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46 The breast

CHRISTOBEL M. SAUNDERS and MICHAEL BAUM

The Breast

Subjects covered n ths cha!ter nc"ude anato#$% nvest&atons o' the breast% the

n!!"e% ben&n and #a"&nant dsorders o' the breast% breast reconstructon% screenn&

'or breast cancer% breast cancer &enetcs and the #a"e breast.

Co#!aratve and sur&ca" anato#$

The !rotuberant !art o' the hu#an breast s &enera""$ descrbed as over"$n& the (nd

to the )th rbs% and e*tendn& 'ro# the "atera" border o' the sternu# to the anteror

a*""ar$ "ne. Actua""$% a thn "a$er o' #a##ar$ tssue e*tends consderab"$ 'arther

'ro# the c"avc"e above to the +th or ,th rbs be"o-% and 'ro# the #d"ne to the ed&e

o' "atss#us dors !osteror"$. Ths 'act s #!ortant -hen !er'or#n& a #astecto#$%the a# o' -hch s to re#ove the -ho"e breast. The anato#$ o' the breast s

""ustrated n &. /).0

The a*""ar$ ta" o' the breast s o' consderab"e sur&ca" #!ortance. In so#e nor#a"

cases t s !a"!ab"e% and n a 'e- t can be seen !re#enstrua""$ or durn& "actaton. A

-e""1deve"o!ed a*""ar$ ta" s so#et#es #sta2en 'or a #ass o' en"ar&ed "$#!h

nodes or a "!o#a.

The "obu"e s the basc structura" unt o' the #a##ar$ &"and. The nu#ber and s3e o'

the "obu"es var$ enor#ous"$4 the$ are #ost nu#erous n $oun& -o#en. ro# 05 to

over 055 "obu"es e#!t$ va ductu"es nto a "act'erous duct o' -hch there are 'ro# 06

to (5. Each "act'erous duct s "ned b$ a s!ra" arran&e#ent o' contract"e

#$oe!the"a" ce""s and s !rovded -th a ter#na" a#!u""a 7 a reservor 'or #"2 orabnor#a" dschar&es.

The "&a#ents o' Coo!er are ho""o- conca" !rojectons o' 'brous tssue '""ed -th

breast tssue% the a!ces o' the cones ben& attached 'r#"$ to the su!er'ca" 'asca and

thereb$ to the s2n over"$n& the breast. These "&a#ents account 'or the d#!"n& o'

the s2n over"$n& a carcno#a.

The areo"a contans nvo"untar$ #usc"e arran&ed n concentrc rn&s as -e"" as

rada""$ n the subcutaneous tssue. The areo"ar e!the"u# contans nu#erous s-eat

&"ands and sebaceous &"ands% the "atter o' -hch en"ar&e durn& !re&nanc$ and serve

to "ubrcate the n!!"e durn& "actaton 8Mont&o#er$9s tuberc"es:.

The n!!"e s covered b$ thc2 s2n -th corru&atons. Near ts a!e* "e the or'ces o'

the "act'erous ducts. The n!!"e contans s#ooth #usc"e 'bres arran&ed

concentrca""$ and "on&tudna""$; thus s an erect"e structure -hch !onts out-ards.

L$#!hatcs o' the breast dran !redo#nant"$ nto the a*""ar$ and nterna" #a##ar$

"$#!h nodes. The a*""ar$ nodes receve a!!ro*#ate"$ +6 !er cent o' the drana&e

and are arran&ed n the 'o""o-n& &rou!s4

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The a!ca" nodes are a"so n contnut$ -th the su!rac"avcu"ar nodes and dran nto

the subc"avan "$#!h trun2 -hch enters the &reat vens drect"$ or va the thoracc

duct or ju&u"ar trun2. The sentna" node s that "$#!h node des&nated as the 'rst

a*""ar$ node drann& the breast.

The nterna" #a##ar$ nodes are 'e-er n nu#ber and "e a"on& the nterna" #a##ar$

vesse"s dee! to the !"ane o' the costa" cart"a&es.

Invest&aton o' the breast

A"thou&h an accurate hstor$ and c"nca" e*a#naton are st"" the #ost #!ortant

#ethods o' detectn& breast dsease there are a nu#ber o' nvest&atons -hch can

assst n the da&noss as 'o""o-s

Ma##o&ra!h$ 8&. /).(:

So't tssue =1ra$s are ta2en b$ !"acn& the breast n drect contact -th u"trasenstve

'"# and e*!osn& t to "o-1vo"ta&e% h&h1a#!era&e =1ra$s. The dose o' radaton s

a!!ro*#ate"$ 5.0 >$ and there'ore #a##o&ra!h$ s a ver$ sa'e nvest&aton.

U"trasoundU"trasound s !artcu"ar"$ use'u" n $oun& -o#en -th dense breasts n -ho#

#a##o&ra#s are d''cu"t to nter!ret% and n dstn&ushn& c$sts 'ro# so"d "esons

8&s /).? and /)./:. It can a"so be used to "oca"se #!a"!ab"e breast "u#!s.

Ma&netc resonance #a&n&

Ma&netc resonance #a&n& 8MRI: s o' ncreasn& nterest to breast sur&eons n a

nu#ber o' settn&s4 t can be use'u" to dstn&ush scar 'ro# recurrence n -o#en -ho

have had !revous breast conservaton thera!$ 'or cancer 8a"thou&h t s not accurate

-thn @#onths o' radothera!$ because o' abnor#a" enhance#ent:; t s the &o"d

standard 'or #a&n& the breasts o' -o#en -th #!"ants; t #a$ !rove use'u" as a

screenn& too" n h&h1rs2 -o#en; and t s ben& eva"uated n the #ana&e#ent o' the

a*""a n both !r#ar$ breast cancer and recurrent dsease 8&. /).6:.

Need"e bo!s$c$to"o&$

Hsto"o&$ can be obtaned usn& a 'ne need"e such as a Trucut or Corecut bo!s$

devce under "oca" anaesthesa 8&. /).):. C$to"o&$ s obtaned usn& a (0 or (?

>au&e need"e and 051#" s$rn&e -th #u"t!"e !asses throu&hout the "u#! -thout

re"easn& the ne&atve !ressure n the s$rn&e. The as!rate s then s#eared on to a

s"de -hch s ar dred 8&. /).+:. ne need"e as!raton c$to"o&$ 8NAC: s the

"east nvasve technue o' obtann& a ce"" da&noss and s ver$ accurate ' both

o!erator and c$to"o&st are e*!erenced. Ho-ever% 'a"se ne&atves do occur% #an"$

throu&h sa#!"n& error% and nvasve cancer cannot be dstn&ushed 'ro# n stu

dsease.Tr!"e assess#ent

In an$ !atent -ho !resents -th a breast "u#! or other s$#!to#s sus!cous o'

carcno#a% the da&noss shou"d be #ade b$ a co#bnaton o' c"nca" assess#ent%

rado"o&ca" #a&n& and a tssue sa#!"e ta2en 'or ether c$to"o&ca" or hsto"o&ca"

ana"$ss 8&. /).,:4 the so1ca""ed tr!"e assess#ent.

The n!!"e

Absence o' the n!!"e s rare% and usua""$ assocated -th a#a3a 8con&enta" absence

o' the breast:.

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Su!ernu#erar$ n!!"es not unco##on"$ occur a"on& a "ne e*tendn& 'ro# the

anteror 'o"d o' the a*""a to the 'o"d o' the &ron 8&. /).@:. Ths consttutes the #"2

"ne o' "o-er #a##a"s.

N!!"e retracton

Ths #a$ occur at !ubert$ or "ater n "'e. Retracton occurrn& at !ubert$% a"so 2no-n

as s#!"e n!!"e nverson% s o' un2no-n aeto"o&$. In about (6 !er cent o' cases t sb"atera". It #a$ cause !rob"e#s -th breast'eedn& and n'ecton can occur% es!eca""$

durn& "actaton% o-n& to retenton o' secretons.

Treat#ent

Treat#ent s usua""$ unnecessar$% and t #a$ s!ontaneous"$ reso"ve durn& !re&nanc$

or "actaton.S#!"e cos#etc sur&er$ can !roduce an adeuate correcton but has the

dra-bac2 o' dvdn& the ducts. Mechanca" sucton devces have been used to atte#!t

to evert the n!!"e -th so#e e''ect. Recent retracton o' the n!!"e #a$ be o'

consderab"e !atho"o&ca" s&n'cance. A s"t1"2e retracton o' the n!!"e #a$ be due

to duct ectasa and chronc !erducta" #astts 8&. /).05a:% but crcu#'erenta"

retracton% -th or -thout an under"$n& "u#!% #a$ -e"" ndcate an under"$n&

carcno#a 8&. /).05b:.Crac2ed n!!"e

Ths #a$ occur durn& "actaton and be the 'orerunner o' acute n'ectve #astts. I'

the n!!"e beco#es crac2ed durn& "actaton% t shou"d be rested 'or (/7/, hours and

the breast e#!ted -th a breast !u#!. eedn& shou"d be resu#ed as soon as

!ossb"e.

a!""o#a o' the n!!"e

a!""o#a o' the n!!"e has the sa#e 'eatures o' an$ cutaneous !a!""o#a 8&. /).00:

and shou"d be e*csed -th a tn$ dsc o' s2n.

Retenton c$st o' a &"and o' Mont&o#er$

These &"ands% stuated n the areo"a% secrete sebu#% and ' the$ beco#e b"oc2ed a

sebaceous c$st 'or#s.

Chancre o' the n!!"e

Ths ver$ rare condton usua""$ occurs b$ n'ecton 'ro# a s$!h"tc bucca" u"cer n

the #outh o' the !artner% a"thou&h can be seen n the -et1nurse o' a s$!h"tc bab$.

The #other o' such an n'ant s ##une to ren'ecton 'ro# her o-n ch"d.

Ec3e#a

Ec3e#a o' the n!!"es s a rare condton and s b"atera"% and usua""$ assocated -th

ec3e#a e"se-here on the bod$.

a&et9s dsease

a&et9s dsease o' the n!!"e #ust be dstn&ushed 'ro# the ec3e#a.

Abnor#a" dschar&es 'ro# the n!!"eDschar&e can occur 'ro# one or #ore "act'erous ducts. Mana&e#ent de!ends on the

!resence o' a "u#! 8-hch shou"d a"-a$s be &ven !rort$ n da&noss and treat#ent:

and o' the !resence o' b"ood n the dschar&e or dschar&e 'ro# a sn&"e duct.

Ma##o&ra!h$ s rare"$ use'u" e*ce!t to e*c"ude an under"$n& #!a"!ab"e #ass.

C$to"o&$ #a$ revea" #a"&nant ce""s but a ne&atve resu"t does not e*c"ude a

carcno#a.

A c"ear% serous dschar&e #a$ be !h$so"o&ca"9 n a !arous -o#an or #a$ be

assocated -th a duct !a!""o#a or #a##ar$ d$s!"asa.

A b"ood1staned dschar&e #a$ be caused b$ duct ectasa or "ess co##on"$ a duct

!a!""o#a or carcno#a. A duct !a!""o#a s usua""$ sn&"e and stuated n one o' the

"ar&er "act'erous ducts and s so#et#es assocated -th a c$stc s-e""n& beneath theareo"a.

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A b"ac2 or &reen dschar&e s usua""$ due to duct ectasa and ts co#!"catons.

Treat#ent

Treat#ent #ust 'rst"$ be to e*c"ude a carcno#a b$ occu"t b"ood test and c$to"o&$.

S#!"e reassurance #a$ then be su''cent% but ' the dschar&e s !rovn& nto"erab"e

an o!eraton to re#ove the a''ected duct or ducts can be !er'or#ed. &ure /).0(

""ustrates so#e causes o' n!!"e dschar&e. Mcrodochecto#$. It s #!ortant not toe*!ress the b"ood be'ore the o!eraton as t #a$ then be d''cu"t to dent'$ the duct

n theatre. A "acr#a" !robe or "en&th o' st'' n$"on suture s nserted nto the duct

'ro# -hch the dschar&e s e#er&n&. A tenns rauet ncson can be #ade to

enco#!ass the entre duct% or a !erareo"ar ncson used and the n!!"e '"a! dssected

to reach the duct. The duct s then e*csed. A !a!""o#a s near"$ a"-a$s stuated

-thn /76c# o' the n!!"e or'ce.

Cone e*cson o' the #ajor ducts 8a'ter Had'"e"d:. hen the duct o' or&n o' n!!"e

b"eedn& s uncertan or -hen there s b"eedn& or dschar&e 'ro# #u"t!"e ducts% the

entre #ajor duct s$ste# can be e*csed 'or hsto"o&ca" e*a#naton -thout sacr'ce

o' the breast 'or#. A !erareo"ar ncson s #ade and a cone o' tssue s re#oved -th

ts a!e* "ust dee! to the sur'ace o' the n!!"e and ts base on the !ectora" 'asca. Theresu"tn& de'ect s ob"terated b$ a seres o' !urse1strn& sutures. It s #!ortant to

-arn the !atent that she -"" be unab"e to breast 'eed a'ter ths and #a$ "ose n!!"e

sensaton.

Ben&n breast dsease

Ths s the #ost co##on cause o' breast !rob"e#s 7 u! to ?5 !er cent o' -o#en -""

su''er 'ro# a ben&n breast dsorder reurn& treat#ent at so#e t#e n ther "ves.

The #ost co##on s$#!to#s are !an% "u#!ness or a "u#!. The a# o' treat#ent s

to e*c"ude cancer and% once ths has been done% to treat an$ re#ann& s$#!to#s.

Ben&n breast dsorders can be c"ass'ed n the 'o""o-n& -a$4

< ANDI0 8"u#!$ breasts% tenderness or a s#ooth "u#!:4

c$c"ca" nodu"art$ and #asta"&a% c$sts% 'broadeno#a;

< duct ectasa!erducta" #astts;

< !re&nanc$ re"ated4

&a"actocoe"e%

!eur!era" abscess;

< con&enta" dsorders4

nverted n!!"e%

su!ernu#ar$ breastsn!!"es;

< nonbreast dsorders4

Tet3e9s dsease;

sebaceous c$sts and other s2n condtons.

Con&enta" abnor#a"tes

A#a3a

Con&enta" absence o' the breast #a$ occur on one 8&. /).0?: or both sdes. It s

so#et#es assocated -th absence o' the sterna" !orton o' the !ectora"s #ajor

8o"and9s s$ndro#e:. It s #ore co##on n #a"es.

o"$#a3a

Accessor$ breasts 8&. /).0/: have been recorded n the a*""a 8the #ost 'reuent

ste:% &ron% buttoc2 and th&h. The$ have been 2no-n to 'uncton durn& "actaton.

Mastts o' n'ants

Mastts o' n'ants s at "east as co##on n the #a"e as n the 'e#a"e. On the ?rd or/th da$ o' "'e% ' the breast o' an n'ant s !ressed "&ht"$% a dro! o' co"our"ess '"ud

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can be e*!ressed; a 'e- da$s "ater there s o'ten a s"&ht #"2$ secreton% -hch

dsa!!ears durn& the ?rd -ee2. Ths s !o!u"ar"$ 2no-n as -tch9s #"29. It s due to

st#u"aton o' the 'oeta" breast b$ #aterna" !ro"actn% thus s essenta""$ !h$so"o&ca".

D''use h$!ertro!h$

D''use h$!ertro!h$ o' the breasts occurs s!oradca""$ n other-se hea"th$ &r"s at

!ubert$ and% #uch "ess o'ten% durn& the 'rst !re&nanc$.The breasts attan enor#ousd#ensons 8&. /).06: and #a$ reach the 2nees -hen the !atent s sttn&. The

condton s rare"$ un"atera". Ths tre#endous over&ro-th s a!!arent"$ due to an

a"teraton n the nor#a" senstvt$ o' the breast to oestro&enc hor#ones% and so#e

success n treatn& t -th antoestro&ens has been re!orted. Treat#ent s other-se b$

reducton #a##o!"ast$.

Injures o' the breast

Hae#ato#a

Hae#ato#a% !artcu"ar"$ a reso"vn& hae#ato#a% &ves rse to a "u#! -hch% n the

absence o' over"$n& brusn&% s d''cu"t to da&nose correct"$ un"ess t s as!rated or

ncsed.

Trau#atc 'at necrossTrau#atc 'at necross #a$ be acute or chronc% and usua""$ occurs n stout% #dd"e1

a&ed -o#en. o""o-n& a b"o-% oreven ndrect vo"ence 8e.&. contracton o' the

!ectora"s #ajor:% a "u#!% o'ten !an"ess% a!!ears. Ths #a$ ##c a carcno#a% even

ds!"a$n& s2n tethern& and n!!"e retracton% and bo!s$ s reured 'or da&noss. A

hstor$ o' trau#a s not da&nostc as ths #a$ #ere"$ have dra-n the !atent9s

attenton to a !re1e*stn& "u#!.

Acute and subacute n'"a##atons o' the breast

Bactera" #astts

Bactera" #astts s the co##onest varet$ o' #astts and near"$ a"-a$s co##ences

acute"$. A"thou&h assocated -th "actaton n the #ajort$ o' cases% t s not

necessar"$ so. O' 055 consecutve cases o' breast abscess% ?( occurred n -o#en

-ho -ere not "actatn& 8De Fode:. So#e o' these -"" be assocated -th an n'ected

hae#ato#a or -th !erducta" #astts and ths -"" be dscussed "ater.

Aeto"o&$. Lactatona" #astts s seen 'ar "ess 'reuent"$ than n 'or#er $ears. Most

cases are caused b$ Sta!h$"ococcus aureus and% ' hos!ta"1acured% are "2e"$ to be

!enc""n resstant. The nter#edar$ s usua""$ the n'ant; a'ter the second da$ o' "'e

65 !er cent o' n'ants harbour sta!h$"ococc n the naso!har$n*.

C"eansn& the bab$9s #outh9 -th a s-ab s a"so an aeto"o&ca" 'actor. The de"cate

bucca" #ucosa s e*corated b$ the !rocess; t beco#es n'ected% and or&ans#s n the

n'ant9s sa"va are nocu"ated on to the #other9s n!!"e.

h"st ascendn& n'ecton 'ro# a sore and crac2ed n!!"e #a$ ntate the #astts% n#an$ cases the "act'erous ducts -"" 'rst beco#e b"oc2ed b$ e!the"a" debrs "eadn&

to stass 7 ths theor$ s su!!orted b$ the re"atve"$ h&h ncdence o' #astts n

-o#en -th a retracted n!!"e. Once -thn the a#!u""a o' the duct% sta!h$"ococc

cause c"ottn& o' #"2 and -thn ths c"ot or&ans#s #u"t!"$.

C"nca" 'eatures. The a''ected breast% or #ore usua""$ a seent o' t% !resents the

c"assca" s&ns o' acute n'"a##aton. Ear"$ on ths s a &enera"sed ce""u"ts% but "ater

an abscess -"" 'or#.

Treat#ent. Durn& the ce""u"tc sta&e the !atent shou"d be treated -th an a!!ro!rate

antbotc% e.&. '"uc"o*ac""n% and the breast rested% -th 'eedn& on the o!!oste sde

on"$. The n'ected breast shou"d be e#!ted o' #"2 usn& a breast !u#!. Su!!ort o'

the breast% "oca" heat and ana"&esa -"" he"! to re"eve !an.

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I' an antbotc s used n the !resence o' undraned !us% an antbo#a9 #a$ 'or#.

Ths s a "ar&e% ster"e bra-n$ oede#atous s-e""n& -hch ta2es #an$ -ee2s to

reso"ve.

The breast shou"d be ncsed and draned ' the n'ecton does not reso"ve -thn /,

hours% or '% a'ter ben& e#!ted o' #"2% there s an area o' tense nduraton or other

evdence o' an under"$n& abscess.The !resence o' !us can be con'r#ed -th a need"e as!raton% and the !us ana"$sed

'or the n'ecton and 'or c$to"o&$. Ths has the advanta&e o' a""o-n& da&noss on the

s#ear o' a rare n'"a##ator$ carcno#a 8&. /).0):. In contrast to the #ajort$ o'

"oca"sed n'ectons% '"uctuaton s a "ate s&n and ncson #ust not be de"a$ed unt" t

a!!ears. Usua""$ the area o' nduraton s sector1sha!ed% and n ear"$ cases about one1

uarter o' the breast s nvo"ved 8&. /).0+:; n #an$ "ate cases the area s #ore

e*tensve 8&. /).0,:. hen n doubt an u"trasound scan #a$ c"ear"$ de'ne an area

r!e9 'or drana&e.

Drana&e o' an ntra#a##ar$ abscess. The usua" ncson s sted n a rada" drecton

over the a''ected seent% a"thou&h ' a crcu#areo"ar ncson -"" a""o- adeuate

access to the a''ected area ths shou"d be !re'erred because o' a better cos#etc resu"t.The ncson !asses throu&h the s2n and the su!er'ca" 'asca. A "on& hae#ostat s

then nserted nto the abscess cavt$. Ever$ !art o' the abscess s !a"!ated a&anst the

!ont o' the hae#ostat and ts ja-s are o!ened. A"" Iocu" that can be 'e"t are entered.

na""$% the hae#ostat havn& been -thdra-n% a 'n&er s ntroduced and an$

re#ann& se!ta are dsru!ted. The -ound #a$ then be "&ht"$ !ac2ed -th rbbon

&au3e or a dran nserted to a""o- de!endent drana&e.

Mastts 'ro# #"2 en&or&e#ent

Mastts 'ro# #"2 en&or&e#ent s "ab"e to occur around -eann& t#e% and

so#et#es n the ear"$ da$s o' "actaton -hen one o' the "act'erous ducts beco#es

b"oc2ed -th e!the"a" debrs. In the "atter nstance on"$ a sector o' the breast

beco#es ndurated and tender.

Chronc ntra#a##ar$ abscess

Chronc ntra#a##ar$ abscess -hch 'o""o-s nadeuate drana&e or njudcous

antbotc treat#ent s o'ten a ver$ d''cu"t condton to da&nose4 -hen enca!su"ated

-thn a thc2 -a"" o' 'brous tssue% the condton cannot be dstn&ushed 'ro# a

carcno#a -thout the hsto"o&ca" evdence 'ro# a bo!s$.

Tubercu"oss o' the breast

Tubercu"oss o' the breast% -hch s co#!aratve"$ rare% s usua""$ assocated -th

actve !u"#onar$ tubercu"oss or tubercu"ous cervca" adents.

Tubercu"oss o' the breast 8&. /).0@: occurs #ore o'ten n !arous -o#en and

usua""$ !resents -th #u"t!"e chronc abscesses and snuses and a t$!ca" b"ushattenuated a!!earance o' the surroundn& s2n. The da&noss rests on bactero"o&ca"

and hsto"o&ca" e*a#naton. Treat#ent s -th anttubercu"ous che#othera!$.

Hea"n& s usua" a"thou&h o'ten de"a$ed% and #astecto#$ shou"d be restrcted to

!atents -th !ersstent resdua" n'ecton.

Actno#$coss

Actno#$coss o' the breast s rarer st"". The "esons !resent the essenta"

characterstcs o' 'acocervca" actno#$coss.

S$!h"s o' the breast

A !r#ar$ chancre o' the n!!"e has been re'erred to 8above:. Secondar$ "esons o'

s$!h"s nc"ude d''use s$!h"tc #astts.

Mondor9s dsease

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Mondor9s dsease s thro#bo!h"ebts o' the su!er'ca" vens o' the breast and

anteror chest -a"" 8&. /).(5: a"thou&h t has a"so been encountered n the ar#.

In the absence o' njur$ or n'ecton% the cause o' thro#bo!h"ebts 7"2e that o'

s!ontaneous thro#bo!h"ebts n other stes 7 s obscure. The !atho&no#onc 'eature

s a thro#bosed subcutaneous cord% usua""$ attached to s2n. hen the s2n over the

breast s stretched b$ rasn& the ar#% a narro-% sha""o- subcutaneous &roovea"on&sde the cord beco#es a!!arent. The d''erenta" da&noss s "$#!hatc

!er#eaton 'ro# an occu"t carcno#a o' the breast. The on"$ treat#ent reured s

restrcted ar# #ove#ents% and n an$ case the condton subsdes -thn a 'e- #onths

-thout recurrence% co#!"catons or de'or#t$.

Duct ectasa!erducta" #astts

atho"o&$

Ths s a d"ataton o' the breast ducts assocated -th !erducta" n'"a##aton% the

!atho&eness o' -hch s obscure and a"#ost certan"$ not un'or# n a"" cases%

a"thou&h the dsease s #uch #ore co##on n s#o2ers.

The c"assca" descr!ton o' the !atho&eness o' duct ectasa asserts that the 'rst sta&e

n the dsorder s a d"ataton n one or #ore o' the "ar&er "act'erous ducts -hch '""-th a sta&nant bro-n or &reen secreton. Ths #a$ dschar&e. These '"uds then set u!

an rrtant reacton n surroundn& tssue "eadn& to !erducta" #astts or even abscess

and 'stu"a 'or#aton 8&s /).(0 and /).((:. In so#e cases a chronc ndurated #ass

'or#s beneath the areo"a -hch ##cs a carcno#a.

bross eventua""$ deve"o!s -hch #a$ cause s"t1"2e n!!"e retracton.

An a"ternatve theor$ su&&ests that !erducta" n'"a##aton s the !r#ar$ condton

and anaerobc bactera" n'ecton s 'ound n so#e cases.

An assocaton bet-een recurrent !erducta" n'"a##aton and s#o2n& has been

de#onstrated -hch #a$ su&&est that artero!ath$ s a contrbutn& 'actor n ts

aeto"o&$.

C"nca" 'eatures

N!!"e dschar&e 8o' an$ co"our:% a subareo"ar #ass% abscess% #a##ar$ duct 'stu"a

andor n!!"e retracton are the co##onest s$#!to#s 8&. /).(?:.

Treat#ent

In the case o' a #ass or n!!"e retracton% a carcno#a #ust be e*c"uded b$ obtann&

a #a##o&ra# and ne&atve c$to"o&$ or hsto"o&$. I' an$ sus!con re#ans the #ass

shou"d be e*csed.

Antbotc thera!$ #a$ be tred% the #ost a!!ro!rate a&ents ben& '"uc"o*ac""n and

#etronda3o"e.Ho-ever% sur&er$ s o'ten the on"$ o!ton "2e"$ to brn& about cure o'

ths notorous"$ d''cu"t condton% and conssts o' e*cson o' a"" o' the #ajor ducts

8the Had'e"d9s o!eraton:.Aberratons o' nor#a" deve"o!#ent and nvo"uton 8ANDI:

No#enc"ature

The no#enc"ature o' ben&n breast dsease s ver$ con'usn&. Ths s because over the

"ast centur$ a varet$ o' c"ncans and !atho"o&sts has chosen to descrbe a #*ture

o' !h$so"o&ca" chan&es and dsease !rocesses accordn& to a varet$ o' c"nca"%

!atho"o&ca" and aeto"o&ca" ter#no"o&$. As -e"" as "eadn& to con'uson% !atents

-ere o'ten undu"$ a"ar#ed or overtreated b$ ascrbn& a !atho"o&ca" na#e to a

varant o' !h$so"o&ca" deve"o!#ent. To sort out ths con'uson% a ne- s$ste# has

been deve"o!ed and descrbed b$ the Card'' Breast C"nc( 7 ANDI. 8Man$

a"ternatve ter#s have been a!!"ed to ths condton nc"udn& 'broc$stc dsease%

'broadenoss% chronc #astts and #asto!ath$.:A eto"o&$

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The breast s a d$na#c structure -hch under&oes chan&es throu&hout a -o#an9s

re!roductve "'e% and su!er#!osed u!on ths% c$c"ca" chan&es throu&hout the

#enstrua" c$c"e. Ths s ""ustrated n &. /).(/. The !atho&eness o' ANDI nvo"ves

dsturbances n the breast !h$so"o&$ e*tendn& 'ro# an e*tre#e o' nor#a"t$ to -e""1

de'ned dsease !rocesses. There s o'ten "tt"e corre"aton bet-een the hsto"o&ca"

a!!earance o' the breast tssue and the s$#!to#s.Rs2 o' #a"&nanc$ deve"o!n& n assocaton -th ben&n breast !atho"o&$

These re"atve rs2s accordn& to d''erent hsto"o&ca" 'eatures 'ound at bo!s$ are

""ustrated n Tab"e /).0.

atho"o&$

The dsease conssts essenta""$ o' 'our 'eatures -hch #a$ var$ n e*tent and de&ree

n an$ one breast.

0.C$st 'or#aton. C$sts are a"#ost nevtab"e and ver$ varab"e n s3e.

(. bross. at and e"astc tssue dsa!!ears and s re!"aced b$ dense -hte 'brous

trabecu"ae. The nterstta" tssue s n'"trated -th chronc n'"a##ator$ ce""s.

?. H$!er!"asa o' e!the"u# n the "nn& o' the ducts and acn #a$ occur -th or

-thout at$!a./. a!""o#atoss. The e!the"a" h$!er!"asa #a$ be so e*tensve that t resu"ts n

!a!""o#atous over&ro-th -thn the ducts.

C"nca" 'eatures

The s$#!to#s o' ANDI nc"ude an area o' "u#!ness 8se"do# dscrete: andor breast

!an 8#asta"&a:.

A ben&n dscrete "u#! n the breast s co##on"$ a c$st or 'broadeno#a. True

"!o#as occur rare"$.

Lu#!ness #a$ be b"atera"% co##on"$ n the u!!er outer uadrant% or "ess co##on"$

con'ned to one uadrant o' one breast. The chan&es #a$ be c$c"ca"% -th an ncrease

n both "u#!ness and o'ten tenderness be'ore a #enstrua" !erod.

Nonc$c"ca" #asta"&a s co##oner n !er#eno!ausa" and !ost#eno!ausa" -o#en.

It #a$ be assocated -th ANDI or -th !erducta" #astts% or re'erred 'ro#% 'or

e*a#!"e% a #uscu"os2e"eta" dsorder. About 05 !er cent o' breast cancers e*hbt !an

at !resentaton. Co##on breast s$#!to#s are ""ustrated n Tab"e /).(.

Treat#ent o' "u#!$ breasts

I' the c"ncan s con'dent that he or she s not dea"n& -th a dscrete abnor#a"t$

8and c"nca" con'dence #a$ be buttressed b$ #a##o&ra!h$ or u"trasound scannn&

' a!!ro!rate:% then nta""$ the -o#an can be o''ered 'r# reassurance. It s !erha!s

-orth-h"e reve-n& the !atent at a d''erent !ont n the #enstrua" c$c"e% sa$ )

-ee2s a'ter the nta" vst% and o'ten the c"nca" s&ns -"" have reso"ved b$ that

t#e. There s a tendenc$ 'or -o#en -th "u#!$ breasts to be rendered unnecessar"$an*ous and to be sub#tted to #u"t!"e rando# bo!ses because the c"ncan "ac2s

the coura&e o' hs or her convctons.

Treat#ent o' #asta"&a

ronounced c$c"ca" #asta"&a #a$ beco#e a s&n'cant c"nca" !rob"e# -here the

!an and tenderness nter'ere -th the -o#an9s "'e% dsturb her s"ee! and #!ar

se*ua" actvt$. Inta""$% 'r# reassurance that the s$#!to#s are not assocated -th

cancer -"" he"! the #ajort$ o' -o#en. A !atent s$#!to# dar$ -"" he"! her to

chart the !attern o' !an throu&hout the #onth and thus deter#ne -hether ths s

c$c"ca" #asta"&a. I' reassurance s nadeuate% then a !"anned esca"aton o' treat#ent

8as sho-n n Tab"e /).?: cou"d be advsed. O" o' evenn& !r#rose% n adeuate doses

&ven over ? #onths% -"" he"! #ore than ha"' o' these -o#en. or those -thntractab"e s$#!to#s a !ro"actn nhbtor such as dana3o" #a$ be &ven. Ger$ rare"$

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t s necessar$ to !rescrbe an antoestro&en% e.&. ta#o*'en or a "uten3n& hor#one1

re"easn& hor#one 8LHRH: a&onst% to de!rve the breast e!the"u# o' oestro&enc

drve.

or nonc$c"ca" #asta"&a t s #!ortant to e*c"ude e*tra#a##ar$ causes such as

chest -a"" !an% and t #a$ be necessar$ to carr$ out a bo!s$ on a ver$ "oca"sed

tender area -hch #&ht be harbourn& a subc"nca" cancer. Treat#ent #a$ be -thnonsteroda" ana"&escs or b$ njecton -th "oca" anaesthetc o' a tr&&er s!ot9.

Breast c$sts

These occur #ost co##on"$ n the "ast decade o' re!roductve "'e due to a

nonnte&rated nvo"uton o' stro#a and e!the"u#. The$ are o'ten #u"t!"e% #a$ be

b"atera" and can ##c #a"&nanc$. Da&noss can be con'r#ed b$ as!raton andor

u"trasound.

Treat#ent

A so"tar$ c$st or s#a"" co""ecton o' c$sts can be as!rated. I' the$ reso"ve

co#!"ete"$% and ' the '"ud s not b"oodstaned% no 'urther treat#ent s reured.

Ho-ever% ?5 !er cent -"" recur and reure reas!raton. C$to"o&ca" e*a#naton o'

c$st '"ud s no "on&er !ractsed routne"$. I' there s a resdua" "u#! or ' the '"ud sb"oodstaned% a "oca" e*cson 'or hsto"o&ca" da&noss s advsab"e% as s a"so the

case ' the c$st re!eated"$ re'or#s.

>a"actoce"e

>a"actoce"e% -hch s rare% usua""$ !resents as a so"tar$% subareo"ar c$st% and a"-a$s

dates 'ro# "actaton. It contans #"2 and n "on&standn& cases ts -a""s tend to

ca"c'$. It can beco#e enor#ous 8&. /).(6:.

broadeno#a

These usua""$ arse n the 'u""$ deve"o!ed breast durn& the 067(61$ear !erod%

a"thou&h occasona""$ the$ occur n #uch o"der -o#en. The$ arse 'ro# h$!er!"asa

o' a sn&"e "obu"e% and usua""$ &ro- u! to (7? c# n s3e. The$ are surrounded b$ a

-e""1#ar2ed ca!su"e and can thus be enuc"eated throu&h a cos#etca""$ a!!ro!rate

ncson. Ho-ever% n a !atent under ?5 $ears these do not reure e*cson un"ess

assocated -th sus!cous c$to"o&$% or ' the$ beco#e ver$ "ar&e% or ' the !atent

e*!ress"$ desres the "u#! to be re#oved.>ant 'broadeno#as occur occasona""$

durn& !ubert$. The$ are over 6c# n da#eter and are o'ten ra!d"$ &ro-n&% but n

other res!ects are s#"ar .to s#a""er 'broadeno#as and can be enuc"eated throu&h a

sub#a##ar$ ncson.

h$""odes tu#our

These ben&n tu#ours% !revous"$ so#et#es 2no-n as seroc$stc dsease o' Brode

or c$stosarco#a !h$""odes% usua""$ occur n -o#en over the a&e o' /5 but can a!!ear

n $oun&er -o#en 8&. /).():. The$ !resent as a "ar&e% so#et#es #assve tu#our%-th an uneven"$ bosse"ated sur'ace. Occasona""$ u"ceraton o' over"$n& s2n occurs

o-n& to !ressure necross. In s!te o' ther s3e the$ re#an #ob"e on the chest -a"".

Hsto"o&ca""$ there s a rese#b"ance to a 'broadeno#a% but des!te the na#e o'

c$stosarco#a !h$""odes the$ are rare"$ c$stc and on"$ ver$ rare"$ deve"o! 'eatures o'

a sarco#atous tu#our. These #a$ #etastasse va the b"oodstrea#.

Treat#ent

Treat#ent 'or the ben&n t$!e s enuc"eaton n ver$ $oun& -o#en or -de "oca"

e*cson. Massve tu#ours% recurrent tu#ours and those o' the #a"&nant t$!e -""

reure #astecto#$.

hen the da&noss o' carcno#a s n doubt

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There -"" a"-a$s be cases -here the c"ncan cannot be sure -hether a !artcu"ar

"u#! n the breast s an area o' #a##ar$ d$s!"asa% a ben&n tu#our or an ear"$

carcno#a.

I' there s doubt on ether c"nca"% c$to"o&ca" or rado"o&ca" e*a#naton t s

essenta" to obtan a tssue da&noss. Ths s o'ten !ossb"e b$ need"e bo!s$. In the

advent o' a ne&atve resu"t% o!en bo!s$ o' the #ass s necessar$. Because o' the!ossb"t$ o' re!ortn& errors% the authors su&&est that 'ro3en secton re!ortn& shou"d

rare"$ be used and certan"$ shou"d not 'or# the bass 'or a decson to underta2e

a#astecto#$. Tab"e /)./ &ves an a"&orth# 'or nvest&atn& an$ breast "u#!. Tab"e

/).6 ""ustrates the 'eatures o' three co##on "u#!s.

Carcno#a o' the breast

Breast cancer s the co##onest cause o' death n #dd"e1a&ed -o#en n estern

countres. In 0@,6% +0@ 555 ne- cases -ere da&nosed -or"d1-de. In En&"and and

a"es one n 0( -o#en -"" deve"o! the dsease durn& ther "'et#e.

Aeto"o&ca" 'actors

I. >eo&ra!hca". It occurs co##on"$ n the estern -or"d accountn& 'or ?76!er cent o' deaths% $et s a rare tu#our n Fa!an. In deve"o!n& countres t accounts

'or 07? !er cent o' deaths.

(. A&e. Carcno#a o' the breast s e*tre#e"$ rare be"o- the a&e o' (5% but

therea'ter the ncdence stead"$ rses so that b$ the a&e o' @5 near"$ (5 !er cent o'

-o#en are a''ected 8&. /).(+:.

B$ a&e (6 0 n 0@)5, B$ a&e )5 0 n (/

B$ a&e ?5 0 n (6(6 B$ a&e )6 0 n 0+

B$ a&e ?6 0 n )(( B$ a&e +5 0 n 0/

B$ a&e /5 0 n (0+ B$ a&e +6 0 n 00

B$ a&e /6 0 n @? B$ a&e ,5 " n 05

B$ a&e 65 " n 65 B$ a&e ,6 " n @

B$ a&e 66 0 n ?? Ever 0n ,

0@,+70@,, Cancer ncdence rates% NCI% USA.

?. >ender. Less than I !er cent o' !atents -th breast cancer are #a"e.

/. >enetc. It occurs #ore co##on"$ n -o#en -th a 'a#"$ hstor$ o' breast

cancer than n the &enera" !o!u"aton. Breast cancer re"ated to a s!ec'c #utaton

accounts 'or about 6 !er cent o' breast cancers% $et has 'ar1reachn& re!ercussons n

ter#s o' counse""n& and atte#!ted !reventon n these -o#en. Ths -"" be dscussed

#ore 'u""$ n a subseuent secton.

6. Det. Because breast cancer so co##on"$ a''ects -o#en n the deve"o!ed9

-or"d% detar$ 'actors #a$ !"a$ a !art n ts causaton. There s so#e evdence thatthere s a "n2 bet-een dets "o- n !h$to1oestro&ens. A h&h nta2e o' a"coho" s

assocated -th an ncreased rs2 o' deve"o!n& breast cancer.

). Endocrne. Breast cancer s co##oner n nu""!arous -o#en and breast'eedn&

n !artcu"ar a!!ears to be !rotectve. A"so !rotectve s havn& a 'rst ch"d at an ear"$

a&e% es!eca""$ ' assocated -th "ate #enarche and ear"$ #eno!ause. It s 2no-n that

n !ost#eno!ausa" -o#en% breast cancer s #ore co##on n the obese. Ths s

thou&ht to he because o' an ncreased converson o' sterod hor#ones to oestrado" n

the bod$ 'at. The ro"e o' e*o&enous hor#ones% n !artcu"ar the ora" contrace!tve !""

and hor#one re!"ace#ent thera!$% n the deve"o!#ent o' breast cancer s #ore

controversa"% but t can be sad -th so#e authort$ that 'or #ost -o#en the bene'ts

o' these treat#ents -"" 'ar out-e&h the s#a"" !utatve rs2.

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The ncrease n the "2e"hood o' deve"o!n& breast cancer assocated -th the above

rs2 'actors s usua""$ uant'ed n ter#s o' the re"atve rs2 8RR:. Thus a RR o' (.5

#eans that the ndvdua" has t-ce the chance o' deve"o!n& breast cancer as the

avera&e 'or the !o!u"aton% -h"st a RR o' 5.6 ndcates a rs2 reducton o' 65 !er

cent.

atho"o&$Breast cancer #a$ arse 'ro# the e!the"u# o' the duct s$ste# an$-here 'ro# the

n!!"e end o' #ajor "act'erous ducts to the ter#na" duct unt -hch s n the breast

"obu"e. It #a$ be entre"$ n stu 7 an ncreasn&"$ co##on !heno#enon -th the

advent o' breast cancer screenn& 7 or #a$ be nvasve cancer. The de&ree o'

d''erentaton o' the tu#our s usua""$ descrbed b$ three &rades 7 -e""

d''erentated% #oderate"$ or !oor"$ d''erentated. Ducta" carcno#a s the #ost

co##on varant% but "obu"ar carcno#a occurs n u! to 05 !er cent o' cases% a"thou&h

ths #a$ be #*ed. Rarer hsto"o&ca" varants% usua""$ carr$n& a better !ro&noss%

nc"ude co""od carcno#a -hose ce""s !roduce abundant #ucn% #edu""ar$ carcno#a

-th so"d sheets o' "ar&e ce""s o'ten assocated -th a #ar2ed "$#!hoc$tc reacton

and tubu"ar carcno#a. Invasve "obu"ar carcno#a s co##on"$ #u"t1'oca" andorb"atera".

In'"a##ator$ carcno#a s a 'ortunate"$ rare% h&h"$ a&&ressve cancer -hch !resents

as a !an'u"% s-o""en breast% -hch s -ar# -th cutaneous oede#a. Ths s due to

b"oc2a&e o' the subder#a" "$#!hatcs -th carcno#a ce""s. In'"a##ator$ cancer

usua""$ nvo"ves at "east one1thrd o' the breast and #a$ ##c a breast abscess. A

bo!s$ -"" con'r# the da&noss and sho- und''erentated carcno#a ce""s.

In stu carcno#a s !renvasve cancer -hch has not breached the e!the"a"

base#ent #e#brane. Ths -as

!revous"$ a rare% usua""$ as$#!to#atc 'ndn& n breast bo!s$ s!ec#ens but s

beco#n& ncreasn&"$ co##on o-n& to the advent o' #a##o&ra!hc screenn& 7

t accounts 'or (5 !er cent o' cancers detected b$ screenn&. In stu carcno#a #a$ be

ducta" 8DCIS: or "obu"ar 8LCIS:% the "atter o'ten #u"t'oca" and b"atera". Both are

#ar2ers 'or the "ater deve"o!#ent o' nvasve cancer -hch -"" &o on to deve"o! n at

"east (5 !et cent o' cases. A"thou&h #astecto#$ s curatve% ths s overtreat#ent n

#an$ cases and the best treat#ent 'or n stu carcno#a s the subject o' a nu#ber o'

c"nca" tra"s.

a&et9s dsease o' the n!!"e

a&er9s dsease o' the n!!"e 8&. /).(,a and b: s a su!er'ca" #an'estaton o' an

under"$n& breast carcno#a. It !resents as an ec3e#a1"2e condton o' the n!!"e and

areo"a -hch !erssts n s!te o' "oca" treat#ent. The n!!"e s eroded s"o-"$ and

eventua""$ dsa!!ears. I' "e't% the under"$n& carcno#a -"" sooner or "ater beco#ec"nca""$ evdent. Thus n!!"e ec3e#a shou"d be bo!sed ' there s an$ doubt about

ts cause. Mcrosco!ca""$ a&er9s dsease s charactersed b$ the !resence o' "ar&e%

ovod ce""s -th abundant% c"ear% !a"e1stann& c$to!"as# n the Ma"!&han "a$er o'

the e!der#s.

The s!read o' #a##ar$ carcno#a

0.Loca" s!read. The tu#our ncreases n s3e and nvades other !ortons o' the breast.

It tends to nvo"ve the s2n and to !enetrate the !ectora" #usc"es% and even the chest

-a"".

(.L$#!hatc #etastass occurs !r#ar"$ to the a*""ar$ "$#!h nodes and to the

nterna" #a##ar$ chan o' "$#!h nodes. The ste o' the tu#our -thn the breast

does not dctate -hch nodes -"" be nvo"ved% e.&. #eda" tu#ours s!read just asread"$ to the a*""ar$ nodes as do "atera" tu#ours. The nvo"ve#ent o' "$#!h nodes s

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not necessar"$ a chrono"o&ca" event n the evo"uton o' the carcno#a% but rather a

#ar2er 'or the #etastatc !otenta" o' that tu#our. In advanced dsease there #a$ be

nvo"ve#ent o' su!rac"avcu"ar nodes and o' an$ contra"atera" "$#!h nodes.

?.S!read b$ the b"oodstrea#. It s b$ ths route that s2e"eta" #etastases occur 8n order

o' 'reuenc$: n the "u#bar vertebrae% 'e#ur% thoracc vertebrae% rb and s2u""; the$

are &enera""$ osteo"$tc. Metastases #a$ a"so occur n the "ver% "un& and bran% andoccasona""$ the adrena" &"ands and ovares.

C"nca" !resentaton

h"e an$ !orton o' the breast% nc"udn& the a*""ar$ ta"% #a$ be nvo"ved% breast

cancer co##ences #ost 'reuent"$ n the u!!er% outer uadrant 8&s /).(@ and

/).?5:. Most breast cancers -"" !resent as a hard "u#!% -hch #a$ be assocated -th

ndra-n& o' the n!!"e. As the dsease advances "oca""$ there #a$ be s2n

nvo"ve#ent -th !eau d9oran&e 8&. /).?0: or 'ran2 u"ceraton and '*aton to the

chest -a"" 8&. /).?(:. Ths s descrbed as cancer1encurasse. About 6 !er cent o'

breast cancers n the U -"" !resent -th ether "oca""$ advanced dsease or

s$#!to#s o' #etastatc dsease. Ths '&ure s nearer (5 !er cent n the deve"o!n&

-or"d. These !atents #ust then under&o a sta&n& eva"uaton so that the 'u"" e*tent o'ther dsease can be ascertaned. Ths -"" nc"ude a care'u" c"nca" e*a#naton% chest

=1ra$% seru# a"2a"ne !hos!hatase and &a##a &"uta#ne transa#nase 8>>T:% -th

"ver u"trasound ' these are abnor#a"% and an soto!e bone scan 8&. /).??:. Ths s

#!ortant 'or both !ro&noss and treat#ent 7 a !atent -th -des!read vscera"

#etastases #a$ obtan an ncreased "en&th and ua"t$ o' survva" 'ro# s$ste#c

hor#one or che#othera!$% but she s not "2e"$ to bene't 'ro# sur&er$ as she -"" de

'ro# her #etastases be'ore "oca" dsease beco#es a !rob"e#. In contrast% !atents -th

re"atve"$ s#a"" 8"ess than 6 c# n da#eter: tu#ours con'ned to the breast and

!s"atera" "$#!h nodes rare"$ need sta&n& be$ond a &ood c"nca" e*a#naton as the

!c21u! rate 'or dstant #etastases s so "o-.

heno#ena resu"tn& 'ro# "$#!hatc obstructon n Sta&n& o' breast cancer

advanced breast cancer

eau d9oran&e s due to cutaneous "$#!hatc oede#a. here the n'"trated s2n s

tethered b$ the s-eat ducts t cannot s-e""% "eadn& to an a!!earance "2e oran&e s2n.

Occasona""$ the sa#e !heno#enon s seen over a chronc abscess.

Late oede#a o' the ar# s a troub"eso#e co#!"caton o' breast cancer treat#ent

'ortunate"$ seen "ess o'ten no- that radca" a*""ar$ dssecton and radothera!$ are

rare"$ co#bned. It does ho-ever occasona""$ st"" occur a'ter ether #oda"t$ o'

treat#ent a"one and a!!ears an$t#e 'ro# #onths to $ears a'ter treat#ent. There s

usua""$ no !rec!tatn& cause but recurrent tu#our shou"d be e*c"uded as neo!"astc

n'"traton o' the a*""a can cause ar# s-e""n& due to both "$#!hatc and venousb"oc2a&e. Ths neo!"astc n'"traton s o'ten !an'u" due to nerve nvo"ve#ent.

An oede#atous "#b s susce!tb"e to bactera" n'ectons 'o""o-n& ute #nor

trau#a% and these reure v&orous antbotc treat#ent. Treat#ent o' "ate oede#a s

d''cu"t but "#b e"evaton% e"astc ar# stoc2n&s and !neu#atc co#!resson devces

can be use'u".

Cancer1en1curasse/. The s2n o' the chest s n'"trated -th carcno#a and has been

"2ened to a coat.

It #a$ be assocated -th a &ross"$ s-o""en ar#. Ths usua""$ occurs n cases -th

"oca" recurrence a'ter #astecto#$% and occasona""$ s seen to 'o""o- the dstrbuton

o' rradaton to the chest -a"". The condton #a$ res!ond to !a""atve s$ste#c

treat#ent but !ro&noss n ter#s o' survva" s !oor.

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L$#!han&osarco#a 8&. /).?/: s a rare co#!"caton o' "$#!hoede#a -th an

onset #an$ $ears 'o""o-n& the or&na" treat#ent. It ta2es the 'or# o' #u"t!"e

subcutaneous nodu"es n the u!!er "#b and #ust be dstn&ushed 'ro# recurrent

carcno#a o' the breast. The !ro&noss s !oor but so#e cases res!ond to c$toto*c

thera!$ or rradaton. Intersca!u"othoracc 8'oreuarter: a#!utaton s so#et#es

ndcated.There are t-o tradtona" s$ste#s o' c"ass'caton 'or breast carcno#a -hch

!redo#nant"$ re"$ on c"nca" sta&n& o' the dsease. These are the Manchester

s$ste# and the Internatona" Unon A&anst Cancer TNM 8tu#our% nodes% #etastases:

sta&n& s$ste#. These are ""ustrated n Tab"e /).).

The TNM s$ste# -as an atte#!t to a""o- a co##on "an&ua&e a#on&st onco"o&sts

-or"d1-de% thus a""o-n& accurate n'or#aton e*chan&e and eva"uaton o' studes o'

treat#ent% as -e"" as !rovdn& !ro&nostc n'or#aton to ad n the !"annn& o'

treat#ent 'or the ndvdua" !atent. Ho-ever% ths re'ne#ent o' ta*ono#$ n 'act

contrbutes "tt"e to an$ o' these actvtes.

urther subdvsons n the TNM s$ste# no- #ean that there are seven T1sta&es% 'our

N1sta&es and three M1sta&es% a""o-n& 'or 0,5 !ossb"e co#bnatons. atho"o&ca""$#!h node sta&n& de!ends on both the nu#ber o' "$#!h nodes re#oved% thus the

e*tent o' sur&er$% and ho- assduous the !atho"o&st s n "oo2n& 'or de!osts o'

tu#our -thn the nodes. M9 sta&n& de!ends on -hat nvest&atons have been

!er'or#ed 7 thus -"" var$ bet-een centres. Conseuent"$ sta&n& s observer

based.

A"thou&h !ro&noss broad"$ corre"ates -th sta&e% other 'actors a"so n'"uence

!ro&noss and shou"d be assessed% 'or e*a#!"e the Nottn&ha# ro&nostc Inde*

nc"udes nor on"$ tu#our s3e and "$#!h node status but tu#our &rade.

Conventona" sta&n& -"" ndcate broad"$ -hch treat#ent s reured but a&an other

'actors #a$ be eua""$ #!ortant. or e*a#!"e% sur&ca" treat#ent o' a s#a"" sta&e I%

or II 8T0 or T(: breast tu#our usua""$ reures on"$ -de "oca" e*cson rather than

#astecto#$ 7 but the "atter #a$ have to be !er'or#ed ' the breast s ver$ s#a""% the

tu#our centra" or #u"t'oca"% or 'or !atent !re'erence. Eua""$ the use o' adjuvant

s$ste#c thera!$ s decded on not on"$ tu#our s3e and "$#!h node status but a"so

bo"o&ca" #easures such as oestro&en rece!tor status% !atent a&e and #eno!ausa"

status% and n the case o' ta#o*'en ths can be reco##ended rres!ectve o'

c"nco!atho"o&ca" varab"es.

Thus as -e &an #ore 2no-"ed&e o' the bo"o&ca" varab"es -hch a''ect !ro&noss t

beco#es ncreasn&"$ c"ear that t s these 'actors 8dscussed n #ore deta" be"o-:

rather than anato#ca" #a!!n& -hch n'"uence outco#e and treat#ent. erha!s a

#ore !raatc a!!roach -ou"d be to c"ass'$ !atents accordn& to the treat#ent thatthe$ reure. Ths s sho-n n Tab"e /).+.

ro&noss o' breast cancer

The best ndcators o' "2e"$ !ro&noss n breast cancer are st"" tu#ours s3e and

"$#!h node status 8&. /).?6:.Ho-ever% t s rea"sed that so#e "ar&e tu#ours -""

re#an con'ned to the breast 'or decades -hereas so#e ver$ s#a"" tu#ours are

ncurab"e at da&noss. Hence the !ro&noss o' a cancer de!ends not on ts

chrono"o&ca" a&e but on ts nvasve and #etastatc !otenta". In an atte#!t to de'ne

-hch tu#ours -"" behave a&&ressve"$% and thus reure ear"$ s$ste#c treat#ent% a

host o' !ro&nostc 'actors has been descrbed. These nc"ude hsto"o&ca" &rade o' the

tu#our% hor#one rece!tor status% #easures o' tu#ours !ro"'eraton such as 61!hase

'racton and th$#dne1"abe""n& nde*% &ro-th 'actor ana"$ss and onco&ene or

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onco&ene !roduct #easure#ents. Man$ others are under nvest&aton but have

!roved o' "tt"e !ractca" va"ue n !atent #ana&e#ent.

Treat#ent o' cancer o' the breast

As has been ndcated above% treat#ent -"" "ar&e"$ de!end u!on c"nca" sta&e o' the

dsease at !resentaton nc"udn& not on"$ c"assca" TMN sta&n& but o'ten other

tu#our characterstcs such as tu#our &rade. Treat#ent o' ear"$ breast cancer -""usua""$ nvo"ve sur&er$ -th or -thout radothera!$. S$ste#c thera!$ such as

che#othera!$ or hor#one thera!$ s added ' there are adverse !ro&nostc 'actors

such as "$#!h node nvason ndcatn& a h&h "2e"hood o' #etastatc re"a!se. At the

other end o' the s!ectru# "oca""$ advanced or #etastatc dsease s usua""$ treated b$

s$ste#c thera!$ to !a""ate s$#!to#s% -th sur&er$ !"a$n& a #uch s#a""er ro"e.

The #u"tdsc!"nar$ tea# a!!roach

As n a"" branches o' #edcne &ood doctor7!atent co##uncaton !"a$s a vta" ro"e

n he"!n& to a""evate !atent an*et$. artc!aton o' the !atent n treat#ent

decsons s o' !artcu"ar #!ortance n breast cancer -here there #a$ be uncertant$

as to the best thera!eutc o!ton and the desre to treat the !atent -thn the !rotoco"

o' a contro""ed c"nca" tra". As !art o' the !reo!eratve and !osto!eratve #ana&e1#ent o' the !atent t s o'ten use'u" to e#!"o$ the s2""s o' a traned breast counse""or

and a"so to have ava"ab"e advce on breast !rostheses% !s$cho"o&ca" su!!ort and

!h$sothera!$% -here a!!ro!rate. In #an$ s!eca"st centres the care o' breast cancer

!atents s underta2en as a jont venture bet-een the sur&eon% #edca" onco"o&st%

radothera!st and a""ed hea"th !ro'essona"s such as the c"nca" nurse s!eca"st.

Treat#ent o' ear"$ breast cancer

The a#s o' treat#ent are4

0 cure94 !ossb"e n so#e !atents but recurrence u! to (5 $ears a'ter nta"

treat#ent s nor unco##on;

(.contro" o' "oca" dsease n the breast and a*""a;

?. conservaton o' "oca" 'or# and 'uncton;

/.!reventon or de"a$ o' the occurrence o' dstant #etastases.

Loca" treat#ent o' ear"$ breast cancer

Loca" contro" s acheved throu&h sur&er$ andor radothera!$.

Sur&er$

Sur&er$ st"" has a centra" ro"e to !"a$ n the #ana&e#ent o' breast cancer but there

has been a &radua" sh't to-ards #ore conservatve technues% bac2ed u! b$ c"nca"

tra"s -hch have sho-n eua" e''cac$ bet-een #astecto#$ and "oca" e*cson

'o""o-ed b$ radothera!$. Ths 'o""o-ed a chan&e n the #ode" o' breast cancer

s!read% -hch s no "on&er thou&ht o' as a centr'u&a" anato#ca" s!read but rather

that t s the !resence o' #cro#etastases -hch !redeter#nes the outco#e o' thedsease.It -as nta""$ ho!ed that avodn& #astecto#$ -ou"d he"! to a""evate the

consderab"e !s$cho"o&ca" #orbdt$ assocated -th breast cancer% but recent studes

have sho-n that over ?5 !er cent o' -o#en deve"o! s&n'cant an*et$ and

de!resson 'o""o-n& both radca" and conservatve sur&er$. A'ter #astecto#$ the$

rend to -orr$ about the e''ect o' the o!eraton on ther a!!earance and re"atonsh!s

-h"st a'ter conservatve sur&er$ -o#en #a$ re#an 'ear'u" o' a recurrence.

Mastecto#$ s no- on"$ strct"$ ndcated 'or "ar&e tu#ours 8n re"aton to the s3e o'

the breast:% centra" tu#ours beneath or nvo"vn& the n!!"e% #u"t'oca" dsease% "oca"

recurrence or 'or !atent !re'erence. The radca" Ha"stead #astecto#$ -hch nc"uded

e*cson o' the breast% a*""ar$ "$#!h nodes% !ectora"s #ajor and #nor #usc"es s no

"on&er ndcated as t causes e*cessve #orbdt$ -th no survva" bene't. Mod'edradca" 8ate$9: #astecto#$ s #ore co##on"$ !er'or#ed and thus s descrbed

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be"o-. S#!"e #astecto#$ nvo"ves re#ova" o' the breast on"$ -th no dssecton o'

the a*""a% e*ce!t 'or the re&on o' the a*""ar$ ta" o' the breast -hch usua""$ has

attached to t a 'e- nodes "o- n the anteror &rou!. Because no !atho"o&ca" sta&n&

o' the a*""a s !er'or#ed -th a s#!"e #astecto#$% t s o'ten 'o""o-ed b$

radothera!$ to the a*""a.

ate$9 #astecto#$. The breast and assocated structures are dssected en b"oc 8see&. /).?): and the e*csed #ass s co#!osed o'4

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Radothera!$ to the chest -a"" a'ter #astecto#$ has been "ar&e"$ abandoned e*ce!t n

cases o' e*tensve "oca" dsease -th n'"traton o' the chest -a"". It s conventona" to

co#bne conservatve sur&er$ -th radothera!$ to the re#ann& breast tssue.

Ho-ever% there s current"$ doubt as to -hether a"" !atents under&on& conservatve

sur&er$ shou"d receve radothera!$ as #ost -"" not deve"o! "oca" recurrence and

thus -"" be overtreated b$ adjuvant radothera!$% -hch s not -thout #orbdt$ andeven "on&1ter# #orta"t$ 'ro# nadvertent rradaton to the #$ocardu#. A U

natona" c"nca" tra" s current"$ under-a$ to tr$ to ascertan -hether there s a

survva" advanta&e -th radothera!$ and to dent'$ -hch !atents are at h&hest rs2

o' "oca" re"a!se% and thus -ou"d bene't #ost 'ro# !osto!eratve breast

rradaton. Current"$ those thou&ht to be at h&hest rs2 nc"ude those -th e*tensve

n stu carcno#a 8or o' course nvasve cancer: at the #ar&ns o' e*cson% !atents

under ?6 $ears and those -th #u"t'oca" dsease.

Adjuvant s$ste#c thera!$

Over the "ast (6 $ears there has been a revo"uton n our understandn& o' the

bo"o&ca" nature o' carcno#a o' the breast. It s no- -de"$ acce!ted that the

outco#es o' treat#ent are !redeter#ned b$ the e*tent o' #cro#etastatc dsease atthe t#e o' da&noss. Garatons n the radca" e*tent o' "oca" thera!$ #&ht n'"uence

"oca" re"a!se% but !robab"$ do not a"ter "on&1ter# #orta"t$ 'ro# the dsease.

Ho-ever% s$ste#c thera!$ tar&eted at these !utatve #cro#etastases #&ht be

e*!ected to de"a$ re"a!se and !ro"on& survva". As a resu"t o' #an$ nternatona"

c"nca" tra"s and recent -or"d overve- ana"$ses% t can be stated -th e*tre#e

statstca" con'dence that the a!!ro!rate use o' adjuvant che#othera!$ or hor#one

thera!$ -"" #!rove re"a!se1'ree survva" b$ a!!ro*#ate"$ ?5 !er cent% -hch

u"t#ate"$ trans"ates nto an abso"ute #!rove#ent n survva" o' the order o' 05 !er

cent at 06 $ears. Bearn& n #nd ho- co##on the dsease s n Northern Euro!e and

the USA% ths trans"ates nto '&ures o' #ajor !ub"c hea"th #!ortance.

ho to treat and -th -hat are st"" uestons 'or -hch abso"ute ans-ers have $et to

'ound% but the data 'ro# an overve- o' recent tra"s su&&est that "$#!h node1!ostve

and !oor !ro&noss node1ne&atve !re#eno!ausa" -o#en shou"d be reco##ended

adjuvant co#bned che#othera!$ and that !ost#eno!ausa" -o#en -"" obtan a

-orth-h"e bene't 'ro# about 6 $ears o' ta#o*'en% (5 #& da"$.

Hor#one thera!$

Ta#o*'en s the #ost -de"$ used hor#ona"9 treat#ent n breast cancer. Its e''cac$

as an adjuvant thera!$ -as 'rst re!orted n 0@,? and t has no- been sho-n to reduce

the annua" rate o' recurrence b$ (6 !er cent% -th a 0+ !er cent reducton n the annua"

rate o' death. The e''ect o' ta#o*'en s 'avourab"e n #ost cases e*ce!t 'or oestro&en

rece!tor ER1ne&atve !re#eno!ausa" -o#en; !ost#eno!ausa" -o#en -th oestro&enrece!tor1rch 8!ostve: tu#ours acheve a &reater reducton n the re"atve rs2 o'

re"a!se than oestro&en rece!tor1ne&atve cases. The bene'ca" e''ects o' ta#o*'en n

reducn& the rs2 o' tu#ours n the contra"atera" breast have a"so been observed. Tra"s

stud$n& the o!t#a" duraton o' treat#ent are c"ose to #aturt$ and su&&est that 6

$ears o' treat#ent #a$ be !re'erab"e to ( $ears.

Other hor#ona" a&ents are ben& deve"o!ed -hch #a$ !rove bene'ca" as adjuvant

thera!$% such as the LHRH a&onsts -hch nduce a reversb"e ovaran su!!resson

and thus re ho!ed to have the sa#e bene'ca" e''ects as sur&ca" or Jradaton1

nduced ovaran ab"aton n !re#eno!ausa" -o+nen% and the ora" aro#atase nhbtors

'or !ost#eno!ausa" No#en.

Che#othera!$

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Che#othera!$ usn& a reen such as a )1#onth"$ c$c"e o' c$c"o!hos!ha#de%

#ethotra*ate and 61'"uorourac" 8CM: -"" acheve a ?5 !er cent reducton n the rs2

o' re"a!se over a 057061$ear !erod. Ths treat#ent has been con'ned to

!re#eno!ausa" !oor !ro&noss -o#en 8-here ts e''ects are "2e"$ to be due n !art to

a che#ca" castraton e''ect: but s ben& ncreasn&"$ o''ered to !ostrneno!ausa"

-o#en -th !oor !ro&noss dsease as -e"". Che#othera!$ #a$ be consdered nnode1ne&atve !atents ' other !ro&nostc 'actors such as tu#our &rade n'er a h&h

rs2 o' recurrence. The e''ect o' co#bnn& hor#one and che#othera!$ s st"" under

nvest&aton and s be&nnn& to "oo2 !ro#sn&.

H&h1dose che#othera!$ -th ste# ce"" rescue 'or !atents -th heav$ "$#!h node

nvo"ve#ent s st"" consdered e*!er#enta" and shou"d not be o''ered outsde

contro""ed tra"s.

r#ar$ che#othera!$ s ben& used n #an$ centres 'or "ar&e hut o!erab"e tu#ours

that -ou"d tradtona""$ reure a #astecto#$ 8and a"#ost certan"$ !osto!eratve

adjuvant che#othera!$:. The a# o' ths treat#ent s to shrn2 the tu#our to enab"e

breast1conservn& sur&er$ to be !er'or#ed. Ths a!!roach s success'u" n u! to ,5 !er

cent o' cases% but s not assocated -th #!rove#ents n survva" co#!ared -thconventona""$ t#ed che#othera!$.

Breast reconstructon

Des!te an ncreasn& trend to-ard conservatve sur&er$% u! to 65 !er cent o' -o#en

st"" reure% or -ant% a #astecto#$. These -o#en can no- he o''ered ##edate or

de"a$ed reconstructon o' the breast. e- contrandcatons to breast reconstructon

e*st 7 even those -th a "#ted "'e e*!ectanc$ #a$ bene't 'ro# the #!roved

ua"t$ o' "'e% ho-ever !atents do reure counse""n& be'ore ths !rocedure so that

ther e*!ectatons o' cos#etc outco#e are not unrea"stc.

The #ost co##on t$!e o' reconstructon s usn& a s"cone &e" #!"ant under the

!ectora"s #ajor #usc"e.

Ths #a$ be co#bned -th !ror tssue e*!anson usn& an e*!andab"e sa"ne

!rosthess 'rst 8or a co#bned devce 7 &. /).?+: -hch creates so#e !toss o' the

ne- breast. I' the s2n at the #astecto#$ ste s !oor 8'or e*a#!"e 'o""o-n&

radothera!$: or ' a "ar&er vo"u#e o' tssue s reured% a #uscu"ocutanous '"a! can

be constructed 'ro# ether the "atss#us dors #usc"e 8an LD '"a!: or the

contra"atera" transversus abdo#ns #usc"e 8a TRAM '"a! 7 sho-n n &. /).?,:.

The "atter &ves an e*ce""ent cos#etc resu"t n e*!erenced hands but s a "en&th$

!rocedure and reures care'u" !atent se"ecton.

N!!"e reconstructon s a re"atve"$ s#!"e !rocedure -hch can be !er'or#ed under

a "oca" anaesthetc. A"ternatve"$ the !atent can be 'tted -th a !rosthetc n!!"e. To

acheve s$##etr$% the o!!oste breast #a$ reure a cos#etc !rocedure such asreducton or auentaton #a##o!"ast$% or #asto!e*$. A breast reconstructve

servce can be o''ered b$ a sutab"$ traned breast sur&eon% a !"astc sur&eon or dea""$

a co#bned onco!"astc a!!roach.

E*terna" breast !rostheses -hch 't -thn the bra #a$ a"so be reco##ended and

so#e o' these are ""ustrated n &. /).?@.

Screenn& 'or breast cancer

Because the !ro&noss o' breast cancer s c"ose"$ re"ated to sta&e at da&noss% t

-ou"d see# reasonab"e to ho!e that a !o!u"aton screenn& !ro&ra##e -hch cou"d

detect tu#ours be'ore the$ co#e to the !atent9s notce #a$ reduce #orta"t$ 'ro#

breast cancer. A nu#ber o' studes has ndeed sho-n that breast screenn& b$#a##o&ra!h$ n -o#en over the a&e o' 65 -"" reduce cause1s!ec'c #orta"t$ b$

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u! to ?5 !er cent. o""o-n& the !ub"caton n 0@,+ o' the orrest re!ort the Natona"

Hea"th Servce n the U has "aunched a !ro&ra##e o' ?1$ear"$ #a##o&ra!hc

screenn& 'or -o#en bet-een the a&es o' 65 and )/. The ntroducton o' ths

!ro&ra##e has undoubted"$ #!roved the ua"t$ o' breast cancer servces but a

nu#ber o' uestons re#ans unans-ered nc"udn& the va"ue o' screenn& -o#en

under 65 and the dea" nterva" bet-een screenn&s. The !s$cho"o&ca" conseuenceso' 'a"se a"ar#s or 'a"se reassurances st"" need to be addressed and se"'1e*a#naton

!ro&ra##es -hch have 'a"ed to sho- an$ bene't 'or the !o!u"aton n ter#s o'

ear"er or decreased #orta"t$ 'ro# breast cancer st"" re#an controversa". &ure

/)./5 ""ustrates so#e bene'ts and dsadvanta&es o' screenn&. The senor author

re#ans doubt'u" re&ardn& the va"ue o' a screenn& !ro&ra##e n ter#s o' the -der

#!"catons o' hea"thcare !"annn&.

a#"a" breast cancer

Recent deve"o!#ents n #o"ecu"ar &enetcs and the dent'caton o' a nu#ber o'

breast cancer !reds!oston &enes 8BRCA0% BRCA( and TS?: have done #uch tost#u"ate nterest n ths 'ascnatn& area. Ket -o#en -hose breast cancer s due to an

nherted &enerc chan&e actua""$ account 'or "ess than 6!er cent o' a"" breast cancers

7 that s about 0(65 cases !er $ear n the U and @555 cases n the USA. A #uch

"ar&er nu#ber o' -o#en -"" have a rs2 e"evated above nor#a" due to an as $et

uns!ec'ed 'a#"a" nhertance. These -o#en have a rs2 o' deve"o!n& breast cancer

t-o to 05 t#es above base"ne.

The rs2s assocated -th 'a#"$ hstor$ are su##arsed n Tab"e /).,.

The BRCAI &ene has been c"oned and s "ocated on the "on& ar# o' chro#oso#e 0+

80+:. The &ene 'reuenc$ n the !o!u"aton s a!!ro*#ate"$ 5.555). BRCA( s

"ocated on chro#oso#e 0?. o#en -ho are thou&ht to be &ene carrers #a$ be

o''ered breast screenn& 8and ovaran screenn& n the case o' BR>A0% -hch s

2no-n to #!art a 65 !er cent "'et#e rs2 o' ovaran cancer:% usua""$ as !art o' a

research !ro&ra##e% or #a$ be o''ered &enerc counse""n& and #utaton ana"$ss.

Those -ho !rove to he &ene !ostve9have an ,5 !er cent rs2 o' deve"o!n& breast

cancer% !redo#nant"$ -h"st !re#eno!ausa". Man$ -"" o!t 'or !ro!h$"actc

#astecto#$% a"thou&h ths does not co#!"ete"$ e"#nate the rs2.

or%those -th a !ostve 'a#"$ hstor$ -ho are un"2e"$ to be carrers o' a breast

cancer &ene% -hch -"" co#!rse the &reat #ajort$ o' -o#en% there s no current"$

!roven !reventve or screenn& #anoeuvre% a"thou&h these are under nvest&aton.

Thus these -o#en are best served b$ ben& assessed and 'o""o-ed u!% ' necessar$% n

a !ro!er"$ or&ansed research 'a#"$ hstor$ c"nc.re&nanc$

The e''ects o' !re&nanc$ on breast cancer are not -e"" studed but t s thou&ht that

breast cancer !resentn& durn& !re&nanc$ or "actaton tends to be at a "ater sta&e 7

!resu#ab"$ because the s$#!to#s are #as2ed b$ the !re&nanc$ 7 but n other

res!ects t behaves n a s#"ar -a$ to breast cancer n a non!re&nant $oun& -o#an%

and shou"d be treated accordn&"$. Thus treat#ent s s#"ar -th so#e !rovsos4

radothera!$ shou"d be avoded durn& !re&nanc$% #a2n& #astecto#$ a #ore

'reuent o!ton than breast conservaton sur&er$; che#othera!$ shou"d he avoded

durn& the 'rst tr#ester but s !robab"$ sa'e subseuent"$; #ost tu#ours are hor#one

rece!tor ne&atve and so hor#one treat#ent% -hch s !otenta""$ terato&enc% s not

reured. Beco#n& !re&nant subseuent to a da&noss o' breast cancer a!!ears not to

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a"ter "2e"$ outco#e% hut -o#en are usua""$ advsed to -at at "east ( $ears% as t s

-thn ths t#e that recurrence #ost o'ten occurs.

The rs2 o' deve"o!n& breast cancer -th ora" contrace!tve use s on"$ s"&ht% and

dsa!!ears 05 $ears a'ter sto!!n& the "".

Hor#one1re!"ace#ent thera!$

Hor#one1re!"ace#ent thera!$ 8HRT: does not a!!ear to ncrease s&n'cant"$ the

rs2 o' deve"o!n& breast cancer un"ess ta2en 'or !ro"on&ed !erods 8over 05 $ears:%

and !erha!s n certan h&h1rs2 &rou!s. HRT #a$% ho-ever% !ro"on& s$#!to#s o'

ben&n breast dsorder and #a2e #a##o&ra!hc a!!earances #ore d''cu"t to

nter!ret.

atents -ho deve"o! breast cancer -h"st on HRT a!!ear to have a #ore 'avourab"e

!ro&noss. The conseuences n ter#s o' recurrence n -o#en usn& HRT 'o""o-n&

breast cancer are un2no-n.

Treat#ent o' advanced breast cancer

Breast cancer #a$ occasona""$ !resent as #etastatc dsease -thout evdence o' a

!r#ar$ tu#our 8that s -th an occu"t !r#ar$:. The da&noss s #ade !art"$ b$

e*c"uson o' another ste 'or the !r#ar$ and #a$ be con'r#ed b$ hsto"o&$ o' the

#etastatc "esons. Treat#ent shou"d be a#ed at !a""aton o' the s$#!to#s and

treatn& the breast cancer% usua""$ b$ endocrne #an!u"aton.

Loca""$ advanced no!erab"e breast cancer

Loca""$ advanced no!erab"e breast cancer% nc"udn& n'"a##ator$ breast cancer% s

usua""$ treated -th s$ste#c thera!$

7 ether che#othera!$ or hor#one thera!$.

Occasona""$ to"et #astecto#$9 or radothera!$ s reured to contro" a 'un&atn&

tu#our% but o'ten ncson throu&h #crosco!ca""$ !er#eated tssues #a2es the

outco#e -orse than the or&na".

Metastatc carcno#a o' the breast

Metastatc carcno#a o' the breast -"" a"so reure so#e 'or# o' !a""atve s$ste#c

thera!$ to a""evate s$#!to#s. Hor#one #an!u"aton s o'ten the 'rst "ne because

o' ts #n#a" sde e''ects. It s !artcu"ar"$ use'u" 'or bon$ #etastases. Ho-ever% on"$

about ?5 !er cent o' these tu#ours -"" be hor#one res!onsve% and un'ortunate"$

even these -"" n t#e beco#e resstant to ths treat#ent. rst1"ne hor#one thera!$

'or !ost#eno!ausa" -o#en s ta#o*'en% and 'or !re#eno!ausa" -o#en ovaran

su!!resson% but -here resstance to these has deve"o!ed% other hor#ona" a&ents can!rove use'u"% -th about ha"' o' the res!onse rate seen n the 'rst1"ne thera!$.

S$nthetc !ro&esta&ens such as #edro*$!ro&esterone acetate 8rovera9: aro#atase

nhbtors or the ne-er a&ents such as ant!ro&estns and !ure antoestro&ens are a""

canddates 'or ths ro"e.

C$toto*c thera!$ s used% !artcu"ar"$ n $oun&er -o#en or those -th vscera"

#etastases and ra!d"$ &ro-n& tu#ours. A varet$ o' reens s ava"ab"e and

a"thou&h none !ro"on&s survva"% contrar$ to e*!ectatons ua"t$ o' "'e and s$#!to#

contro" s o'ten better -th #ore a&&ressve treat#ents% res!onses ben& seen n u! to

+5 !er cent o' !atents.

Loca" treat#ent #a$ a"so !rove use'u" 'or so#e #etastatc dsease such as

radothera!$ 'or !an'u" bon$ de!osts and nterna" '*aton o' !atho"o&ca" 'ractures.

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The #a"e breast

>$naeco#asta

Ido!athc

H$!ertro!h$ o' the #a"e breast #a$ be un"atera" or b"atera". The breasts en"ar&e at

!ubert$ and so#et#es !resent the characterstcs o' 'e#a"e breasts 8&. /)./0:.

Hor#ona"En"ar&e#ent o' the breasts o'ten acco#!aned st"boestro" thera!$ 'or !rostate cancer

7 no- rare"$ used. It #a$ a"so occur as a resu"t o' a terato#a o' the tests% n

anorchs# and a'ter castraton. Rare"$ t #a$ he a 'eature o' ecto!c hor#ona"

!roducton n broncha" carcno#a and n adrena" and !tutar$ dsease.

Assocated -th "e!ros$

>$naeco#asta s ver$ co##on n #en su''ern& 'ro# "e!ros$. Ths s !ossb"$

because o' b"atera" testcu"ar atro!h$% -hch s a 'reuent acco#!an#ent o' "e!ros$.

Assocated -th "ver 'a"ure

>$naeco#asta so#et#es occurs n !atents -th crrhoss due to 'a"ure o' the "ver

to #etabo"se oestro&ens. It s assocated -th dru&s that nter'ere -th the he!atc

#etabo"s# o' oestro&ens% such as c#etdne.>$naeco#asta #a$ occur n !atents -th "ne'e"ter9s s$ndro#e% a se* chro#oso#e

ano#a"$ havn& ==K trso#$. It s a"so seen -th certan dru&s such as c#etdne%

d&ta"s and s!rono"actone.

Treat#ent

rovded the !atent s hea"th$ and co#!aratve"$ $oun&% reassurance #a$ be

su''cent. I' not #astecto#$ -th !reservaton o' the areo"a and n!!"e can be

!er'or#ed.

Carcno#a o' the #a"e breast

Carcno#a o' the #a"e breast 8&s /)./( and /)./?: accounts 'or "ess than ( !er cent

o' a"" cases o' breast cancer. The 2no-n !reds!osn& causes nc"ude &$naeco#asta

and e*cess endo&enous or e*o&enous oestro&en. As n the 'e#a"e t tends to !resent as

a "u#! and s #ost co##on"$ an n'"tratn& ducta" carcno#a.

Treat#ent

Sta&e 'or sta&e the treat#ent s the sa#e as 'or carcno#a n the 'e#a"e and !ro&noss

de!ends u!on sta&e at !resentaton. Adeuate "oca" e*cson% because o' the s#a"" s3e

o' the breast% shou"d a"-a$s be -th a #astecto#$

Other tu#ours o' the breast

L!o#a

A true "!o#a s ver$ rare.

Sarco#a o' the breastSarco#a o' the breast s usua""$ o' the s!nd"e1ce"" varet$% and accounts 'or 5.6 !er

cent o' #a"&nant tu#ours o' the breast. So#e o' these &ro-ths arse n an

ntracana"cu"ar 'broadeno#a or #a$ 'o""o- !revous radothera!$% e.&. 'or

Hod&2n9s "$#!ho#a #an$ $ears !revous"$. It #a$ be #!ossb"e to dstn&ush

c"nca""$ a sarco#a o' the breast 'ro# a #edu""ar$ carcno#a% hut areas o' c$stc

de&eneraton su&&est a sarco#a and on ncsn& the neo!"as# t s !a"e and 'rab"e.

Sarco#a tends to occur n $oun&er -o#en bet-een the a&es o' ?5 and /5. Treat#ent

s b$ s#!"e #astecto#$ 'o""o-ed b$ radothera!$. The !ro&noss de!ends on the

sta&e and hsto"o&ca" t$!e.

Metastases

On rare occasons% cancer e"se-here #a$ !resent -th a #etastass n the breast. Thebreast s a"so occasona""$ n'"trated b$ Hod&2n9s dsease and other "$#!ho#as.

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urther readn&

D*on% M. and Sansbur$% R. 80@@?: Dseases o' the Breast% Church"" Lvn&stone%

Ednbur&h.

Harrs% F.R.% He""#an% S.% Henderson% F.C. and nne% D. 80@,+: Breast Dsease%

L!!ncott% h"ade"!ha% A.Ha$es% D.. 80@@?: At"as o' Breast Cancer% o"'e% London.

Hu&hes% L.E.% Manse"% R.E. and ebster% D.F.T. 80@,@: Ben&n Dsorders and

Dseases o' the Breast% Ba""ere Tnda""% London.

Manse"% R.E. and Bundred% N.F. 80@@): Co"our At"as o' Breast Dseases% Mosb$1

o"'e% London.

o-"es% T.F. and S#th% I.E. 80@@0: Medca" Mana&e#ent o' Breast Cancer% Martn

Dunt3% London.