Clinical overview and surgical considerations for management of Primary Breast Cancer and other subtypes. Covers screening recommendations, mammography (including BIRADS score interpretation), pathophysiology, staging, prognosis, surgical management, breast anatomy, non-surgical management, follow-up considerations. Given at Jackson Park Medical Center on 1/30/2014. Includes references.

1. Breast Cancer
Riaz Rahman, MSIII

2. Epidemiology & Risk Factors

3. Screening Recommendations
*In women between 35 and 60 years of age, breast
masses are cancerous until proven otherwise*

4. Mammography
 Types of Mammographic Abnormalities: Masses,
Asymmetric densities, Microcalicifications
 Breast Imaging and Database System (BI-RADS): a
quality-control system designed to standardize
reporting mammography results and estimate breast
cancer risk
 .

5. Interpretation of Mammographic Findings
 When abnormalities are found on screening,
additional imaging is usually necessary:
 Microcalcifications: magnification mammography
 Masses/Asymetric Densities: magnification + ultrasound
 “Probably Benign” (BIRADS 3): warrants Follow-Up
only,
 Risk of Malignancy: 2% of lesions prove to be malignant
 Observe affected patients regularly
 “Suspicious” (BIRADS 4): warrants biopsy.
 Risk of Malignancy: 15%-35% of lesions prove to be
malignant
 Initial diagnosis by stereotactic guided Core-Needle Biopsy
 Positive biopsy result permits directive surgical planning

6. Ductal Carcinoma in Situ
 Often multifocal, with several histologic patterns
 Comedo, micropapillary, cribriform
 Mammography: incidental microcalcifications
 10%-20% of DCIS lesions have an infiltrative
component
 Careful examination and complete excision is important
 Incomplete excision: 10-year risk of invasive carcinoma =
30%
 Gold Standard Treatment:
 Simple Mastectomy with or without reconstruction
 Wide excision and radiation therapy drops recurrence to
22%
 Nodal dissection is not necessary, nodal metastasis is

7. Progression of Breast Duct Lining

8. Lobar Carcinoma in Situ &
Atypical Ductal Hyperplasia
 Lobar Carcinoma in Situ
 LCIS is usually an incidental finding at histopathology
 When found adjacent to benign mass  surveillance
 Malignant disease marker; 15%-20% chance of
development of invasive cancer in either breast in 20 next
years
 Almost no risk of axillary metastasis
 Treatment: Close observation with examination and
mammography every 6 months for the next several years
 Atypical Ductal Hyperplasia
 Similar in appearance to DCIS; 15%-50% prove malignant
 Associated risk of cancer is 4-5x higher (depends on
histology)
 Needle localization and excision are appropriate
 Treatment is similar to DCIS (complete excision &

9. Paget’s Disease & Fibrocystic Disease
 Paget’s Disease of the Breast
 Chronic eczematoid lesion of the nipple
 95% have underlying carcinoma; DCIS/infiltrating
carcinoma
 Associated masses are present in approximately 50% of
cases, these patients should undergo mastectomy and
staging
 If lesion is confined to the nipple (~10%) treatment may
involve excision of the nipple areolar complex or
radiotherapy
 Fibrocystic Disease of the Breast
 “Lumpy” tender breasts, usually before menstrual periods
 Cysts, fibrosis, sclerosing adenosis, apocrine change,
hyperplasia

10. Primary Breast Mass
 Fibroadenoma
 Most common breast tumor in women <25yo
 Benign lesion, more common in African Americans
 Firm, rubbery, painless, movable, well-circumscribed
 Excision establishes diagnosis, observation may be
appropriate
 Phyllodes Tumor
 Giant cell fibroadenomas: “cystosarcoma phyllodes”
 Large, bulky mass of variable malignant potential
 Occasional ulceration of overlying skin
 Increased number of mitoses per high power field
increases chance of malignancy
 Treatment is local excision with generous margins

11. Staging of Breast Cancer

12. Prognostic Indicators of Breast Cancer

13. Surgical Management of Breast Cancer
 Surgical Principles:
 Establish a diagnosis
 Completely eradicate the primary tumor
 Determine if regional nodes are involved with metastasis
 Wide excision with radiation therapy for local tumors
 Mastectomy recommended for a multicentric/larger
tumors.
 Removal of axillary nodes is necessary for accurate
staging
 Modified Radical Mastectomy (Auchincloss)
 Most commonly performed mastectomy
 Surgeon removes breast tissue, skin, axillary lymph
nodes
 Pectoralis major muscle is spared. Radiation typically not

14. Surgical Management
 Traditional Radical Mastectomy (Halsted procedure)
 Very disfiguring: breast tissue, skin, pectoralis major,
pectoralis minor, and axillary lymph nodes are all removed
 Rarely performed today, early studies foun no difference in
survival between modified radical vs. traditional radical
 Simple Mastectomy: removal of breast tissue, nipple-areolar
complex and skin. Often done for LCIS/DCIS
 Reconstruction:
 Immediate reconstruction avoids a 2nd operation, allows exact
defect to be duplicated/replaced, & yields excellent cosmetic
results
 Silicone gel, saline-filled prostheses, or vascularized flaps
may all be used depending on patient size & amount of skin
and breast

15. Surgical Management
 Lumpectomy/Segmental Mastectomy
 Breast conserving therapy that provides much better
cosmetic result compared to modified radical mastectomy
 Involves removal of primary lesion with clear gross and
histologic margins, accompanied by axillary node sampling
and local radiotherapy to the entire breast.
 Appropriate for a solitary tumor <5cm in size, provided
breast size is acceptable and the patient is a good
candidate for post-operative radiation therapy (which
greatly reduces recurrence)
 May involve irradiation of the axillary nodes, internal
mammary nodes, and supraclavicular nodes, if more than
four nodes are positive or if extrascapular invasion is
present.

16. Anatomy of the Breast

17. Anatomy of the Breast

18. Lymphatic Drainage of the Breast

19. Surgical Management

20. Nonsurgical Therapy for Breast Disease

21. Follow-Up
 Patients with breast cancer should follow-up with
their physician at least twice a year.
 Annual CXR and liver function studies are
appropriate
 Patients who have had lumpectomy with radiation
should undergo mammography of the affected
breast every 6 months for 2 years, followed by yearly
mammograms
 5-year survival rates:
 Early stage: 15%
 Stage I: 93%
 Stage II: 72%

22. References
 Sariego J (2010). "Breast cancer in the young patient". The American surgeon 76 (12):
1397–1401. PMID 21265355. edit
 US NIH: Male Breast Cancer
 Florescu A, Amir E, Bouganim N, Clemons M (2011). "Immune therapy for breast cancer
in 2010—hype or hope?". Current Oncology 18 (1): e9–
e18. PMC 3031364.PMID 21331271.
 Buchholz TA (January 2009). "Radiation therapy for early-stage breast cancer after
breast-conserving surgery". N. Engl. J. Med. 360 (1): 63–
70. doi:10.1056/NEJMct0803525.PMID 19118305.
 "World Cancer Report". International Agency for Research on Cancer. 2008. Retrieved
2011-02-26. (cancer statistics often exclude non-melanoma skin cancers such asbasal-
cell carcinoma, which are common but rarely fatal)
 "World Cancer Report". International Agency for Research on Cancer. 2008. Retrieved
2011-02-26.
 "Male Breast Cancer Treatment". National Cancer Institute. 2011. Retrieved 2011-02-26.
 ONS, Cancer Survival in England, patients diagnosed 2007–11, followed up to
2012.http://www.ons.gov.uk/ons/rel/cancer-unit/cancer-survival/cancer-survival-in-
england--patients-diagnosed-2007-2011-and-followed-up-to-2012/stb-cancer-survival-in-
england--patients-diagnosed-2007-2011-and-followed-up-to-2012.html
 Merck Manual of Diagnosis and Therapy (February 2003). "Breast Disorders: Breast
Cancer". Retrieved 2008-02-05.
 American Cancer Society (2007). "Cancer Facts & Figures 2007" (PDF). Archived
fromthe original on 10 April 2007. Retrieved 2007-04-26.