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Breast Tumors

Breast cancer is a disease resulting from the malignant transformation of some breast cells that grow autonomously and acquire the ability to infiltrate the surrounding tissues and organs and migrate to other parts of the body and form metastases.

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Prevention and the appropriate treatments have been shown to reduce the damage that breast cancer can cause. Thanks to prevention and care, the survival rate is clearly progressively increasing.

 

Attending a Centre of Excellence like IEO for prevention, early and accurate diagnosis of breast cancer and its biological characteristics, and treatments maximises the probability of complete cure.

 

The expertise in the diverse areas of Radiology, Surgery, Medical Oncology, Radiotherapy, Chemoprevention, Nuclear Medicine and other specialties involved in the management of breast cancer patients work together in order to define the best approach for every single case. Personalised diagnosis, treatment and follow up is the strategy that allows us to achieve optimal results in terms of cure, disease control, quality of life.

 

That's why the IEO Breast Program, which brings together all competent Divisions and Units in the prevention, diagnosis and treatment of breast cancer was created. Breast cancer treatment is multidisciplinary. It is not enough to speak only about surgery, radiotherapy or pharmacotherapy without integrating the various disciplines.

 

 

 

Non-palpable breast lesions


Very few precancerous lesions are known. Recognising these lesions helps intervene before the cells acquire tumour characteristics. Precancerous forms are called ductal intraepithelial neoplasia and lobular intraepithelial neoplasia (both formerly called carcinoma in situ). They are not capable of causing metastasis and their treatment is specific and personalised.

 

Diagnosis is usually radiological (often the lesion is small), and management is multidisciplinary, involving a breast surgeon, anatomy cess s and is well tolerated. Tpathologist, specialist radiologist, medical oncologist, pharmacoprevention expert and sometimes    a radiation therapist. Nuclear Medicine Physicians have a key role in localising the non-palpable breast lesions.

 

 

Ductal carcinoma and lobular carcinoma

The most frequent types of breast cancer are ductal carcinoma (in particular infiltrating ductal carcinoma) and lobular carcinoma. They are so-called because they derive from the ducts and lobules of the breast, respectively. There are other, less frequent types for which definition is important for treatment choice.

 

The most common symptoms of breast cancer

Breast cancer should not be discovered by symptoms. Early diagnosis means identifying problems before they appear as symptoms. Medical attention should be sought when one can see or feel:

  • one or more nodules of the breast – by nodule we mean a circular hardening, a part that is differently textured from the rest of the breast, or a real lump, whether mobile or fixed.
  • swelling or thickening of the breast or underarm area
  • changes in the shape or size of the breast
  • secretion of fluid from the nipple - the liquid can come out spontaneously (spots on the bra or clothing) or when the nipple is squeezed or touched, and may have different colours (white, transparent, yellow, green, bright red, dark red)
  • changes in appearance of the skin, nipple or areola, such as dimples or retraction, swelling, redness, heat, cracking.


Breast pain is not usually a symptom of the disease. It is better to report it anyway for your reassurance.

Risk factors for breast cancer

Being predisposed to the development of breast cancer is associated with several factors.

  • genetic factors are relatively rare, but of particular interest
  • epidemiological factors of relative importance: family history, early age menstruation and late age menopause, no pregnancy or first pregnancy after the age of thirty, little or no breastfeeding, obesity and alcohol consumption.

Despite their importance, these risk factors are not sufficient to explain all cases of the disease.

Seventy per cent of breast cancer cases occur in women presenting no known risk factors, which is why it is right and appropriate that all women are informed about prevention, thereby deciding to adopt it with the help of specialist centres. Based on current knowledge, risk factors do not necessarily have an impact on the rate and type of early diagnosis, except in cases of genetic mutation. Prevention can save the lives of all women, regardless of risk factors.

 

The importance of prevention in breast cancer

At IEO, the primary prevention of breast cancer is promoted by integrating different approaches. A specific area of oncology is dedicated to prevention by studying and applying new strategies aimed at identifying individuals or family groups at high risk (genetic, familial, metabolic), people with precancerous lesions and patients of IEO at high risk of developing a second cancer. Personalised check-ups and close supervision of those who are at high risk forms part of the clinical activities of this specific area.

 

 

Primary prevention can prevent the onset and development of a disease. Primary prevention takes the form of adopting a behaviour (or taking a substance) that can reduce the risk of getting a disease. Breast cancer primary prevention is based on lifestyle and - still at the experimental stage - on taking certain substances in very high risk cases documented by positive genetic test. A correct lifestyle involves constant and regular exercise at least three times every week (60 minutes per session), abstaining from smoking and alcohol consumption and proper nutrition.

 

 

Secondary prevention is early detection. Discovering a tumour while still at an early stage, small and still non-palpable, means a high probability of complete cure with surgical and pharmacological treatments of minimal intensity and minor discomfort. However, if diagnosis is later there are still effective treatments available. An initial stage tumour has a higher chance of a full and complete recovery, but even those with a more advanced breast cancer have a good chance of controlling the disease in the long term with care and adequate follow up.

 

 

 

How to recognize breast cancer

Diagnosis is based on diagnostic tests and clinical breast examination. Whether it is prevention (early detection) or follow-up visits after treatments already received for breast cancer, these procedures are fundamental for all women.

 

 

 

Mammography

Mammography, i.e. an X-ray of the breast, is useful for detecting the presence of nodules, microcalcifications or other indirect tumour signs. It is based on X-rays that imprint the image onto a plate (or computer) after passing through the breast. The X-ray dose you receive during mammography is not harmful to your health. It is performed from the age of 40, every year or every two years. 

Ultrasound 

Ultrasound makes use of high-frequency sounds to detect the presence of a nodule and its consistency, solid or liquid, defining whether it is benign, doubtful or malignant in nature. Ultrasound is completely harmless from a biological point of view and is carried out every year from the age of 30; it is stopped when the radiologist recommends it. 

 

Breast MRI 

Breast Magnetic Resonance Imaging (MRI) makes use of a magnetic field to create the image of the tissue with mammography and ultrasound, or when prostheses or images near a surgical scar are to be displayed in detail. It is indicated when necessary or is planned as part of early diagnosis in women who have a high risk due to family history or when the mammary structure appears complex using the other image investigations. 

Fine-needle biopsy

Fine needle biopsy is a test during which a sample of cells from a breast nodule is taken using a thin needle and a cytological examination is thus obtained. 

 

Needle-biopsy

Needle biopsy is a technique that takes a sample of tissue from an area or from a suspected nodule in order to obtain a histological examination accompanied by all the biological characteristics of the malignant tissue. 

Self-examination

Self-examination is not a tool for early diagnosis and not enough to keep your health under control. The optimum early diagnosis is achieved when breast cancer is discovered when not yet palpable (with diagnostic tests). 

Genetic test

The genetic test is a blood test that allows an assessment of whether there is a mutation in one of two genes known to be the most frequent in highly increasing the risk of breast cancer and/or ovarian cancer: they are called BRCA1 and BRCA2. Patients will then receive genetic counselling in which they may discuss the consequences of a positive, negative or uncertain result of the test. 

Clinical breast examination

The clinical breast examination completes the diagnostic testing and concludes the process in view of further and future controls (healthy breast) or the necessary care (presence of tumour or suspected lesions). During the examination, test results are checked, the breast, armpit and supra clavicle lymph nodes are palpated, and treatment is prescribed should it be useful to resolve doubt or certainty of the disease. 

The preventive bilateral mastectomy is not seen as a tool of standard prevention; the basis for effective prevention is personalisation. Depending on the rapport between the patient and the referring physicians, it may be possible to take the decision to remove both breasts in very high risk cases (positive genetic test) and in cases of particular requirements discussed with the person. The clinical breast examination is performed at the outpatient clinic of the Breast Division or at the outpatient office of one of IEO breast specialists. 

Breast cancer preventive nutrition

Thanks to the SmartFood project, healthy-eating based on scientific findings is explained and disseminated via events, publications, courses, and personalised advice. Ten recommendations for women's health were presented at the IEO women’s health event.

Personalized care for breast cancer treatment: excellence at IEO

The treatment of breast cancer is based on surgery associated with radiation therapy and pharmacological treatment, according to the specific situation. An element of excellence that characterises the IEO Breast Program is exact biological knowledge of each individual tumour before starting treatment. Breast medicine is a discipline that combines different competencies and specialisations that together determine every therapeutic decision and study or control for each patient.

 

A crucial moment in the personalisation of care is the multidisciplinary discussion among the members of the Programme: each single case is discussed in its specificity with the biological characteristics of the disease, physical characteristics and personal and family medical history and with distinguishing psychological needs and expectations.

 

The discussion occurs after surgery in the majority of cases, or before each type of therapeutic approach if the tumour has a diameter or local extension that requires a decision to be made between primary surgery or secondary surgery following drug treatment: for this, every time breast cancer is considered to be locally extended (for example if the diameter exceeds 2 cm), we proceed to the next microbiopsy with group discussion to determine the orientation toward surgery or neoadjuvant drug therapy.

 

 

 

 

Knowing the biology of the tumour is crucial so that every patient is given indications with the highest probability

of efficacy on the tumour with the least detriment to their quality of life.

 

 

 

 

 

IEO breast surgery leads the world in terms of operations performed each year. Seventy per cent of the  cases performed are quadrantectomy, or partial resection, i.e. removal of the breast lesion with a certain  amount of the surrounding healthy tissue. In 30% of cases, mastectomy must be performed, which is removal of the entire breast followed by immediate reconstruction via plastic-reconstructive surgery techniques.

 

 

ROLL

When the tumour is not palpable (micro calcifications or very small nodules), localisation techniques are used to avoid errors and unnecessary removal of healthy tissue: ROLL (Radioguided Occult Lesion Localisation), invented at IEO, is the most widely-used technique around the world with the best results, but it is possible to opt for preoperative skin marking of the part to be operated on.

 

 

Radiotherapy and mastectomy for breast cancer

When mastectomy is required, in the majority of cases IEO can provide immediate reconstruction using techniques that depend on the individual situation: cooperation between breast experts and plastic-reconstructive surgeons allows us to achieve the best aesthetic result following breast surgery. Breast-conserving surgery and, more rarely, mastectomy may be followed by radiation therapy.

 

 

 

Radiotherapy

Radiotherapy following breast cancer surgery is a normal procedure in the case of  quadrantectomy or partial resection. It is defined as "complementary" because it completes breast-conserving surgery and reduces the risk of disease recurrence. It can be prescribed after surgery in some special situations when it is necessary to treat the chest wall and / or lymph nodes. The use of radiation therapy is expected in metastatic disease in locations responding well to treatment with ionising radiation (such as bones).

 

 

Intraoperative Radiotherapy

Intraoperative radiation therapy forms one of the symbols of excellence in breast cancer care at IEO. Thanks to studies carried out at IEO, it can be performed in the course of a quadrantectomy intervention as a single dose of 21 Gy that completely replaces the course of external beam radiation therapy or at a dose of 12 Gy as an early boost followed by a shorter course of external beam radiation therapy. Intraoperative radiotherapy is used in some cases of nipple-sparing mastectomy for irradiating the nipple-areolar complex kept in place.   

  

Nipple-sparing mastecomy

"Nipple-sparing" mastectomy is a surgical technique that was developed by our institute more than 10 years ago (first interventions dating back to 2002). This action allows the removal of the mammary gland while preserving the outer shell (skin and nipple) entirely with optimal preservation of feminine appearance. Breast reconstruction is performed simultaneously with the mastectomy, usually with implants (expander or definitive prosthesis). Over the years, the technique has constantly improved. The tissue behind the areola is completely and radically removed and thanks to the refinements of surgical technique, the risk of complications, nipple necrosis in particular, is very low and constantly reducing. In order to maximise tumour eradication, an intraoperative histological examination is always performed of the tissue immediately below the nipple. In cases of histologically positive neoplasia or carcinoma in situ, the nipple-areolar complex must be removed. Should additional elements emerge from the definitive histological examination, the need for postoperative irradiation limited to the nipple-areolar complex or extended to the entire breast area and/or lymph node region is assessed through multidisciplinary consulting. 

 



Pharmacological treatments for breast cancer

The pharmacological treatments, that is chemotherapy and/or endocrine therapy and/or the so called receptor medications, depend on the histological examination related to surgery.


 

Chemotherapy

Chemotherapy consists of drugs and regimens that vary according to the person and tumour characteristics and it is prescribed as a precautionary measure when risk factors suggest a higher coverage or in cases of breast cancer that is not sensitive to the hormones oestrogen and progesterone. Chemotherapy may be prescribed together with endocrine therapy or receptor medications but not in all cases. 

 

Endocrine theraphy

Endocrine therapy is based on drugs that reduce the activity of oestrogen hormones and progesterone. It is prescribed when the breast cancer is sensitive to these hormones and must therefore be blocked for a certain period of time. There are different drugs and their prescription depends on the individual situation. 

 

Receptor medication

The receptor drugs are very specific and their effectiveness is linked to some details of the histology exam evaluated by the oncologists. 

 

 

Updating page

Based on careful evaluation of results provided by scientific research, it has been possible to identify specific risk factors and protective factors in nutrition for specific cancers. Experts have classified the results into four levels: "convincing evidence", "probable evidence", "limited evidence" and a last level for those effects for which the evidence of their association with cancer is highly "unlikely." Probable and convincing evidence classification is based on recommendations.

 

In breast cancer, convincing evidence has shown alcoholic beverages as an increasing factor for the risk of both pre- and postmenopausal development. Being overweight and obesity have been identified as risk factors, in particular for the postmenopausal onset of cancer, while an excess of abdominal fat showed “probable evidence” of increased risk. Among the preventive factors for the onset of this disease is persuasive evidence related to the beneficial role of breastfeeding, while physical activity prevents the risk in particular for postmenopausal development.

  • EVALUATE YOUR RISK OF BREAST CANCER

    The first step to a proper prevention programme is to assess the risk profile and the probability that a person has of developing breast cancer. It has now been demonstrated that the risk of developing the disease is different for every woman and this can be evaluated by a thorough assessment of personal, family, and biological characteristics.

     

    Assessment of individual breast cancer risk

    It is no longer sufficient to talk about "risk" referred to the general population but it is instead appropriate to make an assessment of an "individual risk" and to do this requires a thorough collection and analysis of the (1) personal, (2) family, and (3) biological characteristics of each person.

     

    1. Individual characteristics: age, medical history, age at first menstruation and menopause, pregnancy, breastfeeding, previous or current hormone therapies, physical characteristics (height, weight, body mass index, overweight and obesity, any presence of metabolic syndrome), lifestyle (diet, physical activity, smoking, alcohol).
    2. Family characteristics: the presence or absence of cancer in the family (especially the presence of breast and/or ovarian cancers in 1st and 2nd degree relatives). There is the possibility - by completing (in appropriate cases) a family questionnaire and by building a family tree - to calculate the risk within a family and begin a process of "genetic counselling" which can in some cases lead to a genetic test for the detection of mutations (e. g. BRCA 1-2), or a series of diagnostic and therapeutic advice to be taken in the event of a high probability of mutation.
    3. Biological characteristics: such as the presence of atypical cells or other types of precancerous lesions, potentially found in previous tests (biopsies, needle-aspirated and/or interventions) or through recently introduced instrument-based screening techniques such as DUCTAL LAVAGE and/or HALO BREAST TEST of breast fluids. (1)

     

    Analysis of this information makes it possible to highlight the individual risk profile of each patient and accordingly set up a PERSONALISED PROGRAMME FOR CLINICAL AND INSTRUMENTAL MONITORING, with particular attention paid to the choice of the tests, frequency, and the age at which you start to take them. In selected cases, assessment of the individual risk can lead to recommendation for a course of drugs as a preventive measure or participation in a clinical trial of drug-prevention. (2)

     

    (1) The understanding of the biological and molecular mechanisms leading to cancer has now clarified that it is nothing more than the end result of a series of biological processes, called carcinogenesis, which although requiring a long time to result in a neoplasm, are not detected by the usual diagnostic techniques until this process has reached a rather advanced stage. That’s why in recent years much attention has been paid to the study of effective systems for the identification of the so-called precancerous lesions or intraepithelial neoplasia (IEN), and then to the possibility of intervening by interrupting the pathological sequence.

    Among the various techniques, one used in recent years for the identification of precancerous lesions is ductal lavage of the milk ducts. This technique is non-invasive and carries no risk for the patient, and it allows cells to be obtained for testing for pre-cancerous conditions, through the injection, and subsequent recovery, of saline solution into the breast milk ducts. Another more recently used technique is the HALO BREAST TEST, which is safe and minimally-invasive. It simulates the action of a breast pump and can stimulate and collect any mammary secretions rich in cellular material suitable for the cytological analyses described above, and potentially useful for assessment of personal risk.

     

    (2) As the name suggests, drug-prevention is defined as a pharmacological intervention aimed at interrupting the biological sequence leading to the formation of a tumour, in subjects at risk. There are many drugs which in recent years have been studied and used. Among the most common are some selective modulators of hormone receptors (SMHRs) such as tamoxifen and raloxifene, which can be used in personalised treatments. Many other drugs seem to be very promising in prevention and are currently under investigation. Among the best known are the aromatase inhibitors, some bisphosphonates (usually used for osteoporosis), metformin (anti-diabetic drug), aspirin, vitamin D and retinoids. Usually taking a medication as a preventive measure takes place in a clinical study following screening by an ethics committee to assure safety and ethics.

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