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Malignant diseases of the breast

Malignant diseases of the breast. Michael G . Hala s ka Dept. of Obstetrics and Gynecology 2nd Medical Faculty, Charles University. I. The breast. reprodu cion - nutrition se condary sexual sign - maturition of the women , important role in sexual life

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Malignant diseases of the breast

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  1. Malignant diseases of the breast Michael G. Halaska Dept. of Obstetrics and Gynecology 2nd Medical Faculty, Charles University

  2. I. The breast • reproducion - nutrition • secondarysexual sign-maturition of the women, important role in sexual life • S. Freud – the role of the breast in the satisfaction of oral libido

  3. II. The structure of the gland • 15-20 lobus,which is divided into 20-40 lobulus • basic structure of the gland: terminalductolobularunit (TDLU) - consists of acini and terminal intralobular duct - hormonally sensitive, estrogens - ductus,progesteron, prolaktin - lobus - size 0,3-0,6 mm (10-100/lobulus)

  4. II. Structure - TDLU

  5. II. Structure - arterial supply • rr. perforantes from a. mammaria interna (a. thoracica interna) • a. mammaria externa (a. thoracica lateralis) • a. thoracoacromialis • a. thoracica suprema(a. axillaris)

  6. II. Structure - venous supply • circulus Luschke • circulus Halleri (under the areola)

  7. II. Structure- lympahytic supply • lateral parts along a. thoracica lateralis intothe axilla • upper parts to the apical axilla andsubclavicular lymph n. • internal parts - a. thoracica interna - mediastinal lymph n.

  8. III. Examination methods • self-examination (2-3 cm) • physical exam – aspection, palpation (1-2cm) • US - excellent differenciation between solid and cystic structure -complementory to MG,young women with higher density of the gland - pregnant women • MRI, CT, SPECT, PET • ductography

  9. III. Examination methods • cytology a) secretory: from the nipple b) punction (FNA) -not by an suspition of malignity - 15-20% false negative benign malign

  10. III. Examination methods • punctional biopsy – core-cut biopsy • open biopsy

  11. III. Examination methods c) Mammotome - vacuum assisted - not possible to evaluate the borders d) ABBI - 3D localisation - 20 mm diameter - possible to evaluate the borders

  12. III. Exam. m.- mammography • over 35 y. • detection ability: from 1-3 mm • dose 0,1-0,2 rad a) screening: 1. entry 35-40 y, 2. 40-50 yevery 2 y., 3. over 50 yevery 1 y (- 75 y.) - mortality reduction 20-45% b) diagnostic

  13. III. Exam. m.- mammography

  14. III. Exam. m.- mammography

  15. 1a. Fibroadenoma • round, well circumscribed • from lobulus • proliferation of epithelial and stromal components • hormonally dependent • a) pericanalicular • b) intracanalicular

  16. 1b. Fibroadenoma • doesn´t increase the risk of breast cancer • therapy: - conservative: follow-up every 6 month - radical: surgical extirpation • italian study: extirpation leads to RR=2,0 (only follow-up) RR=0,97

  17. 2. Cysts • one of the most common changes • from the lobular acini • proliferation of the stromal component • leads to an increased density of the gland • therapy: conservative or punction of the cyst

  18. 3a. Fibrocystic changes • present at 50-90% of women between 35-50 years of age, often asymptomatic • dysproportion of the involution - decrease of the amount of the stromal component (dominance of epithelial component) • histopathologic finding: fibrosis, cysts, adenosis, lymfoid infiltration, periductalinflammation

  19. 3b. Fibrocystic changes • intensity of „mastopatic“ changes which doesn´t correlate with the intensity of complaints • belongs to non-proliferative lesions of the breast • zero proliferation indexes • lead to worse mammographic lucidity • therapy: conservative

  20. 4a. Papiloma • from the main ductus • serose or bloody secretion from the nipple • therapy: extirpation

  21. 4b. Juvenile papilomatosis • young women (under 20 years) • solid, palpable formation (2-3cm) • often upper outer quadrant • multicystic

  22. 4c. Multifocal papilomatosis • from TDLU • combination of epithelial and cystic changes • precancerosis • therapy: extirpation, dispensarisation

  23. 5. Cystosarcoma phylloides • phyloides tumor • proliferation of stromal component • histologicaly commemorates intracanalicular fibroadenoma • often metaplasy: bone • therapy: extirpation, often relaps

  24. 6. Rare tumours • lipoma • adenolipoma • myoepitelioma • desmoidal tumour

  25. 7. Inflammation • juvenile hypertrophy - stromal hyperplasy • duktektasis - dilatation of the large ductus • in perimenopausis or menopausis • mechanical obstruction (deficiency of vit. A) • cyklic mastodynie, palp. lesion, inflammation signs therapy: symptomatic, ATB, excision • subareolar absces - chronic fistula • therapy: incision, drainage, ATB • fat necrosis - trauma, radiotherapy, surgery

  26. V. Carcinoma in situ A) Ductal carcinoma in situ – DCIS B) Lobular carcinoma in situ – LCIS • RR amplified 8-10x

  27. A) Ductal carcinoma in situ • ductal epithelium has been replaced by carcinoma cells which doesn´t penetrate the basal membrane • often recidives in the place of biopsy • microcalcifications often present • therapy: extirpation + radioterapy or simple mastectomy

  28. B) Lobular carcinoma in situ • few clinical features • no microcalcifications • in 15-45% bilateral • recidives bilateral • LCIS – high risk

  29. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Kancerogenesis • Characteristics of the tumour cell • Therapy

  30. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  31. 1a. Histologic type • ductalcarcinoma: 70-80% • intraductal c.- type of DCIS • lobularcarcinoma - 10 % - difficult to detect by mammography (no calcifications) • medullarcarcinoma - up to 5% - good prognosis, doesn´t involve lymph nodes • mucinous - coloid carcinoma - 3% - veryslow growth • papilarcarcinoma - 1% - bloody secretion

  32. 1b. Histologic type - special ca • inflammatorycarcinoma – 1-4%, erythema, increased temperature, surgical treatment contraindicated, primary treatment: radiotherapy • Paget´sdisease (carcinoma) – 4-5%, erosive lesion of the nipple

  33. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  34. 2. Staging T1 – tumour < 2 cm T2 – tumour 2-5 cm T3 – tumourover 5cm T4 – penetration of the tumour into the chest N1 – isolated metastasis, moveable l. nodes N2 – isolated metastasis, fixated l. nodes N3 – metastasis in internal mammaryl. nodes M1 – distant metastasis

  35. 2. Staging - metastasis Brain + Skin + Lung + + + Pleura + + + Liver + + Adrenals + + Bone + + + +

  36. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  37. 3. Prognosis • smaller than 1cm: survival rate 90-95% • tumor 2-3 cm: survival rate 65% • involvement of 1-3 LN: survival rate 62% • involvment of more than 4 LN: survival rate 32% • positivity of estrogen/progesterone receptors • EGF receptor – worse grade, lymfatic invasion

  38. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  39. 4a. Risk factors Cancer Commitee of the College of American Pathologists, 1998

  40. 4b. Risk factors • sex - frequency of ca female x male: 135 : 1 • age - 65 years over 30 years: RR 17 • absolute risk in 50 years: 7-10% • menarche – early onset: RR 2 • first delivery – delivery after 20. year: RR 2-3 • menopausis – late menopausis: RR 2 • breast feeding over 1 year reduces the risk by 20%

  41. 4c. Risk factors • FH - 1.line: RR 2 - 3 - 2.line: RR do 1,5 • genetic carcinomabreast/ovary (BRCA 1,2) - tumoursupresor gen, AD heriditary - absolute risk: 85% • life style, body weight – alcohol, obesity (BMI > 35),hyperinsulinemie

  42. 4d. Risk factors • environment – chemicalcancerogens, genotoxic substances • society status: high socioeconomic standart, stress • radiation • drugs- prolactine agonists • HRT -slight elevation by the use over 10 years (kontroversy)

  43. 4e. Epidemiology incidence: 90/100 000, mortality: 35/100 000

  44. 4f. Epidemiology

  45. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  46. 5. Cancerogenesis • oncogene activation • genetics: genes BRCA 1,2, p53 1. Iniciation: during menarche - first deliverycancerogenes, radiation, nutrition, endogenous hormones 2. Promotion: premenopausis (hormones) • postmenopausis - failure of apoptosis, failure of control of the cell cycle

  47. 5. Cancerogenesis Menarche lifestyle 1. delivery defekty apoptozy, antioxydační ochrany, opravy DNA 1020 30 40 50 accumultaion of defect DNA INDUCTIONCancerogens Radiation Hormones PROMOTION Hormones Growth factors carcinoma BRCA

  48. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

  49. 6. Characteristics of tumour cell • no control of proliferation • loss of intercell adhesion • loss of epithelium-stromal interaction (loss of contact inhibition of growth) • loss of diferenciation • elevated metabolic activity • changes of HR, abnormal reaction to hormones

  50. VI. Invasive breast carcinoma • Histologic type • Staging • Prognosis • Risk factors • Cancerogenesis • Characteristics of the tumour cell • Therapy

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