Diagnosis and Surgical Management

of Breast Cancer

Vivien LiIntern

Introduction

Most commonly diagnosed cancer among women in Australia.

Lifetime risk of 1 in 9, risk increases with age.

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.

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%)

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

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

Diagnosis (2) – Imaging

Mammogram › Asymmetry› Micro-

calcifications› Mass› Architectural

distortion

Ultrasound

MRI › Screening of

high risk patients

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

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

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

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

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.

Management – Surgery

DCIS Resection of primary cancer Adjuvant radiotherapy

Management – Surgery

Post-operative complications› Seroma› Wound infection› Bleeding› Need for re-excision

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

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.

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

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.

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.

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