THE PRINCIPAL QUESTIONS CONCERNS THE TUMOR OF THE BREAST

MAIN QUESTIONS ABOUT BENIGN AND MALIGNANT PATHOLOGY OF THE BREAST

Do Mammary cysts, fibroadenomas and fibrocistic mastopathy predispose to breast cancer?

Mammary cists, fibroadenomas and fibrocistic mastopathy represent common benign illnesses of the breast, normally without tendency to degenerate in malignant sense . The presence in a patient of such alterations doesn't have to generate unjustified alarmisms, but simply stimulate to a more frequent senological control, because mammary glands in this cases result of more difficult and complex evaluation.

Do fibroadenomas have to be always removed?

Fibroadenomas - as said - don't have tendency to degenerate in malignant sense. For such motive removing systematically all fibroadenomas is not necessary, in particular in presence of multiple fibroadenomas. The actual tendency is to set indication to intervention only in case of diagnostic doubt or in presence of fibroadenomas with rapid growth or with such dimensions ( superior to 3-4 centimetres ) to determine psychological or aesthetical problems in the patients.

Does lactation have to be interrupted in case of acute mastitis during the nursing?

It's not necessary to interrupt breast lactation of the newborn in case of acute mastitis. The secretion of bacteria with the milk doesn't constitute in fact a danger for the health of the child and - of other part - the interruption of lactation provokes a worsening of milk stagnation, with further inflammatory stimulus to the breast. The patient has then to be encouraged to continue the nursing. Eventually - in alternative - the nutrition of the newborn may be continued with the healthy breast, having care to empty manually the sick breast.

Is mammary pain an alarming symptom?

Mammary pain ( mastalgia ) is the mammary symptom most frequently found in women from the puberty to the menopause. As a rule, breast pain is not a worrisome symptom and has usually a benign meaning . Especially in the young patients, the presence of a cyclical , unilateral or bilateral mammary pain - that usually get worse in proximity of the menstrual cycle -absolutely doesn't have to alarm and is not worthy of particular diagnostic checks.. With more attention has to be considered a localized, fixed and persistent mammary pain in a post-menopausal woman. In a little percentage of cases, in fact, this mammary pain may be the first symptom of a breast carcinoma in initial phase. In these patients the execution of a mammography is an useful diagnostic test.

When do secretions from the nipple have to alarm?

Mammary secretions, if bilateral, pluriorifitials and of lactescent or yellow-brown-greenish color, are related to benign pathology and don't have to worry the patients. Instead monoorifitials hematic or sero-hematic secretions need further diagnostic tests ( cytologic examination, echography, mammography ) to exclude the presence of breast cancer.

Is breast cancer a familiar illness?

Without doubt exists a family predisposition to develop a mammary carcinoma . A relative of first degree of a patient with breast cancer has a double risk to develop a mammary tumor in comparison with control population. Some cases of mammary carcinoma ( fortunately rare: 5% of the cases ) have a strict hereditary transmission. They are associated with mutations of two genes, called BRCA-1 and BRCA-2, which encode proteins that partecipate in the cellular response to DNA damage; inactivating mutations in these genes heighten susceptibility not only to breast but also to ovarian cancer. These ereditary cases generally involve patients in juvenile age and are often bilateral. A carrier of BRCA-1 or BRCA-2 mutation has an extremely elevated risk (80%) to develop in the course of life a mammary carcinoma, often, as said, in juvenile age.

Are contraceptive pill or hormonal treatments for menopause able to cause breast cancer?

The problem of the relationship among hormonal estrogenic treatments ( contraceptive pill and substitutive hormonal therapy in menopause ) is still today broadly debated and not entirely clarified.

Contraceptive pill is able to increase of about 20% the risk to develop a mammary neoplasia . Such increase in risk extinguishes after ten years from the suspension of the contraceptive treatment: ten years after the term of the assumption of the pill the risk to develop a mammary carcinoma returns to be the same of the women that have never assumed contraceptives. The increased risk of mammary carcinoma results in per cent more meaningful in women that began to assume the pill more precociously - in particular under the twenty years - and that used the contraceptive for a long period (over the 10 years ).

Now we consider shortly the discourse of the mammary carcinogenic risk related to the substitutive hormonal treatment in menopause . Treatments of 5 years or less do not increase the risk to develop a neoplasia of the mammary gland. Treatments superior to 5 years are instead associated to a risk increase in the order of the 20-40%. . The hormonal treatment determines besides, in the 20-25% of cases, modifications of the mammographic aspect of the breasts, that are able to reduce the identification of mammary carcinoma in precocious phase. Post-menopausal women in substitutive hormonal treatment have therefore to perform a mammography annually, in association to a mammary echography.

In any case a previous carcinoma is considered a contraindication to the treatment with estrogenic substances ( contraceptive pill and substitutive hormonal therapy in menopause ); in the same way the familiarity for breast cancer contraindicates a therapy with estrogens : women with a family history for mammary tumors, if treated with estrogens, have a risk of mammary carcinoma more that doubled in comparison with patients without family history and submitted to hormonal therapy.

When does mammographic screening have to begin in the asymptomatic woman?

Even this is an enough controversial matter, that still not finds unanimous answers to international level.

In accordance with the indications of various Cancer Societies, we recommend to submit asimptomatic patients to screening mammography at least every two years from the 40 years of age, till the 70 years of age.

Of course we have not to confuse the screening in an asymptomatic woman, finalized to discover silent tumors in precocious phase, with the diagnostic tests that have to be performed in a patient affected by a mammary nodule: the suspect of a mammary tumor imposes the execution of a mammography ( and in case of an echography and a biopsy of the suspect lesion) even in a patient under the 40 years of age.

Which controls - and when - are advisable in a woman with familiar cases of breast cancer ?

In a woman with familiarity for mammary carcinoma ( presence of two relatives of first degree with history of mammary neoplasia ) the mammographic controls have to begin at 35 years of age and have to be continued with annual recurrence . When the family cases involves persons in juvenile age, an hereditary illness has to be suspected and a genetic test can be performed to evaluate the presence of mutations of genes BRCA-1 and BRCA-2; in these patients, the annual mammographic controls have to begin at 25 years of age and however five years before the age when breast cancer has been diagnosed in the family member.

Is mammography more useful than mammary ecography in the diagnosis of mammary illnesses?

Mammography and mammary ecography have to be considered, in the symptomatic woman ( that is a woman with a mammary swelling ), two diagnostic investigations not alternative but complementary. In presence of a suspect nodule, any is the age of the patient, only the combination of the informations derived from the two examinations allow a correct diagnosis.

In the young woman, however - given the rarity of breast cancer at this age - in presence of nodules without characteristics typical of malignant neoplasia, may be correct to perform only a mammary echography.

Echography is not in any case useful as screening examination in the asymptomatic woman; therefore is not correct to replace the mammographic biennal control after the 40 years with a mammary ecography.

Is breast self examination important in the early diagnosis of breast cancer?

Monthly breast self examination is certainly very important and has to be recommended.

However, breast self examination does not replace periodical medical examination and mammographic screening.

Do mammographic radiations expose patients to risk of breast cancer?

With actual equipments and mammographic technologies, the radiation dose absorbed from each breast during a mammographic examination is very low. Controlled studies on the possible carcinogenic effects of mammographic radiations demonstrate that cumulative radiation dose related to periodic mammographic screening does not increase meaningfully the incidence of mammary carcinoma in patients .

When does the breast have to be removed entirely, in case of mammary neoplasia?

The removal of all the mammary gland, with the portion of surrounding skin, including the areola and the nipple ( total mastectomy ), has to be performed when mammary carcinoma overcomes the dimensions of 3 centimetres or when tumors even more little involve directly the skin or the thoracic wall.

What is quadrantectomy? When is quadrantectomy advisable?

Quadrantectomy consists in the removal of the quarter of breast (quadrant) interested by the neoplasia. Quadrantectomy is performed when neoplastic lesion has a diameter equal or inferior to 3 centimetres.

This surgical technique - defined " conservative ", because destined to preserve as much as possible the anatomical identity of the patient and to limit consequently the psychological impact of the removal of the affected breast - was introduced by Umberto Veronesi at the Istituto dei Tumori of Milan in the seventy years.

The cosmetic result in the most of cases is excellent. Various studies have demonstrated that in tumors of little dimensions the recovery percentage is the same with both total mastectomy and quadrantectomy .

Is breast surgery for neoplastic lesions always associated with the removal of axillary lymph nodes?

The removal of all axillary lymph nodes ( total axillary lymphoadenectomy or total axillary dissection) is usually associated with surgical interventions for breast carcinoma, both total mastectomy and quadrantectomy. That because the axillary lymph nodes represents generally the first localization of possible metastasis of mammary carcinoma.

Only recently is gaining ground a new surgical technique ( "sentinel lymph node" ) , that imply only the removal of the first lymph node of the axillary lymphatic chain. If the sentinel lymph node results - at the histological examination - not infiltrated by neoplastic cells, total linfoadenectomy may be avoided.. This procedure - recently scientifically validated - is performed in case of little tumors with axillary lymph nodes not clinically appreciable. Of course it is necessary the presence, in the hospital structure, of a good department of nuclear medicine, of pathology, of radiotherapy, of oncology and of senological surgery.

Are swelling, sensibility defects, paresthesias and reduced mobility in the omolateral superior limb common after a surgical intervention for breast cancer?

Mastectomy and quadrantectomy are usually associated with the removal of the axillary lymph nodes (lymphoadenectomy). That involves an inevitable damage to lymphatic circle and to nervous structures that passes through the axilla. It is therefore common that - after a surgical intervention for mammary carcinoma - patients have swelling, sensibility defects, paresthesias and reduced mobility in the omolateral superior limb. The patient has to be informed on the importance of early exercise in order to restore arm mobility and to reduce the incidence of arm swelling. The precocious mobilization of the arm and the shoulder - effected already the first day after the intervention and then gradually and regularly continued - is certainly the best therapy to attenuate the entity of this troubles.

The most important post- surgical complication is certainly represented by swelling of the omolateral superior limb (lymphedema). Following axillary dissection, lymphedema presents with incidences varying from 1 to 10%. Incidence increases significantly if axillary radiotherapy is performed after surgery. The removal of the axillary lymph nodes involves the local stagnation of lymphatic fluid (lymph stasis), with progressive sclerosis of the lymphatic vessels and swelling of the arm.

Early rehabilitation, with exercises (image A and image B) to be started on the first post-operative day and to be continued at home, and a low lipid and low protein diet (especially in obese women), may protect against lymphedema.

A pleasant and effective technique for the treatment of lymphedema is represented by manual lymphatic drainage, that consists in the stimulation of lymphatic flow and reabsorption by massage, manipulation, and compressive manoeuvers, to be performed by a rehabilitation therapist with experience in this type of treatment. Manual lymphatic drainage requires sessions of the duration of about one hour, at least 3 times a week for 4-6 weeks.

The patient with lymphedema has to avoid to lift weighs , to draw blood samples and to undergo intramuscolar or subcutaneous injections on the affected arm .

When does reconstructive surgery with insertion of a silicone prosthesis have to be performed in case of total mastectomy or quadrantectomy?

There is now a general tendency to perform - if possible - immediate breast reconstruction with silicone prosthesis, that is mammary reconstruction during the surgical procedure of mastectomy or quadrantectomy for breast cancer.. That allows two big advantages: it reduces the psychological damage deriving from the breast mutilation and avoids besides the necessity for patients to have to be submitted to a new surgical intervention. When immediate reconstruction is not possible for technical or logistic problems, delayed breast reconstruction - that is mammary reconstruction performed subsequently to mastectomy or quadrantectomy - may be however applied.

Are there medical risks connected with the use of silicone prosthesis for breast reconstruction?

Silicone prosthesis did not demonstrate ability to induce breast cancer.

Various clinical studies moreover did not demonstrate a connection among silicone prosthesis and autoimmune diseases (sclerodermia, rheumatoid arthritis ).

The more frequent local complication due to silicone breast prosthesis is represented by a fibrous reaction , that makes the reconstructed breast more hard and, in rare cases, deformed.

When the prosthesis is broken , it is necessary to replace it surgically, to prevent that silicone gel diffuses to tissues determining the formation of granulomas.

In which patients does chemotherapy have to be performed after mastectomy or quadrantectomy?

After a surgical intervention for breast carcinoma, adjuvant chemotherapy (that is precautional chemotherapy) has to be performed in the patients whith positive axillary lymph nodes (that is in the patients with axillary limph nodes infiltrated by tumoral cells), to prevent metastasis in other organs.

There is now a general tendency in clinical practice to submit to adjuvant chemotherapy even the node- negative patients (that is the patients without tumoral infiltration of axillary lymph nodes), when tumor aggressiveness is high and biological and clinical parameters - including woman age, tumor grade, receptor and DNA ploidy status - predict a poor prognosis..

Adiuvant chemotherapy has a precautional meaning: and is finalized to eliminate possible residual tumoral cells and to prevent then the risk of metastasis.

When does adjuvant chemotherapy have to begin after surgical intervention and how long does it last?

Adjuvant chemotherapy begins usually within 2-3 weeks after the surgical intervention for breast cancer. According to the type of chemotherapeutic regimen selected by the oncologist, the chemotherapeutic treatment includes six monthly cycles (six months of therapy with antineoplastic drugs) or four monthly cycles (four months of therapy with antineoplastic drugs). Treatment with a combination-chemotherapy regimen such as cyclophosphamide, methotrexate and fluorouracil (CMF) for a period longer than six months is no more effective than a treatment for four to six months.

Which are the most common side effects induced by chemotherapy?

The most common side effects induced by chemotherapeutic treatments are represented by nausea and vomit ( that may now be usually prevented with the use of new antihemetic drugs), by reduction of white blood cells, red blood cells and platelets , by amenorrhoea - resulting from direct toxicity to the ovary - and by temporary hair loss (alopecia).

Some chemotherapeutic regimens are rarely associated with serious , even life-threatening, late sequelae, in particular secondary leukemia and cardiac impairment.

Leukemias associated with chemotherapy for breast cancer may arise five to seven years after treatment and are usually preceded by a myelodsplastic syndrome with persistent citopenia (reduction of white and red blood cells and of platelets).

Congestive heart failure develops in 1.0 percent of patients treated with anthracycline-based chemotherapeutic regimens, in particular in women with older age, preexisting cardiac disease and irradiation of the thoracic wall.

Is hair loss definitive after chemotherapy?

Hair loss (alopecia) resulting from chemotherapeutic treatment often involves also pubic and axillary hairs and eyebrows. Alopecia is temporary and always reverses after the suspension of chemotherapy.

Alopecia may be partially prevented with the application - for about thirty minutes before and after the intravenous administration of chemotherapeutic drugs - of a plastic helmet containing some ice.

Is amenorrhoea definitive after chemotherapy?

Chemotherapeutic treatment of mammary carcinoma is generally associated with the disappearance of menstruations (amenorrhoea). In young women ( age less than 40 years ) amenorrhoea is reversible in the 80% of the cases and consequently most of the patients - too being in risk to develop a precocious menopause - after some months returns to have regular menstrual cycles. In older women (age over 40 years) amenorrhoea is instead generally irreversible and the patients develop a precocious menopause induced by chemotherapeutic treatment.

Are pregnancies possible in women submitted to chemotherapy for breast cancer?

In young patients submitted to chemotherapy for mammary carcinoma the disappearance of the menstrual cycles (amenorrhoea) is reversible, therefore after some months the women return to have regular menstruations, being able to conceive a child.

Currently is advisable to await a period of five years after the end of the chemotherapeutic treatment before undertaking a pregnancy: this in consideration of the fact that in the first years after the therapy the relapses of the illness are more frequent.

Various clinical studies demonstrate that children born from patient treated with surgery, chemotherapy and radiotherapy for mammary carcinoma do not have an higher incidence of malformations in comparison with the general population.

How is usually managed a neoplastic nodule of the breast diagnosed during pregnancy?

When a mammography has to be be necessarily performed during pregnancy for the correct diagnosis of a palpable nodule of the breast , it is mandatory to minimize the radiation dose transmitted to the fetus, using a suitable protection..

Biopsies in local anaesthesia and surgical interventions in general anaesthesia may be performed at any time during pregnancy, without particular risks for the fetus. The recourse to chemotherapy and radiotherapy instead has to be preferably avoided during all the period of the pregnancy, for the danger of fetal damage.

When radiotherapy has to be performed after surgery for breast carcinoma?

Radiotherapy of the residual portion of the affected breast has always to be performed after a conservative surgical intervention for breast cancer (quadrantectomy). The meaning of the radiotherapeutic treatment in this cases is that to eliminate tumoral cells not removed by the surgical treatment.

After the intervention of total mastectomy radiotherapy is not usually performed, becuse surgery is considered radical and radiotherapy is therefore considered not useful in these cases.

When does radiotherapy have to begin after surgical intervention and how long has to be continued?

Radiotherapy of the residual portion of the affected breast usually begins 4-5 weeks after the conservative surgical intervention (quadrantectomy). An even more long interval (3-6 months), caused by organizing problems, do not compromise the results in recovery terms.

Chemiotherapy and radiotherapy may be performed contemporarily, without particular toxic effects.

The radiotherapeutic treatment is constituted generally by 5 sittings a week, for a total of 5-6 weeks of therapy.

Clinicians are now studying the effectiveness of intraoperatory radiotherapy , that is radiotherapy performed directly during the surgical intervention, rather than subsequently to it. This is yet an experimental method and is not still applicable on a large scale.

Which are the side effects of radiotherapy?

Radiotherapy of the residual affected breast after a conservative surgical intervention determines generally swelling and erythema of the radiated part. These side effects are usually transitory and disappear within some weeks with the help of cortisone-based ointment.

The radiated breast during a following pregnancy and lactation is not able to answer to hormonal stimulation and produces small quantity of milk.

When does hormonal therapy for breast cancer have to be performed after surgery, chemotherapy and radiotherapy?

Hormonal therapy has to be performed after surgery, chemotherapy and radiotherapy in all women affected by tumors that - at the histological examination - result positive to estrogen-receptors. Patients with tumors not sensitive to estrogens and patients with tumors characterized by a low metastatic risk ( that is patients with tumors with a diameter less than one centimetre, constituted by cells with low malignant tendency and without involvement of the axillary lymph nodes ) may be exempted from the hormonal therapy.

Which drugs are commonly used in hormonal adjuvant therapy?

Hormonal adjuvant therapy at the moment consists usually in the oral assumption of a daily dose of 20 mg of tamoxifen. This substance has an anti-estrogenic effect on mammary cells; therefore it is able to stop the proliferation of neoplastic cells eventually remained in the organism of the patient after the surgical, chemotherapeutic and radiant treatment.

Other drugs chracterized by an anti-estrogenic action (anastrozole in particular) seem now effective in hormonal adjuvant treatment and begin to be used in clinical practice.

Which are the side effects of the hormonal therapy with tamoxifen?

The most common side effects of the hormonal therapy with tamoxifen are represented by menopausal symptoms, that are usually more intense during the first months of treatment. They consist in hot flushes, night sweats, menstrual alterations or interruptions (amenorrhoea), vaginal losses, vaginal dryness and itching, reduction of sexual desire and pain during sexual intercourse.

Seldom the hormonal therapy with tamoxifene cause phlebitis and/or embolic symptoms. Tamoxifen is also associated with the possible development of uterine tumors (both adenocarcinomas and sarcomas); in these women is therefore mandatory to perform annually a transvaginal echography.

How long hormonal therapy with tamoxifen has to be continued?

Oral therapy with tamoxifene begins usuually some days after the surgical intervention and has to be continued for five years. More prolonged treatments do not increase the preventive effectiveness of the therapy but increase the risk of side effects, in particular uterine tumors.

Which is the optimal follow-up in a woman treated for breast cancer?

The patients submitted to surgical intervention and chemotherapeutic/radiant/hormonal treatment for a breast carcinoma have to undergo to a senological examination every six months and to a mammography every year during theyr remaining life. This follow-up allows the precocious diagnosis of local relapses (that is relapses at the thoracic wall, at the residual portion of the affected breast or at the axillary lymph nodes) and of a new neoplasia in the same or in the opposite breast. There is not still agreement in the scientific community about the usefulness of an intensive follow up, with the addition of a periodical dosage of tumoral markers, as CEA or CA15.3, and of a chest radiography, a bone scintigraphy and an abdominal ecography.

How do local relapses of breast cancer have to be treated?

In case of local tumoral relapses at axillary lymph nodes or at the residual portion of the affected breast after a conservative surgical intervention (quadrantectomy), a new surgical intervention with removal of the tumoral mass and of the remaining portion of breast is usually performed. When the local recurrence occurs very close to the surgical scar, a new limited resection may also be considered if the relapse is small.

In case of relapses in correspondence of the thoracic wall a radiotherapeutic treatment is usually preferred.

How do tumoral metastasis have to be treated?

The presence of tumoral metastatic localizations contraindicates generally the execution of surgical or radiotherapeutic treatments. Chemotherapy (preferably using combinations of antineoplatic drugs) is in these case the treatment of choice; in estrogen-receptors positive tumors hormonal therapy with tamoxifen (and with second-line hormonal drugs when tamoxifen does not result effective) is usually performed.

Which is the correct treatment in the elderly patients with breast cancer?

Since the mammary tumor in the elderly patients represents usually a neoplasia characterized by a slow progression and a low grade of malignancy (so that death in a lot of cases occurs unexpectedly for causes independent from the tumoral illness), in women over the 80 years of age - in particular if in precarious general conditions - the oncologist may decide to limit the antineoplastic therapy only to the surgical treatment ( more or less conservative depending on the circumstances and the situations: when there are contraindications for the execution of a surgical intervention in general anaesthesia the surgeon usually practises the simple excision of the tumor in local anaesthesia , avoiding the removal of the axillary lymph nodes ), followed by an hormonal therapy with tamoxifen orally for 5 years. In these patients radiotherapy and chemotherapy are usually avoided because of the side effects invariably related to this treatments.

May breast cancer appear even in males?

Breast cancer may appear even in males; it originates from the mammary glandular buds. Breast cancers in men represent the 1% of total mammary neoplasias; breast cancers constitute besides the 1% of all male tumors.

The diagnosis of mammary carcinoma is effected even in males using mammography, echography and, if necessary, needle biopsy or surgical biopsy

Which is the therapy of breast cancer in males?

The therapy of breast cancer in males is not much different from that practised in case of female mammary neoplasias. Total mastectomy (which consists in the removal of the whole breast gland, including the surrounding skin, areola and nipple) with complete axillary dissection is the treatment of choice. Surgical treatment is followed by adjuvant chemotherapy ( in particular if axillary lymph nodes are involved), radiotherapy of the thoracic wall (in cases more locally advanced ) and hormonal therapy with tamoxifen ( to be continued for five years if the tumor results positive to estrogen-receptors and sensitive to the hormonal treatment ).

May pain be controlled in metastatic breast cancer?

The presence of metastatic localizations, in particular to bone, often determines in the affected patients an important painful symptomatology. Opioid drugs (in particular morphine) are however able to control even pain syndromes otherwise unmanageable .

Morphine has to be administered preferably by mouth; only in presence of difficulty to swallow is necessary intramuscular or subcutaneous administration. Morphine is generally well tolerated: usual side effects - in particular during the first days of therapy - are represented by constipation and vomit, that may be controlled with opportune therapeutic interventions.

The use of morphine in these patients is not associated with risk of respiratory depression or of opioid dependence.