Anatomy

1
Anatomy

• The breast is composed of 1520 lobes, which are
  each composed of several lobules.
• Each lobe of the breast terminates in a major
  (lactiferous) duct (24 mm in diameter), which
  opens through a constricted orifice (0.40.7 mm
  in diam- eter) into the ampulla of the nipple.
• Fibrous bands of connective tissue travel through
  the breast (suspensory ligaments of Cooper),
  which insert perpendicularly into the dermis and
  provide structural support.
• The axillary tail of Spence extends laterally
  across the anterior axillary fold.
• The upper outer quadrant of the breast contains a
  greater volume of tissue than do the other
  quadrants.

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BLOOD SUPPLY, INNERVATION

• Blood supply, innervation, and lymphatics. The
  breast receives its blood supply from (1)
  perforating branches of the internal mammary
  artery (2) lateral branches of the posterior
  intercostal arteries and (3) branches from the
  axillary artery, including the highest thoracic,
  lateral thoracic, and pectoral branches of the
  thoracoacromial artery.
• The veins and lymph vessels of the breast follow
  the course of the arteries with venous drainage
  being toward the axilla. The vertebral venous
  plexus of Batson, which invests the vertebrae and
  extends from the base of the skull to the sacrum,
  can provide a
• route for breast cancer metastases
• to the vertebrae, skull, pelvic bones,
• and central nervous system.

3

• Lateral cutaneous branches of the third through
  sixth intercostal nerves provide sensory
  innervation of the breast (lateral mammary
  branches) and of the anterolateral chest wall.
• The intercostobrachial nerve is the lateral
  cutaneous branch of the second intercostal nerve
  and may be visualized during surgical dissection
  of the axilla.
• Resection of the intercostobrachial nerve causes
  loss of sensation over the medial aspect of the
  upper arm.

4
LYMPHATICS

• The boundaries for lymph drainage of the axilla
  are not well demarcated, and there is
  considerable variation in the position of the
  axillary lymph nodes.
• The 6 axillary lymph node groups recognized by
  surgeons are (1) the axillary vein group
  (lateral) (2) the external mammary group
  (anterior or pectoral) (3) the scapular group
  (posterior or subscapular) (4) the central
  group (5) the subclavicular group (apical) and
  (6) the interpectoral group (Rotters).

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• The lymph node groups are assigned levels
  according to their relationship to the pectoralis
  minor muscle.
• Lymph nodes located lateral to or below the lower
  border of the pectoralis minor muscle are
  referred to as level I lymph nodes, which include
  the axillary vein, external mammary, and scapular
  groups.
• Lymph nodes located superficial or deep to the
  pectoralis minor muscle are referred to as level
  II lymph nodes, which include the central and
  interpectoral groups.
• Lymph nodes located medial to or above the upper
  border of the pectoralis minor muscle are
  referred to as level III lymph nodes, which make
  up the subclavicular group.
• The axillary lymph nodes usually receive more
  than 75 percent of the lymph drainage from the
  breast.

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Selected Benign Breast Disorders and
DiseasesCYSTS

• Cysts In practice, the first investigation of
  palpable breast masses is frequently needle
  biopsy, which allows for the early diagnosis of
  cysts. A 21-gauge needle attached to a 10-mL
  syringe is placed directly into the mass. The
  volume of a typical cyst is 510 mL, but it may
  be 75 mL or more.
• If the fluid that is aspirated is not
  bloodstained, then the cyst is aspirated to
  dryness, the needle is removed, and the fluid is
  discarded as cytologic examination of such fluid
  is not cost-effective. After aspiration, the
  breast is carefully palpated to exclude a
  residual mass. If one exists, ultrasound
  examination is performed to exclude a persistent
  cyst, which is reaspirated if present.
• If the mass is solid, a tissue specimen is
  obtained.
• When cystic fluid is bloodstained, 2 mL of fluid
  are taken for cytology.
• The mass is then imaged with ultrasound and any
  solid area on the cyst wall is biopsied by
  needle.
• The two cardinal rules of safe cyst aspiration
  are (1) the mass must disappear completely after
  aspiration, and (2) the fluid must not be
  bloodstained. If either of these conditions is
  not met, then ultrasound, needle biopsy, and
  perhaps excisional biopsy are recommended.

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Selected Benign Breast Disorders and
DiseasesFIBROADENOMAS

• Fibroadenomas Removal of all fibroadenomas has
  been advocated irrespective of patient age or
  other considerations, and solitary fibroadenomas
  in young women are frequently removed to
  alleviate patient concern.
• Yet most fibroade- nomas are self-limiting and
  many go undiagnosed, so a more conservative
  approach is reasonable.
• Careful ultrasound examination with core-needle
  biopsy will provide for an accurate diagnosis.
• Subsequently, the patient is counseled concerning
  the biopsy results, and excision of the
  fibroadenoma may be avoided.

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Selected Benign Breast Disorders and
DiseasesSCLEROSING DISORDERS

• Sclerosing Disorders The clinical significance
  of sclerosing adenosis lies in its mimicry of
  cancer.
• It may be confused with cancer on physical exam-
  ination, by mammography, and at gross pathologic
  examination.
• Excisional biopsy and histologic examination are
  frequently necessary to exclude the diagnosis of
  cancer.
• The diagnostic work-up for radial scars and
  complex scle- rosing lesions frequently involves
  stereoscopic biopsy.
• It is usually not possible to differentiate these
  lesions with certainty from cancer by mammography
  features, hence biopsy is recommended.

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Selected Benign Breast Disorders and
DiseasesPERIDUCTAL MASTITIS

• Periductal Mastitis Painful and tender masses
  behind the nipple-areola complex are aspirated
  with a 21-gauge needle attached to a 10-mL
  syringe.
• Any fluid obtained is submitted for cytology and
  for culture using a trans- port medium
  appropriate for the detection of anaerobic
  organisms.
• Women are started on a combination of
  metronidazole and dicloxacillin while awaiting
  the results of culture.
• A subareolar abscess usually is unilocular and
  often is associated with a single duct system.
  Preoperative ultrasound will accurately delineate
  its extent
• The surgeon may either undertake simple drainage
  with a view toward formal surgery, should the
  problem recur, or proceed with definitive
  surgery.
• In a woman of childbearing age, simple drainage
  is preferred, but if there is an anaerobic
  infection, recurrent infection frequently
  develops.
• Recurrent abscess with fistula is a difficult
  problem and may be treated by fistulectomy or by
  major duct excision, depending on the
  circumstances.
• Antibiotic therapy is useful for recurrent
  infection after fistula excision, and a 24-week
  course is recommended prior to total duct
  excision.

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Selected Benign Breast Disorders and
DiseasesNIPPLE INVERSION

• Nipple Inversion More women request correction
  of congenital nipple inversion than request
  correction for the nipple inversion that occurs
  secondary to duct ectasia.
• surgical complications of altered nipple
  sensation, nipple necrosis, and postoperative
  fibrosis with nipple retraction.
• Because nipple inversion is a result of
  shortening of the subareolar ducts, a complete
  division of these ducts is necessary for
  permanent correction of the disorder.

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INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTBacterial Infection

• Bacterial infection. Staphylococcus aureus and
  Streptococcus species are the organisms most
  frequently recovered from nipple discharge from
  an infected breast.
• Breast abscesses are typically seen in
  staphylococcal infections and present with point
  tenderness, erythema, and hyperthermia.
• These abscesses are related to lactation and
  occur within the first few weeks of
  breast-feeding. Progression of a staphylococcal
  infection may result in subcutaneous, sub-
  areolar, interlobular (periductal), and
  retromammary abscesses (unicentric or
  multicentric),
• necessitating operative drainage of fluctuant
  areas.
• Preoperative ultrasonography is effective in
  delineating the extent of the needed drainage
  procedure, which is best accomplished via
  circumareolar incisions or incisions paralleling
  Langer lines.
• Although staphylococcal infections tend to be
  more localized and may be located deep in the
  breast tissues, streptococcal infections usually
  present with diffuse superficial involvement.
• They are treated with local wound care, including
  warm compresses, and the administration of
  intravenous antibiotics (penicillins or
  cephalosporins).
• Breast infections may be chronic, possibly with
  recurrent abscess formation.
• In this situation, cultures are taken to identify
  acid-fast bacilli, anaerobic and aerobic
  bacteria, and fungi.
• Uncommon organisms may be encountered and
  long-term antibiotic therapy may be required.

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INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTHidradenitis Suppurativa

• Hidradenitissuppurativa. Hidradenitis suppurativa
  of the nipple-areolacomplex or axilla is a
  chronic inflammatory condition that originates
  within the accessory areolar glands of Montgomery
  or within the axillary sebaceous glands.
• When located in and about the nipple-areola
  complex, this disease may mimic other chronic
  inflammatory states, Paget disease of the nipple,
  or invasive breast cancer.
• Involvement of the axillary skin is often
  multifocal and contiguous.
• Antibiotic therapy with incision and drainage of
  fluctuant areas is appropriate treatment.
• Complete excision of the involved areas may be
  required and may necessitate coverage with
  advancement flaps or split-thickness skin grafts.

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INFECTIOUS AND INFLAMMATORY DISORDERS OF THE
BREASTMondor's Disease

• Mondors disease. This variant of
  thrombophlebitis involves the superficial veins
  of the anterior chest wall and breast.
• In 1939, Mondor described the condition as
  string phlebitis, a thrombosed vein presenting
  as a tender, cord- like structure.
• Typically, a woman presents with acute pain in
  the lateral aspect of the breast or the anterior
  chest wall.
• A tender, firm cord is found to follow the
  distribution of one of the major superficial
  veins.
• Most women have no evidence of thrombophlebitis
  in other anatomic sites.
• When the diagnosis is uncertain, or when a mass
  is present near the tender cord, biopsy is
  indicated.
• Therapy for Mondor disease includes the liberal
  use of antiinflammatory medications and warm
  compresses that are applied along the symptomatic
  vein.
• Restriction of motion of the ipsilateral
  extremity and shoulder and brassiere support of
  the breast are important.
• The process usually resolves within 46 weeks.
  When symptoms persist or are refractory to
  therapy, excision of the involved vein segment is
  appropriate.

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RISK FACTORS FOR BREAST CANCER

• Hormonal Risk Factors
• Increased exposure to estrogen is associated with
  an increased risk for developing breast cancer,
  whereas reducing exposure is thought to be
  protective
• Correspondingly, factors that increase the number
  of menstrual cycles, such as early menarche,
  nulliparity, and late menopause, are associated
  with increased risk
• Moderate levels of exercise and a longer
  lactation period, factors that decrease the total
  number of menstrual cycles, are protective.
• Older age at first live birth is associated with
  an increased risk of breast cancer.
• There is an association between obesity and
  increased breast cancer risk

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RISK FACTORS FOR BREAST CANCER

• Nonhormonal Risk Factors
• Radiation (radiation therapy for Hodgkin's
  lymphoma have a breast cancer risk that is 75
  times greater)
• Studies also suggest that the risk of breast
  cancer increases as the amount of alcohol a woman
  consumes increases.
• high fat content diet

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Risk Assessment

• The average lifetime risk of breast cancer for
  newborn U.S. females is 12.
• A software program incorporating the Gail model
  is available from the National Cancer Institute
  at http//bcra.nci.nih.gov/brc.
• Claus and colleagues

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Factors Associated with Increased Risk of Breast
Cancer

• White
• Older
• Family history Breast cancer in mother, sister,
  or daughter (especially bilateral or
  premenopausal)
• BRCA1 or BRCA2 mutation
• Endometrial cancer
• Proliferative forms of fibrocystic disease
• Cancer in other breast
• Early menarche (under age 12)
• Late menopause (after age 50)
• Nulliparous or late first pregnancy

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screening mammography

• Routine use of screening mammography in women 50
  years of age reduces mortality from breast cancer
  by 33.
• This reduction comes without substantial risks
  and at an acceptable economic cost.
• However, the use of screening mammography in
  women lt50 years of age is more controversial for
  several reasons (a) breast density is greater
  and screening mammography is less likely to
  detect early breast cancer (b) screening
  mammography results in more false-positive test
  findings, which results in unnecessary biopsies
  and (c) younger women are less likely to have
  breast cancer, so fewer young women will benefit
  from screening.
• Current recommendations are that women undergo
  baseline mammography at age 35 and then have
  annual mammographic screening beginning at age 40.

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Incidence of Sporadic, Familial, and Hereditary
Breast Cancer

• Sporadic breast cancer 6575
• Familial breast cancer 2030
• Hereditary breast cancer 510
• BRCA1 a 45
• BRCA2 35
• p53a (Li-Fraumeni syndrome) 1
• STK11/LKB1a (Peutz-Jeghers syndrome) lt1
• PTENa (Cowden disease) lt1
• MSH2/MLH1a (Muir-Torre syndrome) lt1
• ATMa (Ataxia-telangiectasia) lt1
• Unknown 20
• Both BRCA1 and BRCA2 function as tumor-suppressor
  genes, and for each gene, loss of both alleles is
  required for the initiation of cancer.

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BRCA MutationsBRCA1

• Five to 10 of breast cancers are caused by
  inheritance of germline mutations such as BRCA1
  and BRCA2, which are inherited in an autosomal
  dominant fashion with varying penetrance
• BRCA1 is located on chromosome arm 17q, spans a
  genomic region of approximately 100 kilobases
  (kb) of DNA, and contains 22 coding exons
• Data accumulated since the isolation of the BRCA1
  gene suggest a role in transcription, cell-cycle
  control, and DNA damage repair pathways.
• More than 500 sequence variations in BRCA1 have
  been identified.

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• predisposing genetic factor in as many as 45 of
  hereditary breast cancers and in at least 80 of
  hereditary ovarian cancers.
• Female mutation carriers have up to a 90
  lifetime risk for developing breast cancer and up
  to a 40 lifetime risk for developing ovarian
  cancer
• Approximately 50 of children of carriers inherit
  the trait.

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• In general, BRCA1-associated breast cancers are
  invasive ductal carcinomas, are poorly
  differentiated, and are hormone receptor
  negative.
• BRCA1-associated breast cancers have a number of
  distinguishing clinical features, such as an
  early age of onset compared with sporadic cases
  a higher prevalence of bilateral breast cancer
  and the presence of associated cancers in some
  affected individuals, specifically ovarian cancer
  and possibly colon and prostate cancers.

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BRCA2

• BRCA2 is located on chromosome arm 13q and spans
  a genomic region of approximately 70 kb of DNA.
  The 11.2-kb coding region contains 26 coding
  exons
• The biologic function of BRCA2 is not well
  defined, but like BRCA1, it is postulated to play
  a role in DNA damage response pathways.
• BRCA2 messenger RNA also is expressed at high
  levels in the late G1 and S phases of the cell
  cycle.
• The mutational spectrum of BRCA2 is not as well
  established as that of BRCA1. To date, gt250
  mutations have been found

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• The breast cancer risk for BRCA2 mutation
  carriers is close to 85, and the lifetime
  ovarian cancer risk, while lower than for BRCA1,
  is still estimated to be close to 20.
• Breast cancer susceptibility in BRCA2 families is
  an autosomal dominant trait and has a high
  penetrance.
• Approximately 50 of children of carriers inherit
  the trait.
• Unlike male carriers of BRCA1 mutations, men with
  germline mutations in BRCA2 have an estimated
  breast cancer risk of 6, which represents a
  100-fold increase over the risk in the general
  male population.

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• BRCA2- associated breast cancers are invasive
  ductal carcinomas, which are more likely to be
  well differentiated and to express hormone
  receptors than are BRCA1-associated breast
  cancers.
• BRCA2-associated breast cancer has a number of
  distinguishing clinical features, such as an
  early age of onset compared with sporadic cases,
  a higher prevalence of bilateral breast cancer,
  and the presence of associated cancers in some
  affected individuals, specifically ovarian,
  colon, prostate, pancreatic, gallbladder, bile
  duct, and stomach cancers, as well as melanoma.
• The 6174delT mutation is found in Ashkenazi Jews
  with a prevalence of 1.2. Another BRCA2 founder
  mutation, 999del5, is observed in Icelandic and
  Finnish populations.

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CANCER PREVENTION FOR BRCA MUTATION CARRIERS

• Risk management strategies for BRCA1 and BRCA2
  mutation carriers include the following
• 1. Prophylactic mastectomy and reconstruction
• 2. Prophylactic oophorectomy and hormone
  replacement therapy
• 3. Intensive surveillance for breast and ovarian
  cancer
• 4. Chemoprevention

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Chemoprevention

• Despite a 49 reduction in the incidence of
  breast cancer in high-risk women taking
  tamoxifen, it is too early to recommend the use
  of tamoxifen uniformly for BRCA mutation
  carriers.
• Cancers arising in BRCA1 mutation carriers are
  usually high grade and are most often hormone
  receptor negative.
• Approximately 66 of BRCA1-associated DCIS
  lesions are estrogen receptor negative, which
  suggests early acquisition of the
  hormoneindependent phenotype. Tamoxifen appears
  to be more effective at preventing estrogen
  receptorpositive breast cancers.

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EPIDEMIOLOGY AND NATURAL HISTORY OF BREAST CANCER

• Breast cancer is the most common site-specific
  cancer in women and is the leading cause of death
  from cancer for women aged 20 to 59 years

30
PRIMARY BREAST CANCER

• More than 80 of breast cancers show productive
  fibrosis that involves the epithelial and stromal
  tissues.

31

• With growth of the cancer and invasion of the
  surrounding breast tissues, the accompanying
  desmoplastic response entraps and shortens
  Cooper's suspensory ligaments to produce a
  characteristic skin retraction.

32

• Localized edema (peau d'orange) develops when
  drainage of lymph fluid from the skin is
  disrupted.

33

• With continued growth, cancer cells invade the
  skin, and eventually ulceration occurs. As new
  areas of skin are invaded, small satellite
  nodules appear near the primary ulceration.

34

• The size of the primary breast cancer correlates
  with disease-free and overall survival, but there
  is a close association between cancer size and
  axillary lymph node involvement

35
AXILLARY LYMPH NODE METASTASES

• As the size of the primary breast cancer
  increases, some cancer cells are shed into
  cellular spaces and transported via the lymphatic
  network of the breast to the regional lymph
  nodes, especially the axillary lymph nodes. Lymph
  nodes that contain metastatic cancer are at first
  ill defined and soft but become firm or hard with
  continued growth of the metastatic cancer.
• the most important prognostic correlate of
  disease-free and overall survival is axillary
  lymph node status

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DISTANT METASTASES

• At approximately the twentieth cell doubling,
  breast cancers acquire their own blood supply
  (neovascularization).
• Thereafter, cancer cells may be shed directly
  into the systemic venous blood to seed the
  pulmonary circulation via the axillary and
  intercostal veins or the vertebral column via
  Batson's plexus of veins, which courses the
  length of the vertebral column.
• These cells are scavenged by natural killer
  lymphocytes and macrophages.
• Successful implantation of metastatic foci from
  breast cancer predictably occurs after the
  primary cancer exceeds 0.5 cm in diameter, which
  corresponds to the twenty-seventh cell doubling.
• Common sites of involvement, in order of
  frequency, are bone, lung, pleura, soft tissues,
  and liver.

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HISTOPATHOLOGY OF BREAST CANCER

• Carcinoma in Situ
• LOBULAR CARCINOMA IN SITU
• DUCTAL CARCINOMA IN SITU
• Invasive Breast Carcinoma
• 1. Paget's disease of the nipple
• 2. Invasive ductal carcinoma
• 3. Adenocarcinoma with productive fibrosis
  (scirrhous, simplex, NST), 80 (invasive ductal
  carcinoma of no special type)
• 4. Medullary carcinoma, 4
• 5. Mucinous (colloid) carcinoma, 2
• 6. Papillary carcinoma, 2
• 7. Tubular carcinoma, 2
• 8. Invasive lobular carcinoma, 10
• 9. Rare cancers (adenoid cystic, squamous cell,
  apocrine)

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Carcinoma in Situ

• Cancer cells are in situ or invasive depending on
  whether or not they invade through the basement
  membrane
• Foote and Stewart published a landmark
  description of LCIS, which distinguished it from
  DCIS
• In the late 1960s, Gallagher and Martin published
  their study of whole-breast sections and
  described a stepwise progression from benign
  breast tissue to in situ cancer and subsequently
  to invasive cancer. They coined the term minimal
  breast cancer (LCIS, DCIS, and invasive cancers
  smaller than 0.5 cm in size) and stressed the
  importance of early detection
• It is now recognized that each type of minimal
  breast cancer has a distinct clinical and
  biologic behavior.

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Lobular Carcinoma In Situ

• LCIS originates from the terminal duct lobular
  units and develops only in the female breast. It
  is characterized by distention and distortion of
  the terminal duct lobular units
• LCIS may be observed in breast tissues that
  contain microcalcifications, but the
  calcifications associated with LCIS typically
  occur in adjacent tissues. This neighborhood
  calcification is a feature that is unique to LCIS
  and contributes to its diagnosis.
• The frequency of LCIS in the general population
  cannot be reliably determined because it usually
  presents as an incidental finding.
• The average age at diagnosis is 45 years, which
  is approximately 15 to 25 years younger than the
  age at diagnosis for invasive breast cancer.

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Lobular Carcinoma In Situ

• Invasive breast cancer develops in 25 to 35 of
  women with LCIS.
• Invasive cancer may develop in either breast,
  regardless of which breast harbored the initial
  focus of LCIS, and is detected synchronously with
  LCIS in 5 of cases.
• In women with a history of LCIS, up to 65 of
  subsequent invasive cancers are ductal, not
  lobular, in origin. For these reasons, LCIS is
  regarded as a marker of increased risk for
  invasive breast cancer rather than as an anatomic
  precursor.
• Individuals should be counseled regarding their
  risk of developing breast cancer and appropriate
  risk reduction strategies, including observation
  with screening, chemoprevention, and
  risk-reducing bilateral mastectomy.

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Ductal Carcinoma In Situ.

• Published series suggest a detection frequency of
  7 in all biopsy tissue specimens.
• DCIS, which carries a high risk for progression
  to an invasive cancer.
• Histologically, DCIS is characterized by a
  proliferation of the epithelium that lines the
  minor ducts, resulting in papillary growths
  within the duct lumina.
• papillary growth pattern, cribriform growth
  pattern, solid growth pattern, comedo growth
  pattern,
• Calcium deposition occurs in the areas of
  necrosis and is a common feature seen on
  mammography.
• Figure From The Breast. Schwartz's Principles
  of Surgery, 10e, 2014

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Ductal Carcinoma In Situ.

• The risk for invasive breast cancer is increased
  nearly fivefold in women with DCIS
• The invasive cancers are observed in the
  ipsilateral breast, usually in the same quadrant
  as the DCIS that was originally detected, which
  suggests that DCIS is an anatomic precursor of
  invasive ductal carcinoma

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• DCIS is now frequently classified based on
  nuclear grade and the presence of necrosis

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Invasive Breast Carcinoma

• Invasive breast cancers have been described as
  lobular or ductal in origin
• About 80 of invasive breast cancers are
  described as invasive ductal carcinoma of no
  special type (NST). These cancers generally have
  a worse prognosis than special-type cancers.
• Foote and Stewart originally proposed the
  following classification for invasive breast
  cancer.
• Pagets disease of the nipple
• Invasive ductal carcinomaAdenocarcinoma with
  productive fibrosis (scirrhous, simplex, NST),
  80
• Medullary carcinoma, 4
• Mucinous (colloid) carcinoma, 2
• Papillary carcinoma, 2
• Tubular carcinoma, 2
• Invasive lobular carcinoma, 10
• Rare cancers (adenoid cystic, squamous cell,
  apocrine)

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Pagets disease of the nipple

• Pagets disease of the nipple was described in
  1874.
• It frequently presents as a chronic, eczematous
  eruption of the nipple, which may be subtle but
  may progress to an ulcerated, weeping lesion.
• Pagets disease usually is associated with
  extensive DCIS and may be associated with an
  invasive cancer.
• A palpable mass may or may not be present.
• A nipple biopsy specimen will show a population
  of cells that are identical to the underlying
  DCIS cells (pagetoid features or pagetoid
  change). Pathognomonic of this cancer is the
  presence of large, pale, vacuolated cells (Paget
  cells) in the rete pegs of the epithelium.
  Pagets disease may be confused with superficial
  spreading melanoma. Differentiation from pagetoid
  intraepithelial melanoma is based on the presence
  of S-100 antigen immunostaining in melanoma and
  carcinoembryonic antigen immunostaining in
  Pagets disease.
• Surgical therapy for Pagets disease may involve
  lumpectomy or mastectomy, depending on the extent
  of involvement of the nipple-areolar complex and
  the presence of DCIS or invasive cancer in the
  underlying breast parenchyma.

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Invasive ductal carcinoma

• Invasive ductal carcinoma of the breast with
  productive fibrosis (scirrhous, simplex, NST)
  accounts for 80 of breast cancers and presents
  with macroscopic or microscopic axillary lymph
  node metastases in up to 25 of screen-detected
  cases and up to 60 of symptomatic cases.
• This cancer occurs most frequently in
  perimenopausal or postmenopausal women in the
  fifth to sixth decades of life as a solitary,
  firm mass.
• It has poorly defined margins and its cut
  surfaces show a central stellate configuration
  with chalky white or yellow streaks extending
  into surrounding breast tissues.
• In a large patient series, 75 of ductal cancers
  showed estrogen receptor expression.

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Invasive lobular carcinoma

• Invasive lobular carcinoma accounts for 10 of
  breast cancers.
• Special stains may confirm the presence of
  intracytoplasmic mucin, which may displace the
  nucleus (signet-ring cell carcinoma).
• At presentation, invasive lobular carcinoma
  varies from clinically inapparent carcinomas to
  those that replace the entire breast with a
  poorly defined mass.
• It is frequently multifocal, multicentric, and
  bilateral. Because of its insidious growth
  pattern and subtle mammographic features,
  invasive lobular carcinoma may be difficult to
  detect.
• Over 90 of lobular cancers express estrogen
  receptor.

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DIAGNOSIS OF BREAST CANCER

• In30 of cases, the woman discovers a lump in
  her breast. Other less frequent presenting signs
  and symptoms of breast cancer include
• (a) breast enlargement or asymmetry
• (b) nipple changes, retraction, or discharge
• (c) ulceration or erythema of the skin of the
  breast
• (d) an axillary mass and
• (e) musculoskeletal discomfort.
• Breast pain usually is associated with benign
  disease.
• Diagnosis of breast cancer
• Examination
• Imaging Techniques Mammography, Ductography,
  Ultrasonography, Magnetic Resonance Imaging
• Breast Biopsy

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Examination

• Symmetry, size, and shape of the breast are
  recorded, as well as any evidence of edema
  (peaudorange), nipple or skin retraction, or
  erythema.
• Careful palpation of supraclavicular and
  parasternal sites also is performed.
• A diagram of the chest and contiguous lymph node
  sites is useful for recording location, size,
  consistency, shape, mobility, fixation, and other
  characteristics of any palpable breast mass or
  lymphadenopathy

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Imaging Techniques Mammography

• Mammography has been used in North America since
  the 1960s
• Conventional mammography delivers a radiation
  dose of 0.1 cGy per study. By comparison, chest
  radiography delivers 25 of this dose. However,
  there is no increased breast cancer risk
  associated with the radiation dose delivered with
  screening mammography.
• Screening mammography is used to detect
  unexpected breast cancer in asymptomatic women.
  In this regard, it supplements history taking and
  physical examination.
• With screening mammography, two views of the
  breast are obtained, the craniocaudal (CC) view
  and the mediolateral oblique (MLO) view. The MLO
  view images the greatest volume of breast tissue,
  including the upper outer quadrant and the
  axillary tail of Spence.
• Compared with the MLO view, the CC view provides
  better visualization of the medial aspect of the
  breast and permits greater breast compression.
• Diagnostic mammography is used to evaluate women
  with abnormal findings such as a breast mass or
  nipple discharge.

52
Imaging Techniques Mammography

• Spot compression may be done in any projection by
  using a small compression device, which is placed
  directly over a mammographic abnormality that is
  obscured by overlying tissues.
• The compression device minimizes motion artifact,
  improves definition, separates overlying tissues,
  and decreases the radiation dose needed to
  penetrate the breast.
• Magnification techniques (1.5) often are
  combined with spot compression to better resolve
  calcifications and the margins of masses.
• Mammography also is used to guide interventional
  procedures, including needle localization and
  needle biopsy.
• Specific mammographic features that suggest a
  diagnosis of breast cancer include a solid mass
  with or without stellate features, asymmetric
  thickening of breast tissues, and clustered
  microcalcifications

53
Imaging Techniques Mammography

• These microcalcifications are an especially
  important sign of cancer in younger women, in
  whom it may be the only mammographic abnormality.
  
• The clinical impetus for screening mammography
  came from the Health Insurance Plan study and the
  Breast Cancer Detection Demonstration Project,
  which demonstrated a 33 reduction in mortality
  for women after screening mammography.
• Current guidelines of the National Comprehensive
  Cancer Network suggest that normal-risk women 20
  years of age should have a breast examination at
  least every 3 years.
• Starting at age 40 years, breast examinations
  should be performed yearly and a yearly mammogram
  should be taken.
• The benefits from screening mammography in women
  50 years of age has been noted above to be
  between 20 and 25 reduction in breast cancer
  mortality

54
Imaging Techniques Mammography

• The use of screening mammography in women lt50
  years of age is more controversial again for
  reasons noted above (a) reduced sensitivity (b)
  reduced specificity and (c) lower incidence of
  breast cancer.
• For the combination of these three reasons
  targeting mammography screening to women lt50
  years at higher risk of breast cancer improves
  the balance of risks and benefits and is the
  approach some health care systems have taken.

55
Imaging Techniques Ductography

• The primary indication for ductography is nipple
  discharge, particularly when the fluid contains
  blood.
• Radiopaque contrast media is injected into one or
  more of the major ducts and mammography is
  performed.
• A duct is gently enlarged with a dilator and then
  a small, blunt cannula is inserted under sterile
  conditions into the nipple ampulla.
• With the patient in a supine position, 0.1 to 0.2
  mL of dilute contrast media is injected and CC
  and MLO mammographic views are obtained without
  compression.
• Intraductal papillomas are seen as small filling
  defects surrounded by contrast media.
• Cancers may appear as irregular masses or as
  multiple intraluminal filling defects.

56
Imaging Techniques Ultrasonography

• Second only to mammography in frequency of use
  for breast imaging, ultrasonography is an
  important method of resolving equivocal
  mammographic findings, defining cystic masses,
  and demonstrating the echogenic qualities of
  specific solid abnormalities.
• Benign breast masses usually show smooth
  contours, round or oval shapes, weak internal
  echoes, and well-defined anterior and posterior
  margins. Breast cancer characteristically has
  irregular walls but may have smooth margins with
  acoustic enhancement.
• Ultrasonography is used to guide fine-needle
  aspiration biopsy, core-needle biopsy, and needle
  localization of breast lesions.
• Ultrasonography can also be utilized to image the
  regional lymph nodes in patients with breast
  cancer.

57
Imaging Techniques Magnetic Resonance Imaging

• In the process of evaluating magnetic resonance
  imaging (MRI) as a means of characterizing
  mammographic abnormalities, additional breast
  lesions have been detected. However, in the
  circumstance of negative findings on both
  mammography and physical examination, the
  probability of a breast cancer being diagnosed by
  MRI is extremely low.
• There is current interest in the use of MRI to
  screen the breasts of high-risk women and of
  women with a newly diagnosed breast cancer. 1)
  women who have a strong family history of breast
  cancer or who carry known genetic mutations
  require screening at an early age, because
  mammographic evaluation is limited due to the
  increased breast density in younger women. 2) an
  MRI study of the contralateral breast in women
  with a known breast cancer has shown a
  contralateral breast cancer in 5.7 of these
  women.
• MRI can also detect additional tumors in the
  index breast (multifocal or multicentric disease)
  that may be missed on routine breast imaging and
  this may alter surgical decision making. In fact,
  MRI has been advocated by some for routine use in
  surgical treatment planning based on the fact
  that additional disease can be identified with
  this advanced imaging modality and the extent of
  disease may be more accurately assessed.

58
Breast Biopsy, Nonpalpable Lesions.

• Image-guided breast biopsy specimens are
  frequently required to diagnose nonpalpable
  lesions.
• Ultrasound localization techniques are used when
  a mass is present, whereas stereotactic
  techniques are used when no mass is present
  (microcalcifications or architectural distortion
  only).
• The combination of diagnostic mammography,
  ultrasound or stereotactic localization, and
  fine-needle aspiration (FNA) biopsy achieves
  almost 100 accuracy in the preoperative
  diagnosis of breast cancer.
• The advantages of core-needle biopsy include a
  low complication rate, minimal scarring, and a
  lower cost compared with excisional breast biopsy.

59
Breast Biopsy, Palpable Lesions.

• FNA or core biopsy of a palpable breast mass can
  usually be performed in an outpatient setting.
• A 1.5-in, 22-gauge needle attached to a 10-mL
  syringe or a 14 gauge core biopsy needle is used.
• The cellular material is then expressed onto
  microscope slides. Both air-dried and 95
  ethanolfixed microscopic sections are prepared
  for analysis
• Automated devices also are available. Vacuum
  assisted core biopsy devices (with 810 gauge
  needles) are commonly utilized with image
  guidance where between 4 and 12 samples can be
  acquired at different positions within a mass,
  area of architectural distortion or
  microcalcifications. If the target lesion was
  microcalcifications, the specimen should be
  radiographed to confirm appropriate sampling. A
  radiopaque marker should be placed at the site of
  the biopsy to mark the area for future
  intervention
• Tissue specimens are placed in formalin and then
  processed to paraffin blocks

60
Examination

• INSPECTION
• PALPATION

61
BREAST CANCER STAGING

• The clinical stage of breast cancer is determined
  primarily through physical examination of the
  skin, breast tissue, and regional lymph nodes
  (axillary, supraclavicular, and cervical).
• Mammography, chest radiography, and
  intraoperative findings (primary tumor size,
  chest wall invasion) also provide necessary
  staging information.
• Pathologic stage combines the findings from
  pathologic examination of the resected primary
  breast cancer and axillary or other regional
  lymph nodes.
• A frequently used staging system is the TNM
  (tumor, nodes, and metastasis) system.
• The single most important predictor of 10- and
  20-year survival rates in breast cancer is the
  number of axillary lymph nodes involved with
  metastatic disease.
• Routine biopsy of internal mammary lymph nodes is
  not generally performed however, with the advent
  of sentinel lymph node dissection and the use of
  preoperative lymphoscintigraphy for localization
  of the sentinel nodes, surgeons have begun to
  biopsy the internal mammary nodes in some cases

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63
SURGICAL TECHNIQUES IN BREAST CANCER THERAPY

• Breast Conservation
• Mastectomy and Axillary Dissection
• MODIFIED RADICAL MASTECTOMY

64
Breast Conservation

• Breast conservation involves resection of the
  primary breast cancer with a margin of
  normal-appearing breast tissue, adjuvant
  radiation therapy, and assessment of regional
  lymph node status.
• Resection of the primary breast cancer is
  alternatively called segmental mastectomy,
  lumpectomy, partial mastectomy, wide local
  excision, and tylectomy. For many women with
  stage I or II breast cancer, breast-conserving
  therapy (BCT) is preferable to total mastectomy
  because BCT produces survival rates equivalent to
  those after total mastectomy while preserving the
  breast
• BCT allows for preservation of breast shape and
  skin as well as preservation of sensation, and
  provides an overall psychologic advantage
  associated with breast preservation.
• Breast conservation surgery is currently the
  standard treatment for women with stage 0, I, or
  II invasive breast cancer. Women with DCIS
  require only resection of the primary cancer and
  adjuvant radiation therapy without assessment of
  regional lymph nodes.
• Sentinel lymph node dissection is now the
  preferred staging procedure with a clinically
  node-negative axilla

65
Oncoplastic techniques are of prime consideration
when

• (a) a significant area of breast skin will need
  to be resected with the specimen to achieve
  negative margins
• (b) a large volume of
• breast parenchyma will be resected resulting in a
  significant defect
• (c) the tumor is located between the nipple and
  the inframammary fold, an area often associated
  with unfavorable cosmetic outcomes or
• (d) excision of the tumor and closure of the
  breast may result in malpositioning of the nipple.

66
Mastectomy and Axillary Dissection

• A skin-sparing mastectomy removes all breast
  tissue, the nipple-areola complex, and scars from
  any prior biopsy procedures. There is a
  recurrence rate of less than 6 to 8, comparable
  to the long-term recurrence rates reported with
  standard mastectomy, when skin-sparing mastectomy
  is used for patients with T1 to T3 cancers.
• A total (simple) mastectomy without skin sparing
  removes all breast tissue, the nipple-areola
  complex, and skin.
• An extended simple mastectomy removes all breast
  tissue, the nipple-areola complex, skin, and the
  level I axillary lymph nodes.
• The Halsted radical mastectomy removes all breast
  tissue and skin, the nipple-areola complex, the
  pectoralis major and pectoralis minor muscles,
  and the level I, II, and III axillary lymph
  nodes.
• The use of systemic chemotherapy and hormonal
  therapy as well as adjuvant radiation therapy for
  breast cancer have nearly eliminated the need for
  the radical mastectomy.

67
MODIFIED RADICAL MASTECTOMY

• A modified radical mastectomy preserves both the
  pectoralis major and pectoralis minor muscles,
  allowing removal of level I and level II axillary
  lymph nodes but not the level III (apical)
  axillary lymph nodes
• Anatomic boundaries of the modified radical
  mastectomy are the anterior margin of the
  latissimus dorsi muscle laterally, the midline of
  the sternum medially, the subclavius muscle
  superiorly, and the caudal extension of the
  breast 2 to 3 cm inferior to the inframammary
  fold inferiorly

68

• The most lateral extent of the axillary vein is
  identified and the areolar tissue of the lateral
  axillary space is elevated as the vein is cleared
  on its anterior and inferior surfaces.
• The long thoracic nerve of Bell is identified and
  preserved as it travels in the investing fascia
  of the serratus anterior muscle. Every effort is
  made to preserve this nerve, because permanent
  disability with a winged scapula and shoulder
  weakness will follow denervation of the serratus
  anterior muscle.
• Care is taken to preserve the thoracodorsal
  neurovascular bundle.

69
In Situ Breast Cancer (Stage 0)

• Both LCIS and DCIS may be difficult to
  distinguish from atypical hyperplasia or from
  cancers with early invasion. Expert pathologic
  review is required in all cases.
• Bilateral mammography is performed to determine
  the extent of the in situ cancer and to exclude a
  second cancer. Because LCIS is considered a
  marker for increased risk rather than an
  inevitable precursor of invasive disease, the
  current treatment options for LCIS include
  observation, chemoprevention with tamoxifen, and
  bilateral total mastectomy.
• There is no benefit to excising LCIS, because the
  disease diffusely involves both breasts
• in many cases and the risk of invasive cancer is
  equal for both breasts. The use of tamoxifen as a
  risk reduction strategy should
• be considered in women with a diagnosis of LCIS.

70
In Situ Breast Cancer (Stage 0)

• Women with DCIS and evidence of extensive disease
  (gt4 cm of disease or disease in more than one
  quadrant) usually require mastectomy.
• For women with limited disease, lumpectomy and
  radiation therapy are recommended.
• For nonpalpable DCIS, needle localization
  techniques are used to guide the surgical
  resection. Specimen mammography is performed to
  ensure that all visible evidence of cancer is
  excised
• The gold standard against which breast
  conservation therapy for DCIS is evaluated is
  mastectomy. Women treated with mastectomy have
  local recurrence and mortality rates of lt2.
  Women treated with lumpectomy and adjuvant
  radiation therapy have a similar mortality rate,
  but the local recurrence rate increases to 9.
• Forty-five percent of these recurrences will be
  invasive cancer when radiation therapy is not
  used.

71
Early Invasive Breast Cancer (Stage I, IIA, or
IIB)

• the disease-free, distant disease-free, and
  overall survival rates for lumpectomy with or
  without radiation therapy were similar to those
  observed after total mastectomy.
• However, the incidence of ipsilateral breast
  cancer recurrence (in-breast recurrence) was
  higher in the lumpectomy group not receiving
  radiation therapy. (39.2 14.3)
• These findings supported the use of lumpectomy
  and radiation therapy in the treatment of stage I
  and II breast cancer.

72

• Currently, mastectomy with assessment of axillary
  lymph node status and breast conserving surgery
  with assessment of axillary lymph node status and
  radiation therapy are considered equivalent
  treatments for patients with stage I and II
  breast cancer.
• Axillary lymphadenopathy confirmed to be
  metastatic disease or metastatic disease in a
  sentinel lymph node necessitates an axillary
  lymph node dissection.

73
Relative contraindications to breast conservation
therapy

• (a) prior radiation therapy to the breast or
  chest wall,
• (b) involved surgical margins or unknown margin
  status after re-excision,
• (c) multicentric disease, and
• (d) scleroderma or lupus erythematosus.

74

• Traditionally, dissection of the level I and II
  axillary lymph nodes has been performed in early
  invasive breast cancer.
• Sentinel lymph node dissection is now considered
  the standard for evaluation of the axillary lymph
  node status in women who have clinically negative
  lymph nodes.
• Candidates for this procedure have clinically
  uninvolved axillary lymph nodes with a T1 or T2
  primary breast cancer. Controversy remains about
  the suitability of sentinel node dissection in
  women with larger primary tumors (T3) and those
  treated with neoadjuvant chemotherapy

75
Advanced Local-Regional Breast Cancer (Stage IIIA
or IIIB)

• Women with stage IIIA and IIIB breast cancer have
  advanced local-regional breast cancer but have no
  clinically detected distant metastases.
• surgery is integrated with radiation therapy and
  chemotherapy
• Surgical therapy for women with stage III disease
  is usually a modified radical mastectomy,
  followed by adjuvant radiation therapy.
  Chemotherapy is used to maximize distant
  disease-free survival, whereas radiation therapy
  is used to maximize local-regional disease-free
  survival. In selected patients with stage IIIA
  cancer, neoadjuvant (preoperative) chemotherapy
  can reduce the size of the primary cancer and
  permit breast-conserving surgery.

76
Distant Metastases (Stage IV)

• Treatment for stage IV breast cancer is not
  curative but may prolong survival and enhance a
  woman's quality of life
• Hormonal therapies that are associated with
  minimal toxicity are preferred to cytotoxic
  chemotherapy.
• Appropriate candidates for initial hormonal
  therapy include women with hormone
  receptorpositive cancers women with bone or
  soft tissue metastases only and women with
  limited and asymptomatic visceral metastases.
• Systemic chemotherapy is indicated for women with
  hormone receptornegative cancers, symptomatic
  visceral metastases, and hormone-refractory
  metastases.

77
SPECIAL CLINICAL SITUATIONS

• Nipple Discharge
• UNILATERAL NIPPLE DISCHARGE
• BILATERAL NIPPLE DISCHARGE
• Axillary Lymph Node Metastases in the Setting of
  an Unknown Primary Cancer
• Breast Cancer during Pregnancy
• Male Breast Cancer
• Phyllodes Tumors
• Inflammatory Breast Carcinoma
• Rare Breast Cancers
• SQUAMOUS CELL (EPIDERMOID) CARCINOMA
• ADENOID CYSTIC CARCINOMA
• APOCRINE CARCINOMA
• SARCOMAS
• LYMPHOMAS

78
Nipple DischargeUNILATERAL NIPPLE DISCHARGE

• Nipple discharge is a finding that can be seen in
  a number of clinical situations.
• It may be suggestive of cancer if it is
  spontaneous, unilateral, localized to a single
  duct, present in women 40 years of age, bloody,
  or associated with a mass
• mammography and ultrasound are indicated for
  further evaluation.
• A ductogram also can be useful and is performed
  by cannulating a single discharging duct with a
  small nylon catheter or needle and injecting 1.0
  mL of watersoluble contrast solution.
• Nipple discharge associated with a cancer may be
  clear, bloody, or serous. Testing for the
  presence of hemoglobin is helpful, but hemoglobin
  may also be detected when nipple discharge is
  secondary to an intraductal papilloma or duct
  ectasia.
• Definitive diagnosis depends on excisional biopsy
  of the offending duct and any associated mass
  lesion
• Another approach is to inject methylene blue dye
  within the duct after ductography.
• Needle localization biopsy is performed when
  there is an associated mass that lies gt2.0 to 3.0
  cm from the nipple.

79
Nipple DischargeBILATERAL NIPPLE DISCHARGE

• Nipple discharge is suggestive of a benign
  condition if it is bilateral and multiductal in
  origin, occurs in women 39 years of age, or is
  milky or blue-green.
• Prolactin-secreting pituitary adenomas are
  responsible for bilateral nipple discharge in lt2
  of cases.
• If serum prolactin levels are repeatedly
  elevated, plain radiographs of the sella turcica
  are indicated and thin section CT scan is
  required.
• Optical nerve compression, visual field loss, and
  infertility are associated with large pituitary
  adenomas.

80
Axillary Lymph Node Metastases in the Setting of
an Unknown Primary Cancer

• A woman who presents with an axillary lymph node
  metastasis that is consistent with a breast
  cancer metastasis has a 90 probability of
  harboring an occult breast cancer
• However, axillary lymphadenopathy is the initial
  presenting sign in only 1 of breast cancer
  patients.
• Fine-needle aspiration biopsy, core-needle
  biopsy, or open biopsy of an enlarged axillary
  lymph node is performed to confirm metastatic
  disease.
• When metastatic cancer is found,
  immunohistochemical analysis may classify the
  cancer as epithelial, melanocytic, or lymphoid in
  origin.
• The presence of hormone receptors (estrogen or
  progesterone receptors) suggests metastasis from
  a breast cancer but is not diagnostic.

81
Axillary Lymph Node Metastases in the Setting of
an Unknown Primary Cancer

• The search for a primary cancer includes careful
  examination of the thyroid, breast, and pelvis,
  including the rectum.
• The breast should be examined with diagnostic
  mammography, ultrasonography, and MRI to evaluate
  for an occult primary lesion.
• Further radiologic and laboratory studies should
  include chest radiography and liver function
  studies. Chest, abdominal, and pelvic CT scans
  also are indicated, as is a bone scan to rule out
  distant metastasis.
• Suspicious findings on mammography,
  ultrasonography, or MRI necessitate breast
  biopsy.
• When a breast cancer is found, treatment consists
  of an axillary lymph node dissection with a
  mastectomy or preservation of the breast followed
  by whole-breast radiation therapy.
• Chemotherapy and endocrine therapy should be
  considered.

82
Breast Cancer during Pregnancy

• Breast cancer occurs in 1 of every 3000 pregnant
  women, and axillary lymph node metastases are
  present in up to 75 of these women
• The average age of the pregnant woman with breast
  cancer is 34 years.
• Fewer than 25 of the breast nodules developing
  during pregnancy and lactation will be cancerous.
  
• Ultrasonography and needle biopsy are used in the
  diagnosis of these nodules.
• Open biopsy may be required.
• Mammography is rarely indicated because of its
  decreased sensitivity during pregnancy and
  lactation however, the fetus can be shielded if
  mammography is needed.

83
Breast Cancer during Pregnancy

• Approximately 30 of the benign conditions
  encountered will be unique to pregnancy and
  lactation (galactoceles, lobular hyperplasia,
  lactating adenoma, and mastitis or abscess).
• Once a breast cancer is diagnosed, complete blood
  count, chest radiography (with shielding of the
  abdomen), and liver function studies are
  performed.

84
Breast Cancer during Pregnancy

• Because of the potential deleterious effects of
  radiation therapy on the fetus, radiation cannot
  be considered until the fetus is delivered.
• A modified radical mastectomy can be performed
  during the first and second trimesters of
  pregnancy, even though there is an increased risk
  of spontaneous abortion after first-trimester
  anesthesia.
• During the third trimester, lumpectomy with
  axillary node dissection can be considered if
  adjuvant radiation therapy is deferred until
  after delivery.
• Lactation is suppressed.

85
Breast Cancer during Pregnancy

• Chemotherapy administered during the first
  trimester carries a risk of spontaneous abortion
  and a 12 risk of birth defects.
• There is no evidence of teratogenicity resulting
  from administration of chemotherapeutic agents in
  the second and third trimesters.
• For this reason, many clinicians now consider
  the optimal strategy to be delivery of
  chemotherapy in the second and third trimesters
  as a neoadjuvant approach, which allows local
  therapy decisions to be made after the delivery
  of the baby.
• Pregnant women with breast cancer often present
  at a later stage of disease because breast tissue
  changes that occur in the hormone-rich
  environment of pregnancy obscure early cancers.
• However, pregnant women with breast cancer have a
  prognosis, stage by stage, that is similar to
  that of nonpregnant women with breast cancer.

86
Male Breast Cancer

• Fewer than 1 of all breast cancers occur in men.
• Breast cancer is rarely seen in young males and
  has a peak incidence in the sixth decade of life.
  
• A firm, nontender mass in the male breast
  requires investigation. Skin or chest wall
  fixation is particularly worrisome.
• It is associated with radiation exposure,
  estrogen therapy, testicular feminizing
  syndromes, and Klinefelter's syndrome (XXY ).
• DCIS makes up lt15 of male breast cancer, whereas
  infiltrating ductal carcinoma makes up gt85.

87
Male Breast Cancer

• Male breast cancer is staged in the same way as
  female breast cancer, and stage by stage, men
  with breast cancer have the same survival rate as
  women.
• Overall, men do worse because of the advanced
  stage of their cancer (stage III or IV) at the
  time of diagnosis.
• The treatment of male breast cancer is surgical,
  with the most common procedure being a modified
  radical mastectomy.
• Sentinel node dissection has been shown to be
  feasible and accurate for nodal assessment in men
  presenting with a clinically node-negative
  axillary nodal basin.
• Adjuvant radiation therapy is appropriate in
  cases in which there is a high risk for
  local-regional recurrence.
• Eighty percent of male breast cancers are hormone
  receptor positive, and adjuvant tamoxifen is
  considered.
• Systemic chemotherapy is considered for men with
  hormone receptornegative cancers and for men
  with large primary tumors, multiple positive
  nodes, and locally advanced disease.

88
Phyllodes Tumors

• These tumors are classified as benign,
  borderline, or malignant. Borderline tumors have
  a greater potential for local recurrence.
• Phyllodes tumors are usually sharply demarcated
  from the surrounding breast tissue, which is
  compressed and distorted.
• The stroma of a phyllodes tumor generally has
  greater cellular activity than that of a
  fibroadenoma.
• Evaluation of the number of mitoses and the
  presence or absence of invasive foci at the tumor
  margins may help to identify a malignant tumor

89
Phyllodes Tumors

• Small phyllodes tumors are excised with a margin
  of normal-appearing breast tissue. When the
  diagnosis of a phyllodes tumor with suspicious
  malignant elements is made, re-excision of the
  biopsy site to ensure complete excision of the
  tumor with a 1-cm margin of normal-appearing
  breast tissue is indicated
• Large phyllodes tumors may require mastectomy.
• Axillary dissection is not recommended because
  axillary lymph node metastases rarely occur.

90
Inflammatory Breast Carcinoma

• Inflammatory breast carcinoma (stage IIIB)
  accounts for lt3 of breast cancers.
• This cancer is characterized by the skin changes
  of brawny induration, erythema with a raised
  edge, and edema (peau d'orange)
• Permeation of the dermal lymph vessels by cancer
  cells is seen in skin biopsy specimens.

91

• The clinical differentiation of inflammatory
  breast cancer may be extremely difficult,
  especially when a locally advanced scirrhous
  carcinoma invades dermal lymph vessels in the
  skin to produce peau d'orange and lymphangitis
• Inflammatory breast cancer also may be mistaken
  for a bacterial infection of the breast. More
  than 75 of women who have inflammatory breast
  cancer present with palpable axillary
  lymphadenopathy, and distant metastases also are
  frequently present.
• Surgery alone and surgery with adjuvant radiation
  therapy have produced disappointing results in
  women with inflammatory breast cancer.
• However, neoadjuvant chemotherapy with a
  doxorubicin-containing regimen may effect
  dramatic regressions in up to 75 of cases. In
  this setting, modified radical mastectomy is
  performed to remove residual cancer from the
  chest wall and axilla.
• Adjuvant chemotherapy may be indicated depending