breast surgery - benign and malignant

8/6/2019 Breast Surgery - Benign and Malignant

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Breast Surgery

Tim Davidson

Consultant Surgeon Royal Free Hospital

7 December 2007



cumulative lifetime risk (by age 85)

= 1 in 10 (incidence, not dying)

age 30 10y risk = 1 in 250age 40 10y risk = 1 in 77

age 50 10y risk = 1 in 43

age 60 10y risk = 1 in 38



BC as cause of dying in women



Breast MRI



breast cancer surgery:

to conserve the breast ?

60% 40%

peripheral central

< 4cm > 4cmunifocal multifocal

WLE + axillary MASTECTOMY

staging (BREAST + axillaryCONSERVATION) staging



unifocal cancer



wide local excision



wide local excision + radiotherapy



multifocal cancer



mastectomy



FIGURE 15.2

modified radical mastectomy



Halsted

radical

mastectomy



mastectomy and



risk of local recurrence and

age EORTC trial 10854

Months



Breast cancer surgery:

axillary node staging

peripheral central

<4cm >4cmunifocal multifocal

WLE + axillary MASTECTOMY

staging + axillary

+ post-op RT staging



Back to ContentsBack to Chapter 13 thumbnails

Nottingham Prognostic Index (NPI)



diagnosed age 28

WLE + axillary clearance

completion mastectomychemo x 8 cycles

chest wall / SCF RT

endocrine therapy

goserelin

delayed reconstruction

to come…

nipple reconstruction

symmetrisation?

fertility issues



screening: NHS BSP

invitations between 50 - 70

not symptomatic clinics mammograms only; recall

aim = mortality reduction

possible reduction by 25



screening women aged 50 - 69

breast cancer incidence

2 / 1000 pa = 20 / 1000 per decade

breast cancer mortality

6 / 1000 will die in next decade

screening reduces it to 4 / 1000

i.e. 0.2% absolute benefit



Breast cancer : UK statistics

Incidence

• 1988 25,000

• 2003 40,000

Mortality

• 1988 16,000

• 2003 12,000



RR of breast cancer in later life

menstrual/obstetric history RR • age at menarche <12 1.3

• first child after 35 2.5

• nulliparous 2.5

family history• 2 relatives average age <40 > 4

• 1 relative <50, Ashkenazi ancestry 5

• BRCA 1 or 2 gene mutation 10

precursor lesions• LCIS 7

• DCIS 10



BREAST

CANCER

STANDARD

RISK 97%(RR<2)

MOD RISK

2% (RR 2-3)

HIGH RISK

<1% (RR>3)

RISK GROUPS



Very high risk for breast cancer

BRCA1 gene mutation

• lifetime risk 85% breast cancer

60% ovarian cancer

BRCA2 gene mutation

previous irradiation for Hodgkin’s

• young, bilateral (15% v 3%)



Bilateral mastectomy and latissimus

dorsi flap reconstruction



Breast cancer surgery

Paradox of extent of surgery

advanced disease

invasive early breast cancer

noninvasive disease (DCIS, LCIS)

surgery for risk reduction



anastrazole

(N=3092)

tamoxifen

(N=3094)

P-value

Hot Flushes 35.7 (34.3) 40.9 (39.7) <0.0001

Vaginal bleeding 5.4 (4.5) 10.2 (8.2) <0.0001

Vaginal discharge 3.5 (2.8) 13.2 (11.4) <0.0001

Endometrial cancer* 0.2 (0.1) 0.8 (0.5) 0.016

Ischaemic Cerebrovascular Event 2.0 (1.0) 2.8 (2.1) 0.03

Venous Thromboembolic Events 2.8 (2.1) 4.5 (3.5) 0.0004

Deep Venous Thromboembolic

Events

1.6 (1.0) 2.4 (1.7) 0.019

Adverse events in favour of AIs

R d i i l l



Reduction in contralateral cancers

with tamoxifen v AIs



Adverse events in favour of tamoxifen

anastrazole(N=3092)

tamoxifen(N=3094)

P-value

Arthralgia 35.6 (27.8) 29.4 (21.3) <0.0001

Fractures 11.0 (5.9) 7.7 (3.7) <0.0001Fractures of Spine Hip Wrist

- spine

- hip

- wrist

(Bisphosphonate usage)

5.0 (2.3)

1.5

1.2

2.3

9.6

3.9 (1.5)

0.9

1.0

2.0

6.4

0.004



use of AIs in early breast cancer

adjuvant AI instead of tamoxifen (5 y)adjuvant AI instead of tamoxifen (5 y)

adjuvant “switch” policy after 2 – 2.5 yadjuvant “switch” policy after 2 – 2.5 y

- anastrazole or exemestane- anastrazole or exemestane

extended adjuvant (after 5y) for further 3 yextended adjuvant (after 5y) for further 3 y

neo-adjuvant AI therapy -neo-adjuvant AI therapy - letrozoleletrozole



HRT and breast cancerMillion Women Study (Lancet 2003)

Increase in risk of breast cancer

• RR = 2.0 with combined HRT

• RR = 1.3 with oestrogen-only HRT

• RR = 1.45 with tibolone

no difference with route of administration

risk declines after stopping HRT and by 5y

reaches same level as for never taken



PREGNANCY AND BREAST CANCER

breast cancer diagnosed during pregnancy

- more advanced stage

- poorer prognosis

- delay in diagnosis / starting treatment

- chemotherapy possible after first trimester

pregnancy following breast cancer

- no worsening of outlook

- advise 2-year wait



Breast cancer : UK statistics

Incidence

• 1988 25,000

• 2003 40,000

Mortality

• 1988 16,000

• 2003 12,000



benign breast

problems surgery less often required

day case procedures

benign : malignant = 20:1

worried well



cyst aspiration



b i l



benign lump

l t



lumpectomy



Peri-ductal

mastitis



invertednipple



accessory

nipple

breast surgery - benign and malignant

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