Welcome back. Thanks for joining me on our discussion of malignant breast diseases in the section
of general surgery. Much like we discussed in the benign lecture, breast masses are typically
thought of as either benign or malignant. We discussed benign breast masses in a different module.
In this one, we’ll discuss malignant. It’s important to focus on both in-situ disease and
invasive disease. Remember, the most important decision in breast masses is whether it’s
benign or malignant. As a review, we always want to start by obtaining a careful history.
This is particularly important with patients that had family histories of breast cancer. We perform
a thorough examination of both the breast bilaterally as well as the lymph node draining basins.
Then, we obtain age-appropriate diagnostic imaging whether it’s an ultrasound or a mammogram.
Remember, obtain this imaging before disturbing the anatomy with tissue biopsies.
Then, we obtain tissue biopsies to guide the next step of management. We put all this information
together and we introduce an optimal treatment plan to the patient. For palpable lesions,
biopsies are easy. But for nonpalpable lesions, biopsies may require additional image guidance.
Physical findings are important and physical examination is important. We want to disrobe
the patient and examine both breasts for symmetry as well as for masses and then we want
to look at all the draining lymph node basins focusing particularly on the supraclavicular, behind
the pectoralis muscles as well as in the armpit. Again, laboratory values in routine nature
are usually not very helpful. These include chemistries and CBCs. Here’s an image of ultrasound.
Again, ultrasounds are especially useful in young patients. Anechoic lesions on an ultrasound
means that it’s likely to be fluid-filled and potentially just a benign cyst. Here’s a mammogram.
In this series of three images, you see microcalcifications and a suspicious mass. Mammograms are
assigned a BI-RADS classification for its suspicion for a breast cancer. Let’s move on to
a discussion of ductal carcinoma in-situ also known as DCIS. DCIS is considered a neoplastic process.
But importantly, it is confined to the ducts alone. It is one of the most common diagnosis due to
the increased detection rates since the introduction of mammography for screening.
It may be shocking to you but screening mammograms did not use to be the standard of care.
On mammograms, DCIS, like these two images, may show itself as microcalcifications.
It is however, difficult to distinguish these from invasive cancers based on imaging alone.
Therefore, biopsies are necessary, again to differentiate between a palpable versus a nonpalpable.
In the vast majority of cases, DCIS will not present itself as a palpable lesion. However, if you do
have a palpable mass, it is amenable to a needle core biopsy. Of course, with nonpalpable
masses, we can perform a stereotactic biopsy with 3D reconstruction image-guided biopsy.
This lessens the need for a surgical excisional biopsy. Excision is recommended for DCIS if it's
obtained on pathology. Patients with DCIS are absolutely candidates for breast conservation therapy.
Breast conservation therapy involves partial mastectomy, removing a portion of the breast,
potentially also assessing the lymph node. This needs to be followed up with radiation
and chemotherapy. Postoperative endocrine therapy is usually offered to the patients with DCIS.
This may include tamoxifen. Once again, breast conservation therapy involves a local excision
to include negative margins. Patients have to have postoperative radiation.
In fact, if the patient is not candidate for radiation therapy or does not want postoperative
radiation therapy, they are not candidates for breast conservation therapy.
The results or outcomes are equivalent to mastectomy. The choice of mastectomy
may be a personal one. We certainly have patients who are diagnosed with DCIS or breast cancer
but choose to have a mastectomy rather than breast conservation therapy.