Breast Cancer: A Surgical Perspective Flashcards
Most common type of breast cancer
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
What is the most lethal type of breast cancer
Inflammatory breast cancer
- ALWAYS shows peau d’orange
- often shows esophagitis ulcerating masess
5% chance of survival
What is brachytherapy in breast cancer?
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
Dr. Halsted and dr. Slamon
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
Signs and physical examination findings suggesting of breast cancer
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
What is peau d’orange?
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)
Important breast anatomy
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)
How are breast ducts and lobules connected
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
What structures need to be preserved when cutting out axilla LNs
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)
What is atypical ductal hyperplasia
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)
What is ductal carcinoma in situ (DCIS)
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
When is atypical ductal hyperplasia officially caricnoma?
Once it breast through the basement membrane
Lobular carcinoma in situ (LCIS)
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
What is breast ductoscopy
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)
Intraductal papilloma
- *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
What is a stereotactic breast biopsy and percutaneous excision all biopsy
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
Cryotherapy in breast pathology
Is used for only benign lesions and uses cold temperatures to freeeze it and kill it
FNA and ductal lavage
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
What is needle-localized breast biopsy?
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
What is the proper surgical margins for breast cancer
Minimum = 2mm of clean tissue on any of the margins of the tumor
What is a screening mammogram and diagnostic mammogram?
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
What is the BIRADS system
A by law criteria that must appear on every screening mammography to help the referring physician interpret the results
Thermography in breast cancer
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
Sclerosis adenosis
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)
General order of working up a breast mass
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**
Levels of axilla LNs
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)
Modified radical mastectomy
Removal of the breast tissues and remove level1 lymph nodes
- don’t remove the pectoral muscles
What gene mutation is more common in men with breast cancer
BRCA2
Women = BRCA1 built both can be present
What is a sentinel lymph node biopsy (SNLB)
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
What is the most common symptom related to axillary lymph node dissection
Lymphedema
- also high risk for lymphangiosarcoma
IV chemotherapy vs adjuvant/targeted chemotherapy
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
“Oral chemotherapy”
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)**
Radiation therapy in breast cancer
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)
General guidelines for breast cancer treatment
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
