Do you you know any good web site about surgery of breast cancer?Regards
breast cancer site
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What do you specifically want to know?
The American Society of Breast Surgeons (ASBS) has lots of statements on treatment, training, etc. http://www.breastsurgeons.org
The National Comprehensive Cancer Network (NCCN) also has updated guidelines on treatment, with decision trees: http://www.nccn.org
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The NCCN site is probably the easiest to manuever around if you don't have a textbook available. If you can access a medical library or borrow one, the best, easiest to understand book is the MD Anderson Handbook of Surgical Oncology. The first two chapters are about the management of breast cancer. http://www.amazon.com/M-D-Anderson-...ef=sr_1_1/002-8541072-6407262?ie=UTF8&s=books It is new, easy to understand and offers info on current controversies in the field.
Remember when you talk about "breast cancer" you are talking about a large range of tumors with different biological behaviors. It is likely easiest for you to divide your discussion into the Surgical Management of Non-Invasive and Invasive Breast Cancers. So essentially DCIS/LCIS vs IDC/ILC and the "others" (ie, tubular, papillary, metastatic, etc.) We don't necessarily treat all patients with DCIS the same, just as we don't treat all patients with lobular carcinoma the same. However, surgically things haven't changed as much since the advent of Breast conservation as things have in the field of medical oncology (which is really focusing on tumor biology, including reecptor status).
Then you'll need to talk about Breast Conserving Treatment (BCT) (ie, partial mastectomy/lumpectomy/quadrantectomy/tylectomy) vs Mastectomy (simple vs Modified Radical. The radical Halstead or Patey operations are not really done anymore because there is no evidence that it improves survival or decreases local recurrence over the MRM).
BCT vs Mastectomy decision tree comes down to a few factors which the surgeon needs to consider:
Favors BCT
relatively small tumors (based on breast size)
single quadrant
able to tolerate, get to Rad Tx
Can get clear margins
Patient preference
Favors Mastectomy
relatively large tumor
multi-centric
Unable to tolerate radiation
Multiple attempts with + margins
Patient preference
Remember that the data from NSABP-32 found that partial mastectomy + radiation treatment = mastectomy in terms of overall survival. There is an increased risk of recurrence in the BCT group over mastectomy, but radiation reduces this by 50%. If you add hormonal blockade (such as with Tamoxifen or Raloxifene) for the premenopausal women or with an Aromatase Inhibitor (such as Femara, Aromasin, etc.) for the post-menopausal, it further reduces the risk of local recurrence yet another 43%. The risk of local recurrence is NOT 0% with a mastectomy - some tissue is left behind or can recur in the scar.
You'll also perhaps want to talk about the management of the axilla. Technically, in situ carcinoma does not have the ability (yet) to spread so the "board answer" is that you leave the axilla alone in DCIS or LCIS. However, I will tell you that in practice, women with large palpable DCIS/LCIS tumors, "microinvasion" in a DCIS/LCIS (which is invasion in my book) or high-grade DCIS will get a sentinel lymph node biopsy and possible axillary clearance. Patients with clinically palpable nodes can undergo frozen section of the removed node and then axillary clearance if the FS is positive.
Patients having a MRM get the axilla cleared at the same time, as do patients with positive sentinel nodes (SLN). Patients with invasive cancer need their axilla staged - so they get SLN biopsy even if they are getting BCT. The number of nodes determines the stage of the cancer and may influence treatment (medical oncology stuff).
Finally, while it is not surgical management, in practice patients over 70, especially those with multiple medical problems, may not be offered radiation routinely after BCT as the risk of recurrence given their lifespan is low.
Does that make sense? Discuss invasive vs non-invasive cancer, when you would do BCT vs mastectomy, and what to do about the axilla. For extra points you can talk about prophylactic mastectomies in gene positive patients, patients with lobular cancer and patients with high anxiety; then there is the issue of reconstruction - which is almost always done immediately these days unless the patient is undergoing radiation (in which case its probably better to wait until rads is done to preserve the flap or give the best cosmetic appearance).
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Great concise summary by Kimberli. I'll add that it's hard to talk about "surgical treatment of breast cancer" in isolation without talking about adjuvant treatment, in particular RT. This is because it's well established that BCT (i.e. lumpectomy + RT) is equivalent to MRM in terms of local recurrence and overall survival rates. At least 6 large RCTs show this.
It's useful to think of management of the breast (local therapy) separately from management of the axilla (regional therapy). The idea is that cancer spreads in a stepwise fashion, first from the primary tumor to the regional draining lymph nodes, then distantly. This is the idea behind sentinal lymph node biopsy -- to more accurately stage how far cancer has spread and be able to spare those with localized disease from the morbidity of a full lymphadenectomy.
Anyway, if you are doing a talk about surgical treatment, i'd suggest including a definition of the anatomy -- the borders of the breast dissection, the borders of the axillary dissection, relevant nerves -- effects of injury, complications (lymphedema, wound infection, flap necrosis).
Another good site is the National Cancer Institute. www.cancer.gov
Click on Breast Cancer for Health Professionals.
It's useful to think of management of the breast (local therapy) separately from management of the axilla (regional therapy). The idea is that cancer spreads in a stepwise fashion, first from the primary tumor to the regional draining lymph nodes, then distantly. This is the idea behind sentinal lymph node biopsy -- to more accurately stage how far cancer has spread and be able to spare those with localized disease from the morbidity of a full lymphadenectomy.
Anyway, if you are doing a talk about surgical treatment, i'd suggest including a definition of the anatomy -- the borders of the breast dissection, the borders of the axillary dissection, relevant nerves -- effects of injury, complications (lymphedema, wound infection, flap necrosis).
Another good site is the National Cancer Institute. www.cancer.gov
Click on Breast Cancer for Health Professionals.
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Good idea to start with discussion of relevant anatomy - includes a couple of well-loved med student pimp questions:
borders of the axilla?
what happens if you bag an intercostal brachial/long thoracic or thoracodorsal nerve?
Agreed that you need to give some perfunctory coverage of adjuvant and perhaps even neoadjuvant tx, including radiation tx, chemo and hormonal manipulation (which would include oophorectomy in high risk patients as well as chemical manipulation).
Depends on how much time you have.
borders of the axilla?
what happens if you bag an intercostal brachial/long thoracic or thoracodorsal nerve?
Agreed that you need to give some perfunctory coverage of adjuvant and perhaps even neoadjuvant tx, including radiation tx, chemo and hormonal manipulation (which would include oophorectomy in high risk patients as well as chemical manipulation).
Depends on how much time you have.
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What do you guys do in terms of pre-operative MRI on patients with breast cancer? We only get these occasionally, but its seems like this may be standard of care in the future, since it may up the tumor from a single quadrant to multi-centric, changing surgical management.
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Kimberli, feel free to correct me if i'm wrong, but as I understand it MRI has 5 established roles:
1) determining extent of locally-advanced disease (i.e. T3, T4, or inflammatory ca)
2) evaluating response to neoadjuvant treatment
3) detecting recurrence in those treated with BCT, specifically differentiating recurrence from radiation fibrosis (ref: Dao TH, Radiology 1993, 187:751-755)
4) detecting implant rupture
5) detecting occult breast primary in pts presenting with axillary mets of unknown origin
So in terms of pre-op MRI, 1) 2) and 5)....
Our institution is conducting a trial to look at screening MRI in high risk women.... currently investigational only.
WBC raises a good question -- detecting multicentric disease... any role for routine MRI for something like ILC which is more likely to be multicentric?
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As Boston notes, there are specific categories in which MRI is recommended.
We have a large population of young and BRCA positive patients, so the most common use of MRI in our practice is:
1) surveillance in high risk patients - we alternate q 6 months btwn mammo and MRI followed by...
2) the young patient with extremely dense breasts, negative mammo and u/s but palpable mass
3) patients with a diagnosis of lobular disease; as boston notes, its more likely to be multicentric or bilateral, so there is definitely a role to use it in this case
4) patients with LABC
5) evaluating response to neoadjuvant - although we more commonly use mammo if the disease was clearly seen on that modality.
I'm not convinced that we are ready to use MRI as a screening tool for patients outside of the high-risk categories. Frankly, our radiologists admit that there is not enough experience in reading breast MRI to be able to reliably distinguish between findings of concern and those that are likely to be benign. Patients screened with MRI need to know that they are trading off the risk of having more benign biopsies for finding something malignant.
We tend not to be the first person seeing a patient with suspected implant rupture, so these tend to be ordered by PRS, although it certainly is the modality you want to use if you suspect this on physical exam.
For MOST patients, I still think digital mammography (which really is the standard of care or at least should be) is good enough to find multicentric diseases. Obviously patients at high risk or with extremely dense breasts do not fall into this category - but they comprise a minority of breast cancer patients (although working here you would get the impression that every 25 year old has breast cancer).
We have a large population of young and BRCA positive patients, so the most common use of MRI in our practice is:
1) surveillance in high risk patients - we alternate q 6 months btwn mammo and MRI followed by...
2) the young patient with extremely dense breasts, negative mammo and u/s but palpable mass
3) patients with a diagnosis of lobular disease; as boston notes, its more likely to be multicentric or bilateral, so there is definitely a role to use it in this case
4) patients with LABC
5) evaluating response to neoadjuvant - although we more commonly use mammo if the disease was clearly seen on that modality.
I'm not convinced that we are ready to use MRI as a screening tool for patients outside of the high-risk categories. Frankly, our radiologists admit that there is not enough experience in reading breast MRI to be able to reliably distinguish between findings of concern and those that are likely to be benign. Patients screened with MRI need to know that they are trading off the risk of having more benign biopsies for finding something malignant.
We tend not to be the first person seeing a patient with suspected implant rupture, so these tend to be ordered by PRS, although it certainly is the modality you want to use if you suspect this on physical exam.
For MOST patients, I still think digital mammography (which really is the standard of care or at least should be) is good enough to find multicentric diseases. Obviously patients at high risk or with extremely dense breasts do not fall into this category - but they comprise a minority of breast cancer patients (although working here you would get the impression that every 25 year old has breast cancer).
I believe you meant to say NSABP B-6. i believe B-32 is the sentinel node trial for which only preliminary results are available.
The NSABP website does a nice job at summarizing all their trials
http://www.nsabp.pitt.edu/NSABP_Protocols.asp#treatment closed
For a great resouce i like the Canadian Breast Guidelines. They are very well organized, evidence based, and are fully referenced and includes a version for patients that is in normal language and easy for them to understand.
http://www.cmaj.ca/cgi/content/full/158/3/DC1
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D'oh...thanks I DID mean to say B-6; I was just discussing B-32 with my PD and guess it was stuck in my mind.
Thanks for the additional guidelines; the CMAJ ones are also very helpful.
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