Tumor Board Farnaz Haji, pgy-2 General surgery Elisa cornelius, ms3 Gilberto vega, ms3

Normal Breast Breast profile A ducts B lobules C dilated section of duct to hold milk D nipple E fat F pectoralis major muscle G chest wall/rib cage Enlargement A normal duct cells B basement membrane (duct wall) C lumen (center of duct)

Ductal Carcinoma in situ (DCIS) Ductal cancer cells Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer Normal ductal cell

DCIS

Invasive Ductal Carcinoma (IDC – 80% of breast cancer) Ductal cancer cells breaking through the wall The cancer has spread to the surrounding tissues Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs

Clock Face Model This schematic drawing demonstrates the four quadrants of the breast: upper inner quadrant (UIQ), upper outer quadrant (UOQ), lower inner quadrant (LIQ), and lower outer quadrant (LOQ). The clock face model is superimposed on the four quadrant model to demonstrate how each breast is subdivided within the quadrant model.

Breast Lymph Nodes Rotor node: inter-pectoral

Bi-RADS BI-RADS : Breast Imaging Reporting and Data System Established by the American College of Radiology Putting the findings from mammogram screening (breast cancer diagnosis) into a small number of well-defined categories

BI-RADS

Nottingham Grade Different "scoring systems" available for determining the grade of a breast cancer Nottingham Histologic Score system Three factors that the pathologists take into consideration: The amount of gland formation ("differentiation" or how well the tumor cells try to recreate normal glands) The nuclear features ("pleomorphism" or how "ugly" the tumor cells look) The mitotic activity (how much the tumor cells are dividing)

Nottingham Grade Each of these features is scored from 1-3 Final total score ranging from 3-9 The final total score is used to determine the grade: Grade 1 tumors have a score of 3-5 Grade 2 tumors have a score of 6-7 Grade 3 tumors have a score of 8-9 Higher the value the worse prognosis

Case Presentation

Chief Complaint: Painful and erythematous L. axillary mass

Case Presentation 60 yo Hispanic Female PMHx: Hyperlipidemia, Diabetes, Hypothyroidism PSHx: Hemorrhoidectomy, Hysterectomy FMHx: Negative for breast, ovarian, uterine malig. Social Hx: Denies alcohol, drug or tobacco use Allergies: NKDA presents to hospital for surgical excision of lymph node d/t painful L. axillary lymphadenopathy

Case Presentation ROS: (-) for discharge from nipple, breast deformity, trauma to chest wall, weight loss, nausea, vomiting, SOB, CP, edema

Physical Exam Gen: AOx3, NAD HEENT: PERRLA, no facial asymmetry, no cervical adenopathy, no JVD Resp: CTABL, no wheezing CV: NSR, no murmur, Abdomen: Soft, NT, ND, Normoactive BSx4 MSK: Tender left axillary lymph node, firm, mobile, no nipple discharge, no breast tenderness or structural deformity

Laboratory (8/25/16): Na 140, K 4.6, Cl 103, CO2 31, BUN 11, Crt 0.65, Glc 118, Ca 9.8 PTT 23, INR 1.0, PT 10.7 CBC: WBC 6.0, Plt 275 EKG: (8/24/16)- NSR

4/22/2016 Bilateral screening mammogram

Bilateral screening mammogram 4/22/2016 Bilateral screening mammogram Dense breast parenchyma, scattered punctate amorphous calcifications Left axillary tail 1.8 x 1.6 cm nodular lesion Recommend continued brest eval to r/o occult breast malignancy BI-RADS 0: incomplete, additional imaging needed

7/25/2016 Left breast U/S

7/25/2016 Left breast U/S: Indication: Abnormal mammogram (from April) Left breast axillary tail at 1 O’clock, 2.1 x 1.7 cm pathological adenopathy with irregular vascularities and increase in thickness of the cortex Bi-RADS 4: suspicious abnormality, biopsy should be considered

FNA vs. Excisional bx? Painful, symptomatic excisional bx

9/12/2016 Lymphadenectomy (excisional biopsy) Pathology of L axillary mass:  

9/12/2016 Lymphadenectomy (excisional biopsy) Pathology of L axillary mass: Invasive ductal carcinoma, Nottingham grade 3 of 3, with necrosis and perineural invasion Ductal carcinoma in situ, high grade, cribriform and comedo necrosis types  

PET imaging, skull-mid thigh: 9/28/2016 PET imaging, skull-mid thigh: In this pt. with a known hx of left breast CA s/p biopsy 9/12/16, no typical regions of increased FDG uptake to suggest a region of FDG avid malignancy or metastatic dz. NEGATIVE PET

9/30/2016 MRI Bilateral breasts MRI NEGATIVE

9/30/2016 MRI Bilateral breasts No findings of occult breast malignancy Site of left axillary tail previous resection did not show any abnormal enhancement or mass Bi-RADS 6: known bx, proven malignancy  Occult breast malignancy that is not even delineated by breast MRI or mammogram

Close follow up vs. mastectomy? Axillary mass out by now, no palpable breast mass

10/10/2016 Left modified radical mastectomy Left axillary lymph node dissection Excision of left axillary biopsy scar site

Mod radical: removes the entire breast — including the breast tissue, skin, areola and nipple — and most of the underarm (axillary) lymph nodes. Simple: just breast Radical mastectomy is a surgical procedure in which the breast, underlying chest muscle (including pectoralis major and pectoralis minor), and lymph nodes of the axilla are removed as a treatment for breast cancer.

Procedure Levels 1, 2, and 3 lymph nodes were palpated and sent to pathology as well as the Rotter's node A 10 cm JP drain was placed in the inferior border of the mastectomy cavity and a 7 cm JP drain was placed in the axilla and sutured in place with 3-0 Vicryl suture.

Timeline Summary Painful Left axillary lymph node U/S Axillary: Necrotic Lymph B/L Breast U/S AND Mammo NEGATIVE FNA vs. Excisional Biopsy? Symptomatic/pain Lymphadenctomy Path: DCIS, comedo Invasive Ductal PET, MRI NEGATIVE Close f/u vs. Mastectomy Left modified radical mastectomy Negative node and Breast

Treatment Post-op care: further workup (PET/CT)? Adjuvant systemic therapy? Postmastectomy chest wall RT ? We recommend that all women with axillary nodal metastases and an occult primary breast cancer undergo systemic adjuvant therapy according to published guidelines for stage II primary breast cancer (Grade 1B)-strong recommend-

Henri Matisse