Breast Cancer
Anatomy of the breast
The breast consists of 15 to 20 lobes, or mammary glands, each containing several lobules.
There is fatty tissue around the milk glands, just under the breast skin.
The milk ducts coming from the mammary glands unite and open to the nipple.
The pigments located on the skin of the nipple complex darken during puberty and form the area called areola.
The areola contains sebaceous glands and sweat glands.
There are also accessory glands called Montgomery tubercles, which form small elevations on the surface of the areola.
Throughout pregnancy, the areola enlarges and pigmentation increases further.
The upper outer quadrant of the breast contains a larger volume of tissue than other quadrants. It has a protruding conical form. The base of the cone is roughly circular and is 10 to 12 cm in diameter.
There is significant variation between individuals in the size, contour, and density of the breast.
The lymph flow of the breast is mostly towards the lymph nodes in the armpit.
How is breast cancer screening done in Turkey?
All developed countries in the world implement breast cancer screening programs.
In accordance with the decision taken by the relevant institutions of each country, women who do not have any complaints are subjected to regular mammographic screening.
The age ranges and screening frequencies of women included in screening vary slightly in each country.
The Turkish Ministry of Health implements the breast cancer screening program in Turkey for women between the ages of 40-69.
According to the program, all women between the ages of 40-69 are invited for regular mammography screening , even if they do not have any complaints.
The program is carried out by Cancer Early Diagnosis, Screening and Training Centers [KETEM] within Family Health Centers (FHC) and Community Health Centers (CHC).
In the free program, women who have no problems with screening mammography are scheduled for follow-up mammography two years later.
If any suspicious findings are detected in the screening program, they are referred to general surgeons or breast surgeons who specialize in this field for further examination and, if necessary, treatment.
What are the risk factors of breast cancer?
Genetic predisposition is the most important risk factor in breast cancer.
The susceptibility to breast cancer and ovarian cancer increases, especially as a result of damage to the tumor suppressor genes called BRCA1 and BRCA2.
As a precaution to reduce the risk in patients with mutations in these two genes;
a) mastectomy (removal of breast tissue) and new breast construction (reconstruction),
b) removal of the uterus and ovaries,
c) close monitoring for breast and ovarian cancer and
d) preventive medication (chemoprevention) can be applied.
Increasing exposure time to estrogen increases the risk of breast cancer.
On the other hand, reducing the duration of exposure to estrogen is thought to be protective in terms of breast cancer risk.
Accordingly, factors that increase the number of menstrual cycles; For example, starting menstruation at an early age, not giving birth, and entering menopause late increase the risk of breast cancer.
Additionally, having your first live birth at an older age also increases the risk of breast cancer.
Finally, there is an association between obesity and increased risk of breast cancer, especially in pre-menopausal women.
Moderate exercise and longer periods of breastfeeding are thought to reduce the risk of breast cancer.
Non-hormonal risk factors include; exposure to radiation, increased alcohol consumption, and long-term consumption of foods with high fat content.
It is also argued that factors such as stressful life, inability to control anger, and depression may be related to the development of breast cancer.
In a woman who has had breast cancer before, the risk of developing a new breast cancer in the same breast or the other breast is slightly higher than in other women.
What are the symptoms of breast cancer?
In 70% of women with breast cancer, the first symptom is the presence of a usually painless, hard and immobile mass in the breast.
The mass generally moves with the surrounding breast tissue. This feature distinguishes it from fibroadenoma.
The boundaries of the crowd are often not well defined. It has an irregular surface.
Sometimes the mass may create asymmetry in the breast or reach a size that is noticeable to the eye. This may become more evident by lifting the arms up or leaning forward.
Tumors located close to the nipple can sometimes cause the nipple to collapse inwards.
Nipple discharge may be the first symptom in approximately 10% of women with breast cancer.
Nearly 90% of spontaneous discharges have a benign cause. However, research and investigations need to be carried out to reveal the cause of the discharge.
Causes of spontaneous nipple discharge include puberty, the last three months of pregnancy, the beginning of breastfeeding, long-term use of birth control pills and menopause.
In 2% of patients, cancer may first manifest itself as an eczema-like wound that may involve the nipple , then the painted area, and in the later stages, an ulcerated wound.
In 2-4% of patients, cancer occurs with signs of inflammation and infection.
The complaint of approximately 50% of patients applying to breast polyclinics is pain in the breast.
However, the majority of breast cancer patients do not experience pain, especially in the early stages.
Breast cancer that does not cause clinical symptoms and begins with only complaints of pain is rare.
Breast cancer can sometimes present itself only with swelling in the armpit.
How is breast cancer surgically treated?
The primary treatment for early breast cancer is surgery.
Which surgical method will be applied is decided by taking into account patient characteristics and other clinical and pathological variables.
The patient's characteristics such as age, family history, menopause status and general health are evaluated. Some patients may undergo genetic testing for BRCA gene mutations at the time of diagnosis.
For some risky patients, it may be recommended to remove both breasts in addition to the breast that usually has cancer, to reduce the risk of cancer in the opposite breast.
For surgery, the location of the tumor in the breast and the size of the tumor are evaluated according to the size of the breast.
What is modified radical mastectomy? In what situations is it done?
The primary treatment for early breast cancer is surgery.
Which surgical method will be applied is decided by taking into account patient characteristics and other clinical and pathological variables.
The patient's characteristics such as age, family history, menopause status and general health are evaluated. Some patients may undergo genetic testing for BRCA gene mutations at the time of diagnosis.
Some high-risk patients with breast cancer may be advised to have both breasts removed, usually to reduce the risk of breast cancer.
For surgical planning, the location of the tumor in the breast and the size of the tumor are evaluated according to the size of the breast.
What is simple mastectomy? In what situations is it done?
It is a surgery to remove the entire breast tissue, including the skin above it and the nipple, without touching the armpit lymph nodes .
Simple mastectomy candidates;
Patients with the beginning of cancer (ductal carcinoma in situ),
Patients with recurrent tumors after breast-conserving surgery,
Patients requiring preventive (prophylactic) mastectomy and
These are patients with advanced tumors that are ulcerated and/or bleeding (toilet mastectomy).
What is breast-conserving surgery? In what situations is it done?
Breast-conserving surgery is simply the removal of the tumor along with some intact breast tissue around it and examination of the armpit lymph nodes.
After this surgery , radiation therapy (radiotherapy) is performed to destroy any tumor cells that may remain around the surgery area.
Breast-conserving surgery has become as common as total breast removal (MRM).
Radiotherapy applied after breast-conserving surgery reduces local recurrence rates to 12%. Thus, it enabled MKC to be an alternative to MRM.
Breast-conserving surgery;
Presence of widespread cancer in the breast,
Pregnancy,
Previous radiotherapy to the chest wall,
Presence of some other diseases,
Breast-tumor disproportion,
The patient does not prefer BCS and
It is not applied in case of tumor larger than 5 cm.
What is preventive (prophylactic) mastectomy? In what situations is it done?
Preventive (prophylactic) mastectomy; It refers to the removal of all breast tissue from a woman with a high risk of breast cancer before cancer develops.
This surgery is principally performed to reduce risk.
It can be applied to women with a strong family history of breast cancer, whether or not they have BRCA1/BRCA2 gene mutations, after all options are explained.
Having a strong history of breast cancer in their family or themselves,
Having risk factors for lobular carcinoma in situ or atypical hyperplasia,
Those with risky genetic structure or
Women who have had breast biopsies multiple times in the past are candidates for prophylactic mastectomy.
What is skin-sparing mastectomy? In what situations is it done?
Skin-sparing mastectomy is the process of removing all breast tissue, including the nipple and the dark colored area around it, while preserving the breast skin.
It is a variant of simple mastectomy and is another option to achieve excellent cosmetic results.
The surgery is completed by placing a breast prosthesis in place of the removed tissue.
What is sentinel lymph node biopsy? In what situations is it done?
The condition of the armpit lymph nodes is an important factor in determining the course of the disease in women with breast cancer.
In patients with early-stage breast cancer and no pathological lymph nodes in the armpit during examination, examining the axillary lymph nodes during surgery and cleaning them, if necessary, has become the gold standard today.
Thus, it is possible to reduce some of the complications expected to arise from surgery. The risk of lymphedema, which may develop especially after surgery, is reduced.
Performing SLNB with blue dye and/or lymphoscintigraphy in such patients prevents unnecessary removal of the axillary lymph nodes in the majority of these patients. Accordingly, undesirable side effects and economic losses are reduced.
In sentinel lymph node biopsy; Before surgery, a radioactive substance is injected into the breast to mark the first lymph nodes leading to the armpit. This marking is sometimes made by injecting a blue liquid into the breast during surgery. These two methods can also be applied together.
Then, if only radioactive material is given, a special detector is used, if only blue dye is given, samples are taken from the lymph nodes leading to the armpit. If both are applied, lymph nodes are searched with both the detector and the eye.
The lymph nodes found are sent to pathology to detect the presence of cancer while the surgery continues. According to the pathology report, if the cancer has spread, the armpit lymph nodes are completely removed. If there is no splashing, the armpit lymph nodes are not touched.
What is Paget's disease? What are the symptoms? How is it treated?
Paget's disease accounts for less than 1% of breast cancers.
It is clinically characterized by redness, itching and associated irritation on the nipple and the dark area around it.
Crusting and ulceration may also occur on the nipple. It can be confused with eczema, contact dermatitis, and post-radiation dermatitis.
Diagnosis is made by surgical biopsy of the nipple and problem area.
More than 95% of patients with Paget's disease have an underlying breast cancer . A palpable mass is detected in slightly more than half of the patients.
Treatment ; Although it can be done by removing intact breast tissue from around the nipple and dark area, it usually involves removing the entire breast (mastectomy) and examining whether there is any spread to the armpit lymph nodes .
What is inflammatory breast cancer? What are the symptoms? How is it treated?
Inflammatory tumors are a rare (1-5%) but dangerous form of breast cancer.
Among its symptoms;
There is skin edema (orange peel appearance) on 1/3 or more of the breast skin, redness and increased temperature of the breast skin.
For this reason, it may be thought to be mastitis and treatment with antibiotics may be tried initially.
However, if there is redness and painful breast inflammation that does not subside with antibiotic treatment, a surgical biopsy involving the skin and subcutaneous tissue is required to determine whether inflammatory breast cancer is present.
Treatment of inflammatory breast cancer begins with chemotherapy.
After surgery, the breast is removed (mastectomy) and the condition of the armpit lymph nodes is examined.
Following the surgery, treatment is continued with chemotherapy and radiotherapy.
Is breast cancer seen in males? What are the symptoms? How is it treated?
Approximately 1% of all breast cancers occur in males.
They are usually noticed as a palpable mass in the breast.
Sometimes the armpit lymph nodes may also become enlarged.
Diagnosis and treatment are done just like breast cancer in women.
Breast cancer during pregnancy
In the presence of breast cancer detected during pregnancy, both the mother and the fetus are taken into consideration.
In general, pregnant women with breast cancer are treated the same as non-pregnant patients, except for some changes that need to be made to protect the fetus.
Breast cancer treatment should not be unnecessarily delayed due to pregnancy.
Termination of pregnancy does not help treat breast cancer better. However, if necessary, termination of pregnancy is considered. During the evaluation phase, diagnostic methods that involve radiation (such as mammography) are avoided to protect the fetus.
The first three months are the most critical period for the organ development of the fetus in the womb. For this reason, although surgical treatment can be performed at any stage of pregnancy, if possible, it is applied from the fourth month.
Pregnancy can be terminated in breast cancer surgeries that must be performed within the first three months. Since radiotherapy is required later, removal of the entire breast (mastectomy) is often preferred in breast cancer surgeries performed during pregnancy. Armpit lymph nodes may be removed or evaluated during surgery.
Treatment methods such as chemotherapy and radiotherapy are evaluated and applied individually for each patient.