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Diagnosis and Surgical Management
of Breast Cancer
Vivien LiIntern
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Introduction
Most commonly diagnosed cancer among women in Australia.
Lifetime risk of 1 in 9, risk increases with age.
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Anatomy & Pathophysiology Each breast contains
15-20 lobes arranged in a circular fashion.
Each lobe is made up of lobules with milk-producing glands at the end.
Cancers develop through molecular changes in breast epithelial cells, especially of hormonal receptors.
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Histopathology
Carcinoma in situ DCIS
› Presentation – mass, pain, nipple discharge. › MMG – microcalcifications.› High risk of progression to invasive breast cancer.
LCIS› Usually incidental finding without clinical symptoms.› Originates from terminal breast lobules.› Marker of increased risk of invasive breast cancer in
either breast.Invasive breast cancer IDC (70-80%) ILC (5-10%)
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Risk factors
Age FHx
› ≥1st degree relative› Young age at diagnosis› Ovarian cancer› Male breast cancer› Ashkenazi Jews
Breast disease› Neoplastic – DCIS, LCIS› Benign
Genetic› BRCA 1/2 mutations › Other – p53 etc.
Hormonal › Endogenous – menstrual, obstetric history› Exogenous – OCP, HRT
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Diagnosis (1) – History & Exam Presentation
› Asymptomatic – screening › Symptomatic – breast lump, nipple changes
Examination› Breast – lump, skin changes› Nipple – inversion, discharge› Axilla – lymphadenopathy › Metastatic – respiratory, abdominal, bone pain,
neurological
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Diagnosis (2) – Imaging
Mammogram › Asymmetry› Micro-
calcifications› Mass› Architectural
distortion
Ultrasound
MRI › Screening of
high risk patients
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Diagnosis (3) - Biopsy
Core biopsy – breast lesion› Histology – IDC, ILC, DCIS, LCIS› Grade› Receptors - ER, PR, Her2› Lymphovascular invasion› Necrosis
FNA – LNs
Triple test = positive if any component is indeterminate, suspicious or malignant
requires specialist referral 99.6% sensitivity
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Investigation of a new breast symptom http://canceraustralia.nbocc.org.au/view-document-details/ibs-the-investigation-of-a-new-breast-symptom-guide-for-gps
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Workup
Staging – TNM› T – histopathology› N – SLN biopsy› M – CT, bone scan (not always indicated for early
cancers due to low risk of metastases) Baseline assessment
› Myocardial function – MUGA/echo prior to chemotherapy/Herceptin
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Management – Surgery
Breast Wide local excision ± SLNB/axillary dissection + radiotherapy
› Clear histological margins with rim of normal breast tissue› Indications – unifocal, <3-4cm› Localisation – carbon/hook-needle› Approach – circumareolar incision for subareolar/central breast lesions, parallel
to Langer’s lines Mastectomy
› Complete excision of breast parenchyma› Indications – multifocal, large tumour size, prior RTx, personal preference› Drains inserted to prevent seroma/haematoma formation
WLE vs. mastectomy› No difference in metastases or survival between mastectomy vs. WLE + RTx› Higher incidence of local recurrence in WLE (1-2%/year) vs. mastectomy
(0.5%/year). Breast reconstruction
› Immediate vs. delayed› Implant vs. flaps
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Management – Surgery
Axilla Prognosis – axillary LN status is best prognosticator of disease-free
interval and survival. 30% of patients with early cancer have positive axillary LNs.
Axillary dissection› Removal of level 1/2 axillary LNs › Previously gold standard but high morbidity.
SLN biopsy› Minimally invasive procedure designed to stage axilla in patients with
clinically negative nodes.› Suitable for clinically node negative unifocal tumours <3cm.› Equivalent accuracy to axillary dissection.› Technique – inject radioactive tracer and blue dye 1-3 LNs tested for
metastases intraoperative frozen section immediate axillary dissection if positive.
Adjuvant therapy – with axillary LN involvement RTx improves disease-free survival and reduces local recurrence.
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Management – Surgery
DCIS Resection of primary cancer Adjuvant radiotherapy
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Management – Surgery
Post-operative complications› Seroma› Wound infection› Bleeding› Need for re-excision
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Management – Radiotherapy Eradicate local subclinical disease Indications
› After WLE of DCIS/early breast cancer› After mastectomy if positive margins, large primary
tumour, ≥4 LNs+ Side effects
› Early – fatigue, pain, skin changes› Late – oedema, pain, fibrosis, hyperpigmentation
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Management – Chemotherapy Chemotherapy agents
› Alkylating agents, e.g. cyclophosphamide› Anthracyclines, e.g. doxorubicin› Antimetabolites, e.g. 5FU, gemcitabine, methotrexate› Taxanes, e.g. paclitaxel› Vinorelbine
Adjuvant› Indications
Locally advanced/metastatic cancer. LN- and <0.5cm – not recommended. LN- and 0.6-1cm – recommended if high risk factors.
› Regimen Combination recommended Assess tumour responsiveness every 6-12 weeks (2-3 cycles) If disease control is confirmed, should be continued for 18-24 weeks (6-8 cycles)
Neoadjuvant› Indications
Large/locally advanced breast cancer prior to surgery and radiotherapy.
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Management – Hormonal therapy
ER + Decrease oestrogen's ability to stimulate existing
micrometastases or dormant cancer cells. Treatment for 5 years Tamoxifen
› Pre- and post-menopausal patients› Side effects – hot flushes, nausea, vomiting, fluid retention
Aromastase inhibitors › Post-menopausal patients› Side effects - osteoporosis
Her2+ 20% of breast cancers are Her2+; more aggressive. Trastuzumab (Herceptin) Side effects – cardiac toxicity
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Follow up
Clinical review every 6 months for first 2 years then annually thereafter.
Mammogram at 6 months then annually thereafter.
Further investigations as dictated by symptoms. DEXA scan for patients on aromatase inhibitors.
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References
Wright, M. (2011). Surgical treatment of breast cancer. http://emedicine.medscape.com/article/1276001-overview#a1. Accessed Sep 1, 2012.
Swart, R. (2012). Adjuvant therapy for breast cancer. http://emedicine.medscape.com/article/1946040-overview#a1. Accessed Sep 1, 2012.
Stopeck, A. (2012). Breast cancer. http://emedicine.medscape.com/article/1947145-overview. Accessed Aug 26, 2012.
NBOCC Recommendations for staging and managing the axilla in early (operable) breast cancer (2011). http://guidelines.nbocc.org.au/guidelines/axilla_early/. Accessed Aug 26, 2012.
NBOCC Recommendations for Aromatase inhibitors as adjuvant endocrine therapy (2006). http://guidelines.nbocc.org.au/guidelines/adjuvant_endocrine_therapy/. Accessed Aug 26, 2012.
NBOCC Recommendations for use of sentinel node biopsy (2007). http://guidelines.nbocc.org.au/guidelines/sentinel_node_biopsy/. Accessed Aug 26, 2012.
Uptodate