Apart from the clumsiness (see previous post for details), I actually observed some pretty cool breast surgery this week.
First, a total axillary clearance following a previous mastectomy and breast reconstruction- as breast malignancy often spreads to the axillary lymph nodes and presumably her nodes were positive for malignant cells so they all had to come out.
Then, there was a U/S wire guided wide local excision and sentinel lymph node biopsy. Now, this is cool. So it’s a small 1cm tumour in the left breast at about 2 o’clock, much too small to actually properly see whilst you’re surgically removing it, so before the surgery they put a wire into the breast via ultrasound guidance and hook it up to the tumour. So, first incision above the areola, the surgeons are essentially following the wire and cutting the breast tissue out where it ends. Then, because it is quite small, we pop down to radiology, get an x-ray of the lump of tissue and make sure that the tumour is inside. Then, the surgeons can carry on with the sentinel node biopsy. The sentinel node is the first lymph node that drains a malignancy and they want to biopsy that one to see if it contains any malignant cells and so, if it’s negative they can leave it at that, but if it’s positive they’ll have to look at all the rest of the lymph nodes and may need a total axillary clearance. But, how do you identify the sentinel lymph node? By a method that is also very cool. Before the surgery they inject a radioactive solution into the breast; this will drain into the lymph nodes and as the sentinel node is the first to drain the breast, it will accumulate the most radioactive dye. Then, they use a Geiger counter, over the breast, like a metal detector, to see where the most radiation is and there you have it, there is your sentinel node. Tadaaa!
Ductal Caricinoma In Situ & Invasive Ductal Carcinoma
Definition: Ductal Carcinoma In Situ (DCIS) is a non-invasive, pre-malignant condition originating in the lactiferous ducts of the breast. Most breast carcinomas are believed to originate as in situ carcinoma before becoming invasive- with 10-50% of DCIS progressing to Invasive Ductal Carcinoma (IDC).
Aetiology/ risk factors:
-R/Fs: Family history; age; uninterrupted oestrogen exposure: early menarche, late menopause, nulliparity (not bearing offspring), first pregnancy > 30yrs, not breastfeeding, HRT; obesity, alcohol, BRCA genes, past breast cancer
-Breast carcinoma affects 1 in 9 women, 40,000 new cases per year in UK -Rare in men
-Peak incidence 40-70 yrs
-Commonest in Western Europe; least common in Japan and Africa
-Ductal adenocarcinoma is the most common type of breast cancer (80%)
-60-70% of breast cancers are oestrogen receptor +ve, conveying better prognosis
~ 30% over-express HER2, associated with aggressive disease and poorer prognosis
–Systemic features: weight loss, anorexia, bone pain (due to metastatic spread)
-Usually painless (unless inflammatory carcinoma)
-Hard and gritty feeling
-May be immobile (held within breast tissue), tethered (attached to surrounding breast tissue or skin) or fixed (attached to chest wall)
-Ill-defined, irregular with poorly defined edges
–Nipple abnormalities (may be affected by underlying carcinoma):
–destroyed, inverted, deviated
–bloody, often single duct discharge (whereas duct ectasia usually gives rise to green/brown/ red discharge, often from multiple ducts and bilateral)
-dimpling, puckering, tethering or colour changes caused by carcinoma beneath skin
-peau d’orange– orange peal appearance resulting from lymphoedema of the skin, suggesting local lymph node involvement or locally advanced cancer
-skin ulceration or fungation of carcinoma through skin- late presentation
-extensive inflammatory changes of the skin- associated with inflammatory carcinoma (aggressive form)
–Systemic features: jaundice, malignant pleural or pericardial effusions, anaemia
→ DCIS is normally asymptomatic and diagnosed on routine mammography. It less commonly may present with a breast lump or nipple discharge.
1) History and clinical examination
2) Imaging: mammogram (Mediolateral Oblique & Craniocaudal view +/- spot compression & magnification view) and U/S if > 35 yrs (40 in the hospital I’m at), U/S if < 35 yrs.
-DCIS is seen as micro-calcification on mammography (unifocal or widespread)
-Features of malignancy include branching or linear micro-calcifications and spiculated (spiky) lesions.
3) Cytology/ histology: by Fine Needle Aspiration cytology or core biopsy.
-For new solid lumps (U/S guided, preferably) core biopsy
-Core biopsy can find oestrogen and HER2 receptor status and differentiates between DCIS and IDC:
DCIS = non-invasive with basement membrane intact
ICD = invaded the basement membrane
–Sentinel lymph node biopsy– inject radioactive tracer near breast lesion, nuclear scan identifies sentinel node and node biopsied to detect spread
–Staging: CT CAP (chest, abdo, pelvis), PET or bone scanning for mets
–Bloods: FBC (anaemia?), U&Es, bone profile, LFTs, tumour marker = CA-15-3
STAGE 1-Confined to breast, mobile
STAGE 2- Growth confined to breast, mobile, lymph nodes in ipsilateral axilla
STAGE 3- Tumour fixed to muscle (but not chest wall), ipsilateral lymph nodesmatted (adherent to each other), and may be fixed (to adjacent tissue), skin involvement larger than tumour
STAGE 4- Complete fixation of tumour to chest wall, distant metastases.
Also TNM Staging:
T1 < 2cm, T2 2-5cm, T3 > 5cm, T4- fixity to chest wall or peau d’orange
N1- Mobile ipsilateral nodes N2- Fixed Nodes
M1- Distant metastases