Mammary Gland Pathology PDF

SURGICAL PATHOLOGY OF THE MAMMARY GLAND Acute inflammatory lesions of the mammary gland Acute mastitis represent acute inflammation of the mammary gland; when the inflammation affects the surrounding adipose tissue = paramastitis;  paramastitis can be: ♦ prema...

SURGICAL PATHOLOGY OF THE MAMMARY GLAND Acute inflammatory lesions of the mammary gland Acute mastitis represent acute inflammation of the mammary gland; when the inflammation affects the surrounding adipose tissue = paramastitis;  paramastitis can be: ♦ prematurity->anterior to the glandular tissue; ♦profound-> realizes inframastites; ♦they are rarely independent lesions; ♦ appear especially during the lactation period; ♦ most of the time it complicates an acute mastitis; When the inflammatory process affects both the gland and the extraglandular tissue= panmastitis = diffuse phlegmon of the gland;  Etiopathology Acute mastitis occurs more frequently in lactating women; The germs involved: ♦ staphylococcus or streptococcus; ♦penetrate through erosions or cracks at the level of the nipple; The infection is favored by engorgement of the breast with milk;  Mastitis can rarely occur in newborns, at puberty or at menopause; A posttraumatic intraglandular hematoma by infection => mastitis Rarely the infestation can occur via blood or lymphatic (during typhoid fever of staphylococci); Pathologoanatomic Only in 20% of cases the lesion is bilateral; The infection starts from a galactophorous channel; It initially affects a single glandular lobe;  When the purulent collection has formed, it exceeds the interlobular connective septa => affects the adjacent lobes; A cavity is created at the breast level with pus and glandular detritus and milk;  Clinical On inspection the breast is: ♦ increased in volume; ♦ with hyperemic skin; ♦with rich collateral circulation; ♦painful spontaneously and on palpation;  On palpation it is evident: ♦ local heat; ♦ fluctuent; ♦ sharp pain on compression; ♦ a yellowish secretion is eliminated through the galactophorous ducts = pus + milk; ♦secretion leaves a yellowish stain on a piece of gauze (Budin’s sign); ♦ lymphangitic trains converging towards the axillary region in hyperseptic cases ± lymphadenitis; ♦when the inflammatory focus has softened, the fluctuation appears;  General phenomena: ♦fever ; ♦ alteration of the general condition; ♦biologically, leukocytosis occurs; Without surgical treatment the process: ♦fistulizes spontaneously on the skin; ♦it can extend pre- and retromammary => so-called panmastitis;  The positive diagnosis is placed on: ♦occurs in a breastfeeding woman; ♦ local and general clinical signs indicating an infection; The differential diagnosis must be made with: 1. Breast engorgement which is characterized by: ▪ represents a physiological state of the gland during lactation; ▪ the swelling is uniform; ▪ without local and general inflammatory phenomena; ▪ it is caused by an insufficient discharge of the gland; ▪ the symptoms of engorgement disappear immediately after the milk is expelled; ▪ the discharged secretion does not have a purulent appearance; ▪ no microbes grow on the culture;  2. Carcinomatous mastitis which: ▪ it also occurs in young women; ▪ occurs during breastfeeding; ▪ it is accompanied by fever, pain and redness; ▪ the orange peel sign is present due to edema of the skin; ▪ palpation reveals: - bulky tumor; - infiltrative character; - axillary adenopathy; - most often it is bilateral; - the dominant sign is toxemia;  3. erysipelas of the skin of the breast region that has: ▪ erysipelatous plaque; ▪ bounded by healthy skin; ▪ begins with chills and high temperature;  Clinical forms prenatal abscess = localization of the suppurative process in the premammary fatty tissue; tuberous abscess = a suppuration that: ▪ affects the sebaceous glands of the breast; ▪ creates a small and very painful inflammatory tumor; ▪ it is similar to suppurations from hydrosadenitis;  retromammary abscess ▪ it is also called inframastitis; ▪ represents the inflammatory process of the retromammary fatty tissue; ▪ it can rarely be primitive; ▪ more often, it is propagated from a gland abscess creating the „shirt button” abscess; ▪ the breast appears greatly enlarged; ▪ with fluctuation and edema in the submammary groove;  diffuse phlegmon of the breast: ▪ it is found in debilitated women; ▪ it has a high tendency to extension and necrosis; ▪ has noisy general signs;  Wood phlegmon of the breast ▪ it is a subacute form; ▪ the gland is enlarged and very hard; ▪ suppuration appears late;  Mastitis of the newborn ▪ appears in the first week after birth; ▪ it is characterized by the presence of greatly enlarged breasts; ▪ they look like „watch bottles”; ▪ general signs of infection are present; ▪ has evolution towards spontaneous healing; ▪ suppurative processes rarely occur;  Pubertal mastitis ▪ it occurs more frequently in boys than in girls; ▪ it is favored by local microtraumatisms; ▪ it heals spontaneously;  Menopausal mastitis is represented by: ▪ hard swelling of both breasts; ▪ concomitant induration of the skin; ▪ palpable nodes; ▪ has a subacute or chronic evolution ▪ it can mimic cancer;  Treatment Prophylactic treatment consists of: ♦rigorous hygiene of the newborn’s nipple and mouth; ♦ great attention to nipple erosions and sores; ♦ when they appear they must be treated by: ▪ bleaching with boric glycerin 10% or powders with sulphamides; ▪ breastfeeding must be interrupted for a few days; ▪ the removal of milk will be done by suction; Curative treatment a. In the galactophoritis stage consists of: ▪ normal expression of the gland ▪ general anti-infective treatment - sulfonamide - antibiotics ▪ local: - wet dressings - anti-inflammatory radiotherapy; ▪ discontinuation of breastfeeding. b. In the abscess stage ▪ the treatment is surgical and consists of : - in the case of a single radio incisional abscess; - arcuate submammary incision in case of multiple abscesses; - drainage of the abscess; - anti-infective treatment;  B. Chronic mastitis are chronic infectious processes of the mammary gland; they can start from acute phenomena noticed or not noticed by the patient; they can wear pseudotumoral forms; lends itself to confusion;  may be: ♦ non-specific – determined by common pathogens; ♦ specific (TB, lues); Nonspecific chronic abscess = chronic mastitis ♦ it is an inflammatory process that usually affects only one glandular lobe; ♦ it has the same symptomatology as the warm abscess, but more faded and lingering;  Etiology Occurs most often on a diabetic site; it can be due to a warm abscess or a traumatic injury; it may be an imperfect healing of an improperly drained warm abscess; Pathologoanatomic macroscopically it has the appearance of a nodule with a wall: ▪ thick; ▪ hard; ▪ sometimes even calcified; ▪ delimited evil; ▪ contains a small amount of pus and serosity inside;  Clinical The symptomatology is characterized by: ♦ pain on palpation, insidiously appearing; ♦ the pain is sometimes discovered during the local toilet; ♦ on the same occasion, the patient remarks: ▪ a mobile node with respect to the adjacent plans; ▪ inflammatory type axillary adenopathy; The objective examination highlights: ♦ the presence of a nodule: ▪ hard; ▪ round or irregular; ▪ of variable size; ▪ poorly defined compared to the adjacent tissues; ▪ mobile; When the nodule is superficially developed it can: - interest the skin; - retract the nipple; - present axillary adenopathy; - prone to confusion with cancer; ▪ upon compression, a purulent or serous secretion may appear on the nipple when there is a communication between the abscess cavity and one or more galactophorous channels; ▪ the diagnosis of certainty is established by puncture or excisional biopsy;  Treatment The treatment is surgical; it can be: - an incision with the evacuation of the abscess; - - a sectorectomy; healing is usually quick;  the extemporaneous histopathological examination is mandatory in both situations; simple mastectomy can be used when the infection is: - severe; - chronic; - extended  Galactocele It is a tumor containing altered milk => a chronic abscess; it is a collection into which several galactophorous channels flow; occurs during lactation; it is quite rare;  Pathologoanatomic It is a round tumor; has a smooth surface; it is mostly unique; it has a cystic appearance on the internal face; it is actually a pseudocyst without an epithelial covering;  Clinical presents as a tumor: ♦ well circumscribed; ♦ furniture compared to adjacent plans; ♦ when pressed, milk flows through the nipple; ♦ leave a well on the breast; the formation increases in volume until suppuration appears;  Treatment The treatment consists of: ♦ stopping lactation ♦ incision ♦ evacuation ♦ extirpation of the pseudocyst via the submammary route Tuberculosis of the breast It is a rare condition; it is caused by the Koch bacillus; seeding can be done by blood or lymphatic route; it is unilateral; it can be: - with multiple nodules, disseminated in the gland; - localized = true intraglandular cold abscess; Clinically we distinguish two forms: Disseminated form: ♦ occurs in women with advanced visceral tuberculosis; ♦ the breast increases in volume; ♦ no skin changes; ♦ with disseminated nodular formations and axillary adenopathy;  The localized form that evolves in two phases: ♦ rawness phase: - well circumscribed but irregular tumor; - axillary adenopathy;  ♦ softening phase: - fluctuating tumor; - hyperemic skin; - tendency to fistulization; - established fistula through which coarse or casey pus flows;  Diagnosis It is difficult to establish, especially due to the rarity of the condition; must take into account the personal antecedents of the patient; most often we discover tuberculosis: ▪ already known and incorrectly treated; ▪ or tuberculous pleuropulmonary lesions unknown to the patient;  Treatment ♦ in the secondary forms it is limited to: ▪ evacuation puncture; ▪ tuberculosis treatment; ♦ in primitive form: ▪ surgical treatment; ▪ it is possible to reach the amputation of the breast with preservation of the pectoral muscles;  Syphilis of the breast can be represented by: ▪ primary chancre; ▪ secondary syphilis; ▪ syphilitic goma; it is an increasingly rare condition; nipple chancre and secondary determinations located in the breast are in the field of dermatological medical pathology;  Only mastitis of the tertiary period (goma) is of surgical interest; The breast tissue goes through the three usual stages: ▪ rawness; ▪ of reclamation; ▪ of ulceration; without axillary adenopathy; The diagnosis is based on: ♦ interrogation ♦ R.B.W. Treatment with antibiotics leads to the rapid regression of gums; sclerotic lesions heal incompletely; rarely requires surgical treatment;  Dystrophic and tumoral lesions of the breast 1. Cystic breast disease = sclerocystic mastosis = fibrocystic = Reclus disease It is a dysplastic lesion; It consists of the appearance of cystic tumors and fibromatous nodules in both breasts;" Etiopathogenesis Fibrocystic mastosis is a frequently encountered disease in adult women; It occurs mainly towards the decline of their menstrual period; It occurs more rarely during puberty; It is very rarely encountered in men  It seems to be a glandular dystrophy through a hormonal disorder: Hyperfolliculinemia; Hyperthyroidism; Thyroid and/or genital hypofunction; There are studies supporting a higher frequency of breast cancer among patients with such lesions; Anatomopathology Macroscopic: Multiple cysts with sclerotic nuclei, Different sizes, With yellow-citrine or brown fluid, more or less syrupy.  Microscopic: Multiple cystic cavities: Composed of fibrous tissue; With or without adenomatous tissue; Disseminated in adjacent dense connective tissue; Lined with cylindrical epithelial cells = true cysts;  Clinical It presents with reduced signs consisting of: - Localized pain; - Spontaneous or upon deep palpation; - Exacerbated during menstruation;  These symptoms are usually reported by individuals with a fragile psyche; on palpation, we feel the presence of: - Disseminated small tumors; - Different sizes, from wheat grain to egg; - Firm consistency, akin to lead pellets.  The tumors are spaced apart and mobile relative to adjacent planes; without axillary adenopathy; there is the solitary breast cyst as a tumor: - Rounded; - Well-defined; - Firm; - Slightly painful to palpation; - Mobile relative to adjacent planes. Positive diagnosis is established based on: History: - Sudden appearance of a formation; - Often with pain at onset; Mammography.  Puncture with aspiration of fluid from inside the cyst followed by cytological examination; The definitive diagnosis belongs to the anatomopathologist, either through intraoperative examination (frozen section) or through examination of the paraffin- embedded tissue.  Evolution: - It is slow; - On the order of years; - With potential for malignancy; - It is considered a precancerous condition. Treatment In young women, the treatment is mainly conservative and consists of: - Breast compression; - General hormonal treatment after establishing the hormonal profile; - Local treatment with Mastoprofen.  Surgical treatment is indicated: - When there are doubts about the diagnosis; - When there is suspicion of malignant transformation; - It consists of sectoral resection with intraoperative histopathological examination.  Benign breast tumors 1. Mammary adenofibroma = mammary fibroadenoma Represents 75% of benign breast tumors; Results from the proliferation of the epithelium and connective tissue of the gland; Microscopic: Several varieties are described: - Pericanalicular adenofibroma; - Intracanalicular adenofibroma; - Cystic adenofibroma; - Arborescent adenofibroma.  Clinical It affects women under 35 years of age; It appears as a single tumor formation: - Small in size (0.5-1cm), sometimes reaching 3-4 cm; - Hard;  ♦ Well-defined; - With smooth surface; - Very mobile (slips under the examiner's fingers, difficult to immobilize) => described as a "breast mouse"; - Becomes painful during menstruation; No axillary adenopathy is observed;  Paraclinical Diagnosis Mammography: - Well-defined opacity; - Costal or subcostal intensity; Biopsy examination definitively determines the diagnosis.  Treatment In principle, the treatment is surgical; It aims to: - Confirm the diagnosis; - Remove a tumor formation that is increasing in volume; - Remove a stress factor for the patient;  The excision is performed through an incision that is as aesthetically pleasing as possible; Periareolar or inframammary groove incisions are preferred, rarely radial ones. 2. Intracanalicular papillary tumor Described by Lecene; It is a proliferation of the epithelium of the lactiferous ducts; It is a rare variety of tumor formation;  Anatomopathological The lactiferous duct appears dilated; It is filled with vegetations floating in a sanguineous fluid.  Clinical The patient presents to the doctor stating nipple discharge, which can be: - Sanguineous or - Serosanguineous; - With intermittent character; - Related to menstruation and/or sexual contacts.  When clinically detectable, the tumor is: - Typically located under the mammary areola; - Cherry-sized; - Round or oval; - Firm; - Adherent to the gland; - Without adhesions to the wall; Upon pressure, sanguineous fluid drains through the nipple.  Progression Benign at onset; Can degenerate into a malignant tumor at any time.  Treatment Is surgical; Involves limited excision of the dilated lactiferous duct and its contents; In case of confirmed malignant degeneration -> breast amputation.  Breast Cancer Epidemiology and Risk Factors Breast cancer is: - The most common malignant tumor in women; - The leading cause of oncological mortality; - With a continuous increase in incidence; - Represents 20% of all neoplasms in women in Europe.  It appears around menopause, between 45-50 years old; In postmenopause, between 55-60 years old; With a tendency of decreasing age of onset observed in recent years.  Predisposing factors: - Early onset of menstruation; - Nulliparity; - First childbirth after the age of 30; - Late menopause; - Ionizing radiation.  Predisposing factors: - Untimely hormonal treatments; - Previous breast traumas; - Hypercaloric and high-fat diet; - Unmarried or late-married women; - Women with a history of breast cancer on the maternal side.  Hereditary breast cancers account for only 8% of all neoplasms ; - History of dysplasia ; - Fibrocystic mastopathy; - Stress; - Neuro-hormonal instability.  Symptomatology In the early stages, symptoms are subtle; The most commonly encountered symptoms are: - Tumor: - Often discovered by the patient herself; - Either through incidental palpation or self-examination. ♦ Pain, as the primary symptom: - Occurs in 8% of cases; - Can be in the form of stabbing or burning sensations; - Is not specific to cancer; - May draw the woman's attention to seek medical care.  In a small percentage of cases, the following may occur at onset: - Nipple discharge; - Erosions and eczematization of the nipple; - Reddening of the breast skin; - Axillary lymphadenopathy in 2% of cases.  Paraclinical Diagnosis Early diagnosis in breast cancer can be achieved through screening programs, with definite benefits for individuals over 50 years old.  Ultrasound - Benign tumor nodules present: - Homogeneous structure; - Hypoechoic or isoechoic with the structure of the mammary gland. - Malignant tumors present: - Nonhomogeneous structure, - Hypoechoic areas alternating with areas of increased echogenicity; - Posterior acoustic shadowing on ultrasound examination. Mammography - It is indispensable in detecting asymptomatic cancer; - Can detect lesions as small as a few millimeters; - A benign nodule appears on mammography as an opacity: - Intense; - Homogeneous; - Well-defined. - A malignant tumor appears on mammography as an opacity: - Nonhomogeneous; - With irregular margins; - With calcifications; - Other findings may include: - Image of retractile fibrosis; - Peritumoral edema; - Thickening of the skin margin = infiltration of the skin.  Cytological Diagnosis Represents the microscopic examination of smears obtained from fine needle aspiration of the breast tumor; A positive cytological examination confirms the diagnosis of malignancy; A negative cytological examination cannot exclude malignancy unless corroborated with other clinical and paraclinical information.  Histopathological Examination - Provides the definitive diagnosis; - Can be performed from: - Tumor samples; - Biopsy puncture; - Resection specimen in case of surgical intervention.  Less commonly used investigative methods include: - Thermography; - Galactography; - Xerography; - Nuclear magnetic resonance: - It is an expensive investigation; - It is used in: - Monitoring conservatively treated breast cancer, - For early diagnosis of local recurrence.  After histopathological confirmation, a pre-therapeutic assessment is performed: - Its aim is to: - Establish the true extent of the disease; - Detect any possible organ-functional insufficiencies or associated diseases. It includes the following mandatory investigations: - Complete clinical examination; - Chest X-ray; - Complete blood count; - Platelets count; - Bleeding time; - Erythrocyte sedimentation rate (ESR); - Fibrinogen level. ▪ Gamma-glutamyltransferase; - Disproteinemia tests; - Bilirubin; - Transaminases; - Uric acid; - Urea; - Electrocardiogram; - Sternal puncture with bone marrow examination before starting cytostatic treatment. Optionally, the following tests will be performed: - Bone X-rays/bone scintigraphy in the presence of bone pain or increased alkaline phosphatase; - Neurological examination; - Cranial CT - in the presence of neurological symptoms. ▪ Tumor markers: - CA15-3; - Carcinoembryonic antigen (CEA); - Useful in therapeutic and post- therapeutic monitoring; - Estrogen receptors; - Progesterone receptors for predicting response to hormone therapy.  Differential Diagnosis 1. Fibrocystic mastopathy - Occurs in women between 30 and 55 years old; - Often bilateral; - Lesions are painful during premenstrual phases; - Nodules are well-defined; - Not associated with axillary lymphadenopathy. 2. Fibroadenoma - Manifests in young women; - Especially between the ages of 20 and 25; - Nodules are generally painless; - Characteristic signs are present on mammography.  3. Intraductal papilloma - Manifests between the ages of 20-65; - The dominant symptom is intermittent nipple discharge.  Evolution and Complications Dissemination occurs: From near to far; Hematogenously; Lymphatically.  Local dissemination is achieved through: Contiguity; Permeation; Embolization into lymphatic vessels.  As it develops, the tumor infiltrates: Lymphatic vessels; Blood vessels; Connective tissue => giving the appearance of "orange peel"; Causes ulceration of the skin; Spreads into the deep plane => adherence and even fixation to the pectoral muscle.  Permeation nodules = a particular form of cutaneous tumor infiltration: They are small-sized tumor formations. They are located in the dermal lymphatic vessels of the breast or on the chest wall.  Through the lymphatic pathway, breast cancer causes metastases in the following lymph nodes: Axillary; Internal mammary; Subclavicular; Supraclavicular, etc.  Through the hematogenous pathway, it causes metastases to: Hepatic, Pulmonary, Osseous, Cerebral, etc.  There is a bone tropism for distant dissemination, manifesting in segments such as: Vertebral, Costal, Pelvic, Cranial.  Prognostic Factors First-generation prognostic factors include: Clinical stage; Histopathologic type: – Medullary and tubular carcinomas have a favorable prognosis; Direct proportionality with tumor size.  Differentiation grading: - The higher the differentiation grade - G1 - the better the prognosis, and vice versa. Axillary lymph nodes status: - The larger the number of invaded axillary lymph nodes, the more unfavorable the prognosis.  Hormonal receptors: – Presence of estrogen and progesterone receptors => good prognosis. Peritumoral cellular reaction. Intralymphatic and intravenous tumor invasion.  Second-generation prognostic factors: Epidermal growth factor. Expression of the p53 gene, often overexpressed in breast cancer = unfavorable prognosis.  TNM 2002 Staging Classification of Breast Cancer Primary Tumor – T Tx: Primary tumor cannot be assessed; Tis: Carcinoma in situ, intraductal carcinoma, lobular carcinoma in situ, or Paget's disease of the nipple without associated tumor mass (Paget's disease associated with a tumor mass is classified according to tumor size);  Tis(DCIS): Ductal carcinoma in situ; Tis(LCIS): Lobular carcinoma in situ; Tis(Paget): Paget's disease of the nipple without tumor. T1: < 2 cm in largest diameter; -T1mic: microinvasion, < 0.1 cm in largest dimension; -T1a: tumor > 0.1 cm but ≤ 0.5 cm in largest diameter; -T1b: tumor > 0.5 cm but ≤ 1.0 cm in largest diameter; -T1c: tumor > 1.0 cm but ≤ 2.0 cm in largest diameter. T2: Tumor > 2 cm but ≤ 5 cm in largest diameter; T3: Tumor > 5 cm in largest diameter.  T4: Tumor of any size with direct extension to the skin or chest wall: - T4a: Extension to the chest wall; - T4b: Edema (including "orange peel" appearance), skin ulceration, or permeation nodules confined to the breast; - T4c: Both characteristics (T4a and T4b) present; - T4d: Inflammatory carcinoma. Regional Lymph Node Involvement - N: Nx: Regional lymph node involvement cannot be assessed; N0: No regional lymph node metastasis; N1: Mobile axillary lymph nodes; N2: Fixed ipsilateral axillary lymph nodes; N3: Metastasis to internal mammary lymph nodes. Distant Metastasis - M Mx: Presence of metastasis cannot be assessed; M0: No distant metastasis; M1: Distant metastasis including ipsilateral supraclavicular lymph nodes.  Histopathology The most common histopathological types are: - Invasive ductal carcinomas: 70%; - Lobular carcinomas; - Tubular carcinomas.  - Medullary carcinomas; - Papillary-tubular carcinoma; - Adenoid cystic carcinoma; - Paget's carcinoma. Less frequently encountered are: - Lymphomas; - Sarcomas.  Treatment Breast cancer treatment is multidisciplinary; different treatment methods are adapted based on: - Disease progression; - Individual risk factors; - Stage of the disease; - Therapeutic response at each stage.  Therapeutic indication is established following the decision of the oncology committee comprised of: - Oncologist - Surgeon - Radiation oncologist - Pathologist  Treatment options include: - Surgery - Chemotherapy - Radiotherapy - Hormone therapy  Surgical Treatment - Radical or conservative surgical procedures can be performed: Halsted's operation: - Today it is less commonly performed; - Involves: En bloc removal of: - The breast; - The pectoral muscles; - The axillary lymph nodes.  Patey procedure involves: - Removal of the breast + anterior fascia of the pectoralis major muscle + axillary lymph nodes; - Preservation of the pectoralis major muscle.  Modified radical mastectomy with axillopectoral lymphadenectomy - IOB technique - Professor Trestioreanu; Modified radical mastectomy - Chiricuță technique; Limited resections - sector resection with axillary lymph node dissection.  Performing conservative surgery requires: - The breast to be of normal volume; - Unilateral tumor; - Unifocal tumor; - No adherence to the fascia of the pectoral muscle.  - N0 (no axillary lymphadenopathy); - Resection to be performed in healthy tissue with clear margins; - Mandatory histopathological examination is carried out; - If axillary lymph nodes are involved, mastectomy is recommended. Chemotherapy Chemotherapy is administered: Neoadjuvant in advanced stages; Adjuvant after the primary tumor has undergone: - Surgery, - Radiotherapy, - If there are unfavorable prognostic factors.  The most commonly used cytostatic drugs are: - Epirubicin - Doxorubicin - Methotrexate - Cyclophosphamide - Taxotere (Docetaxel) - 5-Fluorouracil - Navelbine (Vinorelbine) - Paclitaxel  Radiation Therapy Radiation therapy is performed using high-energy radiation with cobalt-60 or 4-6 MEV photons.  Preoperative radiation therapy can be performed and has the following roles: - To reduce the viability of tumor cells; - To decrease tumor volume; - To heal ulcerated lesions; - To mobilize tumors fixed to the chest wall, adapting them to surgical intervention in locally advanced breast cancers.  Postoperative radiation therapy is administered to reduce the risk of locoregional recurrence. The doses administered: - Range between 40-50 Gy; - Given in 25 fractions; - Over 4-5 weeks; - A dose of 40 Gy is considered sufficient to control subclinical disease. Hormone Therapy It can be suppressive, which involves suppressing an endogenous hormonal source through: - Surgery - Radiation - Medications The main methods are: Surgical castration via classical or laparoscopic methods; - Used when a rapid response is desired. Ovarian suppression through radiation therapy, with doses ranging from 15- 17 Gy; Medical castration. Additive hormone therapy: - Utilizes sex hormones and their derivatives.  The most commonly used products in hormone therapy are: - Antiestrogens; The most frequently used medication is Tamoxifen; -It competitively binds to estrogen receptors, thus inhibiting the action of estrogens; -It is more effective in postmenopausal women. – It reduces the risk of recurrence and bilateralization of cancer. – It is extremely useful in advanced stages and with bone metastases, achieving remissions of approximately 30-40%. – In the presence of estrogen receptors, the response rate reaches 60-70%.  - Progestogens; The most commonly used are: - Medroxyprogesterone acetate (Farlutal, Provera, Clinovir); - Megestrol acetate (Megace); - They are used as second-line hormonal treatment after failure of first-line hormone therapy. - Adrenal function inhibitors.  Hyperthermia Increasing the temperature above a certain value for a certain duration can induce lethal cellular damage. The optimal therapeutic temperature is considered to be around 41.5°C for 30 minutes.  Current hyperthermia methods are based on the use of: Ultrasound; Electromagnetic radiation, which can induce heating: - Locally - Regionally - Generally  Clinical and Therapeutic Situations Operable Breast Cancers Include staged tumors T1N0; T1N1; and T2N0; The therapeutic objective is cure; The first therapeutic step is surgical intervention.  subsequently, depending on the morphopathological prognostic factors, the following are indicated: ♦ chemotherapy ♦ radiotherapy ♦ hormone therapy  surgery can be: ♦ conservative = sector with lymph node clearance ♦ radical mastectomy.  the prognostic factors for recurrence and evolution are: ♦ tumor over 2cm; ♦ age under 35 years; ♦ G2-3 of malignancy; ♦ more than 4 invaded axillary nodes; ♦ multicentric tumors; in the presence of these prognostic factors, chemotherapy is indicated. Loco-regionally advanced breast cancer this category includes injuries from the following stages: ▪ IIB (T2N1, T3N0); ▪ IIIA (T0N2, T1N2, T2N2, T3N1, T3N2); ▪ IIIB (T4N3); the initial treatment that is indicated is the medical one;  4 - 6 courses of neoadjuvant chemotherapy and re-evaluation after the end of the last course are recommended;  depending on tumor regression, the following are indicated: ▪ conservative surgery or radical mastectomy (if there is a risk of ulceration); ▪ exclusive locoregional radiotherapy if: - no tumor regression changes were found; -no elements appeared to indicate local or distant evolution; ♦ after radiotherapy, the case will be evaluated for surgical intervention; ♦ postoperatively, depending on the prognostic factors, adjuvant chemotherapy and hormone therapy will be administered;