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Bardají Bofill Manel

Cirugía General Adultos

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Breast cancer

Mammary Gland Diseases: Carcicoma

Cáncer de mama

Breast carcinoma is the most common cancer in women in the United States, and since 1940 the age-adjusted incidence has increased; It is currently diagnosed in one in nine Americans during their lifetime. The death rate from breast cancer is second only to lung cancer.

Its cause is likely to be multifactorial. Female sex is a predisposing factor, since only one male shows breast carcinoma for every 100 women diagnosed.

The incidence increases with age. It begins after age 20 and reaches a stable level (plateau) around menopause, then increases net after that change. Genetic factors are important in 15% of cases, and are most noticeable in women whose mother had carcinoma in both breasts before menopause. England and Wales have the highest national breast cancer mortality and Japan the lowest.

The highest risk is related to nulliparity and the first pregnancy in the last years of fertility. Estrogens induce breast cancer in mice, but no theory of induction by hormones or birth control pills has been substantiated in humans.

Among the risk factors that have been proposed are obesity, abundant consumption of animal fats and viral factors transmitted by breast milk.

The natural course of the disease has been cited in studies since the end of the last century, at Middlesex Hospital, London, in which the median survival in 250 untreated women was 2.7 years; Survival was calculated based on the description of the onset of the first symptoms.

The five-year survival was 18% and the decennial 3.76%. Necropsies showed that 95% of women died of breast carcinoma and of them 75% had breast ulcers. Biological features of breast cancer: typical scirrhosal adenocarcinoma begins in the superoexternal quadrant (45%) of the left breast (60%) and it takes 30 duplications from the single-cell stage, for a period of five to eight years to reach a palpable size (1 cm in diameter).

Metastases arise when the tumor is 0.5 cm in diameter and the prognosis is adversely influenced by the number of axillary lymph nodes affected. With the aforementioned enlargement fibrosis shortens the Cooper's ligament and there is the characteristic depression or dimpling of the skin.

Systemic spread is most common to lungs (65%), bone (56%), and liver (56%).

The diagnostic investigation should be done in an orderly manner. In any suspicious lesion, aspiration biopsy should be performed and then by partial (incisional) removal, in the direction of the skin folds (periareolar), or as a convenient resource in case of possible segmental resection or subsequent mastectomy. Staging can be done before definitive treatment and includes a chest x-ray and liver function tests. Skeletal x-rays and bone scans are not required when there are no specific symptoms.

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Physical examination
- Lump or nodule.
- Bloody discharge from the nipple.
- Skin depression.
- Asymmetrical contour Nipple inversion.
- Palpable lymph nodes in the armpit or supraclavicular hollow
Clinical data
- Breast pain.
- Presence of a mass.
- Bloody discharge from the nipple.
- Skin depressions.
- Nipple inversion
Mammography
- Microcalcifications.
- Higher density dominant mass.
- Deformation of the breast architecture.
- Mammographic changes in the intervals between one and another studies
Biopsy
- Palpable dough.
- Needle aspiration.
- Open biopsy Total resection.
- Partial (incisional) resection.
- Obtaining samples with tru-cut needle.
- Non-palpable lesion.
- Location by means of needle, with material socket.
Patient follow-up
- Annual surveillance.
- Chest x-ray.
- Liver function tests; If there is an increase in your values, ultrasound or liver scan.
- Bone scan.
- Measurement of estrogen/progesterone receptors definitive treatment: surgical
Stadium standings
For the classification, the TNM system proposed by the American Joint Committee on Cancer is followed.
Classification of mammary carcinoma
- Stage I. Tumor smaller than 2 cm, without lymph node involvement (GL) or distant metastases.
- Stage IIa. Tumor smaller than 5 cm, with no lymph node (GL) involvement or distant spread. Tumor smaller than 2 cm with invasion of GL.
- Stage IIb. Tumor smaller than 5 cm with GL invasion. Tumor larger than 5 cm without GL involvement.
- Stage IIIa. Tumor larger than 5 cm in diameter with or without lymph node involvement, or any tumor with lymph node coalescence, without distant metastasis.
- Stage IIIb. Any tumor with direct extension to the chest wall or skin or any neoplasm resulting in arm edema or supraclavicular node involvement.
- Stage IV. Any tumor with distant metastasis.
Histological features
Canalicular carcinomas comprise 80% of malignancies of the breast.

Noninfiltrating carcinomas are also called carcinomas in situ (CIS), and can be ductal (CISD) or lobular carcinomas (CISL). These tumors constitute 1% of carcinomas, although they are increasingly detected by screening mammography. Often, these lesions are multicentric and are accompanied by ductal carcinoma. Nearly 10 to 30% of patients with CISL will develop invasive carcinoma 15 to 20 years later. It is not possible to predict the site or histology of recurrence. 20 to 30% of patients with CISD will also have recurrences. The latter tend to occur in the same quadrant as the initial injury.

Infiltrating canalicular carcinoma is the most common form of breast cancer. In typical form the lesion is hard scirrous, with infiltrating tentacles and with "clayey" consistency in the cross section.

Paget's disease is the manifestation of canalicular carcinoma that invades the nipple, with an exfoliative eczematoid lesion. Large cells with clear cytoplasm are observed on histological study and usually carry a better prognosis than average canalicular carcinoma. Modified radical mastectomy is a recommended treatment.

Papillary carcinoma represents a softer tumor, with greater growth before sending metastases to lymph nodes, and for this reason carries a better prognosis. Medullary carcinomas are large, bulky soft lesions, often with areas of central necrosis and lymphoid infiltration. Metastases arise late. Colloid carcinomas are poorly defined soft lesions in large mucinous "lakes" in the cross-section and with a satisfactory prognosis.

Tubular carcinoma is a differentiated tumor that carries a good prognosis.

Inflammatory carcinoma is usually canalicular carcinoma that affects the dermal lymphatics, which indicates an advanced stage of the disease whose clinical picture is that of "orange peel" (stage IIIb). The skin is indurated and erythematous. The prognosis is very poor, with a survival rate that is usually less than 20 percent.

Lobular carcinomas arise in the epithelium of the terminal duct and spread as an invasive layer. They are often multicentric in the same breast and in 30% of cases the lesions invade both breasts. Typical histologic features include the spread of tumor cells through the mammary stroma.

Breast sarcomas are rare, but the most common is a giant benign variant of fibroadenoma, called cystosarcoma phyllodes. Only one in 10 tumors is malignant.

They appear in older women who have fibrodenoma (between 40 to 49 years) and are more cellular. Total mastectomy is recommended in the benign and malignant varieties because metastases to axillary nodes are rare (they are more common to lungs and bone).
Treatment
Halsted began the modern era of breast surgery in 1882, with his first radical mastectomy. Removal of breast tissue, axillary nodes and both pectorals (major and minor) defined reliable local-regional control in advanced breast carcinoma. Their inoperability criteria excluded patients (25%) who were likely to present distant metastases: fixation of auxiliary nodes, or presence of supraclavicular nodes, and inflammatory mammary carcinoma. By the 1960s, Halsted's radical mastectomy became the only acceptable treatment for operable mammary carcinoma.

Modifications to Halsted's radical mastectomy include the following operative options: pectoralis major (Patey) preservation; preservation of both pectorals (Madden), and extension of radical mastectomy (Urban removed the internal mammary nodes and the neighboring chest wall, in addition to the tissues removed in radical matectomy).

In the last 10 years, limited ablations were found with good results. In 1980 Veronesi reported the same local survival and recurrence rates in patients who had had tumors 2 cm or smaller with palpable axillary nodes and who had undergone radical mastectomy, compared with quadrantectomy, axillary dissection, and whole-breast radiation therapy. In 1985 Fisher published the results of the National Surgical Adjuvant Breast Project (NSABP), which compared the results of modified radical mastectomy with segmental ablation/axillary dissection/radiation therapy in women with tumors 4 cm or smaller, with palpable or nonpalpable axillary nodes. Local recurrence and survival figures remained the same. In a third "phase" of NSABP, segmental resection/axillary dissection without radiation therapy was performed and a high rate of recurrence was observed (24% in women without lymph node involvement and 36% in those with lymph node involvement). This was the justification for local treatment of the whole breast (with ablation or radiotherapy) because of the multicentric nature of the breast cancer that caused local recurrence.

For stage I and II cancers, the acceptable surgical treatment is modified radical mastectomy or segmental resection/axillary dissection/radiation therapy. Axillary dissection (not sample collection) is required to know exactly what stage the disease is at and to prevent local axillary recurrence (and also to avoid armpit radiation with possible complications, such as brachial plexopathy and intensification of lymphedema). The technique can be modified according to the patient's preference and, even then, does not alter local-regional control. In case of extensive multicentric disease, subareolar lesions, large lesions or in the inner quadrant that would produce a great deformity after segmental resection, modified radical mastectomy is recommended and also in women whose general condition would deteriorate with radiotherapy. Extensive intracanicular carcinoma with invasion led to a 10% higher rate of local recurrence when treated with local ablation and radiotherapy and for this reason mastectomy is preferable. Operative mortality in both therapeutic modalities is less than 1%. Complications include infarction, skin necrosis, serum accumulation and lymphedema.

Surgery for stage III or IV breast cancer may be indicated for large or deep tumors to prevent uncontrollable and recurrent local disease, although the culmination may be death from distant metastasis.
Lymphatic glands adjacent to the mammary area
- A pectoralis muscle Major.
- B axillary lymph nodes: Level I.
- C axillary lymph nodes: Level II.
- D axillary lymph nodes: Level III.
- E supraclavicular lymph nodes
- Lymph nodes of the internal mammary chain.
Subcutaneous mastectomy is not usually indicated in any cancerous lesion because the recurrence rate is greater than the proportion of breast tissue left under the areola. Total mastectomy (removal of the nipple-areola complex along with all breast tissue) may be indicated in case of canalicular or lobular carcinoma in situ or in women with large risk factors for carcinoma. In this group of patients, controversy persists as to whether surgery is better than careful surveillance.

On average, 30% of women with in situ lesions end up presenting invasive carcinoma, although not necessarily in the same quadrant (in the case of lobular CIS, there is an equal probability that an invasive lesion will arise in the opposite breast and therefore biopsy is recommended in that breast). In women who have had breast carcinoma, the risk of the neoplasm arising in the opposite breast is 1% per year.

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Centro Médico Teknon

Bardají Bofill Manel

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