Copyright The Surgery 101 team (www. surgery101.org) 2012

7. Breast Cancer

In this episode, Dr. Parveen Boora discusses breast cancer. Topics covered include:

• approach to the history and physical exam of breast masses • indications for breast imaging and biopsy • staging invasive cancer • management of breast cancer

o surgery for primary tumors o surgery for axillary tumors

• post-operative therapy Introduction

• most common cancer affecting women • 1 in 9 will be diagnosed, 1 in 28 will die from it • risk of malignancy increases with age • less than 1% of breast cancers occur in women under 30 • vast majority of patients are over 50

 

Copyright The Surgery 101 team (www. surgery101.org) 2012

Taking a History

• how long has mass been present • has mass changed in size and how rapidly • mass’s relationship to menstruation • if mass is tender, determine if mobile or fixed • skin changes at nipple, any discharge and what type of discharge • patient’s age of menarche and menopause • any children and age at birth of first child • past breast masses • previous diagnosis of benign or malignant breast condition • previous cancer history of any type • medications -> hormones • family history and age of onset of any affected • constitutional symptoms, e.g. weight loss, anorexia, cough,

neurologic symptoms, bony pain

The Physical Exam

• symmetry • skin changes • dimpling • nipple retraction, excoriation or discharge • palpation of both axillae and supraclavicular fossae • location, consistency, mobility of masses

Investigations

• imaging -> mammogram most common, U/S, MRI • fine needle aspiration • biopsy

 

Copyright The Surgery 101 team (www. surgery101.org) 2012

DCIS

• proliferation of malignant epithelial cells completely confined within breast ducts

• most commonly found on mammograms but can present as a palpable mass

• considered precursor malignant lesion • treatment is excision of lesion followed by radiation therapy

Invasive Breast Cancer

• Patient should have chest x-ray and CT or U/S of abdomen to evaluate for metastases to lung and liver

• CT of brain should be arranged if patient complains of neurologic symptoms

• bone pain should be investigated with a bone scan • staging based on tumor, nodes, metastasis (TNM system) • stages range from I-IV

Stages I & II of Invasive Breast Cancer

• 85% of breast cancers • surgical approach to tumor and lymph nodes • treatment is usually modified radical mastectomy, or lumpectomy

followed by radiation • breast-conserving therapy may be an option

Inflammatory Breast Cancer

• aggressive and most deadliest form of breast cancer • presents as swollen, erythematous, tender breast • often mistaken for mastitis • diagnosis needs to be done by biopsy • urgent referral for multimodal treatment is indicated

 

Copyright The Surgery 101 team (www. surgery101.org) 2012

Summary

• Increasing age, female gender, and personal and family history of breast cancer are the main risk factors for breast cancer. Other risk factors include menarche before age 12, menopause after age 55, age greater than 30 at first pregnancy, history of previous breast biopsy and exogenous hormone use.

• Screening mammograms for normal risk individuals begin at age 50 and continue every 2 years until age 70.

• Breast cancers can be classified as lobular or ductal, and either type can be invasive or in situ.

• Lobar carcinoma in situ is a marker for increased risk of malignancy in both breasts. Treatment is with tamoxifen or with bilateral prophylactic mastectomy.

• Ductal carcinoma in situ and invasive stage 1 and 2 carcinomas can be treated with breast conserving therapy, involving a lumpectomy followed by radiation therapy.

• The presence of palpable lymph nodes in the axilla requires a complete lymph node dissection. However, if there are no clinically positive nodes, a sentinel lymph node biopsy can be carried out. A positive sentinel node dictates a completion axillary lymph node dissection while a negative sentinel node means that the remainder of the lymph nodes can be left in situ.

• Beware the swollen, erythematous, tender breast. Inflammatory breast cancer presents in this way and is extremely aggressive.