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Histopathological analysis and surgical treatment of breast cancer--our experience/Histopatoloska analiza ihirurski tretman raka dojke--nase iskustvo.

Introduction

With their incidence and high mortality, malignant diseases are at the top of epidemiological studies [1].

Breast cancer is the most common malignancy among women in both developed and developing countries, with 1.38 million of new cases diagnosed in the world in 2008 [2, 3].

About 430,000 new cases of breast cancers are diagnosed in Europe every year, while in the United States Of America this number is around 250,000 [4, 5]. The incidence is now higher in more developed countries; however, an increase in the incidence of this disease is expected in countries in transition in the future [6].

In our country, breast cancer is diagnosed in up to 4,000 women annually and it results in 1,600 deaths, which accounts for 18% of cancer mortality in general.

The average standardized incidence rate of breast cancer in Central Serbia in the period from 1999-2009 was 60.8/100,000, and the mortality rate was 20. 2/100,000 [7].

The incidence of most malignant diseases grows with the age, and later, older age is one of the risk factors for breast cancer [8] even though today breast cancer often occurs before the age of 30, which used to be very rare. Risk factors are often intertwined and it is difficult to isolate the specific role of each. Most patients are with a history of un- known risk factors [9].

The aim of this paper was to show the descriptive and histopathological analysis and the applied surgical technique with early and late post-operative complications in patients with breast cancer who were hospitalized and treated at the General Hospital in Novi Pazar.

Material and Methods

The analysis included 59 patients operated for malignant breast tumor at the General Hospital in Novi Pazar during the period from 2009 to 2011. Data from medical records, operation and histopathological reports were reviewed.

Histopathological analysis was performed at the Department of Pathology and Forensic Medicine of the General Hospital Novi Pazar in order to examine the size and type of the tumor, disease stage, surgical techniques and complications, the age of the patients at the moment of the surgery and its correlation with the number of metastatic lymph nodes in the axilla and the tumor size, as well as the correlation of the tumor size with the number of metastases in the axillary lymph nodes.

The study sample did not include patients who had been operated for benign breast tumor.

The descriptive and retrospective data analysis was done based on the clinical examination, pathohistological analysis of tumors and performed surgical techniques.

The findings were summarized by means of the methods of descriptive statistics. The statistical analysis was performed using SPSS 19.0 (SPSS Inc., Chicago, IL, USA). The data were processed by using the Mann-Whitney U-test or the T- test, depending on the number and distribution of the compared groups. Spearman's Rho was calculated as a non parametric correlation coefficient in the clinical outcome between the individual markers. P<0.05 was considered statistically significant.

Results

During the period from 2009 to 2011, 59 patients were operated for breast cancer at the General Hospital in Novi Pazar.

The age structure is presented in Graph 1. The youngest patient was 23 and the oldest was 79 years old. The average age of the patients at the moment of surgery was 54.37 years. Most of patients (11.9%) were at the age of 43, 37.4% were younger than 50, 5.1% were younger than 40, while 32.3% of women were between 40-49 years of age.

All patients were operated according to decision made by the Consulting team. The preoperative diagnostic preparations included clinical examination, laboratory analyses, radiological examinations (ultrasound, radiography, mammography, computed tomography). All operations were performed under the general anesthesia. At the time of surgery no patient had systemic manifestation of distant metastases.

In our case, most surgical techniques were breast-conserving. Quadrantectomy was performed in 64.4% and tumorectomy in 3.4% of patients. Modified radical mastectomy (Madden technique) was performed in 19 patients (32.2%) (Table 1).

[GRAPHIC 1 OMITTED]

No intra-operative complications were noted. Early complications developed as lymphorrhea in 1.69% and wound infection in 1.69% of patients. Lymphedema was observed in 2 patients (3.39%) as a late postoperative complication. One patient refused postoperative chemotherapy and she had a relapse after 6 months. The results are shown in Table 2.

According to the pathology report, 4 patients (6.78%) had in situ stage (stage 0) of the breast cancer, 9 (15.25%) had stage I, 30 (49,14%) patients had stage II, and 17 (28.82%) patients had stage IIIA of the breast cancer. There was no patients with stage IIIC and stage IV (Table 1).

Metastases in axillary lymph nodes were found in 32 patients (54.24%) (Table 1).

The size of the primary tumor determined on the basis of the largest diameter measured during the histopathological analysis was found to be less than or equal to 2 cm in 28 (47.46%) patients, between 2-5 cm in 26 patients (44.07%) and larger than 5 cm in the largest diameter in 5 (8.47%) patients (Table 1).

The smallest recorded tumor size was 6 mm, while the largest tumor diameter was 60 mm. The average size of the tumor was 26.49 [+ or -] 14.556 mm. The difference in tumor size in relation to the age, among women younger than 50 and those older than 50 years was not statistically significant (T = -1.203, p> 0.05).

The largest number of positive lymph nodes in the axilla found in one patient was 10. The mean number of positive lymph nodes in the axilla was 2.24 [+ or -] 2.602. By analyzing the number of positive nodes in relation to the age, no statistically significant difference was observed between the number of positive lymph nodes in women younger and older than 50 years (Mann-Whitney U test, p> 0.05).

Nonparametric variance analysis by Spearman's Rho ([rho]= 0.308, p<0.05) revealed a significant positive correlation between the tumor size and the number of positive axillary lymph nodes, meaning the larger the tumor the higher was the number of metastatic lymph nodes in the axilla. A significant positive correlation of the patient's age and the breast cancer stage was also confirmed with nonparametric variance analysis by Spearman's Rho ([rho]= 0.337, p<0.05), which means that the breast cancer was more often diagnosed at a higher stage in elderly patients in our study.

Rapid diagnosis during the surgery was performed in all patients. The interpretations were as follows: malignant lesions in 52 cases (88.13%), which was also confirmed by the definite histological analyses; benign lesions in 1 case (1.7%), but the definite histological analyses showed that it was a malignant lesion. Definitive histological diagnosis was delayed in 6 cases (10.17%) which was later confirmed to be a malignant tumor.

In our sample, the most common histological type of the tumor was ductal carcinoma in 62.7% of patients, while a lobular carcinoma was on the second place, being present in 11 cases (18.6%). The results are shown in Table 3.

Discussion

In recent years, there has been a remarkable progress in the diagnosis and treatment of breast diseases, especially breast cancer [10].

If untreated, breast cancer has the fatal outcome. Death is inevitable if patients with breast cancer refuse any treatment. Spontaneous evolution and the length of illness vary, and most often, if not treated, the disease ends in death within three years, but in a small percentage, 1.4%, it can last for more than a decade [1].

Breast cancer is a heterogeneous disease with varied morphological appearances, molecular features, behavior and response to therapy. This tumor continues to remain the most lethal malignancy in women throughout the world. The incidence rates of breast cancer vary worldwide. The highest rate has been reported in the northern America, and the Western Europe [11-13] whereas it is very low in most of the Asian countries [14].

The incidence rates are high in developed regions of the world (except Japan) and low in most of the developing regions [6].

The incidence of most malignant disease increases with the age, and older age is a risk factor for breast cancer. The incidence of breast cancer increases with the age, getting twice higher with every 10 years until the menopause, after which the rate of growth slows down considerably [8, 15].

The most commonly affected women are over 50 years of age [9]. Before the age of 35, breast cancer is rare. Approximately 7% of all breast can cers are diagnosed in women under 40 years of age and less than 4% of women are under 35 years of age. The prognosis tends to be negative when the disease is diagnosed at young age [16, 17].

The average age of patients at the time of operation was 54.37 years in our sample, while the percentage of women over 50 years of age was 63.6%, which correlates with the literature data and 5.1% of patients were under 40 years of age, which also correlates with the results of studies done by other authors.

Axillary lymph node status is the most important prognostic factor. Breast cancer that has spread to the lymph nodes (positive lymph nodes) has a higher risk of recurring and a less favorable prognosis than breast cancer that has not spread to the lymph nodes (negative lymph nodes). The number of positive lymph nodes is also an important prognostic factor. The five-year survival, regardless of the size of the primary tumor, significantly decreases with the increase in the positive lymph node number. So, the five-year survival is 70% if the number of positive lymph nodes is 3, it is 50% if the number of positive lymph nodes is 7-12, and only 28.4% if the number of positive lypmh nodes is 13 and more [18].

In our sample, the average number of positive axillary lymph nodes was 2.24 [+ or -] 2.602. Due to the short time period of the study there was no possibility to determine the five-year survival.

Many authors suggest that the number of positive axillary lymph nodes increases with the tumor size in their research [19-21].

In our analysis, it was determined that the correlation between the tumor size and the number of positive axillary lymph nodes was medium strong, which coincides with the results in the literature.

In countries where the screening program for early detection of breast cancer is implemented, there is a trend of detection of tumors at early stages. In countries where there is no screening, tumors are detected at later stages.

Early diagnosis can lead to a dramatic reduction in the size of tumor, better prognostic features, more conservative surgery and improvement of survival [22-24].

Invasive ductal carcinoma accounts for 50-60% of all breast cancer. Many authors in their studies pre sented data that this is the most common malignant tumor [25-28]. Similar to other studies, our study found that ductal carcinoma, accounting for 62.7% of the all cases, is the most frequent type of breast cancer. Lobular carcinoma takes the second place with 18.6%.

The surgeon has a fundamental role in diagnosis and treatment of breast cancer, which must be multidisciplinary. The main objectives are early diagnosis and radical treatment in order to cure the patient, or to prolong their life and improve its quality [9]. Breast cancer management involves either modified radical mastectomy (MRM) or breast conservation surgery (BCS) as the primary treatment modality followed by adjuvant treatments based on pathological characteristics [29, 30].

In this regard, breast conservation surgery was performed in 67.8% of cases of our study sample, and modified radical mastectomy was performed in 32.2%.

Conclusion

The fact that the majority of women in our study sample had breast cancer stage II emphasizes the necessity for better prevention and education of women in order to improve early diagnosis of breast cancer. The number of positive axillary lymph nodes appears to be an important prognostic factor and a significant positive correlation between the tumor size and the number of positive axillary lymph nodes is revealed. In the future, it will be necessary to evaluate more potentially useful factors in a prospective fashion using standardized assay and statistical methodology.

DOI:10.2298/MPNS1602059D

References

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Dzemail S. DETANAC (1), Dzenana A. DETANAC (1), Avdo CERANIC (1) and Merima A. CERANIC

General Hospital Novi Pazar, Serbia (1)

University of Belgrade, Faculty of Medicine (2)

Corresponding Author: Dr Dzemail S. Detanac, Opsta bolnica Novi Pazar, 36300 Novi Pazar, Generala Zivkovica 1, E-mail: dzemail.detanac@gmail.com
Table 1. Characteristics of the disease and surgical techniques

Tabela 1. Karakteristike bolesti i hirurske tehnike

Characteristic of disease            Total No. of patients
and types of surgery                    (N = 59) No. (%)
Karakteristike bolesti i             Ukupan broj pacijenata
tip hirurske intervencije              (N = 59) broj (%)

Stage of disease/Stadijum bolesti
O                                           4 (6.78)
I                                          9 (15.25)
IIA                                        22 (37.29)
IIB                                        7 (11.86)
IIIA                                       17 (28.82)
IIIB                                           0
IIIC                                           0
IV                                             0

Metastases in lymph nodes/Metastaze u limfnim cvorovima

Yes/Da                                     32 (54.24)
No/Ne                                      27 (45.76)

Tumor size/Velicina tumora

<2 cm                                      28 (47.46)
2-5 cm                                     26 (44.07)
>5 cm                                       5 (8.47)

Type of surgical technique/Vrsta hirurske intervencije

MRM                                        19 (32.2)
Quadrantectomy /Kvadrantektomija           38 (64.4)
Tumorectomy /Tumorektomija                  2 (3.4)

* MRM--modified radical mastectomy/Modifikovana
radikalna mastektomija

Table 2. Postoperative complications

Tabela 2. Postoperativne komplikacije

Postoperative complications/Postoperativne komplikacije     n    %

Early/Rane

Lymphorrhea/Limforeja                                       1   1.69

Wound infection/Infekcije rane                              1   1.69

Late/Kasne

Lymphedema/Limfedem                                         2   3.39

Relapse/Recidiv                                             1   1.69

Table 3. Histological types of breast cancer

Tabela 3. Histopatoloski tipovi tumora dojke

                                                       N     %

Ductal carcinoma/Duktalni karcinom                     37   62.7
Lobular carcinoma/Lobularni karcinom                   11   18.6
Mucinous carcinoma/Mucinozni karcinom                  1    1.7
Papillar carcinoma/Papilarni karcinom                  2    3.4
Ductal carcinoma in situ/Duktalni karcinom in situ     4    6.8
Undifferentiated carcinoma/Nediferentovani karcinom    1    1.7
Carcinosarcoma/Karcinosarkom                           2    3.4
Mb Paget/Padzetova bolest                              1    1.7
Total/Ukupno                                           59   100
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Title Annotation:Seminar for physicians/Seminar za lekare u praksi
Author:Detanac, Dzemail S.; Detanac, Dzenana A.; Ceranic, Avdo; Ceranic, Merima A.
Publication:Medicinski Pregled
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2016
Words:3176
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