Surgical Treatment of Breast Cancer

Question 1

What predicts outcome after surgical treatment

Answer 1

• Metastasis to ipsilateral axillary nodes predicts outcome after surgical treatment more powerfully than tumor size.

Question 2

What is T4

Answer 2

T4a :
Extension to the chest wall, not including only pectoralis muscle adherence or invasion

T4b :
Ulceration and/or ipsilateral satellite nodules and/or edema of the skin
T4c :
Both T4a and T4b

T4d :
Inflammatory carcinoma

Question 3

What is Tis (Paget)

Answer 3

• Paget disease of the nipple not associated with invasive carcinoma or carcinoma in situ (DCIS) in underlying breast parenchyma

Question 4

T1mi, T1, T2, T3

Answer 4

T1
Tumor ≤20 mm in greatest dimension

T1mi
Tumor ≤1 mm in greatest dimension

T1a
Tumor >1 mm but ≤5 mm in greatest dimension

T1b
Tumor >5 mm but ≤10 mm in greatest dimension

T1c
Tumor >10 mm but ≤20 mm in greatest dimension

T2
Tumor >20 mm but ≤50 mm in greatest dimension

T3
Tumor >50 mm in greatest dimension

Question 5

What is pN0(i+) and pN0(mol+)

Answer 5

pN0(i+)
» ITCs only (malignant cell clusters no larger than 0.2 mm) in regional lymph node(s)

pN0(mol+)
Positive molecular findings by reverse transcriptase polymerase chain reaction (RT-PCR); no ITCs detected

Question 6

pN1

Answer 6

Micrometastases
or
metastases in 1–3 axillary lymph nodes
and/or
clinically negative internal mammary nodes with micrometastases or macrometastases by sentinel lymph node biopsy

Question 7

pN1mi

Answer 7

Micrometastases
(approximately 200 cells, larger than 0.2 mm, but none larger than 2.0 mm)

Question 8

pN1a, pN1b, pN1c

Answer 8

pN1a
Metastases in 1–3 axillary lymph nodes, at least one metastasis larger than 2.0 mm

pN1b
Metastases in ipsilateral internal mammary sentinel nodes, excluding ITCs

pN1c
pN1a and pN1b combined

Question 9

pN2a , pN2b

Answer 9

pN2a
Metastases in 4–9 axillary lymph nodes (at least one tumor deposit larger than 2.0 mm)

pN2b
Metastases in clinically detected internal mammary lymph nodes with or without microscopic confirmation; with pathologically negative axillary nodes

Question 10

pN3a, pN3b, pN3c

Answer 10

pN3a
Metastases in 10 or more axillary lymph nodes (at least one tumor deposit larger than 2.0 mm);
or metastases to the infraclavicular (Level III axillary lymph) nodes

pN3b
pN1a or pN2a in the presence of cN2b (positive internal mammary nodes by imaging);
or pN2a in the presence of pN1b

pN3c
Metastases in ipsilateral supraclavicular lymph nodes

Question 11

cM0(i+)

Answer 11

No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are no larger than 0.2 mm in a patient without symptoms or signs of metastases

Question 12

cTNM, pTNM, pT(m)NM, ypTNM, rTNM

Answer 12

cTNM (Clinical)
pTNM (pathologic)

“m” suffix, which signifies multiple primary tumors, pT(m)NM

“y” prefix, which denotes patients who have received systemic therapy before surgery, ypTNM

“r” prefix, which indicates a recurrent tumor, rTNM

Question 13

radical mastectomy Vs MRM

Answer 13

radical mastectomy :
removal of the breast
overlying skin,
underlying pectoralis muscles ( Major and Minor ) in continuity with the regional lymph nodes along the axillary vein up to the costoclavicular ligament ( All 3 Levels )

(MRM) :
Removes Levels I and II axillary lymph nodes
Spares the pectoralis major and minor muscle

Question 14

The NSABP B-04 trial

Answer 14

> > demonstrated that less radical surgery (total mastectomy with or without radiation) is as effective as radical mastectomy in terms of long-term overall survival and disease-free survival — making radical mastectomy obsolete in most modern breast cancer management protocols.

Question 15

When to Do Oncotype DX

Answer 15

Oncotype DX is indicated for patients with ER-positive, node- negative disease

Question 16

The most common sites of distant metastases from breast cancer are

Answer 16

• The bone, liver, and lungs followed by brain

Question 17

Computed tomography scans, bone scans, and other imaging studies are generally reserved for

Answer 17

• patients with clinically positive nodes
• abnormalities on blood chemistry tests
• or chest radiographs
• and for patients with locally advanced
• or inflammatory breast cancer

Question 18

Breast MRI may be used in selected cases to define the

Answer 18

extent of tumor and look for additional breast lesions or to document response to neoadjuvant chemotherapy

Question 19

Who should receive systemic therapy before surgery

Answer 19

Patients with locally advanced and inflammatory breast cancers

Question 20

Patients with a known BRCA mutation are generally counseled toward

Answer 20

bilateral mastectomy for treatment of the index breast and reduction of the risk of contralateral breast cancer

Question 21

Important thing to check for before planing surgery

Answer 21

The location of the tumor within the breast and tumor size relative to breast size are evaluated.

Question 22

Contraindications to radiation

Answer 22

Absolute :
* Pregnancy

Relative :
* Systemic scleroderma ∗
* Active systemic lupus erythematosus ∗
* Prior radiation to breast or chest wall
* Severe pulmonary disease
* Severe cardiac disease (if tumor is left sided)
* Inability to lie supine
* Inability to abduct arm on affected side
* p53 mutation

Question 23

In patients with large tumors, what do you give ?

Answer 23

for whom adjuvant (postoperative) systemic chemotherapy will likely be recommended, the use of preoperative chemotherapy may be considered.

Question 24

Benefit of Chemotherapy

Answer 24

Chemotherapy administered before surgery may decrease the tumor size sufficiently to permit breast-conserving surgery in patients who would not otherwise appear to be good candidates.

Question 25

Patients with multicentric tumors are usually served best by

Answer 25

mastectomy because it is difficult to perform more than one breast-conserving surgery in the same breast with acceptable cosmesis

Question 26

what factors increase local recurrence rates ?

Answer 26

- high nuclear grade - presence of lymphovascular invasion - negative hormone receptor status >> all have been linked to increased local recurrence rates, none of these factors are considered contraindications to breast conservation

Question 27

local recurrence rates after lumpectomy and radiation therapy are

Answer 27

less than 5% at 10 years at many large centers.

Question 28

Lumpectomy and tumor Size

Answer 28

lumpectomy is considered when the tumor, regardless of size, can be excised with clear margins and an acceptable cosmetic result.

Question 29

Invasive Breast Cancer Margins

Answer 29

“no ink on tumor” should be used as the standard for an adequate margin in invasive breast cancer. European consensus groups vary on their recommendations for margin width ranging from 2 mm to 5 mm

Question 30

If ADH, ALH, or LCIS, Found at the margin , Do you need to do more excision ?

Answer 30

Atypical hyperplasia (ductal and lobular) and LCIS at resection margins do not increase local recurrence rates

Question 31

The boundaries of the axillary dissection are

Answer 31

the axillary vein superiorly the latissimus dorsi muscle laterally the chest wall medially

Question 32

When the primary tumor is resected using an incision directly over the tumor and closure of the skin without reapproximation of any breast tissue

Answer 32

- volumetric deformity - skin–pectoral muscle adherence deformity - lower pole deformity with downward turning of the nipple (bird beak deformity)

Question 33

oncoplastic techniques in the following situations:

Answer 33

(1) a significant area of skin is to be resected with the tumor (2) a large-volume resection is expected (3) the tumor is in an area associated with poor cosmetic outcomes (e.g., lower hemisphere below the nipple) (4) resection may lead to nipple malposition.

Question 34

oncoplastic surgery should be considered when

Answer 34

The size of the surgical defect is likely to be greater than 20% to 30% of the breast volume and for any tumor resection in the lower breast

Question 35

who might require reduction mammoplasty

Answer 35

Obese patients should be considered for this approach because they are often poor candidates for autologous tissue reconstruction after mastectomy, and implants are often not large enough to recreate a breast proportional in size to the contralateral breast.

Question 36

Should you do oncoplasty before or after radiation ?

Answer 36

- deformities in the contour will be exacerbated by radiation and may be more challenging to correct at a later date.

Question 37

When to consider resconstruction after radiation

Answer 37

If a cosmetic defect occurs after breast-conserving surgery and radiation therapy, reconstruction of the treated breast is generally not recommended for 1 to 2 years after radiation therapy has been completed

Question 38

radiation effect on implants and expanders

Answer 38

Tissue expanders and implants are not recommended to fill partial mastectomy defects because radiation may lead to capsular contracture, distortion, and infection

Question 39

If the main deformity is caused by asymmetry with the contralateral breast

Answer 39

a mastopexy of the contralateral breast can be considered

Question 40

Mastectomy Indications

Answer 40

-tumors that are large relative to breast size -tumors with extensive calcifications on mammography, -tumors for which clear margins cannot be obtained on wide local excision -tumors in patients with contraindications to breast irradiation -Patient preference for mastectomy or a desire to avoid radiation

Question 41

Immediate reconstruction has the advantages of

Answer 41

preserving the maximum amount of breast skin for use in reconstruction

Question 42

Reconstruction options include

Answer 42

- tissue expander/implant - autologous tissue reconstructions most often with : - transverse rectus abdominis muscle flaps - latissimus dorsi flaps - muscle-preserving perforator abdominal flaps

Question 43

If immediate reconstruction is planned, which type mastectomy

Answer 43

a skin-sparing mastectomy may be performed in which only the nipple-areola complex is removed and the maximum amount of skin is left

Question 44

nipple-areola–sparing mastectomy

Answer 44

- comparably low recurrence rates - Nipple-areola–sparing mastectomy >> safe in patients undergoing prophylactic mastectomy for risk reduction including BRCA1 and BRCA2

Question 45

Level I nodes, level II nodes

Answer 45

Level I nodes : >> nodes inferior to the axillary vein and lateral to the pectoralis minor muscle level II nodes >> nodes anterior or posterior to the pectoralis minor.

Question 46

SLNB performed By

Answer 46

- radiolabeled colloid, blue dye, or both are injected into breast tissue at the site of the primary tumor - the material passes through the lymphatics to the first draining node(s), where it accumulates. - The procedure can also be performed with injection of the mapping agents that can be injected subareolar position or in a subdermal location overlying the site of the primary tumor.

Question 47

What pathologist do with SLNB

Answer 47

- pathologists section the sentinel node along its short axis and submit all the sections for paraffin embedding of the tissues. The paraffin blocks can be sectioned and examined with hematoxylin-eosin staining of sections from each block.

Question 48

Lymphatic mapping can be performed with

Answer 48

combination of 99mTc-labeled sulfur colloid and a vital blue dye isosulfan blue (Lymphazurin) fluorescence magnetic particles or with a single agent for localization of the sentinel node(s).

Question 49

What else you can do before SLNB surgery

Answer 49

Preoperative lympho‑scintigraphy can provide information on the specific nodal basins draining the primary tumor.

Question 50

Percentage of Drainage

Answer 50

>> peritumoral injection technique, - approximately 70% of patients have drainage to the axilla - 20% have drainage to the axilla and the internal mammary nodal basin - 2% to 3% have drainage to the internal mammary nodal basin alone - 8% do not show any drainage to the regional nodal basins.

Question 51

Dose of 99mTc-labeled sulfur colloid

Answer 51

A dose of 2.5 mCi of 99mTc-labeled sulfur colloid can be injected on the day before surgery for preoperative lymphoscintigraphy >> this allows for adequate activity to remain in the sentinel nodes for the intraoperative lymphatic mapping procedure the following day without the need for reinjection. >> Alternatively, for surgeons not using preoperative lymphoscintigraphy 0.5 to 1.0 mCi of 99mTc-labeled sulfur colloid can be injected in the operating suite and avoids the preoperative pain and vasovagal events.

Question 52

How much Blue Dye to give ?

Answer 52

3 to 5 mL of blue dye can be injected peritumorally,

Question 53

If a blue-stained lymphatic channel or a specific area of radioactivity (“hot spot”) cannot be identified

Answer 53

the primary tumor can be resected to remove the site of injection decreasing the background shine-through radioactivity.

Question 54

Some studies have shown that patients who have undergone previous excisional biopsy of the primary tumor are more likely to have ? regarding SLNB

Answer 54

false-negative sentinel node

Question 55

Patients who present with clinically palpable lymph nodes

Answer 55

>> axillary ultrasonography >> fine-needle aspiration biopsy (FNAB) >> If axillary metastasis is confirmed >> proceed directly to standard axillary node dissection or be considered for preoperative chemotherapy. If axillary metastasis is not confirmed by FNAB, patients can proceed to sentinel node surgery for staging.

Question 56

ACOSOG Z0011

Answer 56

- The trial now with 10-year follow-up, ACOSOG Z0011, enrolled patients with clinical T1 or T2 breast cancer with one or two positive sentinel nodes who were planning to undergo breast-conserving surgery and whole breast irradiation (WBI). - The primary end point of the Z0011 study was OS; - secondary end points were locoregional recurrence and lymphedema - This study did not include mastectomy patients - there was no significant difference in lymphedema seen between the groups. - This may be because this trial included WBI - which in most patients included the Level I axilla or higher.

Question 57

What Procedure Reduce the risk of Lymphadema ?

Answer 57

- axillary reverse mapping (ARM) procedure to intraoperatively recognize the lymphatic drainage of the upper extremity and preserve it. The procedure consists of radioactivity in the breast and blue dye in the arm (split mapping) in order to identify and protect the lymphatics draining the upper extremity. In a 26-month median follow-up of a phase II trial of 654 patients receiving SLND or ALND with ARM the rate of lymphedema was less than 1% and 6%, respectively.

Question 58

ALND remains the standard of care for patients with

Answer 58

- locally advanced breast cancer - inflammatory breast cancer - patients with a positive sentinel node who are scheduled for mastectomy - patients with a positive sentinel node who are scheduled for accelerated partial breast irradiation (PBI) - patients with clinically positive nodes - as well as a positive sentinel node after neoadjuvant chemotherapy