Chapter 5: Breast Surgery

DISEASES AND OPERATIONS

• Radiographic abnormalities of the breast (c), excisional biopsy (c)

• Breast mass, invasive breast cancer (c), partial mastectomy (c), sentinel lymph node biopsy (c)

• Locally advanced breast cancer, simple mastectomy (c), axillary lymph node dissection (c)

• Inflammatory breast cancer (c), modified radical mastectomy (c)

• Breast cancer in pregnancy (c)

• Male breast disease (c)

• Hereditary breast cancer (c)

• Paget’s disease of the breast

• Fibroadenoma, phyllodes tumors (c)

• Nipple discharge (c), duct excision (c)

• Infectious breast disease (c)

• Benign breast disease (c), breast cyst aspiration (c)

GENERAL TIPS FOR BREAST SCENARIOS

• - There is a set of questions you should ask for essentially every patient with a breast complaint to evaluate for risk factors for breast cancer including:

  • Prior breast abnormalities/biopsies?

  • Age of menarche/menopause?

  • Number of pregnancies? Age at time of pregnancies?

  • Breast feeding history?

  • Estrogen exposure (ie, OCPs, hormone replacement therapy)?

  • Family history of cancer (including age of cancer diagnoses)?

  • History of radiation (XRT)?

• - Discuss all patients with breast cancer at a multidisciplinary committee, which should include the medical oncology, radiation oncology, and surgery teams.

• - Patients with breast cancer need axillary staging—in general, patients with a clinically negative axilla should have a sentinel lymph node biopsy (SLNB) while patients with a clinically positive axilla should undergo axillary lymph node dissection (ALND).

  • Caveat: There is potential to downstage a clinically positive axilla with neoadjuvant chemotherapy so that the patient can undergo SLNB.

• - Make sure that you discuss all reasonable treatment options in a given scenario with the patient (breast conserving therapy, mastectomy, neoadjuvant chemo, etc), rather than choosing for the patient.

• - You must remember that breast-conserving therapy (BCT) includes partial mastectomy and adjuvant whole breast radiation. Patients with a large tumor to breast ratio, widespread calcifications, or multicentric disease may not be candidates for breast-conserving therapy. Additionally, patients with a history of prior XRT and scleroderma are not able to receive XRT and, therefore, are not candidates for BCT.

  • Addition of adjuvant XRT reduces recurrence, but makes no difference in overall survival.

• - When performing excision, The recommended margin for DCIS is 2 mm; however, the recommended margin for invasive cancer is no tumor on ink.

• - The management of breast cancer is rapidly evolving and getting more nuanced all the time. Try to focus on the big picture and be well-versed in the management of the more common breast scenarios.