Procedure in the EBZ

Breast Consultation

For the investigation of suspicious findings in the breast your gynaecologist can refer you to an EBZ breast consultation as an outpatient. The breast consultation is conducted (as in the case with all further treatment procedures) by a specially trained core medical team.

Appointments must be arranged by email or fax in advance

Tuesdays:

8:00am to 2:00pm

Thursdays:

8:00am to 1:00pm

 

Diagnostic investigation during the breast consultation involves:

  • Clinical examination (visual examination and palpation of the breast and armpit)
  • Mammary sonography (ultrasound)
  • Arranging a mammography and/or further imaging methods such as MRT (magnetic resonance tomography or nuclear magnetic resonance tomography) as required
  • Secondary diagnosis
  • Taking tissue samples using all currently established procedures (e.g. radiologically and ultrasonically-controlled vacuum and punch biopsy)
  • Histological and cytological examination by the pathologist

Diagnostics (biopsy):

A biopsy means taking a tissue sample from the suspected breast tissue. This is performed on an outpatient basis under local anaesthetic as part of the consultation or during another appointment. The tissue samples are then examined under a microscope by a pathologist and we receive the result as to whether a benign or malignant finding is involved within 2 days at the most.

Biopsy is a very safe and low-risk examination method during which there is no risk of tumour cells being ‘spread’.

Nowadays every suspicious focal finding is investigated using biopsy before surgery, with very few exceptions. The advantage here is that unnecessary operations are avoided in the event of benign findings and necessary surgery can be better planned in the event of malignant findings. This also allows for more conservative surgical procedures to be used (e.g. sentinel node technique in the armpit area).

Discussion of Findings and Admission

If the fine tissue result from the biopsy is available, your situation will be presented and discussed in the preoperative Tumour Conference. A recommendation will be made for the next steps of treatment.

Once we have the results, we will discuss potential further treatment with you during the breast consultation.

To help you overcome any initial shock and fear, you and your relatives have the opportunity to seek help and support by talking to our gynaecologists, our female psycho-oncologist and/or our ‘breast nurse’.

We then aim to schedule an operation as soon as possible. It is, however, also important to be aware of the fact that breast cancer is not an emergency and does not deteriorate overnight. It is therefore advisable to instead arrange additional examinations (e.g. of the lungs, liver and bones) before surgery and perform the operation under the best possible conditions with the right preparation.

Inpatient admission takes place in ward 4 A.

Neoadjunctive (primary systemic) Chemotherapy (chemotherapy before a scheduled operation)

Surgery is almost always the initial treatment stage in breast cancer. In some cases, however, it may be useful to perform chemotherapy before an operation. This is, for example, the case with tumours larger than 2cm in order to reduce the size of the tumours before surgery and thus make it easier to perform breast-retaining surgery. It is also the case if it can be predicted in advance that chemotherapy will be useful after surgery. A further advantage of neoadjunctive chemotherapy is the possibility of telling whether the chemotherapy used is also the ‘right’ procedure for the tumour based on tumour response (reduction in size).

Surgery

Breast-retaining surgical techniques are at the forefront of surgery and aim to completely remove malignant tumours with an adequate safety distance from healthy tissue.

In certain cases, a breast-retaining operation cannot be performed (e.g. in the case of tumours in various different areas of the breast or with very large tumours) and the whole breast must therefore be completely removed (ablation or mastectomy).

Various options for breast reconstruction are available, for example immediate or subsequent reconstruction and use of the patient’s own tissue or prostheses. You will be offered advice on the various options with the help of plastic surgeons.

In the case of breast cancer, it is particularly important to examine the lymph nodes of the armpit for any tumour activity because this information is highly significant in estimating the extent of the disease. In the past  it was necessary to remove a large number of lymph nodes in order to obtain this information, meaning that many women with tumour-free lymph nodes had to undergo unnecessary radical surgery. Nowadays we are able to use a more conservative surgical technique by radiolabelling the ‘sentinel lymph node’ on the day before surgery. The sentinel lymph node is the first lymph node in the armpit to receive lymph from the breast and therefore the first to receive and filter out any potential cancer cells. During the operation, the sentinel lymph node is examined using the frozen-section technique. If it is free of cancer cells. the other lymph nodes in the armpit do not need to be removed because the sentinel lymph node is representative of all of the other lymph nodes in the armpit. If the sentinel lymph node is affected by cancer cells, we remove a further 10-20 lymph nodes.

The inpatient stay after surgery lasts approx. 1 week depending on the progress of cicatrisation. During this period you will be looked after by nursing staff and the ward doctors. You also have the opportunity to visit the ‘breast nurse’, the psycho-oncologist, physiotherapy, social services and the health care supply store as required.

The Tumour Conference

Please refer to "The Tumour Conference"

Adjunctive Therapy (follow-up treatment)

Adjunctive therapy means further treatment following surgery. After establishing the potential therapeutic programme during the Tumour Conference we will discuss it with you in detail. We will inform you of the characteristics of your tumour and the potential treatment options.

The type of treatment depends on various factors including the size of the tumour, its aggressiveness, the lymph node status, the tumour’s response to hormones and antibodies, etc. These factors give us a reference point for calculating your personal risk of recurrence.

Once you have received all of the relevant information, you can discuss the further treatment that you will receive with us, taking your general condition and your personal preferences into consideration.

A distinction is generally drawn between two types of therapy: local treatment acting on a specific region of the body (for example radiotherapy) and systemic treatment, i.e. treatment acting on the entire body (such as chemotherapy, antibody therapy and anti-hormone therapy).

Radiotherapy

In the past, it was common for women with breast cancer to have a mastectomy. In recent years, however, it has become evident that using breast-retaining therapy where tumours do not exceed a certain size can produce results that are just as good as those produced by a more ‘radical’ mastectomy. It is, however, necessary for the breast that has been operated on to be treated with radiotherapy after surgery.

Following a breast-retaining operation, we recommend irradiation of the breast that has been operated on. The aim of irradiation is to destroy any breast cancer cells that still remain so that the risk of recurrence of the cancer is reduced. In certain cases it may also be necessary to irradiate the chest wall and/or armpit after removal of a breast.

Radiotherapy can be carried out on an outpatient basis in the radiotherapy practice at the St. Antonius Hospital. It usually lasts for around 6 weeks.

A separate consultation is arranged to discuss and plan the radiotherapy programme.

Chemotherapy

Chemotherapy with cytostatic agents (medication that inhibit cell division) is part of the systemic treatment of breast cancer, in which the medication reaches all regions of the body through the bloodstream. This can be necessary due to the ability of the cancer cells to detach themselves from the tumour and spread throughout the entire body via the lymph and blood vessels. If the tumour cells become established in specific organs (e.g. the liver, lungs and bones) this is referred to as metastasis.

The use of chemotherapy is a sensible method when there is an increased risk of the presence of tumour cells in the blood and therefore a high risk of metastasis. This is, for example, the case with large tumours, evidence of lymph node involvement in the armpit, a negative response of the tumour cells to hormones, younger women and with highly aggressive (rapidly dividing) tumours.

The recommendation for chemotherapy for each individual patient is discussed at the Tumour Conference. Alongside the characteristics of the tumour, the patient's age and general condition are also taken into account. The undesirable side effects of the chemotherapy must be tolerable for the patient and we must always ask ourselves whether the expected benefit justifies these anticipated side effects.

The Effect of Chemotherapy

Chemotherapy attacks cells that are in the process of dividing. Given that tumour cells generally divide rapidly it is these cells in particular that are attacked. Healthy cells do, however, also divide within the body and the potential undesirable side effects are a direct result of the effect of the chemotherapy on these cells.

The most frequent undesirable side effects involve the haematopoietic system, the gastrointestinal tract, the hair and nails and the nervous system.

These undesirable side effects usually diminish once treatment with chemotherapy has come to an end. They do not necessarily always occur and much depends on the type of cystostatic agent used.

The undesirable side effects of chemotherapy may be prevented by administering other medication but if they still occur then there are a number of options available for reducing these effects.

Chemotherapy Procedure

Chemotherapy usually begins 3-4 weeks after surgery. Various options are available in terms of the type of cytostatic agents administered and the intervals at which they are given. Chemotherapy usually involves a combination of several cytostatic agents and is administered in 6 cycles, with the cytostatic mixture administered on a single day over several hours on an outpatient basis, which is then followed by a 3-week pause before the next cycle starts.

Antibody Treatment

20-30% of all breast cancer cells display a structure on their surface known as an HER2 receptor. This receptor is important in signalling to the cell that it must divide. The HER2 receptor status is determined by the pathologist based on samples from the breast tumour. If a specific number of these receptors are found, the breast cancer cells are considered to be HER2-positive.

It only makes sense to administer  medication that binds to HER2 receptors in HER2-positive patients. This medication is an antibody known under the proprietary name of herceptin. As the antibody binds with the HER2 receptors the receptors become blocked and restrict cell growth while the body's own immune system recognises the tumour cell as ’foreign’ and destroys it.

Antibody treatment is administered intravenously in combination with chemotherapy.

Anti-hormone Treatment

60-80% of all breast cancer cells display structures on the surface known as "hormone receptors". Receptors are like a lock into which specific hormones (specifically oestrogens and progesterone) fit like a key. Histological examination by the pathologist will tell us whether hormone receptors are present.

It is important to know that breast cancer cells tend to react to the presence of the hormones oestrogen and progesterone by growing.

It therefore naturally makes sense to switch off the effect of oestrogen on the breast cancer cells using anti-hormone treatment (endocrine treatment). Drugs that inhibit the oestrogen effect on cells in different ways are available for this purpose:

  • Anti-oestrogens (e.g. tamoxifen) are oestrogen antagonists. They bind to the same receptors as oestrogen but do not trigger any corresponding effect on the breast cancer cell. They ‘occupy’ the space normally taken up by the oestrogen and thus prevent it from binding.
  • Aromatase inhibitors prevent oestrogen from forming from its chemical precursors. Oestrogen is produced in the ovaries, the adrenal glands and in fatty tissue. An enzyme by the name of "aromatase" occurs in the cells of these organs and produces oestrogen from precursor molecules. Drugs that inhibit aromatase are known as aromatase inhibitors and are currently contained in 3 products: anastrozole, letrozole and exemestane
  • GnRH analogues: Oestrogens are released from the ovaries in premenopausal women by means of a regulatory circuit controlled by the brain. GnRH analogues are medication that acts like a hormone from a specific part of the diencephalon and inhibits brain impulses to the ovaries.

The decision as to which anti-hormone treatment is used in your case depends on your own particular circumstances including whether you are suffering from breast cancer before or after the menopause, how high your risk of recurrence is, whether there are other illnesses present and, if so, which illnesses and whether other organs are also involved and, if so, which organs.

Anti-hormone treatment usually extends over 5 years with administration of one tablet a day. The anti-hormone preparation should always be administered following any chemotherapy. It can be taken during or after radiotherapy.

Undesirable Side Effects of Anti-hormone Treatment

The relatively few undesirable side effects of anti-hormone treatment compared to chemotherapy are mainly related to oestrogen deficiency and manifest themselves in hot flushes, palpitations, dry mucosae, joint symptoms, etc.

Regular monitoring of the uterus is required during administration of tamoxifen and of bone density during administration of aromatase inhibitors.

 

Search site:
St.-Antonius-Hospital

Academic teaching hospital of the RWTH technical university, Aachen

Euregio Breast Centre

(Euregio-Brust-Zentrum)

Dechant-Deckers-Str. 8
52249 Eschweiler

+49 2402 - 76-1835

 
St.-Antonius-Hospital Eschweiler
Dechant-Deckers-Str. 8
52249 Eschweiler
tel.: 02403 76 - 0
fax: 02403 76 -1119