Assessment of Breast Problems

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Assessment of Breast Problems
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Initial assessment

• History
• Examination
• Mammography
• Ultrasound
• FNA
• Core Biopsy

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Accuracy of Investigations
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Changing Biology of Breast Cancer

• Galen, Systemic disease therefore no surgery
• Valsalva, Cancer a local process which spread
  progressively
• Halstead, Local treatment was important
• Baum, Individual treatment necessary
• Who Was correct ?

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Triple Assessment
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Approach to Nipple Discharge
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Nipple Retraction
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ANDI
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Management of Mastalgia
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FNA
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Localisation Biopsy
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Regional Surgery

• Staging
• Regional control
• Survival

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Treatment Plans
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Axillary Staging Procedure
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Surgical Management of the Axilla
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The Importance of the Axilla
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The Importance of the Axilla
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Sentinel Node Biopsy

• Sentinel node first to receive tumour drainage
• If sentinel node is free others should be free
• If sentinel node is involved others probably are

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Sentinel Node Biopsy

• Previously used in
• Penile carcinoma (Cabanas 1977)
• Melanoma (Morton et al)
• As yet no randomised trials for breast cancer
• Currently in UK ALMANAC trial

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Technique
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Known Prognostic Factors
Axillary involvement ER Status Tumour
size Tumour grade HER-2 status Low s-phase
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Combined Modality Treatment
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Cancer During Pregnancy
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Breast Cancer and Pregnancy

• 1 to 3 of every 10,000 pregnancies
• 25 all cancers in women under 35 occur within
  one year or during pregnancy
• 65 of all pregnant women have node positive
  disease

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Combined Modality Treatment
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Survival and Oopherectomy
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DCIS Demographics

• Autopsy incidence
• 4 15 DCIS,
• 1 2 invasive cancer
• Previously
• 1 2 all breast cancers
• Now 25 30 of all cancers detected by
  mammogram

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Changing Nature of DCIS
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History of DCIS

• Before mammography less than 1
• Presentation mass, Pagets disease, nipple
  discharge
• Now 15 20 (of all presentations)
• With screening incidence is 30 40

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Van Nuys Prognostic Indicator
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Final Conclusions of NSABP B-17 (1995 Analysis)

• Invasive and non invasive recurrent disease
  reduced by radiation therapy (by 40-50)
• Tumour size is not a predictor of recurrence
• Margins and comedo necrosis predict recurrence
• All conservatively treated patients benefit from
  radiation

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DCIS Cure May Be Possible
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Inflammatory tumour
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Fungating Reccurrence
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Fungating Tumour
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Fungating Disease
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Management of Disease Relapse
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Mastectomy
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Restore Body Form / Function
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Prosthesis
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Immediate reconstruction Prosthesis
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Immediate Oncoplastic Surgery

• Large breast
• Inferior tumour
• Potential Asymmetry
• Core biopsy

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Latissimus Dorsi Flap
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Latissimus Dorsi Flap
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Tram Reconstruction