Breast—Invasive Ductal Carcinoma

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Concept

Malignancy that needs complete staging work-up and then adjuvant treatment. Most women are candidates for breast conservation therapy (BCT). Need to know the absolute and relative contraindications to BCT.

Way Question May be Asked?

“45 y/o female presents to your office with a palpable mass in the UOQ of the right breast. What would you do?” Will likely be presented with pt with either a palpable abnormality, a locally advanced lesion, or a suspicious mammographic abnormality. Just be systematic and do what you would normally do in your practice.

How to Answer?

History

Establish risk factors for breast cancer (menarche, breast-feeding, family history of breast/ovarian/

prostate cancer, number of children, age first pregnancy previous breast cancer, previous breast prob- lems, etc.)

Sx’s: bone pain, wt loss, change in breast appearance

Physical Exam

Symmetry, dimpling, erythema, edema

Try to palpate any mass (hard/soft, well circumscribed?, mobile/fixed, tender)

Check both breasts!

Examine for cervical/axillary adenopathy Examine liver

How to Answer

Need to order bilateral mammograms and compare to any previous

Ultrasound useful in palpable masses to determine if cystic or solid (especially in premenopausal breasts and may show characteristics of malignancy) FNA can be done in office setting of any palpable

lesion

Core-needle bx can be done in office or under stereo- tactic/U/S guidance

Excisional biopsy should be performed on:

Solid mass

Cyst with bloody content Cyst that recurs more than twice

If FNA reveals malignancy, then can plan full cancer staging in one trip to the OR.

Contraindications for breast conservation therapy:

Tumor ≥ 5 cm

Large tumor to breast ratio (cosmetic outcome) Two or more primary tumors in separate quadrants

(multifocal)

Previous breast irradiation (from prior BCT) Collagen vascular disease (scleroderma or lupus—

can’t receive XRT)

Diffuse suspicious or indeterminate calcifications Subareolar tumor

Surgical Treatment

(1) Lumpectomy (with clear margins), ALND, and post-op XRT

(2) MRM (combines total mastectomy and ALND) ALND includes level 1 and 2 (lateral to and behind the

pectoralis minor muscle) and should be done in all pts

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10 Breast—Invasive Ductal Carcinoma SLN Bx is now accepted technique, but if positive by

frozen section or final pathology, would proceed to complete ALND until results of latest NSABP trial are scrutinized (only mention if you know how to do SLN Bx and use lymphazurin blue dye and tech- netium-99 sulfur colloid)

Adjuvant chemotherapy treatment (Adriamycin/Cyto- xan = AC)

(1) All premenopausal women with invasive breast cancer > 1 cm in size

(2) All postmenopausal women with positive lymph nodes

(3) Postmenopausal women with T2 or greater lesions (> 2 cm in size)

Adjuvant hormonal treatment (Tamoxifen)

(1) All premenopausal women with invasive breast cancer > 1 cm in size

(2) All postmenopausal women (unless contraindication)

Adjuvant XRT

(1) 5000 rad in divided doses to chest wall in all pts who underwent BCT (can’t give during pregnancy, but can usually delay until after pregnancy as need 6 months chemoTx→no therapeutic abortions!!!)

(2) When > 4 LNs involved with tumor, XRT to axilla reduces local recurrence

Pathology results

Need to know tumor characteristics: nuclear grade, vascular invasion, tumor size, ER/PR receptors, S-phase fraction, Her-2 Neu

Only go into Sentinel Lymph Node Biopsy if you do this in your practice and are prepared to perform complete ALND in any pt with metastatic cancer seen on the sentinel node (whether intra-op frozen section or post-op final histology)

Common Curveballs

There will be a separate mammographic finding There will be palpable lesion not seen on mammogram There will be lesion in opposite breast

Pt will have recurrence after your surgical treatment Don’t do pulmonary/liver metastatectomy

Margins will be positive for cancer or DCIS (or less than 1mm)

Sentinel node biopsy won’t work or will be only positive lymph node

Pt will be pregnant (no XRT, SLN bx, or antimetabolite based chemoTx)

Can give AC after late 1st trimester (only antimetabolite methotrexate nsafe during pregnancy)

No XRT until pt delivers (needs 24 weeks chemo so ok unless < 14 weeks pregnant)

No Tamoxifen or bone scan

Pt will have contraindication to BCT

Pt will have contraindication to adriamycin (poor EF) Pt will initially present with nipple discharge

Pt will have clinically positive axillary nodes

Pt will have very strong family history (discussion of BRCA1,2)

Cancer will present in a cyst that had bloody fluid on FNA

Retroarealor cancer—will you perform mastectomy?

T1 lesion, and lymph nodes negative in postmenopausal but receptors are unfavorable→ will you give chemo?

T2 lesion in postmenopausal and receptors are favorable→ will you give chemo and/or hormonal therapy?

T1a lesion (<5mm) in premenopausal woman, will you offer chemo/XRT

Strikeouts

Forgetting to examine both breasts

Forgetting to order bilateral mammograms Not asking about receptors on pathology

Forgetting post-op chemo/XRT treatment when appro- priate

Forgetting ALND if invasive cancer identified

Going into lengthy discussion about sentinel lymph node biopsy when you don’t do these routinely in your practice

Performing therapeutic abortion for breast Ca in the pregnant pt

Not knowing contraindications to BCT

Not knowing who gets adjuvant treatment and with what chemo/hormonal agents

Not recognizing Stage IIIB (signs of inoperability → neoadjuvant chemo→mastectomy →XRT):

Chest wall invasion

Inflammatory breast cancer Ulceration

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