Socratic Rounds: Breast

Tricia A. Kelly, M.D., F.A.C.S.

Assistant Professor of Surgery
Associate Director, Breast Care Center
Associate Director, Undergraduate Surgical Education
George Washington University MFA
Objectives:

Anatomy

breast cancer risk factors

breast imaging-mammogram, ultrasound

image guided biopsy

indications for excisional biopsy (+/- wire)

precursor lesions

DCIS

Invasive carcinoma

benign breast disease

Understanding Breast Anatomy
Benign Breast Disease
Fibrocystic changes
Mastodynia (pain)

Nipple discharge
Gynecomastia
Mastitis/Abscess

Fibrocystic Changes
Physiologic responses of breast tissue to normal hormonal cycles
Often a pathologic diagnosis

No increased risk of breast cancer

Often present with lumps and cyclical pain
Treatment

Mastodynia

Can be related to cyclical hormonal changes

May be caused by nonbreast problems

Treatment
vitamins E and B complex, decreasing caffeine have unproven
benefit-no longer use vit E

Evening Primrose Oil*

Nonsteroidals, danazol, tamoxifen

Nipple Discharge
Physiologic discharge does not require evaluation

bilateral, nonspontaneous
Milky discharge: prolactin level, TFTs
Bloody discharge: biopsy

intraductal papilloma most common

Nipple Discharge
10% of nipple discharge due to cancer is not bloody
A spontaneous, unilateral discharge requires evaluation and
treatment
Ductogram may be helpful-historically; now use MRI more often
Excisional biopsy of the draining duct is required; central duct
excision may be necessary
NIPPLE DISCHARGE
PAPILLOMA Nipple Discharge
Gynecomastia

Enlargement of male breast tissue

Often idiopathic

Other causes: drug-induced, liver or renal failure, genetic

abnormalities

Treatment:

discontinue offending meds if possible

education and reassurance

subareolar excision for relief of symptoms

medical therapy
Breast Abscess
Most common in lactating women
Usually caused by Staph Aureus

Rule out cancer

Surgical drainage often necessary

Antibiotics if there is inflammation of the breast-mastitis

Mechanical emptying and temporary cessation of nursing in
lactating women

Breast Imaging and diagnosis

Mammogram
Ultrasound

MRI / (BSGI)
Image guided biopsy
core biopsy
stereotactic biopsy
MRI guided biopsy

MAMMOGRAM
BREAST ULTRASOUND
DUCTOGRAM
DUCTOGRAM WITH CONTRAST
INFUSED THROUGH
DUCTAL LAVAGE MICROCATHETER
BREAST MRI
ULTRASOUND GUIDED BIOPSY
STEREOTACTIC ROOM
STEREOTACTIC BIOPSY
Excisional biopsy
INDICATIONS
Breast cancer
Risk factors
management of high risk patients

in situ carcinoma
invasive carcinoma

Breast Cancer Facts

2nd most frequent cause of cancer death among American
women behind lung cancer
Lifetime risk in the US for the development of breast cancer is
13.2%
Breast Cancer Facts
Breast cancer incidence increased slightly between 1987-2001

with a rise of 0.5% per year from

but decreased from 2001-2004 by 3.5% per year
death rates have decreased since 1990 with a decrease of 2.2%
per year
Breast Cancer Facts
American Cancer Society estimated 178,480 new breast cancer
cases in 2007
40,460 breast cancer deaths
Additional 62,030 cases of pre-invasive breast cancer
American Cancer Society Breast Cancer Screening Guidelines
Annual mammography starting age 40
Annual clinical breast examination

Monthly breast self-examination (optional)

promote self awareness

Early Detection and Screening:

Mammography

Mammography is the single most effective method of early

detection.

It can identify cancer several years before physical symptoms

develop.

When a cancer is discovered, it is generally found earlier than by

exam.
Efficacy of Screening Mammography: Mortality Reduction
Prognostic Factors in Breast Cancer: Proven Clinical Use
Tumor size
Node status

Hormone receptor status

Cytologic and nuclear grade

Who Gets Breast Cancer?

Excluding cancers of the skin, breast cancer is the most common
cancer among women.
In 2007, approximately 178,480 new cases of invasive breast
cancer, and 62,030 in situ cancers will be diagnosed among women.
Breast Cancer Risk

Who Gets Breast Cancer?

By Age

Breast cancer incidence and mortality increase as the population

ages

95% of new cases and 97% of breast cancer deaths occur in

women aged 40 and older from 2000-2004

1.4 in 100,000 for women aged 20-24 vs. 464.8 cases per
100,000 for women aged 75-79
The Probability of Developing Breast Cancer Before a Given Age
Who Gets Breast Cancer?
By Gender
About 2,030 new cases of breast cancer and 450 deaths from
breast cancer are expected in men in 2007.
This accounts for about 1% of breast cancer incidence and
mortality.
Who Gets Breast Cancer?
Family History
First degree relative with breast cancer, especially
premenopausal breast cancer
Two or more relatives with breast cancer
Who Gets Breast Cancer?
Precursor Lesions
LCIS (lobular carcinoma in situ)

10-15% chance of developing invasive breast cancer in either

breast over a 20 year time period
Atypical hyperplasia

either ductal or lobular type

Atypical Cells and Increased Risk
Atypical Cells, Positive Family History and Increased Risk
Who Gets Breast Cancer?
Gynecologic Events
Early menarche and/or late menopause
Nulliparity or age at first live birth over 30 years

Who Gets Breast Cancer?

Genetic Factors
Approximately 5-7% of breast cancers are inherited
Approximately 85% of inherited breast cancers due to BRCA 1 and 2
mutations
cumulative cancer risk by age 70 as high as 87% for breast and 44%
for ovarian
associated with an increased risk of early onset cancer, multiple
cancers and cancer in men
Genetic Testing: BRCA 1 and 2
Mutations on chromosomes 17 and 13
The risk of developing a primary breast cancer in a patient who
tests positive is 55-85%
The risk of developing a second breast cancer in a patient who
tests positive is 65%
BRCA Testing
Who Gets Breast Cancer?
Radiation Exposure
Atomic bombs survivors
Hodgkins treatment
Who Gets Breast Cancer?
Hormone Replacement
Womens Health Initiative-randomized trial of 16,608
postmenopausal women receiving combined HRT vs. placebo

trial stopped after 5 yrs f/u because incidence of invasive breast

cancer exceeded stopping rules of the trial
Who is at High Risk?
Gail Model
Mathematical model based on data from 280,000 women
recruited for the BCDDP
Validated by three independent projects
Gail index >1.7 significant
Gail Model
Five specific factors

age

age at menarche

age at first live birth

number of breast biopsies and results

number of first degree relatives with breast cancer

Management of the
High-Risk Patient
Close Surveillance
Chemoprevention

Surgical Intervention

Increased Surveillance
Clinical examination every 6 months
Additional imaging modalities

MRI

BSGI (Breast specific gamma imaging)

NSABP P-1 Prevention Study
Randomized trial healthy women age 35 or older with 1.7% or
greater 5-year risk for developing breast cancer
Randomized to Tamoxifen 20mg/d for 5yrs vs. placebo
Tamoxifen reduced breast cancer risk by 49%
Prophylactic Mastectomy
Should be limited to those at very high risk or known BRCA
carriers
Decreases risk of developing breast cancer by greater than 90%

Prophylactic Mastectomy
Appropriate psychosocial counseling
Plastic surgery consultation to consider immediate reconstruction
Prophylactic
Oophorectomy
Consider in women with BRCA mutations after completion of
childbearing
Breast cancer risk reduction as high as 50%
HISTORICAL PROSPECTIVE
Breast Cancer: Surgical History

19th Century: small surgical procedures on large tumors, leaving

tumor behind

1907-1925: Halsted Radical Mastectomy

1971-85: Modified Radical Mastectomy

1976-89: Lumpectomy, XRT, and axillary lymph node dissection

1985-1993: lumpectomy, XRT for DCIS

1998: Sentinel lymph node biopsy

Breast Cancer: 19th Century
Small procedures were attempted on locally advanced cancer,
leaving tumor behind
Recurrence rates approached 100%, with high death rates
There was no effective local or systemic anti-cancer therapy
Halsted Radical Mastectomy: 1907-1925
Description
The first important therapeutic advance against breast cancer

Local recurrence was reduced to 25% and the cure rate was
raised to 50%
Extended radical and supraradical mastectomies showed no
improvement in outcome
Modified Radical Mastectomy: NSABP B-04 1971-1985
Description of MRM
Survival rates of patients undergoing radical mastectomy vs total
mastectomy +/- axillary radiation were the same
Distant disease occurrence is independent of local treatment
Lumpectomy, XRT, Axillary Lymph Node Dissection NSABP B-06 19761989
Local recurrence was 35% with lumpectomy alone
Local recurrence was 10% with lumpectomy and XRT

No survival differences for mastectomy vs lumpectomy +/- XRT

All had axillary lymph node dissection

Ductal Carcinoma In Situ NSABP B-17 1985-1993

Treatment by total mastectomy should produce a cure rate near
100%
Lumpectomy +/- XRT has similar survival rates
Local recurrence in lumpectomy without XRT is 16.4%

Local recurrence in lumpectomy with XRT is 7%

Breast Cancer Develops Over Time

Carcinoma In Situ:

Ductal and Lobular

Lobular Carcinoma in Situ: Treatment

Close observation

Physical exam every 6 months

Annual mammograms

Monthly self exams

Tamoxifen
Bilateral prophylactic simple mastectomies

with or without reconstruction

DCIS
DCIS

Often presents as microcalcifications on a mammogram

Ductal Carcinoma In Situ: Treatment

Breast conservation: lumpectomy +/- XRT
Simple mastectomy

with or without reconstruction

Sentinel lymph node biopsy (SLNB) and chemotherapy are not
indicated

Caveats on SLNB
Tamoxifen
Invasive Ductal Carcinoma
Invasive Ductal Carcinoma
Treatment of Invasive
Breast Cancer
Surgery
Chemotherapy

Radiation therapy
Hormonal therapy
Often, two or more methods are used in combination

Treatment Options
Invasive Cancers

Breast Cancer: Surgical Therapy

Options include modified radical mastectomy vs. lumpectomy
with SLNB/ALND and radiation therapy
Patient preference is a major factor in the choice because the
options are therapeutically equivalent
Treatment of Invasive
Breast Cancer: Surgery
Breast Conservation Therapy: partial mastectomy/lumpectomy

local removal of the tumor

removal/sampling of the axillary lymph nodes

radiation therapy
IDC: Breast Conservation Surgery
Patient preference
Tumor size and location favorable for a good aesthetic result

Unifocal tumor
Ability to obtain negative margins
Contraindications to radiation

Treatment of Invasive Breast Cancer: Surgery

Mastectomy

Simple/Total Mastectomy: surgical removal of the breast

With/without lymph node sampling

Modified Radical Mastectomy: surgical removal of the breast and

removal of the axillary lymph nodes

Possible radiation as well

Radiation Therapy
Post lumpectomy for DCIS
Post lumpectomy for invasive cancer

Post mastectomy in high risk women

>4 positive nodes, stage 3 tumor
Given 5 days per week for 6 weeks
Partial breast irradiation (APBI)

Tamoxifen
Activity: anti-estrogenic and estrogenic
Effectiveness: In pre- and postmenopausal women with ER+ tumors
and as a chemopreventive agent in high-risk
Side Effects: thrombosis, endometrial cancer

Chemotherapy
Most Common Regimens:
Cytoxan, Adriamycin (AC) +/- Taxol (T)
Given every 2-3 weeks for 4-8 cycles
Chemotherapy: Current Recommendations

Premenopausal:

Chemotherapy for tumors > 1cm or node positive

Tamoxifen for ER/PR positive

Oncotype Dx

Postmenopausal:

Chemotherapy for poorly differentiated tumors > 1cm or node

positive

Arimidex or other aromatase inhibitor for ER/PR positive

Oncotype Dx
Breast Reconstruction
Options
Immediate vs delayed
Autogenous vs prosthetic

Indications:

All women undergoing mastectomy who desire reconstruction

and are not likely to require postoperative radiation therapy
EVEN 30 YEARS AGO...
TRADITIONAL MODIFIED RADICAL MASTECTOMY
PARTIAL MASTECTOMY
SKIN SPARING MASTECTOMY
WITH IMPLANT
SKIN SPARING MASTECTOMY WITH TRAM RECONSTRUCTION
Sentinel Lymph Node Biopsy
Sentinel Lymph Node Biopsy

A minimally invasive technique for detecting lymph node

involvement in patients with breast cancer

A sentinel lymph node is the first lymph node to receive

lymphatic drainage from a tumor

Biopsy of sentinel lymph nodes can predict the presence or

absence of axillary node metastases in patients with breast cancer

An alternative to traditional axillary lymph node dissection

Review of Lymphatic Drainage

The axillary and internal mammary lymph nodes receive lymph from all
quadrants of the breast.
Turner-Warwick, 1959
Review of Lymphatic Drainage
Lymph flows from superficial to deep
Review of Lymphatic Drainage
The subareolar plexus connects directly to axillary nodes most often
through a single lymphatic trunk
Halsell, 1963
Mapping the Lymphatic Channels
Radioactive tracer

technetium
Blue dye tracer

Lymphazarium/methylene blue
Injection Site for Breast Sentinel Lymph Node Biopsy
Subareolar Injection
Which node(s) are excised?
Radioactive nodes
Blue nodes

Nonblue nodes with blue draining channel

Firm, palpable nodes
If cannot identify then standard axillary dissection

Uptake Of Blue Dye In

Lymphatic Channels
SENTINEL NODE
Sentinel Lymph Node Biopsy: Accuracy

Sentinel lymph node can be identified in >90%

Sentinel lymph node(s) accurately predict the status of the

remaining axillary lymph nodes in 97-99%

When positive, the sentinel lymph node is often the only affected
axillary lymph node(s)

The Utility of Sentinel Lymph Node Biopsy

For Stage I breast cancer, the long-term prognosis is excellent for

70% of patients treated with surgery alone, but 30% will develop
distant disease and die in 10 years

It has been proposed that the 30% at-risk patients may harbor
micrometastatic disease in the lymph nodes
The Utility of Sentinel Lymph Node Biopsy
The sentinel lymph node is micro-sectioned and stained for a
variety of molecular and immunohistochemical markers, allowing
identification of previously undetected spread
If the sentinel lymph node is negative, the other axillary nodes
are presumed to be negative, and an axillary lymph node dissection is
avoided
The Utility of Sentinel Lymph Node Biopsy

Morbidity of traditional axillary dissection:

78% numbness

4-50% seroma

16-25% lymphedema

22% pain

No therapeutic benefit in node negative patients

Debatable whether there is any benefit in node positive patients