1. BREAST CANCER
Breast cancer is a malignant tumor. Appears in the cells of the mammary gland. Breast cancer presents itself, often as a hard mass (breast nodule) and irregular. That’s why it’s so important to palpation of the breast every month. Is much more frequent in women and with higher incidence after menopause.
The early diagnosis of breast cancer is crucial, because it increases the chances of cure. Prevents the cancer from spreading to other parts of the body, favoring the prognosis.
So all women should do a monthly self-examination and visit the Surgeon General once a year.
The woman with breast cancer may have a nodule or a change in breast shape, changes in skin of the breast or nipple discharge. The diagnosis is made through exploitation by doctor, by clinical history, family and for complementary examinations of diagnosis:
1. Mammography: the main breast examination. How is very accurate, allows the doctor to know the approximate size, location and characteristics of a node with only a few millimeters, when still cannot be felt on palpation.
2. Ultrasound: should complement always the mammogram. Reports whether the lump is solid or contains liquid (cyst) and lets you know the exact size of the nodule.
3. Aspiration Cytology: with a thin needle and a syringe, sucks up some amount of liquid or a small portion of the nodule tissue for microscopic examination. This technique explains if a breast lump is cancerous or not. Can be inconclusive in some cases.
4. Biopsy: procedure for collecting a sample of the suspect nodule (or even remove all excisional biopsy the nodule). The removed tissue is examined under a microscope by a pathologist Doctor. This procedure allows you to confirm that we are dealing with a breast cancer. If the biopsy to detect a malignant tumor, other laboratory tests are made in the fabric in order to obtain more data about the characteristics of the tumor.
5. Hormone receptors (estrogen and progesterone): If the biopsy allows the diagnosis of cancer, these lab tests reveal whether hormones can stimulate their growth. With this information, the doctor may decide whether or not it is advisable to include in the therapeutic treatment plan based on antagonists of those hormones, i.e. drugs that counteract its effect. The sample of the tumor tissue is harvested during the biopsy.
6. Should be requested examinations (x-rays, blood tests, ultrasound of the abdomen, bone cintilograma, TAC) to check whether the cancer is present in other organs of the body.
The staging system for breast cancer (TNM) takes into account the size of the tumor, the involvement of lymph nodes near the breast of the Axilla and the presence or absence of distant metastases.
TYPES OF BREAST CANCER:
The treatment and prognosis vary from patient to patient and depending on the type of tumor. Almost all malignant tumors originate in breast ducts or the lobules of the breast, which are glandular tissues. The two most common types are the ductal carcinoma and lobular carcinoma.
• Ductal Carcinoma in situ: is the non-invasive breast tumor more often. Virtually all women with this disease can be cured. Mammography is the best method for diagnosing breast cancer in this early stage.
• Lobular Carcinoma in situ: although not a real cancer, some authors classify it as a non-invasive breast cancer. Many experts think that CLIS are not transformed into an attacker carcinoma, but women with this cancer have a higher risk of developing invasive breast cancer.
• Invasive ductal Carcinoma: this is the most common breast cancer. Originates in the ducts and invade neighboring tissues. At this stage can spread via the lymphatics or blood, affecting other organs. About 80 percent of breast cancers invading (or invasive) ductal carcinomas are.
• Invasive lobular Carcinoma: originates in the milk-producing units, i.e. in the lobes. Similar to the previous one, can spread to other parts of the body. About ten percent of breast cancers are Lobular, carcinomas invaders.
• Inflammatory Carcinoma of the breast: this is an aggressive cancer, but rare.
There are still other types of breast cancer, rarer as the Medullary Carcinoma, Mucinous Carcinoma, Tubular Carcinoma and Malignant phyllodes, among others.
BREAST CANCER TREATMENT:
The choice between the various options of treatment depends on the stage of disease, the type of tumor and the general health of the patient. Depending on the needs of each patient, the clinician may opt for one or the combination of two or more treatments.
• Surgery: is the most common initial treatment and the main local treatment. The breast tumor is removed, as well as one or more lymph nodes in the armpit. These lymph nodes filter lymph that flows from the breast to other parts of the body and it is through them that the cancer can spread. There are several types of surgery for breast cancer, which are indicated according to the evolutionary stage of the tumor, its location or size of the breast.
• Lumpectomy: surgery that removes only the tumor. Then, applies to radiation therapy. Sometimes, the underarm lymph nodes are removed as a preventive measure. Is applied in minimum tumors.
• Quadrantectomy: is surgery to remove the tumor, a part of the normal tissue that surrounds it and the fabric that covers the chest below the tumor. It is therefore a treatment that preserves the breast. Radiation therapy is applied after the surgery.
• Simple or total Mastectomy: surgery that removes only the breast. Sometimes, however, the nearest lymph nodes are also removed. Is applied in cases of diffuse tumor. You can keep the skin of the breast, that will help a lot to plastic reconstruction.
• Modified radical mastectomy: surgery that removes the breast, the underarm lymph nodes and the tissue that covers the chest muscles.
• Radiation: radiation can be external or internal.
• Chemotherapy: is the use of drugs that Act on the destruction of malignant cells.
• Hormone therapy: the treatment can include the use of drugs, which modify the way of acting of hormones. Hormone therapy plays in the cells of the body.
• Rehabilitation: come help the methods of treatment for the patient better quality of life. Is made through the medical services (physiotherapy, psychology, etc.)
BREAST RECONSTRUCTION. IS MADE THROUGH ONCOPLASTIC SURGERY TECHNIQUES:
1. Reconstruction with the flap of rectus abdominis muscle (TRAM),
2. DIEP Flap (Flap free inferior epigastric artery deep penetrating),
3. Flap of latissimus dorsi (GD) and the use of an Expander, which subsequently is replaced by a silicone prosthesis.
4. Is also being widely used the patient’s own fat transplantation in breast reconstruction (Lipofilling) as adjuvant method of previous or even alone, when the patient was not amputated the entire breast (breast-sparing surgery).
We are in favour of immediate breast reconstruction. Several studies seem to demonstrate a better quality of life for patients operated immediately.
5. When the breast is subjected to Conservative Surgery, there are several techniques of oncoplastic surgery to reconstruct the breast:
a. inferior Pedicle: for tumors located in upper quadrants;
b. upper Pedicle: for tumors located in the quadrants below;
c. Periareolar: visa tumors in any quarters that may be addressed by the periareolar incision.
Advantages: it allows for partial immediate breast reconstruction or tardy. Is ideal for patients with big breasts who want breast reduction and feature a relatively small tumor. Is performed similarly to breast reduction aesthetics. Generally, the Symmetrization of the breast are is performed in the same surgery.
In some cases of tumors very close to areola, there is a need to rebuild the complex areólo-reconstruction (CAM). Can be associated with the placement of silicone prosthesis. So the end result is similar to cosmetic surgery (unless CAM or made incisions dry in atypical locations). The whole reconstruction can be done in only one surgical time ranging from 90 to 120 minutes. When it is associated with the Symmetrization of the breast on the other side, the operative time is 180 minutes
2. BREAST LUMPS
The breast lumps can be benign or malignant. The malignancy has already been seen in the previous chapter, the benign diseases are addressed in the following chapter.
The nodules may be tangible or non tangible. Everyone should be studied by imaging (ultrasound, mammography and MRI or nuclear ragnética).
Whenever there is doubt, must be made a puncture aspiration biopsy.
3. BENIGN BREAST DISEASES
Is the most common benign tumor of the breast. Is dependent on the hormonal influence, so you can increase during pregnancy and with contraceptive intake. The most common age to bring up is between 15 and 30 years.
The crisp edges and furniture presents palpation in breast tissue thickness. The usual size varies between 1 and 3 cm. growth is slow. With the onset of menopause, can reduce its size and even disappear. Sometimes, there are multiple fibroadenomas, in one or both breasts (multiple fibroadenoma). Palpation reveals tumor hard mobile contours well delimited.
Ultrasound shows a well-defined nodule without posterior band. It can be used to guide aspiration puncture.
The relationship of fibroadenoma with cancer is minimal. Just have been described the return of 100 cases of malignant degeneration of fibroadenomas in the world. The surgical treatment is the only one valid. The attitude of vigilance through exploration and is also correct ecografía. The surgical excision should be performed with totally aesthetic procedures, not to cause unsightly scars.
In recent appearance, nodules in women of advanced age or with risk factors for breast cancer, a biopsy is needed before surgery.
B. PHYLLODES TUMOR
Called cellular intracanalicular fibroadenoma; is considered a variant of fibroadenoma with clinical features of rapid growth and large size, should be differentiated sarcomas.
Approximately represents 1% of breast tumors. Has two peaks of emergence: before the 25 years and after 40 years.
Appears as a well-defined mass, unilateral, painless, fast-growing mobile and that can affect the skin by compression, acquiring a large size, sometimes more than 10 cm. Histology demonstrates an important growth of the epithelial and stromal tissues.
Apparently, the intralobular stroma and periductal, sensitive to hormone action. Benign character defined by cellular atypia and scant necrosis, with less than 5 mitosis per field of large increase, and the absence of infiltrating character on the periphery. Can the regional ganglion metastasized in case of malignancy. Is benign or malignant, almost never multifocal. According to marginal growth of tumor connective component, mitosis in the area of increased activity of the tumor, stromal cellularity and atypical cells, tumor phyllodes may be classified as benign, borderline and malignant.
The treatment is the Lumpectomy expanded: with resection margin of 1-2 cm to prevent recurrences. Intraoperative histological inspection should be made of surgical edge, since, if you get infected, also be excised.
If the remaining breast tissue is scarce, it may be necessary to conduct a subcutaneous mastectomy with placement of prostheses.
Normally, you don’t need a lymphadenectomy, why the invasion didn’t ganglionic surpasses 2% of cases.
Pure mesenchymal Tumor. Others are the hemangioma, Leiomyoma, miofibroblastoma and granular cell tumor, that appear anywhere in the mammary parenchyma.
It is a well-defined nodule, formed by fat cells and limited by a capsule. The size goes from 2 to 10 cm. Palpation reveals a solitary nodule, well delimited, soft, mobile and non-adherent to any structure. Treatment is excision or surveillance.
D. BREAST HAMARTONA/FIBROADENOLIPOMA
Well-defined nodular lesion and encapsulated that clinically resembles a fibroadenoma. Is infrequent and usually appears in the 4th and 5th decades of life. Palpation demonstrates hard tumor palpation for consistency similar to breast tissue.
Echo identifies a well-defined solid mass, Hypo-ecoica, with echographic shadow later. The puncture biopsy identifies the components of normal breast tissue. Treatment is excision or surveillance.
Is a benign epithelial component pure. In the clinic is similar to fibroadenoma, being a purely pathological criteria (all you can see in the analysis of the piece) and very infrequent. The treatment is surgical.
F. DUCTAL ECTASIA
This dilation produces a considerable disproportion of collecting ducts in relation to its neighbors. The cavity is occupied by lipid material and debris. It’s own adulthood with a peak of appearance between 40-60 years. It can manifest as a spontaneous and intermittent spillage mammillary, usually greenish, flowing through one or more orifices. The woman presents pruritus, tension and finally the retraction of the nipple by fibrosis of the flue.
At the stage of granuloma, fumbles a tumor underneath the areola. There is fibrosis and even distortion of skin next. Can be confused with a carcinoma. The ultrasound may show dilation of ducts. Mammography does not give much information. If the process is lightweight do not need treatment, if it is very symptomatic, the extirpation of galactophores ducts affected.
G. LYMPHOCYTIC MASTITIS
Observed associated with Hashimoto’s Thyroiditis, diabetes mellitus, arthritis, lumbar localization collagen sclerosis, evolucionais changes in the ducts. With outbreaks linfocitários of b cells.
H. SUBAREOLAR ABSCESS
The patient is usually a young woman with recurrent episodes of abscesses in the subareolar region.
The lesion originates in the milk ducts under the nipple or in the ducts of the glands of Montgomery that drain to the areola. The ultrasound can reveal subareolar fluid.
They do not respond to antibiotics and usually requires surgical treatment.
I. TUBERCULOSIS AND FUNGAL MASTITIS
The clinical studies with tumor and swelling. There may be pain. Mammography does not give information for the diagnosis, the ultrasound may show a zone with lower echogenicity. Harvest should be made to culture. In rare cases it can co-exist with cancer.
J. BREAST CYSTS
Are lumps filled with fluid of the breast, whose formation mechanism, natural history and pathogenesis are unknown.
His relationship with cancer is unknown (his Association is probably a coincidence).
Are more frequent in women in pré-perimenopausa (40-50 years), but can occur at any age. It is, however, rare before the age of 20 years and menopause.
Are well-defined and tumors are diagnosed by ultrasound. Your treatment may be done by aspiration or excision (surgery).
• Simple Cyst
The simple cyst is an expansion of secondary and tertiary ducts, occupied by color liquid variable. Whether it’s a simple cyst, the content will be an aseptic fluid; If it’s an abscess, the content will be a purulent liquid and if it is a bruise the content will be blood.
Can be single or multiple and varying sizes. They are characterised by being palpable when are bigger one or more inches and can give some pain, in relation with the ovarian cycle. Usually disappear after puncture-aspiration.
The ultrasound gives us information: the image has an oval or circular contour very well-defined. The image is anecoica (appears as a dark spot on the ultrasound).
The aspiration is required for fluid cytology. Then is inflated air. This allows an immediate or pneumorradiografia before 2-3 weeks, which also serves as a treatment. This cure puncture 70 to 90% of cysts.
The mammogram shows a nodular tumor, well circumscribed, round or oval contour, homogeneous and well defined. May have a radiolucent peripheral halo that covers all or part of the lesion.
A galactocele is a simple cyst containing fluid or thick milk produced by a dilation of a breast milk duct. Prior breastfeeding is associated with this problem and usually develops when this was interrupted abruptly.
It feels like a “chat” floating spherical, non-adherent, circumscribed and variable in which the expression can make milk appear through the nipple.
The mammography image features rounded edges and uniform content dense, very similar to simple cysts, but that never usually exceed 60 mm. The ultrasound image features a nodular and regular margin. The cytology material reveals the existence of milk.
It’s not convenient to operate to prevent the formation of fistulas. The treatment of choice is puncture-aspiration and excision.