CHAPTER 24- BREAST.txt

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CHAPTER 24- BREAST.txt
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  1. Breast Development
    • 1) breast formed from ectoderm milk streak
    • 2) estrogen- duct development (double layer of columnar cells)
    • 3) progesterone- lobular development
    • 4) prolactin- synergizes estrogen and progesterone
  2. Cyclic changes
    • 1) Estrogen- increases breast swelling, growth of glandular tissue
    • 2) Progesterone- increases maturation of glandular tissue; withdrawal causes menses
    • 3) FSH/LH surge- causes ovum release
    • 4) After menopause, lack of estrogen and progesterone results in atrophy of breast tissue
  3. Long thoracic nerve
    • 1) innervates serratus anterior
    • 2) injury results in winged scapula
    • 3) lateral thoracic artery to serratus anterior
  4. Thoracodorsal nerve
    • 1) innervates the latissimus dorsi
    • 2) injury results in weak arm pullups and adduction
  5. Medial pectoral nerve
    innervates petoralis major and pectoralis minor
  6. lateral pectoral nerve
    pectoralis major only
  7. intercostobrachial nerve
    • 1) lateral cutaneous branch of the 2nd intercostal nerve
    • 2) provides sensation to medial arm and axilla
    • 3) encountered just below the axillary vein when performing axillary dissection
    • 4) can transect without serious consequences
  8. Whats the blood supply to the breast:
    • Branches of the:
    • 1) internal thoracic artery
    • 2) intercostal arteries
    • 3) thoracoacromial artery
    • 4) lateral thoracic artery
  9. Batson's plexus
    valveless vein plexus that allows direct hematogenous metastasis of breast Ca to spine
  10. Lymphatic drainage
    • 1) 97% is to the axillary nodes
    • 2) 1-2% is to the internal mammary nodes
    • 3) any quadrant can drain to the internal mammary nodes
    • 4) supraclavicular nodes- considered M1 disease
  11. Whats the most likely cause of primary axillary adenopathy:
    #1 lymphoma
  12. Cooper's ligaments
    • 1) suspensory ligaments
    • 2) divide breast into segments
    • 3) breast cancer involving these strands can dimple
  13. Abscesses
    • 1) usually assocaited with breast-feeding
    • 2) Staph aureus most common, strep
    • 3) Tx:
    • 1- incision and drainage
    • 2- discontinue breast feeding
    • 3- antibiotics
    • 4- ice, heat, breast pump
  14. Infectious mastitis
    • 1) most commonly associated with breast feeding
    • 2) S. aureus most common
    • 3) in nonlactating women can be due to chronic inflammatory diseases (actinomyces, tuberculosis, syphilis) or autoimmune disease (SLE)
    • 4) may need to rule out necrotic cancer- need incisional biopsy including the skin
  15. Periductal mastitis
    • 1) mammary duct ectasia or plasma cell mastitis
    • 2) dilated mammary ducts, inspissated secretions, marked periductal inflammation
    • 3) Symptoms:
    • 1- noncyclical mastodynia
    • 2- nipple retraction
    • 3- creamy discharge from nipple
    • 4- can have sterile subareolar abscess
    • 5- patients have a history of difficulty breastfeeding
    • 6- Tx:
    • 1) if typical creamy discharge is present that is not bloody and not associated with nipple retraction, may be able to reassure; otherwise need to rule out malignancy
  16. galactocele
    • 1) breast cysts filled with milk; occurs with breast-feeding
    • 2) Tx: ranges from aspiration to incision/drainage
  17. galactorrhea
    • Can be caused by:
    • 1- increased prolactin (pituitary adenoma)
    • 2- OCPs
    • 3- TCAs
    • 4- phenothiazines
    • 5- metoclopramide
    • 6- alpha-methyl dopa
    • 7- reserpine
    • 2) is often associated with ammenhorrea
  18. gynecomastia
    • 1) 2cm pinch
    • 2) Can be associated with:
    • 1- cimetidine
    • 2- spironolactone
    • 3- marijuana
    • 3) idiopathic in most
    • 4) Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems
  19. neonatal breast enlargement
    due to circulating maternal estrogens; will regress
  20. accessory breast tissue/ accessory nipples
    • (polythelia)
    • 1- can present in axilla (most common location)

    accessory nipples can be found from axilla to groin (most common breast anomaly)
  21. Breast reduction
    ability to lactate frequently compromised
  22. Breast asymmetry
    common
  23. Poland's syndrome
    • 1) hypoplasia of chest wall
    • 2) amastia
    • 3) hypoplastic shoulder
    • 4) no pectoralis muscle
  24. Mastodynia
    • 1) pain in breast
    • 2) rarely represents breast Ca
    • 3) H+P and get bilateral mammogram
    • 4) Tx:
    • 1- danazol
    • 2- OCPs
    • 3- NSAIDs
    • 4- evening primrose oil
    • 5- bromocriptine
    • 5) discontinue caffeine, nicotine, methylxanthines
  25. Cyclic mastodynia
    pain before menstrual period; most commonly from fibrocystic disease
  26. Continuous mastodynia
    • 1) continuous pain; most commonly represents acute or subacute infection
    • 2) continuous mastodynia more refractory to treatment than cyclic mastodynia
  27. Mondor's disease
    • 1) superficial vein thrombophlebitis of breast
    • 2) feels cordlike
    • 3) can be painful
    • 4) Associated with: trauma and strenuous exercise
    • 5) usually occurs in lower outer quadrant
    • 6) Tx: NSAIDs
  28. Fibrocystic disease
    • 1) Catchall phrase; lots of types: papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, and lobular hyperplasia
    • 2) Symptoms:
    • 1- breast pain
    • 2- nipple discharge (uncommon, can be yellow/brown)
    • 3- masses
    • 4- lumpy breast tissue that varies with hormonal cycle
    • 3) Only cancer risk is in atypical ductal or lobular hyperplasia (an unusual finding)
    • 1- do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e. calcifications) that appear on mammogram
  29. Sclerosing adenosis
    • 1) can manifest as a cluster of calcification on mammogram without a mass or pain--> can look like breast Ca
    • 2) is differentiated from breast Ca by regularity of nuclei and abscence of mitosis
  30. Risk factors for benign breast disease:
    • 1) early menarche
    • 2) late menopause
    • 3) small breast size
    • 4) normal or low body weight
    • 5) history of cyclic breast discomfort
    • 6) irregular menses
    • 7) history of spontaneous abortions
    • 8) premenopausal status
  31. Intraductal papilloma
    • 1) most common cause of bloody discharge from nipple
    • 2) are usually small, nonpalpable and close to the nipple
    • 3) these lesions are not premalignant --> can get contrast ductogram to find papilloma
    • 4) Tx: resection (subareloar resection usually curative)
  32. Fibroadenoma
    • 1) most common breast lesion in adolescents and young women
    • 2)10% multiple
    • 3) usually painless, slow growing, well circumscribed, firm, and rubbery
    • 4) often grows to several cm in size and then stops
    • 5) can change in size with menstrual cycle and can enlarge in pregnancy
    • 6) giant fibromas can be >5cm (treatment is the same)
    • 7) prominent fibrous tissue compressing epithelial cells on pathology
    • 8) can have large, coarse calcifications (popcorn lesions) on mammography from degeneration
  33. Fibroadenoma: in patients <30 years:
    • 1) mass needs to feel clinically benign (firm, rubbery, rolls, not fixed)
    • 2) ultrasound or mammogram needs to be consistent with fibroadenoma
    • 3) need fine-needle aspiration (FNA) or core needle biopsy showing the lesion (not just normal breast tissue
  34. Fibroadenoma: in patients >30 years:
    • 1) excisional biopsy to ensure diagnosis
    • 2) avoid resection of breast tissue in teenagers and younger children--> can affect breast development
  35. See pg 149 chart:
    Diagnosis and management of cystic lesions. Bloody fluid on aspiration, failure of the mass to resolve completely, and prompt refilling of the same cyst are indications for surgical biopsy
  36. Classifications of benign breast disease
    • Nonproliferative: no increase in risk
    • 1) cysts: micro or macro
    • 2) ductal ectasia
    • 3) simple fibroadenoma
    • 4) mastitis
    • 5) fibrosis
    • 6) metaplasia: squamous or apocrine
    • 7) mild hyperplasia

    • Proliferative: RR 1.5-2.0
    • 1- complex fibroadenoma
    • 2- papilloma
    • 3- sclerosing adenosis
    • 4- hyperplasia: moderate/severe

    • Proliferative w/atypia RR 4.5-5.0
    • 1- atypical ductal hyperplasia
    • 2- atypical lobular hyperplasia
  37. Nipple discharge
    • 1) most nipple discharge is benign
    • 2) all of these patients need H+P and bilateral mammogram
    • 3) try to find the trigger point or mass on exam
  38. Green discharge
    • 1) usually fibrocystic disease
    • 2) Tx: if cyclical and nonspontaneous, reassure patient
  39. Bloody discharge
    • 1) most commonly intraductal papilloma
    • 2) occasionally ductal Ca
    • 3) Tx: need galactogram and excision of that ductal area
  40. Serous discharge
    • 1) worrisome for cancer, especially if coming from only 1 duct or spontaneous
    • 2) Tx: excisional biopsy of that ductal area
  41. Spontaneous discharge
    • 1)no matter what the color or consistency is worrisome for cancer
    • 2) all these patients need some sort of biopsy in the area of the duct causing the discharge
  42. Nonspontaneous discharge
    • 1- (occurs only with pressure, tight garments, exercise, etc)
    • 2- not as worrisome but may still need excisional biopsy (i.e. bloody)
  43. What do you do if the area with discharge cannot be properly identified (i.e. no trigger point/mass felt)
    may have to do a complete subareolar resection
  44. Diffuse papillomatosis
    • 1) affects multiple ducts of both breasts
    • 2) papillomas are larger than when they occur solitarily
    • 3) usually have serous discharge
    • 4) mammogram shows swiss cheese appearance
    • 5) increased risk of breast Ca with diffuse papillomatosis (40% get breast Ca)
  45. Ductal carcinoma in situ
    • 1) malignant cells of the ductal epithelium without invasion of the basement membrane
    • 2) 50-60% get cancer if not resected (ipsilateral breast); 5-10% get cancer in contralateral breast
    • 3) considered a premalignant lesion
    • 4) usually not palpable and presents as a cluster of calcifications on mammography
    • 5) need a 2-3mm margin with excision
    • 6) can have solid, cribriform, papillary, and comedo patterns
    • 1- comedo pattern- most aggressive subtype; has necrotic areas
    • 2- high risk for multicentricity, microinvasion, recurrence
    • 3- Tx: simple mastectomy
    • 7) increased recurrence risk with comedo type and lesions >2.5 cm
    • 8) Tx:
    • 1- lumpectomy and XRT; possibly tamoxifen
    • 2- Simple mastectomy if:
    • 1- high grade (i.e. comedo type, multicentric, multifocal)
    • 2- if a large tumor not amenable to lumpectomy
    • 3- if not able to get good margins
    • 4- no ALND
    • 5) DCIS with a small focus (<10%) of microinvasive disease can be treated with lumpectomy and XRT or simple mastectomy; need negative margins, no ALND
  46. Lobar carcinoma in situ
    • 1) 40% get cancer (either breast)
    • 2) considered a marker for the development of breast Ca
    • 3) not premalignant itself
    • 4) has no calcifications; is not palpable
    • 5) primarily found in premenopausal women
    • 6) patients who develop breat Ca are more likely to develop a ductal Ca (70%)
    • 7) usually an incidental finding; multifocal disease is common
    • 8) 5% risk of having a synchronous breast Ca at the time of diagnosis of lobular carcinoma in situ (LCIS; most likely ductal)
    • 9) Do not need negative margins
    • 10) Tx:
    • 1- nothing
    • 2- tamoxifen
    • or
    • 3- bilateral subcutaneous mastectomy
    • 4) No ALND

  47. Breast Cancer
    • 1) breast Ca decreased in economically poor areas
    • 2) Japan has lowest rate of breast Ca worldwide
    • 3) breast Ca risk ~1 in 8 women (12%); 4-5% in women with no risk factors
    • 4) screening decreases mortality by 25%
    • 5) untreated breast Ca- median survival 2-3 years
    • 6) 10% of breast Cas have negative mammogram and negative ultrasound
  48. Clinical features of breast Ca:
    • 1) distortion of normal architecture
    • 2) skin/nipple distortion or retraction
    • 3) hard, tethered, indistinct borders
  49. Symptomatic breast Ca workup:
    • <30 years old
    • 1- ultrasound
    • 2- if solid --> FNA
    • 3- excisional biopsy if FNA is nondiagnostic
    • 4- these patients most commonly have fibroadenomas that can be left alone if FNA is diagnostic. However, if the fibroadenoma enlarges, need excisional biopsy

    • 30-50 years
    • 1- bilateral mammograms and FNA
    • 2- excisional biopsy is FNA is nondiagnostic

    • >50 years
    • 1- bilateral mammograms and excisional or core needle biopsy
  50. What does core needle biopsy give you?
    gives architecture
  51. FNA:
    gives cytology (just the cells)
  52. Cyst fluid:
    • 1) if bloody- need cyst excisional biopsy
    • 2) if clear and recurs- need cyst excisional biopsy
    • 3) if complex cyst- need cyst excisional biopsy
  53. See table on pg 151:
    1- Diagnosis and managment of the patient with a clinically indeterminate or suspect solid breast mass.
  54. Management of breast masses based on FNA diagnosis:
    • Malignant- definitive therapy
    • Suspicious- surgical biopsy
    • Atypia- surgical biopsy
    • Benign- possible observation*
    • Nondiagnostic- repeated FNA or surgical biopsy
  55. Mammography
    • 1) has 90% sensitivity/specificity
    • 2) sensitivity increases with age as the dense parenchymal tissue is relaced with fat
    • 3) mass needs to be >5mm to be detected
    • 4) irregular borders; spiculated; multiple clustered, small, thin, linear, and/or branching calcifications; can have crushed appearance; asymmetric density, ductal asymmetry, distortion of architecture
    • 5) 5% of cancers have sharp margin
    • 6) suspicious lesion on mammogram--> needle localization and excisional biopsy (core needle biopsy also an option)
  56. Screening
    • 1) mammogram every 2-3 years after age 40, yearly after 50
    • 2) High risk screening:
    • 1- mammogram 10 years before the youngest age of diagnosis of breast Ca in first-degree relative
    • 3) No mammography in patients <30 unless high risk--> hard to interpret because of dense parenchyma
    • 1- decreased radiation dose in young patients
    • 4) suspicious calcifications or architecture on mammography--> perform localized stereotactic needle excisional biopsy
    • 5) indeterminate calcifications or architecture on mammography--> can perform core needle biopsy; if indeterminate, perform localized stereotactic needle excisional biopsy
  57. BI-RADS Classificaiton of Mammographic Abnormalities (BI-RADS stands for: breast imaging, reporting, and data system)
    • Category 1
    • Assessment: negative
    • Recommendation: routine screening

    • Category: 2
    • Assessment: benign finding
    • Reccomendation: routine screening

    • Category: 3
    • Assessment: probable benign finding
    • Reccomendation: short-interval follow-up


    • Category 4:
    • Assessment:suspicious abnormality
    • Reccomendation: definite probability of malignancy; consider biopsy

    • Category: 5
    • Assessment: highly suggestive of malignancy
    • Reccomendation:high probability of cancer; appropriate action should be taken
  58. Node levels
    • I- lateral to pectoralis minor muscle
    • II- beneath pectoralis minor muscle
    • III- medial to pectoralis minor muscle
    • Rotter's nodes- between pectoralis major and pectoralis minor muscles

    The axillary lymph nodes are devided into three levels by the pectoralis minor muscle. The level I nodes are inferior and lateral to the pec minor, the level II nodes are below the axillary vein and behind the pectoralis minor, and the level III nodes are medial to the muscle against the chest wall
  59. Which nodes do you need to sample?
    need to sample only level I nodes
  60. What is the most important prognostic staging factor? What are other factors?
    • 1) Nodes are the most important prognostic staging factor.
    • 2) Other factors include:
    • 1- tumor size
    • 2- tumor grade
    • 3- progesterone and estrogen receptor status

    • 3) survival is directly related to the number of positive nodes.
    • 4) large tumors are more likely to have positive nodes
    • 5) 30% of nonpalpable nodes are positive at surgery
    • 6)
    • 0 nodes positive- 75% 5-year survival
    • 1-3 nodes positive- 60% 5-year survival
    • 4-10 nodes positive- 40% 5-year survival
  61. What is the most common site for distant mets? What are other site?
    • 1) Bone- most common distant metastasis
    • 2) can also go to lung, liver, brain
  62. How long long does it take to go from single malignant cell to 1cm tumor?
    approx 5-7 years
  63. Which tumors have increased risk of multicentricity
    central and subareolar tumors have increased risk of multicentricity
  64. TNM staging system for breast Ca:
    • T1: <2cm
    • T2: 2-5cm
    • T3: >5cm
    • T4: skin or chest wall involvement (does not include pectoral muscles), peau d'orange, inflammatory cancer

    • N1: ipsilateral axillary nodes
    • N2: fixed ipsilateral axillary nodes
    • N3: ipsilateral internal mammary nodes

    M1: distant metastasis (includes ipsilateral supraclavicular nodes)
  65. Stage/ TNM status
    • I- T1, N0, M0
    • IIa- T0-1,N1,M0 or T2,N0,M0
    • IIb- T2, N1,M0 or T3,M0,M0
    • IIIa- T0-3, N2, M0 or T3,N1-2,M0
    • IIIb- any T4 or N3 tumors
    • IV- M1
  66. Breast cancer risk
    • Greatly increased risk:
    • 1) BRCA gene in patient with family history of breast Ca
    • 2) >2 primary relatives with bilateral or premenopausal breast Ca
    • 3) DCIS (ipsilateral breast at risk) and LCIS (both breasts have same high risk)
    • 4) Fibrocystic disease with atypical hyperplasia

    • Moderately increased risk:
    • 1) family history of breast cancer other than above
    • 2) early menarch (<12 years), late menopause (>55 years)
    • 3) nulliparity or first birth after age 30
    • 4) radiation
    • 5) previous breast Ca
    • 6) environmental risk factor- high-fat diet (obesity)
  67. Magnitude of known breast cancer risk factors:
    • Relative risk <2
    • 1- early menarch
    • 2- late menopause
    • 3- nulliparity
    • 4- proliferative benign disease
    • 5- obesity
    • 6- alcohol use
    • 7- hormone replacement therapy

    • Relative risk 2-4
    • 1- age >35 first birth
    • 2- first degree relative with breast Ca
    • 3- radiation exposure
    • 4- prior breast Ca

    • Relative Risk >4
    • 1- gene mutation
    • 2- LCIS
    • 3- atypical hyperplasia
  68. How much does breast Ca risk increase is someone has a 1st degree relative with bilateral, premenopausal breast Ca:
    increases breast Ca risk by 50%
  69. BRCA I is associated with:
    • 1) ovarian (50%)
    • 2) endometrial Ca
    • 3) consider TAH and bilateral oophorectomies in BRCA I families
  70. BRCA II is associated with:
    male breast Ca
  71. Considerations for prophylactic mastectomy:
    • 1) family Hx and BRCA gene
    • 2) LCIS
    • 3) also need one of the following:
    • 1- high patient anxiety
    • 2- poor patient access for follow-up exams and mammograms
    • 3- difficult lesion to follow on exam or with mammograms
    • 4- patient preference for mastectomy
  72. Receptors:
    • 1) positive receptors-
    • 1- better response to hormones, chemotherapy, surgery, and better overall prognosis
    • 2- receptor-positive tumors are more common in postmenopausal women

    • 2) Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors
    • 3) tumor that is both progesterone receptor and estrogen receptor-positive has best prognosis
    • 4) 10% of breast Cas negative for both receptors
  73. Male breast Ca
    • 1) <1% of all breast Cas; usually ductal
    • 2) poorer prognosis because of late presentation
    • 3)- have increased pectoral muscle involvement
    • 4)- Associated with:
    • 1- steroid use
    • 2- previous XRT
    • 3- family history
    • 4- klinefelter's syndrome
    • 5- prolonged hyperestrogenic state
    • 5) Tx: modified radical mastectomy (MRM)
  74. Ductal Ca:
    1) 85% of all breast Cas; can have various subtypes:

    • Medullary breast Ca:
    • 1- smooth borders
    • 2- increased lymphoctes
    • 3- ductal type cancer with bizarre cells
    • 4- vast majority are estrogen and progesterone receptor positive
    • 5- more favorible prognosis

    • Tubular Ca-
    • 1- small tubule formations
    • 2- nodes positive in 10%
    • 3- more favorible prognosis

    • Mucinous Ca (colloid)
    • 1- produces an abundance of mucin
    • 2- more favorible prognosis

    • Scirrhotic Ca
    • 1) worst prognosis

    • Treatment:
    • MRM or lumpectomy w/ALND (or SLNB); postop XRT
  75. Lobular Ca
    • 1) 10% of all breast Cas
    • 2) does not form calcifications
    • 3) extensively infiltrative, increased bilateral, multifocal/multicentric
    • 4) signet cells confer worse prognosis
    • 5) Tx: MRM or lumpectomy with ALND (or SLNB); postop XRT
  76. Inflammatory cancer
    • 1) may need chemotherapy and XRT 1st, then mastectomy
    • 2) considered T4 disease
    • 3) Very aggressive--> median survival of 36 months
    • 4) has dermal lymphatic invasion, which causes peau d'orange lymphedema appearance, erythematous and warm
  77. Metaplastic adenocarcinoma
    • 1) take on the appearance of nonglandular cells
    • 2) most common types-
    • 1- squamous
    • 2- pseudosarcomatous
    • 3) prognosis is the same as the tumor cell line from which it was derived
  78. Adenoid cystic carcinoma:
    • 1) large, well-circumscribed lesions
    • 2) better prognosis than ductal Cas
  79. Preoperative studies:
    • 1) CXR, bilateral mammograms, CBC, LFTs
    • 2) abdominal CT if LFTs elevated
    • 3) head CT if patient reports headache
    • 4) bone scan if patient has bone pain or abnormal alkaline phosphatase
    • 5) for patients with more advanced local primary, consider more extensive preop evaluations (head and abdominal CT, bone scan)
  80. Surgical Options (next slides):
  81. Subcutaneous (simple mastectomy):
    • 1) leaves 1-2% of breast tissue
    • 2) preserves the nipple
    • 3) NOT indicated for breast Ca treatment
    • 4) used for DCIS and LCIS
  82. Lumpectomy and SLNB (or ALND), postop XRT
    need 1cm margin
  83. SLNB
    • 1) fewer complications than ALND
    • 2) indicated only for malignant tumors >1cm
    • 3) not indicated in patients with clinically positive nodes; they need ALND
    • 4) accuracy best when primary tumor is present (finds the right lymphatic channels)
    • 5) well suited for small tumors with low risk of axillary metastases
    • 6) radioactive material or blue dye can be used
    • 7) dye or radiotracer is injected directly into the tumor area
    • 8) Type I hypersensitivity reactions have been reported with Lymphazurin blue dye
    • 9) usually find 1-3 nodes; 95% of the time, the sentinel node is found
    • 10) during SLND- if no radiotracer or dye is found, need to do a formal ALND
  84. Contraindications to SLNB:
    • 1) pregnancy
    • 2) multicentric disease
    • 3) neoadjuvant
    • 4) clinically positive nodes
    • 5) prior axillary surgery
    • 6) inflammatory or locally advanced disease
  85. Modified radical mastectomy
    • 1) removes all breast tissue including the nipple areolar complex
    • 2) includes axillary node dissection (level I nodes)
  86. Radical mastectomy:
    • (rarely performed anymore)
    • 1) includes MRM and overlying skin, pectoralis major and minor muscles, and level I, II, and III lymph nodes
  87. Complications of mastectomy:
    • 1) infection
    • 2) flap necrosis
    • 3) seromas
  88. Complications of axillary lymph node dissection
    • 1) infection, lymphadema, lymphangiosarcoma
    • 2) axillary vein thrombosis- sudden, early, postop swelling
    • 3) lymphatic fibrosis- slow swelling over 18 months
    • 4) intercostal brachiocutaneous nerve- hyperesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy; no significant sequelae
  89. Contraindicaitons to Breast-Conserving Therapy in Invasive Carcinoma:
    • Absolute Contraindications:
    • 1) two or more primary tumors in separate quadrants of the breast
    • 2) persistent positive margins after reasonable surgical attemps
    • 3) pregnancy is an absolute contraindication to the use of breast irradiation. When cancer is diagnosed in the third trimester, it may be possible to perform breast-conserving surgery and treated the patient with irradiation after delivery.
    • 4) A history of prior therapeutic irradiation to the breast region that would result in retreatment to an excessively high radiation dose.
    • 5) diffuse malignant-appearing microcalcifications

    • Relative Contraindications
    • 1) a history of scleroderma or active systemic lupus erythematosus
    • 2) extensive gross, multifocal disease in the same quadrant. Studies in this area are not definitive
    • 3) large tumor in a small breast that would result in cosmesis unacceptable to the patient
    • 4) very large or pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured
  90. When do you leave drains in until:
    leave in until drainage <40cc/day
  91. How strong is the radiation used for lumpectomy and XRT:
    usually consists of 5,000 rad for lumpectomy and XRT
  92. Complications of XRT:
    • 1- edema
    • 2- erythema
    • 3- rib fractures
    • 4- pneumonitis
    • 5- ulceration
    • 6- sarcoma
    • 7- contralateral breast Ca
  93. Contraindications to XRT:
    • 1) scleroderma (results in severe fibrosis and necrosis)
    • 2) SLE (relative)
    • 3) active rheumatoid arthritis (relative)
    • 4) previous XRT
  94. Indications for XRT after mastectomy
    • 1) >4 nodes
    • 2) skin or chest wall involvement
    • 3) positive margins
    • 4) tumor >5cm (T3)
    • 5) extracapsular nodal invasion
    • 6) inflammatory Ca
    • 7) fixed axillary nodes (N2) or internal mammary nodes (N3)
  95. Lumpectomy with XRT
    • 1) 10% chance of local recurrence, usually occurs within 2 years of 1st operation
    • 2) these patients often also have distant disease
    • 3) need salvage MRM for local recurrence
    • 4) need to have negative margins following lumpectomy before starting XRT
  96. Chemotherapy
    • 1) TAC for 6-12 weeks (taxotere, adriamycin and cyclophosphamide)
    • 2) positive nodes- everyone gets chemo except postmenopausal women with positive estrogen receptors--> tamoxifen
    • 3) >1cm and negative nodes- everyone gets chemo except patients with positive estrogen receptors--> tamoxifen
    • 4) <1cm and negative nodes- no further treatment
  97. Chart on pg 158 - Recommendations for Adjuvant Therapy (type it in)
  98. Alternative hormonal/chemotherapy options:
    • 1) androgenic steroid
    • 2) aminoglutethimide
    • 3) bilateral oophorectomy
    • 4) megace
    • 5) aromatase inhibitors (anastrozole, letrozole)

    Both chemotherapy and hormonal therapy have been shown to decrease recurrence and improve survival
  99. Tamoxifen:
    • 1) decreases short-term risk of breast Ca by 50-60%
    • 2) 1% risk of blood clots, 0.1% risk of endometrial Ca
  100. What percent of women die due to recurrence of breast Ca:
    almost all women with recurrence die of disease
  101. Increased recurrences and metastases occur with:
    • 1) positive nodes
    • 2) larger tumors
    • 3) negative receptors
    • 4) unfavorable subtypes
  102. Metastatic flare:
    • 1) pain
    • 2) swelling
    • 3) erythema in metastatic areas
    • 4) XRT can help
    • 5) XRT is good for bone metastases
  103. Occult breast Ca
    • 1) breast Ca that presents as axillary metastases with unknown primary
    • 2) 70% are found to have breast Ca at mastectomy
  104. Benign conditions that mimic breast Ca:
    • 1) Radial scar- can present as a stellate, irregular, spiculated mass lesion
    • 2) Fibromatosis- locally invasive spindle cells; can have skin retraction/dimpling
    • 3) Granular cell tumors (skin retraction/dimpling)
    • 4) Fat necrosis- poorly defined borders, skin retraction; accompanying fibrosis causes these findings; thought to be related to trauma
    • 5) pathology shows macrophages laden with fat or foriegn body giant cells (FNA or core needle biopsy)
  105. Malignant tumors with benign appearance:
    • smooth/rounded masses
    • 1) mucinous Ca
    • 2) medullary Ca
    • 3) cystosarcoma phyllodes
  106. Masses that contain fat:
    • 1) most masses that contain fat are benign:
    • 1- nodes
    • 2- postraumatic oil cyst
    • 3- hamartomas
    • 4- fibrolipoadenomas
  107. Paget's disease"
    • 1) scaly skin lesion on nipple
    • 2) biopsy shows Paget's cells
    • 3) patients have DCIS or Ductal Ca in breast
    • 4) Tx: need MRM if cancer present; otherwise simple mastectomy
  108. Cystosarcoma phyllodes
    • 1) 10% malignant, based on mitosis per high-power field (>5-10)
    • 2) No nodal metastases, hematagenous spread in any (rare)
    • 3) resembles giant fibroadenoma; has stromal and epithelial elements (mesenchymal tissue)
    • 4) can often be large tumors
    • 5) Tx: WLE with negative margins; No ALND
  109. Stewart-Treves syndrome
    • 1) lymphangiosarcoma from chronic lymphedema following axillary dissection (MRM)
    • 2) Patients present with dark purple nodule or lesion on arm 5-10 years after surgery
  110. Pregnancy with mass:
    • 1) tends to present late, leading to worse prognosis
    • 2) mammography and ultrasound do not work as well during pregnancy
    • 3) try to use ultrasound to avoid radiation
    • 4) if cyst, drain it and sent FNA for cytology
    • 5) if solid, perform core needle biopsy or FNA
    • 6) if core needle and FNA equivocal, need to go to excisional biopsy
    • 7) If breast Ca:
    • 1st trimester- MRM
    • 2nd trimester-MRM
    • 3rd trimester- MRM or if late can perform lumpectomy with ALND and postpartum XRT
    • 8) may be able to wait until delivery for treatment
    • 9) no chemotherapy or XRT while pregnant, no breast-feeding after delivery

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