Surgical Options for the Treatment of Breast Cancer

Helen Krontiras, M.D.Assistant Professor

University of Alabama School of Medicine

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

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

Breast Imaging

Mammogram

Ultrasound

(MRI)

Biopsy

• Incisional– Core biopsy

• Palpation • Image Guided

– Stereotactic– Ultrasound guided

• Excisional– Operative removal of entire lesion

Histology

Lobular carcinoma in situ

Ductal carcinoma in situ

Invasive ductal carcinoma

Invasive lobular carcinoma

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

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

Invasive ductal carcinoma

• Most common, 75% of all breast cancers

• AKA IDC, infiltrating ductal

• Increased spread to axillary nodes with increase in size

Invasive lobular carcinoma

• 5-10% of all breast cancers

• Usually presents as an ill defined thickening

• May be mammographically occult

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

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

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

Earlier stage - better survival

0102030405060708090

100

% 5

-year su

rviv

al

I IIA IIB IIIA IIIB IV

Survival

Stage

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

Mastectomy

Neoadjuvant ChemotherapyClinicalStage III

Invasive Breast Cancer

Radiation Therapy

Breast Cancer Treatment

Local Systemic

Local Therapy

Breast Axilla

Local Therapy

SurgeryRadiation Therapy

Breast

Mastectomy

Breast conservation

Neoadjuvant chemotherapy

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

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

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

BCT vs Mastectomy

Since 1970, 7 prospective randomized

studies demonstrate equivalent outcome

regardless of surgical choice for patients with Stage I or II disease

Radiation Therapy

• External beam

• Daily therapy for 6 weeks

• Side effects– Skin changes– Pulmonary toxicity– Cardiotoxicity

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

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

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

Neoadjuvant chemotherapy

Chemotherapy given before surgery

• Shrink the tumor

• In Vivo assessment of response to chemo

• No survival advantage or disadvantage

Therapy of Regional Nodes

• Axillary Node Dissection

• Sentinel Lymph Node Biopsy

Axillary Node Dissection

• Typically Levels I and II • 10 – 30 lymph nodes

removed• 15-20% incidence of

lymphedema

Silverstein, The Breast Journal 4:324, 1998

Positive axillary lymph node versus T stage

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

Sentinel node biopsy

                                                 

Systemic Therapy

CytotoxicChemotherapy

Endocrine

Monoclonal

antibody

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

Adjuvant therapy recommendation

Tumor size ER status Nodal Status Recommendation

<1 cm +/- - None required

>1 cm + - Tam +/- Chemo

- - Chemo

Any size + + Tam +/- Chemo - + Chemo

Chemotherapy

• Adriamycin/ Cytoxan (AC) x 4

• Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6

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

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

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