1. Breast diseases
Csaba Kósa M.D.

2. 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

3. Causes of palpable breast lumps (female)

4. Causes of gynecomastia

5. 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

6. Lifetime risk of breast cancer
Rate of inherited breast cancer

7. Main risk factors

8. Percentage of all deaths in women attributable to breast cancer

9. Asymptomatic breast cancer screening
Mammography between age 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

10. Mammography

11. MAMMOGRAPHY

12. Symptomatic Breast Cancer Most frequent symptoms

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

14. TNM

15. TNM

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

17. Site of metastasis of breast cancer
-autopsy material

18. Pathological Classification of Invasive Epithelial Tumours
Invasive ductal carcinoma (70-75%)
Invasive lobular carcinoma (8-10%)
Medullary carcinoma (3-5%)
Mucinous carcinoma (2-3%)

19. 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)

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

21. 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

22. Contraindications for BCT for invasive carcinoma

23. 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

24. 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 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

25. Division of breast operations by diagnosis (1991-2002)

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

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

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

29. Prospective randomized trials comparing surgery with and without radiation therapy

30. Nodal Status and Survival

31. Survival of patients with breast cancer

32. Morbidity of axillary block dissection (ABD)

33. 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 % of cases.

34. 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

42. 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

43. 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

44. 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

45. 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.

46. 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.

47. 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

48. Breast reconstruction after mastectomy

49. Breast reconstruction after mastectomy

50. Breast reconstruction after mastectomy

52. Giant fibroadenoma

53. Male breast cancer

54. Inflammatory breast cancer
Before chemotherapy
After chemotherapy

55. Duplex carcinoma

56. Duplex tumor, mastectomy

57. Infiltrating ductal carcinoma

58. T4: Infiltration and retraction of mamilla, orange sign

62. Paget infiltration of nipple

65. THANK YOU FOR YOUR ATTENTION!