Selim Breast Diseases
The presence of many nipple-areola complexes is ca...
Istanbul Breast cancer; It is a type of cancer that develops in the cells of the breast tissue. It occurs in the cells that form the mammary glands or milk ducts, which are usually seen in women. These are tumors that have the potential to grow uncontrollably and spread to other organs. It is the most common type of cancer in women. It is the most common type of cancer that causes death after lung cancer.
Women's manual examination of themselves periodically every month and consulting a doctor when they notice any abnormalities ensures early diagnosis of breast cancer and initiation of treatment. It is recommended that women be examined in the clinic periodically every year, especially after the age of 40. Breast cancer can be diagnosed with mammography screening. Thanks to the development of screening methods and early diagnosis, the treatment process and surgery are provided much more comfortably.
Istanbul Breast cancer is the most common type of cancer in women, accounting for 26% of all cancers, according to 2007 statistics. After lung cancer (26%), breast cancer takes the second place in cancer-related deaths (15%). Although there are many risk factors in breast cancer (Table 1), 70% of women who develop breast cancer have no risk factors.
Istanbul Breast cancer ranks first in terms of frequency and mortality among cancers seen during pregnancy. Its incidence is between 0.2% and 3.8%, and it occurs on average once in every 3000 pregnancies. The average age of occurrence is 32-38 years.
Fine needle aspiration biopsy (iiab) should be performed on clinically suspicious masses. In stages I-II, bone scintigraphy can be postponed until the end of pregnancy.
The preferred method in the surgical treatment of pregnancy-associated breast cancers is modified radical mastectomy. Radiotherapy has harm to the fetus during pregnancy. Breast conserving surgery at the end of the second trimester and beyond; Radiotherapy can be postponed until after birth. Hormone therapy should be delayed until after birth due to the potential adverse effects of tamoxifen and aromatose inhibitors on the fetus.
Male breast cancer accounts for less than 1% of all breast cancers. It is diagnosed 5-8 years later than women. Although it is seen between the ages of 5-93, the average age of occurrence has been determined to be between 60-65 years.
Approximately 40% of breast cancers in men are accompanied by gynecomastia.
The general treatment principles of male breast cancer are the same as in women. The surgery to be performed for disease localized to the breast and axilla is modified radical mastectomy. In metastatic disease, ablative hormonal treatments such as orchiectomy, adrenalectomy and hypophysectomy can be performed.
Prophylactic mastectomy, which can be performed in lobular carcinoma in situ, BRCA 1-2 carriers, and patients with a high risk of developing breast cancer, can reduce the incidence of breast cancer by 85-90%, although it does not completely eliminate the risk of breast cancer. The treatment principles of bilateral breast cancer are the same as those of unilateral breast cancer. Breast-conserving surgery can be performed in suitable patients.
Paget's disease is a breast disease that occurs as a result of intraductal carcinoma developing anywhere in the ductal system of the breast and infiltrating the nipple and areola. The most common age is between 55-60. It is usually unilateral. In Paget's disease, there is often an ulcerated nipple appearance similar to eczema. In a patient with nipple-areola changes, a full-thickness biopsy of the nipple and areola is performed for definitive diagnosis.
Although mastectomy is generally preferred in surgical treatment, breast-conserving surgery can be performed in appropriate cases.
Inflammatory breast carcinoma is a clinical definition in which the breast becomes red, hot, and edematous, mimicking mastitis. It is a locally advanced breast tumor with a three-year prognosis of 30-40%. In staging, inflammatory breast cancer is staged as T4. Neoadjuvant chemotherapy reduces tumor size and reduces the risk of recurrence. Then, modified radical mastectomy is performed in suitable patients. Afterwards, the treatment is completed with adjuvant chemotherapy and radiotherapy.
Istanbul Breast cancer is more common in the postmenopausal period. The frequency of breast cancer doubles every 10 years until menopause. The risk is 6 times higher in women over 65 than in younger women.
BRCA1 and BRCA2, defined as breast and ovarian cancer susceptibility genes, are located on chromosomes 17 and 13. Women with the BRCA1 gene have a 60-85% risk of developing breast cancer and a 10-40% risk of developing ovarian cancer during their lifetime. BRCA2 gene is a gene that plays a role in the emergence and bilateral occurrence of breast cancer in familial cases. The risk of developing breast cancer in those who carry this gene is 87%.
Having a family history of breast cancer is an important risk factor for breast cancer. This risk is higher in first-degree relatives (mother, sister, daughter) with breast cancer. This risk increases as the number of breast cancer patients in the family increases. Mothers of breast cancer patients have 2 times the risk of developing breast cancer, and sisters have 2.5 times the risk of developing breast cancer, compared to the normal population. Having bilateral cancer increases the risk of breast cancer by 5 times. The risk increase in relatives of a patient with premenopausal bilateral cancer is 9 times. A young woman whose mother and sister have breast cancer has a 50% lifetime risk of developing breast cancer.
Early menarche and late menopause are associated with an increased risk of breast cancer because they increase the time women are exposed to hormones. Every year that menarche is delayed reduces the risk of breast cancer by 20%.
The risk of developing breast cancer in women who enter menopause after the age of 55 is twice as high as those who enter menopause after the age of 45.
While nulliparity and having the first birth at a late age increases the risk of breast cancer, a pregnancy ending in early birth reduces the risk of breast cancer by -13. Women who give birth for the first time after the age of 30 have twice the risk of cancer compared to women who give birth before the age of 20. Paradoxically, the risk of pregnancy after age 35 is higher than in nulliparous women. Second birth at an early age provides additional reduction in breast cancer.
Some studies suggest that lactation reduces the risk of breast cancer.
In patients diagnosed with breast cancer, the risk of developing breast cancer on the other side is 0.5-1% per year. This risk varies depending on the age at which breast cancer is diagnosed.
Non-proliferating benign lesions such as simple cyst, fibrosis, simple fibroadenoma, and ductus ectasia do not increase the risk (Table 2). There is a 4.5 times increased risk in women with atypical hyperplasia, and a 9 times increased risk in women with atypical hyperplasia and a history of breast cancer in a first-degree relative.
The relationship between OCS use and breast cancer is controversial.
There is a relationship between long-term use of HRT and an increased risk of breast cancer. The risk increase occurs mostly with combined preparations. Use of estrogen and progesterone combinations for 5 years causes a 26% increase in risk.
Although obesity doubles the risk in postmenopausal women, obesity appears to be protective in premenopausal women.
Studies show that alcohol consumption increases the risk of breast cancer. Consuming 15 grams or more of alcohol per day increases the risk by 50% compared to non-drinkers.
There are opposing views on the increased risk of breast cancer with a fat-rich diet. Intake of vitamins A, C and E may reduce the incidence of premenopausal breast cancer.
Women under the age of 40 who exercise 4 hours or more a week have a 60% reduced risk of breast cancer compared to women who do not exercise at all.
The development of radiation-induced breast cancer is related to the duration of radiation exposure and develops over a long period of time. After age 40, the increased risk of mammography is not significant and screening is associated with a reduction in mortality.
Ductal Carcinoma In Situ (noninvasive, noninfiltrating or intraductal carcinoma) refers to malignant cell proliferation that is limited within the duct system and does not show invasion. It is seen in women around the age of 50. 70% of patients are in the postmenopausal period. Surgical methods used in the treatment of DCIS. It is mastectomy and breast-conserving surgery. Extent of the disease (size), Resection margin (+ or -) and grade of the lesion are prognostic factors affecting local control.
LCIS is almost always found in premenopausal women between the ages of 35 and 55 and in postmenopausal women on hormone replacement therapy. The frequency of invasive cancer development after LCIS varies between 4% and 35%. Although they have been diagnosed with LCIS and know that their disease is a risk factor rather than cancer, for some women, living under the threat of cancer and knowing the fact that they may get cancer later is an unbearable situation, causing them to choose mastectomy with or without reconstruction. However, mastectomy is a prophylactic procedure, not a curative one. If chosen, it should be done bilaterally as both breasts are at equal risk.
Early Stage Breast Cancer According to the TNM classification, the early stages of invasive breast cancers are stages I and II. With appropriate treatment, 5-year survival rates are over 75%.
Stage I T1 N0 M0
Stage IIA T0 N1 M0
T1 N1 M0
T2 N0 M0
StageIIB T2 N1 M0
T3 N0 M0
Tumor :
T1 Tumor: 2cm or smaller in diameter
T1a Tumor diameter greater than 0.1cm, 0.5cm or less
T1b Tumor diameter greater than 0.5cm, 1cm or less
T1c Tumor diameter greater than 1cm, 2cm or less
T2 Tumor: Greater than 2cm in diameter but 5cm or smaller
Nodules:
N0: No regional lymph node metastasis
N1: Ipsilateral mobile lymph node metastasis
Metastases:
M0: No metastasis
The main symptom in the majority of women is a lump in the breast. Other symptoms are nipple discharge, nipple erosion, retraction, itching. Rarely, women may complain of swelling in the armpit.
Breast cancers are most commonly localized in the upper outer quadrant (45%). The frequency of occurrence in other quadrants is central (25%), upper inner (8), lower outer (8%) and lower inner (5%), respectively.
During clinical examination, a hard, irregularly bordered, painless, non-mobile (but can be moved with the breast tissue) mass is palpated. In early stage breast cancer, mobile, non-adherent lymph nodes can be palpated in the axilla.
Clinical Findings:
Mammography: Generally not very helpful in diagnosis in women under 35 years of age. Because during this period, the breast parenchyma is dense.
Ultrasonography: Provides more information than mammography in young women. In malignant tumors, blood flow is increased and the shape of blood vessels is radial.
MRI: Provides important information in the detailed description of the lesion in the breast.
Cytology: Cytological examination of nipple discharge or cyst fluid may rarely be helpful.
Breast Biopsy:
Fine needle aspiration biopsy: It is performed using a 22 g (gauge) fine needle. It has high sensitivity and specificity in diagnosing malignancy.
Core needle biopsy: It is superior to FNAB as it allows a larger tissue sample to be taken. It also allows advanced pathological tests such as hormone receptor determination.
Incisional biopsy: It is the process of removing a small piece from the mass without surgically removing the entire mass.
Excisional biopsy: It is the process of surgically removing the entire mass.
vacuum biopsy
Today, the primary treatment for early stage breast cancer is surgery. Surgical treatment of breast cancer is performed on the breast and axilla. To remove the tumor in the breast, conservative breast surgery (tumorectomy, wide local excision, lumpectomy, quadrantectomy) or mastectomy (removal of the entire breast gland and pectoral fascia along with the skin) is performed. If axillary curettage is performed along with mastectomy, this procedure is called modified radical mastectomy. Prospective studies have shown that radical surgical resections do not change long-term survival outcomes. For this reason, preventive breast surgery has become more preferred in recent years. Preventive breast surgery is an accepted approach in the following cases:
Monofocal (unifocal) tumors with a diameter of 4cm or less
Breast volume is sufficient to obtain a good cosmetic result
Possibility of large local removal of the tumor
In order to reduce the possibility of local recurrence, the patient must accept radiotherapy or have no obstacle to radiotherapy.
In the pathological examination of the specimen, there should be an intact section at the excision margins that does not contain tumor cells.
The patient prefers preventive breast surgery
Mastectomy is the appropriate surgical approach in the following cases:
Multifocal or multicentric tumors
Centrally located tumors
Small breasts where a good cosmetic result cannot be achieved
Presence of widespread microcalcifications of malignant type around the tumor or alone on mammography
Failure to obtain a tumor-free surgical edge despite repeat excisions
Collagen tissue disease (relative contraindication)
Patient preference
Radiotherapy is applied after preventive breast surgery because it significantly reduces local recurrence rates.
Recent studies have shown that 70-80% of patients with early-stage breast cancer do not have axillary lymph node metastases. Therefore, SLN biopsy is a method that prevents unnecessary ALND. Sentinel lymph nodes are the first nodule or nodules that drain from the breast.
When recurrence is detected in the breast after BCS, mastectomy is the standard treatment.
The most important determinant of prognosis in breast cancer is stage. Tumors without axillary metastasis and localized to the breast have the best prognosis. As the number of lymph nodes involved in the axilla increases, survival decreases. Apart from these, tumor differentiation, hormone receptor status, proliferation rate, degree of aneuploidy, presence of amplified, mutated, activated oncogenes, degree of angiogenesis and presence or absence of lymphovascular invasion affect prognosis. The 5-year survival rate in a patient with a small tumor detected during mammographic examination, positive for hormone receptors, without axillary metastases, is more than 95%. When there is axillary lymph metastasis, 5-year survival rates decrease to 50-70%.
Due to its different prognostic properties, breast cancer; They are divided into three large groups: early, locally advanced and metastatic. Approximately one-third of breast cancer cases occur at a locally advanced stage.
Stage IIIA, which includes N2 tumors other than T3N1M0, which are operable at diagnosis, Stage IIIB, which includes T4 tumors, and Stage IIIC, which includes N3 tumors, are included in this group. Large Stage IIA tumors that receive breast-conserving surgical treatment after neoadjuvant chemotherapy are excluded from this definition.
If the patient meets other breast-conserving treatment criteria other than tumor size, the option of breast-conserving surgical treatment after neoadjuvant treatment in large stage IIA, IIB and T3N1M0 tumors becomes a must.
Locally advanced tumors usually present with signs of infiltration into the skin or chest wall or with fixed lymph nodes in the ipsilateral axilla.
Among locally advanced breast cancers, the tumors with the fastest course and unfavorable prognosis are inflammatory carcinomas.
However, the commonly used sequence is generally a combination of neoadjuvant chemotherapy followed by surgical treatment followed by adjuvant chemotherapy, radiotherapy and endocrine therapy according to receptor status.
Tumor (T)
Tx: Primary tumor cannot be evaluated
To: No primary tumor
Tis: In situ cancer
Tis (DCIS): Ductal carcinoma in situ
Tis (LCIS): Lobular carcinoma in situ
Tis (Paget): Paget's disease without masses
T1: Tumor up to 2.0 cm in largest diameter
T1mic: Microinvasive tumor diameter 0.1 cm or less
T1a: Tumor diameter 0.5 cm or less
T1b: Tumor diameter between 0.5-1.0 cm
T1c: Tumor diameter between 1.0-2.0 cm
T2: The largest diameter of the tumor is between 2.0-5.0 cm
T3: The largest diameter of the tumor is greater than 5.0 cm
T4: Tumor that has spread to the skin or chest wall, regardless of size
T4a: Tumor spread to the chest wall
T4b: Edema, ulcer or satellite skin nodules on the breast skin
T4c: T4a and T4b together
T4d:Inflammatory carcinoma