BreastSurgeon

Buddy Marterre, MD
© ShrewdSurgery, Inc 2002

Table of Contents
Introduction Screening Breast CA Risk Assessment Nipple Discharge Breast Mass / Abnormal Mammogram FNAs / Bxs Phyllodes Tumor Fibroadenoma ADH DCIS LCIS Early Invasive Breast CA Chemotherapy Mastectomy Sentinel Lymph Node Bx Axillary LN Dissection Lymphedema Staging Survival Breast Erythema Mastalgia Inflammatory Breast CA Locally Advanced Breast CA Distant Metastases Locally Recurrent Breast CA Breast Reconstruction Geriatric Breast CA Breast CA in Pregnancy Male Breast Enlargement / Mass AdenoCA in an Axillary LN Future / Research © Shrewd Surgery, Inc, 2002. This file may be beamed, copied, or otherwise distributed free. No portion of it may be reproduced in any way for profit. ¤ INTRO Visit www.ShrewdSurgery.com for more info! BreastSurgeon is a free document for your Pocket PC and offers a concise, common sense, clinically-oriented approach to breast disease. It is designed as a reference for surgery residents, OB/GYNs, and primary care physicians caring for patients with breast problems. It is best read w/ Acrobat Reader for Pocket PCs, which can be downloaded from www.adobe.com/products/acrobat/readerforppc.html. Other titles, available soon are VascularSurgeon, GISurgeon, HBPSurgeon, OncologySurgeon, EndocrineSurgeon, TraumaSurgeon, CriticalCareSurgeon, GeneralSurgeon (the core set) and ShrewdSurgeon (the entire set, including PedSurgeon, CTSurgeon, HandSurgeon, PlasticSurgeon, and TxpSurgeon). A student / PA version of the entire set, ShrewdSurgeonLite is also planned! Please visit www.ShrewdSurgery.com for definitions / abbreviations, references, disclaimer, other available titles, and author info.

¤ SCREENING All 3 modalities are critical: Hx, physical, and mammography. Last mammogram / MD exam? Breast self exams (BSEs)? Previous Bxs / pathology? Notice lump, skin changes or retraction, nipple D/C? Risk assessment Hx. Examine both breasts for dominant masses, both axillae for lymphadenopathy and check for supraclavicular nodes. Inspect skin, symmetry, cup size and areolae. Yearly MD exam and mammogram and monthly BSE starting at age 40 (earlier and / or q6mos MD exam in high-risk women). ¤ BREAST CA RISK ASSESSMENT Determine risk / STAR trial eligibility by current age (older is higher risk), age at menarche (younger worse), age at 1st child’s birth (older), # primary relatives with breast CA, # previous Bxs / ADH. Use the Gail model (available for PDA [Breast Ca 30kb by Phillip Cheng, MD or MedRules 185kb by Kent Willyard, MD; both free from www.palmgear.com], or on the internet at http://bcra.nci.nih.gov/brc/q1.htm). Also determine age at menopause, estrogen / oral contraceptive exposure, breast feeding Hx (> 6 mos decreases Br CA risk), and family Hx of breast, colon, prostrate, and ovarian CA (BRCA1 and 2 / Lynch syndrome). The STAR trial randomizes high-risk women to 5 years of prophylactic Raloxifene or Tamoxifen, with an approximate 50% reduction of lifetime CA risk. Candidates are those with a five year risk of > 1.7%. It is most appealing to women > 50, postmenopausal, or post-hysterectomy patients. Offer bilateral prophylactic mastectomies and genetic counseling (or more aggressive screening) for women w/ very strong family Hx of breast, CA. Screen for colon and ovarian CA too, in these cases, w/ colonoscopy and pelvic CT or U/S. Consider testing for BRCA1 and 2, but very expensive (~$2,000). ¤ NIPPLE DISCHARGE Hx to determine pathological vs. physiologic 1st: Physiologic is bilateral, multiple ducts, secondary to drugs (anti-hypertensives, BCPs, phenothiazines), hypothyroidism, pituitary adenoma, and the character is non-bloody or milky. Question relation to menstruation. Pathologic is from one duct of one breast, and bloody or watery. Reassure physiologic pts (+/check prolactin, visual fields, drug Hx). Breast CA screening and risk assessment if pathologic. Good breast and axillary exam, bilateral mammograms. Guiac test if “brownish” or bloody d/c. Cytology can be misleading. Ductograms are difficult and unhelpful. Ductal lavage is new and untested. Advise the pt that future lactation may be hindered on that side and do a terminal ductal excision. If she’s young and desires to breast feed in the future, a localized, limited terminal duct excision can be attempted: No expression for 2 - 3 days preop. Surgeon expresses d/c in OR and cannulates the duct with a small angiocath, injects blue dye, circumareolar incision and excise the blue duct(s) if localized, or that quadrant of ducts if not. Pathology is usually intraductal papilloma or duct ectasia. ¤ BREAST MASS / ABNORMAL MAMMOGRAM Hx and exam as above, bilateral mammograms: all categorized by BIRADS (Breast Imaging Reporting and Data System) classification (based on mass, microcalcification, spiculation, etc.): BIRADS 0 1,2 3 4 5 Implication Inadequate Benign NPV = 0.995 PPV ~ 0.15 PPV > 0.80 Action Repeat 1 year F/U 6 mos F/U U/S, FNA/Bx U/S, FNA/Bx

U/S is usually not very useful for screening, but is a useful adjunct in palpable masses, w/ very dense breasts, and in BIRADS score 4 and 5 non-palpable lesions. ¤ TISSUE ASSESSMENT (Bx / FNA) All palpable masses (regardless of low BIRADS score on mammogram because 10% of breast CAs have a false negative mammogram!) FNA [fine needle aspiration with 21 – 25 gauge needle and 10 – 20 ml syringe]. If the mass is a simple cyst, discard non-bloody aspirate, and ascertain complete resolution with post-aspirate exam and U/S in 6 weeks. If the aspirate is bloody, send for cytology also. If it is not a simple cyst, the cyst (mass) doesn’t completely resolve, or it recurs, obtain an adequate tissue diagnosis with open excisional or rotating knife blade core needle Bx (10 -14 gauge, suction-assisted). U/S guided or stereotactic Bx may be necessary in non-palpable or deep lesions in large breasts. Lesions close to the chest wall cannot be biopsied this way. Repeat Bx or use a different technique if non-diagnostic, particularly if suspicious or high risk. Any suspicious or atypical cytology demands another biopsy! Remember that ductal carcinoma on FNA could be either invasive CA or DCIS; core needle Bx may be used to differentiate the two. Open surgical excisional Bx is always an option and can be done with some margin of normal breast tissue so as to constitute a lumpectomy (if an invasive CA and the margins are negative). Use mammographic wire localization if non-palpable and XRay / compare the specimen to the mammogram to assure removal of the lesion. Excisional Bx incisions should be cosmetic and such that they can be incorporated inside a future mastectomy incision if possible. Use circumareolar incisions for central lesions, circumferential incisions superiorly, and circumferential or radial incisions laterally and inferiorly. All invasive CAs should be sent for ER and PR receptors (and ploidy, HER-2/neu receptor status, and Ki-67 for risk stratification). Non-Palpable BIRADS 4 or 5 mammogram (clustered, branching, linear, microcalcifications in a spiculated mass) lesion mammotome core needle Bx with stereotactic or U/S guidance or wire localization by radiology and surgical excisional Bx. Wire-localized and core needle Bx specimens of non-palpable lesions should be XRayed during the procedure to confirm that the entire (microcalcified) lesion was removed and oriented for the pathologist (if excisional), in case the margin is positive for CA and a re-excision is required. The Bx cavity can be marked w/ clips in case an invasive CA w/ a negative margin is Dx-ed (lumpectomy) for postop XRT planning. A lumpectomy and sentinel lymph node Bx with frozen section may be done initially for BIRADS 5 lesions with appropriate preoperative counseling. Prior to the performance of a MRM (modified radical mastectomy) or simple mastectomy + SLN Bx, confirm invasive carcinoma with an intraoperative frozen section on the lumpectomy specimen. Defense of this approach is that a false negative BIRADS 5 * false positive frozen section ~ 0.1 * 0.02 = 0.2%, and most of those lesions will be a large, palpable DCIS (which will be high-grade – usually with microinvasion - and for which SLN Bx and mastectomy is acceptable). ¤ (CYSTOSARCOMA) PHYLLODES TUMOR Locally aggressive, rapidly growing (usually large) tumor that may be benign or malignant, depending on cellularity, pleomorphism, nuclear atypia, and # of mitoses. Has finger-like projections into breast parenchyma. Tx is very wide excision (2 – 3 cm margin, as if it were a sarcoma, which it isn't) or mastectomy. No role for chemoTx or XRT. Re-excision (in large breasts) or mastectomy for local recurrences (25 % risk). ¤ FIBROADENOMA Usually 1 – 2 cm, rubbery mass in young women (more commonly of black race), typically under 30. Breast CA risk assessment, exam, and mammogram. Core needle or open Bx to r/o CA; FNA not as reliable in this scenario.

¤ ADH (atypical ductal hyperplasia) 5x increased risk of invasive breast CA and 50% are associated with DCIS. (Re-)excisional breast Bx unless all ADH removed with clear margins. This is the ONLY concerning pathology of all the fibrocystic diseases. Perform risk assessment to determine candidacy for prophylactic Tamoxifen or STAR trial eligibility. ¤ DCIS (ductal carcinoma-in-situ) Premalignant. Paget's disease is DCIS of the nipple. Typically has microcalcifications on mammogram. Risk of progression to invasive CA is approximately 25% in 5 years (> 10x general population). Palpable DCIS is rare. If so, there is likely an (undiagnosed, or possibly micro-) invasive CA component. Not candidates for STAR trial. Risk of axillary mets in true DCIS is theoretically 0, (actually 5%, but with progression to axillary recurrence in only 1%), but the entire breast must be treated: + High grade, comedo type (necrosis from fast growth), multicentric disease (1/3 of DCIS cases), young patients (long-term risk is higher), recurrent DCIS, pregnant, extensive lesion in a small breast, and Paget’s disease (nipple areolar DCIS) simple mastectomy +/- immediate reconstruction. Yearly MD exam and mammogram of contralateral breast. 2% risk of recurrence following mastectomy vs. 20% w/ lumpectomy and XRT. Consider bilateral mastectomy for extensive positive family Hx. + Low-grade, localized lumpectomy with 5 -10 mm negative margin and breast XRT (5,000 cGy). Post-op mammogram and close follow-up because recurrence risk is ∼ 1% per year (20% w/out XRT and 4% w/ XRT overall). Yearly MD exam, mammogram, monthly BSE. + Small (< 1 cm), low-grade, elderly (w/ short life expectancy), reliable patient and yearly follow-up. ∼ 10% recurrence risk. wide excision

¤ LCIS (lobular carcinoma-in-situ) Rarely has microcalcifications. Tumor marker. Risk of invasive CA (usually ductal, actually) is ∼ 1% per year. Multicentric, underestimated by mammography, frequently bilateral. Unnecessary to completely excise this. A positive margin is acceptable. Close f/u with BSE qmos, MD exam q6mos and mammogram qyr or prophylactic bilateral mastectomy (particularly if young, unreliable, with strong family Hx, but only in about 2% of cases). Consider prophylactic Tamoxifen or STAR trial, particularly if candidate by Gail risk analysis model. ¤ EARLY INVASIVE BREAST CA Once positive tissue Dx Stage the patient with CBC, LFT’s, CXR. Bone scan for bone pain or increase in alkaline phosphatase. Discuss options with patient, based on pathology, size of the tumor, size of the breasts, and desire to lactate (menopausal status). Must: 1. Treat the entire breast and 2. Either assess (with SLN Bx, and treat if positive) or prophylactically treat / sample the axillary nodes. Axillary failure rate decreases from 20% (12% if primary < 1cm) to 1% with treatment. The breast can be treated w/ lumpectomy (w/ a clearly negative margin) and 5,000 cGy breast XRT (+/- boost to primary). Breast XRT doesn’t impact survival, but it decreases local recurrence by ∼ 20%. This breast-conserving treatment is best if the tumor is < T3 (no extension and < 5 cm), it is unifocal, and the breast is not too small for an acceptable cosmetic result. Total mastectomy w/ or w/out immediate reconstruction is also acceptable. The axillary nodes can be staged with axillary dissection of level 1 and 2 nodes (≥ 6 usually, to the medial border of the pectoralis minor) (6% risk of edema) or SLN Bx(s) (PPV = 0.985). SNL Bx is inappropriate for multiple CA's. Add 5,000 cGy chest wall/axillary XRT (1% risk of brachial plexopathy) for patients with > 3 positive nodes. May offer clinical trial: B32 and Z11 trials

randomize 1/2 of SLN negative patients to completion axillary dissection. Risk of lymph node involvement is ∼ 15% for ≤ 1 cm (T1a and T1b) tumor and 30% for ≥ 2 cm (T2) tumor, higher in young women and lower in women over 40. Axillary nodes are removed both for staging and to decrease regional recurrence; there is no proven impact on survival. All patients get routine f/u with CXR, exam for local recurrence, and bi- or contra- lateral mammography. Risk of contralateral invasive CA is greatest in invasive lobular CA, but still only 8%, so “mirror-image” biopsy is no longer recommended, but follow the other breast closely. ¤ CHEMOTHERAPY Chemotherapy is given post-op after counseling with the following expected marginal benefits at 10 years (it decreases the death rate by ∼ 1/3 following surgery +/- XRT): Stage I:T1a/bN0 I: T1c N0 IIa: T2 N0 IIb: T3 or N1 Survival Change no benefit 87% → 90% 70% → 80% 35% → 55%

Therefore, it is clearly beneficial with positive nodes, but only marginally beneficial with negative nodes and small tumors (in fact, the benefit is about equal to the risk for Stage I). Enroll in trial if qualified and interested. Standard regimens are q3wk AC (Adriamycin, Cytoxan) +/- followed by Taxol, or CMF (Cytotoxan, Methotrexate, 5-FU) for 4 - 6 cycles. All ER/PR positive tumors get Tamoxifen (anti-estrogen) 20 mg qd x 5 years. Tamoxifen causes menopause suddenly in pre-menopausal women, can cause thrombocytopenia and GI Sx (nausea, vomiting, diarrhea) and it increases the risk of thrombosis (from 0.3% to 0.6% for DVT, to 2.0% for CVA). It very slightly increases the risk of endometrial CA, (from 0.1% to 0.25%), and decreases the risk of fractures by a factor of 1/3. An expensive alternative, which may be even more efficacious, is Arimidex (Anastrozole, an aromatase-inhibitor) 1 mg qd (0.5% DVT, 1.5% CVA). ¤ MASTECTOMY Elliptical transverse skin incision encompassing the entire areola and Bx site or a skin-sparing technique w/ areola-only excision and a laterally extended skin incision. Raise 5 – 10 mm skin flaps between the subcutaneous and breast tissue to the lateral sternal border, clavicle, rectus sheath / inframammary fold, and latissimus dorsi m. Include pec major fascia w/ detachment of breast from chest wall in a superomedial to inferolateral direction. Axillary dissection if MRM or identify the latissimus dorsi m. to include the axillary tail of Spence for a total / simple mastectomy. 2 J/P drains (remove when < 15 cc/day). Close or reconstruct immediately. Cellulitis 10%. ¤ SENTINEL LYMPH NODE Bx Unreliable w/ multifocal tumors. Better before the mass is excised than from around a cavity. More difficult w/ upper outer lesions (because of proximity to axilla). Nuclear medicine injection of 99 Tc-sulfur-colloid in 4 quadrants either subdermal or surrounding the lumpectomy cavity / mass. Peak gamma activity is immediate, best to operate ∼ 2 hrs and good for 6 hours (to localize the sentinel axillary LN). Intraoperative injection of ∼ 4 ml vital blue dye either subcutaneous or surrounding the lesion in 4 quadrants and massage the mass / lumpectomy cavity for 5 minutes. Obtain primary counts, background with gamma probe, resect the mass / cavity (if positive margin), point probe away from primary and localize the hot node. Counts should markedly decrease as you move away from the primary and increase again at the hot node (and be > 4X

background) as you move the probe toward the axilla. Post-excision counts should also decrease after the SLN is removed. If the node(s) cannot be found, do a complete level II axillary dissection. Make incision that can be extended to perform an axillary dissection through it and remove 1 - 4 hot, blue nodes, and send for frozen section pathology. If positive, complete the axillary dissection, o/w close. Frozen section false negative rate 10 % (usually in lobular CA). If initially negative and positive on final pathology, complete the axillary LND secondarily or give axillary XRT (in 50% of cases, the SNL is the only positive node). ¤ AXILLARY LN DISSECTION Transverse axillary incision from pectoralis to latissimus dorsi. Borders: Medially, the interpectoral tissue (sparing the medial pectoral n, which is LATERAL to the pec minor m superiorly – because it originates from the lateral cord - and innervates the pec major muscle). Laterally, the latissimus dorsi m (sparing the long thoracic n on the chest wall to the serratus anterior m, causing winged scapula if damaged, and the thoracodorsal n – more dorsal and away from the chest wall - to the latissimus m). Deep, the chest wall (intercostal ms, ribs, and serratus anterior m). Superomedially, the axillary vein (which is superficial and inferior to the brachial plexus) from the lateral thoracic bundle to medial border of the pectoralis minor m. Intercostobrachial n(s) are divided leaving a small numb patch of the upper inner arm. Level III nodes are medial to the pectoralis minor m. and add significantly to the arm edema risk (of 6 % for levels I & II) if removed, and add no advantage unless they are grossly involved. One or two J/P’s. Remove J/P’s when drainage < 15 cc/day. Aspirate fluid collections or replace the drain, if necessary. “Finger walk” up the wall exercises for shoulder mobility rehabilitation. ¤ LYMPHEDEMA Tx w/ graduated compression garment, centripetal massage w/ pneumatic compressive pump. Lower rate (than ~ 15%) may be accomplished by leaving 1 cm of lymphatic tissue below the axillary v and reserving level III dissections for gross disease. Avoidance of injuries and scratches to prevent cellulitis. Elevation (out in front using the 'Heil Hitler' position as opposed to a baseball throwing position, which kinks the SCV) and IV Anti-Staph ABx if cellulitis develops. ¤ STAGING T is primary tumor, N is lymph Nodes, M is distant metastases Criteria TNM T1a < 5 mm T1b 5 - 10 mm T1c 1 - 2 cm T2 2 - 5 cm T3 > 5 cm T4 chest wall T4 skin N0 neg nodes N1 1 – 3 pos N2 4 – 9 pos, im N3 > 10, supraclav M0 no mets M1 distant mets Microinvasion seen in a primary tumor must be > 1 mm to qualify as T1a. Micrometastasis to a LN must be > 2 mm by histology to qualify as N1mi. A histologically negative node that stains positively by immunohistochemistry is designated N0(i+) and positive PCR molecular findings is designated N0(mol+) but most clinicians consider i+ and mol+ as representing metastatic CA cells, and therefore portend a worse biology even though they are classified as N0 by AJCC!

¤ SURVIVAL Approximate 5-year survival with treated breast CA: Stage I IIb III IV TNM Class T1N0 T2N1, T3N0 T3N1, T4NX, TXN2 TXNXM1 Surv 90% 70% 50% 15%

¤ BREAST ERYTHEMA DDx is mastitis (lactating mother), breast abscess, Mondor’s disease, and inflammatory breast CA. Hx, exam, mammography. If non-lactating, not pregnant, no fluctuance, and no superficial thrombophlebitis of a breast vein, assume and w/u inflammatory CA first, particularly with a palpable mass, axillary nodes, and / or peau d’orange skin edema. O/W, diagnose and treat the other disease: + Lactating Mastitis vs. milk stasis. Red, tender, swollen, +/- febrile. Staphylococcus. Wean the baby or feed from the uninvolved breast, pump the affected breast, warm compresses, and ABx. + Fluctuance Breast abscess vs. subareolar abscess (blind sweat gland at areolar edge). U/S. I & D with Bx of abscess wall Bx to rule out CA. Close over a drain. Usually Staph. ABx. Milk fistulas can be treated with bromocriptine (2.5 mg qd x 3 days, 5 mg qd x 3 days, 7.5 mg qd x 1-2 weeks) if lactation can be stopped. + Superficial thrombophlebitis Mondor’s disease. NSAIDs, heat, mammogram once resolved (5% risk of concominant CA). ¤ MASTALGIA Breast pain with normal exam and mammogram. Support bra, decrease fat in diet, high-dose Vitamin E (800 IU / day) are all helpful. Low-dose Vitamin E, Vitamin B-6, and decreasing caffeine are not unhelpful. Tamoxifen 10 mg qd or Danazol 50 - 200 mg bid (LH and FSH suppressant causing amenorrhea and hirsutism) x 3 months, only in severe cases. Reassurance after exam and mammogram negative, particularly in low-risk scenarios. ¤ INFLAMATORY (IBC) AND LOCALLY ADVANCED (LABC) BREAST CA If suspicious for inflammatory breast CA (IBC) Punch skin Bx (dermal lymphatic invasion is typical, but not necessary to make Dx). FNA primary and palpable nodes, core needle Bx if necessary, CBC, LFT's, CXR, bone scan and CT abdomen vs. PET scan for staging. Unlike DCIS and early (< T2) invasive Br CA, do not offer immediate breast reconstruction and only rarely offer breast-conserving Tx (rare in LABC, never in IBC). Delayed reconstruction is an option after a disease free interval of > 1 year. + Locally advanced or Stage IIIa (T3NXM0: > 5 cm tumor, no chest wall or skin involvement) breast CA (LABC) Modified radical mastectomy with post-operative chemotherapy. May use neoadjuvant chemoTx and XRT to down-stage a tumor if the patient strongly desires breast conserving surgery, but there is no survival benefit to preop (over postop) chemotherapy / XRT when done routinely. + IBC or Stage IIIb (T4: Chest wall or skin involvement) 3 - 4 cycles of AC (Adriamycin, which is cardiotoxic, and Cyclophosphamide) chemoTx. If no response, 2 cycles of Taxol

chemoTx. Still no response, XRT. Once a response is achieved, modified radical mastectomy followed by 4 more cycles of Taxol chemoTx and completion XRT (if not done preop). If young, and desires children, infertility consult for possible frozen embryos prior to chemoTx. ¤ STAGE IV (MI) or DISTANT METASTATIC FAILURE + ER/PR positive Ovarian ablation w/ GnRH antagonist or bilateral salpingo-oophorectomy in premenopausal patients followed by Tamoxifen. Tamoxifen in post-menopausal patients. Chemotherapy with Taxol-based regimen regardless of menopausal status. + ER/PR negative Taxol-based chemotherapy. Consider Herceptin for HER-2/neu positive tumors. XRT for bone mets, supraclavicular and internal mammary nodes. No advantage shown with bone marrow transplant. Megace, 20cc of 20 mg/cc (400 mg) qam for anorexia (progestational agent). ¤ LOCALLY RECURRENT BREAST CA Review therapy up to that point, biopsy, re-send ER/PR receptors, restage with a metastatic w/u consisting of a CXR, LFT's, bone scan, PET scan, and contralateral mammogram. + In breast (after lumpectomy) Mastectomy. Modified radical if no previous axillary dissection. Postop chemoTx and Tamoxifen (if ER/PR positive). + In axilla If mobile (and no previous dissection), axillary dissection with postop chemoTx / Tamoxifen. If immobile, chemoTx first and surgery if downsized. + Chest wall / internal mammary nodes XRT. Don’t assume the XRT dose maximum has been reached; review the fields and dose with a radiation oncologist. ¤ BREAST RECONSTRUCTION Immediate or delayed. Most commonly TRAM (transverse rectus abdominus musculocutaneous, using tunneled infraumbilical skin and subcutaneous tissue based on inferior epigastric), or latissimus dorsi flap or sub-pectoralis silicone or water-filled implants. Can be done following skin sparing or simple mastectomy, with (MRM) or without axillary LND. Other options are deep inferior epigastric (sparing the rectus abdominus) and inferior gluteal free flaps. Consult plastic surgeon pre-mastectomy! ¤ GERIATRIC BREAST CA + Life expectancy reasonable Consider all options with curative intent, as in a younger patient. Lumpectomy vs. mastectomy, axillary node dissection for palpable, positive disease (by FNA, frozen section). Consider SLN Bx and axillary dissection vs. XRT for > T2 tumors because axillary failure rate ∼ 30% (although, axillary dissection does not improve overall survival). No chemotherapy except Arimidex or Tamoxifen if ER/PR positive. + Poor life expectancy Goal is loco-regional control. Lumpectomy vs. mastectomy. No axillary dissection, XRT, or chemotherapy. Medial survival with palpable breast cancer (Stage I) is 2 ½ years, even without chemotherapy and XRT! Use Arimidex 1 mg qd (Aromatase inhibitor) if ER/PR positive, since the DVT and CVA risk is lower than Tamoxifen. Consider XRT of painful bone mets. ¤ BREAST CA IN PREGNANCY W/U (no bone scan) with tissue diagnosis confirmation, stage, and then do a modified radical mastectomy, because XRT is contraindicated. No anti-estrogen until post-partum (delivery may

be hastened after fetal viability is certain (∼ 34 weeks). OB consult. See HPBSurgeon for operative / anesthetic considerations. Only consider therapeutic abortion (even in early pregnancies) demanding chemotherapy for advanced disease. Refer to CA center for chemoTx during second and third trimester. TA decreases (mom’s too) survival. ¤ MALE BREAST ENLARGEMENT / MASS Hx of drug use (Rx meds and illicit), cirrhosis, hyperthyroidism, hypogonadism. Hormonal agents, Ketoconazole, Tagamet, Digoxin, Thiazide, Spironolactone and marijuana are common causes. Painful and bilateral is commonly gynecomastia. Eccentric, firm, and unilateral is worrisome for CA, particularly with nipple discharge, skin retractions, or palpable nodes. Testicular exam to rule out testicular CA. If suspicious, mammogram and FNA or open excisional Bx. + Male breast CA Stage, and do MRM or radical mastectomy (for pectoralis invasion). Most are ER positive, and respond to Tamoxifen. Chemotherapy for N1. Orchiectomy for symptomatic bone metastases. + Gynecomastia D/C offending drug. Most spontaneous cases resolve, but if persistent and painful (with negative Bx), Aromatase inhibitor (Arimidex), Tamoxifen, and DHEA are medical therapies. Subcutaneous mastectomy for medical failures. ¤ ADENOCA IN AXILLARY LN Most likely source is breast. Unlike a cervical node, thyroid, GI, GU, and lung CA don’t cause isolated axillary mets. Have pathologist check for breast-specific and sweat gland-specific tumor markers such as cytokeratin, ER/PR receptors, etc. Family Hx, good breast exam, and examine other lymph node areas, skin of arm, shoulder, liver and spleen. Bilateral mammograms. +/- MRI of breast. Stage with CXR, +/- bone scan, +/- CT abdomen and pelvis, +/- PET scan. If all negative, treat for Stage II breast CA (T0N1). 40% of women that are followed will ‘develop’ a primary and 70% of mastectomy specimens are found to have a primary pathologically. So, either breast irradiation or mastectomy with axillary dissection and post-op hormone / chemotherapy is appropriate as in any Stage II patient. Chest wall XRT for > 3 nodes (this is common with an occult primary). ¤ FUTURE / RESEARCH Radiofrequency ablation (RFA) using a multi-pronged probe to 95 degrees C x 15 minutes, cryotherapy in two freeze-thaw cycles (w/ ice ball formation seen on U/S), and even laser ablation techniques for very selected tumors appears promising. Masses must be < 1.5 cm, core Bxproven, unifocal invasive CAs (w/ < 25 % DCIS) and are usually marked for F/U, XRT. SLN Bx done prior to ablation technique in most cases. RFA may be the most 'user friendly' technique of the three… ¤ THE END ¤ Fashion a breastpiece for making decisions – the work of a skilled craftsman. - Exodus 28:15a © Shrewd Surgery, Inc, 2002. This file may be beamed, copied, or otherwise distributed free. No portion of it may be reproduced in any way for profit.

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