Breast cancer is a major global problem with nearly one million cases occurring each year over the past several decades, the incidence of the disease has rising worldwide, increasing in developing and developed countries. It comprises 17% of all cancers.
Female breast cancer is the most commonly diagnosed malignancy amongst women worldwide (23% of all new cancer cases), with an incidence rate > twice that of colorectal cancer and cervical cancer, and about three times that of lung cancer. It is the second leading cause of cancer deaths in women today secondary to lung cancer
In Egypt, breast cancer represents the most common cancer among Egyptian females and constitutes 37% of all female cancers
The male breast cancer is uncommon comprising < 1 % of all breast cancer. It represents 1 % of all cancers in males. Klinefelter’s syndrome and elevated estrogen levels have been associated with male breast cancer. Generally, it occurs in males around 60 years old. It is commonly bilateral and of the intraductal type. Early invasion of skin and pectoral muscles occurs. The surgical treatment follows the same protocol as for females
The diagnostic process of breast cancer is made by a combination of clinical assessment, radiological imaging and a tissue sample taken by either cytological or histological analysis that is called triple assessment
Clinical assessment of breast cancer begins with assessment of family history, personal history of breast problems and physical examination. Clinically breast cancer presents by irregular hard breast lumps, breast pain, skin changes, metastatic disease to a distant organ or to the axillary lymph nodes (ALNs) or breast cancer may be asymptomatic. There are two clinical classifications for breast cancer. Manchester classification which classifies breast cancer into four stages from I to IV & T.N.M. classification which classifies breast cancer according to tumor size (T), presence or absence of ALNs (N) and presence or absence of metastasis (M)
Investigations for breast cancers include mammography, complementary breast ultrasound (for women 30 years of age or less) and biopsy (fine needle aspiration FNAC, core needle biopsy, excisional biopsy or needle-guided biopsy for non-palpable mammographic abnormalities). CT and MRI are recently used for diagnosis of breast cancer
Surgery remains the mainstay of treatment for breast cancer despite recent and continuing advances in medical treatment. Surgical approaches have changed from radical procedures performed by Halsted in 1882 to the modified radical mastectomy (MRM) of Patey and lastly to breast conserving therapy (BCT), the standard technique for the past twenty years
BCT represents an important step forward in the treatment of breast carcinoma. It has evolved rapidly in recent years and currently account for as much as 40% of breast cancer surgery
This is due to; First, screening has resulted in increased detection of early-stage breast cancers. Second, the increasing use of adjuvant chemotherapy and endocrine therapies has resulted in lower risk of ipsilateral breast tumor events. Third, the introduction of preoperative neoadjuvant chemotherapy for patients with operable breast cancer has meant that some tumors initially too large to be treated with BCT ultimately shrink enough to be amenable to this treatment approach.
Randomized controlled clinical trials have shown that in tumors up to 4 cm in size, treatment by mastectomy or breast conservation results in no significant difference in overall survival. Patients undergoing BCT have greater freedom of dress and better body image& life style than women who have had mastectomy, local recurrence rate are similar with a non-significant relative reduction in favor of mastectomy
So that BCT became now a well-established treatment modality for early breast cancer (clinical stage I or II that not fixed to the skin or muscle and if palpable ALNs; they are not fixed to each other or to underlying structures) that causes less physical disfigurement and less psychological trauma to the patient
The gold standard treatment for early breast cancer is based on conservative breast surgery (CBS) which consists principally of complete primary breast tumor excision with accepted safety margin of normal-appearing breast tissue and assessment of ALN status (axillary lymphadenectomy) followed by postoperative adjuvant radiotherapy of the remaining breast tissue. This technique could decrease morbidity following standard MRM and allow women with different forms of breast cancer to conserve their breasts.
Radiotherapy given after surgery reduces the risk of isolated local recurrence by approximately ⅔, thus radiotherapy is of potential benefit to all patients undergoing CBS and should only be omitted if its morbidity does not justify the excess recurrence risk for that patient .
Adjuvant systemic (hormonal and or chemo) therapy is given according to the policy at the time when the patient was seen. It should not begin before the 14th postoperative day, and may be delayed if there are complications or drains are still in situ.
Adjuvant systemic therapy includes endocrine therapy as tamoxifen that is a competitive inhibitor blocking estrogen receptor alpha and is the most widely used adjuvant systemic therapy for most postmenopausal women; while ovarian ablation is of benefit to premenopausal women. Cytotoxic chemotherapy, regimen was a combination of cyclophosphamide, methotrexate and 5-fluorouracil (CMF). Recently, 5-fluorouracil, Adriamycin and cyclophosphamide (FAC) are used; the current studies results stressed the value of primary chemotherapy to increase conservative surgery and as a predictor of outcome
Neoadjuvant therapy involves giving chemotherapy or hormonal therapy before surgery to patients with non-metastatic primary locally advanced breast cancer which is potentially operable as a part of the multimodality management .This neoadjuvant treatment can reduce tumor size significantly (down staging) and allow for breast conservation with acceptable rates of local recurrence
ALN status has been considered an important prognostic factor in women with breast cancer and is essential in the planning of treatment. Clinical assessment and imaging modalities are not always reliable.
Axillary lymph node dissection (ALND) also known as axillary clearance) or (axillary lymphadenectomy) has been a part of the surgical management of breast cancer since the era of Halsted. Initially, it was thought to be therapeutic, but came to be regarded as a staging procedure when it became evident that the majority of women with nodal metastases died of breast cancer after receiving local therapy alone
Sentinel lymph node biopsy (SLNB) is one of the minimally invasive procedures that have been introduced in breast surgery to decrease morbidity following ALND. The SLN is the first lymph node or the first group of lymph nodes that drain the cancer. SLNB has become an accurate method and has been developed as an alternative to full ALND for staging the axilla in women with operable clinically node-negative breast cancer; being associated with less morbidity than ALND . It is possible to identify the SLN by injection of a tracer marker, such as a blue dye or a radionuclide (that can be used individually or in combination) into the breast around the site of the tumor.
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