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Anatomy

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Anatomy The breast is composed of 15 20 lobes, which are each composed of several lobules. Each lobe of the breast terminates in a major (lactiferous) duct (2 4 ... – PowerPoint PPT presentation

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Title: Anatomy


1
Anatomy
  • The breast is composed of 1520 lobes, which are
    each composed of several lobules.
  • Each lobe of the breast terminates in a major
    (lactiferous) duct (24 mm in diameter), which
    opens through a constricted orifice (0.40.7 mm
    in diam- eter) into the ampulla of the nipple.
  • Fibrous bands of connective tissue travel through
    the breast (suspensory ligaments of Cooper),
    which insert perpendicularly into the dermis and
    provide structural support.
  • The axillary tail of Spence extends laterally
    across the anterior axillary fold.
  • The upper outer quadrant of the breast contains a
    greater volume of tissue than do the other
    quadrants.

2
BLOOD SUPPLY, INNERVATION
  • Blood supply, innervation, and lymphatics. The
    breast receives its blood supply from (1)
    perforating branches of the internal mammary
    artery (2) lateral branches of the posterior
    intercostal arteries and (3) branches from the
    axillary artery, including the highest thoracic,
    lateral thoracic, and pectoral branches of the
    thoracoacromial artery.
  • The veins and lymph vessels of the breast follow
    the course of the arteries with venous drainage
    being toward the axilla. The vertebral venous
    plexus of Batson, which invests the vertebrae and
    extends from the base of the skull to the sacrum,
    can provide a
  • route for breast cancer metastases
  • to the vertebrae, skull, pelvic bones,
  • and central nervous system.

3
  • Lateral cutaneous branches of the third through
    sixth intercostal nerves provide sensory
    innervation of the breast (lateral mammary
    branches) and of the anterolateral chest wall.
  • The intercostobrachial nerve is the lateral
    cutaneous branch of the second intercostal nerve
    and may be visualized during surgical dissection
    of the axilla.
  • Resection of the intercostobrachial nerve causes
    loss of sensation over the medial aspect of the
    upper arm.

4
LYMPHATICS
  • The boundaries for lymph drainage of the axilla
    are not well demarcated, and there is
    considerable variation in the position of the
    axillary lymph nodes.
  • The 6 axillary lymph node groups recognized by
    surgeons are (1) the axillary vein group
    (lateral) (2) the external mammary group
    (anterior or pectoral) (3) the scapular group
    (posterior or subscapular) (4) the central
    group (5) the subclavicular group (apical) and
    (6) the interpectoral group (Rotters).

5
  • The lymph node groups are assigned levels
    according to their relationship to the pectoralis
    minor muscle.
  • Lymph nodes located lateral to or below the lower
    border of the pectoralis minor muscle are
    referred to as level I lymph nodes, which include
    the axillary vein, external mammary, and scapular
    groups.
  • Lymph nodes located superficial or deep to the
    pectoralis minor muscle are referred to as level
    II lymph nodes, which include the central and
    interpectoral groups.
  • Lymph nodes located medial to or above the upper
    border of the pectoralis minor muscle are
    referred to as level III lymph nodes, which make
    up the subclavicular group.
  • The axillary lymph nodes usually receive more
    than 75 percent of the lymph drainage from the
    breast.

6
Selected Benign Breast Disorders and
DiseasesCYSTS
  • Cysts In practice, the first investigation of
    palpable breast masses is frequently needle
    biopsy, which allows for the early diagnosis of
    cysts. A 21-gauge needle attached to a 10-mL
    syringe is placed directly into the mass. The
    volume of a typical cyst is 510 mL, but it may
    be 75 mL or more.
  • If the fluid that is aspirated is not
    bloodstained, then the cyst is aspirated to
    dryness, the needle is removed, and the fluid is
    discarded as cytologic examination of such fluid
    is not cost-effective. After aspiration, the
    breast is carefully palpated to exclude a
    residual mass. If one exists, ultrasound
    examination is performed to exclude a persistent
    cyst, which is reaspirated if present.
  • If the mass is solid, a tissue specimen is
    obtained.
  • When cystic fluid is bloodstained, 2 mL of fluid
    are taken for cytology.
  • The mass is then imaged with ultrasound and any
    solid area on the cyst wall is biopsied by
    needle.
  • The two cardinal rules of safe cyst aspiration
    are (1) the mass must disappear completely after
    aspiration, and (2) the fluid must not be
    bloodstained. If either of these conditions is
    not met, then ultrasound, needle biopsy, and
    perhaps excisional biopsy are recommended.

7
Selected Benign Breast Disorders and
DiseasesFIBROADENOMAS
  • Fibroadenomas Removal of all fibroadenomas has
    been advocated irrespective of patient age or
    other considerations, and solitary fibroadenomas
    in young women are frequently removed to
    alleviate patient concern.
  • Yet most fibroade- nomas are self-limiting and
    many go undiagnosed, so a more conservative
    approach is reasonable.
  • Careful ultrasound examination with core-needle
    biopsy will provide for an accurate diagnosis.
  • Subsequently, the patient is counseled concerning
    the biopsy results, and excision of the
    fibroadenoma may be avoided.

8
Selected Benign Breast Disorders and
DiseasesSCLEROSING DISORDERS
  • Sclerosing Disorders The clinical significance
    of sclerosing adenosis lies in its mimicry of
    cancer.
  • It may be confused with cancer on physical exam-
    ination, by mammography, and at gross pathologic
    examination.
  • Excisional biopsy and histologic examination are
    frequently necessary to exclude the diagnosis of
    cancer.
  • The diagnostic work-up for radial scars and
    complex scle- rosing lesions frequently involves
    stereoscopic biopsy.
  • It is usually not possible to differentiate these
    lesions with certainty from cancer by mammography
    features, hence biopsy is recommended.

9
Selected Benign Breast Disorders and
DiseasesPERIDUCTAL MASTITIS
  • Periductal Mastitis Painful and tender masses
    behind the nipple-areola complex are aspirated
    with a 21-gauge needle attached to a 10-mL
    syringe.
  • Any fluid obtained is submitted for cytology and
    for culture using a trans- port medium
    appropriate for the detection of anaerobic
    organisms.
  • Women are started on a combination of
    metronidazole and dicloxacillin while awaiting
    the results of culture.
  • A subareolar abscess usually is unilocular and
    often is associated with a single duct system.
    Preoperative ultrasound will accurately delineate
    its extent
  • The surgeon may either undertake simple drainage
    with a view toward formal surgery, should the
    problem recur, or proceed with definitive
    surgery.
  • In a woman of childbearing age, simple drainage
    is preferred, but if there is an anaerobic
    infection, recurrent infection frequently
    develops.
  • Recurrent abscess with fistula is a difficult
    problem and may be treated by fistulectomy or by
    major duct excision, depending on the
    circumstances.
  • Antibiotic therapy is useful for recurrent
    infection after fistula excision, and a 24-week
    course is recommended prior to total duct
    excision.

10
Selected Benign Breast Disorders and
DiseasesNIPPLE INVERSION
  • Nipple Inversion More women request correction
    of congenital nipple inversion than request
    correction for the nipple inversion that occurs
    secondary to duct ectasia.
  • surgical complications of altered nipple
    sensation, nipple necrosis, and postoperative
    fibrosis with nipple retraction.
  • Because nipple inversion is a result of
    shortening of the subareolar ducts, a complete
    division of these ducts is necessary for
    permanent correction of the disorder.

11
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTBacterial Infection
  • Bacterial infection. Staphylococcus aureus and
    Streptococcus species are the organisms most
    frequently recovered from nipple discharge from
    an infected breast.
  • Breast abscesses are typically seen in
    staphylococcal infections and present with point
    tenderness, erythema, and hyperthermia.
  • These abscesses are related to lactation and
    occur within the first few weeks of
    breast-feeding. Progression of a staphylococcal
    infection may result in subcutaneous, sub-
    areolar, interlobular (periductal), and
    retromammary abscesses (unicentric or
    multicentric),
  • necessitating operative drainage of fluctuant
    areas.
  • Preoperative ultrasonography is effective in
    delineating the extent of the needed drainage
    procedure, which is best accomplished via
    circumareolar incisions or incisions paralleling
    Langer lines.
  • Although staphylococcal infections tend to be
    more localized and may be located deep in the
    breast tissues, streptococcal infections usually
    present with diffuse superficial involvement.
  • They are treated with local wound care, including
    warm compresses, and the administration of
    intravenous antibiotics (penicillins or
    cephalosporins).
  • Breast infections may be chronic, possibly with
    recurrent abscess formation.
  • In this situation, cultures are taken to identify
    acid-fast bacilli, anaerobic and aerobic
    bacteria, and fungi.
  • Uncommon organisms may be encountered and
    long-term antibiotic therapy may be required.

12
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTHidradenitis Suppurativa
  • Hidradenitissuppurativa. Hidradenitis suppurativa
    of the nipple-areolacomplex or axilla is a
    chronic inflammatory condition that originates
    within the accessory areolar glands of Montgomery
    or within the axillary sebaceous glands.
  • When located in and about the nipple-areola
    complex, this disease may mimic other chronic
    inflammatory states, Paget disease of the nipple,
    or invasive breast cancer.
  • Involvement of the axillary skin is often
    multifocal and contiguous.
  • Antibiotic therapy with incision and drainage of
    fluctuant areas is appropriate treatment.
  • Complete excision of the involved areas may be
    required and may necessitate coverage with
    advancement flaps or split-thickness skin grafts.

13
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTMondor's Disease
  • Mondors disease. This variant of
    thrombophlebitis involves the superficial veins
    of the anterior chest wall and breast.
  • In 1939, Mondor described the condition as
    string phlebitis, a thrombosed vein presenting
    as a tender, cord- like structure.
  • Typically, a woman presents with acute pain in
    the lateral aspect of the breast or the anterior
    chest wall.
  • A tender, firm cord is found to follow the
    distribution of one of the major superficial
    veins.
  • Most women have no evidence of thrombophlebitis
    in other anatomic sites.
  • When the diagnosis is uncertain, or when a mass
    is present near the tender cord, biopsy is
    indicated.
  • Therapy for Mondor disease includes the liberal
    use of antiinflammatory medications and warm
    compresses that are applied along the symptomatic
    vein.
  • Restriction of motion of the ipsilateral
    extremity and shoulder and brassiere support of
    the breast are important.
  • The process usually resolves within 46 weeks.
    When symptoms persist or are refractory to
    therapy, excision of the involved vein segment is
    appropriate.

14
RISK FACTORS FOR BREAST CANCER
  • Hormonal Risk Factors
  • Increased exposure to estrogen is associated with
    an increased risk for developing breast cancer,
    whereas reducing exposure is thought to be
    protective
  • Correspondingly, factors that increase the number
    of menstrual cycles, such as early menarche,
    nulliparity, and late menopause, are associated
    with increased risk
  • Moderate levels of exercise and a longer
    lactation period, factors that decrease the total
    number of menstrual cycles, are protective.
  • Older age at first live birth is associated with
    an increased risk of breast cancer.
  • There is an association between obesity and
    increased breast cancer risk

15
RISK FACTORS FOR BREAST CANCER
  • Nonhormonal Risk Factors
  • Radiation (radiation therapy for Hodgkin's
    lymphoma have a breast cancer risk that is 75
    times greater)
  • Studies also suggest that the risk of breast
    cancer increases as the amount of alcohol a woman
    consumes increases.
  • high fat content diet

16
Risk Assessment
  • The average lifetime risk of breast cancer for
    newborn U.S. females is 12.
  • A software program incorporating the Gail model
    is available from the National Cancer Institute
    at http//bcra.nci.nih.gov/brc.
  • Claus and colleagues

17
Factors Associated with Increased Risk of Breast
Cancer
  • White
  • Older
  • Family history Breast cancer in mother, sister,
    or daughter (especially bilateral or
    premenopausal)
  • BRCA1 or BRCA2 mutation
  • Endometrial cancer
  • Proliferative forms of fibrocystic disease
  • Cancer in other breast
  • Early menarche (under age 12)
  • Late menopause (after age 50)
  • Nulliparous or late first pregnancy

18
screening mammography
  • Routine use of screening mammography in women 50
    years of age reduces mortality from breast cancer
    by 33.
  • This reduction comes without substantial risks
    and at an acceptable economic cost.
  • However, the use of screening mammography in
    women lt50 years of age is more controversial for
    several reasons (a) breast density is greater
    and screening mammography is less likely to
    detect early breast cancer (b) screening
    mammography results in more false-positive test
    findings, which results in unnecessary biopsies
    and (c) younger women are less likely to have
    breast cancer, so fewer young women will benefit
    from screening.
  • Current recommendations are that women undergo
    baseline mammography at age 35 and then have
    annual mammographic screening beginning at age 40.

19
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20
Incidence of Sporadic, Familial, and Hereditary
Breast Cancer
  • Sporadic breast cancer 6575
  • Familial breast cancer 2030
  • Hereditary breast cancer 510
  • BRCA1 a 45
  • BRCA2 35
  • p53a (Li-Fraumeni syndrome) 1
  • STK11/LKB1a (Peutz-Jeghers syndrome) lt1
  • PTENa (Cowden disease) lt1
  • MSH2/MLH1a (Muir-Torre syndrome) lt1
  • ATMa (Ataxia-telangiectasia) lt1
  • Unknown 20
  • Both BRCA1 and BRCA2 function as tumor-suppressor
    genes, and for each gene, loss of both alleles is
    required for the initiation of cancer.

21
BRCA MutationsBRCA1
  • Five to 10 of breast cancers are caused by
    inheritance of germline mutations such as BRCA1
    and BRCA2, which are inherited in an autosomal
    dominant fashion with varying penetrance
  • BRCA1 is located on chromosome arm 17q, spans a
    genomic region of approximately 100 kilobases
    (kb) of DNA, and contains 22 coding exons
  • Data accumulated since the isolation of the BRCA1
    gene suggest a role in transcription, cell-cycle
    control, and DNA damage repair pathways.
  • More than 500 sequence variations in BRCA1 have
    been identified.

22
  • predisposing genetic factor in as many as 45 of
    hereditary breast cancers and in at least 80 of
    hereditary ovarian cancers.
  • Female mutation carriers have up to a 90
    lifetime risk for developing breast cancer and up
    to a 40 lifetime risk for developing ovarian
    cancer
  • Approximately 50 of children of carriers inherit
    the trait.

23
  • In general, BRCA1-associated breast cancers are
    invasive ductal carcinomas, are poorly
    differentiated, and are hormone receptor
    negative.
  • BRCA1-associated breast cancers have a number of
    distinguishing clinical features, such as an
    early age of onset compared with sporadic cases
    a higher prevalence of bilateral breast cancer
    and the presence of associated cancers in some
    affected individuals, specifically ovarian cancer
    and possibly colon and prostate cancers.

24
BRCA2
  • BRCA2 is located on chromosome arm 13q and spans
    a genomic region of approximately 70 kb of DNA.
    The 11.2-kb coding region contains 26 coding
    exons
  • The biologic function of BRCA2 is not well
    defined, but like BRCA1, it is postulated to play
    a role in DNA damage response pathways.
  • BRCA2 messenger RNA also is expressed at high
    levels in the late G1 and S phases of the cell
    cycle.
  • The mutational spectrum of BRCA2 is not as well
    established as that of BRCA1. To date, gt250
    mutations have been found

25
  • The breast cancer risk for BRCA2 mutation
    carriers is close to 85, and the lifetime
    ovarian cancer risk, while lower than for BRCA1,
    is still estimated to be close to 20.
  • Breast cancer susceptibility in BRCA2 families is
    an autosomal dominant trait and has a high
    penetrance.
  • Approximately 50 of children of carriers inherit
    the trait.
  • Unlike male carriers of BRCA1 mutations, men with
    germline mutations in BRCA2 have an estimated
    breast cancer risk of 6, which represents a
    100-fold increase over the risk in the general
    male population.

26
  • BRCA2- associated breast cancers are invasive
    ductal carcinomas, which are more likely to be
    well differentiated and to express hormone
    receptors than are BRCA1-associated breast
    cancers.
  • BRCA2-associated breast cancer has a number of
    distinguishing clinical features, such as an
    early age of onset compared with sporadic cases,
    a higher prevalence of bilateral breast cancer,
    and the presence of associated cancers in some
    affected individuals, specifically ovarian,
    colon, prostate, pancreatic, gallbladder, bile
    duct, and stomach cancers, as well as melanoma.
  • The 6174delT mutation is found in Ashkenazi Jews
    with a prevalence of 1.2. Another BRCA2 founder
    mutation, 999del5, is observed in Icelandic and
    Finnish populations.

27
CANCER PREVENTION FOR BRCA MUTATION CARRIERS
  • Risk management strategies for BRCA1 and BRCA2
    mutation carriers include the following
  • 1. Prophylactic mastectomy and reconstruction
  • 2. Prophylactic oophorectomy and hormone
    replacement therapy
  • 3. Intensive surveillance for breast and ovarian
    cancer
  • 4. Chemoprevention

28
Chemoprevention
  • Despite a 49 reduction in the incidence of
    breast cancer in high-risk women taking
    tamoxifen, it is too early to recommend the use
    of tamoxifen uniformly for BRCA mutation
    carriers.
  • Cancers arising in BRCA1 mutation carriers are
    usually high grade and are most often hormone
    receptor negative.
  • Approximately 66 of BRCA1-associated DCIS
    lesions are estrogen receptor negative, which
    suggests early acquisition of the
    hormoneindependent phenotype. Tamoxifen appears
    to be more effective at preventing estrogen
    receptorpositive breast cancers.

29
EPIDEMIOLOGY AND NATURAL HISTORY OF BREAST CANCER
  • Breast cancer is the most common site-specific
    cancer in women and is the leading cause of death
    from cancer for women aged 20 to 59 years

30
PRIMARY BREAST CANCER
  • More than 80 of breast cancers show productive
    fibrosis that involves the epithelial and stromal
    tissues.

31
  • With growth of the cancer and invasion of the
    surrounding breast tissues, the accompanying
    desmoplastic response entraps and shortens
    Cooper's suspensory ligaments to produce a
    characteristic skin retraction.

32
  • Localized edema (peau d'orange) develops when
    drainage of lymph fluid from the skin is
    disrupted.

33
  • With continued growth, cancer cells invade the
    skin, and eventually ulceration occurs. As new
    areas of skin are invaded, small satellite
    nodules appear near the primary ulceration.

34
  • The size of the primary breast cancer correlates
    with disease-free and overall survival, but there
    is a close association between cancer size and
    axillary lymph node involvement

35
AXILLARY LYMPH NODE METASTASES
  • As the size of the primary breast cancer
    increases, some cancer cells are shed into
    cellular spaces and transported via the lymphatic
    network of the breast to the regional lymph
    nodes, especially the axillary lymph nodes. Lymph
    nodes that contain metastatic cancer are at first
    ill defined and soft but become firm or hard with
    continued growth of the metastatic cancer.
  • the most important prognostic correlate of
    disease-free and overall survival is axillary
    lymph node status

36
DISTANT METASTASES
  • At approximately the twentieth cell doubling,
    breast cancers acquire their own blood supply
    (neovascularization).
  • Thereafter, cancer cells may be shed directly
    into the systemic venous blood to seed the
    pulmonary circulation via the axillary and
    intercostal veins or the vertebral column via
    Batson's plexus of veins, which courses the
    length of the vertebral column.
  • These cells are scavenged by natural killer
    lymphocytes and macrophages.
  • Successful implantation of metastatic foci from
    breast cancer predictably occurs after the
    primary cancer exceeds 0.5 cm in diameter, which
    corresponds to the twenty-seventh cell doubling.
  • Common sites of involvement, in order of
    frequency, are bone, lung, pleura, soft tissues,
    and liver.

37
HISTOPATHOLOGY OF BREAST CANCER
  • Carcinoma in Situ
  • LOBULAR CARCINOMA IN SITU
  • DUCTAL CARCINOMA IN SITU
  • Invasive Breast Carcinoma
  • 1. Paget's disease of the nipple
  • 2. Invasive ductal carcinoma
  • 3. Adenocarcinoma with productive fibrosis
    (scirrhous, simplex, NST), 80 (invasive ductal
    carcinoma of no special type)
  • 4. Medullary carcinoma, 4
  • 5. Mucinous (colloid) carcinoma, 2
  • 6. Papillary carcinoma, 2
  • 7. Tubular carcinoma, 2
  • 8. Invasive lobular carcinoma, 10
  • 9. Rare cancers (adenoid cystic, squamous cell,
    apocrine)

38
Carcinoma in Situ
  • Cancer cells are in situ or invasive depending on
    whether or not they invade through the basement
    membrane
  • Foote and Stewart published a landmark
    description of LCIS, which distinguished it from
    DCIS
  • In the late 1960s, Gallagher and Martin published
    their study of whole-breast sections and
    described a stepwise progression from benign
    breast tissue to in situ cancer and subsequently
    to invasive cancer. They coined the term minimal
    breast cancer (LCIS, DCIS, and invasive cancers
    smaller than 0.5 cm in size) and stressed the
    importance of early detection
  • It is now recognized that each type of minimal
    breast cancer has a distinct clinical and
    biologic behavior.

39
Lobular Carcinoma In Situ
  • LCIS originates from the terminal duct lobular
    units and develops only in the female breast. It
    is characterized by distention and distortion of
    the terminal duct lobular units
  • LCIS may be observed in breast tissues that
    contain microcalcifications, but the
    calcifications associated with LCIS typically
    occur in adjacent tissues. This neighborhood
    calcification is a feature that is unique to LCIS
    and contributes to its diagnosis.
  • The frequency of LCIS in the general population
    cannot be reliably determined because it usually
    presents as an incidental finding.
  • The average age at diagnosis is 45 years, which
    is approximately 15 to 25 years younger than the
    age at diagnosis for invasive breast cancer.

40
Lobular Carcinoma In Situ
  • Invasive breast cancer develops in 25 to 35 of
    women with LCIS.
  • Invasive cancer may develop in either breast,
    regardless of which breast harbored the initial
    focus of LCIS, and is detected synchronously with
    LCIS in 5 of cases.
  • In women with a history of LCIS, up to 65 of
    subsequent invasive cancers are ductal, not
    lobular, in origin. For these reasons, LCIS is
    regarded as a marker of increased risk for
    invasive breast cancer rather than as an anatomic
    precursor.
  • Individuals should be counseled regarding their
    risk of developing breast cancer and appropriate
    risk reduction strategies, including observation
    with screening, chemoprevention, and
    risk-reducing bilateral mastectomy.

41
Ductal Carcinoma In Situ.
  • Published series suggest a detection frequency of
    7 in all biopsy tissue specimens.
  • DCIS, which carries a high risk for progression
    to an invasive cancer.
  • Histologically, DCIS is characterized by a
    proliferation of the epithelium that lines the
    minor ducts, resulting in papillary growths
    within the duct lumina.
  • papillary growth pattern, cribriform growth
    pattern, solid growth pattern, comedo growth
    pattern,
  • Calcium deposition occurs in the areas of
    necrosis and is a common feature seen on
    mammography.
  • Figure From The Breast. Schwartz's Principles
    of Surgery, 10e, 2014

42
Ductal Carcinoma In Situ.
  • The risk for invasive breast cancer is increased
    nearly fivefold in women with DCIS
  • The invasive cancers are observed in the
    ipsilateral breast, usually in the same quadrant
    as the DCIS that was originally detected, which
    suggests that DCIS is an anatomic precursor of
    invasive ductal carcinoma

43
  • DCIS is now frequently classified based on
    nuclear grade and the presence of necrosis

44
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45
Invasive Breast Carcinoma
  • Invasive breast cancers have been described as
    lobular or ductal in origin
  • About 80 of invasive breast cancers are
    described as invasive ductal carcinoma of no
    special type (NST). These cancers generally have
    a worse prognosis than special-type cancers.
  • Foote and Stewart originally proposed the
    following classification for invasive breast
    cancer.
  • Pagets disease of the nipple
  • Invasive ductal carcinomaAdenocarcinoma with
    productive fibrosis (scirrhous, simplex, NST),
    80
  • Medullary carcinoma, 4
  • Mucinous (colloid) carcinoma, 2
  • Papillary carcinoma, 2
  • Tubular carcinoma, 2
  • Invasive lobular carcinoma, 10
  • Rare cancers (adenoid cystic, squamous cell,
    apocrine)

46
Pagets disease of the nipple
  • Pagets disease of the nipple was described in
    1874.
  • It frequently presents as a chronic, eczematous
    eruption of the nipple, which may be subtle but
    may progress to an ulcerated, weeping lesion.
  • Pagets disease usually is associated with
    extensive DCIS and may be associated with an
    invasive cancer.
  • A palpable mass may or may not be present.
  • A nipple biopsy specimen will show a population
    of cells that are identical to the underlying
    DCIS cells (pagetoid features or pagetoid
    change). Pathognomonic of this cancer is the
    presence of large, pale, vacuolated cells (Paget
    cells) in the rete pegs of the epithelium.
    Pagets disease may be confused with superficial
    spreading melanoma. Differentiation from pagetoid
    intraepithelial melanoma is based on the presence
    of S-100 antigen immunostaining in melanoma and
    carcinoembryonic antigen immunostaining in
    Pagets disease.
  • Surgical therapy for Pagets disease may involve
    lumpectomy or mastectomy, depending on the extent
    of involvement of the nipple-areolar complex and
    the presence of DCIS or invasive cancer in the
    underlying breast parenchyma.

47
Invasive ductal carcinoma
  • Invasive ductal carcinoma of the breast with
    productive fibrosis (scirrhous, simplex, NST)
    accounts for 80 of breast cancers and presents
    with macroscopic or microscopic axillary lymph
    node metastases in up to 25 of screen-detected
    cases and up to 60 of symptomatic cases.
  • This cancer occurs most frequently in
    perimenopausal or postmenopausal women in the
    fifth to sixth decades of life as a solitary,
    firm mass.
  • It has poorly defined margins and its cut
    surfaces show a central stellate configuration
    with chalky white or yellow streaks extending
    into surrounding breast tissues.
  • In a large patient series, 75 of ductal cancers
    showed estrogen receptor expression.

48
Invasive lobular carcinoma
  • Invasive lobular carcinoma accounts for 10 of
    breast cancers.
  • Special stains may confirm the presence of
    intracytoplasmic mucin, which may displace the
    nucleus (signet-ring cell carcinoma).
  • At presentation, invasive lobular carcinoma
    varies from clinically inapparent carcinomas to
    those that replace the entire breast with a
    poorly defined mass.
  • It is frequently multifocal, multicentric, and
    bilateral. Because of its insidious growth
    pattern and subtle mammographic features,
    invasive lobular carcinoma may be difficult to
    detect.
  • Over 90 of lobular cancers express estrogen
    receptor.

49
DIAGNOSIS OF BREAST CANCER
  • In30 of cases, the woman discovers a lump in
    her breast. Other less frequent presenting signs
    and symptoms of breast cancer include
  • (a) breast enlargement or asymmetry
  • (b) nipple changes, retraction, or discharge
  • (c) ulceration or erythema of the skin of the
    breast
  • (d) an axillary mass and
  • (e) musculoskeletal discomfort.
  • Breast pain usually is associated with benign
    disease.
  • Diagnosis of breast cancer
  • Examination
  • Imaging Techniques Mammography, Ductography,
    Ultrasonography, Magnetic Resonance Imaging
  • Breast Biopsy

50
Examination
  • Symmetry, size, and shape of the breast are
    recorded, as well as any evidence of edema
    (peaudorange), nipple or skin retraction, or
    erythema.
  • Careful palpation of supraclavicular and
    parasternal sites also is performed.
  • A diagram of the chest and contiguous lymph node
    sites is useful for recording location, size,
    consistency, shape, mobility, fixation, and other
    characteristics of any palpable breast mass or
    lymphadenopathy

51
Imaging Techniques Mammography
  • Mammography has been used in North America since
    the 1960s
  • Conventional mammography delivers a radiation
    dose of 0.1 cGy per study. By comparison, chest
    radiography delivers 25 of this dose. However,
    there is no increased breast cancer risk
    associated with the radiation dose delivered with
    screening mammography.
  • Screening mammography is used to detect
    unexpected breast cancer in asymptomatic women.
    In this regard, it supplements history taking and
    physical examination.
  • With screening mammography, two views of the
    breast are obtained, the craniocaudal (CC) view
    and the mediolateral oblique (MLO) view. The MLO
    view images the greatest volume of breast tissue,
    including the upper outer quadrant and the
    axillary tail of Spence.
  • Compared with the MLO view, the CC view provides
    better visualization of the medial aspect of the
    breast and permits greater breast compression.
  • Diagnostic mammography is used to evaluate women
    with abnormal findings such as a breast mass or
    nipple discharge.

52
Imaging Techniques Mammography
  • Spot compression may be done in any projection by
    using a small compression device, which is placed
    directly over a mammographic abnormality that is
    obscured by overlying tissues.
  • The compression device minimizes motion artifact,
    improves definition, separates overlying tissues,
    and decreases the radiation dose needed to
    penetrate the breast.
  • Magnification techniques (1.5) often are
    combined with spot compression to better resolve
    calcifications and the margins of masses.
  • Mammography also is used to guide interventional
    procedures, including needle localization and
    needle biopsy.
  • Specific mammographic features that suggest a
    diagnosis of breast cancer include a solid mass
    with or without stellate features, asymmetric
    thickening of breast tissues, and clustered
    microcalcifications

53
Imaging Techniques Mammography
  • These microcalcifications are an especially
    important sign of cancer in younger women, in
    whom it may be the only mammographic abnormality.
  • The clinical impetus for screening mammography
    came from the Health Insurance Plan study and the
    Breast Cancer Detection Demonstration Project,
    which demonstrated a 33 reduction in mortality
    for women after screening mammography.
  • Current guidelines of the National Comprehensive
    Cancer Network suggest that normal-risk women 20
    years of age should have a breast examination at
    least every 3 years.
  • Starting at age 40 years, breast examinations
    should be performed yearly and a yearly mammogram
    should be taken.
  • The benefits from screening mammography in women
    50 years of age has been noted above to be
    between 20 and 25 reduction in breast cancer
    mortality

54
Imaging Techniques Mammography
  • The use of screening mammography in women lt50
    years of age is more controversial again for
    reasons noted above (a) reduced sensitivity (b)
    reduced specificity and (c) lower incidence of
    breast cancer.
  • For the combination of these three reasons
    targeting mammography screening to women lt50
    years at higher risk of breast cancer improves
    the balance of risks and benefits and is the
    approach some health care systems have taken.

55
Imaging Techniques Ductography
  • The primary indication for ductography is nipple
    discharge, particularly when the fluid contains
    blood.
  • Radiopaque contrast media is injected into one or
    more of the major ducts and mammography is
    performed.
  • A duct is gently enlarged with a dilator and then
    a small, blunt cannula is inserted under sterile
    conditions into the nipple ampulla.
  • With the patient in a supine position, 0.1 to 0.2
    mL of dilute contrast media is injected and CC
    and MLO mammographic views are obtained without
    compression.
  • Intraductal papillomas are seen as small filling
    defects surrounded by contrast media.
  • Cancers may appear as irregular masses or as
    multiple intraluminal filling defects.

56
Imaging Techniques Ultrasonography
  • Second only to mammography in frequency of use
    for breast imaging, ultrasonography is an
    important method of resolving equivocal
    mammographic findings, defining cystic masses,
    and demonstrating the echogenic qualities of
    specific solid abnormalities.
  • Benign breast masses usually show smooth
    contours, round or oval shapes, weak internal
    echoes, and well-defined anterior and posterior
    margins. Breast cancer characteristically has
    irregular walls but may have smooth margins with
    acoustic enhancement.
  • Ultrasonography is used to guide fine-needle
    aspiration biopsy, core-needle biopsy, and needle
    localization of breast lesions.
  • Ultrasonography can also be utilized to image the
    regional lymph nodes in patients with breast
    cancer.

57
Imaging Techniques Magnetic Resonance Imaging
  • In the process of evaluating magnetic resonance
    imaging (MRI) as a means of characterizing
    mammographic abnormalities, additional breast
    lesions have been detected. However, in the
    circumstance of negative findings on both
    mammography and physical examination, the
    probability of a breast cancer being diagnosed by
    MRI is extremely low.
  • There is current interest in the use of MRI to
    screen the breasts of high-risk women and of
    women with a newly diagnosed breast cancer. 1)
    women who have a strong family history of breast
    cancer or who carry known genetic mutations
    require screening at an early age, because
    mammographic evaluation is limited due to the
    increased breast density in younger women. 2) an
    MRI study of the contralateral breast in women
    with a known breast cancer has shown a
    contralateral breast cancer in 5.7 of these
    women.
  • MRI can also detect additional tumors in the
    index breast (multifocal or multicentric disease)
    that may be missed on routine breast imaging and
    this may alter surgical decision making. In fact,
    MRI has been advocated by some for routine use in
    surgical treatment planning based on the fact
    that additional disease can be identified with
    this advanced imaging modality and the extent of
    disease may be more accurately assessed.

58
Breast Biopsy, Nonpalpable Lesions.
  • Image-guided breast biopsy specimens are
    frequently required to diagnose nonpalpable
    lesions.
  • Ultrasound localization techniques are used when
    a mass is present, whereas stereotactic
    techniques are used when no mass is present
    (microcalcifications or architectural distortion
    only).
  • The combination of diagnostic mammography,
    ultrasound or stereotactic localization, and
    fine-needle aspiration (FNA) biopsy achieves
    almost 100 accuracy in the preoperative
    diagnosis of breast cancer.
  • The advantages of core-needle biopsy include a
    low complication rate, minimal scarring, and a
    lower cost compared with excisional breast biopsy.

59
Breast Biopsy, Palpable Lesions.
  • FNA or core biopsy of a palpable breast mass can
    usually be performed in an outpatient setting.
  • A 1.5-in, 22-gauge needle attached to a 10-mL
    syringe or a 14 gauge core biopsy needle is used.
  • The cellular material is then expressed onto
    microscope slides. Both air-dried and 95
    ethanolfixed microscopic sections are prepared
    for analysis
  • Automated devices also are available. Vacuum
    assisted core biopsy devices (with 810 gauge
    needles) are commonly utilized with image
    guidance where between 4 and 12 samples can be
    acquired at different positions within a mass,
    area of architectural distortion or
    microcalcifications. If the target lesion was
    microcalcifications, the specimen should be
    radiographed to confirm appropriate sampling. A
    radiopaque marker should be placed at the site of
    the biopsy to mark the area for future
    intervention
  • Tissue specimens are placed in formalin and then
    processed to paraffin blocks

60
Examination
  • INSPECTION
  • PALPATION

61
BREAST CANCER STAGING
  • The clinical stage of breast cancer is determined
    primarily through physical examination of the
    skin, breast tissue, and regional lymph nodes
    (axillary, supraclavicular, and cervical).
  • Mammography, chest radiography, and
    intraoperative findings (primary tumor size,
    chest wall invasion) also provide necessary
    staging information.
  • Pathologic stage combines the findings from
    pathologic examination of the resected primary
    breast cancer and axillary or other regional
    lymph nodes.
  • A frequently used staging system is the TNM
    (tumor, nodes, and metastasis) system.
  • The single most important predictor of 10- and
    20-year survival rates in breast cancer is the
    number of axillary lymph nodes involved with
    metastatic disease.
  • Routine biopsy of internal mammary lymph nodes is
    not generally performed however, with the advent
    of sentinel lymph node dissection and the use of
    preoperative lymphoscintigraphy for localization
    of the sentinel nodes, surgeons have begun to
    biopsy the internal mammary nodes in some cases

62
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63
SURGICAL TECHNIQUES IN BREAST CANCER THERAPY
  • Breast Conservation
  • Mastectomy and Axillary Dissection
  • MODIFIED RADICAL MASTECTOMY

64
Breast Conservation
  • Breast conservation involves resection of the
    primary breast cancer with a margin of
    normal-appearing breast tissue, adjuvant
    radiation therapy, and assessment of regional
    lymph node status.
  • Resection of the primary breast cancer is
    alternatively called segmental mastectomy,
    lumpectomy, partial mastectomy, wide local
    excision, and tylectomy. For many women with
    stage I or II breast cancer, breast-conserving
    therapy (BCT) is preferable to total mastectomy
    because BCT produces survival rates equivalent to
    those after total mastectomy while preserving the
    breast
  • BCT allows for preservation of breast shape and
    skin as well as preservation of sensation, and
    provides an overall psychologic advantage
    associated with breast preservation.
  • Breast conservation surgery is currently the
    standard treatment for women with stage 0, I, or
    II invasive breast cancer. Women with DCIS
    require only resection of the primary cancer and
    adjuvant radiation therapy without assessment of
    regional lymph nodes.
  • Sentinel lymph node dissection is now the
    preferred staging procedure with a clinically
    node-negative axilla

65
Oncoplastic techniques are of prime consideration
when
  • (a) a significant area of breast skin will need
    to be resected with the specimen to achieve
    negative margins
  • (b) a large volume of
  • breast parenchyma will be resected resulting in a
    significant defect
  • (c) the tumor is located between the nipple and
    the inframammary fold, an area often associated
    with unfavorable cosmetic outcomes or
  • (d) excision of the tumor and closure of the
    breast may result in malpositioning of the nipple.

66
Mastectomy and Axillary Dissection
  • A skin-sparing mastectomy removes all breast
    tissue, the nipple-areola complex, and scars from
    any prior biopsy procedures. There is a
    recurrence rate of less than 6 to 8, comparable
    to the long-term recurrence rates reported with
    standard mastectomy, when skin-sparing mastectomy
    is used for patients with T1 to T3 cancers.
  • A total (simple) mastectomy without skin sparing
    removes all breast tissue, the nipple-areola
    complex, and skin.
  • An extended simple mastectomy removes all breast
    tissue, the nipple-areola complex, skin, and the
    level I axillary lymph nodes.
  • The Halsted radical mastectomy removes all breast
    tissue and skin, the nipple-areola complex, the
    pectoralis major and pectoralis minor muscles,
    and the level I, II, and III axillary lymph
    nodes.
  • The use of systemic chemotherapy and hormonal
    therapy as well as adjuvant radiation therapy for
    breast cancer have nearly eliminated the need for
    the radical mastectomy.

67
MODIFIED RADICAL MASTECTOMY
  • A modified radical mastectomy preserves both the
    pectoralis major and pectoralis minor muscles,
    allowing removal of level I and level II axillary
    lymph nodes but not the level III (apical)
    axillary lymph nodes
  • Anatomic boundaries of the modified radical
    mastectomy are the anterior margin of the
    latissimus dorsi muscle laterally, the midline of
    the sternum medially, the subclavius muscle
    superiorly, and the caudal extension of the
    breast 2 to 3 cm inferior to the inframammary
    fold inferiorly

68
  • The most lateral extent of the axillary vein is
    identified and the areolar tissue of the lateral
    axillary space is elevated as the vein is cleared
    on its anterior and inferior surfaces.
  • The long thoracic nerve of Bell is identified and
    preserved as it travels in the investing fascia
    of the serratus anterior muscle. Every effort is
    made to preserve this nerve, because permanent
    disability with a winged scapula and shoulder
    weakness will follow denervation of the serratus
    anterior muscle.
  • Care is taken to preserve the thoracodorsal
    neurovascular bundle.

69
In Situ Breast Cancer (Stage 0)
  • Both LCIS and DCIS may be difficult to
    distinguish from atypical hyperplasia or from
    cancers with early invasion. Expert pathologic
    review is required in all cases.
  • Bilateral mammography is performed to determine
    the extent of the in situ cancer and to exclude a
    second cancer. Because LCIS is considered a
    marker for increased risk rather than an
    inevitable precursor of invasive disease, the
    current treatment options for LCIS include
    observation, chemoprevention with tamoxifen, and
    bilateral total mastectomy.
  • There is no benefit to excising LCIS, because the
    disease diffusely involves both breasts
  • in many cases and the risk of invasive cancer is
    equal for both breasts. The use of tamoxifen as a
    risk reduction strategy should
  • be considered in women with a diagnosis of LCIS.

70
In Situ Breast Cancer (Stage 0)
  • Women with DCIS and evidence of extensive disease
    (gt4 cm of disease or disease in more than one
    quadrant) usually require mastectomy.
  • For women with limited disease, lumpectomy and
    radiation therapy are recommended.
  • For nonpalpable DCIS, needle localization
    techniques are used to guide the surgical
    resection. Specimen mammography is performed to
    ensure that all visible evidence of cancer is
    excised
  • The gold standard against which breast
    conservation therapy for DCIS is evaluated is
    mastectomy. Women treated with mastectomy have
    local recurrence and mortality rates of lt2.
    Women treated with lumpectomy and adjuvant
    radiation therapy have a similar mortality rate,
    but the local recurrence rate increases to 9.
  • Forty-five percent of these recurrences will be
    invasive cancer when radiation therapy is not
    used.

71
Early Invasive Breast Cancer (Stage I, IIA, or
IIB)
  • the disease-free, distant disease-free, and
    overall survival rates for lumpectomy with or
    without radiation therapy were similar to those
    observed after total mastectomy.
  • However, the incidence of ipsilateral breast
    cancer recurrence (in-breast recurrence) was
    higher in the lumpectomy group not receiving
    radiation therapy. (39.2 14.3)
  • These findings supported the use of lumpectomy
    and radiation therapy in the treatment of stage I
    and II breast cancer.

72
  • Currently, mastectomy with assessment of axillary
    lymph node status and breast conserving surgery
    with assessment of axillary lymph node status and
    radiation therapy are considered equivalent
    treatments for patients with stage I and II
    breast cancer.
  • Axillary lymphadenopathy confirmed to be
    metastatic disease or metastatic disease in a
    sentinel lymph node necessitates an axillary
    lymph node dissection.

73
Relative contraindications to breast conservation
therapy
  • (a) prior radiation therapy to the breast or
    chest wall,
  • (b) involved surgical margins or unknown margin
    status after re-excision,
  • (c) multicentric disease, and
  • (d) scleroderma or lupus erythematosus.

74
  • Traditionally, dissection of the level I and II
    axillary lymph nodes has been performed in early
    invasive breast cancer.
  • Sentinel lymph node dissection is now considered
    the standard for evaluation of the axillary lymph
    node status in women who have clinically negative
    lymph nodes.
  • Candidates for this procedure have clinically
    uninvolved axillary lymph nodes with a T1 or T2
    primary breast cancer. Controversy remains about
    the suitability of sentinel node dissection in
    women with larger primary tumors (T3) and those
    treated with neoadjuvant chemotherapy

75
Advanced Local-Regional Breast Cancer (Stage IIIA
or IIIB)
  • Women with stage IIIA and IIIB breast cancer have
    advanced local-regional breast cancer but have no
    clinically detected distant metastases.
  • surgery is integrated with radiation therapy and
    chemotherapy
  • Surgical therapy for women with stage III disease
    is usually a modified radical mastectomy,
    followed by adjuvant radiation therapy.
    Chemotherapy is used to maximize distant
    disease-free survival, whereas radiation therapy
    is used to maximize local-regional disease-free
    survival. In selected patients with stage IIIA
    cancer, neoadjuvant (preoperative) chemotherapy
    can reduce the size of the primary cancer and
    permit breast-conserving surgery.

76
Distant Metastases (Stage IV)
  • Treatment for stage IV breast cancer is not
    curative but may prolong survival and enhance a
    woman's quality of life
  • Hormonal therapies that are associated with
    minimal toxicity are preferred to cytotoxic
    chemotherapy.
  • Appropriate candidates for initial hormonal
    therapy include women with hormone
    receptorpositive cancers women with bone or
    soft tissue metastases only and women with
    limited and asymptomatic visceral metastases.
  • Systemic chemotherapy is indicated for women with
    hormone receptornegative cancers, symptomatic
    visceral metastases, and hormone-refractory
    metastases.

77
SPECIAL CLINICAL SITUATIONS
  • Nipple Discharge
  • UNILATERAL NIPPLE DISCHARGE
  • BILATERAL NIPPLE DISCHARGE
  • Axillary Lymph Node Metastases in the Setting of
    an Unknown Primary Cancer
  • Breast Cancer during Pregnancy
  • Male Breast Cancer
  • Phyllodes Tumors
  • Inflammatory Breast Carcinoma
  • Rare Breast Cancers
  • SQUAMOUS CELL (EPIDERMOID) CARCINOMA
  • ADENOID CYSTIC CARCINOMA
  • APOCRINE CARCINOMA
  • SARCOMAS
  • LYMPHOMAS

78
Nipple DischargeUNILATERAL NIPPLE DISCHARGE
  • Nipple discharge is a finding that can be seen in
    a number of clinical situations.
  • It may be suggestive of cancer if it is
    spontaneous, unilateral, localized to a single
    duct, present in women 40 years of age, bloody,
    or associated with a mass
  • mammography and ultrasound are indicated for
    further evaluation.
  • A ductogram also can be useful and is performed
    by cannulating a single discharging duct with a
    small nylon catheter or needle and injecting 1.0
    mL of watersoluble contrast solution.
  • Nipple discharge associated with a cancer may be
    clear, bloody, or serous. Testing for the
    presence of hemoglobin is helpful, but hemoglobin
    may also be detected when nipple discharge is
    secondary to an intraductal papilloma or duct
    ectasia.
  • Definitive diagnosis depends on excisional biopsy
    of the offending duct and any associated mass
    lesion
  • Another approach is to inject methylene blue dye
    within the duct after ductography.
  • Needle localization biopsy is performed when
    there is an associated mass that lies gt2.0 to 3.0
    cm from the nipple.

79
Nipple DischargeBILATERAL NIPPLE DISCHARGE
  • Nipple discharge is suggestive of a benign
    condition if it is bilateral and multiductal in
    origin, occurs in women 39 years of age, or is
    milky or blue-green.
  • Prolactin-secreting pituitary adenomas are
    responsible for bilateral nipple discharge in lt2
    of cases.
  • If serum prolactin levels are repeatedly
    elevated, plain radiographs of the sella turcica
    are indicated and thin section CT scan is
    required.
  • Optical nerve compression, visual field loss, and
    infertility are associated with large pituitary
    adenomas.

80
Axillary Lymph Node Metastases in the Setting of
an Unknown Primary Cancer
  • A woman who presents with an axillary lymph node
    metastasis that is consistent with a breast
    cancer metastasis has a 90 probability of
    harboring an occult breast cancer
  • However, axillary lymphadenopathy is the initial
    presenting sign in only 1 of breast cancer
    patients.
  • Fine-needle aspiration biopsy, core-needle
    biopsy, or open biopsy of an enlarged axillary
    lymph node is performed to confirm metastatic
    disease.
  • When metastatic cancer is found,
    immunohistochemical analysis may classify the
    cancer as epithelial, melanocytic, or lymphoid in
    origin.
  • The presence of hormone receptors (estrogen or
    progesterone receptors) suggests metastasis from
    a breast cancer but is not diagnostic.

81
Axillary Lymph Node Metastases in the Setting of
an Unknown Primary Cancer
  • The search for a primary cancer includes careful
    examination of the thyroid, breast, and pelvis,
    including the rectum.
  • The breast should be examined with diagnostic
    mammography, ultrasonography, and MRI to evaluate
    for an occult primary lesion.
  • Further radiologic and laboratory studies should
    include chest radiography and liver function
    studies. Chest, abdominal, and pelvic CT scans
    also are indicated, as is a bone scan to rule out
    distant metastasis.
  • Suspicious findings on mammography,
    ultrasonography, or MRI necessitate breast
    biopsy.
  • When a breast cancer is found, treatment consists
    of an axillary lymph node dissection with a
    mastectomy or preservation of the breast followed
    by whole-breast radiation therapy.
  • Chemotherapy and endocrine therapy should be
    considered.

82
Breast Cancer during Pregnancy
  • Breast cancer occurs in 1 of every 3000 pregnant
    women, and axillary lymph node metastases are
    present in up to 75 of these women
  • The average age of the pregnant woman with breast
    cancer is 34 years.
  • Fewer than 25 of the breast nodules developing
    during pregnancy and lactation will be cancerous.
  • Ultrasonography and needle biopsy are used in the
    diagnosis of these nodules.
  • Open biopsy may be required.
  • Mammography is rarely indicated because of its
    decreased sensitivity during pregnancy and
    lactation however, the fetus can be shielded if
    mammography is needed.

83
Breast Cancer during Pregnancy
  • Approximately 30 of the benign conditions
    encountered will be unique to pregnancy and
    lactation (galactoceles, lobular hyperplasia,
    lactating adenoma, and mastitis or abscess).
  • Once a breast cancer is diagnosed, complete blood
    count, chest radiography (with shielding of the
    abdomen), and liver function studies are
    performed.

84
Breast Cancer during Pregnancy
  • Because of the potential deleterious effects of
    radiation therapy on the fetus, radiation cannot
    be considered until the fetus is delivered.
  • A modified radical mastectomy can be performed
    during the first and second trimesters of
    pregnancy, even though there is an increased risk
    of spontaneous abortion after first-trimester
    anesthesia.
  • During the third trimester, lumpectomy with
    axillary node dissection can be considered if
    adjuvant radiation therapy is deferred until
    after delivery.
  • Lactation is suppressed.

85
Breast Cancer during Pregnancy
  • Chemotherapy administered during the first
    trimester carries a risk of spontaneous abortion
    and a 12 risk of birth defects.
  • There is no evidence of teratogenicity resulting
    from administration of chemotherapeutic agents in
    the second and third trimesters.
  • For this reason, many clinicians now consider
    the optimal strategy to be delivery of
    chemotherapy in the second and third trimesters
    as a neoadjuvant approach, which allows local
    therapy decisions to be made after the delivery
    of the baby.
  • Pregnant women with breast cancer often present
    at a later stage of disease because breast tissue
    changes that occur in the hormone-rich
    environment of pregnancy obscure early cancers.
  • However, pregnant women with breast cancer have a
    prognosis, stage by stage, that is similar to
    that of nonpregnant women with breast cancer.

86
Male Breast Cancer
  • Fewer than 1 of all breast cancers occur in men.
  • Breast cancer is rarely seen in young males and
    has a peak incidence in the sixth decade of life.
  • A firm, nontender mass in the male breast
    requires investigation. Skin or chest wall
    fixation is particularly worrisome.
  • It is associated with radiation exposure,
    estrogen therapy, testicular feminizing
    syndromes, and Klinefelter's syndrome (XXY ).
  • DCIS makes up lt15 of male breast cancer, whereas
    infiltrating ductal carcinoma makes up gt85.

87
Male Breast Cancer
  • Male breast cancer is staged in the same way as
    female breast cancer, and stage by stage, men
    with breast cancer have the same survival rate as
    women.
  • Overall, men do worse because of the advanced
    stage of their cancer (stage III or IV) at the
    time of diagnosis.
  • The treatment of male breast cancer is surgical,
    with the most common procedure being a modified
    radical mastectomy.
  • Sentinel node dissection has been shown to be
    feasible and accurate for nodal assessment in men
    presenting with a clinically node-negative
    axillary nodal basin.
  • Adjuvant radiation therapy is appropriate in
    cases in which there is a high risk for
    local-regional recurrence.
  • Eighty percent of male breast cancers are hormone
    receptor positive, and adjuvant tamoxifen is
    considered.
  • Systemic chemotherapy is considered for men with
    hormone receptornegative cancers and for men
    with large primary tumors, multiple positive
    nodes, and locally advanced disease.

88
Phyllodes Tumors
  • These tumors are classified as benign,
    borderline, or malignant. Borderline tumors have
    a greater potential for local recurrence.
  • Phyllodes tumors are usually sharply demarcated
    from the surrounding breast tissue, which is
    compressed and distorted.
  • The stroma of a phyllodes tumor generally has
    greater cellular activity than that of a
    fibroadenoma.
  • Evaluation of the number of mitoses and the
    presence or absence of invasive foci at the tumor
    margins may help to identify a malignant tumor

89
Phyllodes Tumors
  • Small phyllodes tumors are excised with a margin
    of normal-appearing breast tissue. When the
    diagnosis of a phyllodes tumor with suspicious
    malignant elements is made, re-excision of the
    biopsy site to ensure complete excision of the
    tumor with a 1-cm margin of normal-appearing
    breast tissue is indicated
  • Large phyllodes tumors may require mastectomy.
  • Axillary dissection is not recommended because
    axillary lymph node metastases rarely occur.

90
Inflammatory Breast Carcinoma
  • Inflammatory breast carcinoma (stage IIIB)
    accounts for lt3 of breast cancers.
  • This cancer is characterized by the skin changes
    of brawny induration, erythema with a raised
    edge, and edema (peau d'orange)
  • Permeation of the dermal lymph vessels by cancer
    cells is seen in skin biopsy specimens.

91
  • The clinical differentiation of inflammatory
    breast cancer may be extremely difficult,
    especially when a locally advanced scirrhous
    carcinoma invades dermal lymph vessels in the
    skin to produce peau d'orange and lymphangitis
  • Inflammatory breast cancer also may be mistaken
    for a bacterial infection of the breast. More
    than 75 of women who have inflammatory breast
    cancer present with palpable axillary
    lymphadenopathy, and distant metastases also are
    frequently present.
  • Surgery alone and surgery with adjuvant radiation
    therapy have produced disappointing results in
    women with inflammatory breast cancer.
  • However, neoadjuvant chemotherapy with a
    doxorubicin-containing regimen may effect
    dramatic regressions in up to 75 of cases. In
    this setting, modified radical mastectomy is
    performed to remove residual cancer from the
    chest wall and axilla.
  • Adjuvant chemotherapy may be indicated depending
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