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Breast Diseases And Breast Cancer

Fibrocystic disease is a meaningless word that has been used for many years by doctors and patients when mentioning about non-cancerous breast problems. The person who uses this word is likely to mean edema, pain, swelling, tenderness or polycystic breast. Such term does not refer to a disease in the breast. Some people use the term 'fibrocystic changes', instead uses this definition. Some physicians recommend their patients to quit consuming caffeinated drinks etc., for complaints about the breasts that they define with this term. Its usefulness is not certain but quitting caffeine does not harm the patient. Breasts defined as fibrocystic or polycystic are normal. The abnormal ones are breasts with diseases and apparent masses. Masses in the breast are under four main headings: Cyst, fibroadenoma, false masses, and cancer.

Only 12% of the masses in pre-menopausal women are cancerous, where this ratio rises up to 50% after menopause. False masses may develop at all ages, whereas cysts and fibroadenomas develop in pre-menopausal periods, when women menstruate, and sometimes they are noticed after years. Fibroadenoma is common in early menstrual periods of women, whereas cysts are more common in periods close to the menopause. Cysts: Cysts are fluid-filled sacs. The presence of a cyst in the breast of a woman does not mean that she has a cancer-prone personality; and only 1% of cysts are malignant. Superficial cysts can easily be felt, while deep-seated ones can usually be detected during ultrasonic screening examinations. Cysts can be distinguished from other masses though these examinations the best. The best way in the diagnosis and treatment of a cystic mass is needle aspiration, and cytological analysis of its fluid content. Surgical excision is not required for a mass diagnosed to be a cyst. Fibroadenomas have a hard and flat surface, and are mobile masses.

If fluid is not obtained during a fine needle aspiration, it is more likely to be a fibroadenoma. In such a case, core biopsy is performed to confirm whether it is a cyst. After the pathological diagnosis of fibroadenoma, the mass does not need to be removed, especially around 20 years of age. In older patients, they can be removed to make sure about the diagnosis. They generally reach a diameter of 2-3 cm within a period up to 12 months, and then they remain in that size. 50%of these have been observed to disappear within 5 years; and all of these have been observed to disappear within 15 years. Fibroadenomas do not turn into cancer. One-third of these are complex, and it has been ascertained that only in this type, patients are at a higher risk of developing breast cancer in the future. 1% of fibroadenomas are cystosarcoma phyllodes, which are malignant. They grow where they are, however, they do not spread to distant areas. False masses: They are non-adenoma, non-cystic, and non-cancerous masses. Fat necroses, and the ones that occur as a result of foreign matter injection are among these. Fat necrosis generally occurs in consequence of a crashing in women with big breasts. It may also develop in transferred tissues. In those who have undergone a breast augmentation surgery through some unscientific means (such as injecting the patient's own fat), calcified masses occur as a result of necrosis of the fat. Since they may be confused with cancer, their performance is extremely inconvenient. Definitive diagnosis of breast cancer can be possible only with biopsy. There are four types of biopsies. The first two are performed with a needle, whereas the other two are open techniques. In fine needle aspiration technique, the liquid content of the mass is taken out if the mess is cystic, and then the free cells in the liquid content are examined. In core biopsy, a thin slice of tissue is taken with a needle that has a large tip. The pathologist can make a diagnosis by looking at that tissue. However, it is not possible define hormone receptors from such a small amount of tissue. Surgically removing a part of the mass by opening the breast tissue is an incisional biopsy; and removing the entire mass is excisional biopsy.

Breast Cancer

In short, cancer is a malignant disease characterized by uncontrolled excessive division of the body's own cells, and their spread to distant organs in its future periods. In this way, they result in death by disrupting other systems in the places, to where they spread. Breast cancer is the most prevalent type of cancer in women. It is the second most common cause of death after lung cancer. One of every 8-9 woman gets breast cancer. 70-80% of the cancers originate from ductal structures, and the rest of them originate from the lobules. Bilateral cancers are often cancers that originate from the lobules. If cancer cells are still in the ductal structures, they are called intraductal carcinoma or carcinoma in situ (DCIS). Approximately 15-20% of the cases diagnosed with breast cancer are in this form. If the cancer cells have exceed the membrane of the duct base, it means that the cancer has developed into an invasive form. There are some people who believe that a period of 1-10 years pass before cancers reach a size that can be felt by hand. A cancer that has reached such a size is likely to have involved distant sites. Therefore, it would be advantageous if they are detected with screening techniques before reaching such a size. There are three major risk factors for a woman, in terms of developing breast cancer: Age, family history and a previous breast cancer. In postmenopausal women, the breast cancer incidence rapidly increases. It is most commonly seen between 50 and 70 years of age. If a woman has a breast cancer history involving her first-degree relatives (mother, sister), it is at a 2-3 times higher risk of getting this disease. Moreover, if the cancer in her relatives has occurred at the both sides, or has developed in the premenopausal period, she is at a 6-fold increased risk; and in such a case, the lifetime risk of getting breast cancer is 50% for her. If a woman has developed breast cancer before the age of 50, the chance of getting cancer for the other is 14%; and if she has developed breast cancer after the age of 50, the chance of getting cancer for the other is 4%. If the cancer is a lobular cancer, the risk is much higher. Recently, BRCA1 and 2 genes have been identified as breast cancer genes. Women who have this gene are at a very high risk of breast cancer. The other factors that lead to a relatively increased risk of breast cancer (even just a bit) are as follows: Breast cancer in other relatives (grandmother, aunt), exposure to radiation, early menstruation, first childbirth after 30 years of age, having no childbirth, late menopause, obesity, history of fibrocystic breast, hormone replacement therapy. Staging is the most important work to do after the diagnosis of breast cancer. Determining the stage of the disease determines both the form of treatment and gives information about the prognosis of the disease. Breast cancer, especially if developed at early stages, is a mostly curable disease. However, prognosis is determined by obtaining a digital number determined based on how many of the patients in a certain group are still living after a certain follow up period; and is expressed as ‘survival percentage’. Staging is made with the evaluation of three main components: the tumor itself, armpits and distant organs. In staging, it is important to know the type and size of the tumor, and whether it has spread to the chest wall and skin (orange peel appearance).

Breast cancer begins to spread through the blood and lymphs after a certain development process. It mainly spread through the lymphs and its main component is the axillary lymph nodes located at the same side. Therefore, when the physician examines the breast, he/she definitely evaluates the armpit, as well. The masses there, which are felt by hand, may have an inflammatory nature; however, if they are fixed and attached to each, especially if they are very big, such a condition suggests the presence of a cancer involvement. The next step of the spread is the distant tissues, and most commonly the lungs and bones. Therefore, chest X-ray, abdominal ultrasound, and whole-body bone scintigraphy should be carried out as the first stage of the evaluation of the distant involvement in such patients. The condition of axillary lymph nodes is the most important parameter for determining the prognosis of the disease. If there is no involvement (Stage I) or 1-3 units of involvement (Stage II), the prognosis is very good. If there is a distant organ metastasis (stage III), the prognosis gets worse. In pathologic representation, invasion of the blood and lymph vessels shows worse prognosis, whereas prognosis is better in tubular and papillary cancers, which are the variants of breast cancer. Positive (ER +) estrogen receptors are a good prognosis, since they indicate both a slow tumor growth and the fact that the tumor responds to the hormonal therapy.

Treatment

The classical treatment of breast cancer is the removal of the tumor together with an adequate amount of healthy tissue around it, cleaning of the axillary lymph nodes, and the addition of radiation therapy, chemotherapy and hormonal therapy, in case of necessity. Mastectomy procedure that is surgical removal of the breast has changed within the scope of its historical development, and has gotten away from radicalism. It has been ascertained that total mastectomy and partial mastectomy (breast-conserving mastectomy) + axillary dissection + radiotherapy provide the same survival percentage in patients, especially those who have small early-stages tumors; and this result was announced by the "National Institutes of Health" in the United States in 1990. Breast-conserving surgery (tumorectomy my lumpectomy, quadrantectomy): Cases in which breast-conserving surgery cannot be done:

  1. Tumor and breast sizes. In a patient with a big tumor and small breasts, there is no point to perform a breast-conserving surgery. Very little breast tissue left after the operation would look very ugly.
  2. Number of tumors in the same breast. If there are more than one and located in different places, a total mastectomy needs to be performed.
  3. Location of the tumor. If the tumor is close to the chest wall, a total mastectomy should be performed.
  4. Type of cancer. If the tumor has an extensive intraductal component, a total mastectomy should be performed.
  5. Diffuse calcification.
  6. Tendencies and fears of the patient. The patient may be undesirous of leaving a breast in its place, which has developed cancer.
  7. Experienced surgeon and radiotherapist.
  8. Pre-radiotherapy.  A second radiation is not administered.
  9. Pregnancy.
  10. Rheumatological diseases.
  11. Inflammatory breast cancer.
  12. radiotherapy center. The patient should go to the radiotherapy center 5 days a week for a period of 5 to 6 weeks. In the presence of all these adverse conditions, total mastectomy is the only option.

Total mastectomies:

  1. Radical mastectomy. In this surgery, the breast, the pectoral muscles under the breast and the axial lymph tissue are totally removed. It was first applied by Halsted in the late 19th century, and has been applied as a standard treatment for 100 years. Today, it is applied in cases where the disease has highly advanced and invaded the muscles.
  2. Modified Radical Mastectomy. Breast as well as axillary lymph nodes are removed. The pectoral muscles are left in their places. Today, it is the most commonly applied form of total mastectomy.
  3. Skin-sparing mastectomy, where the breast skin is spared. This can only be applied to patients, in whom an immediate breast restoration will be performed. The nipple, areola and breast tissue are completely removed but the breast skin is spared; and then the breast is filled with one of the breast reconstruction techniques. Today, it is the most modern form of treatment utilized for breast cancers.

  

Mastectomies

Removal of the axillary lymph nodes (axillary dissection): Recently, this technique has undergone major changes, as well. Modern application is made with vital dyes. During the operation, vital dyes are injected around the tumor, before removal of the breast tissue. After waiting a short time, by making a short incision in the armpit, the first dyed lymph node (sentinel node) is determined, and then it is removed and sent to pathology for "frozen section" examination. Meanwhile a mastectomy is performed. If cancer cells are detected in the lymph node, an axillary dissection is performed. If no cancer cell is detected, no process is performed in the armpit, and it is closed. Any supportive radiotherapy, chemotherapy, or hormonal therapy after the performance of all the surgical procedures depends on the decision of the breast cancer team, who undertook the treatment.