breast%20cancer
BREAST CANCER
Breast cancer is the presence of malignant breast nodule, mass or abscess.
Most common symptom of breast cancer is a new lump or mass in the breast. The lump or mass is usually painless, hard & irregular but it can also be tender, soft, rounded or painful.
Other signs & symptoms include breast pain or nipple pain, nipple discharge, nipple retraction and presence of breast skin changes (eg peau d' orange, nipple excoriation, scaling, inflammation, skin tethering, ulceration, abscess).

Surgical Intervention

Primary Treatment for Ductal Carcinoma In Situ 

  • Patients with breast cancer in 1 area with positive margins after complete surgical excision are advised to undergo either total mastectomy or lumpectomy, or excision of margin

Lumpectomy

  • Higher recurrence rate when done alone, without radiation therapy, endocrine therapy or chemotherapy especially in high-risk patients
  • RT may be offered in patients who are treated with lumpectomy
    • Several trials support the findings that lumpectomy with RT reduce recurrent DCIS and invasive disease in ipsilateral breast
    • Accelerated partial breast irradiation (APBI) may be considered in patients w/ DCIS measuring ≤2.5 cm with negative margin width ≥3 mm
  • Sentinel node biopsy may be done
  • Mammogram is advised postlumpectomy to ensure complete removal of the tumor

Total Mastectomy

  • Associated with near-total avoidance of recurrence in 3-20 years
  • Recommended in widespread DCIS with involvement of ≥2 areas and when there is persistent marginal involvement even after repeat surgery
  • May not require post-op radiation unless the carcinoma is at the margin of the mastectomy
  • Sentinel node biopsy may be done

Breast-conserving Surgery

  • Local treatment of choice for majority of invasive breast cancer
  • Purpose is to provide a pathologically negative margin of resection
    • Negative margin should be reported as ink is not touching invasive cancer or DCIS & >2 mm (for in situ disease) is preferred
    • Image-detectable markers are placed during core biopsy for tumor bed demarcation for surgical management post chemotherapy
    • In cases where there is a positive margin, the option is to re-excise or perform mastectomy to achieve a negative margin
  • Radiation is usually done after breast-conserving surgery
  • Survival rates are similar to mastectomy alone for stage I or II treated with lumpectomy and RT and in patients with DCIS treated with breast-conserving surgery and RT
  • Absolute contraindications for breast-conserving surgery requiring RT:
    • RT during pregnancy
    • Pathologic margins that are diffusely positive
    • Suspicious or malignant-appearing microcalcifications that are disseminated throughout the breast
    • Extensive disease that cannot be incorporated by local excision through a single incision that may result in negative margins with acceptable cosmetic result
  • Relative contraindications:
    • Tumor size >5 cm
    • Positive pathologic margin
    • Prior chest wall or breast radiation therapy
    • Active connective tissue disease involving the skin (eg scleroderma, lupus)
    • Women with known or suspected genetic predisposition to breast cancer
    • Others include very young age (<35 years old), multicentric disease, tumor located near nipple, BRCA1 or BRCA2 gene mutation

Lumpectomy

  • Selective removal of breast mass and a margin of normal surrounding tissues

Partial or Segmental Mastectomy or Quadrantectomy

  • Removal of up to one-quarter of the breast

Mastectomy

  • Entire breast removal
    • Women at high risk of breast cancer may be offered prophylactic bilateral mastectomy with reconstruction as a risk-reducing surgery

Simple or Total Mastectomy

  • Removal of the entire breast, including the nipple, but sparing the axillary LNs or muscle tissue from beneath the breast
  • Most common type of mastectomy used to treat breast cancer

Skin-sparing Mastectomy

  • Same amount of breast tissue is removed as with simple mastectomy but keeping most of the skin over the breast (other than areola and nipple) intact
  • Only performed in women who will undergo immediate reconstruction
  • May not be suitable for larger tumors or tumors that are close to the skin surface

Nipple-sparing Mastectomy

  • Variation of the skin-sparing mastectomy where breast tissue is removed but sparing the skin and nipple
  • Alternative for women who have small early-stage cancer near the outer part of the breast with no signs of cancer in the skin or near the nipple

Modified Radical Mastectomy

  • Simple mastectomy with removal of the level I/II axillary LNs
  • As effective as radical mastectomy

Radical Mastectomy

  • Removal of the entire breast, axillary LNs, and pectoral muscles
  • Rarely performed because of disfigurement and side effects
  • May still be done for large tumors that are growing into the pectoral muscles under the breast

Lymph Node Surgery

  • Includes axillary LN dissection and sentinel LN biopsy
  • To assess LN status, ie if the cancer cell has spread to axillary LN
  • Important in determining the stage, therapy, and outcome
  • Indicated in patients with large tumors (eg T2, T3)
  • Not usually done in pure DCIS or pure lobular neoplasia

Axillary Lymph Node Dissection

  • Removal of 10-40 (usually <20) level I/II axillary LNs and examined for cancer metastasis
  • Usually performed simultaneously with mastectomy or breast-conserving surgery, but may be done in a subsequent operation

Sentinel Lymph Node Biopsy

  • Removal of the sentinel LN to determine if the cancer cells have spread to nearby LNs
    • New standard of care rather than complete axillary LN excision
    • Sentinel LN is the 1st LN that is most likely to contain cancer cells if metastases have already started
    • Full axillary dissection is done if cancer is found in the sentinel LN
      • Axillary dissection can be safely omitted with <2 positive sentinel LNs if whole breast radiation treatment will be given after breast-conserving surgery
    • No further LN surgery is needed if:
      • Sentinel node is negative
      • Sentinel node is positive but only micrometastases or isolated tumor cells (ITC) are seen
  • Decreases the risk of lymphedema because only few LNs are removed
  • Considered in patients with clinically negative axillary LNs, with no previous chemotherapy nor hormone therapy
  • Preferred method of axillary LN staging provided that there is an experienced sentinel node team and the patient is an appropriate candidate for sentinel LN biopsy

Reconstructive Surgery

  • Procedure that restores the breast’s appearance
  • Offered to patients after mastectomy or breast-conserving surgery which can be done as either immediate breast reconstruction or delayed breast reconstruction
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