What type of chemotherapy is usually used for breast cancer?

Chemotherapy for high-risk tumors with negative lymph nodes should be considered. What makes a tumor “HIGH RISK”?

DCIS

CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil) or CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)

High risk:

1 cm in size Lymphatic/vascular invasion Nuclear grade (high)

S phase (high) ER negative

HER-2/neu overexpression

412 Section II / General Surgery

What are the signs/symptoms?

What are the mammographic findings?

How is the diagnosis made?

What is the most aggressive histologic type?

What is the risk of lymph node metastasis with DCIS?

What is the major risk with DCIS?

What is the treatment for DCIS in the following cases:

Tumor 1 cm (low grade)?

Tumor 1 cm?

What is a total (simple) mastectomy?

When must a simple mastectomy be performed for DCIS?

What is the role of axillary node dissection with DCIS?

Usually none; usually nonpalpable

Microcalcifications

Core or open biopsy

Comedo

2% (usually when microinvasion is seen)

Subsequent development of infiltrating ductal carcinoma in the same breast

Remove with 1 cm margins / XRT

Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)

Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)

Diffuse breast involvement (e.g., diffuse microcalcifications), 1 cm and contraindication to radiation

No role in true DCIS (i.e., without microinvasion); some perform a sentinel lymph node dissection for high-grade DCIS

What is adjuvant for DCIS?

What is the role of tamoxifen in DCIS?

1.Tamoxifen

2.Postlumpectomy XRT

Tamoxifen for 5 years will lower the risk up to 50%, but with increased risk of endometrial cancer and clots; it must be an individual patient determination

What is a memory aid for the breast in which DCIS breast cancer arises?

LCIS

Chapter 56 / Breast 413

Cancer arises in the same breast as DCIS (Think: DCIS Directly in same breast)

What are the signs/ symptoms?

What are the mammographic findings?

How is the diagnosis made?

What is the major risk?

Which breast is most at risk for developing an invasive carcinoma?

What percentage of women with LCIS develop an invasive breast carcinoma?

What type of invasive breast cancer do patients with LCIS develop?

What medication may lower the risk of developing breast cancer in LCIS?

What is the treatment of LCIS?

What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?

There are none

There are none

LCIS is found incidentally on biopsy

Carcinoma of either breast

Equal risk in both breasts! (Think of LCIS as a risk marker for future development of cancer in either breast)

30% in the 20 years after diagnosis of LCIS!

Most commonly, infiltrating ductal carcinoma, with equal distribution in the contralateral and ipsilateral breasts

Tamoxifen for 5 years will lower the risk up to 50%, but with an increased risk of endometrial cancer and clots; it must be an individual patient determination

Close follow-up (or bilateral simple mastectomy in high-risk patients)

LCIS cancer develops in either breast; DCIS cancer develops in the ipsilateral breast

What is the incidence of breast cancer in men?

What is the average age at diagnosis?

What are the risk factors?

1% of all breast cancer cases (1/150)

65 years of age

Increased estrogen Radiation

Gynecomastia from increased estrogen Estrogen therapy

Klinefelter’s syndrome (XXY) BRCA2 carriers

Is benign gynecomastia a risk factor for male breast cancer?

What type of breast cancer do men develop?

No

Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)