[SURGERY] THE BREAST (PART 2) – DR.

ACUÑA

THE BREAST – PART 2 HORMONAL NON-HORMONAL

Dr. Roberto B. Acuña  Exposure to Estrogen  Radiation Exposure
 Increased Risk  75x 
BREAST CANCER - Early menarche  Alcohol Intake
 Risk Factors - Nulliparity  1.5x 
 Epidemiology - Late menopause  High Fat Diet
 Natural History  Decrease Risk  1st Degree Relative with Breast Cancer
 In Situ vs. Invasive Breast Cancer - Moderate exercise  2-3x 
 Diagnosis - Prolonged lactation  BRCA1 & BRCA2 mutation
 Staging and Biomarkers  Obesity  85% lifetime risk (AR)
 Surgical Techniques in Breast Cancer Surgery
 Breast Cancer Treatment by Stage  Those who take estrogen pills and those who did not complete their pregnancy
 Special Clinical Situations also has and increased risk for breast cancer

RISK FACTORS MANAGEMENT FOR THOSE WITH RISKS OF BREAST CANCER:

 For those with Hormonal Risk  Can just observe
 Breast Cancer is one of the cancers wherein there can be a pinpointed cause.  For those with Non-Hormonal Risk  Have higher risk
 70%  Caused by estrogen  That is why estrogen is one of the risk factors 1. Observation: Through mammogram  Every year
 Take Note: Mammogram is also a form of radiation  Cannot do
 RISK mammogram on a very young patient
 Chance for an event to occur
 Can also use MRI
2. Chemoprevention  TAMOXIFEN
 ABSOLUTE RISK (AR)
 But the problem with Tamoxifen is that it is a competitive inhibitor to
 Absolute Risk  Your own personal risk estrogen  May disrupt your cycle
 Random Risk  12%  May cause Endometrial Cancer
 May also cause early osteoporosis
 An individual’s likelihood of developing breast cancer 3. Prophylactic Mastectomy
 12% chance over an 80 year lifespan

 RELATIVE RISK (RR) EPIDEMIOLOGY

 Compares risk of one group with exposure VS general population
 Example: Alcoholics = 1.5x RR of breast cancer = 18%
 EXAMPLES:
1. Alcoholism will increase your risk by 1.5 percent
 1.5 times 12 (Absolute Risk or Individual Risk)  18%
2. You have a 1st degree family member with breast cancer
 First Degree  Parents and Children
 2-3 times 12 (Absolute Risk or Individual Risk)  24 to 36%
 Most common site-specific cancer in women
 Most common cause of mortality in women 20-59 years old
 Environmental Pollution
 Radiation
 Pampanga
 Highest breast cancer density in the Philippines
 2nd Highest: MANILA  If you live near or around Pasig River

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 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 INCIDENCE
Specific Breast Cancer 65-75% (70)
Familial Breast Cancer 20-30% (25)
Hereditary Breast Cancer 5-10% (5)

BRCA1 45%
BRCA2 35%
p53 (Li-Fraumeni syndrome) 2%
STK11AKB1 (Peutz-Jeghers syndrome) <1%
PTEN (Cowden syndrome) <1%
MSH2/MLH1 (Muir-Torre syndrome) <1%
ATM (Ataxia-Talengectasia) <1%
Unknown 20%

 3 TYPES OF BREAST CANCER:

 Specific Breast Cancer
 Familial Breast Cancer
 Hereditary Breast Cancer

 FAMILIAL VS HEREDITARY
 Hereditary  Have identifiable genes
 Familial  Have the same risk groups

 Fibrosis  Nipple Retraction

NATURAL HISTORY OF BREAST CANCER  Peau d’ Orange
 UNTREATED BREAST CANCER  Lymphedema
 Median survival of 2.7 years  Sign of lymphatic obstruction
 Ulceration
 Nobody goes beyond 3 years without
treatment   Satellite Nodules

 18% 5 year survival rate

 3.6% 10 year survival rate IN-SITU VERSUS INVASIVE CA
 Often with ulceration
 If you catch a Breast Cancer in the IN SITU stage (Stage 0), it is as if you didn’t
 The breast is 30% breast tissue and 70% fat. have cancer at all.
 Cooper’s Ligament  In the USA, you will see a lot of cases of In Situ Breast Cancer  Because they
 Holds the breast upright maximize their insurance  Go for a check-up/undergo screening procedures
 One end is connected under the skin and the even if they were not able to palpate any mass
other end is connected to the fascia of the  In the Philippines, you have to pay for everything  You will notice that most
Pectoralis Major cases are already in their Early Stage or Invasive Stage

LEA THERESE R. PACIS 2

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

SERIES OF EVENTS FROM A  SALIENT CHARACTERISTICS OF LCIS VS. DCIS

NORMAL TO AN INVASIVE CELL: LCIS DCIS
1. Normal Cells Age (Years) 44-47 (seen in women only) 54-58 (seen in women only)
 1 cell layer Incidence 2-5%
2. Ductal Hyperplasia Clinical Signs None Mass, pain, discharge
 2 cell layer Mammogram None
Microcalcifications
3. Atypical Ductal Hyperplasia Signs (only in neighboring tissues)
 3 cell layer Premenopausal 2/3 1/3
 Pre-malignant condition Incidence,
5% 2-46%
 TAKE NOTE: Florid Epithelial Invasive CA
Hyperplasia  One of the Multricentricity 60-90% 40-80%
premalignant breast lesions Bilaterality 50-70% 10-20%
4. Ductal Carcinoma In Situ Axillary
5. DCIS-MI (Ductal Carcinoma In 1% 1-2%
Metastasis
Situ with Microinvasion)
6. Invasive Ductal Take note of the highlighted parts. Baka daw ilabas niya sa exam kasi
 Basement membrane is common board exam questions daw siya 
already invaded Both of them will develop Ductal Carcinoma later on
Axillary Metastasis  Does not require axillary resection
What protects us is the basement membrane 
If the basement membrane is intact  IN SITU  INVASIVE BREAST CANCER TYPES
If the basement membrane is already  Invasive Ductal Carcinoma – 80%
invaded  Could metastasize  Invasive Lobular Carcinoma- 10%
3 REASONS FOR METASTASIS/3 ROUTES  Medullary Carcinoma – 4%
OF SPREAD:  All of the subtypes have a good prognosis except for Medullary Carcinoma
1. Vein  Via the blood
2. Lymphatics  Via the lymph  Mucinous Carcinoma – 2%
3. Nerve  Via the nerves  Papillary Carcinoma – 2%
 Tubular Carcinoma – 2%
 LOBULAR VS DUCTAL  Paget’s disease of the nipple
 Rare Cancers
 Lesion in the LOBULES  Lobular Carcinoma or
 Adenoid Cystic Carcinoma
Lobular Carcinoma In Situ
 Squamous Carcinoma
 Lesion in the DUCTS  Ductal Carcinoma or
 Apocrine Carcinoma
Ductal Carcinoma In Situ (Majority  DUCTAL)
Treatment for Invasive Carcinoma is the same
 INVASIVE DUCTAL CARCINOMA
 Lobular Carcinoma  You have to treat the
 80%
opposite breast first – Because there is a high
 Stellate
chance of developing breast CA in the
 Microcalcifications
opposite breast

LEA THERESE R. PACIS 3

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 INVASIVE BREAST CANCER  For teenagers, most common breast tumor would be Fibroadenoma
Ductal Lobular Medullary Mucinous Papillary Tubular  For those in their 20’s-40’s  Fibrocystic Change
Age in Perimeno-
40-60 Elderly  Breast Cancer  Likely to occur at ages 40 and above
Years pausal
 The older you are, the more chances you have to develop breast cancer
Soft
Hemorrhagic Small,
Physical Examination
Gross Stellate
Bulky
Bulky
<3cm  Hard
Deep  Could not find the edges
LN (+) 60% 33% Low 10%  Moves together with the skin
ER (+) 75% >90% <10% >90% 87% 94%  Other Signs:
Bilateral Low High 20%  Dimpling
 Retraction
 Compatible with long survival  Tubular Carcinoma  Peau d’orange
 Satellite Nodules
Sabi ni doc isang question lang daw tatanungin ni doc dito and most likely 1. IMAGING
and sagot daw is Medullary Carcinoma  So alam na. HAHA! We only request for breast imaging if we were not able to palpate
anything especially if you have high risk of having Breast Cancer
 MICROSCOPIC 16-40 years old who has a cyst  Best way to define this is through
ultrasound, not mammogram
Above 40 years old  Do mammogram
 Below 40 years old  Not advisable to do mammogram  Breast is so
dense = You will not be able to see if there is a mass or not  Do MRI
instead
2. BIOPSY
If you were now able to detect the mass, either through clinical
examination (“nakakapa”) or through imaging  Get a piece of that
bukol 
 Poke a needle  Needle Biopsy
 Get a piece of it  Incision Biopsy
 Get the whole mass  Excision Biopsy
DIAGNOSIS OF BREAST CANCER  FOUR CHIEF COMPLAINTS
3. CLINICAL 1. Mass in the Breast or Axilla
Classic History of Breast Cancer: Very slow growing, painless mass (Picture on the Right) BREAST
 Is it painful?  If it is painful, most of the time it is not Breast Cancer  AND/OR AXILLARY MASS
Could be Fibrocystic Change  Cancer? DEFINITELY
Age is a good factor  If the patient is too young, it might not be Breast  Will you do mammogram? OF
Cancer COURSE NOT!
 If you see Breast Cancer in children  Most likely it is from Lymphoma or  If you have a mass already 
from Rhabdomyosarcoma Proceed to biopsy

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 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

2. Breast Pain
 What will you do to diagnose:
 Hidradenitis Suppurativa  Gram Stain
 Mycosis  KOH Mount
 Paget’s Disease  Biopsy

 Pain  Benign Disease

 Is pain bad? NO. Pain is good!

 If there is pain  Fibrocystic Change = BENIGN

3.Nipple Changes  If the discharge from a single duct is blood-tinged  Highest chance of
a. Erythema, Scaling Breast Cancer (but only 20%)
b. Retraction  80%  Benign Intraductal Papilloma
c. Nipple Discharge
What is the most common cause of bloody nipple discharge from a single
duct? BENIGN  But it has the highest chance of malignancy

4. Skin Changes
a. Erythema
b. Ulceration
c. Satellite Nodules

 If you see excoriation around the nipple, think of:

 Hidradenitis Suppurativa
 Mycosis
 Paget’s Disease

LEA THERESE R. PACIS 5

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 New study about Breast Density  If you are already postmenopausal and
you have a dense breast = Higher chances of breast cancer

 Post-menopausal Breast should be featureless

BENIGN VS MALIGNANT
BENIGN

 BREAST IMAGING
1. MAMMOGRAPHY

MALIGNANT:

 First letter  Location of the beam

 Second letter  Location of the x-ray plate
 Patient will be the one control when to stop compressing the breast 

 Indications of Mammography
 Screening Mammography
 Detect unexpected cancer in asymptomatic women  3 Signs of Breast Cancer
 Diagnostic Mammography 1. Spiculated/Stellate
 Evaluate abnormal findings such as breast mass or nipple discharge 2. Linear/Branching
 Branching  DUCTAL
3. Asymmetrical Thickening

 Advantages of Mammography
 More sensitive than clinical examination
 90% true positive rate
 In women 50-59 y/o
 25% decrease mortality

LEA THERESE R. PACIS 6

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 NCCN 2014 Guidelines for Normal Risk Women  REMEMBER

 ≥20y/o  CBE (Clinical Breast Exam) every 3 years
 Best time for Breast Examination  Immediately after menstruation
 ≥40y/o  Annual Mammogram
 Decreased accuracy due to dense breast
 Breast Tomosynthesis (3D) is better in <50y/o

2. DUCTOGRAPHY
 For bloody nipple discharge MALIGNANT

3. ULTRASOUND
 To resolve equivocal mammographic features
 To define cystic masses 4. MAGNETIC RESONANCE IMAGING
 To define the echogenic qualities of solid lesions  Used only if ultrasound and mammogram are not conclusive
 To guide needle biopsy  Possible applications:
 To image axillary nodes in patients with breast cancer  REMEMBER  Assess axillary metastasis without breast primary
 Cortical thickening  Assess result of neoadjuvant treatment
 Loss of fatty hilum  Board Exam Question   Evaluate the breast for tumor recurrence in BCS (Breast Conserving Surgery)
 Change to a more circular shape
 Size more than 10 mm IMAGING SUMMARY
 Hypoechoic internal features <40 YEARS OLD, LOW RISK >40 YEARS OLD
 CBE every 3 years  Mammogram
BENIGN  Ultrasound  Ultrasound
 Breast Tomosynthesis  MRI?

 BREAST BIOPSY
 BREAST BIOPSY (NOT PALPABLE)
 With a Mass
 Ultrasound-Guided Needle Localization Biopsy
 Without Mass (architectural distortion or calcification only)
 Mammogram-Guided Needle Localization Biopsy
LEA THERESE R. PACIS 7
 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 Stereotactic  T = TUMOR SIZE

 Negative Correlation
 Disease-free interval
 Overall survival
 Positive Correlation
 Axillary node metastasis

 N= AXILLARY NODAL STATUS

 Bigger tumor  More lymph nodes  Higher chances of recurrence
 Lymph Node  Single most important prognosticator of survival
 2nd  ER-PR Status
 3rd  Tumor Size
 BREAST BIOPSY (PALPABLE MASS)
 Negative Correlation
 Fine Needle Aspiration Cytology  Cells
 Disease-free interval
 Core Needle Biopsy  Tissue
 Overall survival
 Excision Biopsy if ≤3cm
 Positive Correlation
 Incision Biopsy if ≥3cm
 Node Negative = 30% recur
 Node Positive = 75% recur
BREAST CANCER STAGING AND BIOMARKERS
BREAST CANCER STAGING
 M = DISTANT METASTASES
 T  Tumor Size  Vertebral Column
 REMEMBER: 2 and 5  Via Batson’s Plexus
 T1: 2 or less  Batson’s Plexus  Direct venous connection between the breast and
 T2: More than 2 up to 5 the thoracic vertebra
 T3: More than 5  That is why the most common bone metastasis is the THORACIC
 T4: Any size involving the skin or chest wall VERTEBRA
 N  Nodes
 REMEMBER: Minimum 10  Lung
 N0: No lymph nodes  Via axillary vein and intercostal veins
 N1: 1-3  Pleura
 N2: 4-9  Soft Tissues
 N3: More than 9  Liver
 M  Metastasis  Brain
 M0: No metastasis  In triple receptor negative tumors
 M1: With metastasis
 95% of breast cancer deaths
 Most common metastasis of Breast Cancer  BONE, LUNG, LIVER, BRAIN  Starts at 27th doubling (0.5cm)

LEA THERESE R. PACIS 8

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

MEMORIZE   Mammalian Target Rapamycin (mTOR)

N0 N1 N2 N3  Tumor Suppressor Genes – p53
Stage 0 T is  The Cell Cycle, Cyclins, Cyclin-dependent Kinases
Stage I T1  The Proteosome
Stage II A T2 T0, T1  COX-2-enzyme
Stage II B T3 T2  Peroxisome Proliferator-activated Receptor (PPARs)
Stage III A T3 T0, T1, T2, T3  Indices of apoptosis and apoptosis moderators such as bcl-2 & hax:bcl-2 ratio
Stage III B T4 T4 T4
Stage III C Any T All breast cancers, after incision, should be examined!
Stage IV Any T, Any N, M1

 COEXPRESSION OF BIOMARKERS
At N1, the smallest tumor  Stage 2A
 ER
 PR
BIOMARKERS  Her2/neu
 Risk Factor Biomarkers
 Familial clustering POSITIVE ER and PR >50% response to Hormonal Therapy
 Inherited germline abnormalities [BRCA1, BRCA2] POSITIVE ER or PR 33% response to Hormonal Therapy
 Proliferative breast disease with atypia NEGATIVE ER and PR <10% response to Hormonal Therapy
 Mammographic densities
If both ER and PR are POSITIVE, there is a higher chance that it will respond
 Exposure Markers
 DNA adducts to hormonal therapy.
 Surrogate Endpoint Markers
 Histologic changes  Her2/neu
 Indices of proliferation  Positive – Poor Prognosis  Good response to Trastuzumab
 Genetic alteration leading to cancer  Negative – Better Prognosis  No response to Trastuzumab
 Prognostic and Predictive Biomarkers
Trastuzumab is prototype immunomodulator chemotherapy
 Steroid Hormone Receptor Pathway (ER/PR assay)
 “-mab”  Monoclonal Antibody
 Growth factors
 Attacks breast cancer
 Human Epidermal Growth Factor Receptor 2 (Her2/neu)  Her2/neu must be POSITIVE for it to respond
 Epidermal Growth Factor Receptor (EGFR)
 Transforming Growth Factor
 Platelet-derived Growth Factor  TRIPLE NEGATIVE
 Insulin-like Growth Factor What if ER, PR, and Her2/neu are all negative?
 Indices of Proliferation  ER and PR Negative  Tamoxifen (Hormonal Therapy) will not work
 Proliferating cell nuclear antigen (PCNA), KI-67  Her2/neu Negative  Trastuzumab will also not work
 Indices of Agenesis  Answer: CHEMOTHERAPY ALONE  DOXORUBICIN
 Vascular Endothelial Growth Factor (VEGF); Angiogenesis Index  Increases life span by 16%

LEA THERESE R. PACIS 9

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

TRASTUZUMAB (HERCEPTIN) SURGICAL TECHNIQUES FOR CANCER

 Trastuzumab alone  RADICAL MASTECTOMY
 Now approved as 1st line for metastatic breast cancer
 Before, it was called “HALSTED MASTECTOMY”
 Trastuzumab + Chemotherapy
 Now approves as 1st line for early breast cancer  The whole breast
 50% reduction of Recurrence Risk  Axillary lymph nodes levels I, II, III
 33% reduction in Mortality  Pectoralis major and minor muscles
ONCOTYPE DX  MODIFIED RADICAL MASTECTOMY
 21-gene assay  The whole breast and lymph nodes I, II, III only
 Determines prognosis and treatment
 QuART  ¼ of the breast + Axillary Nodes + Radiotherapy
 RECURRENCE SCORE
 If node negative and ER positive
 HIGH RECURRENCE SCORES  Chemotherapy
 LOW RECURRENCE SCORES  Hormonal (Endocrine Therapy)
 INTERMEDIATE SCORE
 Research ongoing
MAMMAPRINT TEST
 70-gene assay
 In node negative and 1-3 node positive breast cancer
 Phase III trial
 MOLECULAR MARKERS VS BIOMARKERS  Qu  Quadrant (1/4 of the breast)
 A  Axillary Nodes
 RT  Radiotherapy
No treatment  3 years survival rate  Same survival rate
Surgery alone  5 year survival rate
 Stage 1 = 90%  BREAST CONSERVATION SURGERY (BCS)
 Stage 2 = 75%  Removes the involved part of the breast only + 1 cm normal margin
 Stage 3 = 50%  Lumpectomy
 Stage 4 = 0%  Remove only the lump
Surgery + Chemotherapy (Doxorubicin)  + 16%
 Stage 1 = 90% + 16%  106% 5 year survival rate  Segmental/Partial Mastectomy
 Stage 2 = 75% + 16%  91% 5 year survival rate  Wide Excision
 Stage 3 = 50% + 16%  66% 5 year survival rate  Difference from Excision? WIDE EXCISION  Add a rim of 1 cm normal
 Stage 4 = 0% + 16%  16% 5 year survival rate breast tissue
Surgery + Trastuzumab  + 33%
 Stage 1 = 90% + 33%  123% 5 year survival rate  Tylectomy
 Stage 2 = 75% + 33%  108% 5 year survival rate  EXTENDED RADICAL MASTECTOMY
 Stage 3 = 50% + 33%  83% 5 year survival rate  Plus ribs and lungs
 Stage 4 = 0% + 33%  33% 5 year survival rate  Radical Mastectomy + Ribs and Lungs  Same survival rate

LEA THERESE R. PACIS 10

 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

DIAGNOSTIC STUDIES FOR BREAST CANCER (ADAPTED)

BREAST CANCER STAGE
0 I II III IV
History and PE • • • • •
CBC • • •
Liver Function Tests,
• • •
including ALP
ER/PR (Hormone
• • • • •
Receptors)
Her2/neu • • • •
Bone Scan S S S • •
Chest X-ray • • •
Abdominal CT scan or
S S S • •
Ultrasound
S – Required if symptomatic

TREATMENT OF STAGE 0 (IN SITU) – MEMORIZE 

Lobular Carcinoma In Situ (LCIS) Ductal Carcinoma In Situ (DCIS)
 Marker for increased risk, rather  Precursor of invasive cancer
than precursor of invasive cancer
 30% develop invasive cancer Treatment Options:
 Adjuvant Tamoxifen
Treatment Options:  ER positive
 Observation after excision  Lumpectomy + RT
 Chemoprevention  For less extensive disease
 Tamoxifen  Mastectomy
 Bilateral Total Mastectomy  For extensive disease
 Usually diffuse & bilateral  Sentinel Node Dissection
BREAST CANCER TREATMENT BY STAGE  NO SINGLE CORRECT TREATMENT
REQUIREMENTS PRIOR TO TREATMENT:
 Biopsy Result EARLY INVASIVE BREAST CANCER (STAGE I, IIA, IIB)
 Clinical Stage  LUMPECTOMY + RT
T  Same DFS, DDFS, OS as Mastectomy
N  For localized disease and no BRCA mutation
M  MASTECTOMY
 METASTATIC SURVEY  BCS + ALND/SLND + RT (QuART)
 Biomarker Assay (Triple Receptor Assay)  Not for multicentric, lobular, BRCA mutation (+), prior RT
 General Health Status of the Individual  MODIFIED RADICAL MASTECTOMY (MRM)
 Reconstruction?

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 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

 Skin sparing GENESEARCH BREAST LYMPH NODE ASSAY

 Nipple Areola-Sparing  Search for mammoglobin and cytokeratin 19
 CHEMOTHERAPY  Same use as frozen section
 To see if lymph nodes harbor metastatic disease
INDICATIONS FOR CHEMOTHERAPY:
1. Tumor more than 1cm
2. Positive Axillary Lymph Nodes  SURGERY (LUMPECTOMY + RT VS BCS/MRM)
3. Positive Visceral Metastasis  ADJUVANT TREATMENT
 Visceral  Brain, Lungs, Bone  Chemotherapy with Paclitaxel + AC or Docetaxel + Carboplatin if ER/PR (-)
 Node Positive (T0, T1, N1)
In general, all those who have cancer needs chemotherapy, EXCEPT those  >1 cm Tumor (T1b, N0; T2 N0)
with tumors less than 1 cm (Stage 1a).  <0.5cm Tumor & Node (-) but with adverse prognostic factors
 ER/PR (-)
 Her2/neu (+)  TRASTUZUMAB
SENTINEL NODE (for <2 (+) LN only)  Lymphovascular invasion
 “Bantay”  “Sa bawat lugar sa breast, may isang nakabantay na kulani”  High nuclear grade
 You should be able to get this!  If you were able to get all 10 lymph  High histologic grade
nodes but not able to get the Sentinel Node = USELESS  Hormonal Therapy if without adverse prognostic factors
 How do you get this?  Tamoxifen vs. Aromatase Inhibitor (AI)

TAMOXIFEN AROMATASE INHIBITOR (AI)

 Competitive inhibitor to estrogen  Inhibits the last step in estrogen
production

 Before Surgery: Inject Methylene Blue on the mass

 After Surgery: Should be able to identify the lymph nodes with the blue
dye
 Could Sentinel Biopsy (remove only the sentinel node) work?
Estrogen receptors are located in the cytoplasm
 YES  But you will not get your full staging
 Estrogen binds to the receptor  Stimulate the pathway
 Tamoxifen is a competitive inhibitor of Estrogen
LYMPHEDEMA (in Elderly and Obese patients)
Aromatase Inhibitor (AI)  Inhibits the last step in estrogen production
 Results from:
in fat cells
 Very aggressive axillary resection
 Local recurrence
Hormonal Therapy  For postmenopausal patients
 Do Salvage Chemotherapy
Aromatase Inhibitor  For premenopausal patients

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 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

TREATMENT DISTANT METASTASES (STAGE IV)

N0 N1
Surgery CT/HT RT  Palliative only especially QoL (Quality of Life)
Stage I A T1 (T1a, T1b) • -/+  Hormonal Therapy + Radiotherapy + Bisphosphonates  Bone Metastasis
T0/T1, N  Chemotherapy  Visceral Metastasis
Stage I B • •
1ml
Stage II A T2 T0, T1 • •
Stage II B T3 T2 • •

ADVANCED LOCAL-REGIONAL BREAST CANCER (STAGE IIIA, IIIB)

TREATMENT
N0 N2 N3
Surgery CT/HT RT
T0, T1,
Stage III A T3 • • •
T2, T3
Stage III B T4 T4 T4 • • •

REQUIREMENTS IF YOU WANT TO OPERATE ON A METASTASIS:

 Single metastasis or
 2 organ but single metastasis (?)
Give chemotherapy after surgery

Surgery of metastasis increases life span by 1-2 years 

STAGE IV BREAST CANCER

 Multidisciplinary Approach
 Resective procedures improve survival
 Including Total Mastectomy
 Local Therapy may be required
 Malignant Pleural effusion
 Impending Pathologic Fracture
Adjuvant Therapy  Chemotherapy AFTER surgery  Spinal Cord Compression
Neoadjuvant Therapy  Chemotherapy BEFORE surgery  Painful Bone and Soft Tissue Metastasis
 Brain Metastasis
 PRIMARY ENDOCRINE THERAPY  Pericardial Effusion
 If ER/PR (+)  Ureteral and Biliary Obstruction
 Also given pre-op
- Followed by sequential HTx
 For locally advanced

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 [SURGERY] THE BREAST (PART 2) – DR. ACUÑA

LOCAL-REGIONAL RECURRENCE 2. MALE BREAST CANCER

Local Recurrence  After surgery, bumalik yung bukol  Asymmetrical
Treatment Protocol for Local Recurrence  RADIOTHERAPY  VS Gynecomastia
 Treat in the same manner that you do for bone metastasis, except you don’t  80% invasive ductal cancer
give Bisphosphonates  Mostly ER/PR (+)  MRM + HT

 After BCS: Chemotherapy or Hormonal Therapy  Total Mastectomy  ER/PR Positive  Responds to Hormonal Therapy (Tamoxifen)
 After MRM: Chemotherapy or Hormonal Therapy  Resection and/or RT 3. INFLAMMATORY CANCER
 ≥ One-third of the breast diameter
PROGNOSIS OF BREAST CANCER 4. RARE CANCERS
STAGE 5-YEAR SURVIVAL RATE (SEER data 2003-2009)  TYPES:
Stage I 98.6%  Squamous Cell Cancer
Stage II 84.4% - No skin invasion
Stage III >50%  Adenoid Cystic Carcinoma
Stage IV 24% - Same histology as the salivary gland
 Apocrine Carcinoma
 Sarcoma
SPECIAL SITUATIONS - Same treatment as Phyllodes Tumors
1. PHYLLODES TUMOR 5. RECONSTRUCTION AFTER MODIFIED RADICAL MASTECTOMY (MRM)
 Phyllodes Tumor  Giant Fibroadenoma
 ALL PHYLLODES TUMORS ARE MALIGNANT!
 Subdivided to low grade and high grade
 Treatment is the same  Remove the whole breast; NO NEED FOR
AXILLARY RESECTION = Total Mastectomy
 Confusion with benign PT, malignant PT and
fibroadenoma
 Differentiated by molecular biology
 Fibroadenoma are monoclonal or polyclonal
 Phyllodes are always monoclonal
 Gross cut sections
 Leaf-like pattern
 Subtypes:
 Benign  <5 mitoses/HPF
 Borderline  5-10 mitoses/HPF
 Malignant  >10 mitoses/HPF
 Treatment:
 Wide excision to BCS to Total Mastectomy*

Thank you Raymond Gonzales sa pagtype  Thank you to Jeff del Rosario for the scanned handouts 
Thank you din sa aking mga consultants: Joyce Cepeda and Nicollete Castillo <3

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