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3rd year - Surgery > General Surgery Breast > Flashcards

General Surgery Breast Flashcards

1
Q

What is the typical lymphatic drainage of the breast

A

> 75% of lymphatic drainage of breast superiorly and laterally to axillary lymph nodes

Mostly from lateral breast (upper and lower outer quadrants)

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2
Q

What are the 3 levels of axillary lymph nodes

A

Level 1 - lateral to pectoral minor

Level 2 - deep to pectoral minor

Level 3 - medial to pectoral minor

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3
Q

What level of lymph node has worst prognosis

A

High level of involvement has worse prognosis

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4
Q

Where does the majority of the lymphatic drainage of breast to para-sternal (aka internal mammary) lymph nodes comes from

A

<25% of lymphatic drainage of breast to para-sternal (aka internal mammary) lymph nodes (mostly from medial (upper and lower inner quadrants) breast)

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5
Q

Where can the breast lymph drain to

A

Axillary lymph nodes

Internal mammary lymph nodes

Opposite breast

Inferior phrenic nodes

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6
Q

Galactorrhea definition

A

galactorrhea usually bilateral milky discharge

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7
Q

What are physiologic causes of galactorrhea

A

pregnancy, lactation, stress

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8
Q

What are pathologic causes of galactorrhea

A

Medication

Hyper-prolactinemia

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9
Q

What is the most common cause of spontaneous unilateral nipple discharge

A

Intraductal papilloma

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10
Q

Provoked nipple discharge usually suggests

A

Physiologic etiology

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11
Q

Differential for nipple discharge

A

benign ductal disorder: intra-ductal papilloma, mammary duct ectasia, fibrocystic changes

malignancy: breast cancer most often intra-ductal carcinoma or invasive ductal carcinoma
(nipple discharge is an uncommon symptom (10%) of breast cancer)

infection: abscess, mastitis

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12
Q

What are medications that can cause nipple dicharge

A

The following cause prolactin release:

Oral contraceptive

Anti-hypertensive meds

Anti-histamine

Opioids

Dopamine antagonist

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13
Q

How to differentiate glactorrhea and nipple discharge

A

nipple discharge usually unilateral

galactorrhea is bilateral milky nipple discharge

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14
Q

What is cyclic mastalgia

A

cyclic mastalgia is bilateral intense soreness or heaviness a few days before menses, usually due to hormonal changes in menstrual cycle

causes include
physiologic: breast pain due to hormonal changes in menstrual cycle

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15
Q

Non-cyclical breast pain definition

A

non-cyclical breast pain describes a variety of pain that does not fit definition of cyclical mastalgia, which usually due to breast or chest wall lesion

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16
Q

Differential diagnosis of non-cyclical breast pain

A

Intra-mammary (pathology inside breast)
structural: large pendulous breast, macro cyst
normal breast: diet, lifestyle, pregnancy
trauma
infection: mastitis, breast abscess
inflammatory: ductal ectasia, hidradenitis suppurative, thrombophlebitis
iatrogenic: hormone replacement therapy, other medications
malignancy: inflammatory breast cancer
mastalgia is an uncommon symptoms (~5%) of breast cancer

B) Extra-mammary

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17
Q

Breast pain investigations

A

if benign history and physical exam consistent with cyclical mastalgia, then no investigations required

if patient age <30 with no risk factor, then breast ultrasound

if patient age >30, mammogram and targeted ultrasound

if mass on physical exam, mammogram

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18
Q

Symptomatic treatment of mastalgia

A

lifestyle modification: sports bra for relief, restriction of caffeine / chocolate

warm or cold compresses

analgesics (acetaminophen or NSAID) for pain

if severe, Danazol can be used but have sginificant androgenic side effects

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19
Q

Mastitis/breast abscess epidemiology

A

common in breast feeding women

risk factors: smoking

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20
Q

Mastitis/breast abscess pathophysiology

A

infection and inflammation of breast tissue, caused by bacterial infection entry through duct system (Staphylococcus aureus, Enterococcus, anaerobic Streptococci, bacteroids
app)

infection of breast tissue may be complicated by formation of an abscess

non-lactational mastitis usually due to peri-ductal (sub-areolar) mastitis

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21
Q

Mastitis/breast abscess clinical presentation

A

breast symptoms: unilateral localized pain, may have sub-areolar mass (abscess), nipple discharge, nipple inversion

constitutional symptoms: fever, chills, malaise

breast exam: inflamed breast skin (erythema, swelling, tenderness, warmth), may have palpable fluctuant mass (abscess)

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22
Q

Mastitis/breast abscess investigations

A

breast ultrasound, which can differentiate abscess from tumor and other lesions

if unresponsive to treatment, then follow up investigations include mammogram and breast biopsy to rule out breast cancer

after resolution, follow up with repeat breast ultrasound and mammogram to rule out pathological breast lesions that predispose to infection

labs: CBC (leukocytosis)
any nipple discharge, milk or drained pus from abscess can be sent for culture and sensitivity (C&S)

consider blood culture if systemically unwell

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23
Q

Mastitis/breast abscess diagnosis

A

diagnosis usually made by physical exam of signs of inflammation confirmed on breast ultrasound

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24
Q

Treatment of mastitis

A

symptomatic management with hot / cold compresses, analgesia medication

antibiotic therapy
1) lactational mastitis: narrow coverage mainly for Staphylococcus aureus such as Dicloxacillin PO or Cephalexin PO or Erythromycin PO

2) non-lactational mastitis: same as lactational mastitis or consider broader coverage with Amoxicillin-Clavulanate

if lactating, continue breast feeding or using breast pump for complete emptying of breast, unless there is a breast abscess or purulent nipple discharge

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25
Q

Breast abscess treatment

A

consider IV antibiotics

abscess drainage by needle aspiration or incision & drainage (I & D)

26
Q

Potential locations of a breast mass

A

premammary, intramammary, retromammary

27
Q

Differential diagnosis for breast mass

A

benign breast mass more likely in younger premenopausal women

malignant breast mass more likely in older post menopausal women

usually differential diagnosis listed below are differentially diagnosed based on pathology of breast biopsy of lesion

1) Benign
structural: cyst, fibrocystic breast disease, fibrosis, adenosis, galactocele, epithelial related calcification
infection: abscess, granulomatous mastitis, papilloma
benign tumor: lipoma, lactational adenoma, papillary aprocrine change, mild hyperplasia of usual type, neurofibroma
pre-malignant tumor
proliferative without atypia (relative risk of ~2 for future breast malignancy): ductal hyperplasia of usual type, intra-ductal papilloma, sclerosing adenosis, fibroadenoma
atypical hyperplasia (relative risk of ~4 for future breast malignancy): atypical ductal hyperplasia, atypical lobular hyperplasia
iatrogenic: silicone implant
other: papillary apocrine change, epithelial related calcification, fat necrosis

2) Malignant
lobular carcinoma in situ, invasive lobular carcinoma
ductal carcinoma in situ, invasive ductal carcinoma (with subtypes)
connective and epithelial: phyllodes tumor, carcinosarcoma, angiosarcoma

28
Q

Risk factors for breast malignancy

A

older age

post-menopausal

early menarche, late menopause

hormone use

null-parity

first live birth

29
Q

Characteristics of benign and malignant breast lesions

A

characteristics of benign lesion: small (<2cm) superficial, smooth, round, rubbery, mobile with well defined border

characteristics of malignant lesion: large (>2cm), hard, irregularly bordered, non-mobile, fixed to skin or chest wall and with less well defined borders

30
Q

Breast mass investigations

A

mammography = 1st imaging study for almost all breast mass

breast ultrasound = usually in pre-menopausal women age <30 for fibroadenoma and cyst; may be follow-up imaging after mammography

breast biopsy (can be guided by imaging including ultrasound, mammogram or MRI) for definitive diagnosis and rule out malignancy

31
Q

Diagnostic work-up for breast mass for young pre-menopausal women

A

if malignant features on clinical exam, then mammogram followed by biopsy to rule out malignancy and for definitive diagnosis
if no malignant features on clinical exam, proceed with mammogram + ultrasound
if cystic changes on ultrasound, then aspirate for diagnosis
if lesion visualized, then core biopsy
if not visualized on mammogram and ultrasound, then consider CT or MRI of breast

32
Q

Diagnostic work-up for breast mass for post-menopausal olderwomen

A

Mammogram with biopsy to confirm diagnosis and rule out breast malignancy for all cases

33
Q

Screening mammogram purpose and sensitivity

A

purpose is to find cancer that is clinically undetectable (i.e. not detected on breast self exam nor clinical breast exam)

sensitivity of screening mammography is 75-90%

34
Q

Diagnostic mammogram purpose

A

purpose is to follow up on a positive breast finding on mammography screen, symptoms or clinical finding
symptoms: pain, nipple discharge, skin change, nipple inversion, shrinking breast, enlarging breast
clinical finding: palpable lump

35
Q

Screening mammography guidelines

A

in asymptomatic women <40 years of age, mammogram is not recommended

in asymptomatic women 40-49 years of age, annual screening mammogram can be done at discretion of physician

in asymptomatic women 50-74 years of age, mammogram screening every 1-2 years is recommended, which is evidence based and generally accepted
mammogram every year if recommended by radiologist, personal history of breast cancer, strong family history of breast / ovarian cancer or increased breast density

in asymptomatic women >74, mammogram screening every 1-2 years is recommended if she is in good health condition

mammogram and MRI sometimes recommended for screening in very high risk groups such as BRCA mutation carriers

36
Q

Mammogram findings

A

main abnormal mammogram findings include microcalficiation, architectural distortion, mass and asymmetry

90% breast cancer present as micro calcification and / or mass

10% breast cancer present with uncommon signs of architectural distortion and asymmetry

37
Q

What is Breast Imaging, Reporting & Data System

A

BIRADS is a standardized system for reporting mammography for uniformity and improve utility
BIRADS applies to all imaging including mammography, ultrasound and MRI

BIRADS 0 - further imaging is required
further imaging usually ultrasound or cones down mammography view
usually any abnormality on any single imaging will be BIRADS 0 until further imaging is done

BIRADS 1 - normal

BIRADS 2 - benign (e.g. cyst, fibroadenoma)

BIRADS 3 - probably benign with very low chance (2%) of malignancy where follow-up imaging is recommended (usually in 6 months)
presence of malignancy features such as non-calcified circumscribed solid mass, focal asymmetry, cluster of round punctate calcification

BIRADS 4 - suspicious abnormality with 2-95% chance of malignancy, where biopsy is recommended
BIRADS 4a have lower chance of malignancy than 4b

BIRADS 5 - likely to be cancer (>95% chance of malignancy), so a biopsy and surgical consultation is recommended

BIRADS 6 - confirmed malignancy with biopsy

38
Q

BIRADS follow-up

A

BIRADS 0 requires further imaging (usually coned compression & magnification view mammogram and ultrasound)
usually, any lesion detected on mammogram is BIRADS 0 until further imaging is done

BIRADS 1 and 2 require no further work-up

BIRADS 3 requires follow-up imaging in 6 months

BIRADS 4 and 5 requires biopsy

BIRADS 6 is post-biopsy

39
Q

Work-up of abnormal lesion on mammogram

A

based on standard 2 view mammography alone, it is not possible to definitively diagnose benign vs. malignant
any lesion detected on standard 2 view mammography alone is classified as BIRAD 0 until further imaging is done

workup of abnormal lesion comprised of 2 steps:

1) localization of lesion on initial mammogram on CC and MLO views

2) follow-up imaging, which may include combination of additional mammogram view (coned compression & magnification view), ultrasound and / or MRI
any lesion detected on mammogram need to be followed up with additional imaging (additional mammographic view, ultrasound or MRI) for correlation, in order to give BIRAD >0
in general, additional mammogram views and ultrasound are always done for all abnormalities
in women age >35 years, always start with additional mammogram views and then followed by ultrasound
indication for MRI of breast include
a) high risk screening: BRCA 1 or 2 mutation, >25% lifetime risk of developing breast cancer, radiotherapy to anterior chest wall
b) complex cases e.g. palpable lump not visualized on mammogram nor ultrasound
c) local staging of diagnosed breast cancer
d) assess response to chemotherapy

3) further work-up based on BIRAD score after follow-up imaging
BIRADS 1 and 2 require no further work-up
BIRADS 3 requires follow-up imaging in 6 months
BIRADS 4 and 5 requires biopsy

40
Q

Role of breast biopsy

A

usually, breast biopsy follows imaging work up with a BIRAD of 4 or 5

breast biopsy is mandatory for diagnosis of breast cancer

41
Q

Breast biopsy procedure

A

breast biopsy is done by radiologist

biopsy is usually guided by the imaging on which the lesion is best visualized

1) ultrasound guided biopsy
1st line except when lesion cannot be visualized on ultrasound
ultrasound guided is in real time, fast and cheap
good for solid and complex solid cystic mass

2) stereotactic (i.e. mammogram guided) biopsy
good for biopsying microcalcification seen on mammogram
good for asymmetry on mammogram that is absent on ultrasound
use X, Y and Z coordinates based on mammogram

3) MRI guided biopsy
2nd last line, usually when lesion cannot be seen on ultrasound nor mammogram

4) excisional biopsy based on palpation clinically
last line, usually when all imaging fails and lesion is palpable on clinical exam

biopsy needle can be fine needle, core needle or vacuum assisted
fine needle aspiration (FNA) is used for lymph node or cyst biopsy, where it produces the smallest amount of sample
core needle biopsy (CNB) is usually used only with some exceptions
vacuum assisted device (VAD) biopsy is used for microcalcification or diffuse lesion or under MRI guidance, where it produces the largest amount of sample

post biopsy
if biopsying for calcification, view biopsy under X-ray to ensure that the calcification is in the biopsy
deploy marker clip at site of biopsy to mark area of original lesion in case of surgery afterwards

42
Q

Breast cancer epidemiology

A

most common cancer in women (1 in 9 women will develop breast cancer during her lifetime; 1 in 29 women will die from it)

2nd most common cause of cancer death in women

most of cancer (~90%) are sporadic

only minority of cancer (5-10%) are hereditary (e.g. BRCA 1 or 2 mutation)

5 year survival rate for breast cancer is ~90% for women and ~80% for men

43
Q

Breast cancer risk factors

A

demographics
female gender
older age, where incidence steadily increase after age 30 and peak at age 80
female gender and age are the most significant risk factor for breast cancer

medical history
personal history of breast cancer
increased breast density on mammogram
prior biopsy for breast abnormalities
pre-malignant breast lesion including atypical ductal or lobular hyperplasia on biopsy
radiation to chest wall for lymphoma

family history of breast cancer
breast or ovarian cancer in 1st degree relatives including mother, sister, daughter

unopposed estrogen
early menarche (age <12)
late menopause (age >55)
long term (>5 years) hormone replacement therapy (for menopause)
nulliparity or first birth after age 30
no breast feeding

modifiable lifestyle risk factors
alcohol
obesity, especially after menopause
physical inactivity

other possible factors
smoking

44
Q

Breast cancer risk calculation

A

age

medical history or breast cancer, ductal carcinoma in situ, lobular carcinoma

genetic syndrome associated with increased risk of breast cancer (BRCA 1, BRCA 2)

age of menarche

nulliparity, age of first live birth

family history of breast cancer

prior breast biopsy

race / ethnicity

any high risk (lifetime breast cancer risk >20%) is refered to breast high risk clinic

in high risk patients, selective estrogen receptor modulators (SERMS) such as tamoxifen and raloxifene decrease breast cancer risk

45
Q

Classification of primary breast cancer

A

Non-invasive epithelial cancers

Invasive epithelial cancer

Mixed connective and epithelial tumours

46
Q

Definition non-invasive in breast

A

atypical hyperplasia confined in basement membrane and duct

47
Q

Types of non-invasive epithelial cancers

A

lobular carcinoma in situ (LCIS), which is a marker of developing breast cancer in either breast

ductal carcinoma in situ (DCIS) with 5 subtypes of DCIS from least to most aggressive: intra-ductal, papillary, cribriform, solid, comedo
DCIS is a marker of developing breast cancer in that breast and not the other breast

48
Q

Types of invasive epithelial cancer

A

invasive lobular carcinoma (~10% of invasive cancer)

invasive ductal carcinoma (~90% of invasive cancer), which have many subtypes
not otherwise specified (50-70% of invasive ductal carcinoma)
medullary carcinoma (5%)
tubular carcinoma (3%)
mucinous or colloid carcinoma (3%)
invasive cribiform carcinoma (3%)
invasive papillary carcinoma (2%)
adenoid cystic carcinoma (1%)
metaplastic carcinoma (1%)
49
Q

Invasive definition in breast

A

invasion beyond the basement membrane and duct

50
Q

Mixed connective and epithelial tumor types

A

phyllodes tumors, which can be benign or malignant

carcinosarcoma

angiosarcoma, which is usually due to radiotherapy to chest wall or post mastectomy

51
Q

Breast cancer clinical presentation

A

cancer can be in any breast quadrant: 50% in upper outer quadrant; 20% around areola; 15% in upper inner quadrant; 10% in lower outer quadrant; 5% in lower inner quadrant

most breast cancers are asymptomatic and detected by screening

breast cancer usually present as lump in breast

other symptoms / signs: nipple charge or discharge (clear or bloody fluid), change in breast skin colour or texture, skin dimpling, skin inversion, axillary lymphadenopathy

Paget’s disease of breast (malignancy involving nipple of breast spreading to areola): eczema of areola (flaky, scaly) which may have nipple discharge, burning sensation or inversion;
usually no breast mass and no mammogram abnormality; diagnosed by pathology of punch biopsy or full thickness biopsy of nipple

inflammatory breast cancer (diffuse tumor involving lymphatic channel within breast and overlying skin): peau d’orange (thickening skin, erythema, edema and warmth of firm breast due
to lymphatic obstruction); typically requiring neo-adjuvant chemotherapy followed by surgical mastectomy
inflammatory breast cancer (diffuse tumor involving lymphatic channel within breast and overlying skin): peau d’orange (thickening skin, erythema, edema and warmth of firm breast due
to lymphatic obstruction); typically requiring neo-adjuvant chemotherapy followed by surgical mastectomy

lobular carcinoma: classically in elderly women presenting as bilateral and multifocal lesions with high recurrence rate (ductal or lobular) in contralateral breast; metastasis to meninges,
pleura, GI series and urinary series; usually ER+ and PR+; requires mastectomy

metastasis: most commonly to axillary lymph nodes, bone, lung and liver; may metastasis to pleural, pericardium and abdominal cavity
bone metastasis have better prognosis than other metastases

52
Q

Breast cancer staging work-up

A

mammogram and ultrasound to visualize lesion and guide biopsy

biopsy to confirm malignancy and for tumor staging

MRI to better visualize lesion, rule out multicentric (multiple tumor sites in >1 quadrant) or multifocal lesion (multiple tumor sites within 1 quadrant) and surgical planning

chest X-ray, liver ultrasound to rule out metastasis

other imaging as indicated by symptoms
bone scan for bone metastasis if bone pain or high alkaline phosphatase
brain CT for brain metastasis if CNS symptoms such as confusion, fall, ataxia
chest CT for lung metastasis if pulmonary symptoms
abdomen and pelvis CT for metastases to bone, liver or GI tract if high alkaline phosphatase, abnormal liver function test, abdominal symptoms or signs

53
Q

Breast cancer prognostic factors

A

TNM staging

Pathological staging (microscopic features for prognosis):
Tumour size, focality, margin
Tumour grade (Nottingham histologic score) based on architectural tubular formation, atypia and mitosis
Lymph node status
Receptor (ER, PR, HER2) status

Hormone receptor status

54
Q

What information does hormone receptor status give you

A

hormone receptors are tested from excised tumor biopsy, which inform chemotherapy and prognosis

hormone receptors include estrogen receptor (ER), progesterone receptor (PR) and HER2 neu overexpression (HER2)

ER+, PR+ are associated with better prognosis and can be treated with hormone therapy

HER2+ can be treated with herceptin

PR- associated with more aggresive cancer

ER- PR- have a worse prognosis

55
Q

3 most important factors affecting breast cancer treatment and prognosis

A
  1. TNM staging
  2. receptor status (ER and HER2)
  3. women’s age and menopausal status
56
Q

Breast cancer surgical procedures

A

a) lumpectomy (aka breast conservative surgery)
procedure = removal of lump with some surrounding healthy tissue (wide local excision), combined with radiotherapy
indication: stage 1 and 2 breast cancer
contraindication: high risk of local recurrence (extensive malignant calcification on mammogram, lobular carcinoma, multi-focal tumor, failure to obtain tumour free margin after
excision); contraindication to radiotherapy (see below); inflammatory chest cancer; lobular carcinoma

b) mastectomy
radical mastectomy = removal of entire breast, skin, pectoralis muscle and axillary nodes
modified radical mastectomy = removal of entire breast, skin and axillary nodes
simple mastectomy = removal of entire breast and skin
indication: invasive lobular carcinoma; multi centric or multifocal breast cancer
complication: skin necrosis
following lumpectomy or mastectomy, breast and nipple can be reconstructed with TRAM flaps or implants under pectoralis muscle
decision of lumpectomy vs. mastectomy depend on size / location / number of tumor, patient decision and cosmesis

c) sentinel lymph node biopsy = biopsy of first lymph node that drains the cancer
procedure = injection of radioisotope (Technetium-99) and blue dye near cancer which is drained by lymph, where lymph node that take up dye and radioisotope are dissected
and sent to pathology for examination
if sentinel lymph node is free of cancer, then no lymph node involvement
if sentinel lymph node contain cancer, then lymph node dissection

d) lymph node dissection
procedure: complete excision of all lymph nodes in axilla
indication: positive lymph node on fine needle aspiration biopsy; positive sentinel lymph node biopsy
complication: injury to brachial plexus nerves (decreased arm sensation, shoulder pain); lymphedema (10-15% risk)

57
Q

Breast cancer surgical options

A

effectiveness of lumpectomy + radiotherapy is equivalent to mastectomy

lumpectomy with sentinel lymph node biopsy, followed by radiation

lumpectomy with sentinel lymph node biopsy -> axillary lymph node dissection followed by radiation

mastectomy with sentinel lymph node biopsy

modified radical mastectomy (mastectomy + axillary lymph node dissection)

58
Q

Breast cancer radiotherapy procedure, indications and contraindications

A

procedure = external beam radiotherapy

indication: radiotherapy always follow lumpectomy to reduce risk of recurrence

radiotherapy usually not required in mastectomy especially with lymph node dissection

contraindication: pregnancy; previous chest radiotherapy; collagen vascular disease (scleroderma, lupus)

59
Q

Breast cancer medical treatment role

A

neoadjuvant chemotherapy given before surgery to shrink aggressive tumor followed by surgical resection

adjuvant systemic chemotherapy given post surgery to reduce risk of recurrence and prolong survival

60
Q

Breast cancer systemic chemotherapy

A

chemotherapy based on comprehensive risk assessment of cancer stage, receptor status, pathological stage and other features

all breast cancer can be treated with any of the chemotherapies below:

anthracyclines (topoisomerase 2 inhibitor): doxorubicin, epirubicin

taxanes (microtubule inhibitor): docetaxel and paclitaxel

platinums: cisplatin, carboplatin

alkylating agent: cyclophosphamide

antimetabolite: 5-FU

chemotherapy regimen include
FEC (fluorouracil, epirubicin, cyclophosphamide

61
Q

Breast cancer hormonal therapy treatment

A

hormone or targeted therapy based on ER and HER2 status

ER+ and HER2-, treat with hormone therapy

ER- and HER2+, treat with herceptin

ER+ and HER2+, treat with hormonal therapy and herceptin

ER- and HER2-, no hormone receptor specific treatment, associated with poor outcome

a) Hormone therapy

selective estrogen modulator for pre-menopausal women: Tamoxifen

aromatase inhibitor for post-menopausal women: Anastrozole, Letrozole
complication: osteoporosis -> risk of fragility fracture

in pre-menopausal women, ovarian ablation or suppression is also a way to lower estrogen level

b) Herceptin
indication: HER2+ breast cancer

62
Q

General breast cancer management guidelines according to stage

A

Stage 0 Breast Cancer

a) lumpectomy + radiotherapy
b) lumpectomy alone if negative margin >1cm and low nuclear grade breast cancer
c) simple mastectomy +/- sentinel lymph node biopsy

Stage 1 Breast Cancer
a) lumpectomy and axillary node dissection + radiotherapy
b) simple mastectomy + (axillary node dissection or sentinel lymph node biopsy)
adjuvant chemotherapy or hormonal therapy after discussion of risk and benefit

Stage 2 Breast Cancer

a) lumpectomy and axillary node dissection + radiotherapy + adjuvant chemotherapy (and hormonal therapy if applicable)
b) simple mastectomy + (axillary node dissection or sentinel lymph node biopsy) + adjuvant chemotherapy (and hormonal therapy if applicable)

Stage 3 Breast Cancer
a) if operable, modified radical mastectomy + radiotherapy + adjuvant chemotherapy (and hormonal therapy if applicable)
b) if inoperable, neoadjuvant chemotherapy (and hormonal therapy if applicable) or radiotherapy -> modified radical mastectomy + radiotherapy + adjuvant systemic
treatment

Stage 4 Breast Cancer
slow disease progression with systemic chemothrapy (and hormonal therapy if applicable)
palliative surgery and / or radiotherapy

3rd year - Surgery (13 decks)

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