유 방 암 , 유방종괴

1. 유 방 암, 유방종괴 충무병원 내분비 연구소 유방,갑상선 클리닉 류 진 우 2004년 1월 27일

2. Female cancer • USA : breast, colon, lung • Japan : stomach, breast, colon • Korea : breast,stomach,uterine cervix (2002, 한국암통계)

3. Breast cancer incidence • USA : 80-100 / 100,000 / year • Japan : 30-40 / 100,000 / year • Korea : 20-25 / 100,000 / year • (매년 약 7000명 신환) • World : 29.8 / 100,000 / year

4. 유방종괴 • 유방암 • 정확한 진단 : 조직학적 진단의 필요성 • 적절한 치료 : 연령, 임신, 수유, 과거력

5. Tabar’s Data(Two-country Swedish screening Trial) • Breast Cancer is localized to the breast for a variable period of time before development of systemic disease • Time to diagnosis becomes critical : the earlier breast cancer is detected, the less likely it is to have become systemic • Irrespective of tumor grade and nodal status, breast cancers less than 1cm in size have a 12-year survival rate of approximately 95% • Node-negative breast cancers less than 1.5cm in size have 12-year survival rate of approximately 94%

6. History Taking • 기간 • 변화 : 생리주기, 형태변화 • 임신, 수유 – galactocele 폐경증후군, 호르몬 치료 – nodularity 외상, 충격 – hematoma, fat necrosis • 유두 분비물 – bloody discharge • 타 병원 진료 기록

7. Improtant Findings from historyin patient with palpable mass • Menstrual cycle • Pregnancy or lactation • Hormone use • Nipple discharge • Prior biopsy diagnosis • Cancer history • Etc.

8. Physical Examination • Comfortable situation • Inspection : sitting position, raising hands • Palpation – from clavicle to inframmary fold - from sternum to mid-axillary line - Horizontal, circular, vertical fashion on pulp of finger - nipple squeezing • Agree with patient’s complaint • Menstrual cycle

9. Suggests benigan Soft Discrete Mobile Multiple Suggests malignant Firm, Fixed, Hard Indiscrete Solitary Skin dimpling Nipple retraction Bloody nipple discharge Findings from physical examination

10. Diagnosis - Mammography • Negative mammography – only the radiologist sees no radiographic evidence of malignancy • American Cancer Society recommendation - Baseline age 35 to 40 - every 1 or 2 years in 40 to 49 y-o-women - Annual Mammography in women over age 50 - Monthly breast self-examination - Annual physical examination by health-care provider • Hish risk group : Screening is started 10 yrs earlier (ago 30)

11. Mammography Screening, breast cancers are missed : • If the threshold for intervention is high (if we wait until a lesion is obviously cancer before recommending biopsy) • If the screening intervals are too long • It is generally accepted that breast cancers grow more quickly in premenopausal women, so we recommend annual screening mammograms in all women starting at ago 40

12. Diagnosis - ultrasonography • Solid Mass VS cystic mass • Benign mass VS malignant mass • Dense Breast in mammography

13. Management • Biopsy– Diagnosis and Treatment - Two-step procedure in malignant cases • FNAB Core Biopsy (ABBI) Incision Biopsy Excision Biopsy

14. Needle localisation biopsy Needle localisation biopsy. (a) Hawkins 2 needle inserted from above with needle tip close to microcalcifications(arrowed). Calcifications were new on second screen having been absent 3 years previously. Stereotactic cytology was positive for cancer. (b) Specimen radiograph confirming excision of calcifications(arrowed). Note ligaclips used to orientate specimen. Histology showed 10 mm zone of large cell comedo ductal carcinoma in situ (DCIS) with 5 mm margins. Patient was randomised to receive tamoxifen as part of DCIS trial.

16. A mammotome Under stereotactic or ultrasound guidance the probe is positioned in the breast to align the aperture with the lesion. Tissue is gently vacuum aspirated into the aperture and the rotating cutter is advanced forward. The cutter is withdrawn, transporting the specimen to the tissue collection chamber while the outer probe remains in the breast. With permission from Ethicon Endo-surgery, Bracknell, Berkshire.

18. Management

19. Management-Biopsy • Circum - areola incision : Tunnel method • Incision on mass : suspicious or malignant

20. Management of nipple discharge Management of nipple discharge No lump Lump management appropriate to lump Milky discharge Exclude mechanical stimulation drugs, hormones, prolactinoma, then ressure Watery, serous serosanguineous, bloody discharge Coloured opalescent discharge physical examination mammography if ＞35 years old Slight or moderate Reassure Profuse Major duct excision if patient wishes it ＞40 years old mammography ＜40 years old Abnormality Treat appropriately No abnormality Localised to one duct Cannot be localised or multiple ducts Can be llocalised to one duct Bleeding ceased, therefore no localisation Major duct excision or microdochectomy Major duct excision and segmental resections if peripheral duct involved Microdochectomy Mammography ＞35 years old Observe 4/12 for 1 year Further bleedint No further bleeding Discharge patient

21. Causes of secondary gynaecomastia

22. Management of Cancer Patient • Mod Radical Mastectomy • MRM + M-plasty • Skin Sparing Mastectomy • Breast Conservation Operation

23. 유방암 수술 • Modified Radical Mastectomy • Breast Conserving Operation • Immediate Reconstruction with Implant

24. Proportional risk reductions with polychemotherapy subdivided by age at randomization

25. Advantages and disadvantages of adjuvant and primary systemic therapy

26. Adjuvant treatment for patients with breast cancer

27. Definitions of risk groups and associated risk of relapse

28. St Gallen Consensus,2003 • Node negative (Intermed, High risk) Pre-meno Post-meno ER/PR pos ER/PR pos OS, Tamo Tamo or or Chemo, Tamo Arimidex or or Chemo, OS withh or out Tam Chemo add A,T

29. 항암제의 분류 • 화학요법제 DNA alkylating: Busulfan Metabolites: Methotrexate, 5-FU Natural products: Taxol, Doxorubicin, Vinca-alkaloids, Mitomycin Hormones: Tamoxifen, Raloxifen, Pred Others: Carboplatin, Mitoxantron

30. 항암제의 분류 2 • 생물 요법제 면역요법- Cytokines: IL-2, INF, G-CSF R Ab: Herceptin, Iressa, Alimta Tumor Vaccine: processing 유전자 치료- Antisense p53, Toxin Angiogenesis MDR

31. Current endocrine therapies in clinical use * Not available in market place