46 The breast

CHRISTOBEL M. SAUNDERS and MICHAEL BAUM The Breast Subjects covered n th s cha!ter nc"ude anato#$% nvest &at ons o' the breast% the n !!"e% ben &n and #a" &nant d sorders o' the breast% breast reconstruct on% screen n& 'or breast cancer% breast cancer &enet cs and the #a"e breast. Co#!arat ve and sur& ca" anato#$ The !rotuberant !art o' the hu#an breast s &enera""$ descr bed as over"$ n& the (nd to the )th r bs% and e*tend n& 'ro# the "atera" border o' the sternu# to the anter or a* ""ar$ " ne. Actua""$% a th n "a$er o' #a##ar$ t ssue e*tends cons derab"$ 'arther 'ro# the c"av c"e above to the +th or ,th r bs be"o-% and 'ro# the # d" ne to the ed&e o' "at ss #us dors !oster or"$. Th s 'act s #!ortant -hen !er'or# n& a #astecto#$% the a # o' -h ch s to re#ove the -ho"e breast. The anato#$ o' the breast s ""ustrated n . &. /).0 The a* ""ar$ ta " o' the breast s o' cons derab"e sur& ca" #!ortance. In so#e nor#a" cases t s !a"!ab"e% and n a 'e- t can be seen !re#enstrua""$ or dur n& "actat on. A -e""1deve"o!ed a* ""ar$ ta " s so#et #es # sta2en 'or a #ass o' en"ar&ed "$#!h nodes or a " !o#a. The "obu"e s the bas c structura" un t o' the #a##ar$ &"and. The nu#ber and s 3e o' the "obu"es var$ enor#ous"$4 the$ are #ost nu#erous n $oun& -o#en. .ro# 05 to over 055 "obu"es e#!t$ v a ductu"es nto a "act 'erous duct o' -h ch there are 'ro# 06 to (5. Each "act 'erous duct s " ned b$ a s! ra" arran&e#ent o' contract "e #$oe! the" a" ce""s and s !rov ded - th a ter# na" a#!u""a 7 a reservo r 'or # "2 or abnor#a" d schar&es. The " &a#ents o' Coo!er are ho""o- con ca" !roject ons o' ' brous t ssue ' ""ed - th breast t ssue% the a! ces o' the cones be n& attached ' r#"$ to the su!er' c a" 'asc a and thereb$ to the s2 n over"$ n& the breast. These " &a#ents account 'or the d #!" n& o' the s2 n over"$ n& a carc no#a. The areo"a conta ns nvo"untar$ #usc"e arran&ed n concentr c r n&s as -e"" as rad a""$ n the subcutaneous t ssue. The areo"ar e! the" u# conta ns nu#erous s-eat &"ands and sebaceous &"ands% the "atter o' -h ch en"ar&e dur n& !re&nanc$ and serve to "ubr cate the n !!"e dur n& "actat on 8Mont&o#er$9s tuberc"es:. The n !!"e s covered b$ th c2 s2 n - th corru&at ons. Near ts a!e* " e the or ' ces o' the "act 'erous ducts. The n !!"e conta ns s#ooth #usc"e ' bres arran&ed concentr ca""$ and "on& tud na""$; thus s an erect "e structure -h ch !o nts out-ards. L$#!hat cs o' the breast dra n !redo# nant"$ nto the a* ""ar$ and nterna" #a##ar$ "$#!h nodes. The a* ""ar$ nodes rece ve a!!ro* #ate"$ +6 !er cent o' the dra na&e and are arran&ed n the 'o""o- n& &rou!s4 <"atera"% a"on& the a* ""ar$ ve n; <anter or% a"on& the "atera" thorac c vesse"s; <!oster or% a"on& the subsca!u"ar vesse"s; <centra" e#bedded n 'at n the centre o' the a* ""a; < nter!ectora"% a 'e- nodes "$ n& bet-een the !ectora" s #ajor and # nor #usc"es; <a! ca"% -h ch " e above the "eve" o' the !ectora" s # nor tendon n cont nu t$ - th the "atera" nodes and rece ve the e''erents o' a"" the other &rou!s.

The a! ca" nodes are a"so n cont nu t$ - th the su!rac"av cu"ar nodes and dra n nto the subc"av an "$#!h trun2 -h ch enters the &reat ve ns d rect"$ or v a the thorac c duct or ju&u"ar trun2. The sent na" node s that "$#!h node des &nated as the ' rst a* ""ar$ node dra n n& the breast. The nterna" #a##ar$ nodes are 'e-er n nu#ber and " e a"on& the nterna" #a##ar$ vesse"s dee! to the !"ane o' the costa" cart "a&es. Invest &at on o' the breast A"thou&h an accurate h stor$ and c" n ca" e*a# nat on are st "" the #ost #!ortant #ethods o' detect n& breast d sease there are a nu#ber o' nvest &at ons -h ch can ass st n the d a&nos s as 'o""o-s Ma##o&ra!h$ 8. &. /).(: So't t ssue =1ra$s are ta2en b$ !"ac n& the breast n d rect contact - th u"trasens t ve ' "# and e*!os n& t to "o-1vo"ta&e% h &h1a#!era&e =1ra$s. The dose o' rad at on s a!!ro* #ate"$ 5.0 >$ and there'ore #a##o&ra!h$ s a ver$ sa'e nvest &at on. U"trasound U"trasound s !art cu"ar"$ use'u" n $oun& -o#en - th dense breasts n -ho# #a##o&ra#s are d '' cu"t to nter!ret% and n d st n&u sh n& c$sts 'ro# so" d "es ons 8. &s /).? and /)./:. It can a"so be used to "oca" se #!a"!ab"e breast "u#!s. Ma&net c resonance #a& n& Ma&net c resonance #a& n& 8MRI: s o' ncreas n& nterest to breast sur&eons n a nu#ber o' sett n&s4 t can be use'u" to d st n&u sh scar 'ro# recurrence n -o#en -ho have had !rev ous breast conservat on thera!$ 'or cancer 8a"thou&h t s not accurate - th n @#onths o' rad othera!$ because o' abnor#a" enhance#ent:; t s the &o"d standard 'or #a& n& the breasts o' -o#en - th #!"ants; t #a$ !rove use'u" as a screen n& too" n h &h1r s2 -o#en; and t s be n& eva"uated n the #ana&e#ent o' the a* ""a n both !r #ar$ breast cancer and recurrent d sease 8. &. /).6:. Need"e b o!s$Ac$to"o&$ H sto"o&$ can be obta ned us n& a ' ne need"e such as a Trucut or Corecut b o!s$ dev ce under "oca" anaesthes a 8. &. /).):. C$to"o&$ s obta ned us n& a (0 or (? >au&e need"e and 051#" s$r n&e - th #u"t !"e !asses throu&hout the "u#! - thout re"eas n& the ne&at ve !ressure n the s$r n&e. The as! rate s then s#eared on to a s" de -h ch s a r dr ed 8. &. /).+:. . ne need"e as! rat on c$to"o&$ 8.NAC: s the "east nvas ve techn Bue o' obta n n& a ce"" d a&nos s and s ver$ accurate ' both o!erator and c$to"o& st are e*!er enced. Ho-ever% 'a"se ne&at ves do occur% #a n"$ throu&h sa#!" n& error% and nvas ve cancer cannot be d st n&u shed 'ro# n s tu d sease. Tr !"e assess#ent In an$ !at ent -ho !resents - th a breast "u#! or other s$#!to#s sus! c ous o' carc no#a% the d a&nos s shou"d be #ade b$ a co#b nat on o' c" n ca" assess#ent% rad o"o& ca" #a& n& and a t ssue sa#!"e ta2en 'or e ther c$to"o& ca" or h sto"o& ca" ana"$s s 8. &. /).,:4 the so1ca""ed tr !"e assess#ent. The n !!"e Absence o' the n !!"e s rare% and usua""$ assoc ated - th a#a3 a 8con&en ta" absence o' the breast:.

Su!ernu#erar$ n !!"es not unco##on"$ occur a"on& a " ne e*tend n& 'ro# the anter or 'o"d o' the a* ""a to the 'o"d o' the &ro n 8. &. /).@:. Th s const tutes the # "2 " ne o' "o-er #a##a"s. N !!"e retract on Th s #a$ occur at !ubert$ or "ater n " 'e. Retract on occurr n& at !ubert$% a"so 2no-n as s #!"e n !!"e nvers on% s o' un2no-n aet o"o&$. In about (6 !er cent o' cases t s b "atera". It #a$ cause !rob"e#s - th breast'eed n& and n'ect on can occur% es!ec a""$ dur n& "actat on% o- n& to retent on o' secret ons. Treat#ent Treat#ent s usua""$ unnecessar$% and t #a$ s!ontaneous"$ reso"ve dur n& !re&nanc$ or "actat on.S #!"e cos#et c sur&er$ can !roduce an adeBuate correct on but has the dra-bac2 o' d v d n& the ducts. Mechan ca" suct on dev ces have been used to atte#!t to evert the n !!"e - th so#e e''ect. Recent retract on o' the n !!"e #a$ be o' cons derab"e !atho"o& ca" s &n ' cance. A s" t1" 2e retract on o' the n !!"e #a$ be due to duct ectas a and chron c !er ducta" #ast t s 8. &. /).05a:% but c rcu#'erent a" retract on% - th or - thout an under"$ n& "u#!% #a$ -e"" nd cate an under"$ n& carc no#a 8. &. /).05b:. Crac2ed n !!"e Th s #a$ occur dur n& "actat on and be the 'orerunner o' acute n'ect ve #ast t s. I' the n !!"e beco#es crac2ed dur n& "actat on% t shou"d be rested 'or (/7/, hours and the breast e#!t ed - th a breast !u#!. .eed n& shou"d be resu#ed as soon as !oss b"e. Ca! ""o#a o' the n !!"e Ca! ""o#a o' the n !!"e has the sa#e 'eatures o' an$ cutaneous !a! ""o#a 8. &. /).00: and shou"d be e*c sed - th a t n$ d sc o' s2 n. Retent on c$st o' a &"and o' Mont&o#er$ These &"ands% s tuated n the areo"a% secrete sebu#% and ' the$ beco#e b"oc2ed a sebaceous c$st 'or#s. Chancre o' the n !!"e Th s ver$ rare cond t on usua""$ occurs b$ n'ect on 'ro# a s$!h " t c bucca" u"cer n the #outh o' the !artner% a"thou&h can be seen n the -et1nurse o' a s$!h " t c bab$. The #other o' such an n'ant s ##une to re n'ect on 'ro# her o-n ch "d. Ec3e#a Ec3e#a o' the n !!"es s a rare cond t on and s b "atera"% and usua""$ assoc ated - th ec3e#a e"se-here on the bod$. Ca&et9s d sease Ca&et9s d sease o' the n !!"e #ust be d st n&u shed 'ro# the ec3e#a. Abnor#a" d schar&es 'ro# the n !!"e D schar&e can occur 'ro# one or #ore "act 'erous ducts. Mana&e#ent de!ends on the !resence o' a "u#! 8-h ch shou"d a"-a$s be & ven !r or t$ n d a&nos s and treat#ent: and o' the !resence o' b"ood n the d schar&e or d schar&e 'ro# a s n&"e duct. Ma##o&ra!h$ s rare"$ use'u" e*ce!t to e*c"ude an under"$ n& #!a"!ab"e #ass. C$to"o&$ #a$ revea" #a" &nant ce""s but a ne&at ve resu"t does not e*c"ude a carc no#a. A c"ear% serous d schar&e #a$ be D!h$s o"o& ca"9 n a !arous -o#an or #a$ be assoc ated - th a duct !a! ""o#a or #a##ar$ d$s!"as a. A b"ood1sta ned d schar&e #a$ be caused b$ duct ectas a or "ess co##on"$ a duct !a! ""o#a or carc no#a. A duct !a! ""o#a s usua""$ s n&"e and s tuated n one o' the "ar&er "act 'erous ducts and s so#et #es assoc ated - th a c$st c s-e"" n& beneath the areo"a.

A b"ac2 or &reen d schar&e s usua""$ due to duct ectas a and ts co#!" cat ons. Treat#ent Treat#ent #ust ' rst"$ be to e*c"ude a carc no#a b$ occu"t b"ood test and c$to"o&$. S #!"e reassurance #a$ then be su'' c ent% but ' the d schar&e s !rov n& nto"erab"e an o!erat on to re#ove the a''ected duct or ducts can be !er'or#ed. . &ure /).0( ""ustrates so#e causes o' n !!"e d schar&e. M crodochecto#$. It s #!ortant not to e*!ress the b"ood be'ore the o!erat on as t #a$ then be d '' cu"t to dent '$ the duct n theatre. A "acr #a" !robe or "en&th o' st '' n$"on suture s nserted nto the duct 'ro# -h ch the d schar&e s e#er& n&. A tenn s raBuet nc s on can be #ade to enco#!ass the ent re duct% or a !er areo"ar nc s on used and the n !!"e '"a! d ssected to reach the duct. The duct s then e*c sed. A !a! ""o#a s near"$ a"-a$s s tuated - th n /76c# o' the n !!"e or ' ce. Cone e*c s on o' the #ajor ducts 8a'ter Had'"e"d:. Ehen the duct o' or & n o' n !!"e b"eed n& s uncerta n or -hen there s b"eed n& or d schar&e 'ro# #u"t !"e ducts% the ent re #ajor duct s$ste# can be e*c sed 'or h sto"o& ca" e*a# nat on - thout sacr ' ce o' the breast 'or#. A !er areo"ar nc s on s #ade and a cone o' t ssue s re#oved - th ts a!e* "ust dee! to the sur'ace o' the n !!"e and ts base on the !ectora" 'asc a. The resu"t n& de'ect s ob" terated b$ a ser es o' !urse1str n& sutures. It s #!ortant to -arn the !at ent that she - "" be unab"e to breast 'eed a'ter th s and #a$ "ose n !!"e sensat on. Ben &n breast d sease Th s s the #ost co##on cause o' breast !rob"e#s 7 u! to ?5 !er cent o' -o#en - "" su''er 'ro# a ben &n breast d sorder reBu r n& treat#ent at so#e t #e n the r " ves. The #ost co##on s$#!to#s are !a n% "u#! ness or a "u#!. The a # o' treat#ent s to e*c"ude cancer and% once th s has been done% to treat an$ re#a n n& s$#!to#s. Ben &n breast d sorders can be c"ass ' ed n the 'o""o- n& -a$4 < ANDI0 8"u#!$ breasts% tenderness or a s#ooth "u#!:4 c$c" ca" nodu"ar t$ and #asta"& a% c$sts% ' broadeno#a; < duct ectas aA!er ducta" #ast t s; < !re&nanc$ re"ated4 &a"actocoe"e% !eur!era" abscess; < con&en ta" d sorders4 nverted n !!"e% su!ernu#ar$ breastsAn !!"es; < nonbreast d sorders4 T et3e9s d sease; sebaceous c$sts and other s2 n cond t ons. Con&en ta" abnor#a" t es A#a3 a Con&en ta" absence o' the breast #a$ occur on one 8. &. /).0?: or both s des. It s so#et #es assoc ated - th absence o' the sterna" !ort on o' the !ectora" s #ajor 8Co"and9s s$ndro#e:. It s #ore co##on n #a"es. Co"$#a3 a Accessor$ breasts 8. &. /).0/: have been recorded n the a* ""a 8the #ost 'reBuent s te:% &ro n% buttoc2 and th &h. The$ have been 2no-n to 'unct on dur n& "actat on. Mast t s o' n'ants Mast t s o' n'ants s at "east as co##on n the #a"e as n the 'e#a"e. On the ?rd or /th da$ o' " 'e% ' the breast o' an n'ant s !ressed " &ht"$% a dro! o' co"our"ess '"u d

can be e*!ressed; a 'e- da$s "ater there s o'ten a s" &ht # "2$ secret on% -h ch d sa!!ears dur n& the ?rd -ee2. Th s s !o!u"ar"$ 2no-n as D- tch9s # "29. It s due to st #u"at on o' the 'oeta" breast b$ #aterna" !ro"act n% thus s essent a""$ !h$s o"o& ca". D ''use h$!ertro!h$ D ''use h$!ertro!h$ o' the breasts occurs s!orad ca""$ n other- se hea"th$ & r"s at !ubert$ and% #uch "ess o'ten% dur n& the ' rst !re&nanc$.The breasts atta n enor#ous d #ens ons 8. &. /).06: and #a$ reach the 2nees -hen the !at ent s s tt n&. The cond t on s rare"$ un "atera". Th s tre#endous over&ro-th s a!!arent"$ due to an a"terat on n the nor#a" sens t v t$ o' the breast to oestro&en c hor#ones% and so#e success n treat n& t - th ant oestro&ens has been re!orted. Treat#ent s other- se b$ reduct on #a##o!"ast$. Injur es o' the breast Hae#ato#a Hae#ato#a% !art cu"ar"$ a reso"v n& hae#ato#a% & ves r se to a "u#! -h ch% n the absence o' over"$ n& bru s n&% s d '' cu"t to d a&nose correct"$ un"ess t s as! rated or nc sed. Trau#at c 'at necros s Trau#at c 'at necros s #a$ be acute or chron c% and usua""$ occurs n stout% # dd"e1 a&ed -o#en. .o""o- n& a b"o-% oreven nd rect v o"ence 8e.&. contract on o' the !ectora" s #ajor:% a "u#!% o'ten !a n"ess% a!!ears. Th s #a$ # # c a carc no#a% even d s!"a$ n& s2 n tether n& and n !!"e retract on% and b o!s$ s reBu red 'or d a&nos s. A h stor$ o' trau#a s not d a&nost c as th s #a$ #ere"$ have dra-n the !at ent9s attent on to a !re1e* st n& "u#!. Acute and subacute n'"a##at ons o' the breast Bacter a" #ast t s Bacter a" #ast t s s the co##onest var et$ o' #ast t s and near"$ a"-a$s co##ences acute"$. A"thou&h assoc ated - th "actat on n the #ajor t$ o' cases% t s not necessar "$ so. O' 055 consecut ve cases o' breast abscess% ?( occurred n -o#en -ho -ere not "actat n& 8De Fode:. So#e o' these - "" be assoc ated - th an n'ected hae#ato#a or - th !er ducta" #ast t s and th s - "" be d scussed "ater. Aet o"o&$. Lactat ona" #ast t s s seen 'ar "ess 'reBuent"$ than n 'or#er $ears. Most cases are caused b$ Sta!h$"ococcus aureus and% ' hos! ta"1acBu red% are " 2e"$ to be !en c "" n res stant. The nter#ed ar$ s usua""$ the n'ant; a'ter the second da$ o' " 'e 65 !er cent o' n'ants harbour sta!h$"ococc n the naso!har$n*. DC"eans n& the bab$9s #outh9 - th a s-ab s a"so an aet o"o& ca" 'actor. The de" cate bucca" #ucosa s e*cor ated b$ the !rocess; t beco#es n'ected% and or&an s#s n the n'ant9s sa" va are nocu"ated on to the #other9s n !!"e. Eh "st ascend n& n'ect on 'ro# a sore and crac2ed n !!"e #a$ n t ate the #ast t s% n #an$ cases the "act 'erous ducts - "" ' rst beco#e b"oc2ed b$ e! the" a" debr s "ead n& to stas s 7 th s theor$ s su!!orted b$ the re"at ve"$ h &h nc dence o' #ast t s n -o#en - th a retracted n !!"e. Once - th n the a#!u""a o' the duct% sta!h$"ococc cause c"ott n& o' # "2 and - th n th s c"ot or&an s#s #u"t !"$. C" n ca" 'eatures. The a''ected breast% or #ore usua""$ a se&#ent o' t% !resents the c"ass ca" s &ns o' acute n'"a##at on. Ear"$ on th s s a &enera" sed ce""u" t s% but "ater an abscess - "" 'or#. Treat#ent. Dur n& the ce""u" t c sta&e the !at ent shou"d be treated - th an a!!ro!r ate ant b ot c% e.&. '"uc"o*ac "" n% and the breast rested% - th 'eed n& on the o!!os te s de on"$. The n'ected breast shou"d be e#!t ed o' # "2 us n& a breast !u#!. Su!!ort o' the breast% "oca" heat and ana"&es a - "" he"! to re" eve !a n.

I' an ant b ot c s used n the !resence o' undra ned !us% an Dant b o#a9 #a$ 'or#. Th s s a "ar&e% ster "e bra-n$ oede#atous s-e"" n& -h ch ta2es #an$ -ee2s to reso"ve. The breast shou"d be nc sed and dra ned ' the n'ect on does not reso"ve - th n /, hours% or '% a'ter be n& e#!t ed o' # "2% there s an area o' tense ndurat on or other ev dence o' an under"$ n& abscess. The !resence o' !us can be con' r#ed - th a need"e as! rat on% and the !us ana"$sed 'or the n'ect on and 'or c$to"o&$. Th s has the advanta&e o' a""o- n& d a&nos s on the s#ear o' a rare n'"a##ator$ carc no#a 8. &. /).0):. In contrast to the #ajor t$ o' "oca" sed n'ect ons% '"uctuat on s a "ate s &n and nc s on #ust not be de"a$ed unt " t a!!ears. Usua""$ the area o' ndurat on s sector1sha!ed% and n ear"$ cases about one1 Buarter o' the breast s nvo"ved 8. &. /).0+:; n #an$ "ate cases the area s #ore e*tens ve 8. &. /).0,:. Ehen n doubt an u"trasound scan #a$ c"ear"$ de' ne an area Dr !e9 'or dra na&e. Dra na&e o' an ntra#a##ar$ abscess. The usua" nc s on s s ted n a rad a" d rect on over the a''ected se&#ent% a"thou&h ' a c rcu#areo"ar nc s on - "" a""o- adeBuate access to the a''ected area th s shou"d be !re'erred because o' a better cos#et c resu"t. The nc s on !asses throu&h the s2 n and the su!er' c a" 'asc a. A "on& hae#ostat s then nserted nto the abscess cav t$. Ever$ !art o' the abscess s !a"!ated a&a nst the !o nt o' the hae#ostat and ts ja-s are o!ened. A"" Iocu" that can be 'e"t are entered. . na""$% the hae#ostat hav n& been - thdra-n% a ' n&er s ntroduced and an$ re#a n n& se!ta are d sru!ted. The -ound #a$ then be " &ht"$ !ac2ed - th r bbon &au3e or a dra n nserted to a""o- de!endent dra na&e. Mast t s 'ro# # "2 en&or&e#ent Mast t s 'ro# # "2 en&or&e#ent s " ab"e to occur around -ean n& t #e% and so#et #es n the ear"$ da$s o' "actat on -hen one o' the "act 'erous ducts beco#es b"oc2ed - th e! the" a" debr s. In the "atter nstance on"$ a sector o' the breast beco#es ndurated and tender. Chron c ntra#a##ar$ abscess Chron c ntra#a##ar$ abscess -h ch 'o""o-s nadeBuate dra na&e or njud c ous ant b ot c treat#ent s o'ten a ver$ d '' cu"t cond t on to d a&nose4 -hen enca!su"ated - th n a th c2 -a"" o' ' brous t ssue% the cond t on cannot be d st n&u shed 'ro# a carc no#a - thout the h sto"o& ca" ev dence 'ro# a b o!s$. Tubercu"os s o' the breast Tubercu"os s o' the breast% -h ch s co#!arat ve"$ rare% s usua""$ assoc ated - th act ve !u"#onar$ tubercu"os s or tubercu"ous cerv ca" aden t s. Tubercu"os s o' the breast 8. &. /).0@: occurs #ore o'ten n !arous -o#en and usua""$ !resents - th #u"t !"e chron c abscesses and s nuses and a t$! ca" b"u sh attenuated a!!earance o' the surround n& s2 n. The d a&nos s rests on bacter o"o& ca" and h sto"o& ca" e*a# nat on. Treat#ent s - th ant tubercu"ous che#othera!$. Hea" n& s usua" a"thou&h o'ten de"a$ed% and #astecto#$ shou"d be restr cted to !at ents - th !ers stent res dua" n'ect on. Act no#$cos s Act no#$cos s o' the breast s rarer st "". The "es ons !resent the essent a" character st cs o' 'ac ocerv ca" act no#$cos s. S$!h " s o' the breast A !r #ar$ chancre o' the n !!"e has been re'erred to 8above:. Secondar$ "es ons o' s$!h " s nc"ude d ''use s$!h " t c #ast t s. Mondor9s d sease

Mondor9s d sease s thro#bo!h"eb t s o' the su!er' c a" ve ns o' the breast and anter or chest -a"" 8. &. /).(5: a"thou&h t has a"so been encountered n the ar#. In the absence o' njur$ or n'ect on% the cause o' thro#bo!h"eb t s 7" 2e that o' s!ontaneous thro#bo!h"eb t s n other s tes 7 s obscure. The !atho&no#on c 'eature s a thro#bosed subcutaneous cord% usua""$ attached to s2 n. Ehen the s2 n over the breast s stretched b$ ra s n& the ar#% a narro-% sha""o- subcutaneous &roove a"on&s de the cord beco#es a!!arent. The d ''erent a" d a&nos s s "$#!hat c !er#eat on 'ro# an occu"t carc no#a o' the breast. The on"$ treat#ent reBu red s restr cted ar# #ove#ents% and n an$ case the cond t on subs des - th n a 'e- #onths - thout recurrence% co#!" cat ons or de'or# t$. Duct ectas aA!er ducta" #ast t s Catho"o&$ Th s s a d "atat on o' the breast ducts assoc ated - th !er ducta" n'"a##at on% the !atho&enes s o' -h ch s obscure and a"#ost certa n"$ not un 'or# n a"" cases% a"thou&h the d sease s #uch #ore co##on n s#o2ers. The c"ass ca" descr !t on o' the !atho&enes s o' duct ectas a asserts that the ' rst sta&e n the d sorder s a d "atat on n one or #ore o' the "ar&er "act 'erous ducts -h ch ' "" - th a sta&nant bro-n or &reen secret on. Th s #a$ d schar&e. These '"u ds then set u! an rr tant react on n surround n& t ssue "ead n& to !er ducta" #ast t s or even abscess and ' stu"a 'or#at on 8. &s /).(0 and /).((:. In so#e cases a chron c ndurated #ass 'or#s beneath the areo"a -h ch # # cs a carc no#a. . bros s eventua""$ deve"o!s -h ch #a$ cause s" t1" 2e n !!"e retract on. An a"ternat ve theor$ su&&ests that !er ducta" n'"a##at on s the !r #ar$ cond t on and anaerob c bacter a" n'ect on s 'ound n so#e cases. An assoc at on bet-een recurrent !er ducta" n'"a##at on and s#o2 n& has been de#onstrated -h ch #a$ su&&est that arter o!ath$ s a contr but n& 'actor n ts aet o"o&$. C" n ca" 'eatures N !!"e d schar&e 8o' an$ co"our:% a subareo"ar #ass% abscess% #a##ar$ duct ' stu"a andAor n !!"e retract on are the co##onest s$#!to#s 8. &. /).(?:. Treat#ent In the case o' a #ass or n !!"e retract on% a carc no#a #ust be e*c"uded b$ obta n n& a #a##o&ra# and ne&at ve c$to"o&$ or h sto"o&$. I' an$ sus! c on re#a ns the #ass shou"d be e*c sed. Ant b ot c thera!$ #a$ be tr ed% the #ost a!!ro!r ate a&ents be n& '"uc"o*ac "" n and #etron da3o"e.Ho-ever% sur&er$ s o'ten the on"$ o!t on " 2e"$ to br n& about cure o' th s notor ous"$ d '' cu"t cond t on% and cons sts o' e*c s on o' a"" o' the #ajor ducts 8the Had' e"d9s o!erat on:. Aberrat ons o' nor#a" deve"o!#ent and nvo"ut on 8ANDI: No#enc"ature The no#enc"ature o' ben &n breast d sease s ver$ con'us n&. Th s s because over the "ast centur$ a var et$ o' c" n c ans and !atho"o& sts has chosen to descr be a # *ture o' !h$s o"o& ca" chan&es and d sease !rocesses accord n& to a var et$ o' c" n ca"% !atho"o& ca" and aet o"o& ca" ter# no"o&$. As -e"" as "ead n& to con'us on% !at ents -ere o'ten undu"$ a"ar#ed or overtreated b$ ascr b n& a !atho"o& ca" na#e to a var ant o' !h$s o"o& ca" deve"o!#ent. To sort out th s con'us on% a ne- s$ste# has been deve"o!ed and descr bed b$ the Card '' Breast C" n c( 7 ANDI. 8Man$ a"ternat ve ter#s have been a!!" ed to th s cond t on nc"ud n& ' broc$st c d sease% ' broadenos s% chron c #ast t s and #asto!ath$.: A et o"o&$

The breast s a d$na# c structure -h ch under&oes chan&es throu&hout a -o#an9s re!roduct ve " 'e% and su!er #!osed u!on th s% c$c" ca" chan&es throu&hout the #enstrua" c$c"e. Th s s ""ustrated n . &. /).(/. The !atho&enes s o' ANDI nvo"ves d sturbances n the breast !h$s o"o&$ e*tend n& 'ro# an e*tre#e o' nor#a" t$ to -e""1 de' ned d sease !rocesses. There s o'ten " tt"e corre"at on bet-een the h sto"o& ca" a!!earance o' the breast t ssue and the s$#!to#s. R s2 o' #a" &nanc$ deve"o! n& n assoc at on - th ben &n breast !atho"o&$ These re"at ve r s2s accord n& to d ''erent h sto"o& ca" 'eatures 'ound at b o!s$ are ""ustrated n Tab"e /).0. Catho"o&$ The d sease cons sts essent a""$ o' 'our 'eatures -h ch #a$ var$ n e*tent and de&ree n an$ one breast. 0.C$st 'or#at on. C$sts are a"#ost nev tab"e and ver$ var ab"e n s 3e. (. . bros s. .at and e"ast c t ssue d sa!!ears and s re!"aced b$ dense -h te ' brous trabecu"ae. The nterst t a" t ssue s n' "trated - th chron c n'"a##ator$ ce""s. ?. H$!er!"as a o' e! the" u# n the " n n& o' the ducts and ac n #a$ occur - th or - thout at$! a. /. Ca! ""o#atos s. The e! the" a" h$!er!"as a #a$ be so e*tens ve that t resu"ts n !a! ""o#atous over&ro-th - th n the ducts. C" n ca" 'eatures The s$#!to#s o' ANDI nc"ude an area o' "u#! ness 8se"do# d screte: andAor breast !a n 8#asta"& a:. A ben &n d screte "u#! n the breast s co##on"$ a c$st or ' broadeno#a. True " !o#as occur rare"$. Lu#! ness #a$ be b "atera"% co##on"$ n the u!!er outer Buadrant% or "ess co##on"$ con' ned to one Buadrant o' one breast. The chan&es #a$ be c$c" ca"% - th an ncrease n both "u#! ness and o'ten tenderness be'ore a #enstrua" !er od. Nonc$c" ca" #asta"& a s co##oner n !er #eno!ausa" and !ost#eno!ausa" -o#en. It #a$ be assoc ated - th ANDI or - th !er ducta" #ast t s% or re'erred 'ro#% 'or e*a#!"e% a #uscu"os2e"eta" d sorder. About 05 !er cent o' breast cancers e*h b t !a n at !resentat on. Co##on breast s$#!to#s are ""ustrated n Tab"e /).(. Treat#ent o' "u#!$ breasts I' the c" n c an s con' dent that he or she s not dea" n& - th a d screte abnor#a" t$ 8and c" n ca" con' dence #a$ be buttressed b$ #a##o&ra!h$ or u"trasound scann n& ' a!!ro!r ate:% then n t a""$ the -o#an can be o''ered ' r# reassurance. It s !erha!s -orth-h "e rev e- n& the !at ent at a d ''erent !o nt n the #enstrua" c$c"e% sa$ ) -ee2s a'ter the n t a" v s t% and o'ten the c" n ca" s &ns - "" have reso"ved b$ that t #e. There s a tendenc$ 'or -o#en - th "u#!$ breasts to be rendered unnecessar "$ an* ous and to be sub# tted to #u"t !"e rando# b o!s es because the c" n c an "ac2s the coura&e o' h s or her conv ct ons. Treat#ent o' #asta"& a Cronounced c$c" ca" #asta"& a #a$ beco#e a s &n ' cant c" n ca" !rob"e# -here the !a n and tenderness nter'ere - th the -o#an9s " 'e% d sturb her s"ee! and #!a r se*ua" act v t$. In t a""$% ' r# reassurance that the s$#!to#s are not assoc ated - th cancer - "" he"! the #ajor t$ o' -o#en. A !at ent s$#!to# d ar$ - "" he"! her to chart the !attern o' !a n throu&hout the #onth and thus deter# ne -hether th s s c$c" ca" #asta"& a. I' reassurance s nadeBuate% then a !"anned esca"at on o' treat#ent 8as sho-n n Tab"e /).?: cou"d be adv sed. O " o' even n& !r #rose% n adeBuate doses & ven over ? #onths% - "" he"! #ore than ha"' o' these -o#en. .or those - th ntractab"e s$#!to#s a !ro"act n nh b tor such as dana3o" #a$ be & ven. Ger$ rare"$

t s necessar$ to !rescr be an ant oestro&en% e.&. ta#o* 'en or a "ute n 3 n& hor#one1 re"eas n& hor#one 8LHRH: a&on st% to de!r ve the breast e! the" u# o' oestro&en c dr ve. .or nonc$c" ca" #asta"& a t s #!ortant to e*c"ude e*tra#a##ar$ causes such as chest -a"" !a n% and t #a$ be necessar$ to carr$ out a b o!s$ on a ver$ "oca" sed tender area -h ch # &ht be harbour n& a subc" n ca" cancer. Treat#ent #a$ be - th nonstero da" ana"&es cs or b$ nject on - th "oca" anaesthet c o' a Dtr &&er s!ot9. Breast c$sts These occur #ost co##on"$ n the "ast decade o' re!roduct ve " 'e due to a non nte&rated nvo"ut on o' stro#a and e! the" u#. The$ are o'ten #u"t !"e% #a$ be b "atera" and can # # c #a" &nanc$. D a&nos s can be con' r#ed b$ as! rat on andAor u"trasound. Treat#ent A so" tar$ c$st or s#a"" co""ect on o' c$sts can be as! rated. I' the$ reso"ve co#!"ete"$% and ' the '"u d s not b"oodsta ned% no 'urther treat#ent s reBu red. Ho-ever% ?5 !er cent - "" recur and reBu re reas! rat on. C$to"o& ca" e*a# nat on o' c$st '"u d s no "on&er !ract sed rout ne"$. I' there s a res dua" "u#! or ' the '"u d s b"oodsta ned% a "oca" e*c s on 'or h sto"o& ca" d a&nos s s adv sab"e% as s a"so the case ' the c$st re!eated"$ re'or#s. >a"actoce"e >a"actoce"e% -h ch s rare% usua""$ !resents as a so" tar$% subareo"ar c$st% and a"-a$s dates 'ro# "actat on. It conta ns # "2 and n "on&stand n& cases ts -a""s tend to ca"c '$. It can beco#e enor#ous 8. &. /).(6:. . broadeno#a These usua""$ ar se n the 'u""$ deve"o!ed breast dur n& the 067(61$ear !er od% a"thou&h occas ona""$ the$ occur n #uch o"der -o#en. The$ ar se 'ro# h$!er!"as a o' a s n&"e "obu"e% and usua""$ &ro- u! to (7? c# n s 3e. The$ are surrounded b$ a -e""1#ar2ed ca!su"e and can thus be enuc"eated throu&h a cos#et ca""$ a!!ro!r ate nc s on. Ho-ever% n a !at ent under ?5 $ears these do not reBu re e*c s on un"ess assoc ated - th sus! c ous c$to"o&$% or ' the$ beco#e ver$ "ar&e% or ' the !at ent e*!ress"$ des res the "u#! to be re#oved.> ant ' broadeno#as occur occas ona""$ dur n& !ubert$. The$ are over 6c# n d a#eter and are o'ten ra! d"$ &ro- n&% but n other res!ects are s # "ar .to s#a""er ' broadeno#as and can be enuc"eated throu&h a sub#a##ar$ nc s on. Ch$""odes tu#our These ben &n tu#ours% !rev ous"$ so#et #es 2no-n as seroc$st c d sease o' Brod e or c$stosarco#a !h$""odes% usua""$ occur n -o#en over the a&e o' /5 but can a!!ear n $oun&er -o#en 8. &. /).():. The$ !resent as a "ar&e% so#et #es #ass ve tu#our% - th an uneven"$ bosse"ated sur'ace. Occas ona""$ u"cerat on o' over"$ n& s2 n occurs o- n& to !ressure necros s. In s! te o' the r s 3e the$ re#a n #ob "e on the chest -a"". H sto"o& ca""$ there s a rese#b"ance to a ' broadeno#a% but des! te the na#e o' c$stosarco#a !h$""odes the$ are rare"$ c$st c and on"$ ver$ rare"$ deve"o! 'eatures o' a sarco#atous tu#our. These #a$ #etastas se v a the b"oodstrea#. Treat#ent Treat#ent 'or the ben &n t$!e s enuc"eat on n ver$ $oun& -o#en or - de "oca" e*c s on. Mass ve tu#ours% recurrent tu#ours and those o' the #a" &nant t$!e - "" reBu re #astecto#$. Ehen the d a&nos s o' carc no#a s n doubt

There - "" a"-a$s be cases -here the c" n c an cannot be sure -hether a !art cu"ar "u#! n the breast s an area o' #a##ar$ d$s!"as a% a ben &n tu#our or an ear"$ carc no#a. I' there s doubt on e ther c" n ca"% c$to"o& ca" or rad o"o& ca" e*a# nat on t s essent a" to obta n a t ssue d a&nos s. Th s s o'ten !oss b"e b$ need"e b o!s$. In the advent o' a ne&at ve resu"t% o!en b o!s$ o' the #ass s necessar$. Because o' the !oss b " t$ o' re!ort n& errors% the authors su&&est that 'ro3en sect on re!ort n& shou"d rare"$ be used and certa n"$ shou"d not 'or# the bas s 'or a dec s on to underta2e a#astecto#$. Tab"e /)./ & ves an a"&or th# 'or nvest &at n& an$ breast "u#!. Tab"e /).6 ""ustrates the 'eatures o' three co##on "u#!s. Carc no#a o' the breast Breast cancer s the co##onest cause o' death n # dd"e1a&ed -o#en n Eestern countr es. In 0@,6% +0@ 555 ne- cases -ere d a&nosed -or"d1- de. In En&"and and Ea"es one n 0( -o#en - "" deve"o! the d sease dur n& the r " 'et #e. Aet o"o& ca" 'actors I. >eo&ra!h ca". It occurs co##on"$ n the Eestern -or"d account n& 'or ?76 !er cent o' deaths% $et s a rare tu#our n Fa!an. In deve"o! n& countr es t accounts 'or 07? !er cent o' deaths. (. A&e. Carc no#a o' the breast s e*tre#e"$ rare be"o- the a&e o' (5% but therea'ter the nc dence stead "$ r ses so that b$ the a&e o' @5 near"$ (5 !er cent o' -o#en are a''ected 8. &. /).(+:. B$ a&e (6 0 n 0@)5, B$ a&e )5 0 n (/ B$ a&e ?5 0 n (6(6 B$ a&e )6 0 n 0+ B$ a&e ?6 0 n )(( B$ a&e +5 0 n 0/ B$ a&e /5 0 n (0+ B$ a&e +6 0 n 00 B$ a&e /6 0 n @? B$ a&e ,5 " n 05 B$ a&e 65 " n 65 B$ a&e ,6 " n@ B$ a&e 66 0 n ?? Ever 0n, 0@,+70@,, Cancer nc dence rates% NCI% USA. ?. >ender. Less than I !er cent o' !at ents - th breast cancer are #a"e. /. >enet c. It occurs #ore co##on"$ n -o#en - th a 'a# "$ h stor$ o' breast cancer than n the &enera" !o!u"at on. Breast cancer re"ated to a s!ec ' c #utat on accounts 'or about 6 !er cent o' breast cancers% $et has 'ar1reach n& re!ercuss ons n ter#s o' counse"" n& and atte#!ted !revent on n these -o#en. Th s - "" be d scussed #ore 'u""$ n a subseBuent sect on. 6. D et. Because breast cancer so co##on"$ a''ects -o#en n the Ddeve"o!ed9 -or"d% d etar$ 'actors #a$ !"a$ a !art n ts causat on. There s so#e ev dence that there s a " n2 bet-een d ets "o- n !h$to1oestro&ens. A h &h nta2e o' a"coho" s assoc ated - th an ncreased r s2 o' deve"o! n& breast cancer. ). Endocr ne. Breast cancer s co##oner n nu"" !arous -o#en and breast'eed n& n !art cu"ar a!!ears to be !rotect ve. A"so !rotect ve s hav n& a ' rst ch "d at an ear"$ a&e% es!ec a""$ ' assoc ated - th "ate #enarche and ear"$ #eno!ause. It s 2no-n that n !ost#eno!ausa" -o#en% breast cancer s #ore co##on n the obese. Th s s thou&ht to he because o' an ncreased convers on o' stero d hor#ones to oestrad o" n the bod$ 'at. The ro"e o' e*o&enous hor#ones% n !art cu"ar the ora" contrace!t ve ! "" and hor#one re!"ace#ent thera!$% n the deve"o!#ent o' breast cancer s #ore controvers a"% but t can be sa d - th so#e author t$ that 'or #ost -o#en the bene' ts o' these treat#ents - "" 'ar out-e &h the s#a"" !utat ve r s2.

The ncrease n the " 2e" hood o' deve"o! n& breast cancer assoc ated - th the above r s2 'actors s usua""$ Buant ' ed n ter#s o' the re"at ve r s2 8RR:. Thus a RR o' (.5 #eans that the nd v dua" has t- ce the chance o' deve"o! n& breast cancer as the avera&e 'or the !o!u"at on% -h "st a RR o' 5.6 nd cates a r s2 reduct on o' 65 !er cent. Catho"o&$ Breast cancer #a$ ar se 'ro# the e! the" u# o' the duct s$ste# an$-here 'ro# the n !!"e end o' #ajor "act 'erous ducts to the ter# na" duct un t -h ch s n the breast "obu"e. It #a$ be ent re"$ n s tu 7 an ncreas n&"$ co##on !heno#enon - th the advent o' breast cancer screen n& 7 or #a$ be nvas ve cancer. The de&ree o' d ''erent at on o' the tu#our s usua""$ descr bed b$ three &rades 7 -e"" d ''erent ated% #oderate"$ or !oor"$ d ''erent ated. Ducta" carc no#a s the #ost co##on var ant% but "obu"ar carc no#a occurs n u! to 05 !er cent o' cases% a"thou&h th s #a$ be # *ed. Rarer h sto"o& ca" var ants% usua""$ carr$ n& a better !ro&nos s% nc"ude co""o d carc no#a -hose ce""s !roduce abundant #uc n% #edu""ar$ carc no#a - th so" d sheets o' "ar&e ce""s o'ten assoc ated - th a #ar2ed "$#!hoc$t c react on and tubu"ar carc no#a. Invas ve "obu"ar carc no#a s co##on"$ #u"t 1'oca" andAor b "atera". In'"a##ator$ carc no#a s a 'ortunate"$ rare% h &h"$ a&&ress ve cancer -h ch !resents as a !a n'u"% s-o""en breast% -h ch s -ar# - th cutaneous oede#a. Th s s due to b"oc2a&e o' the subder#a" "$#!hat cs - th carc no#a ce""s. In'"a##ator$ cancer usua""$ nvo"ves at "east one1th rd o' the breast and #a$ # # c a breast abscess. A b o!s$ - "" con' r# the d a&nos s and sho- und ''erent ated carc no#a ce""s. In s tu carc no#a s !re nvas ve cancer -h ch has not breached the e! the" a" base#ent #e#brane. Th s -as !rev ous"$ a rare% usua""$ as$#!to#at c ' nd n& n breast b o!s$ s!ec #ens but s beco# n& ncreas n&"$ co##on o- n& to the advent o' #a##o&ra!h c screen n& 7 t accounts 'or (5 !er cent o' cancers detected b$ screen n&. In s tu carc no#a #a$ be ducta" 8DCIS: or "obu"ar 8LCIS:% the "atter o'ten #u"t 'oca" and b "atera". Both are #ar2ers 'or the "ater deve"o!#ent o' nvas ve cancer -h ch - "" &o on to deve"o! n at "east (5 !et cent o' cases. A"thou&h #astecto#$ s curat ve% th s s overtreat#ent n #an$ cases and the best treat#ent 'or n s tu carc no#a s the subject o' a nu#ber o' c" n ca" tr a"s. Ca&et9s d sease o' the n !!"e Ca&er9s d sease o' the n !!"e 8. &. /).(,a and b: s a su!er' c a" #an 'estat on o' an under"$ n& breast carc no#a. It !resents as an ec3e#a1" 2e cond t on o' the n !!"e and areo"a -h ch !ers sts n s! te o' "oca" treat#ent. The n !!"e s eroded s"o-"$ and eventua""$ d sa!!ears. I' "e't% the under"$ n& carc no#a - "" sooner or "ater beco#e c" n ca""$ ev dent. Thus n !!"e ec3e#a shou"d be b o!s ed ' there s an$ doubt about ts cause. M crosco! ca""$ Ca&er9s d sease s character sed b$ the !resence o' "ar&e% ovo d ce""s - th abundant% c"ear% !a"e1sta n n& c$to!"as# n the Ma"! &h an "a$er o' the e! der# s. The s!read o' #a##ar$ carc no#a 0.Loca" s!read. The tu#our ncreases n s 3e and nvades other !ort ons o' the breast. It tends to nvo"ve the s2 n and to !enetrate the !ectora" #usc"es% and even the chest -a"". (.L$#!hat c #etastas s occurs !r #ar "$ to the a* ""ar$ "$#!h nodes and to the nterna" #a##ar$ cha n o' "$#!h nodes. The s te o' the tu#our - th n the breast does not d ctate -h ch nodes - "" be nvo"ved% e.&. #ed a" tu#ours s!read just as read "$ to the a* ""ar$ nodes as do "atera" tu#ours. The nvo"ve#ent o' "$#!h nodes s

not necessar "$ a chrono"o& ca" event n the evo"ut on o' the carc no#a% but rather a #ar2er 'or the #etastat c !otent a" o' that tu#our. In advanced d sease there #a$ be nvo"ve#ent o' su!rac"av cu"ar nodes and o' an$ contra"atera" "$#!h nodes. ?.S!read b$ the b"oodstrea#. It s b$ th s route that s2e"eta" #etastases occur 8 n order o' 'reBuenc$: n the "u#bar vertebrae% 'e#ur% thorac c vertebrae% r b and s2u""; the$ are &enera""$ osteo"$t c. Metastases #a$ a"so occur n the " ver% "un& and bra n% and occas ona""$ the adrena" &"ands and ovar es. C" n ca" !resentat on Eh "e an$ !ort on o' the breast% nc"ud n& the a* ""ar$ ta "% #a$ be nvo"ved% breast cancer co##ences #ost 'reBuent"$ n the u!!er% outer Buadrant 8. &s /).(@ and /).?5:. Most breast cancers - "" !resent as a hard "u#!% -h ch #a$ be assoc ated - th ndra- n& o' the n !!"e. As the d sease advances "oca""$ there #a$ be s2 n nvo"ve#ent - th !eau d9oran&e 8. &. /).?0: or 'ran2 u"cerat on and ' *at on to the chest -a"" 8. &. /).?(:. Th s s descr bed as cancer1encu rasse. About 6 !er cent o' breast cancers n the UH - "" !resent - th e ther "oca""$ advanced d sease or s$#!to#s o' #etastat c d sease. Th s ' &ure s nearer (5 !er cent n the deve"o! n& -or"d. These !at ents #ust then under&o a sta& n& eva"uat on so that the 'u"" e*tent o' the r d sease can be ascerta ned. Th s - "" nc"ude a care'u" c" n ca" e*a# nat on% chest =1ra$% seru# a"2a" ne !hos!hatase and &a##a &"uta# ne transa# nase 8>>T:% - th " ver u"trasound ' these are abnor#a"% and an soto!e bone scan 8. &. /).??:. Th s s #!ortant 'or both !ro&nos s and treat#ent 7 a !at ent - th - des!read v scera" #etastases #a$ obta n an ncreased "en&th and Bua" t$ o' surv va" 'ro# s$ste# c hor#one or che#othera!$% but she s not " 2e"$ to bene' t 'ro# sur&er$ as she - "" d e 'ro# her #etastases be'ore "oca" d sease beco#es a !rob"e#. In contrast% !at ents - th re"at ve"$ s#a"" 8"ess than 6 c# n d a#eter: tu#ours con' ned to the breast and !s "atera" "$#!h nodes rare"$ need sta& n& be$ond a &ood c" n ca" e*a# nat on as the ! c21u! rate 'or d stant #etastases s so "o-. Cheno#ena resu"t n& 'ro# "$#!hat c obstruct on n Sta& n& o' breast cancer advanced breast cancer Ceau d9oran&e s due to cutaneous "$#!hat c oede#a. Ehere the n' "trated s2 n s tethered b$ the s-eat ducts t cannot s-e""% "ead n& to an a!!earance " 2e oran&e s2 n. Occas ona""$ the sa#e !heno#enon s seen over a chron c abscess. Late oede#a o' the ar# s a troub"eso#e co#!" cat on o' breast cancer treat#ent 'ortunate"$ seen "ess o'ten no- that rad ca" a* ""ar$ d ssect on and rad othera!$ are rare"$ co#b ned. It does ho-ever occas ona""$ st "" occur a'ter e ther #oda" t$ o' treat#ent a"one and a!!ears an$t #e 'ro# #onths to $ears a'ter treat#ent. There s usua""$ no !rec ! tat n& cause but recurrent tu#our shou"d be e*c"uded as neo!"ast c n' "trat on o' the a* ""a can cause ar# s-e"" n& due to both "$#!hat c and venous b"oc2a&e. Th s neo!"ast c n' "trat on s o'ten !a n'u" due to nerve nvo"ve#ent. An oede#atous " #b s susce!t b"e to bacter a" n'ect ons 'o""o- n& Bu te # nor trau#a% and these reBu re v &orous ant b ot c treat#ent. Treat#ent o' "ate oede#a s d '' cu"t but " #b e"evat on% e"ast c ar# stoc2 n&s and !neu#at c co#!ress on dev ces can be use'u". Cancer1en1cu rasse/. The s2 n o' the chest s n' "trated - th carc no#a and has been " 2ened to a coat. It #a$ be assoc ated - th a &ross"$ s-o""en ar#. Th s usua""$ occurs n cases - th "oca" recurrence a'ter #astecto#$% and occas ona""$ s seen to 'o""o- the d str but on o' rrad at on to the chest -a"". The cond t on #a$ res!ond to !a"" at ve s$ste# c treat#ent but !ro&nos s n ter#s o' surv va" s !oor.

L$#!han& osarco#a 8. &. /).?/: s a rare co#!" cat on o' "$#!hoede#a - th an onset #an$ $ears 'o""o- n& the or & na" treat#ent. It ta2es the 'or# o' #u"t !"e subcutaneous nodu"es n the u!!er " #b and #ust be d st n&u shed 'ro# recurrent carc no#a o' the breast. The !ro&nos s s !oor but so#e cases res!ond to c$toto* c thera!$ or rrad at on. Intersca!u"othorac c 8'oreBuarter: a#!utat on s so#et #es nd cated. There are t-o trad t ona" s$ste#s o' c"ass ' cat on 'or breast carc no#a -h ch !redo# nant"$ re"$ on c" n ca" sta& n& o' the d sease. These are the Manchester s$ste# and the Internat ona" Un on A&a nst Cancer TNM 8tu#our% nodes% #etastases: sta& n& s$ste#. These are ""ustrated n Tab"e /).). The TNM s$ste# -as an atte#!t to a""o- a co##on "an&ua&e a#on&st onco"o& sts -or"d1- de% thus a""o- n& accurate n'or#at on e*chan&e and eva"uat on o' stud es o' treat#ent% as -e"" as !rov d n& !ro&nost c n'or#at on to a d n the !"ann n& o' treat#ent 'or the nd v dua" !at ent. Ho-ever% th s re' ne#ent o' ta*ono#$ n 'act contr butes " tt"e to an$ o' these act v t es. .urther subd v s ons n the TNM s$ste# no- #ean that there are seven T1sta&es% 'our N1sta&es and three M1sta&es% a""o- n& 'or 0,5 !oss b"e co#b nat ons. Catho"o& ca" "$#!h node sta& n& de!ends on both the nu#ber o' "$#!h nodes re#oved% thus the e*tent o' sur&er$% and ho- ass duous the !atho"o& st s n "oo2 n& 'or de!os ts o' tu#our - th n the nodes. DM9 sta& n& de!ends on -hat nvest &at ons have been !er'or#ed 7 thus - "" var$ bet-een centres. ConseBuent"$ sta& n& s observer b ased. A"thou&h !ro&nos s broad"$ corre"ates - th sta&e% other 'actors a"so n'"uence !ro&nos s and shou"d be assessed% 'or e*a#!"e the Nott n&ha# Cro&nost c Inde* nc"udes nor on"$ tu#our s 3e and "$#!h node status but tu#our &rade. Convent ona" sta& n& - "" nd cate broad"$ -h ch treat#ent s reBu red but a&a n other 'actors #a$ be eBua""$ #!ortant. .or e*a#!"e% sur& ca" treat#ent o' a s#a"" sta&e I% or II 8T0 or T(: breast tu#our usua""$ reBu res on"$ - de "oca" e*c s on rather than #astecto#$ 7 but the "atter #a$ have to be !er'or#ed ' the breast s ver$ s#a""% the tu#our centra" or #u"t 'oca"% or 'or !at ent !re'erence. EBua""$ the use o' adjuvant s$ste# c thera!$ s dec ded on not on"$ tu#our s 3e and "$#!h node status but a"so b o"o& ca" #easures such as oestro&en rece!tor status% !at ent a&e and #eno!ausa" status% and n the case o' ta#o* 'en th s can be reco##ended rres!ect ve o' c" n co!atho"o& ca" var ab"es. Thus as -e &a n #ore 2no-"ed&e o' the b o"o& ca" var ab"es -h ch a''ect !ro&nos s t beco#es ncreas n&"$ c"ear that t s these 'actors 8d scussed n #ore deta " be"o-: rather than anato# ca" #a!! n& -h ch n'"uence outco#e and treat#ent. Cerha!s a #ore !ra&#at c a!!roach -ou"d be to c"ass '$ !at ents accord n& to the treat#ent that the$ reBu re. Th s s sho-n n Tab"e /).+. Cro&nos s o' breast cancer The best nd cators o' " 2e"$ !ro&nos s n breast cancer are st "" tu#ours s 3e and "$#!h node status 8. &. /).?6:.Ho-ever% t s rea" sed that so#e "ar&e tu#ours - "" re#a n con' ned to the breast 'or decades -hereas so#e ver$ s#a"" tu#ours are ncurab"e at d a&nos s. Hence the !ro&nos s o' a cancer de!ends not on ts chrono"o& ca" a&e but on ts nvas ve and #etastat c !otent a". In an atte#!t to de' ne -h ch tu#ours - "" behave a&&ress ve"$% and thus reBu re ear"$ s$ste# c treat#ent% a host o' !ro&nost c 'actors has been descr bed. These nc"ude h sto"o& ca" &rade o' the tu#our% hor#one rece!tor status% #easures o' tu#ours !ro" 'erat on such as 61!hase 'ract on and th$# d ne1"abe"" n& nde*% &ro-th 'actor ana"$s s and onco&ene or

onco&ene !roduct #easure#ents. Man$ others are under nvest &at on but have !roved o' " tt"e !ract ca" va"ue n !at ent #ana&e#ent. Treat#ent o' cancer o' the breast As has been nd cated above% treat#ent - "" "ar&e"$ de!end u!on c" n ca" sta&e o' the d sease at !resentat on nc"ud n& not on"$ c"ass ca" TMN sta& n& but o'ten other tu#our character st cs such as tu#our &rade. Treat#ent o' ear"$ breast cancer - "" usua""$ nvo"ve sur&er$ - th or - thout rad othera!$. S$ste# c thera!$ such as che#othera!$ or hor#one thera!$ s added ' there are adverse !ro&nost c 'actors such as "$#!h node nvas on nd cat n& a h &h " 2e" hood o' #etastat c re"a!se. At the other end o' the s!ectru# "oca""$ advanced or #etastat c d sease s usua""$ treated b$ s$ste# c thera!$ to !a"" ate s$#!to#s% - th sur&er$ !"a$ n& a #uch s#a""er ro"e. The #u"t d sc !" nar$ tea# a!!roach As n a"" branches o' #ed c ne &ood doctor7!at ent co##un cat on !"a$s a v ta" ro"e n he"! n& to a""ev ate !at ent an* et$. Cart c !at on o' the !at ent n treat#ent dec s ons s o' !art cu"ar #!ortance n breast cancer -here there #a$ be uncerta nt$ as to the best thera!eut c o!t on and the des re to treat the !at ent - th n the !rotoco" o' a contro""ed c" n ca" tr a". As !art o' the !reo!erat ve and !osto!erat ve #ana&e1 #ent o' the !at ent t s o'ten use'u" to e#!"o$ the s2 ""s o' a tra ned breast counse""or and a"so to have ava "ab"e adv ce on breast !rostheses% !s$cho"o& ca" su!!ort and !h$s othera!$% -here a!!ro!r ate. In #an$ s!ec a" st centres the care o' breast cancer !at ents s underta2en as a jo nt venture bet-een the sur&eon% #ed ca" onco"o& st% rad othera! st and a"" ed hea"th !ro'ess ona"s such as the c" n ca" nurse s!ec a" st. Treat#ent o' ear"$ breast cancer The a #s o' treat#ent are4 0 Dcure94 !oss b"e n so#e !at ents but recurrence u! to (5 $ears a'ter n t a" treat#ent s nor unco##on; (.contro" o' "oca" d sease n the breast and a* ""a; ?. conservat on o' "oca" 'or# and 'unct on; /.!revent on or de"a$ o' the occurrence o' d stant #etastases. Loca" treat#ent o' ear"$ breast cancer Loca" contro" s ach eved throu&h sur&er$ andAor rad othera!$. Sur&er$ Sur&er$ st "" has a centra" ro"e to !"a$ n the #ana&e#ent o' breast cancer but there has been a &radua" sh 't to-ards #ore conservat ve techn Bues% bac2ed u! b$ c" n ca" tr a"s -h ch have sho-n eBua" e'' cac$ bet-een #astecto#$ and "oca" e*c s on 'o""o-ed b$ rad othera!$. Th s 'o""o-ed a chan&e n the #ode" o' breast cancer s!read% -h ch s no "on&er thou&ht o' as a centr 'u&a" anato# ca" s!read but rather that t s the !resence o' # cro#etastases -h ch !redeter# nes the outco#e o' the d sease.It -as n t a""$ ho!ed that avo d n& #astecto#$ -ou"d he"! to a""ev ate the cons derab"e !s$cho"o& ca" #orb d t$ assoc ated - th breast cancer% but recent stud es have sho-n that over ?5 !er cent o' -o#en deve"o! s &n ' cant an* et$ and de!ress on 'o""o- n& both rad ca" and conservat ve sur&er$. A'ter #astecto#$ the$ rend to -orr$ about the e''ect o' the o!erat on on the r a!!earance and re"at onsh !s -h "st a'ter conservat ve sur&er$ -o#en #a$ re#a n 'ear'u" o' a recurrence. Mastecto#$ s no- on"$ str ct"$ nd cated 'or "ar&e tu#ours 8 n re"at on to the s 3e o' the breast:% centra" tu#ours beneath or nvo"v n& the n !!"e% #u"t 'oca" d sease% "oca" recurrence or 'or !at ent !re'erence. The rad ca" Ha"stead #astecto#$ -h ch nc"uded e*c s on o' the breast% a* ""ar$ "$#!h nodes% !ectora" s #ajor and # nor #usc"es s no "on&er nd cated as t causes e*cess ve #orb d t$ - th no surv va" bene' t. Mod ' ed rad ca" 8DCate$9: #astecto#$ s #ore co##on"$ !er'or#ed and thus s descr bed

be"o-. S #!"e #astecto#$ nvo"ves re#ova" o' the breast on"$ - th no d ssect on o' the a* ""a% e*ce!t 'or the re& on o' the a* ""ar$ ta " o' the breast -h ch usua""$ has attached to t a 'e- nodes "o- n the anter or &rou!. Because no !atho"o& ca" sta& n& o' the a* ""a s !er'or#ed - th a s #!"e #astecto#$% t s o'ten 'o""o-ed b$ rad othera!$ to the a* ""a. Cate$9 #astecto#$. The breast and assoc ated structures are d ssected en b"oc 8see . &. /).?): and the e*c sed #ass s co#!osed o'4 <the -ho"e breast; <a "ar&e !ort on o' s2 n% the centre o' -h ch over" es the tu#our% but a"-a$s nc"udes the n !!"e; <a"" o' the 'at% 'asc a and "$#!h nodes o' the a* ""a. The !ectora" s # nor #usc"e s e ther d v ded or re#oved to &a n access to the u!!er t-o1th rds o' the a* ""a. The a* ""ar$ ve n and nerves to serratus anter or and "at ss #us dors shou"d be !reserved. The -ound s dra ned us n& a - de1bore suct on tube. Ear"$ #ob " sat on o' the ar# s encoura&ed and !h$s othera!$ he"!s nor#a" 'unct on to return ver$ Bu c2"$ 7 #ost !at ents are ab"e to resu#e " &ht -or2 or house-or2 - th n a 'e- -ee2s.Conservat ve breast cancer sur&er$ s a #ed at re#ov n& the tu#our !"us a r # o' at "east 0 c# o' nor#a" breast t ssue. Th s s co##on"$ re'erred to as a - de "oca" e*c s on or "u#!ecto#$. A Buadrantecto#$ nvo"ves re#ov n& the ent re se&#ent o' the breast -h ch conta ns the tu#our. These are usua""$ co#b ned - th a* ""ar$ sur&er$% usua""$ v a a se!arate nc s on n the a* ""a% to e ther sa#!"e the a* ""a% re#ove nodes beh nd and "atera" to !ectora" s # nor 8"eve" II: or !er'or# a 'u"" a* ""ar$ d ssect on 8"eve" III:. A Buadrantecto#$% a* ""ar$ d ssect on and rad othera!$ s 2no-n as IUART and has been !o!u"ar sed b$ Cro'essor U#berto Gerones 'ro# M "an. Eh "st t s reco&n sed that there s a so#e-hat h &her rate o' "oca" recurrence 'o""o- n& conservat ve sur&er$% even ' co#b ned - th rad othera!$% the "on&1ter# out"oo2 n ter#s o' surv va" s unchan&ed. The ro"e o' a* ""ar$ sur&er$ s st "" debated% but t s acce!ted that the !resence o' #etastat c d sease - th n the a* ""ar$ "$#!h nodes s st "" the best #ar2er 'or !ro&nos s. Ho-ever% treat#ent o' the a* ""a does not a''ect "on&1ter# surv va"% su&&est n& that the a* ""ar$ nodes act not as a Dreservo r9 'or d sease but as a #ar2er 'or #etastat c !otent a". An acce!tab"e -a$ to a!!roach th s !rob"e# n !re#eno!ausa" -o#en s to sta&e the a* ""a b$ o!erat on as there s a &ood case 'or & v n& che#othera!$ to "$#!h node1!os t ve !at ents. In !ost#eno!ausa" !at ents% ta#o* 'en s usua""$ & ven re&ard"ess o' a* ""ar$ "$#!h node status. I' #astecto#$ s !er'or#ed t s reasonab"e to c"ear the a* ""a as !art o' the o!erat on% but ' a - de "oca" e*c s on s !"anned the sur&eon #a$ choose e ther o!erat ve d ssect on or !osto!erat ve rad othera!$. A* ""ar$ sur&er$ shou"d not be co#b ned - th rad othera!$ to the a* ""a because o' e*cess #orb d t$. Re#ova" o' the nterna" #a##ar$ "$#!h nodes s unnecessar$. Sent na" node b o!s$ s a techn Bue current"$ under eva"uat on -h ch #a$ -e"" !rove the -a$ 'or-ard n the 'uture n the #ana&e#ent o' the a* ""a n !at ents - th c" n ca""$ node1ne&at ve d sease. The sent na" node s "oca" sed !er o!erat ve"$ b$ the nject on o' !atent b"ue d$e andAor rad o soto!e1"abe""ed a"bu# n near the tu#our. The #ar2er - "" !ass to the !r #ar$ node dra n n& the area% be detected v sua""$ or - th a hand1he"d &a##a ca#era% and sent 'or 'ro3en sect on h sto"o& ca" ana"$s s. In !at ents n -ho# there s no tu#our nvo"ve#ent o' the sent na" node% t s ho!ed that 'urther a* ""ar$ d ssect on can be avo ded as s2 ! "es ons are thou&ht to occur n "ess than ? !er cent o' !at ents. Rad othera!$

Rad othera!$ to the chest -a"" a'ter #astecto#$ has been "ar&e"$ abandoned e*ce!t n cases o' e*tens ve "oca" d sease - th n' "trat on o' the chest -a"". It s convent ona" to co#b ne conservat ve sur&er$ - th rad othera!$ to the re#a n n& breast t ssue. Ho-ever% there s current"$ doubt as to -hether a"" !at ents under&o n& conservat ve sur&er$ shou"d rece ve rad othera!$ as #ost - "" not deve"o! "oca" recurrence and thus - "" be overtreated b$ adjuvant rad othera!$% -h ch s not - thout #orb d t$ and even "on&1ter# #orta" t$ 'ro# nadvertent rrad at on to the #$ocard u#. A UH nat ona" c" n ca" tr a" s current"$ under-a$ to tr$ to ascerta n -hether there s a surv va" advanta&e - th rad othera!$ and to dent '$ -h ch !at ents are at h &hest r s2 o' "oca" re"a!se% and thus -ou"d bene' t #ost 'ro# !osto!erat ve breast rrad at on. Current"$ those thou&ht to be at h &hest r s2 nc"ude those - th e*tens ve n s tu carc no#a 8or o' course nvas ve cancer: at the #ar& ns o' e*c s on% !at ents under ?6 $ears and those - th #u"t 'oca" d sease. Adjuvant s$ste# c thera!$ Over the "ast (6 $ears there has been a revo"ut on n our understand n& o' the b o"o& ca" nature o' carc no#a o' the breast. It s no- - de"$ acce!ted that the outco#es o' treat#ent are !redeter# ned b$ the e*tent o' # cro#etastat c d sease at the t #e o' d a&nos s. Gar at ons n the rad ca" e*tent o' "oca" thera!$ # &ht n'"uence "oca" re"a!se% but !robab"$ do not a"ter "on&1ter# #orta" t$ 'ro# the d sease. Ho-ever% s$ste# c thera!$ tar&eted at these !utat ve # cro#etastases # &ht be e*!ected to de"a$ re"a!se and !ro"on& surv va". As a resu"t o' #an$ nternat ona" c" n ca" tr a"s and recent -or"d overv e- ana"$ses% t can be stated - th e*tre#e stat st ca" con' dence that the a!!ro!r ate use o' adjuvant che#othera!$ or hor#one thera!$ - "" #!rove re"a!se1'ree surv va" b$ a!!ro* #ate"$ ?5 !er cent% -h ch u"t #ate"$ trans"ates nto an abso"ute #!rove#ent n surv va" o' the order o' 05 !er cent at 06 $ears. Bear n& n # nd ho- co##on the d sease s n Northern Euro!e and the USA% th s trans"ates nto ' &ures o' #ajor !ub" c hea"th #!ortance. Eho to treat and - th -hat are st "" Buest ons 'or -h ch abso"ute ans-ers have $et to 'ound% but the data 'ro# an overv e- o' recent tr a"s su&&est that "$#!h node1!os t ve and !oor !ro&nos s node1ne&at ve !re#eno!ausa" -o#en shou"d be reco##ended adjuvant co#b ned che#othera!$ and that !ost#eno!ausa" -o#en - "" obta n a -orth-h "e bene' t 'ro# about 6 $ears o' ta#o* 'en% (5 #& da "$. Hor#one thera!$ Ta#o* 'en s the #ost - de"$ used Dhor#ona"9 treat#ent n breast cancer. Its e'' cac$ as an adjuvant thera!$ -as ' rst re!orted n 0@,? and t has no- been sho-n to reduce the annua" rate o' recurrence b$ (6 !er cent% - th a 0+ !er cent reduct on n the annua" rate o' death. The e''ect o' ta#o* 'en s 'avourab"e n #ost cases e*ce!t 'or oestro&en rece!tor ER1ne&at ve !re#eno!ausa" -o#en; !ost#eno!ausa" -o#en - th oestro&en rece!tor1r ch 8!os t ve: tu#ours ach eve a &reater reduct on n the re"at ve r s2 o' re"a!se than oestro&en rece!tor1ne&at ve cases. The bene' c a" e''ects o' ta#o* 'en n reduc n& the r s2 o' tu#ours n the contra"atera" breast have a"so been observed. Tr a"s stud$ n& the o!t #a" durat on o' treat#ent are c"ose to #atur t$ and su&&est that 6 $ears o' treat#ent #a$ be !re'erab"e to ( $ears. Other hor#ona" a&ents are be n& deve"o!ed -h ch #a$ !rove bene' c a" as adjuvant thera!$% such as the LHRH a&on sts -h ch nduce a revers b"e ovar an su!!ress on and thus re ho!ed to have the sa#e bene' c a" e''ects as sur& ca" or Jrad at on1 nduced ovar an ab"at on n !re#eno!ausa" -o+nen% and the ora" aro#atase nh b tors 'or !ost#eno!ausa" No#en. Che#othera!$

Che#othera!$ us n& a re& #en such as a )1#onth"$ c$c"e o' c$c"o!hos!ha# de% #ethotra*ate and 61'"uorourac " 8CM.: - "" ach eve a ?5 !er cent reduct on n the r s2 o' re"a!se over a 057061$ear !er od. Th s treat#ent has been con' ned to !re#eno!ausa" !oor !ro&nos s -o#en 8-here ts e''ects are " 2e"$ to be due n !art to a che# ca" castrat on e''ect: but s be n& ncreas n&"$ o''ered to !ostrneno!ausa" -o#en - th !oor !ro&nos s d sease as -e"". Che#othera!$ #a$ be cons dered n node1ne&at ve !at ents ' other !ro&nost c 'actors such as tu#our &rade n'er a h &h r s2 o' recurrence. The e''ect o' co#b n n& hor#one and che#othera!$ s st "" under nvest &at on and s be& nn n& to "oo2 !ro# s n&. H &h1dose che#othera!$ - th ste# ce"" rescue 'or !at ents - th heav$ "$#!h node nvo"ve#ent s st "" cons dered e*!er #enta" and shou"d not be o''ered outs de contro""ed tr a"s. Cr #ar$ che#othera!$ s be n& used n #an$ centres 'or "ar&e hut o!erab"e tu#ours that -ou"d trad t ona""$ reBu re a #astecto#$ 8and a"#ost certa n"$ !osto!erat ve adjuvant che#othera!$:. The a # o' th s treat#ent s to shr n2 the tu#our to enab"e breast1conserv n& sur&er$ to be !er'or#ed. Th s a!!roach s success'u" n u! to ,5 !er cent o' cases% but s not assoc ated - th #!rove#ents n surv va" co#!ared - th convent ona""$ t #ed che#othera!$. Breast reconstruct on Des! te an ncreas n& trend to-ard conservat ve sur&er$% u! to 65 !er cent o' -o#en st "" reBu re% or -ant% a #astecto#$. These -o#en can no- he o''ered ##ed ate or de"a$ed reconstruct on o' the breast. .e- contra nd cat ons to breast reconstruct on e* st 7 even those - th a " # ted " 'e e*!ectanc$ #a$ bene' t 'ro# the #!roved Bua" t$ o' " 'e% ho-ever !at ents do reBu re counse"" n& be'ore th s !rocedure so that the r e*!ectat ons o' cos#et c outco#e are not unrea" st c. The #ost co##on t$!e o' reconstruct on s us n& a s " cone &e" #!"ant under the !ectora" s #ajor #usc"e. Th s #a$ be co#b ned - th !r or t ssue e*!ans on us n& an e*!andab"e sa" ne !rosthes s ' rst 8or a co#b ned dev ce 7 . &. /).?+: -h ch creates so#e !tos s o' the ne- breast. I' the s2 n at the #astecto#$ s te s !oor 8'or e*a#!"e 'o""o- n& rad othera!$: or ' a "ar&er vo"u#e o' t ssue s reBu red% a #uscu"ocutanous '"a! can be constructed 'ro# e ther the "at ss #us dors #usc"e 8an LD '"a!: or the contra"atera" transversus abdo# n s #usc"e 8a TRAM '"a! 7 sho-n n . &. /).?,:. The "atter & ves an e*ce""ent cos#et c resu"t n e*!er enced hands but s a "en&th$ !rocedure and reBu res care'u" !at ent se"ect on. N !!"e reconstruct on s a re"at ve"$ s #!"e !rocedure -h ch can be !er'or#ed under a "oca" anaesthet c. A"ternat ve"$ the !at ent can be ' tted - th a !rosthet c n !!"e. To ach eve s$##etr$% the o!!os te breast #a$ reBu re a cos#et c !rocedure such as reduct on or au&#entat on #a##o!"ast$% or #asto!e*$. A breast reconstruct ve serv ce can be o''ered b$ a su tab"$ tra ned breast sur&eon% a !"ast c sur&eon or dea""$ a co#b ned onco!"ast c a!!roach. E*terna" breast !rostheses -h ch ' t - th n the bra #a$ a"so be reco##ended and so#e o' these are ""ustrated n . &. /).?@. Screen n& 'or breast cancer Because the !ro&nos s o' breast cancer s c"ose"$ re"ated to sta&e at d a&nos s% t -ou"d see# reasonab"e to ho!e that a !o!u"at on screen n& !ro&ra##e -h ch cou"d detect tu#ours be'ore the$ co#e to the !at ent9s not ce #a$ reduce #orta" t$ 'ro# breast cancer. A nu#ber o' stud es has ndeed sho-n that breast screen n& b$ #a##o&ra!h$ n -o#en over the a&e o' 65 - "" reduce cause1s!ec ' c #orta" t$ b$

u! to ?5 !er cent. .o""o- n& the !ub" cat on n 0@,+ o' the .orrest re!ort the Nat ona" Hea"th Serv ce n the UH has "aunched a !ro&ra##e o' ?1$ear"$ #a##o&ra!h c screen n& 'or -o#en bet-een the a&es o' 65 and )/. The ntroduct on o' th s !ro&ra##e has undoubted"$ #!roved the Bua" t$ o' breast cancer serv ces but a nu#ber o' Buest ons re#a ns unans-ered nc"ud n& the va"ue o' screen n& -o#en under 65 and the dea" nterva" bet-een screen n&s. The !s$cho"o& ca" conseBuences o' 'a"se a"ar#s or 'a"se reassurances st "" need to be addressed and se"'1e*a# nat on !ro&ra##es -h ch have 'a "ed to sho- an$ bene' t 'or the !o!u"at on n ter#s o' ear" er or decreased #orta" t$ 'ro# breast cancer st "" re#a n controvers a". . &ure /)./5 ""ustrates so#e bene' ts and d sadvanta&es o' screen n&. The sen or author re#a ns doubt'u" re&ard n& the va"ue o' a screen n& !ro&ra##e n ter#s o' the - der #!" cat ons o' hea"thcare !"ann n&. .a# " a" breast cancer Recent deve"o!#ents n #o"ecu"ar &enet cs and the dent ' cat on o' a nu#ber o' breast cancer !red s!os t on &enes 8BRCA0% BRCA( and TCS?: have done #uch to st #u"ate nterest n th s 'asc nat n& area. Ket -o#en -hose breast cancer s due to an nher ted &ener c chan&e actua""$ account 'or "ess than 6!er cent o' a"" breast cancers 7 that s about 0(65 cases !er $ear n the UH and @555 cases n the USA. A #uch "ar&er nu#ber o' -o#en - "" have a r s2 e"evated above nor#a" due to an as $et uns!ec ' ed 'a# " a" nher tance. These -o#en have a r s2 o' deve"o! n& breast cancer t-o to 05 t #es above base" ne. The r s2s assoc ated - th 'a# "$ h stor$ are su##ar sed n Tab"e /).,. The BRCAI &ene has been c"oned and s "ocated on the "on& ar# o' chro#oso#e 0+ 80+B:. The &ene 'reBuenc$ n the !o!u"at on s a!!ro* #ate"$ 5.555). BRCA( s "ocated on chro#oso#e 0?B. Eo#en -ho are thou&ht to be &ene carr ers #a$ be o''ered breast screen n& 8and ovar an screen n& n the case o' BR>A0% -h ch s 2no-n to #!art a 65 !er cent " 'et #e r s2 o' ovar an cancer:% usua""$ as !art o' a research !ro&ra##e% or #a$ be o''ered &ener c counse"" n& and #utat on ana"$s s. Those -ho !rove to he D&ene !os t ve9have an ,5 !er cent r s2 o' deve"o! n& breast cancer% !redo# nant"$ -h "st !re#eno!ausa". Man$ - "" o!t 'or !ro!h$"act c #astecto#$% a"thou&h th s does not co#!"ete"$ e" # nate the r s2. .or%those - th a !os t ve 'a# "$ h stor$ -ho are un" 2e"$ to be carr ers o' a breast cancer &ene% -h ch - "" co#!r se the &reat #ajor t$ o' -o#en% there s no current"$ !roven !revent ve or screen n& #anoeuvre% a"thou&h these are under nvest &at on. Thus these -o#en are best served b$ be n& assessed and 'o""o-ed u!% ' necessar$% n a !ro!er"$ or&an sed research 'a# "$ h stor$ c" n c. Cre&nanc$ The e''ects o' !re&nanc$ on breast cancer are not -e"" stud ed but t s thou&ht that breast cancer !resent n& dur n& !re&nanc$ or "actat on tends to be at a "ater sta&e 7 !resu#ab"$ because the s$#!to#s are #as2ed b$ the !re&nanc$ 7 but n other res!ects t behaves n a s # "ar -a$ to breast cancer n a non!re&nant $oun& -o#an% and shou"d be treated accord n&"$. Thus treat#ent s s # "ar - th so#e !rov sos4 rad othera!$ shou"d be avo ded dur n& !re&nanc$% #a2 n& #astecto#$ a #ore 'reBuent o!t on than breast conservat on sur&er$; che#othera!$ shou"d he avo ded dur n& the ' rst tr #ester but s !robab"$ sa'e subseBuent"$; #ost tu#ours are hor#one rece!tor ne&at ve and so hor#one treat#ent% -h ch s !otent a""$ terato&en c% s not reBu red. Beco# n& !re&nant subseBuent to a d a&nos s o' breast cancer a!!ears not to

a"ter " 2e"$ outco#e% hut -o#en are usua""$ adv sed to -a t at "east ( $ears% as t s - th n th s t #e that recurrence #ost o'ten occurs. The r s2 o' deve"o! n& breast cancer - th ora" contrace!t ve use s on"$ s" &ht% and d sa!!ears 05 $ears a'ter sto!! n& the C "". Hor#one1re!"ace#ent thera!$ Hor#one1re!"ace#ent thera!$ 8HRT: does not a!!ear to ncrease s &n ' cant"$ the r s2 o' deve"o! n& breast cancer un"ess ta2en 'or !ro"on&ed !er ods 8over 05 $ears:% and !erha!s n certa n h &h1r s2 &rou!s. HRT #a$% ho-ever% !ro"on& s$#!to#s o' ben &n breast d sorder and #a2e #a##o&ra!h c a!!earances #ore d '' cu"t to nter!ret. Cat ents -ho deve"o! breast cancer -h "st on HRT a!!ear to have a #ore 'avourab"e !ro&nos s. The conseBuences n ter#s o' recurrence n -o#en us n& HRT 'o""o- n& breast cancer are un2no-n. Treat#ent o' advanced breast cancer Breast cancer #a$ occas ona""$ !resent as #etastat c d sease - thout ev dence o' a !r #ar$ tu#our 8that s - th an occu"t !r #ar$:. The d a&nos s s #ade !art"$ b$ e*c"us on o' another s te 'or the !r #ar$ and #a$ be con' r#ed b$ h sto"o&$ o' the #etastat c "es ons. Treat#ent shou"d be a #ed at !a"" at on o' the s$#!to#s and treat n& the breast cancer% usua""$ b$ endocr ne #an !u"at on. Loca""$ advanced no!erab"e breast cancer Loca""$ advanced no!erab"e breast cancer% nc"ud n& n'"a##ator$ breast cancer% s usua""$ treated - th s$ste# c thera!$ 7 e ther che#othera!$ or hor#one thera!$. Occas ona""$ Dto "et #astecto#$9 or rad othera!$ s reBu red to contro" a 'un&at n& tu#our% but o'ten nc s on throu&h # crosco! ca""$ !er#eated t ssues #a2es the outco#e -orse than the or & na". Metastat c carc no#a o' the breast Metastat c carc no#a o' the breast - "" a"so reBu re so#e 'or# o' !a"" at ve s$ste# c thera!$ to a""ev ate s$#!to#s. Hor#one #an !u"at on s o'ten the ' rst " ne because o' ts # n #a" s de e''ects. It s !art cu"ar"$ use'u" 'or bon$ #etastases. Ho-ever% on"$ about ?5 !er cent o' these tu#ours - "" be hor#one res!ons ve% and un'ortunate"$ even these - "" n t #e beco#e res stant to th s treat#ent. . rst1" ne hor#one thera!$ 'or !ost#eno!ausa" -o#en s ta#o* 'en% and 'or !re#eno!ausa" -o#en ovar an su!!ress on% but -here res stance to these has deve"o!ed% other hor#ona" a&ents can !rove use'u"% - th about ha"' o' the res!onse rate seen n the ' rst1" ne thera!$. S$nthet c !ro&esta&ens such as #edro*$!ro&esterone acetate 8DCrovera9: aro#atase nh b tors or the ne-er a&ents such as ant !ro&est ns and !ure ant oestro&ens are a"" cand dates 'or th s ro"e. C$toto* c thera!$ s used% !art cu"ar"$ n $oun&er -o#en or those - th v scera" #etastases and ra! d"$ &ro- n& tu#ours. A var et$ o' re& #ens s ava "ab"e and a"thou&h none !ro"on&s surv va"% contrar$ to e*!ectat ons Bua" t$ o' " 'e and s$#!to# contro" s o'ten better - th #ore a&&ress ve treat#ents% res!onses be n& seen n u! to +5 !er cent o' !at ents. Loca" treat#ent #a$ a"so !rove use'u" 'or so#e #etastat c d sease such as rad othera!$ 'or !a n'u" bon$ de!os ts and nterna" ' *at on o' !atho"o& ca" 'ractures.

The #a"e breast >$naeco#ast a Id o!ath c H$!ertro!h$ o' the #a"e breast #a$ be un "atera" or b "atera". The breasts en"ar&e at !ubert$ and so#et #es !resent the character st cs o' 'e#a"e breasts 8. &. /)./0:. Hor#ona" En"ar&e#ent o' the breasts o'ten acco#!an ed st "boestro" thera!$ 'or !rostate cancer 7 no- rare"$ used. It #a$ a"so occur as a resu"t o' a terato#a o' the test s% n anorch s# and a'ter castrat on. Rare"$ t #a$ he a 'eature o' ecto! c hor#ona" !roduct on n bronch a" carc no#a and n adrena" and ! tu tar$ d sease. Assoc ated - th "e!ros$ >$naeco#ast a s ver$ co##on n #en su''er n& 'ro# "e!ros$. Th s s !oss b"$ because o' b "atera" test cu"ar atro!h$% -h ch s a 'reBuent acco#!an #ent o' "e!ros$. Assoc ated - th " ver 'a "ure >$naeco#ast a so#et #es occurs n !at ents - th c rrhos s due to 'a "ure o' the " ver to #etabo" se oestro&ens. It s assoc ated - th dru&s that nter'ere - th the he!at c #etabo" s# o' oestro&ens% such as c #et d ne. >$naeco#ast a #a$ occur n !at ents - th H" ne'e"ter9s s$ndro#e% a se* chro#oso#e ano#a"$ hav n& ==K tr so#$. It s a"so seen - th certa n dru&s such as c #et d ne% d & ta" s and s! rono"actone. Treat#ent Crov ded the !at ent s hea"th$ and co#!arat ve"$ $oun&% reassurance #a$ be su'' c ent. I' not #astecto#$ - th !reservat on o' the areo"a and n !!"e can be !er'or#ed. Carc no#a o' the #a"e breast Carc no#a o' the #a"e breast 8. &s /)./( and /)./?: accounts 'or "ess than ( !er cent o' a"" cases o' breast cancer. The 2no-n !red s!os n& causes nc"ude &$naeco#ast a and e*cess endo&enous or e*o&enous oestro&en. As n the 'e#a"e t tends to !resent as a "u#! and s #ost co##on"$ an n' "trat n& ducta" carc no#a. Treat#ent Sta&e 'or sta&e the treat#ent s the sa#e as 'or carc no#a n the 'e#a"e and !ro&nos s de!ends u!on sta&e at !resentat on. AdeBuate "oca" e*c s on% because o' the s#a"" s 3e o' the breast% shou"d a"-a$s be - th a #astecto#$ Other tu#ours o' the breast L !o#a A true " !o#a s ver$ rare. Sarco#a o' the breast Sarco#a o' the breast s usua""$ o' the s! nd"e1ce"" var et$% and accounts 'or 5.6 !er cent o' #a" &nant tu#ours o' the breast. So#e o' these &ro-ths ar se n an ntracana" cu"ar ' broadeno#a or #a$ 'o""o- !rev ous rad othera!$% e.&. 'or Hod&2 n9s "$#!ho#a #an$ $ears !rev ous"$. It #a$ be #!oss b"e to d st n&u sh c" n ca""$ a sarco#a o' the breast 'ro# a #edu""ar$ carc no#a% hut areas o' c$st c de&enerat on su&&est a sarco#a and on nc s n& the neo!"as# t s !a"e and 'r ab"e. Sarco#a tends to occur n $oun&er -o#en bet-een the a&es o' ?5 and /5. Treat#ent s b$ s #!"e #astecto#$ 'o""o-ed b$ rad othera!$. The !ro&nos s de!ends on the sta&e and h sto"o& ca" t$!e. Metastases On rare occas ons% cancer e"se-here #a$ !resent - th a #etastas s n the breast. The breast s a"so occas ona""$ n' "trated b$ Hod&2 n9s d sease and other "$#!ho#as.

.urther read n& D *on% M. and Sa nsbur$% R. 80@@?: D seases o' the Breast% Church "" L v n&stone% Ed nbur&h. Harr s% F.R.% He""#an% S.% Henderson% F.C. and H nne% D.E 80@,+: Breast D sease% L !! ncott% Ch "ade"!h a% CA. Ha$es% D... 80@@?: At"as o' Breast Cancer% Eo"'e% London. Hu&hes% L.E.% Manse"% R.E. and Eebster% D.F.T. 80@,@: Ben &n D sorders and D seases o' the Breast% Ba"" ere T nda""% London. Manse"% R.E. and Bundred% N.F. 80@@): Co"our At"as o' Breast D seases% Mosb$1 Eo"'e% London. Co-"es% T.F. and S# th% I.E. 80@@0: Med ca" Mana&e#ent o' Breast Cancer% Mart n Dun t3% London.