BREAST CANCER AND SENTINEL LYMPH NODE BIOPSY A woman may be diagnosed with a breast abnormality either by physical examination or by radiographic study. The majority of abnormalities picked up either way are benign (non-cancerous) in nature. Some will eventually be determined to be malignant (cancerous) however. The methods used to determine whether an abnormality is benign or malignant depends on a number of factors. This presentation will attempt to outline some basic concepts and general courses of action, but there are many variables involved in the process of both diagnosis and treatment. A woman should feel free to ask questions and get fully comfortable with her own situation. This is frequently a time of anxiety and we would like to reduce that anxiety as much as possible by having our patients well informed. Our surgeons are all experts in breast disease and work closely with radiologists, pathologists, and radiation and medical oncologists. The diagnosis and treatment of breast disease is really quite complex and requires input from multiple medical specialties. The Community Breast Program at Mission Hospitals works with us to insure that optimal diagnosis and treatment is utilized. DETECTION PALPABLE MASS A woman may feel a mass (lump) on her own or her physician may pick it up during a physical examination. In either case, she may see a surgeon as the next step. This may take place before or after radiographic studies are done. Typical radiographic studies would include a mammogram, possibly an ultrasound, and rarely an MRI. If the mass can be felt, the physician may aspirate it with a small needle to decompress a cyst or to send cells to pathology if the mass is solid. A core needle biopsy, where a larger needle is used to remove a larger specimen, may be utilized. The pathology report will determine what further evaluation, if anything, needs to be done. It is not infrequent for patients to be asked to return for repeat physical examination in a number of months, undergo repeat radiographic studies in the future, and sometimes a decision is made to proceed with an open biopsy. This is a technique where the abnormality is removed and is usually done in the outpatient surgical department under sedation and local anesthesia. RADIOGRAPHIC ABNORMALITY Many abnormalities detected on mammogram or ultrasound can be conclusively determined to be benign by their radiographic features. Some lesions are highly suspicious and another group is considered indeterminate. The latter two groups require tissue to prove whether they are benign or malignant. Core needle biopsies can be obtained under mammogram control and are called stereotactic breast biopsies. Other lesions may be either core biopsied or removed under ultrasound guidance. A guidewire may be placed under stereotactic guidance by the radiologist to allow the surgeon to remove the area in question. The actual technique utilized will depend on the specific radiographic findings. The surgeon and radiologist will work together to optimize this evaluation. PATHOLOGY FINDINGS BENIGN LESIONS The majority of specimens will be determined to be benign. Common lesions include fibroadenomas, fibrocystic change, and papillomas. Atypical hyperplasias and some types of fibrocystic change indicate that a woman is at increased risk of developing breast cancer in the future. In some situations, a discussion may be held regarding giving medications to try to reduce that risk. Modifications in diet and the utilization of vitamin E may be suggested to reduce the risk of developing similar problems in the future. NON-INVASIVE CANCER Breast cancers can be categorized as either in situ (non-invasive) or invasive. The non-invasive tumors can spread in the breast through the ductal system, but do not penetrate into the tissues where malignant cells can travel through lymph channels or the blood stream. Although this disease process may spread rather widely inside the milk ducts, the potential for disease in the rest of the body is negligible. The most common kind of non-invasive cancer is known as Ductal Carcinoma In Situ (DCIS). There is also Lobular Carcinoma In Situ (LCIS), which is treated quite differently than DCIS. LCIS is an indicator that a woman has an increased risk of breast cancer in the future. INVASIVE CANCER There are many different types of invasive cancers of the breast, and the most common is ductal. With these cancers, we are not only concerned about the treatment of the breast, but spread of cancer cells to lymph nodes or through the blood stream. The breast treatment is basically the same as for non-invasive cancers. TREATMENT OF CANCERS A discussion of breast cancer involves three basic areas of the body. The first is the breast, the second is the lymph nodal area draining the breast, and third is the rest of the body, which can serve as a location for metastasizing breast cancer cells. THE BREAST The number one job of the surgeon is to clarify whether or not cancer is present. As mentioned previously, this can be detected in a number of ways and sometimes more than one modality will be needed in order to be certain of a diagnosis. Once a diagnosis is made, then the patient will frequently have a number of options to be considered with her physician. Basically, in 2006, there are two methods of treatment. The first is breast conserving surgery, which means removal of the portion of breast containing the tumor and obtaining a margin of tissue around that tumor that is free of disease. That treatment is usually followed by radiation therapy. Another specialist, the radiation therapist, will be involved in that treatment. The other major option is mastectomy (total removal of the breast) which generally allows the patient to avoid postoperative radiation therapy. Some women would chose to have breast reconstruction after a mastectomy, which consists of placing a silicone implant or moving her own tissues into position to rebuild a breast. A consultation with a plastic surgeon may be appropriate prior to surgery. An external prosthesis can also be utilized and makes it impossible to detect the changes from surgery with the patient dressed. There are many nuances involved in making a decision as to whether one can do breast conserving surgery versus full mastectomy. These factors include the type of tumor, size of the tumor, size of the breast, location of the tumor and, of course, the desires of the individual patient. LYMPH NODES The second area of concern is the status of the lymph nodes in the armpit (axilla) as either containing or not containing breast cancer cells. If there are significant cancerous cells located in lymph nodes, it is best to remove those before they expand and invade surrounding structures, particularly the vessels and nerves supplying the arm. Secondly, having that information is extremely helpful in determining how aggressively we treat the individual woman to reduce her risk of metastases (spread elsewhere in the body). In general, intravenous chemotherapy is prescribed for those women with cancerous lymph nodes. We know that situation puts them at greater risk of developing disease elsewhere. There is a new technique for sampling lymph nodes. This is called a sentinel lymph node biopsy and allows us to get the information needed with much less morbidity to the patient. The incidence of arm swelling and chronic changes in the skin sensation are greatly reduced with this technique. By utilizing a combination of radioactive material injected the morning of surgery, as well as a blue dye injected at the time of surgery, we can usually find the lymph node or nodes that first catch any material coming out of the breast, including malignant cells. This allows us to carefully examine those sentinel lymph nodes and be rather certain that if they do not contain disease, the rest of the axilla is also clear of disease. SYSTEMIC TREATMENT The third issue deals with the rest of the body. We use medications that affect the whole body (systemically) when indicated. With non-invasive cancer, this is not an issue, but with invasive cancers we do know that some will spread elsewhere and be noted years after the initial treatment. For this reason, it is important to carefully stage the tumor. This is done based on the surgical results. The size of the tumor, as well as involvement of lymph nodes will allow a much more accurate determination as to how aggressive to be with systemic treatment. Sometimes a hormonal treatment may be undertaken and/or intravenous chemotherapy may be needed. Other factors involved in helping with those decisions include the estrogen, progesterone, and Her2Neu receptor status, as well as the patient’s menopausal status and overall health. A medical oncologist (a specialist in systemic treatment) is usually involved with these decisions and therapies. SUMMARY The majority of women with breast cancer are long-term survivors. Breast cancer survival rates are increasing. The detection and treatment of breast cancer is very complex and frequently requires the expertise of many specialists. Each patient has a distinct situation and we strive to find the diagnostic tests, surgical procedures, and systemic treatments that will best enable her to achieve a long-term cure with the least trauma possible. RDJ/bkh

Regional Surgical Specialists 2006