Surgical Therapy1

Question 1

What is the tissue diagnostic procedure of choice for a breast mass?

Answer 1

Core bx. An excisional bx is not necessary.

Question 2

When should an excisional bx be considered for a breast mass?

Answer 2

Only if the core bx is unsuccessful in obtaining sufficient tissue or there is a discordance between the clinical or mammographic findings from core bx.

Question 3

When is it OK to do only a lumpectomy without XRT for breast cancer?

Answer 3

Patients > 70 years of age, with ER+ breast tumors

Question 4

Relative contraindications to breast conservation

Answer 4

1. Large breast CA relative to small breast sizeﾠﾠ
2. Inability to undergo radiation therapy
3. Multicentric disease

Question 5

Describe how to do a lumpectomy

Answer 5

1. Curvilinear incision over site of tumor, following the skin tension lines.
2. Avoid tunnelling.
3. Dissect out mass.
4. Orient specimen.
5. Place clips for XRT/mammography.
6. Close.

Question 6

What are adequate margins for a lumpectomy?

Answer 6

2-3 mm of microscopically tumor-free tissue

Question 7

Does a nipple-sparing mastectomy provide the same local recurrence tumor rate as a standard mastectomy?

Answer 7

Yes

Question 8

Is local recurrence of breast cancer after skin sparing mastectomy associated with systemic relapse?

Answer 8

No

Question 9

Where in the duct does cancer originate?

Answer 9

In the terminal duct lobular unit.

Question 10

What % of nipples contain a terminal duct lobular unit?

Answer 10

9% - thus do not core out the nipple duct bundle during a nipple-sparing mastectomy. This may result in nipple necrosis.

Question 11

What criteria must be met for a nipple-sparing mastectomy?

Answer 11

Tumors = 4.5 cm or smaller, tumor at least 2.5 cm away from areolar edge or at least 4 cm from nipple center, no gross involvement of the nipple-areolar complex.

Question 12

What are the borders of level I axillary lymph nodes?

Answer 12

Ant: clavipectoral fascia; Post: subscapularis muscle; Inf: axillary tail; Sup: below axillary vein; Med: lat edge of pec major; Lat: ant border of latissimus dorsi.

Question 13

What is the incidence of positive nodes in DCIS?

Answer 13

1-3%

Question 14

What are the indications for a sentinel lymph node biopsy for DCIS?

Answer 14

1. Extensive disease with core bx diagnosis
2. High-grade disease with or without comedo necrosis
3. Evidence or suggestion of microinvasion
4. Disease in the subareolar area or upper outer quadrant
5. Treatment with mastectomy