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Breast Cancer: Surgical Management

Breast cancer affects about 1 out of every 8 women in the United States every year. It's anticipated that next year there will be probably about 194,000 new cases diagnosed. 30% of cancer cases are breast cancer. It is the second most common cause of cancer death in females after breast cancer, brest, canser.

These are some of the major risk factors for breast cancer. Lobular carcinoma in situ is not a precursor of cancer. Ductal carcinoma in situ is a precursor of invasive cancer. Lobular carcinoma in situ is simply a risk factor for breast cancer just like family history of nulliparity. Atypical hyperplasia increases the risk about four to eight-fold. Family history of premenopausal bilateral breast cancer increases your risk about four-fold.

Age at first pregnancy increases the risk of breast cancer about two to four-fold. If you delay your first pregnancy beyond the age of 30, that

Obesity increases the risk slightly. This is probably due to the fact that fat cells have a higher circulating level of estrogen than do nonfat cells. Prior history of ovarian or endometrial cancer increases the risk two to four-fold.

Other minor risk factors. History of radiation exposure to the chest. I see probably three or four young women a year here who have breast cancer in the medial aspect of the breast almost certainly as a result of radiation and that is probably because we see a lot of patients with lymphoma here. There are a lot of young women who have been treated for Hodgkin's Disease that have been exposed to radiation so that certainly increases the

There is an increased risk in Caucasians versus people of color, about 1.5-fold. An increased risk in the upper versus the lower socioeconomic classes and an increased risk in urban dwellers versus those that live in the rural areas. So what I tell people when they ask, "How can we reduce our

This is something that I think should be interesting to you because you see a lot of people that are sent for breast biopsies and they come back with these diagnoses and sometimes it's hard to sort out what's important and what isn't. These are all nonproliferative diseases that carry no increased risk: adenosis, cysts, mastitis, duct ectasia, fibroadenoma, metaplasia, squamous metaplasia or mild hyperplasia.

Some of the proliferative disorders that increase the risk slightly. Moderate hyperplasia. Papillomas increase the risk and the very proliferative diseases with atypical hyperplasia increase the risk about eight-fold. Lobular ductal carcinoma in situ also increases the risk.

Now, I'm going to talk to you a little bit about screening for breast cancer. I can take this slide and change it about every month because the recommendations keep coming out from different groups. Largely this is being driven by the third party carriers who don't want to pay for anything at

The fact of the matter is that it is all very well individualized among patients and patients really don't want to hear about the economic ramifications. These are still the recommendations of the American Cancer Society. These are largely the recommendations that the public is familiar with that 

This is a mammogram. Does anybody know what it is? This is a test to see how late in the day it really is. Oftentimes, I give this talk to medical students and throw up a slide like this and ask them what it is and they all try to not make eye contact with you so

This is the cephalocaudad view and here you see something that's just got all the features you'd want to find in a breast cancer. If this was a film you

Another thing you have either heard about or will be hearing about is sentinel node biopsy. I bring this up to you not to give you a play by play on all this technology and bore you with the technical details but simply because these are the questions that you are going to be asked by the patients where a specialist recommends something like this and they come back to you to find out what this is all about.

The whole idea behind sentinel node biopsy is there's going to be, for whatever cancer you have, and this was started out with primarily in use of skin cancers like melanoma, it's a way of mapping and identifying the one node that preferentially drains that area of the body. In the breast, if you have 

So, the way this is done is that just prior to operation, we inject the area around the tumor, or if it's been removed, we inject the biopsy cavity with a substance called technetium sulfur colloid it's a tagged albumin molecule. It's picked up by the lymphatics. It travels through the lymphatics to that

In addition to that, the pathologist on permanence cut it about 20 times, do immunoperoxidase stains on it and this is called ultrastaging and sometimes we find a few cells in there that we didn't otherwise know about. I think it's really kind of the wave of the future and we've done quite a few of them.

Now I want to talk about some dermatologic manifestations or physical findings that are indicative of cancer. This is an example of a bloody nipple discharge. About 85% of bloody nipple discharges are due to a benign condition called intraductal papilloma or papillomatosis. Papillomas do carry about a four to eight-fold increased risk for subsequently developing breast cancer but they are benign entities.

However, about 15% of bloody nipple discharges are due to an occult malignancy. So if you find somebody with a bloody nipple discharge, it certainly warrants attention. From a technical standpoint, the best way to deal with this is probably not to send someone for a ductogram and

This is example of Paget's disease of the nipple. This is a scaling, eczematoid white lesion here. Sometimes it gets excoriated and looks raw and then heals over and you get that eczematoid area again. It's a dermatologic manifestation of an underlying breast cancer. It's the presenting finding in less

So if you see something like this, what you ought to do is refer them on or what you could do alternatively, and what we do, is simply anesthetize a representative area here and just take a little punch biopsy like you do with the skin. If it comes back with these typical pagetoid cells in the dermal lymphatics then the diagnosis is made and they are treated like you would treat any other breast cancer.

I put up this slide. This is obviously a lactating breast and you can look up here and you can see what is obviously mastitis with an underlying abscess. If you touch it, it's warm and it's tender and it's red and hot, etc. I want you to compare it to this. This breast here is also red and it's warm but the

The only role surgeons play in this is simply a biopsy of the skin to confirm that diagnosis and then these people are treated up front, usually with neoadjuvant chemotherapy, to get this down to a manageable situation. Then they come back and we do what's called a toilette mastectomy which is

I told you the peak incidence of female breast cancer is about 57 years of age. The peak incidence of male breast cancer is almost two decades later than that. So you are dealing with older gentlemen who are probably a little less tuned in. Secondly, they don't have the index of suspicion that a

I want to talk now about the surgical management of breast cancer. Just from a historical perspective, this is an example of the Halsted radical mastectomy. I'm sure you all have some patients that are probably a generation or two older than us who have had this done, it was the standard of care in this country from about 1898, when it was devised by William Halsted, up until the early 1970s.

What it involves is removal of the entire breast, a generous amount of overlying skin (so much so that these people often needed a skin graft), removal of the axillary contents and removal of the pectoralis major and minor muscle. It's a very disfiguring operation. When you think about it, the

Modified radical mastectomy. Removal of the breast itself, removal of the axillary contents but preservation of the pectoralis major and minor muscle. The incidence of arm edema following an operation like this is about 7%. Arm weakness is virtually nonexistent. It lends itself well to

Finally, I want to talk about lumpectomy, or tylectomy or quadrantectomy, minimal breast surgery, breast conserving surgery. These are all synonyms that are used, in large part, interchangeably. This involves removal of the tumor itself with the surrounding margin of normal tissue usually about

How do we identify those people who are candidates for limited breast surgery? That's the whole key. Absolute indications for mastectomy are recurrent disease within the breast after lumpectomy. In other words, if they failed and recurred within the breast, they get a mastectomy. Multicentric 

Pregnancy is a contraindication and the reason, of course, is because it is impossible to adequately shield the fetus from the radiation field. One exception to this would be if somebody did develop breast cancer late in their third trimester, they could go ahead and have a lumpectomy axillary node sampling and radiation could be deferred for several weeks or so until she completed her pregnancy.

Finally, a patient who is not motivated to preserve her breast tissue. Well, you can see if we do a mastectomy on somebody, they're in the hospital about one to two days, they go home, they have some drains in place, sutures are removed within a week. For many of these people, they don't need

So there is a bigger commitment for the patient in terms of their time. There's a bigger commitment financially which I can guarantee you when you add radiation to this whole thing. So if somebody is ambivalent about preserving their breast tissue, and there are many women who are, especially

Logistic or physiologic problems which preclude ease of delivery of radiation therapy. One of the things that comes up not uncommonly is the person with severe pulmonary disease. Even though they use tangential fields or tangential ports to radiate the breasts, there is a certain amount of 

Patients who live in an area remote from radiation therapy facilities. That's a very important consideration here in 

Now, I want to talk a little bit about breast reconstruction. Once again, I mention these things to you because these patients are going to come back to you after a recommendation has been made and ask what this is all about.

You probably look at this slide and say, "What in the world does this have to do with breast reconstruction?" Actually, I saw this guy on a beach one day and I took a picture of him because I thought, "Some day I may have to give a talk about tissue expansion and this guy would be like the

I'm a big fan of immediate breast reconstruction for many women who are candidates because breast cancer or mastectomy has two components to the whole thing. (1) Somebody has cancer and that has a tremendous psychological impact and (2) it's a potentially very disfiguring operation and so

This is a tissue expander and what this has done is that we remove a generous amount of skin when we do a mastectomy. We can't put a prosthesis in, we put in a tissue expander. There's this little thing that goes out to a port underneath the skin and it is gradually expanded over a period of weeks

Genetic testing. This is something that you are going to hear about. Has somebody talked to you about genetic testing for breast cancer? BRCA-1 genes. The BRCA-1 gene and the BRCA-2 gene were cloned about four years ago by a fellow from Salt Lake City and introduced for commercial application a year ago last September. What this is is a gene, and if you carry this gene, the chances of you developing breast cancer by the age of 70 is about 82% as opposed to the normal population at about 8%. Not everybody who has a family history of breast cancer carries the BRCA gene.

Who do we test for this? One of the problems with genetic testing, as you know, is insurance companies have access to this information. They ask you that question when you apply for any kind of insurance. Now, you could fib and tell them you never had any if you tested positive but clearly that is a fib and I'm not subjoining in perjury. But I can tell you that that is information that is in the public domain. The test costs about

People who might be candidates include women who have been diagnosed with breast cancer, especially at an early onset, to determine their risk of developing cancer in the opposite breast as well as the risk to their offspring. Women who have been diagnosed with ovarian cancer. Because if you carry the BRAC-1 gene, your chances of developing ovarian cancer are about 42%. Women with a family history of breast or ovarian cancer and men and woman who are blood relatives of those who carry a BRAC-1 mutation and