Breast Surgical Techniques and Interdisciplinary Management (eBook)

Frederick M. Dirbas, M.D. Associate Professor of Surgery Breast Disease Management Group Leader Clinical Care Sub-Team Division of Surgical Oncology Department of Surgery Stanford University School of Medicine, Stanford Cancer Center 875 Blake Wilbur Drive, CC2235 Stanford, CA 94025, USA Carol E. H. Scott-Conner, M.D., Ph.D. Department of Surgery University of Iowa Hospitals and Clinic 200 Hawkins Drive, 1516 JCP Iowa City, IA 52242-1086, USA

Breast Surgical Techniques and Interdisciplinary Management 3
Foreword 7
Preface 9
Contents 11
Contributors 19
Part I Fundamentals 31
1: Professionalism in the Approach to the Patient 32
Key Concepts 32
Background 33
Breast Patients 33
Respect 34
Listening to the Patient 35
Delivering Good or Bad News 36
Clinical Excellence 37
Implications of Breast Disease for Women and Men 38
Conclusions 39
References 39
2: The Clinical Breast Cancer Team 40
Key Concepts 40
Background 41
Structure for Delivery of Care 41
Components of the Team 42
Conclusions 44
References 44
3: The Role of the Specialist Breast Nurse 46
Key Concepts 46
Background 46
Medical Assistant 47
Registered Nurse 47
Nurse Practitioner 47
Physician’s Assistant 48
Specialist Breast Nurse 48
UK Model for Emotional Support 49
Australian Model of Patient Education 50
America: Model of Care Coordination 51
Nurse-Led Clinics 52
Nurse-Led Follow-Up Clinics 53
Effective Doctor/Nurse Collaboration 53
Conclusions 54
References 54
4: Social Work and Breast Cancer Care 56
Key Concepts 56
Background 56
Initial Referral 57
Support Groups 58
Decreasing Emotional Distress 58
Specific Psychosocial Issues 59
Choice of Surgery 60
Recovery and Survivorship Issues 61
Suggested Reading 62
5: Reducing Medical Malpractice Risk in Breast Cancer Care: A Surgical Perspective 63
Key Concepts 63
Pitfalls 64
Background 64
Office-Based Strategies 65
Operative Strategies 67
Postprocedure and Tracking Strategies 68
Conclusions 69
References 70
6: Career Development for Breast Surgical Oncology 71
Background 71
Basic Skill Set 71
Patient Expectations of the Breast Surgeon 72
Current Breast Surgical Oncology Training in the USA 73
Practice Considerations: The First Job 73
Financial Considerations 77
Breast Surgical Oncology Training in the Future 78
Promoting Wellness and Balancing Your Career in Breast Surgery 78
The Critical Importance of Mentorship 79
Conclusions 81
Suggested Reading 81
7: Successful Management of a Breast Surgery Practice 83
Key Concepts 83
Background 83
Be Involved in Your Practice 84
Increase the Efficiency of Your Practice 84
Understand How to Use the Standard Practice Management Reports 85
The Basic Practice Analysis Report 85
The Payor Mix 86
The Denial Report 86
Insurance Tracking Report 86
Accounts Receivable Reports 86
Collection Reports 87
Understand the Five Major Divisions of a Successful Breast Practice 87
Patient Registration/Front Desk 87
Surgery Scheduling Division 87
Charge Collection and Entry Division 88
Insurance Tracking Division 88
Collections Division 89
Putting all of this Together: Analysis of Practice Patterns and Selection of Best Market/Patient Base 89
Conclusions 89
Part II Biologic Principles 90
8: Normal Morphology, Physiological Changes, and Benign Breast Disease 91
Key Concepts 91
Background 92
Normal Physiological Changes 93
Puberty 93
Resting Stage 94
Pregnancy and Lactation 95
Postlactational Involution 95
Postmenopausal Breast 95
Benign Breast Disease 96
Fibroadenoma 97
Clinical Features 97
Pathology 97
Giant Fibroadenomas vs. Juvenile 97
Fibroadenoma in Postmenopausal Women 98
Fibroadenoma and Breast Cancer 100
Should the Fibroadenoma Be Excised? 100
Differential Diagnoses of a Fibroadenoma 100
Fibrocystic Change 100
Clinical Features 100
Pathology of Fibrocystic Change 101
Intraductal Papilloma 102
Sclerosing Adenosis 103
Radial Scar 104
Benign Calcification 104
Pseudoangiomatous Stromal Hyperplasia (PASH) 105
Risk of Breast Cancer Associated with Benign Breast Disease 106
Suggested Reading 107
9: The Biology of Breast Cancer 108
Key Concepts 108
Background 109
Normal Breast Development 109
Steroid Hormone Receptors 110
HER2/neu/C-ErbB2 112
Breast Cancer Oncogenesis 113
Characterization of Breast Cancer Phenotypes 114
Additional Gene Markers 115
Familial Breast Cancers 117
Stem Cell Theory 117
References 119
Part III Initial Evaluation of the Patient 121
10: Obtaining a History and Performing the Clinical Breast Examination 122
Key Concepts 122
Background 123
The Breast History 123
Review of Systems 123
Past Medical History 123
Past Surgical History 124
Social History 125
Family History 125
Risk Assessment 126
Components of the Physical Examination 127
Inspection 127
Palpation 127
Male Breast Examination 128
Documentation 128
Axillary Examination 129
References 130
11: Primer on Ultrasound for the Breast Surgeon 132
Key Concepts 132
Background 132
Adding Ultrasound to Your Office Practice 133
Selection of Ultrasound Equipment 133
Additional Equipment 134
Changes to the Office 134
Using Ultrasound as an Adjunct to Clinical Exam 135
Image-Guided Breast Procedures 138
Use of Ultrasound in the Operating Room 140
Certification and Accreditation 141
Suggested Reading 143
12: The Complete Radiology Workup 144
Key Concepts 144
Sec2_12 145
Background 145
Physical Examination 145
Mammography 146
Breast Ultrasound 148
Axillary Ultrasound 148
Breast Magnetic Resonance Imaging 149
Indications for MRI 149
Positron Emission Tomography Breast Imaging 150
Molecular Breast Imaging 150
Image-Guided Percutaneous Breast Biopsy 150
Fine Needle Aspiration Biopsy 151
Core Needle Biopsy 151
Preoperative Localization 151
Imaging Patients with Augmented Breasts 154
References 155
Part IV Common Presenting Complaints and Concerns 156
13: Identification and Management of Women at High Familial Risk for Breast Cancer 157
Key Concepts 157
Background 158
Hereditary Patterns of Breast Cancer 159
Clinical Breast Cancer Risk Assessment 159
Management of Women with High Breast Cancer Risk 161
Conclusions 163
References 164
14: Clinical Management of Breast Pain 168
Key Concepts 168
Background 168
Prevalence and Classification 169
Natural History and Impact on Daily Activities 169
Etiology of Mastalgia 170
Histological Abnormality 170
Hormonal 170
Psychogenic Factors 170
Increased Prolactin (PRL) Response 170
Essential Fatty Acids 171
Management 171
History Taking and Characterization of Pain 171
Physical Examination and Imaging 171
Lifestyle Measures and Dietary Changes 171
Endocrine Therapy 172
Nonhormonal Therapy 173
References 173
15: Breast Mass 175
Key Concepts 175
Background 175
Cystic Breast Disease 176
Solid Masses 177
Fibroadenoma 178
Radial Scar 178
Fat Necrosis 179
Breast Cancer 179
Conclusions 179
References 180
16: Breast Infection 181
Key Concepts 181
Background 182
Infections Associated with Breast Feeding 182
Management of a Suspected Breast Abscess Associated with Breast Feeding 182
Infections Not Associated with Pregnancy 186
Central Subareolar Infections 186
Management of a Central Subareolar Abscess 186
Total Duct Excision in Patients with Periductal Mastitis 188
Surgical Management of Mammary Duct Fistula 190
Complications 192
Peripheral Non-Lactating Infection 193
Nipple Piercing 193
Granulomatous Lobular Mastitis 195
Skin-Associated Infections 196
Abscesses Associated with Sebaceous Cysts 196
Hidradenitis Suppurativa 197
References 197
17: The Evaluation and Treatment of Nipple Discharge 198
Key Concepts 198
Background 199
Workup for Pathologic Discharge 199
Surgery for Diagnosis and Treatment 201
Suggested Reading 204
18: Gynecomastia 206
Key Concepts 206
Background 207
Gynecomastia 207
Presentation and Clinical Evaluation 208
Imaging Studies 209
Differentiation from Male Breast Cancer 209
Treatment of Gynecomastia 210
Conclusions 214
References 214
19: The Effects of Menopausal Hormone Therapy on Breast Cancer: Evidence from the Women’s Health Initiative Randomized Place 216
Key Concepts 216
Background 217
The Women’s Health Initiative Hormone (WHI) Trials 218
WHI E+P Trial of Postmenopausal Women Aged 50–79 Years with a Uterus 218
WHI E-Alone Trial of Women Aged 50–79 Years with Prior Hysterectomy 219
Breast Cancer Risk After Stopping Menopausal Hormone Therapy 219
The Women’s Health Initiative Observational Study 222
Conclusions 224
References 225
Part V Diagnostic Techniques 227
20: Office-Based Diagnostic Procedures 228
Key Concepts 228
Overview 228
Biochemical Assays 229
Guaiac Test for Nipple Discharge 229
Background 229
Materials 229
Method 229
Cytology-Based Assays 230
Cytology Evaluation of Nipple Discharge 230
Background 230
Materials 230
Methods 231
Fine Needle Aspiration of Palpable Abnormalities 231
Materials 232
Patient Positioning 232
Method 233
Histology-Based Procedures 234
Punch Biopsy 234
Background 234
Materials 234
Method 234
Core Needle Biopsy 235
Materials 237
Patient Positioning 237
Method 237
References 238
21: Image-Guided Breast Biopsy 240
Key Concepts 240
Background 241
Needle Types 241
Fine Needle Aspiration Biopsy 241
Core Needle Biopsy 242
Image-Guided Biopsy Options for Mammographic, Ultrasound, and MRI Findings 242
Mammographic Abnormalities 242
Stereotactic Percutaneous Core Biopsy for Mammographic Abnormalities 243
X-Ray-Guided Preoperative Needle Localization and Open Surgical Biopsy for Mammographic Abnormalities 245
Ultrasound Abnormalities 246
Ultrasound-Guided Fine Needle Aspiration Biopsy 247
Ultrasound-Guided Core Needle Biopsy 247
Ultrasound-Guided Preoperative Needle/Hookwire Localization 248
MRI Abnormalities 249
Managing Core Biopsy of Large or Multiple Lesions 252
Interpretation of Results and Quality Assurance with Image-Guided Biopsy 253
Conclusions 255
References 255
22: Breast Biopsy Techniques 258
Background 258
Workup of the Abnormal Breast Finding: Palpable Masses 259
Workup of the Abnormal Breast Finding: Nonpalpable Masses 260
FNA vs. Core Needle Biopsy vs. Open Excisional Biopsy 263
Planning the Surgical Biopsy/Lumpectomy Incision 265
Planning the Lumpectomy Resection 266
Needle-Localized Breast Biopsy Technique 266
Conclusions 268
References 268
23: Mammary Ductoscopy 270
Key Concepts 270
Background 270
Current Status of Ductoscopy 272
Technical Aspects 274
References 275
Part VI Breast Cancer Overview 277
24: Assessment of Extent of Disease in Primary Breast Cancer 278
Key Concepts 278
Background 278
Risk of Occult Metastatic Disease 279
Current Recommendations for Staging 280
Evaluation of Abnormal Results 281
Future Directions 282
FDG PET 282
Detection of Disseminated and Circulating Tumor Cells 283
References 283
25: Breast Cancer Staging: Predicting Outcome and Response to Treatment 284
Key Concepts 284
Background 285
Cancer Staging Systems and General Rules of Staging 285
Breast Cancer Staging 289
Nonanatomic Prognostic and Predictive Factors 296
Synthesizing and Communicating Stage and Prognostic Information 298
Conclusions 298
References 298
26: Breast Cancer Treatment Guidelines 301
Key Concepts 301
Background 301
Types of Clinical Practice Guidelines 302
Conflicts of Interest 303
Guideline Endpoints 303
Frequency of Updating 304
Major Guidelines in Clinical Use 304
Guideline Usage 306
Conclusions 306
References 307
27: Introduction to Gene Expression Profiling in Breast Cancer 309
Key Concepts 309
Significance to the Management of Breast Cancer 310
Background 310
Potential Applications of Gene Microarrays 315
Initial Uses of Gene Microarrays in Breast Cancer 317
Complications/Pitfalls/Solutions 323
New Developments/Clinical Trials on the Horizon 324
Conclusions 326
References 327
28: Clinical Trial Overview and Enrollment 329
Key Concepts 329
Background 330
Overview of Clinical Trials 330
Trial Types 330
Clinical Trials Infrastructure 331
National and International Cooperative Groups 331
NCI and the Cooperative Groups 332
Designing a Clinical Trial 332
The Hypothesis and Primary Endpoint 332
Statistics and Power Calculations 333
Secondary Endpoints, Subset Analysis, and Laboratory Studies 333
Consent and Data Collection Forms 334
Feedback and Refinement 334
The Regulatory Process: Hurdles or Opportunities for Refinement? 334
Institutional Review Board (IRB) and Scientific Review Committee (SRC) 334
Data Safety Monitoring Board (DSMB) 335
Budget Considerations 335
Mandatory Clinical Trial Registration 336
Assembling Infrastructure Necessary to Administer Clinical Trials 336
Identification and Selection of Patients for Trial Participation 337
Enrollment and Follow-Up 338
Adverse Events 338
Interim Data Analysis, Stopping Rules 338
Other Considerations 339
References 339
29: Psychiatric and Psychological Issues 341
Key Concepts 341
Background 341
Anxiety and Depression Among Cancer Patients 342
Effects on Treatment Adherence 342
Principles of Good Coping 343
Face Rather Than Flee the Problem 343
Alter Perception and Thinking About Stressors 343
Cope Actively 344
Express Emotion 345
Seek Social Support 345
Psychopharmacology 346
Conclusions 346
References 346
30: Fertility Issues for Newly Diagnosed Women Interested in Child Bearing: Strategies and Options 350
Key Concepts 350
Background 350
Brief History 351
Indications for Treatment 352
Description of Management Options and Observations 353
Ovarian Suppression During Chemotherapy 353
Stimulation Protocols 353
Embryo Freezing 354
Egg Freezing 354
Ovarian Tissue Freezing 354
Gestational Carrier 355
Egg Donation 355
Adoption 355
Postchemotherapy 356
Challenges of Infertility Treatments 356
New Developments/Clinical Trials on the Horizon 357
References 357
Part VII Breast Surgery – Management of the Primary Tumor 359
31: Regional Anesthesia for Breast Surgery 360
Key Concepts 360
Background 360
Regional Anesthesia Anatomy Relevant to the Breast Region 362
Regional Anesthesia Anatomy Relevant to the Axilla 363
Sedation Options 365
Regional Anesthesia for the Breast 365
Thoracic Epidural Anesthesia 365
Paravertebral Nerve Block 366
Advantages of the Thoracic Paravertebral Block 366
Complications of Thoracic Paravertebral Block 367
Anatomy of the Paravertebral Space (See Fig. 31.6) 367
Technique for Thoracic Paravertebral Block (Fig. 31.6) 369
Method 370
Contraindications for Paravertebral Block 371
Intrapleural Block 372
Technique of Intrapleural Catheter Insertion 375
Contraindications to Intrapleural Block 375
Regional Anesthesia for the Axilla 375
Nerve Block of the Intercostbrachial Nerve 376
Nerve Block of Axilla Anterior and Posterior Walls 377
Regional Anesthesia for the Pectoral Muscles 378
Regional Anesthesia for the Supraclavicular Nerves 378
Know the Surgery 378
Conclusions 378
Addendum: Frequently Asked Questions 380
References 381
32: Lumpectomy 383
Key Concepts 383
Background 384
Current Technique of Breast Conserving Therapy with Lumpectomy 385
Conclusions 389
References 390
33: Oncoplastic Techniques for Breast Conservation Surgery 391
Significance to Management of Breast Cancer 391
Brief History/Background 392
Indications for Treatment 392
Required Preparative Studies 392
Description of Techniques 393
Complications, Pitfalls, and Solutions 398
New Developments/Clinical Trials on the Horizon 398
References 399
34: Ablative Therapies 401
Key Concepts 401
Background 401
Ablation Techniques 402
Cryoablation (CrA) 403
Radiofrequency Ablation 407
Interstitial Laser Ablation 409
Microwave Ablation 412
Focused Ultrasound 412
Summary and Future Directions 413
References 415
35: Mastectomy 418
Key Concepts 418
Background 418
Indications for Mastectomy 419
Major Technical Considerations in Planning Mastectomy 419
Steps in Total Mastectomy: Choice of Skin Incision 420
Creating the Flaps 422
Dissection from the Pectoral Muscles 425
Major Differences Between the Initial Steps of TM and SSM 426
Contraindications to SSM (Hence Indications for TM) 428
Complications of Mastectomy 428
Special Considerations 429
Suggested Reading 431
36: Nipple and Areola-Sparing Mastectomy 432
Key Concepts 432
Background 432
Areola-Sparing Mastectomy 433
Nipple-Sparing Mastectomy 436
Suggested Reading 439
37: Integration of Neoadjuvant Systemic Therapy into Surgical Practice 440
Key Concepts 440
Background 441
Indications for Neoadjuvant Chemotherapy 441
Locally Advanced and Large Primary Breast Cancer 441
Stage I and Stage II Breast Cancer 442
Initial Evaluation of Patients Being Considered for Neoadjuvant Chemotherapy 442
Monitoring Response to Neoadjuvant Chemotherapy 443
Breast Surgery After Neoadjuvant Chemotherapy 444
Predicting Residual Tumor Size and the Probability of Successful Conservative Surgery with Neoadjuvant Chemotherapy 445
Breast Conservation Surgery 445
Axillary Surgery After Neoadjuvant Chemotherapy 447
New Developments and Clinical Trials on the Horizon 448
References 449
38: Oncologic Breast Reconstruction: Principles and Practice 451
Introduction 451
The Plastic Surgery Consultation 451
Guiding Principles of Breast Reconstruction 452
Breast Reconstruction Options 453
External Prosthesis 453
Implant-Based Reconstructions 453
Implant Basics 453
Implant Types 453
Implant Position 454
Implant Complications 455
Immediate Insertion of Permanent Implant 456
Tissue Expanders 456
Autologous Tissue 460
Abdominal Tissue Flaps 461
TRAM Flap 461
Muscle-Sparing TRAM Flap 461
DIEP Flap 461
SIEA Flap 462
Selecting the Optimal Flap: Minimizing the Risk of Complications 464
Gluteal Flap 465
DCIA/Rubens Flap 466
Gracilis 466
Latissimus Dorsi Flap 466
Recipient Vessels Used for Free Flaps 467
Combined Reconstructive Techniques: Autologous Tissue and Implant 468
Adjunct Procedures to Optimize Symmetry 468
Contralateral Breast Surgery 468
Reconstructed Breast Mound Procedures 469
Revisional Surgery 469
Nipple Reconstruction 469
Timing of Breast Reconstruction 471
Immediate vs. Delayed 471
Influence of Radiation Therapy 471
Influence of Chemotherapy 472
Locally Advanced Cancer or Metastatic Disease 472
Partial Mastectomy Reconstruction 473
Choosing the Appropriate Reconstructive Option 473
Conclusions 475
References 475
Part VIII Breast Surgery – Sentinel Node Biopsy and Axillary Dissection 477
39: Sentinel Lymph Node Biopsy: An Overview 478
Key Concepts 478
Background 479
Technique 479
Specimen Handling 480
False-Negative Findings on SLNB 481
Complications 482
Continuing Controversies 483
Do All Patients with an Involved SLN Need Further Axillary Treatment? 483
Number of SLNs Removed 484
Breast Cancer in Males 484
SLNB for DCIS 485
Prophylactic Mastectomy and SLNB 485
SLNB in Patients with Prior Breast or Axillary Surgery 485
References 486
40: Sentinel Lymph Node Biopsy Radiotracer Technique at Memorial Sloan-Kettering Cancer Center 488
Key Concepts 488
Background 489
Choice of Radioisotope 490
Dose of Radioisotope 490
Site and Volume of Injection 491
Timing of Injection 491
Lymphoscintigraphy 491
Operative Technique 492
Intraoperative Assessment of SLN 493
The Belatedly Positive SLN 493
References 494
41: Sentinel Node Biopsy Using Lymphazurin 496
Key Concepts 496
Background 496
Development of the Technique Using Blue Dye 497
Choice of Blue Dye 499
References 500
42: The Use of Methylene Blue as a Tracer Agent in Sentinel Lymph Node Biopsy 502
Key Concepts 502
Background 502
History of Methylene Blue Dye Use in Sentinel Node Biopsy 503
Efficacy of Sentinel Node Mapping with Methylene Blue 504
Technical Aspects of Sentinel Node Biopsy Specific to the Use of Methylene Blue 505
Preparation of Methylene Blue 505
Method of Injection 505
SN Procedure 506
Adverse Reactions 507
Blue Staining of Skin and Urine 507
Skin Necrosis 508
Capsular Contracture After Breast Augmentation 508
Pulse Oximetry Interference 508
Future Directions 509
Conclusions 509
References 509
43: Axillary Lymph Node Dissection 511
Key Concepts 511
Background 511
Indications 512
Technique 513
Level III Dissection 517
Troubleshooting 517
Identifying the Axillary Vein 517
Identifying the Thoracodorsal Nerve 518
Identifying the Long Thoracic Nerve 518
Complications 518
Seroma 518
Nerve Injury 518
Edema 519
New Developments 519
Axillary Metastases with Unknown Primary 519
References 520
Part IX Breast Surgery – Special Issues 524
44: Evaluation and Management of Women Presenting with Breast Symptoms During Pregnancy 525
Key Concepts 525
Background 526
Normal Physiology of the Breast During Pregnancy 526
Clinical Problems During Pregnancy 526
Palpable Masses 526
Nipple Discharge 529
Accessory Breast Tissue 530
Breast Imaging During Pregnancy 530
Breast Cancer During Pregnancy 531
Local Management of Breast Cancer Diagnosed During Pregnancy 532
Sentinel Lymph Node Sampling 533
Anesthesia During Pregnancy 534
References 535
45: Paget’s Disease of the Breast 537
Key Concepts 537
Background 537
Clinical Presentation 539
Management Options 543
References 545
46: Male Breast Cancer 548
Key Concepts 548
Background 549
Risk Factors 549
Genetic 549
Occupation 549
Radiation Exposure 550
Endocrine Factors 550
Presentation 551
Histopathology 551
Management 552
Treatment of Local Disease 552
Surgery 552
Endocrine Therapy 553
Radiotherapy 553
Chemotherapy 553
Treatment of Advanced Disease 553
Prognosis 554
Conclusions 554
References 555
47: Breast Sarcomas 558
Key Concepts 558
Background 559
Primary Breast Sarcomas 559
Secondary Breast Sarcomas 561
Brief History/Background 561
Indications for Treatment 563
Workup and Staging 563
Description of Management/Options/Observations 565
Breast Conservation vs. Mastectomy 568
The Role of Radiation Therapy 568
Immediate vs. Delayed Reconstruction 570
Impact of Postoperative Radiation on Reconstruction 570
Oncoplastic Surgery 571
The Role of Chemotherapy and Other Adjuvant Treatments 571
Potential Difficulties 573
New Developments 574
Other Chemotherapy Agents 574
Biological Therapies 574
Antiangiogenesis 574
EGFR Inhibition 575
Imatinib 575
Hyperthermia 575
References 576
48: Axillary Metastases with Unknown Primary 583
Key Concepts 583
Background 583
Workup 584
Treatment of the Breast 584
Management of the Axilla 585
Systemic Therapy 586
Prognosis 586
References 587
Part X Cytology and Pathology 588
49: Breast Cytology 589
Key Concepts 589
Background 590
Nipple Discharge 590
Breast Cyst Fluid 590
Fine Needle Aspiration Biopsy 591
FNA by Palpation 591
Image-Guided FNA 592
Random Periareolar FNA 592
Complications of FNA 592
Ductal Lavage 592
Specimen Preparatory Methods 593
Direct Smears 593
Liquid-Based Samples 594
Cell Blocks 594
Diagnostic Categories 595
Unsatisfactory 595
Benign 595
Atypical/Indeterminate 595
Suspicious/Probably Malignant 596
Malignant 596
Triple Test 596
Limitations 596
Cannot Distinguish In Situ from Invasive Carcinoma 596
Cannot Distinguish Low-Grade Phyllodes Tumor from Fibroadenoma 597
Cannot Give Cytologic Diagnosis in Specific Histologic Terms 597
Causes of False Negative Diagnoses 597
Causes of False Positive Diagnoses 597
Ancillary Studies 597
Fine Needle Aspiration vs. Needle Core Biopsy 598
References 598
50: The Breast Pathology Report 600
Key Concepts 600
Background 601
Diagnosis 601
Risk Prediction 602
Identification of Borderline Breast Lesions 602
Detection of Tumor Metastasis in Sentinel Lymph Node Biopsy 602
Detection of Tumor Cells at Surgical Margins in Lumpectomy Specimens 603
Prognosis: Treatment Planning 603
Tumor Size 603
Tumor Type 604
Histologic Grade 604
Lymph Node Status 604
Presence or Absence of Ductal Carcinoma In Situ, Presence or Absence of Vascular Invasion, and the Status of Margins 605
Prediction of Response to Therapy 605
Estrogen and Progesterone Receptors 605
HER-2/neu Oncogene 605
The Current Challenges Associated with the Practice of Breast Pathology 606
The Opportunities for Standardization and Improved Quality of Breast Pathology 608
Suggested Reading 609
51: Risk Lesions of the Breast: Usual Ductal Hyperplasia, Atypical Ductal Hyperplasia, Lobular Neoplasia, and the Spectrum o 611
Key Concepts 611
Background 611
Usual Ductal Hyperplasia 612
Atypical Ductal Hyperplasia 613
Lobular Neoplasia 614
Lobular Carcinoma In Situ 614
Atypical Lobular Hyperplasia 616
Pleomorphic Lobular Neoplasia 616
Lobular Neoplasia in Core Needle Biopsies 617
Spectrum of Columnar Cell Alterations 618
Columnar Cell Change and Columnar Cell Hyperplasia 618
Flat Epithelial Atypia (Columnar Cell Change/Hyperplasia with Atypia) 618
References 620
52: Duct Carcinoma In Situ: A Gordian Knot Untied 621
Key Concepts 621
Background 622
Prognostic Factors 623
Grade 623
Extent (Size) 624
Margin Status 625
Sentinel Node Biopsy for DCIS 626
Practical Application of Prognostic Factors 626
Conclusions 627
References 627
53: Pathology: Invasive Carcinoma 630
Key Concepts 630
Background 631
Special Histologic Types of Invasive Breast Carcinoma 632
Invasive Lobular Carcinoma 632
Classic Form of Invasive Lobular Carcinoma 632
Variants of Invasive Lobular Carcinoma 633
Invasive Tumors with Features of both Ductal and Lobular Carcinoma 634
Tubular Carcinoma 634
Invasive Cribriform Carcinoma 635
Mucinous (Colloid) Carcinoma 635
Invasive Papillary Carcinoma 636
Invasive Micropapillary Carcinoma 636
Special Types of Hormone Receptor Negative, HER2 Negative Carcinoma 637
Medullary Carcinoma 637
Metaplastic Carcinoma 637
Fibromatosis-Like Carcinomas 637
Adenocarcinoma with Spindle Cell Metaplasia (Sarcomatoid Carcinoma) 638
Mixed Epithelial/Mesenchymal Carcinoma 638
Adenosquamous Carcinoma 639
Squamous Carcinoma 639
Conclusions 639
Suggested Reading 639
54: Interpreting Breast Pathology in the Setting of Neoadjuvant Chemotherapy 641
Key Concepts 641
Background 642
Pathologic Changes Occurring in Breast Cancers During Treatment 643
Invasive and In Situ Carcinoma 643
Size 643
Cellularity 644
Histologic Appearance and Grade 644
Tumor Markers 645
Lymph Node Metastases 645
Systems for Evaluating Pathologic Response to Treatment 646
Critical Pathologic Issues for Surgeons Treating Patients Undergoing NAT 649
The Pretreatment Biopsy 649
Pretreatment Lymph Node Evaluation 649
Posttreatment Lymph Node Evaluation 650
Identification of the Tumor Bed 650
Margins 651
Evaluation of Pathologic Tumor Response 651
Conclusions 652
References 652
55: Pathology of Sentinel Lymph Nodes and Axillary Nodes 654
Key Concepts 654
Background 655
Indications 655
Pathology Results 656
False-Negative Sentinel Lymph Node 659
False-Positive Sentinel Lymph Node 661
Intraoperative Evaluation of Sentinel Lymph Nodes 662
New Methodologies 664
References 664
56: Selected Fibroepithelial, Mesenchymal, and Hematolymphoid Tumors of the Breast 666
Key Concepts 666
Fibroepithelial Tumors 667
Fibroadenoma 667
Phyllodes Tumor 667
Selected Benign Stromal Tumors of the Breast 671
Myofibroblastoma 671
Fibromatosis of the Breast 673
Selected Sarcomas of the Breast 675
Angiosarcoma 675
Rhabdomyosarcoma 679
Other Breast Sarcomas 681
Hematolymphoid Lesions of the Breast 685
Lymphocytic Lobulitis (Diabetic Mastopathy) 685
Primary Breast Lymphoma 685
Involvement by Acute Leukemia 689
References 690
57: Banking Tissue Specimens for Research 692
Key Concepts 692
Background 693
Types of Specimens Banked 693
Benefits of a Centralized Tissue Bank 694
Informed Consent 694
Collecting and Processing Tissue 695
Tissue Storage 696
Procuring and Processing Blood Specimens 696
Tissue Banking Database 696
Access to Specimens 697
Costs 697
Conclusions 697
References 698
Part XI Systemic Therapy for Breast Cancer 699
58: Basic Principles of Antineoplastic Therapies 700
Key Concepts 700
Background and Definitions 701
Factors Influencing Efficacy of Therapy 701
Tumor Cell Kinetics and Growth 701
Clinical Application of Tumor Kinetics 702
Combination Chemotherapy 703
Pharmacokinetics 703
Pharmacodynamics 703
Pharmacogenomics 704
Classification of Antineoplastic Therapies 704
Cell Cycle 704
Hormonal Therapy 705
Cellular Receptor and Signal Transduction Pathways 706
Angiogenesis Inhibitors 706
Immunotherapy 706
The Future 707
References 707
59: Neoadjuvant Endocrine Therapy in the Treatment of Early-Stage Breast Cancer 709
Key Concepts 709
Background 709
Rationale for Neoadjuvant Hormonal Therapy 710
Patient Selection for Neoadjuvant Endocrine Therapy 711
Endocrine Agents Used in the Neoadjuvant Setting 712
Tamoxifen 712
Aromatase Inhibitors 712
Tamoxifen as Primary Treatment for Invasive Breast Cancer 713
Clinical Trials of Neoadjuvant Hormonal Therapy in Invasive Breast Cancer 713
Utility of Biomarkers in Neoadjuvant Endocrine Trials 714
Clinical Assessment of Response 714
Association of HER2 and Response to Endocrine Therapy 716
Ki67 as a Potential Surrogate Marker of Prognosis 717
Neoadjuvant Endocrine Therapy for DCIS 717
Conclusions 718
References 719
60: Neoadjuvant Systemic Therapy for Breast Cancer 722
Key Concepts 722
Background 723
Neoadjuvant Systemic Chemotherapy 723
Primary Systemic Endocrine Therapy (see also Chap. 59) 725
Primary Systemic Therapy for Her2-Positive Disease 726
Prognostic Factors 726
Evaluation Before and During Treatment 727
Surgical Oncology Considerations 727
Conclusions 729
References 729
61: Adjuvant Systemic Therapy 731
Key Concepts 731
Background 732
Cytotoxic Chemotherapy 732
Combination Chemotherapy 732
Anthracycline-Based Regimens 733
Integration of Taxanes 733
The Role of Anthracyclines in the Taxane Era 734
High-Dose Chemotherapy 735
Targeted Therapy-Trastuzumab 735
Overview of Current Standard Treatment Regimens 736
Special Problems and the Triple-Negative Patient 739
Future Directions 739
References 739
62: Adjuvant Endocrine Therapy 744
Background 744
Tamoxifen 745
Adjuvant Endocrine Therapy in Premenopausal Women 746
Adjuvant Endocrine Therapy in Postmenopausal Women 747
Conclusions 750
References 750
63: Systemic Treatment During Pregnancy 754
Key Concepts 754
Background 755
Epidemiology 755
BRCA1 and BRCA2 Mutation Carriers 755
Diagnosis 756
Mammography 756
Ultrasonography 756
Breast MRI 757
Biopsy 757
Pathology 757
Staging Evaluations During Pregnancy 757
Locoregional Therapy 758
Surgery 758
Radiation Therapy 758
Systemic Therapy 758
Chemotherapy 758
Biologic Agents 759
Endocrine Therapy 759
Side Effect Modulation 759
Granulocyte Colony-Stimulating Factor (GCSF) 760
Monitoring the Pregnancy 760
Breast Feeding 760
Prognosis 760
Short- and Long-Term Complications for the Child 761
Future Pregnancies After Treatment for Breast Cancer 761
Conclusions 762
References 762
64: Breast Cancer in the Elderly 765
Key Concepts 765
Background 766
Assessment of Older Patients 766
Tumor Biology 767
Treatment 768
Treatment: Adjuvant Therapy 768
Metastatic Disease 770
Conclusions 772
References 772
65: Complementary and Alternative Medicine in Breast Cancer 774
Key Concepts 774
Background 775
Diet and Exercise 776
Dietary Supplements 776
Herbal Medicines and Oriental Medicine 777
Acupuncture and Massage Therapy 777
Other Alternative Systems 778
Yoga, Movement and Physical/Meditative Therapies 778
Alternative Approaches Shown to be Ineffective for Breast Cancer 779
Recommendation for Alternative and Complementary Medicine in Breast Cancer 779
References 781
Part XII Radiation Therapy of the Breast 784
66: Basic Principles of Radiobiology 785
Key Concepts 785
Background 786
An Historical Perspective: Early Concepts of Radiobiology 786
Fractionation 786
Oxygen Effect 786
Cell Survival 787
The Four R’s of Radiobiology 788
The Biologic Effects of Radiation 789
DNA Strand Breaks 789
Double-strand Break Repair 789
Homologous Recombination (HR) 790
Syndromes Associated with a Failure in DNA Repair 790
Ataxia Telangiectasia (AT) 790
The p53 Tumor Suppressor Gene and Li-Fraumeni Syndrome 791
Familial Breast Cancer, BRCA1 and BRCA2 791
Survival Curves and Dose-Response Relationships 792
Clinical Applications of Radiobiologic Principles for Breast Cancer 792
Fractionation 792
The UK START 793
Accelerated Partial Breast Irradiation 793
Age and Tumor Recurrence 794
Ductal Carcinoma In Situ (DCIS) 794
HER-2 Overexpressing Breast Cancer 794
Future Directions 795
Conclusions 795
Suggested Reading 796
67: Whole Breast Radiotherapy 798
Key Concepts 798
Background 799
Candidates for Breast-Conserving Therapy 799
Sequencing of Radiotherapy with Chemotherapy and Hormonal Therapy 801
Radiation Treatment 802
Simulation 802
Treatment Planning 803
Treatment 809
Side Effects 810
Future Directions 810
References 811
68: Accelerated, Partial Breast Irradiation Overview 813
Key Concepts 813
Background 813
References 819
69: PBI: Brachytherapy Techniques 821
Key Concepts 821
Background: A New Hypothesis and a Potential Paradigm Shift 821
The Target Volume 823
Indications for Treatment 823
Brachytherapy Techniques 824
Open Freehand Interstitial Catheter Insertion 824
Ultrasound-Guided Supine Catheter Insertion 829
Image-Guided Prone Catheter Insertion with a Special Breast Template 832
CT-Guided Supine Catheter Insertion with a Special Breast Template 838
Balloon Intracavitary Catheter Insertion 844
Complications, Pitfalls, and Solutions 845
Infection (Risk in Our Practice ~10%) 845
Bleeding or Ecchymosis (Less Than 1% of Our Practice) 846
Fat Necrosis (Less Than 10% in Our Practice) 846
Skin Changes (~1% of Our Interstitial Cases, and 5% of MammoSite Cases) 846
Cosmetic Failure (Less Than 5% of Our Practice) 846
Rib Fractures (1% with External Beam Whole Breast RT) 847
Pitfall: Choosing the Right APBI Method for Your Patient 847
The Future of Brachytherapy for Select Breast Cancers 848
References 849
70: Accelerated Partial Breast Irradiation: Balloon Catheter Brachytherapy 851
Key Concepts 851
Background 852
Device Description 852
Patient Selection 853
Breast Lumpectomy Cavity Requirements 853
Device Insertion Techniques 855
Open Cavity Technique 855
Ultrasound-Guided/Lateral Technique (US/Lat) 856
Scar-Entry Technique (SET) 856
Comparison of Insertion Techniques 856
Conclusions 857
References 857
71: APBI 3D Conformal External Beam: The NYU Technique 859
Background 859
EB-APBI Techniques 861
References 864
72: Accelerated, Partial Breast Irradiation with Intraoperative Radiotherapy 866
Key Concepts 866
Background 866
Historical Development of IORT 867
Introduction of Breast IORT 867
APBI with IORT-Recent Use 869
TARGIT 869
ELIOT 871
Other Methods of APBI with IORT 872
Additional Trials with Collimator-Based Breast IORT 872
Additional Trials with Intracavitary Breast IORT 874
Potential Difficulties and Advantages of Breast IORT 876
Summary and Future Directions 877
References 879
73: Postmastectomy Radiation Therapy 881
Key Concepts 881
Background 881
Brief History, Background, and Indications for Treatment 882
Techniques 884
Complications 885
New Developments/Clinical Trials on the Horizon 886
References 886
74: Regional Nodal Radiation as an Alternative to Surgery 888
Key Concepts 888
Background 888
Axillary Radiation in Clinically Node-Negative Breast Cancer 889
Treatment of the Axilla After a Positive Sentinel Node Biopsy 890
Do All Patients with Invasive Carcinoma Require Axillary Treatment? 893
Morbidity of Axillary Radiation vs. Axillary Surgery 893
Axillary Radiation After Mastectomy 894
Conclusions 895
References 895
75: Controversial Indications for Breast Conserving Therapy and Radiation 898
Key Concepts 898
Background 898
Breast Conserving Surgery and Radiation in Carriers of BRCA1/2 Mutations 899
Collagen Vascular Disease 902
Breast Irradiation in Patients Previously Irradiated for Hodgkin’s Disease 904
References 906
Part XIII The Breast Cancer Survivor 908
76: Survivorship 909
Key Concepts 909
Background 909
Common Scenarios 911
Recommendations 912
New Developments/Clinical Trials on the Horizon 915
Websites and Organizations for Your Patients 915
References 916
77: Follow-Up Strategies After Breast Cancer Treatment 917
Key Concepts 917
Background 917
Guidelines for Follow-Up Care 918
Surveillance Breast Imaging 919
Surveillance for Distant Metastasis 920
Detection of Complications from Primary Breast Cancer Therapy 921
Cardiovascular Disease 921
Postmenopausal Symptoms 922
Complications of Tamoxifen 922
Conclusions 923
References 923
78: Pregnancy After Breast Cancer 924
Key Concepts 924
Background 925
Available Data on Effects of Pregnancy After Breast Cancer 925
Clinical Scenarios 927
Risk to Offspring 928
Psychosocial Concerns 928
Research on the Horizon 929
Conclusions 929
References 929
79: The Potential of the Electronic Health Record in the Breast Center 931
Key Concepts 931
Background 931
A Case Study 932
Electronic Health Records Today 932
Ideal Electronic Health Records 933
Real Successes in Electronic Health Records 933
Self-Administered Questionnaires 934
Comprehensive Breast Center Software for the Surgeon 934
Open Source Software 935
Quality of Care Measures 936
Conclusions 937
End Note 937
Disclosure 937
References 937
80: Clinical Breast Examination After Treatment of Breast Cancer 938
Key Concepts 938
Background 939
Principles of Breast Examination After Treatment of Breast Cancer 939
Know What You Seek 939
Pay Attention 941
Think About the Breast in General 943
Keep Meticulous Records to Facilitate Recognition of What Might Change 945
Know Your Limits 947
Know the Limits of the Tests on Which You Rely 948
The Reconstructed Breast 948
Conclusions 949
References 949
81: Breast Imaging Following Breast Conservation Therapy 951
Key Concepts 951
Background 951
Breast Imaging Following Breast Conservation Therapy 953
Mammography 953
Breast Ultrasound 964
Magnetic Resonance Imaging 967
Conclusions 970
Suggested Reading 970
82: Detection and Management of Ipsilateral Breast Cancer Recurrence 972
Key Concepts 972
Background 973
Detection of Local Recurrence 976
Management of Local Recurrence 977
Conclusions 979
References 979
83: Lumpectomy or Mastectomy in Patients Presenting with Metastatic Disease 982
Key Concepts 982
Background 982
Overview of Studies on the Effectiveness of Locoregional Treatment of Metastatic Breast Cancer 983
The Northwestern University Medical School-American College of Surgeons Experience 983
The Edinburgh Breast Unit Experience 984
The Geneva Cancer Registry Experience 984
The University of Texas M. D. Anderson Cancer Center Experience 985
The Baylor College of Medicine Experience 986
Clinical Implications for Metastatic Breast Cancer Patients at Diagnosis 986
Perspectives and Conclusion 987
References 988
84: Managing Breast Cancer-Associated Lymphedema 990
Key Concepts 990
Background 991
Pathophysiology of Breast Cancer-Associated Lymphedema 991
Natural History of Breast Cancer-Associated Lymphedema 992
Diagnosis of Lymphedema 993
Management of Breast Cancer-Associated Lymphedema 995
Future Directions in Breast Cancer Lymphedema Management 997
References 998
85: Chronic Pain After Surgery for Breast Cancer 1003
Key Concepts 1003
Background 1004
Risk Factors for Chronic Pain 1004
Anatomy and Associated Physiology 1004
Description of Common Clinical Scenarios 1005
Comments/Observations/Recommendations 1007
Interventional Approaches 1008
Psychosocial Supportive Approaches 1008
Prognosis 1009
New Developments/Clinical Trials on the Horizon 1009
Advances in Pain Management and Neuropathic Pain 1009
Opportunities to Influence Outcome with Anesthetic Technique 1009
Thoracic Epidural and Paravertebral Blocks 1009
NMDA Antagonists 1010
Intrathecal (IT) Clonidine 1010
Conclusions 1010
References 1010
86: Systemic Treatment of Metastatic Breast Cancer 1012
Key Concepts 1012
Background 1013
Hormone Therapy 1013
Chemotherapy 1015
References 1017
Index 1018