breast surgery - benign and malignant

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Breast Surgery

Tim Davidson

Consultant Surgeon Royal Free Hospital

7 December 2007

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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

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BC as cause of dying in women

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Breast MRI

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breast cancer surgery:

to conserve the breast ?

60% 40%

peripheral central

< 4cm > 4cmunifocal multifocal

WLE + axillary MASTECTOMY

staging (BREAST + axillaryCONSERVATION) staging

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unifocal cancer 

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wide local excision

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wide local excision + radiotherapy

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multifocal cancer 

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mastectomy

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FIGURE 15.2

modified radical mastectomy

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Halsted

radical

mastectomy

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mastectomy and

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risk of local recurrence and

age EORTC trial 10854

Months

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Breast cancer surgery: 

axillary node staging

peripheral central

<4cm >4cmunifocal multifocal

WLE + axillary MASTECTOMY

staging + axillary

+ post-op RT staging

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Back to ContentsBack to Chapter 13 thumbnails

Nottingham Prognostic Index (NPI)

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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

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screening: NHS BSP

invitations between 50 - 70

not symptomatic clinics mammograms only; recall

aim = mortality reduction

possible reduction by 25

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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

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Breast cancer : UK statistics

Incidence

• 1988 25,000

• 2003 40,000

Mortality

• 1988 16,000

• 2003 12,000

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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

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BREAST

CANCER

STANDARD 

RISK  97%(RR<2)

MOD RISK

2% (RR 2-3)

HIGH RISK

<1% (RR>3)

RISK GROUPS

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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%)

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Bilateral mastectomy and latissimus

dorsi flap reconstruction

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Breast cancer surgery

Paradox of extent of surgery

  advanced disease

invasive early breast cancer 

noninvasive disease (DCIS, LCIS)

surgery for risk reduction

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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

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Reduction in contralateral cancers

with tamoxifen v AIs

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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

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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

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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

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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

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Breast cancer : UK statistics

Incidence

• 1988 25,000

• 2003 40,000

Mortality

• 1988 16,000

• 2003 12,000

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benign breast

problems  surgery less often required

day case procedures

benign : malignant = 20:1

worried well

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cyst aspiration

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cyst aspiration

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b i l

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benign lump

l t

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lumpectomy

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Peri-ductal

mastitis

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invertednipple

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accessory

nipple

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