Breasts consist of milk nodes and ducts carrying the milk produced from those nodes to the nipple and fat and connective tissues which fill the interstitial area. Each breast is found in front of the pectoral muscles over the ribs. The nipple is the center of the dusky skin area called the areola. The breast also contains lymphatic ducts carrying a colorless fluid called lymph. Lymph ducts open out onto small round lymph nodes. Lymph node groups belonging to the breast are found primarily near the breast in the armpit, over the collar bone and nearby the sternum. Lymph nodes hold bacteria, cancer cells and the other harmful components to be found in the lymph system.
In the branches of Breast Cancer Surgery, Plastic Surgery, Radiotherapy, Chemotherapy, the opportunity of multidisciplinary diagnosis and therapy is being provided to our patients with the specialist and experienced team in one’s field and with the devices of latest technology.
Apart from these, a multidisciplinary care including supportive services like disease management of breast cancer, nutrition and genetic counseling, psychosocial support programs, physic therapy is being given to breast cancer patients most comprehensively.
In our Breast Health Centers, early diagnosis, therapy and follow-up programs are being implemented with the devices of latest technology (3 dimensional Mammography with Tomosynthesis, 4 dimensional Breast Ultrasonography, Vacuum-assisted Biopsy and Biopsy under the guidance of MRI).
In Breast Health Centers of ACIBADEM, the opportunity of early detection and correct diagnosis is being provided by comprehensive approach.
We are creating a difference through mammography with tomosynthesis, 4 dimensional ultrasonography, clinical breast examination and by self examination education and with breast cancer scanning services. Also, for women who have high risk of contracting breast cancer, early detection opportunity is being provided by minimizing their chance of contracting cancer in the future via regular examine and special counseling service.
Our specialist team consists of breast surgeons, medical oncologists, plastic surgeons, oncologists of radiation, radiologists, pathologists and medical geneticists, all experienced specialists in their field and they provide comprehensive care of patients in the ACIBADEM Breast Health Center. Also nutrition counseling, physical therapy and comprehensive psychosocial support program for patients with breast cancer are ensured.
Oncoplastic surgery and innovative reconstructive techniques are being provided by breast surger specialist in their field.
Lumps in the breast
The most frequent lumps in the breast are:
Other solid (solid content) benign lesions:
Radial scar and complex sclerosant lesions, papilloma, lipoma, hamartoma, fat necrosis, leiomyoma, granular cell tumors etc.
Specialists of general surgery, radiology, pathology, medical oncology and radiation oncology are working together and in cooperation using a multidisciplinary approach in the planning of treatment of breast cancer. The specialist who evaluates the patient first is usually a surgeon. It is also important that psychologists and psychiatrists evaluate the patient before and after the treatment.
The first choice in breast cancers caught at the early stage is surgery. In the surgical method, cancerous tumor is excised either from the breast tissue or around it clearly or the whole breast is taken. Also to understand whether the tumor spread to the armpit or not, some lymph nodes are excised. By performing surgical interventions, first the stage of disease is detected and the patient’s additional therapy requirements (radiation, hormone, chemotherapy) are determined.
Today, excellent results in a lot of patients can be obtained through developments in surgical treatment and improvements in additional treatments.
Patients with breast cancer are being lost due to systemic recurrence, or in other words spread (metastasis), not recurrences in the breast. In this context, removing tissue with a tumor by way of breast protective surgery in suitable cases with single tumor focus is being preferred instead of taking of whole breast. Tumor tissue is excised with about 1-2 cm normal breast tissue around the tumor in breast protective surgery (large excision, tumorectomy, lumpectomy).
Other techniques based on larger excisions of that region in the breast are called “quadrantectomy” or “partial mastectomy”.
As for lumps being thought as non-palpable and malign and marked by wire through mammography or ultrasound are filmed after excision by wire guided or ROLL (Radionuclide-Guided Occult Lesion Localisation) techniques and are controlled whether they are excised or not.
Mastectomy is a method applied in situations that breast protective surgery is not suitable. While it was common in the past, today mastectomy is preferred for patients with tumor unsuitable for the breast protective surgery, with a large diameter and/or showing spread distribution in the breast (multi focal tumors). Again, according to patient’s situation modified radical mastectomy, or in other words excising the whole breast and a big part of the axillary lymph nodes can be considered in this case. Due to excision of a big part of the axillary lymph nodes some complaints like swelling in the arm, numbness, tingling may be seen in some patients.
Breast cancer spreads mostly to axillary lymph nodes. In the past, excision of the whole axillary lymph nodes was preferred to detect the stage of disease, to determine the involvement in axillary lymph nodes and provide local control (axillary disection). But researchers focused on the pursuit of another method because of complaints of side effects like swelling in arms (lymphedema), shoulder restriction and deformation, low strength and numbness in arms. In recent years, “Sentinel Lymph Node Biopsy Technique”, a method of excision of the most possible lymph nodes was improved due to being able to find single tumor cells.
In this technique, a radioactive substance like 99mTc is injected into the breast with the tumor before surgery. The lymph node or nodes (sentinel lymph node) are excised by a radioactive substance detector or counter tool called gamma probe after lymphoscintigraphy,monitored either in the afternoon one day before the operation or in the morning of operation day and sent to pathology to be analyzed during surgery. A blue stain injection can also be into administered into the breast with the tumor during the operation. In this case, blue colored lymph nodes can be excised as sentinel lymph node by finding the blue colored lymph duct. It is then sent to pathology during the operation. If the sentinel lymph node are involved, all axillary lymph nodes will be excised. If it is found negative during operation, it is left as is. Thus, side effects like lymph edema, shoulder restriction or numbness in arm are seen in fewer patients compared to just sentinel lymph node biopsy. These sentinel lymph nodes are treated by special processes and sections of negative patients are subject to special stains. Thus, if a minimal involvement is determined in the lymph nodes, the patient should be operated a second time as required and supplemental axillary dissection is performed, in other words, whole lymph nodes are excised.
Breast restoration is performed to restore the natural form of the breast after cancer. In this context breast restoration is not a cosmetic surgery but a restoration (reconstruction), in other words, it should be seen as replacement of a lost limb due to disease. Through new improvements in medical science, surgeons can now generate a lifelike breast. Plastic and reconstructive surgery specialists are also found in the treatment team of breast cancer. These specialists perform operations to transform the breast naturally if required.
Psychologically, breast loss influences a lot of women negatively. The result of a breast reconstruction operation can be like a new life for most patients. The sexual and familial lives of these patients gets better. Furthermore, a stronger spiritual state can help patients to cope with the disease.
Breast reconstruction has 3 basic stages. These are; generation of breast tissue, reconstruction of nipple and areola, creating symmetry between breasts.
Regeneration of removed breasts can be done in two ways:
1- Breast prostheses,
2- Patient’s own tissue (autogenous tissue).
A lot of factors like patient’s general health, age, body features, characteristics of mastectomy operation, whether radiotherapy was administered or not, status of the other breast, patient’s preferences, surgical experience and skills of plastic surgeon play a role in the choice of the operation method and reconstruction time.
Breast prostheses come in two types: gel-filled or serum physiologic-filled (salt water). In both prostheses the exterior surface consists of a silicon wall. According to patient’s status, reconstruction can be done by placing the prosthesis directly, or with help of a balloon called “tissue expander”, by placing it to expand soft tissue in the chest wall and then removing it so that the permanent breast prosthesis can be put in place. This method is preferred especially in late reconstructions.
Breast reconstructions by autogenous tissue are more complex and require surgical operations by experienced specialists.
Skin and subcutaneous fat tissue is split completely from the abdomen, dorsum or hip region where they are connected by feeder veins. The plastic surgeon has to be experienced in microsurgery for this operation because stitching of thin veins is only possible under a microscope.
Sometimes a few operations may be required to obtain a natural breast image. The first operation, to regenerate tissue is the most difficult one. Secondary operations such as regeneration of the nipple and areola (area around the nipple) are easier and these are done using local anesthesia. Nipple is made from tissue taken from the area. Skin taken from the other nipple or groin may be used to cover up the areola.
Earliest determining method of breast cancer: MAMMOGRAPHY
Obtaining an image by using lower dose x-ray is the most basic method. It can be likened to an x-ray machine that takes breast images. The purpose of mammography is determining breast cancer in early stages; the sooner breast cancer is determined, the more its therapy can be performed successfully. Among all breast cancer imaging and diagnosis methods, mammography is the earliest. Today, different mammography techniques are used, including a classic and a digital one.
Digital mammography is a method becoming important and indispensable so quickly in imaging breast. The difference from classic mammography, like in digital cameras, is that the image is obtained in digital media by a detector. This image was developed especially for mammographies by breast radiologists, was investigated on the screens which can process the image and can also be filmed, if may be wanted.
High technology imaging 3 dimensional: TOMOSYNTHESIS
Tomosynthesis which may be defined as 3 dimensional mammography is one of the newest and most important opportunity presented by digital technology. Actually tomosynthesis is also a digital mammography device. The device and imaging style is too much similar to mammography.
Ultrasonography (US) is a imaging method providing to obtain image by sound waves.
ABVS (Automatic Breast Volumetric Scanner) the newest technologic development in breast ultrasonography is also named as automatic breast ultrasound, volumetric breast ultrasound and 4 dimensional ultrasonography.
Magnetic Resonance so MR can be described simply as ‘the technic imaging by radiofrequency waves in a strong magnetic field environment’. Very successful results can be taken by MR technique including no radiation especially in imaging soft tissues.
When suspicious findings are determined in the breast, performing needle biopsy or exsicing that area by surgery is required to diagnose. As for in the situations that suspicious findings are not determined by hand examination, to be performed needle biopsy is approved under the guidance of imaging methods in the radiology clinic. Processing time is depending on the different methods and continuing approximately 20-40 minutes.
After process, findings are being reported as benign, suspicious (atypical) or malign.
· Fine-needle aspiration biopsy (FNAB)
This method is usually being performed under the guidance of US. It is being preferred to clear out of breast cysts and for biopsy of axillary lymph nodes. Also by this way, biopsy can be made to very small-sized lumps or lumps localized deeply in the breast.
· Tru-cut Biopsy (cutting-needle biopsy)
This process is being performed by thicker (3-4 mm) needles and a biopsy pistol.
· Vacuum Biopsy
Vacuum biopsy is the most advanced one among the needle biopsy methods. This method is usually being used for the diagnosis of findings which can be seen only in the mammography and are suspicious from the point of breast cancer.
· Biopsy under the guidance of MR
Breast MR investigation is being used often on women determined breast cancer to detect whether another focus is in breast or not before surgery and to scan on high risky women.