Breast diseasesBreast diseases

Csaba KósaCsaba Kósa M.D. M.D.

Symptoms of benign breast Symptoms of benign breast diseasedisease

• Breast pain (mastalgia)Breast pain (mastalgia) – CyclicalCyclical– Primary non-cyclical Primary non-cyclical

• Musculoskeletal Musculoskeletal • Sclerosing adenosis Sclerosing adenosis • PostoperativePostoperative• Cervical root painCervical root pain

• Breast lumps Breast lumps – Fibroadenoma Fibroadenoma – Cyclical nodularity Cyclical nodularity – CystsCysts– Galactocele Galactocele – Sclerosing adenosis Sclerosing adenosis – Fat necrosis Fat necrosis – LipomaLipoma– Chronic abscessChronic abscess– Normal structures (Normal structures (prominent rib, edge of previous breast biopsy, margin of breast prominent rib, edge of previous breast biopsy, margin of breast

tissue, etc.)tissue, etc.)

• Disorders of the nipple and periareolar regionDisorders of the nipple and periareolar region– Discharge Discharge – Retraction Retraction – SepsisSepsis

• Breast infectionBreast infection – Lactational Lactational – Non-lactationalNon-lactational

Causes of palpable breast Causes of palpable breast lumps (female)lumps (female)

Causes of gynecomastiaCauses of gynecomastia

Breast cancerBreast cancer

• Lifetime risk: 10-12% (1 in 8-10 Lifetime risk: 10-12% (1 in 8-10 women)women)

• Incidence: 1. (6500 per year in Incidence: 1. (6500 per year in Hungary)Hungary)

• Mortality: 2. (2200 per year in Mortality: 2. (2200 per year in Hungary)Hungary)

• Asymptomatic - symptomaticAsymptomatic - symptomatic

Lifetime risk of breast cancer

Rate of inherited breast cancer

Main risk factorsMain risk factors

Percentage of all deaths in Percentage of all deaths in women attributable to breast women attributable to breast

cancercancer

Asymptomatic breast cancerAsymptomatic breast cancerscreeningscreening

- Mammography between age 45-65 Mammography between age 45-65 every 2 yearsevery 2 years

- Sensitivity 91-97% (false negative)Sensitivity 91-97% (false negative)

- Specificity 87-97% (false positive)Specificity 87-97% (false positive)

- 100 in 1000 screening are „not 100 in 1000 screening are „not negative”negative”

- 3-4 in this 100 prooves to be cancer3-4 in this 100 prooves to be cancer

• MammographyMammography

MAMMOGRAPHYMAMMOGRAPHY

Symptomatic Breast CancerSymptomatic Breast CancerMost frequent symptomsMost frequent symptoms

Triplet Diagnostic ProcedureTriplet Diagnostic Procedure

• Physical examination (palpation of Physical examination (palpation of breast and axilla)breast and axilla)

• Diagnostic imaging (mammography, Diagnostic imaging (mammography, ultrasound)ultrasound)

• Biopsy (FNA and/or core biopsy)Biopsy (FNA and/or core biopsy)

TTNMNM

TTNNMM

TNTNMM

• Mx – distant metastasis has not been Mx – distant metastasis has not been assessedassessed

• M0 – no distant metastasisM0 – no distant metastasis

• M1 – distant metastasis veryfiedM1 – distant metastasis veryfied

•Site of Site of metastasis of metastasis of breast cancerbreast cancer

-autopsy -autopsy materialmaterial

Pathological Classification of Pathological Classification of Invasive Epithelial TumoursInvasive Epithelial Tumours

• Invasive ductal carcinoma (70-75%)Invasive ductal carcinoma (70-75%)

• Invasive lobular carcinoma (8-10%)Invasive lobular carcinoma (8-10%)

• Medullary carcinoma (3-5%)Medullary carcinoma (3-5%)

• Mucinous carcinoma (2-3%)Mucinous carcinoma (2-3%)

Surgical treatment of early Surgical treatment of early breast cancerbreast cancer

Past and Past and PPresentresent

• Anatomically determined mechanical Anatomically determined mechanical view –sometimes ended in ultraradical view –sometimes ended in ultraradical surgerysurgery

• Biological view - reduced radical surgery Biological view - reduced radical surgery (ablation + axillay block dissection)(ablation + axillay block dissection)

• Breast preserving surgery (wide tumour Breast preserving surgery (wide tumour excision + sentinel node biopsy/axillary excision + sentinel node biopsy/axillary block dissection)block dissection)

Radical changes, becauseRadical changes, because

• Mechanical view replaced by a Mechanical view replaced by a biological aspect based on the biological aspect based on the biological behaviour of breast biological behaviour of breast tumourstumours

• Nationally organized breast cancer Nationally organized breast cancer screeningscreening

Invasive epithelial tumoursInvasive epithelial tumours

• Breast Conserving Surgery + Breast Conserving Surgery + SNB/ABD:SNB/ABD:– Tumour size is less than 40 mmTumour size is less than 40 mm– Excision with satisfactory safety zoneExcision with satisfactory safety zone– Rest mammal tissue is esthetically Rest mammal tissue is esthetically

acceptable acceptable – tumour is not centrally locatedtumour is not centrally located– Multicentrical, but in the same quadrant Multicentrical, but in the same quadrant

and radiotherapy accessibleand radiotherapy accessible– In case of lobular hystology In case of lobular hystology

mammography excluded multicentricitymammography excluded multicentricity– Radiotherapy is availableRadiotherapy is available

Contraindications for BCT Contraindications for BCT for invasive carcinomafor invasive carcinoma

Advanced Breast CancerAdvanced Breast Cancer

• In case of advanced breast cancer – In case of advanced breast cancer – without distant metastasis – better to without distant metastasis – better to start with chemo-radio-hormontherapy start with chemo-radio-hormontherapy and operate after required regressionand operate after required regression

• Advanced breast cancer – with distant Advanced breast cancer – with distant metastasis and/or exulceration – can metastasis and/or exulceration – can not be treated curatively but ablation is not be treated curatively but ablation is considerable for hygienic reasonsconsiderable for hygienic reasons

Non-invasive epithelial tumoursNon-invasive epithelial tumours

• DCIS: ABD is not neccessary because the DCIS: ABD is not neccessary because the probability of occult metastasis is 1-2 %probability of occult metastasis is 1-2 %– stereotaxical biopsy in case of unpalpabilitystereotaxical biopsy in case of unpalpability– Size is more than 4 cm or multicentrical: Size is more than 4 cm or multicentrical:

ablationablation– Size between 2.5-4 cm: wide excision or Size between 2.5-4 cm: wide excision or

ablationablation– Size less than 2.5 cm: wide excisionSize less than 2.5 cm: wide excision

• LCIS: increased risk of invasive tumour(6-LCIS: increased risk of invasive tumour(6-18x) but not obligate praecursor. Excision 18x) but not obligate praecursor. Excision and close observationand close observation

Division of breast Division of breast operations by diagnosis operations by diagnosis

(1991-2002)(1991-2002)

0

10

20

30

40

50

60

70

%

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

benignmalignant

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

2002)2002)

0102030405060708090

%

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

breast conserving

mastectomy

TN division of breast tumours TN division of breast tumours in screened and unscreened in screened and unscreened

patients (2002-2003)patients (2002-2003)

0

5

10

15

20

25

30

35

40

45

T1aN0 T1bN0 T1cN0 T1aN1 T1bN1 T1cN1 T2N0 T2N1 T3N0 T1N2 T2N2 T3N1 T4N1 T4N2

unscreened 188 ptsscreened 114 pts

Survival in prospective Survival in prospective randomized trials comparing randomized trials comparing

surgery and radiation therapy with surgery and radiation therapy with mastectomymastectomy

Prospective randomized trials Prospective randomized trials comparing surgery with and comparing surgery with and

without radiation therapywithout radiation therapy

Nodal Status and SurvivalNodal Status and Survival

Survival of patients withSurvival of patients with breast cancer breast cancer

Morbidity of axillary block Morbidity of axillary block dissection (ABD)dissection (ABD)

Sentinel Lymph Node BiopsySentinel Lymph Node Biopsy

• Peritumoural injection of Technecium Peritumoural injection of Technecium isotope isotope

• Subareolar injection of Patent blue solution Subareolar injection of Patent blue solution to visualize lymph nodes and vesselsto visualize lymph nodes and vessels

• Localisation of first (sentinel) lymph node Localisation of first (sentinel) lymph node with gamma camera (GPS locator) and with gamma camera (GPS locator) and excisionexcision

• With this double marking technique the With this double marking technique the sentinel lymph node detection is successful sentinel lymph node detection is successful in 96-98 % of cases.in 96-98 % of cases.

• Axillary block dissection should only Axillary block dissection should only be performed if intraoperative be performed if intraoperative histology confirmes metastatic lymph histology confirmes metastatic lymph nodesnodes

• Applicable if T1, T2 or T3 and Applicable if T1, T2 or T3 and preoperative nodal status is negativepreoperative nodal status is negative

• If performed correctly and routinely If performed correctly and routinely clinical value is equal to ABDclinical value is equal to ABD

Risk factors other than nodal Risk factors other than nodal status for survivalstatus 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 Rare appearances of breast cancer I.I.

• Inflammatory BC:Inflammatory BC: first treatment is non- first treatment is non-surgical, after neoadjuvant therapy and surgical, after neoadjuvant therapy and regression palliative ablatio+ABD possibleregression palliative ablatio+ABD possible

• Pregnancy and BC:Pregnancy and BC: poor prognosis. In st. I-II. poor prognosis. In st. I-II. surgery then postop. therapy considering surgery then postop. therapy considering foetus. Advanced BC - chemo-radiotherapy. foetus. Advanced BC - chemo-radiotherapy.

• Male BC:Male BC: mastectomy and ABD mastectomy and ABD

Rare appearances of breast cancer Rare appearances of breast cancer II.II.

• Occult cancer with axillary metastasis: Occult cancer with axillary metastasis: ABD and chemo-radio-hormone therapy ABD and chemo-radio-hormone therapy and observation.and observation.

• Paget carcinoma: if only mamilla is Paget carcinoma: if only mamilla is involved - mamillectomy and central involved - mamillectomy and central excision of ducts (cone excision). If excision of ducts (cone excision). If invasive component is also present – invasive component is also present – mastectomy and SNB/ABD.mastectomy and SNB/ABD.

BRCA-1 or BRCA-2 positive cases BRCA-1 or BRCA-2 positive cases (inherited breast cancer)(inherited breast cancer)

The risk of developing breast cancer is The risk of developing breast cancer is more than 90%, therefore family more than 90%, therefore family planning should be completed ASAP planning should be completed ASAP than bilateral mastectomy is than bilateral mastectomy is suggested with immediate suggested with immediate reconstruction.reconstruction.

Reconstruction after Breast Reconstruction after Breast Cancer SurgeryCancer Surgery

• Primary reconstruction:Primary reconstruction: at the time of at the time of tumour removaltumour removal

• Delayed primary reconstruction: Delayed primary reconstruction: after after tumour removal and histological results tumour removal and histological results together with definitive surgerytogether with definitive surgery

• Secondary reconstruction:Secondary reconstruction: 1-2 years after 1-2 years after definitive surgery and adjuvant therapy if definitive surgery and adjuvant therapy if no recurrence is detectable.no recurrence is detectable.

• Methods:Methods: prostesis, TRAM-, LD-flap, free prostesis, TRAM-, LD-flap, free fasciocutan flapfasciocutan flap

Breast reconstruction after

mastectomy

Breast reconstruction after

mastectomy

Breast reconstruction

after mastectomy

Giant fibroadenomaGiant fibroadenoma

Male breast cancerMale breast cancer

Inflammatory breast cancerInflammatory breast cancer

Before chemotherapy After chemotherapy

Duplex carcinomaDuplex carcinoma

Duplex tumor, mastectomyDuplex tumor, mastectomy

Infiltrating ductal carcinomaInfiltrating ductal carcinoma

T4: Infiltration and T4: Infiltration and retraction of mamilla, retraction of mamilla,

orange signorange sign

Paget infiltration of nipplePaget infiltration of nipple

THANK YOU FOR YOUR THANK YOU FOR YOUR ATTENTION!ATTENTION!