Overview

SENOLOGY CENTER

At our center, a multidisciplinary approach is adopted for the diagnosis and treatment of breast diseases. Our experienced team consists of breast surgeons, radiologists, pathologists, medical oncologists, radiation oncologists, nuclear medicine specialists, plastic surgeons, medical geneticists, and gynecologic oncologists. Each patient is evaluated meticulously, and the most appropriate treatment plan is determined according to the individual patient’s needs. In addition, supporting specialties such as psychiatry, physical medicine and rehabilitation, and dietetics are incorporated into the treatment process to ensure that our patients receive the best possible physical and psychological support.
At our center, advanced breast imaging technologies are used for the early diagnosis of breast diseases, including clinical breast examination, breast ultrasonography (US), digital breast tomosynthesis, contrast-enhanced mammography with artificial intelligence support, and breast MRI. These technologies enable breast cancer to be detected and treated at an early stage, thereby helping to prevent loss of the breast and the need for extensive surgical procedures.
In the treatment process, innovative approaches are applied in accordance with the latest developments in medical oncology, including chemotherapy, targeted therapies, immunotherapies, and hormone therapies. In addition, oncoplastic breast surgery techniques are used to achieve better aesthetic and functional outcomes. In this way, the physical integrity of breast cancer patients can be preserved while enabling them to maintain a long and healthy life.
As the Senology Center, we plan the treatment of every breast cancer patient on an individualized basis. We take into consideration many factors, including the patient’s age, menopausal status, stage of the disease, biological characteristics of the tumor, hereditary predisposition, and the patient’s preferences, in determining the most appropriate treatment approach.
With the awareness that early diagnosis of breast cancer can save lives, we are proud to provide our patients with the most advanced diagnostic and treatment services. Our center is here to ensure that our patients are thoroughly informed, supported, and treated throughout every stage of their care.

BREAST HEALTH

The breast is one of the most important female reproductive organs and has the vital function of breastfeeding. It is the organ in which milk is produced to nourish the newborn baby.
Breast tissue is located on the anterior chest wall. The nipple and the surrounding darker skin area, called the areola, are located in the central portion of the breast.
The smallest unit responsible for milk production in the breast is called a lobule. These small lobules combine to form lobes. Each breast contains approximately 15–20 lobes. The milk produced in the lobules is transported into ducts. These ducts merge and open into the major milk ducts behind the nipple, through which milk is delivered to the nipple.
In addition to the glandular structures responsible for milk production, the breast contains fatty and connective tissues that support the breast.
The lymphatic drainage of the breast primarily flows to the axillary lymph nodes, as well as the internal mammary (parasternal), supraclavicular, and infraclavicular lymph nodes.
Breast tissue undergoes continuous changes throughout a woman’s life, from puberty and childbirth through menopause. Breast health is therefore important throughout every stage of a woman’s life.

SELF-BREAST EXAMINATION

Women over the age of 25 are advised to perform a self-breast examination once a month. Proper technique and appropriate education regarding self-breast examination should be provided by breast specialists.
For women who menstruate, self-examination should ideally be performed between the 7th and 10th days of the menstrual cycle, counting the first day of menstruation as day zero. Women who have reached menopause may perform the examination on a day of their choice each month.
Self-breast examination alone should not be relied upon. Women should also undergo regular examinations by breast specialists and have appropriate breast imaging, such as breast ultrasonography, mammography, and breast MRI, when indicated.
Self-breast examination helps women become familiar with the normal appearance and feel of their own breast tissue. If a new suspicious lump or any change in the breast is noticed between routine examinations, a breast specialist should be consulted without delay.

ROUTINE BREAST CHECK-UPS

Between the ages of 25 and 40, women should undergo a breast examination by a breast specialist every 1–3 years, receive information about breast health, and undergo breast imaging when clinically indicated.
Women over the age of 40 should have an annual examination by a breast specialist, receive appropriate counseling, and undergo screening mammography.
Breast screening should preferably be performed using mammography systems equipped with tomosynthesis.
If the breast tissue is very dense or heterogeneous, more advanced breast imaging techniques, such as contrast-enhanced mammography and contrast-enhanced breast MRI, may be considered.
If a woman has a first-degree relative diagnosed with breast cancer—for example, a twin sister, sister, or mother—breast examinations and screening should generally begin 10 years before the age at which the relative was diagnosed, according to the individual’s risk assessment.

BENIGN BREAST DISEASES

Benign breast diseases are particularly common among young women who are still menstruating. Their importance lies in ensuring that an underlying breast cancer is not overlooked. Therefore, benign breast conditions should be evaluated carefully and appropriately.

BREAST PAIN (MASTODYNIA)

Breast pain is one of the most common breast symptoms. Approximately 70% of women in Western societies experience breast pain at some point. Breast pain can be classified into three categories.

Cyclic Breast Pain

This type accounts for a significant proportion of true breast pain. It is caused by hormonal fluctuations during the menstrual cycle.
It usually occurs during the week preceding menstruation. It is frequently experienced in both breasts and is often more pronounced in the upper outer quadrants, close to the armpit. It is generally a completely natural physiological process.

Non-Cyclic Breast Pain

Non-cyclic breast pain accounts for approximately one-third of cases of true breast pain.
Possible causes include large or sagging breasts, dietary and lifestyle factors, hormone replacement therapy, breast cysts, dilated milk ducts, mastitis, inflammatory diseases, inflammatory breast cancer, pregnancy, thrombophlebitis (Mondor’s disease), trauma, previous breast surgery, and certain medications such as antidepressants, cardiovascular medications, and antibiotics.
Treatment should be directed toward the underlying cause.

Pain Originating Outside the Breast

Pain originating from the chest wall may be mistaken for breast pain. Possible causes include pectoralis muscle strain or injury associated with physical activity, rib-related pain, spinal or nerve compression, trauma, and previous thoracic surgery, among other conditions.

BREAST CYSTS

Breast cysts are fluid-filled formations that develop within the glandular structures of the breast. They may be found in approximately one out of every three women presenting for breast evaluation.
They are most commonly seen in women between the ages of 35 and 50. Simple breast cysts do not increase the risk of breast cancer and generally do not require treatment.

FIBROADENOMAS

Fibroadenomas are the most common benign solid breast tumors. Although their exact cause is unknown, they are thought to be influenced by hormonal changes during the reproductive years.
They are most commonly seen between the ages of 15 and 35. Simple fibroadenomas can usually be followed clinically and radiologically. If they increase in size or demonstrate suspicious structural characteristics, biopsy may be required. When indicated, the fibroadenoma can be completely surgically removed.

NIPPLE DISCHARGE

Physiological milk discharge from the breast occurs during the postpartum breastfeeding period.
Occasionally, milk may be produced outside the breastfeeding period due to excessive secretion of the hormone prolactin, which is produced by the pituitary gland. This condition is called galactorrhea. Galactorrhea does not itself increase the risk of breast cancer. It can often be controlled by treating the underlying cause and, when appropriate, suppressing prolactin secretion with medication.
Nipple discharge other than milk may also occur. Dilated milk ducts can cause nipple discharge. Such discharge usually occurs when the nipple is squeezed and may be yellowish or greenish in color. These types of discharge are generally not associated with malignancy.
However, if nipple discharge occurs spontaneously, without stimulation, from a single breast, and is bloody, it must be investigated.
The most common cause of bloody nipple discharge is an intraductal papilloma, a benign growth arising within the major milk ducts. These lesions generally do not carry a significant risk of cancer. However, they may be surgically removed together with the affected duct to eliminate the discharge and exclude the possibility of an underlying breast cancer.
Bloody nipple discharge can occasionally be a sign of breast cancer. Therefore, the breast should be carefully evaluated to determine whether a suspicious lesion is present.

BREAST INFECTIONS

As with other parts of the body, infections can occur in breast tissue. If these infections progress to form a breast abscess, urgent surgical drainage or aspiration may be required.

Lactational Mastitis

Lactational mastitis is a breast infection that occurs during breastfeeding. It is most commonly seen during the 4th to 6th weeks of lactation.
The process usually begins with obstruction of the milk ducts and subsequent inflammation. If the baby does not adequately empty the breast, accumulated milk can provide a favorable environment for bacterial growth, potentially leading to infection and eventually an abscess.
Proper nipple hygiene, appropriate warm or cold applications, and emptying the breast with a breast pump may help relieve the infection. However, if the infection does not improve, the patient should be evaluated by a breast specialist. If necessary, antibiotics and anti-inflammatory medications that are compatible with breastfeeding may be prescribed.
If an abscess develops despite these measures, surgical drainage or aspiration may be required.
In cases that do not respond to treatment, breast imaging should be performed to ensure that an underlying breast cancer has not been overlooked.

Infections of the Breast Tissue and Skin

Infections can also develop in breast tissue and breast skin outside the breastfeeding period, particularly in women with reduced immunity, after breast trauma, or following a surgical procedure.
Treatment is similar to that of other infections. If an abscess develops, surgical intervention may be necessary. An underlying breast cancer should always be excluded when clinically appropriate.

Idiopathic Granulomatous Mastitis

The cause of idiopathic granulomatous mastitis is unknown, and it is thought to be an autoimmune condition. It usually occurs in young women who have previously given birth.
The differential diagnosis should include tuberculous mastitis and breast cancer.
Treatment is primarily systemic. If a bacterial infection is present, appropriate antibiotic therapy is administered. If an abscess develops, surgical intervention may be required.
Systemic treatment may include corticosteroids and low-dose methotrexate. In patients with limited disease that is resistant to medical treatment, surgical excision of the affected area may be considered.

BREAST CANCER

Breast cancer is the most commonly diagnosed cancer in women. Approximately one in every seven to eight women develops breast cancer at some point in her lifetime.
Breast cancer occurs when cells in the breast tissue multiply excessively and uncontrollably. Most breast cancers originate from the cells lining the milk ducts and are known as invasive ductal carcinoma. Some breast cancers arise from the lobules and are known as invasive lobular carcinoma.
A less common type is inflammatory breast cancer, which may present with swelling, redness, and increased warmth of the breast, resembling an inflammatory process.
Thanks to early diagnosis and advances in treatment, highly successful outcomes can be achieved in the fight against breast cancer.
For patients with a long life expectancy, treatment aims not only to control the disease but also to preserve quality of life, body integrity, and satisfactory aesthetic outcomes.

SIGNS AND SYMPTOMS OF BREAST CANCER

• A lump or swelling in the breast
• A lump or swelling in the armpit
• Changes in breast size or shape
• Changes in the breast skin, including redness, thickening, or an orange-peel appearance (peau d’orange)
• Skin dimpling or retraction
• Nipple discharge, particularly unilateral, spontaneous, or bloody discharge
• Scaling or flaking of the nipple or areola
• Changes in the nipple, including inversion, retraction, or deviation
• An open sore or ulcer on the breast or nipple

RISK FACTORS FOR BREAST CANCER

• Age: The risk of breast cancer increases with age. Most breast cancers are diagnosed after the age of 50.
• Inherited genetic mutations: Specific genetic mutations can increase the risk of breast cancer, particularly BRCA1 and BRCA2. Other genes and syndromes associated with increased risk include PALB2, CHEK2, ATM, Li-Fraumeni syndrome, and PTEN.
• Family history: Having a mother, father, sibling, or child with breast cancer increases the risk.
• Early menstruation: Women who begin menstruating before the age of 12 may have a higher risk of breast cancer.
• Pregnancy history: Women who have never had a full-term pregnancy or who have their first full-term pregnancy after the age of 30 may have an increased risk.
• Previous breast cancer: Women who have previously had breast cancer have an increased risk of developing another breast cancer.
• Previous radiation therapy: Women who received radiation therapy to the chest during childhood or early adulthood for treatment of another cancer have an increased risk of breast cancer. However, in the circumstances in which it is medically indicated, the benefits of radiation treatment outweigh its potential long-term risks.
• Obesity: Particularly after menopause, obesity may increase the risk of breast cancer.
• Dense breast tissue: Women with dense breasts, containing a greater proportion of glandular tissue, have an increased risk of breast cancer.
• Postmenopausal hormone therapy: Some women use estrogen and progesterone-containing hormone therapy to relieve menopausal symptoms. Certain hormone therapy regimens may increase breast cancer risk.
• Alcohol consumption: Frequent and high levels of alcohol consumption are associated with a greater increase in breast cancer risk.

DIAGNOSIS OF BREAST CANCER

Breast Screening

Breast screening consists of examinations performed to detect breast cancer at a very early stage, before symptoms develop. The goal is to identify the disease early enough that it can be effectively treated and potentially cured.

Breast Imaging Methods

• Breast ultrasonography (US)
• Digital mammography with tomosynthesis
• Contrast-enhanced mammography
• Contrast-enhanced dynamic breast MRI with diffusion-weighted imaging

Biopsy

• Core needle biopsy: The most commonly used biopsy technique today
• Fine-needle aspiration biopsy: Particularly useful for evaluating suspicious lymph nodes
• Stereotactic vacuum-assisted breast biopsy: An advanced biopsy technique used particularly for the diagnosis of suspicious, non-palpable microcalcifications

STAGING OF A PATIENT DIAGNOSED WITH BREAST CANCER

Patients diagnosed with breast cancer may undergo systemic staging to evaluate for distant organ metastases. Depending on the estimated risk of metastatic disease, staging methods may include:

• Abdominal ultrasonography and chest X-ray
• Chest and abdominal CT
• Bone scintigraphy
• PET/CT

GENETIC COUNSELING

Today, genetic counseling should be considered for patients diagnosed with breast cancer according to their individual and family risk factors. Medical geneticists evaluate patients and determine whether genetic testing is appropriate.
Genetic testing may be recommended in the following situations:

• Breast cancer diagnosed before the age of 65
• At any age:
  • Triple-negative breast cancer
• Multiple primary breast cancers
• When genetic results will influence treatment decisions, such as the use of PARP inhibitors in metastatic HER2-negative breast cancer or adjuvant olaparib in patients at high risk
• Male breast cancer
• A family history of any of the following:
  • Breast cancer in a first-degree relative, such as a mother or sister
  • Breast cancer diagnosed before the age of 50
  • Male breast cancer
  • Ovarian cancer
  • Pancreatic cancer
  • Metastatic prostate cancer
  • Three or more breast and/or prostate cancer diagnoses on the same side of the family

GENES ASSOCIATED WITH HEREDITARY BREAST CANCER RISK

• BRCA1 and BRCA2
• PALB2
• ATM — Ataxia-telangiectasia
• CHEK2
• TP53 — Li-Fraumeni syndrome
• PTEN — Cowden syndrome
• STK11 — Peutz-Jeghers syndrome

BREAST CANCER TREATMENT

Individualized Treatment

The treatment of breast cancer is determined according to the individual characteristics of each patient.
These factors include:

• Patient’s age
• Tumor type
• Biological characteristics of the tumor
• Stage of the disease
• Genetic predisposition
• Family planning, including future pregnancy and breastfeeding
• Patient preferences

Multidisciplinary Approach

The Multidisciplinary Breast Cancer Board includes a breast surgeon (general surgeon), radiologist, pathologist, medical oncologist, radiation oncologist, nuclear medicine specialist, plastic surgeon, medical geneticist, and gynecologic oncologist.
Supporting specialties include psychiatry, physical medicine and rehabilitation, and dietetics.
By placing the patient at the center of care, this multidisciplinary team jointly determines the most appropriate individualized treatment strategy for each patient.

SURGICAL TREATMENT OF BREAST CANCER

Today, breast surgery is one of the most important and effective components of breast cancer treatment. Breast surgery can broadly be divided into two main categories: surgery of the breast itself and surgery of the axilla (armpit).

Breast Surgery

1. Breast-Conserving Surgery

Breast-conserving surgery involves removing only the area containing the tumor with adequate and safe surgical margins, without removing the entire breast.

2. Oncoplastic Breast Surgery

Oncoplastic breast surgery involves removing the breast tumor according to oncological principles while achieving clear and safe surgical margins, followed by reshaping the resulting defect using plastic surgical techniques.
The goal is to achieve a good cosmetic result while improving quality of life.
With oncoplastic techniques, even larger tumors and multifocal tumors can sometimes be removed while maintaining satisfactory aesthetic outcomes.

3. Mastectomy

If the disease is too extensive to allow breast conservation, if breast-conserving surgery would result in an unacceptable cosmetic outcome, or in certain special types of breast cancer such as inflammatory breast cancer, complete removal of the breast may be necessary.
Removal of the breast tissue together with the nipple and overlying skin is referred to as a mastectomy.

4. Immediate Reconstruction with Plastic and Reconstructive Surgery

When breast conservation is not possible, reconstruction may be performed simultaneously with mastectomy by a plastic and reconstructive surgeon.
Nipple-Sparing Mastectomy + Immediate Reconstruction
Reconstruction may be performed using:

• Autologous tissue: Reconstruction using the patient’s own muscle and subcutaneous tissue.
• Implant-based reconstruction: Reconstruction using silicone implants selected according to the patient’s body structure and breast volume.

Skin-Sparing Mastectomy
In this procedure, the nipple is removed while most of the breast skin is preserved. It may be preferred particularly in patients in whom the nipple is involved by breast cancer.
Immediate reconstruction can be performed during the same operation.
The nipple can subsequently be reconstructed using plastic surgical techniques after completion of the patient’s cancer treatment.
Reconstruction may be performed using:

• Autologous tissue
• Silicone implants

TWO-STAGE RECONSTRUCTION WITH PLASTIC AND RECONSTRUCTIVE SURGERY

Depending on the patient’s individual characteristics and the extent of the breast cancer, some patients undergoing mastectomy may not be suitable for immediate reconstruction.
In such cases, a two-stage reconstruction may be preferred.
After mastectomy, a temporary tissue expander is placed. The expander is gradually filled with saline to create sufficient breast volume. In a second operation, the expander can be removed and replaced with a silicone implant.

AXILLARY SURGERY

One of the most important components of breast cancer surgery is surgery of the axilla (armpit).
Axillary surgery provides information about whether the breast tumor has spread to the axillary lymph nodes and helps determine the stage of the disease and subsequent treatment.

Axillary Lymph Node Dissection

Axillary lymph node dissection involves removal of lymph nodes at levels I and II of the axilla.
In the past, axillary lymph node dissection was routinely performed. However, it can cause postoperative complications such as sensory loss, numbness, restricted arm movement, infection, and, most importantly, lymphedema.
Lymphedema can have a significant negative impact on quality of life.
Today, axillary lymph node dissection is generally reserved for selected clinical situations, such as patients with a high burden of nodal disease or patients who do not respond adequately to neoadjuvant chemotherapy.

SENTINEL LYMPH NODE BIOPSY

The lymph nodes to which a breast tumor is most likely to spread first are called the sentinel lymph nodes.
Identifying and removing these lymph nodes during surgery is known as sentinel lymph node biopsy or excision.
If the breast tumor has not spread to the sentinel lymph nodes, the likelihood of involvement of the remaining axillary lymph nodes is low. Therefore, it is not necessary to remove all of the axillary lymph nodes in such cases.

How Is Sentinel Lymph Node Biopsy Performed?

A dual technique is generally preferred for the most accurate identification of sentinel lymph nodes.
Before surgery, a radiocolloid tracer is injected around the nipple, followed by lymphoscintigraphy to identify the sentinel lymph nodes in the axilla.
During surgery, a device called a gamma probe is used to locate the sentinel lymph nodes.
Another method involves injecting isosulfan blue dye beneath the nipple at the beginning of surgery. During the operation, sentinel lymph nodes stained blue by the dye are identified and removed.
The sentinel lymph nodes can be identified most successfully when these two techniques are used together.

Does Every Patient with Sentinel Lymph Node Involvement Require Axillary Dissection?

If there is no sentinel lymph node involvement, or if there are only isolated tumor cells or micrometastases (less than 2 mm), or if only one or two lymph nodes are involved in appropriately selected patients, further axillary surgery may not be necessary.

RISK-REDUCING BREAST SURGERY

Risk-reducing mastectomy may be recommended for women who carry genetic mutations associated with a high risk of breast cancer.
Risk-reducing surgery may be considered for women carrying pathogenic mutations in high-penetrance genes such as BRCA1 and BRCA2, as well as for selected women with a very strong family history.
Risk-reducing mastectomy and immediate breast reconstruction can be performed by breast surgeons together with plastic and reconstructive surgeons.

SYSTEMIC THERAPIES

Systemic therapies are medical treatments administered by medical oncologists to patients with breast cancer. These treatments have significantly improved survival and have also enabled more limited breast surgery in appropriately selected patients.
Systemic treatments include:

• Chemotherapy
• Hormone therapy
• Targeted therapy
• Immunotherapy

Neoadjuvant Systemic Therapy

Neoadjuvant systemic therapy refers to systemic treatment, such as chemotherapy and targeted therapy, administered before surgery.
The objectives include:

• Shrinking locally advanced disease
• Increasing the possibility of breast-conserving surgery
• Achieving a pathological complete response in selected patients with early-stage breast cancer
• Continuing appropriate systemic treatment after surgery if a pathological complete response is not achieved
• Assessing the tumor’s response to treatment
• Allowing time for genetic testing and treatment planning

Adjuvant Systemic Therapy

Adjuvant systemic therapy is administered after breast surgery.
The aim is to control residual microscopic disease and reduce the risk of distant metastases and local recurrence.
After the appropriate treatment options have been determined for the individual patient, adjuvant chemotherapy, hormone therapy, targeted therapy, immunotherapy, or combinations of these treatments may be administered.

RADIOTHERAPY

Radiotherapy is administered by radiation oncologists to improve local disease control and reduce the risk of recurrence.
Advances in radiotherapy have contributed to more limited breast surgery and significantly reduced local recurrence in appropriately selected patients.
With specialized techniques, radiotherapy may also be used with curative intent in selected patients with metastatic disease.

FOLLOW-UP OF BREAST CANCER PATIENTS

After treatment, breast cancer patients are followed by medical oncologists and breast surgeons at intervals determined according to their individual clinical circumstances.
Throughout follow-up, patients are supported by a multidisciplinary team including specialists in radiology, pathology, medical oncology, radiation oncology, nuclear medicine, plastic and reconstructive surgery, gynecologic oncology, medical genetics, physical medicine and rehabilitation, psychiatry, and dietetics.

EARLY DETECTION SAVES LIVES. DO NOT NEGLECT YOUR BREAST HEALTH.