August 19, 2016 SURGERY II

Breast Dr. Medina Abnormal result of screening modality such as in Mammogram

becomes now one of the major complaints of major population seeking
consult to the breast surgeon.

A. BREAST MASS
 BENIGN
- Younger population
 Well circumscribed mass usually
associated WITH PAIN, cyclical in nature
(corresponds to the menstruation of the
female) and appears after menstruation
Stage IV Breast Cancer  Mass < 2cm  Do not OPERATE
st
 If the patient has a (+) family history: 1 Degree
If a patient in 1960’s have a stage IV breast cancer  it will not be relatives
 Every mass should be evaluated
operated at all (unresectable).
B. NIPPLE DISCHARGE
Now:
st  Look for the site or the source of the discharge
 1960 -21 Century: Simple Breast Carcinoma can be
managed even in Stage IVa and Stage IVb and still there is a  If the source is coming from the single duct,
room for mastectomy. (Modified Radical Mastecomy) spontaneous discharge, bloody serous, NO
Reason: ASSOCIATED PAIN Malignant
 Before the only prognostic factor that they consider is the  Bloody discharge, multiple ducts, not spontaneous
breast mass and involvement of the lymph node. and WITH PAIN  Benign (Most common:
Intraductal papilloma, duct ectasia, fibrocystic
 Today, there are so many factors that determine whether
disease)
you are going to touch the patient or you do nothing. (more
 It is the main problem because the layman
on Biologic properties on Breast Carcinoma)
especially the female population believe that
carcinoma they are painful. That’s why, when
ANATOMY OF THE BREAST they don’t experience any pain with a breast
mass they don’t bother it and don’t seek
consult. They seek consult when the mass
enlarges and they already palpated another
mass in the axilla (advanced stage)
C. PAIN
 With Pain  Benign
 Without Pain  Malignant

D. BREAST INFECTION
 Found in lactating mother
 Organism: Staphylococcus and Streptococcus
 The reason why the most common breast carcinoma is species
INVASIVE DUCTAL CARCINOMA (IDC) the lesions start in the  Presence all the cardinal signs of Inflammation
intraductal part of the breast  Extend to develop an ABSCESS

nd
2 most common is the INVASIVE LOBULAR CARCINOMA. o Treatment : Incision and Drainage
o New Modality for Benign lesion:
They are found in the lobes.
Ultrasound
 If you are going to divide a breast into 4 quadrants the If there is a localize collection of pus you can
highest incidence of breast carcinoma happens in the UPPER aspirate it.
OUTER QUADRANT. The reason for this is that the area has If there a pockets of pus distributed on the breast it
the highest percentage of breast tissue. is better you performed Incision and Drainage
 In males, the breast is rudimentary in functioning. Therefore under general anesthesia.
the incidence of breast carcinoma in male is only 1 % but still
MAMMOGRAPHY
there are so many factors like BRCA gene. This puts the male  The recommendation is 40 years old (current American
population at risk to develop breast carcinoma. Cancer Society) or 50 years old by the US recommendation.

COMPLAINTS: FIBROADENOMA
A. Breast mass  Needs to undergo surgically
B. Nipple discharge - cut off to be excised or resected is 2cm and above
C. Pain GIANT FIBROADENOMA
D. Infection (seldomly) Treatment:
 Mastectomy
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August 19, 2016 SURGERY II
 Early reconstruction is advocated
 We do not reconstruct if we plan to radiate the
chest wall. (malignant)
 If it is BENIGN – do reconstructive surgery
GALACTOCOELE
- Lactating mother, whitish discharge
*A “powder like lesion” this is so called microcalcification.
*If you have bloody discharge, multiple ducts – BENIGN (Lesion:
Microcalcification is a usual findings of a malignant breast mass or
Intraductal Papilloma)
carcinoma.
Inflammatory Breast CA
*Our objective is when a patient presents with all the aforementioned
lesion is to know whether we are dealing here a benign or a malignant.
(Objective of clinical breast examination)
 To differentiate a physiologic change from a pathologic
change

American data:
 Lifetime risk of a female even in the absence of familial
disease is 13.22%
 By 2013 there are 232,000 cases diagnosed Breast CA and
the majority of 232,000 were diagnosed at an early stage
 This is a danger of having an infection. Remember this, an
(because of the advocacy of the National Council Institute
infection in a patient who is post-menopausal, non-lactating
and the US preventive Task force)
you have to consider the presence of INFLAMMATORY
BREAST CA.  1990, they observe that there were a significant decline in
the mortality rate of breast CA patient who were diagnosed
 Before DO NOT DO SURGERY!
by the screening by 30%.
 HANGELSON CRITERIA OF UNRESECTABLE BREAST:
 2/3 of the patients have no any identifiable risk. (Early
- Presence of peau de orange
menarche, family history, etc...)
- Matted nodes
- Erythema
INDEPENDENT PRONOGNOSTIC FACTOR
 Now you will touch them with Neoadjuvant therapy.
 Axillary Lymph node status
 If you have the cardinal signs of infection the least you can
 Tumor size
do is subject the patient to an ULTRASOUND.
 Lymphatic/ Vascular invasion
 The Ultrasound will tell you if there are underlying mass on
 Patient Age ( patient develop CA in younger age – aggressive
top of that inflammation. If the mass is present perform
tumor, late stage 60 -80 y/o – non aggressive tumor)
biopsy immediately.
 Histologic grade
 Histologic subtypes (tubular, mucinous, papillary)
MAMMOGRAM ABNORMALITY
 Response to neoadjuvant therapy
 ER/ PR status – routinely done prior to surgery or adjuvant tx
 HER 2 gene amplification or overexpression (mandatory)

LYMPH NODES
 10 axillary Lymph nodes to properly stage the disease –
within 5 years’ time, 82% of them will have recurrence.
 3 or more lymph nodes in the axilla – adjuvant radiotherapy
- This mammogram shows dense breast
BASED ON THE MOLECULAR BIOLOGY:
- Young patient and below 40 y/o  Dense Breast
Digital Mammography TYPE CHARACTERISTICS MARKERS
- Also known as Full field digital mammography Luminal A Low grade ER + PR + HER2 + CK8 + CKL8 +
- Is very effective High ER
- Clearly show if there is any lesion among patient 50% of all Breast CA
with dense breast Luminal B Higher grade ER + PR +/-, HER 2 +/-
- The more younger the patient the more denser the Lower ER
breast 10% of Breast CA
- Cut off: (-) family history, (-)BRCA gene HER 2 High grade ER – PR - HER2 +
- 40 years old perform mammography P53 mutations
- Below 40 forget about mammography  5% to 10% of Breast
cancer
*Synchronous Lesion – lesions that occur at the same time but you BASAL High proliferation ER – PR – HER2 –
cannot be palpated. Bes thing to do is to do Mammography. 30% of Breast CA *most responsive to Neoadjuvant therapy

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 The first two tell you that the particular Breast Carcinoma is  If the patient doesn’t want
negative for ER and PR and they are BASAL and HER 2. tissue biopsy. Do Core Need
 The BASAL type of Breast CA  the triple negative is biopsy via ultrasound guided.
considered the most aggressive type of tumor but this is the
most responsive tumor when we talk about Neoadjuvant o If it is a solid mass - the gold standard
therapy biopsy: CORE NEEDLE BIOPSY
 Most common types ER and PR positive  Luminal A and  Rationale: Gets bigger tissue,
Luminal B. higher positive yield, more
 Around 70% of breast CA in the Philippines falls under samples, less error.
Luminal A.  FNAB – good for cytopath, you
don’t hit the real target.
BRCA Gene  Young patient with palpable breast mass prefer
 5 -10 % hereditary breast CA Ultrasound.
 80 % familial breast CA - MRI
 45 % lifetime risk ovarian cancer Pathology Review
 Autosomal dominant  Tumor size
 The tumor is more aggressive.  Lymph node status
 Young individuals with aggressive tumor will respond  Nuclear grade
better from chemotherapy. It is mandatory.  Histologic grade
 Very young patient with Luminal A Breast CA and the  HER2/neu and ER,PR status
surgeon just did surgery. What is the next treatment?  Extracapsular extension
Chemotherapy followed by Hormonal  Vascularity and Lymphatic Invasion
 Old patient 70y/o, ER + and PR + with LN, Luminal A.
What is the first treatment? HORMONAL (DOC: Anastrazole for 5 Mammography – 40 years old recommended
years) – for post-menopausal patient. Anastrazole is the first line  First imaging modality
of treatment for post-menopausal patient.  Screening and diagnostic
 HER 2  aggressive  Evaluation of the contralateral breast
 ER / PR  less aggressive  10 – 15% failure to detect palpable lesions
 Decrease accuracy for dense breast tissue
BRCA2  Detect synchronous lesion or non-palpable calcifications.
 1- 2 % early onset breast cancer 2 views of mammogram: Mediolateral and Craniocaudal view
 Estrogen receptor positive - better prognosis  The US Preventive Services Task Force (USPSTF) estimates
 Increase risk for non-breast CA, prostate (4,65), gallbladder the benefit of mammography in women aged 50 – 74 years
(4,97), stomach (2.59), malignant melanoma (2.58) to be a 30% reduction in risk of death from breast cancer.
Diagnosis  For women aged 40 – 49 years, the risk of death is decreased
1. SBE / CBE by 17 %.
2. CNB
3. Imaging COMPARISION OF AMERICAN CANCER SOCIETY and USPSTF breast
- MMG cancer screening recommendations
- Ultrasound – size of the mass, nature of the mass VARIABLE ACS 2009 USPSTF
(solid or cystic) GUIDELINES GUIDELINES
o If it is cystic – aspirate!
Age to begin 40y 50y
 But before you aspirate ask the
mammograms
sinologist “are we dealing for
Frequency of Annually Every 2 years
simple cyst or a multinucleated
mammograms
or complex cyst or combination
CBE Annually Insufficient evidence to
of mass?”
assess additional benefits
 Complex Cyst – increase risk of
and harms of CBE beyond
being malignant
screening mammography
 Now if you aspirate, if this is
serous and the cyst collapse  in woman aged > 40y
OBSERVE! SBE Optional Recommends against SBE
 If after aspiration – it is bloody
 send it to cystopathologic
examination and REEVALUATE
the mass via UTZ.
 If the sonologist tells you
meron natira – schedule the
patient for tissue biopsy.

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Breast Imaging Reporting and Data System (BIRADS) classification comedo type –
imaging *MEMORIZE THIS  aggressive. It presents
multicentric  you need
to perform sentinel
lymph node biopsy 
tumor may present an
invasive ductal CA)
*If positive do an
axillary LN dissection
*if negative, no touch!

Staging
 The 5 year survival rates are highly correlated with tumor
stage as follows:
 Stage 0 – 99 -100%
ULTRASUNOGRAPHY  Stage I – 95 - 100%
 Solid vs. Cystic in NON palpable lesion  Stage II – 86 %
 Directing FNAB, core biopsy of the lesion  Stage III – 57 %
 Confirms position of the needle  Stage IV – 20%
 Not for screening
 Localizing non palpable lesion for excision Surgical Treatment of Breast CA
 Quantify response of tumor and nodal mets to neoadjuvant  Modified Radical Mastectomy – primary treatment of Breast CA
*In ultrasound, can be used to assess the real tumor size.  Wide local excision and radiation therapy (BCT) – same
*TI – T3  Assess the sized overall 5 year survival with MRM
*T4  involves the skin  Advantage of BCT: remove the quadrant of the
breast involve + radiation including the axillary
MRI nodes.
1. Screening high risk – presence of BRCA gene, lifetime risk of - Both are considered primary treatment of Breast
20-25%, first degree relative. Perform MRI at the age of 25. CA
At the age of 30 do annual mammogram. Axillary dissection
2. Evaluation integrity of implants  ALND – removal of axillary nodes level I and II
3. Extent of malignancy  SLND – removal of stained axillary nodes
 Annual screening for BRCA carrier *Axillary dissection + radiation can increase risk of having lymphedema
 Detection of occult cancer (25 -35%)
*Sentinel lymph node biopsy is recommended ONLY in No (no lymph
Classification of Primary Breast Cancer node palpated).
NON INVASVE EPITHELIAL CANCERS * If puro breast mass lang at walang LN palpated you do SLN biopsy!
1. Lobular Carcinoma in situ *In SLN biopsy, you inject a dye (isosulfan blue dye) in the areola and
2. Ductal Carcinoma in situ or intraductal carcinoma (papillary, after a while you do the dissection. Then you will see the first chain of
cribriform, solid, comedo) nodes that is affected. Yun lang yung tatanggalin mo. But if the nodes
*You can use MRI in both LCIS and DCIS for surveillance. were positive, you have to perform axillary dissection.
*Both need for additional mammography or biopsy because around 15
– 20% associated with invasive ductal carcinoma. AVOIDANCE OF AXILLARY LYMPH NODE DISSECTION PATIENT
*In situ  not invasive SELECTION GUIDELINES (ACOSOG Z0011)
 Tumor size < 5cm (T1 and T2)
COMPARISION OF LCIS and DCIS  Fewer than three positive SLN
LCIS DCIS  No evidence extracapsular tumor extension in SLN
Age at presentation Premenopausal Postmenopausal  Planned whole breast radiation therapy
PE Negative Occ palpable mass  Planned standard of care of adjuvant therapy
MMG Negative Microcalcification
Diagnosis Incidental Workup of Indications for BCT
abnormality  Small breast CA < 4cm
Risk In all breast tissue All sites of diagnosis  Clinically (-) axillary LN
Treatment Observation vs Lumpectomy +  Breast volume adequate size to allow uniform dosage of
chemoprevention vs radiation vs ipsilateral irradiation
bilateral single mastectomy  Radiation therapist experience to avoid damage of retained
mastectomy with no axillary node breast
dissection because it Relative Contraindications for BCT
is just a non-invasive  Multifocal disease
carcinoma.  History of previous radiation therapy to the area of
(If the patient has treatment

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 Inability to undergo radiation therapy for invasive disease Indication for Radiation therapy
 First or second trimester of pregnancy – advise MRM  Close margin – defines as the presence of malignant cells 1-
 Persistent positive margins _____ attempts at conservation 2mm from the resected specimen
 4 or more positive lymph nodes  undergo radiation
*The only thing that is NOT STANDARD is when the patient tells you
“Doc tanggalin mo na din yung kabila” it is called Contralateral Chemotherapeutic Agents for breast cancer
Prophylactic Mastectomy. There is no evidence for high survival rate. 1. Cyclophosphamide (C) *
2. Methotrexate (M)
Breast Reconstruction 3. 5FU (F) – Severe hypersensitivity reaction
 Immediately done after Mastectomy 4. Doxorubicin (A)*
 Not requiring adjuvant radiation 5. Epirubicin (E)
 Implants, Autologous tissue (transverse rectus abdominis, 6. Docetaxel (T)*
latissimus dorsi) 7. Paclitaxel (P)*
 Safe (*)FIRST LINE TREATMENT
 No increase in local recurrence Before C,M,F is the first line.
*When you give Chemotherapy drugs in Neoadjuvant it is for 4months
Advantages of Disadvantages of Neoadjuvant and it requires 3 cycles.
Neoadjuvant therapy chemotherapy * Then you assess if there is metastasis, size of tumor. If there is a
complete pathologic response, then that particular regimen should be
 Assessment of tumor  Loss of prognostic information
given after surgery. But after 4 months ganun pa din yung tumor, STOP
response to  Axillary lymph node the neoadjuvant you precede to surgery and you give other type of
chemotherapy status neoadjuvant.
 Potential decrease in de  Microscopic tumor
novo chemotherapy size Endocrine Therapy / Hormonal Therapy
resistance  Delayed local and regional  Premenopausal
 Increase in breast –
therapy o Tamoxifen for 5 years
conserving surgery
 Induction of drug resistance o LHRH analogue
 Improved cosmetic
results o Ovarian ablation – response is variable
 Treatment of  Postmenopausal
micrometastases o Anastrazole for 5 years
 Decrease the size
o Tamoxifen for 5 years
*Some studies show that Anastrazole can be also given to
premenopausal but not well accepted.
*Neoadjuvant Therapy is a form of therapy given prior to surgery. It is
* A patient with an ER and PR positive  then you take tamoxifen and
a systemic form of therapy  Chemotherapy + Hormonal Therapy +
Anastrazole for 5 years. You will reach the 5 year period by 70 – 80%.
Target Therapy
Good prognosis
*Radiation Therapy and Surgery is a local form of therapy. You cannot
*A patient with ER and PR negative and still you take the hormonal
treat a systemic disease by just giving local form of therapy.
therapy, only 10% is the survival rate.
*Breast Carcinoma is a systemic disease.
*ER and PR negative DO CHEMOTHERAPY DO NOT INSIST ON
HORMONAL THERAPY
TUMOR CHARACTERISTICS AND RESPONSIVENESS TO
NEOADJUVANT CHEMOTHERAPY
Targeted Therapy
Patient and Increased Decreased
 Trastuzumab – 50% DFS, 33 % OS regardless of
clinical likelihood of pCR likelihood of pCR
chemotherapy regimen
characteristics
 1 year improved DFS, OS (early, HER2 +)
Age < 40 years >60 years
 Pertuzumab
Tumor size < 2 cm >4cm  Lapatinib
Histologic features Ductal Lobular  Combination - pertuzumab + trastuzumab + docetaxel improves
Grade High Low DFS (metastatic, HER2+)
KI67 protein levels High score > 20 Low score < 20 o Trastuzumab must be given for 52 weeks
Estrogen receptor Negative Positive  Neoadjuvant pertuzumab _ Trastuzumab + docetaxel (LABC
Her2/neu Positive Negative inflammatory early)
*pCR = pathologic complete response
Note: The younger the patient the more aggressive the tumor, the Systemic agent Time of treatment Side effect
more aggressive the tumor the better response to neoadjuvant class:
therapy. Specific agent
The more aggressive the tumor the less role of surgery as the first line. Taxanes: Docetaxel Neoadjuvant, Cutaneous reaction
Do not touch that! What are these tumors? Stage IIIB and Stage IV, Paclitaxel adjuvant Motor and sensory
Inflammatory Breast CA  Neoadjuvant Therapy is the first line. neuropathy
Embryo fetus toxicity

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Myelosuppression
Anthracyclines: Neoadjuvant, Cardiomyopathy,
Doxorubicin adjuvant congestive heart
(Adriamycin), failure
epirubicin Myelosuppression
Carboplatin Neoadjuvant, Neuropathy
Adjuvant Myelosuppression
Trastuzumab Neoadjuvant, With doxorubicin,
Adjuvant cumulative risk of
congestive heart
failure, decreased
left ventricular
ejection fraction
Cardiomyopathy,
embryo – fetus
toxicity, pulmonary
toxicity
__________Inhibitors: Neoadjuvant, Arthralgias, myalgias,
adjuvant osteoporosis,
embryo – fetus
toxicity

Note: Do not combine Trastuzumab with Doxorubicin  you are going

to kill the patient because both of them have a cardiotoxic effect.
*Trastuzumab can also be given in neoadjuvant treatment.

Treatment protocols
 Local disease Stage 0, I, II, or IIIA (T3 N1 M0)
 Surveillance, lumpectomy, mastectomy, CT, RT
 Preoperative chemotherapy ( stage IIA – IIIA) TAC, ACP, AC,
TC
 Docetaxel (taxotere,T) doxorubicin (Adriamycin,A),
cyclosphosphamide (C), paclitaxel (P)
 Adjuvant chemotherapy Her2 + , localized disease stage I,
II,IIIA
 AC – paclitaxel + Trastuzumab
 AC- docetaxel + Trastuzumab

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