Breast Cancer: A Surgical Perspective

Question 1

Most common type of breast cancer

Answer 1

Intraductal adenocarcinoma
- is 95% curable as long as caught in time

Progression begins in the normal duct and hyperplasia of the duct occurs
- atypia ductal hyperplasia

Then turns into ductal carcinoma in situ and finally (once piercing the basement membrane) = invasive intraductal carcinoma

Risk factors

• age
• genetic mutations (BRCA1/2 genes)
• estrogen exposure
• excessive progesterone exposure
• past radiation

Question 2

What is the most lethal type of breast cancer

Answer 2

Inflammatory breast cancer

• ALWAYS shows peau d’orange
• often shows esophagitis ulcerating masess

5% chance of survival

Question 3

What is brachytherapy in breast cancer?

Answer 3

Treatment for breast cancer that is only in the breast (no metastasis)

Requires cathertization in the breast tissue and inflate a balloon at the site to both make it easier to excise and also place “radiation pellets” to prevent recurrence

Question 4

Dr. Halsted and dr. Slamon

Answer 4

Dr. Halstead = first method of breast cancer

• essentially very radical mastectomy = removed breast, all lymph nodes pectoralis major and minor muscles
• he had super high infection rates and lymphedema in the patients

Dr. Slamon = developed Herceptin(trastuzumab) which is a mab that binds to the HER-2 receptors

Question 5

Signs and physical examination findings suggesting of breast cancer

Answer 5

Asymmetry, edema, erythema around the breast

Peau d’orange features

Skin dimpling (especially around nipple) 
- this often implies contracture of the underlying  suspensions ligaments of cooper

Question 6

What is peau d’orange?

Answer 6

Dimpling and edema of the breast skin that looks similar to orange peel skin

Can indicate:

• edema via infection or inflammation
• tumor infiltration of the lymphatics (most common and also most serious)

Question 7

Important breast anatomy

Answer 7

1) the skin
- changes here can indicate Paget’s disease or infalmmatory breast cancer

2) terminal ducts in nipple
- changes here can indicate ductal atypia, ductal carcinoma in situ and intraductal carcinoma

3) lobes
- changes here can indicate lobular carcinoma in situ (LCIS) and lobular carcinoma

4) lymphatic
- changes here can be inflammatory carcinoma

5) suspensions ligaments of cooper
- changes here mean peau d’orange usually

6) axillary nodes and sentinel lymph nodes (can be any cancer if changes here)

Question 8

How are breast ducts and lobules connected

Answer 8

The ducts connect/terminate in the lobules via a terminal acinus
- this means that intraductal and lobular carcinomas are essentially the same disease just at different progression stages

Question 9

What structures need to be preserved when cutting out axilla LNs

Answer 9

Intercostal brachial nerves and pectoralis muscles
- small nerves that innervate skin sensation of the axilla (often sacrificed)

Long thoracic nerve

• controls serratus anterior
• NEEDs to be conserved

Thoracolumbar-dorsal nerve and the latissimus Dorsi
- needs to be conserved

Axillary vein (found in the superior lateral aspect of the axilla)

Question 10

What is atypical ductal hyperplasia

Answer 10

Hyperplasia of cells with ducts of the breasts (has not expanded past this

**the progression of this goes: normal duct > ductal hyperplasia > atypical ductal hyperplasia > ductal caricnoma in situ (DCIS) > DCIS with comedo necrosis > invasive breast cancer > metastatic breast cancer

Treatment = resect and/or give Tamoxifen (estrogen antagonists)

Question 11

What is ductal carcinoma in situ (DCIS)

Answer 11

Ductal hyperplasia with malignant-appearing cells that is confined to the lumen of the breast ductal system

• there is no invasion through the basement membrane
• can be multi focal and multi centric
• *hall mark for most diagnosis = linear microcalcification of the breast in one area of one breast on bilateral breast MRI**
• can use mammography also but MRI is more specific

often gets mistaken with sclerosis adenosis

Presence of comedonecrosis (central necrosis) = poor prognosis

Question 12

When is atypical ductal hyperplasia officially caricnoma?

Answer 12

Once it breast through the basement membrane

Question 13

Lobular carcinoma in situ (LCIS)

Answer 13

Is essentially DCIS except that it occurs in the terminal duct-acinar junction (lobes or where all the ducts converge into one lobe)

• more common in younger pre-menopausal women and is usually an incidental finding at biopsy
• does not show calcifications or masses usually

While technically not having any metastatic potential by itself, it does increase the risk of having invasive carcinoma in EITHER breast

Diagnosis = breast MRI is gold standard (ultrasound and mammography doesnt visualize this well)

Treatment = can just watch and wait but if pleomorphic = wide excisions with radiation

Question 14

What is breast ductoscopy

Answer 14

Endoscopy of the breast essentially. Not done often but is a good tool for checking for cancer (often mixed with lavage of the ductal system)

Question 15

Intraductal papilloma

Answer 15

• *most common cause of bloody nipple discharge**
• sending this discharge for cytological analysis isnt really useful

HPV may be causative agent of intraductal papilloma but as of now it is NOT considered related to intraductal papilloma

Question 16

What is a stereotactic breast biopsy and percutaneous excision all biopsy

Answer 16

Used when a breast mass is only seen on mammography but is NOT palpable or seen on US
- Machine assisted xrays are used to coordinated where to do a FNA

Percutaneous excisional biopsy = useful for masses that can seen in ultrasound.

• insets a large cannula needle into he breast and pull checks of tissues out (takes multiple times in)
• can also use a hot wire to spin around it and cauterize it to remove the specimen
• can also use multiple prongs as well

BOTH are used only for bengin lesions

Question 17

Cryotherapy in breast pathology

Answer 17

Is used for only benign lesions and uses cold temperatures to freeeze it and kill it

Question 18

FNA and ductal lavage

Answer 18

Used for fibrocystic breast disease often or work up of a mass with ultrasound

FNA is more common since ductal lavage takes longer and is more complicated

Difficulties with FNA though = sample may be too small for definitive diagnosis and sometimes there isnt a cytopathologist present to look at the cells

Question 19

What is needle-localized breast biopsy?

Answer 19

Rarely done anymore since office ultrasound and core biopsy techniques (vacuum assisted or stereotactic biopsy) are easier and more common

Patient is knocked out and a guide wire is inserted into the lesion
- then drops of methylene blue dye is injected to tell the surgeon where to remove down to (in order to ensure clear margins

really only indicated is the lesion can only be seen on mammography or MRI and is not palpable

Question 20

What is the proper surgical margins for breast cancer

Answer 20

Minimum = 2mm of clean tissue on any of the margins of the tumor

Question 21

What is a screening mammogram and diagnostic mammogram?

Answer 21

Screening mammography:
Consists of two views of each breast
- cranial-caudal
- medial-lateral/oblique

Diagnostic mammogram:

• only done after screening shows abnormalities that aren’t palpable
• high magnification of “cone-down” views
• *note that mammography is NOT recommended in women <40 since the breast is very dense due to estrogen/progesterone levels**
• often causes more negative than good

Question 22

What is the BIRADS system

Answer 22

A by law criteria that must appear on every screening mammography to help the referring physician interpret the results

Question 23

Thermography in breast cancer

Answer 23

Used for large tumors only
- large tumors use more blood flow and “light up” more on thermo-imaging

Doesnt work for small tumors or micro calcifications

because it’s so hard to find small tumors its pretty much never used

Question 24

Sclerosis adenosis

Answer 24

Often confused for breast cancer that are microcalcifcations of tiny necrotic centers of breast cell tissues that undergo sclerosis

Often too large of calcifications compared to cancer (so this is how its determined to not be cancer)

Question 25

General order of working up a breast mass

Answer 25

1) do a Physical exam
2) order a screening mammogram
3) compare the mammogram to any old mammogram
4) if changes are seen = perform a ultrasound to see if its a cyst, fibroadenoma or cancer
5) biopsy mass (if not cyst) discuss mastectomy if its cancer

6) if the patient wants to conserve breast tissues
- chunkectomy with radiation therapy

7) radiation therapy = brachytherapy or external beam

8) arimidex if estrogen receptor is positive for > 5 years
- if HER-2 positive = add herceptin

9) systemic chemotherapy if she is young and wants breast conservation
- also any patient who has positive lymph nodes

** breast saving therapy always requires radiation to prevent extra/recurrent angiogenesis**

Question 26

Levels of axilla LNs

Answer 26

Level 1 = lateral to the pectoralis muscle
- almost all sentinel lymph nodes are present here

Level 2 = between lateral medial borders of the pectoralis minor muscle

Level 3 = medial to the pectoralis minor muscle (behind it)

Level 1 is always removed and sometimes level 2 if the cancer has pierced the basement membrane (or you suspect it may have but cant confirm)

Question 27

Modified radical mastectomy

Answer 27

Removal of the breast tissues and remove level1 lymph nodes

- don’t remove the pectoral muscles

Question 28

What gene mutation is more common in men with breast cancer

Answer 28

BRCA2

Women = BRCA1 built both can be present

Question 29

What is a sentinel lymph node biopsy (SNLB)

Answer 29

The first node that is hit by metastatic cancer is removed along with he cancer

Cancer spreads in a linear fashion and this is why taking this node out first is required

if you can feel large lymph nodes = full axillary dissection is needed and you cant do SLNB

Requires injection of lymphazurin or methylene blue around the tumor and then massage the breast tissues for 5 minutes

• then take them to radiology and the radiologist will find the sentinel lymph node
• then remove the mass and lymph node

Question 30

What is the most common symptom related to axillary lymph node dissection

Answer 30

Lymphedema

- also high risk for lymphangiosarcoma

Question 31

IV chemotherapy vs adjuvant/targeted chemotherapy

Answer 31

Young women <40 yrs almost always get chemotherapy if they have breast cancer (or at least considered)

Targeted = cancer in any lymph nodes

IV = if any lymph nodes are taken and found to have cancer or the entire axilla needed to be dissected

Question 32

“Oral chemotherapy”

Answer 32

Includes tamoxifen or arimidex

• essentially estrogen and progesterone antagonists
• used in patients tumors that have estrogen/progesterone (+) receptors (used for 5 years)

** if the patient tumor is (+) for HER-2/neu protein receptors = IV herceptin (trastuzumab)**

Question 33

Radiation therapy in breast cancer

Answer 33

Is always electron beam therapy
- is for local control only and is a type of breast conservation therapy

there is a maximum life-time dose however and this must be calculated before beginning therapy

The longer you do this = less angiogenesis and skin damage occurs as a ADR (brawny edema of skin)

Question 34

General guidelines for breast cancer treatment

Answer 34

If young (>40) = adjuvant and neoadjuvant chemotherapy 
- also gets lumpectomy 

If inflammatory carcinoma = both types of chemotherapy regardless of age

If older than <40 = usually no adjuvant chemotherapy
- lumpectomy with SLNB and external beam radiation