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![Page 1: BM](https://reader033.fdocuments.in/reader033/viewer/2022042814/54c9054c4a7959c9648b456b/html5/thumbnails/1.jpg)
Surgical Options for the Treatment of Breast Cancer
Helen Krontiras, M.D.Assistant Professor
University of Alabama School of Medicine
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History Physical Examination
• Questions regarding presenting symptom
• Questions regarding risk factors
• Past medical history • Family history• Review of systems
• Masses• Skin changes• Nipple changes• Nipple discharge• Lymphadenopathy
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Risk factors for breast cancer
Gender Age
Personal history of breast cancerReproductive and menstrual history
Breast densityFamily history of breast cancer
Genetic factorsProliferative breast disease
Diet and lifestyle factors
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Breast Imaging
Mammogram
Ultrasound
(MRI)
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Biopsy
• Incisional– Core biopsy
• Palpation • Image Guided
– Stereotactic– Ultrasound guided
• Excisional– Operative removal of entire lesion
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Histology
Lobular carcinoma in situ
Ductal carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma
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Lobular Carcinoma in situ
• Usually diagnosed as an incidental finding
• Marker for increased risk for breast cancer
• If found on core biopsy, excision warranted to rule out coexisting cancer
• Management– Surveillance– Chemoprevention– Bilateral Total Prophylactic Mastectomy
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Ductal Carcinoma in situ
• Stage 0, pre-invasive
• By definition, does not spread to the axillary lymph nodes
• Usually detected mammographically as microcalcifications
• Surgical treatment similar to invasive breast cancer
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Invasive ductal carcinoma
• Most common, 75% of all breast cancers
• AKA IDC, infiltrating ductal
• Increased spread to axillary nodes with increase in size
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Invasive lobular carcinoma
• 5-10% of all breast cancers
• Usually presents as an ill defined thickening
• May be mammographically occult
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Inflammatory breast cancer
• Variant with rapid onset
• Poor prognosis
• Erythema, edema of the overlying skin (peau d’orange) secondary to tumor within the dermal lymphatics
• Treatment is chemotherapy followed by surgery and or radiation
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Paget’s Disease
• Benign appearing eczematoid lesion of the nipple
• Caused by large malignant cells (Paget's cells) which arise from the ducts and which invade the surrounding nipple epithelium.
• Usually due to an intraductal carcinoma• An underlying palpable mass usually indicates
invasive ductal carcinoma
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Phyllodes Tumor
• Rare, 0.5%- 1% of breast cancers
• A fibroepithelial tumor of unpredictable behavior
• Treatment is wide local excision with
2cm margins, no role for chemotherapy or radiation therapy
• Like other stromal tumors, lymph node metastasis is rare
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Earlier stage - better survival
0102030405060708090
100
% 5
-year su
rviv
al
I IIA IIB IIIA IIIB IV
Survival
Stage
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Lumpectomy +
Mastectomy
Neoadjuvant Chemotherapy (SLN BX before,surgery after)
Clinical Stage I or II Invasive
Breast Cancer
SLN BX
AND
Total + SLN BX
Modified Radical
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Mastectomy
Neoadjuvant ChemotherapyClinicalStage III
Invasive Breast Cancer
Radiation Therapy
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Breast Cancer Treatment
Local Systemic
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Local Therapy
Breast Axilla
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Local Therapy
SurgeryRadiation Therapy
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Breast
Mastectomy
Breast conservation
Neoadjuvant chemotherapy
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Mastectomy
• Total Mastectomy– With or without reconstruction– With or without sentinel lymph node biopsy
• Remove only the breast
• Modified Radical Mastectomy – With or without reconstruction
• Remove the breast and axillary lymph nodes
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Mastectomy with reconstruction
Total or MRM plus (immediate or delayed) TRAM (Transverse Rectus Abdominis Myocutaneous flap)
Free – deep inferior epigastric Thorocodorsal, subscpular, circumflex scapular Internal mammary, thoracoacromial, lateral thoracic
Pedicled – superior epigastric Latissimus dorsi myocutaneous flap Expander/Implant
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Breast Conservation Therapy
Lumpectomy + Radiation Therapy• Remove the bulk of the tumor surgically and
to use moderate doses of radiation therapy to eradicate any residual cancer
• Goal– Preserve cosmetic outcome – Provide survival equivalent to mastectomy– Provide low rate of local recurrence
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BCT vs Mastectomy
Since 1970, 7 prospective randomized
studies demonstrate equivalent outcome
regardless of surgical choice for patients with Stage I or II disease
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Radiation Therapy
• External beam
• Daily therapy for 6 weeks
• Side effects– Skin changes– Pulmonary toxicity– Cardiotoxicity
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Contraindications to breast conservation therapy
Absolute 2 or more primary tumors in separate
quadrants Diffuse malignant appearing calcifications History of previous irradiation to the breast
region Pregnancy Persistent positive margins
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Contraindications to breast conservation therapy
Relative History of collagen vascular disease Multiple gross tumors in the same quadrant
and indeterminate calcifications Large tumor in a small breast Breast size
Winchester et al, Ca Cancer J Clin, 1998
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Contraindications to breast conservation therapy
The following should not prevent patients from being candidates for BCT:
Presence of clinical or pathologic involvement of axillary lymph nodes
Tumor location Family history
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Neoadjuvant chemotherapy
Chemotherapy given before surgery
• Shrink the tumor
• In Vivo assessment of response to chemo
• No survival advantage or disadvantage
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Therapy of Regional Nodes
• Axillary Node Dissection
• Sentinel Lymph Node Biopsy
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Axillary Node Dissection
• Typically Levels I and II • 10 – 30 lymph nodes
removed• 15-20% incidence of
lymphedema
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Silverstein, The Breast Journal 4:324, 1998
Positive axillary lymph node versus T stage
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Sentinel node biopsy
• The sentinel node is the first node to receive lymphatic drainage from a primary breast cancer and reflects the status of the entire nodal basin– Identifies the node(s) most likely to contain cancer– Lessens the morbidity of lymph node staging (3-4%
incidence of lymphedema)– More detailed pathologic analysis with H&E– Axillary node dissection for those with positive sentinel
nodes
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Sentinel node biopsy
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Systemic Therapy
CytotoxicChemotherapy
Endocrine
Monoclonal
antibody
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Adjuvant therapy
The administration of chemotherapy or radiation therapy after primary surgery of breast cancer to kill or inhibit clinically occult micrometastases or residual disease
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Adjuvant therapy recommendation
Tumor size ER status Nodal Status Recommendation
<1 cm +/- - None required
>1 cm + - Tam +/- Chemo
- - Chemo
Any size + + Tam +/- Chemo - + Chemo
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Chemotherapy
• Adriamycin/ Cytoxan (AC) x 4
• Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6
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SERMSelective estrogen receptor modulators
Tamoxifen• For those with ER (estrogen receptor) positive
breast cancer• Prescribed for 5 years• Antiestrogenic and estrogenic effects• Side effects
• Hot flashes• Vaginal dryness, discharge• Increased risk of endometrial cancer• Increased risk of thromboembolic events• Cataracts
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Aromatase inhibitors
• Blocks aromatase enzyme peripherally• For those with ER positive disease • Less side effects than tamoxifen• May be more effective for treatment and
prevention– Arimidex– Femara– Exemestane
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Herceptin(trastuzumab)
• Monoclonal antibody that targets the Her2neu gene
• Her2neu is overexpressed in 25% of breast cancers
• Codes for a growth factor
• Clinical trials indicate that Herceptin may increase the effectiveness of chemotherapy without added toxicity