Breast Cancer and Breast Reconstruction


Chapter 9

Breast Cancer and Breast Reconstruction



1. Breast cancer epidemiology


Most common noncutaneous malignancy among women


Affects 1 : 8 women


Independent risk factors


Exposure to estrogen


Early age at menarche


Late menopause


First full-term pregnancy after 30 years of age (yo)


Personal history of breast cancer or benign proliferative breast disease


BRCA mutation (occurs in <1% of women; accounts for 5% of breast cancers; 60% to 80% lifetime risk)


BRCA1 mutation associated with the following malignancies: Breast (85%), ovarian (62%), male breast, pancreatic, testicular, and early-onset prostate cancers


BRCA2 associated with the following malignancies: Breast (85%), ovarian (25%), male breast (7%), pancreatic, and prostate cancers


Breast cancer in a first-degree relative


Age of affected <50 yo → Risk ratio (RR) 2.3


Age of affected >50 yo → RR 1.8


Bilateral breast cancer → RR 5.5


2. Breast cancer diagnosis


Clinical breast exam


Mammography


Radiographic imaging of the breast that is an excellent screening tool for abnormal masses or calcifications


Linear or branching calcifications may suggest malignancy.


Pleomorphic/granular calcifications may suggest malignancy.


Popcorn-like calcifications suggest fibroadenoma.


Large rod-like calcifications suggest secretory ducts.


Round eggshell calcifications suggest oil cysts.


Dystrophic/coarse calcifications suggest fat necrosis.


Calcifications can be found in ~25% of women who have had inferior pedicle breast reductions.


Patients with implants may get mammograms; however, they require a special view called the Eklund view, where the prosthesis is pushed against the chest wall and the breast parenchyma is pulled anteriorly around and away from the implant.


Implant position, capsular contracture, and small native breasts can compromise the reliability of mammography.


Implant size has not been shown to affect mammography.


Magnetic resonance imaging (MRI)


Newer tool for evaluating the breast for breast cancer


Especially useful for screening high-risk patients


May have high false-positive rate, resulting in increased secondary procedures such as biopsy and mastectomy


Ultrasound


Widely used as a diagnostic modality; often used as a secondary study to work up a mass


Useful in women with dense breasts (i.e., younger women)


Ultrasound findings can help differentiate between malignant and benign lesions.


The following ultrasound findings suggest malignancy: Spiculations, asymmetric mass, calcifications, angular margins, hypoechoic lesion with posterior shadowing, heterogenous


Histologic diagnostic modalities


Core biopsy


Image guided


Fine-needle aspiration


Disadvantages


Does not provide structural information to determine invasive from in situ


High false-negative rates from sampling error (2% to 22%)


Excisional biopsy


Indications: Disagreement between mammography and histology, atypical ductal hyperplasia on percutaneous biopsy, radial scar on mammography, or percutaneous biopsy


3. Breast cancer types


Ductal carcinoma in situ (DCIS)


Lobular carcinoma in situ (LCIS)


Invasive ductal carcinoma (IDC)


Invasive lobular carcinoma (ILC)


Inflammatory breast carcinoma


Can often involve chest wall, requiring a modified radical mastectomy with wide skin defect


Treatment options include a rectus abdominal myocutaneous flap (preferred choice, especially if breast reconstruction desired), latissimus (lat) flap +/− split thickness skin graft, omental flap + split thickness skin graft.


4. Breast cancer staging (see Tables 9.1 and 9.2)



Table 9.1


Staging of Breast Cancer: TNM System





















































































Tumor Size: T (Largest Diameter)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS) Ductal carcinoma in situ
Tis (LCIS) Lobular carcinoma in situ
Tis (Paget’s) Paget’s disease of the nipple not associated with invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget’s disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget’s disease should still be noted.
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 not ≤50 mm in greatest dimension
T3 Tumor >50 mm in greatest dimension
T4 Tumor of any size with direct extension to chest wall or skin (includes inflammatory carcinoma)
Nodal Involvement: N (Nodal Status)
NX Regional lymph nodes cannot be assessed (e.g., previously removed, not removed).
N0 No regional lymph node metastases histologically
N1 Metastases to movable ipsilateral level-I, -II axillary lymph node(s)
N2 Metastases in ipsilateral level-I, -II axillary lymph nodes that are clinically fixed or matted or in clinically detected* ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases
N3 Metastases in ipsilateral infraclavicular (level-III axillary) lymph node(s) with or without level-I, -II axillary lymph node involvement, clinically detected* ipsilateral internal mammary lymph node(s) with clinically evident level-I, -II axillary lymph node metastases, or ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement
N3a Metastases in ipsilateral infraclavicular lymph node(s)
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)
Metastases: M
M0 No clinical or radiographic evidence of distant metastases
cM0(i+) No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells that are no larger than 0.2 mm in circulating blood, bone marrow, or other nonregional nodal tissue in a patient without symptoms or signs of metastases
M1 Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven larger than 0.2 mm


image



*Detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis based on fine-needle biopsy with cytologic examination.


TNM, Tumor/node/metastasis.


From 2010. AJCC Cancer Staging Manual and Handbook, 7th ed. Springer-Verlag, New York.



5. Breast cancer treatment


Breast-conserving therapy


Lumpectomy and radiation


Equivalent to mastectomy in long-term survival


Requires adjunctive radiation to limit risk for local recurrence


General indications


Women who have small, easily accessible cancer with relatively large breasts and desire to avoid mastectomy


Contraindications


Large cancer with small breasts, such that tumor removal would result in significant distortion of the remaining breast


Complications


Contracture and scarring


Radiation-related complications


Unfavorable esthetic outcomes (estimated to be 20% to 35%)


Reconstructive options (see Figures 9.1 and 9.2)


Oncoplastic reduction or mastopexy


Balancing the resection with breast landmarks and shape to preserve aesthetics


Lat flap


Sep 2, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Breast Cancer and Breast Reconstruction

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