: be used only when indicated palpation: easy- older, more fatty palpation: easy- older, more fatty Malignancy: thickening area amid normal nodulaity Malignancy: thickening area amid normal nodulaity skin dimpling skin dimpling nipple retraction nipple retraction skin erosion skin erosion clinically malignancy: 30~40% benign on histology clinically malignancy: 30~40% benign on histology clinically benign: 20~25% malignant by biopsy clinically benign: 20~25% malignant by biopsy

Biopsy techniques Fine-needle aspiration cytology (FNA) Fine-needle aspiration cytology (FNA) or 22- gauge needle or 22- gauge needle - a high level of diagnostic accuracy - a high level of diagnostic accuracy :10-15% false negative :10-15% false negative rare false positive rare false positive -negative FNA cytology results do not exclude -negative FNA cytology results do not exclude malignancy and usually are followes by excisional malignancy and usually are followes by excisional biopsy or careful observation biopsy or careful observation

Open biopsy Open biopsy -FNA cytology has not been performed -FNA cytology has not been performed the results are negative or eqivocal the results are negative or eqivocal 1. the location of the mass confirmed 1. the location of the mass confirmed 2. local anesthesia: skin, suncutaneous around mass 2. local anesthesia: skin, suncutaneous around mass 3. incision: directly over the mass (ellise-cosmetically) 3. incision: directly over the mass (ellise-cosmetically) paraareolar(near the nipple-areolar complex) paraareolar(near the nipple-areolar complex) 4. mass: gently grasped with Allis forcep or stay suture 4. mass: gently grasped with Allis forcep or stay suture 5. the mass should be excised completely 5. the mass should be excised completely

6. adequate hemostasis 6. adequate hemostasis breast parenchyma : not reapproximated deeply breast parenchyma : not reapproximated deeply subcutaneous fat: with fine absorbable suture subcutaneous fat: with fine absorbable suture skin: subcuticular suture and adhesive strips skin: subcuticular suture and adhesive strips usually a drain is not necessary usually a drain is not necessary

Mammographic localization biopsy Mammographic localization biopsy - biopsy of nonpalpable lesion - biopsy of nonpalpable lesion - mammographer : localization & a biologic dye - mammographer : localization & a biologic dye surgeon: review & excised surgeon: review & excised Stereotactic core biopsy Stereotactic core biopsy - localize abnormalities and perform needle biopsy - localize abnormalities and perform needle biopsy without surgery without surgery

PATHOLOGY AND NATURAL HISTORY Breast ca : in the intermediate-sized ducts or terminal Breast ca : in the intermediate-sized ducts or terminal ducts and lobules ducts and lobules -the diagnosis of lobular and intraductal carcinoma is -the diagnosis of lobular and intraductal carcinoma is based on histological appearance than site of origin based on histological appearance than site of origin infiltrating ductal carcinoma: 60-70% infiltrating ductal carcinoma: 60-70% -mammographically, stellate density -mammographically, stellate density -macroscopically, gritty and chalky -macroscopically, gritty and chalky Medullary carcinoma Medullary carcinoma -a dence lymphocytic infiltration -a dence lymphocytic infiltration -sloe growing, less aggressive malignancy -sloe growing, less aggressive malignancy

Mucinous (colloid) carcinoma : 5% of breast ca Mucinous (colloid) carcinoma : 5% of breast ca -glossly, mucinous, gelatinous -glossly, mucinous, gelatinous Papillary carcinoma Papillary carcinoma -noninvasive ductal carcinoma -noninvasive ductal carcinoma Tubualr carcinoma: 1% of breast ca Tubualr carcinoma: 1% of breast ca -better prognosis than infiltrating ductal carcinoma -better prognosis than infiltrating ductal carcinoma rarely metastasize to axillary LN rarely metastasize to axillary LN