The document discusses surgical and treatment options for breast cancer, including: 1) Local therapy options like mastectomy, lumpectomy, and radiation therapy. Mastectomy can be total, modified radical, or with reconstruction. Lumpectomy followed by radiation therapy provides equivalent survival to mastectomy. 2) Systemic therapy options like chemotherapy, endocrine therapy using tamoxifen or aromatase inhibitors, and monoclonal antibodies like Herceptin for HER2-positive cancers. 3) Adjuvant therapy is given after surgery to kill micrometastases and residual disease, with recommendations based on tumor size, hormone receptor status, and nodal status.

1. Surgical Options for the Treatment of Breast Cancer Helen Krontiras, M.D. Assistant Professor University of Alabama School of Medicine

2. 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

3. Risk factors for breast cancer Gender Age Personal history of breast cancer Reproductive and menstrual history Breast density Family history of breast cancer Genetic factors Proliferative breast disease Diet and lifestyle factors

4. Breast Imaging Mammogram Ultrasound (MRI)

5. Biopsy Incisional Core biopsy Palpation Image Guided Stereotactic Ultrasound guided Excisional Operative removal of entire lesion

6. Histology Lobular carcinoma in situ Ductal carcinoma in situ Invasive ductal carcinoma Invasive lobular carcinoma

7. 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

8. 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

9. Invasive ductal carcinoma Most common, 75% of all breast cancers AKA IDC, infiltrating ductal Increased spread to axillary nodes with increase in size

10. Invasive lobular carcinoma 5-10% of all breast cancers Usually presents as an ill defined thickening May be mammographically occult

11. 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

12. 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

13. 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

14. Earlier stage - better survival Stage

15. 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

16. Mastectomy Neoadjuvant Chemotherapy ClinicalStage III Invasive Breast Cancer Radiation Therapy

17. Breast Cancer Treatment Local Systemic

18. Local Therapy Breast Axilla

19. Local Therapy Surgery Radiation Therapy

20. Breast Mastectomy Breast conservation Neoadjuvant chemotherapy

22. 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

23. 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

25. 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

26. BCT vs Mastectomy Since 1970, 7 prospective randomized studies demonstrate equivalent outcome regardless of surgical choice for patients with Stage I or II disease

27. Radiation Therapy External beam Daily therapy for 6 weeks Side effects Skin changes Pulmonary toxicity Cardiotoxicity

28. 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

29. 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

30. 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

31. Neoadjuvant chemotherapy Chemotherapy given before surgery Shrink the tumor In Vivo assessment of response to chemo No survival advantage or disadvantage

32. Therapy of Regional Nodes Axillary Node Dissection Sentinel Lymph Node Biopsy

33. Axillary Node Dissection Typically Levels I and II 10 – 30 lymph nodes removed 15-20% incidence of lymphedema

34. Silverstein, The Breast Journal 4:324, 1998 Positive axillary lymph node versus T stage

35. 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

36. Sentinel node biopsy

37. Systemic Therapy Cytotoxic Chemotherapy Endocrine Monoclonal antibody

38. 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

39. Adjuvant therapy recommendation Tumor size ER status Nodal Status Recommendation < 1 cm +/- - None required >1 cm + - Tam +/- Chemo - - Chemo Any size + + Tam +/- Chemo - + Chemo

40. Chemotherapy Adriamycin/ Cytoxan (AC) x 4 Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6

41. SERM Selective 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

42. 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

43. 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