1. Breast Alicia M. Terando, MD Assistant Professor of Surgery
LSI Part 2
Understanding Patients with Reproductive and Surgical Needs
Alicia M. Terando, MD
Assistant Professor of Surgery
AUDIO NARRATION:
Good morning! My name is Alicia Terando and I am a surgical oncologist here at the James Comprehensive Cancer Center. My clinical interests include management of soft tissue malignancies including breast cancer and melanoma. The topic of today’s module is “Breast”. Breast cancer itself is the most common cancer in women, and breast complaints in general are a very frequent patient presentation that you will surely encounter no matter your choice of specialty. It is important to have a general appreciation of what is normal and what is not, how to do a breast exam, and to understand the basic work-up of breast complaints and when to refer to a surgeon.
Please feel free to contact me directly with any questions you may have after completing this module.

2. Learning Objectives
Understand the importance of breast screening in disease prevention
Assess symptoms and physical exam findings of various benign and malignant conditions of the breast
Develop competency in performing a clinical breast exam
Understand the diagnostic work-up of different breast pathologies including imaging and procedures
Differentiate between benign and malignant diseases of the breast
Describe the initial management of benign and malignant conditions of the breast
AUDIO NARRATION:
“These are the learning objectives for this module. Upon completion of the module, you should be able to accomplish each of these objectives.”

3. Foundational Science – Breast Anatomy
The breast parenchyma is made up of lobules which make milk, and the ducts that transport milk to the nipple. These structures are embedded in stroma containing fat and fibrous connective tissue. The upper outer quadrant of the breast contains a greater volume of tissue than any other quadrant.
UOQ contains a greater volume of tissue than any other quadrant.

4. Foundational Science – Breast and Chest Wall Anatomy
Depicted on the left is the breast and chest wall anatomy. Note that the breast sits on the pectoralis major muscle, and under this is the pectoralis minor. There are three levels of axillary lymph nodes, defined by their location with respect to the pectoralis minor muscle. Level I is lateral/inferior to the pectoralis minor, level II is behind the pectoralis minor, and level III is medial to the pectoralis minor.
Depicted on the right is a schematic of the lobules and ductal anatomy.

5. Foundational Science – Breast Physiology
Estrogen: ductal development
Progesterone: differentiation of epithelium and lobular development
Prolactin: primary stimulus for lactation
LH and FSH from anterior pituitary regular release of estrogen and progesterone from ovaries
GnRH from hypothalamus regulates release of LH/FSH
The breast tissue is affected by the hormonal environment. Estrogen is responsible for ductal development, and progesterone is responsible for differentiation of the epithelium as well as lobular development. Prolactin is the primary stimulus for lactation.

6. Breast Cancer Screening Guidelines - American Cancer Society
Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health
Clinical breast exam (CBE) ~ every 3 years for women in their 20’s and 30’s, and every year for women age 40 and over
Women should know how their breasts normally look and feel, and they should report any breast changes promptly to their health care provider. Breast self exam (BSE) is an option for women starting in their 20’s
Annual mammography is recommended for women starting at age 40, and continuing for as long as a woman is in good general health. Clinical breast examination is recommended every 3 years for women in their 20's and 30's, and every year for women age 40 and over.
Women should know how their breasts normally look and feel. This is what we refer to as breast awareness. Women should report any breast changes promptly to their health care provider. Breast self examination is an option for women starting in their 20's.

7. Screening Mammography
33% reduction in mortality in women > 50 years old
Relatively low specificity
Only 10-30% of biopsies of suspicious lesions found on screening mammography are actually malignant
Screening mammography has been credited with a 33% reduction in mortality from breast cancer in women over 50 years old. However, mammography has a relatively low specificity. Only 10-30% of biopsies performed of suspicious lesions that are found on screening mammogram are actually malignant.

8. Common Clinical Presentations of Breast Diseases
Abnormal mammogram
Generalized lumpiness and discomfort
Palpable Mass
Skin changes
Dimpling
Redness/induration
Peau d’orange
Nipple discharge
Character – serous, bloody, milky
Onset – spontaneous vs expressed
Location – unilateral vs bilateral, single vs multiple ducts
Axillary mass
Here are some common clinical presentations of breast diseases.
Many women present with no particular complaints, but for evaluation of an abnormal mammogram. Others may present for evaluation of generalized lumpiness and discomfort, or a palpable mass.
Less frequently, women present due to skin changes such as dimpling of the skin, redness, or thickening. Peau d'orange is a thickening of the skin that has the appearance of an orange peel and is one of the classic presentations of inflammatory breast cancer.
Nipple discharge is a relatively common presentation, and it is important to determine the character, onset and location of the discharge as this is important in determining if the discharge is physiologic or pathologic.
An axillary mass in a woman is breast cancer until proven otherwise, so a new onset axillary mass will often be referred to a breast surgeon.

9. Evaluation of Breast Problems
Complete History and Physical Exam
Particular attention to breast exam
Always evaluate nodal basins
Diagnostic imaging
When evaluating breast problems it is important to obtain a complete history and physical exam with particular attention to the breast exam. Always remember to evaluate the nodal basins. This includes the cervical, supraclavicular and axillary nodal basins. Diagnostic imaging is then performed based on the history and physical exam findings.

10. Risk Factors for Breast Cancer
Early menarche (age < 12)
Late menopause (age > 50)
Nulliparous
Age > 30 at first childbirth
Obesity
Family history
Atypical hyperplasia, LCIS
Risk factors for breast cancer include long reproductive life, with either early menarche or late onset of menopause. Reproductive risk factors include nulliparity and age over 30 at first childbirth. Obesity is a risk factor, as androgens are converted to estrogens in the fatty tissues of the body. Family history of breast cancer is important to consider, including the number of affected relatives, especially first degree relatives, and the age of onset of their cancers. High risk lesions that predispose one to a higher risk of developing breast cancer in the future include atypical hyperplasia and lobular carcinoma in situ.

11. Breast Examination Visual inspection with patient seated
Arms over head
Hands on hips, pressing tightly
Assess for symmetry in shape, contour
Assess skin changes, particularly erythema, retraction, dimpling, nipple changes
Palpation with patient seated
Examination of cervical, supraclavicular, axillary lymph nodes
Palpation with patient lying down
Ipsilateral hand overhead
Pattern – vertical strips, concentric circles, wedges; cover entire breast
Using pads of fingers, palpate at superficial, intermediate, and deep level
Here are the steps to performing a complete breast examination.
First is visual inspection with the patient seated. The breasts are inspected while the patient places her arms up above her head, and then her hands on her hips, pressing tightly. During these maneuvers, you will assess the breasts for symmetry in shape and contour, as well as assess for skin changes such as erythema, retraction, dimpling, or nipple changes.
With the patient seated, you can then palpate the cervical, supraclavicular and axillary lymph nodes.
Finally with the patient lying down, have her place the ipsilateral hand over her head. Palpate the entire breast using some kind of pattern that you can remember such as vertical strips, concentric circles or wedges, taking care to palpate the entire breast. While doing this, remember to use the pads of your fingers and palpate at a superficial, intermediate and deep level.
Saslow D, et al: CA Cancer J Clin 2004:54:

12. Documentation of Breast Findings
Describe location of findings
axis of breast as if looking at a clock (eg, 12:00)
Location relative to the nipple or areolar margin (eg, 2cm from areolar margin, or subareolar)
For larger or diffuse findings, describe quadrant (eg, upper outer quadrant)
Masses
Size
Location
Character
Well circumscribed vs ill-defined
Soft vs firm vs hard
Mobile vs fixed
When documenting breast findings, describe the location of findings. We typically report the axis of the breast as if looking at a clock, for example, "12:00 axis of the breast". Note the location of the finding relative to the nipple or areolar margin. For larger or diffuse findings, indicate the quadrant where the findings are located.
For masses, indicate the size, location and character, for example, is it well circumscribed vs indistinct or ill-defined? Soft vs firm vs hard? Mobile vs fixed? If fixed, fixed to the underlying pectoralis? Fixed to the skin?

13. Skin dimpling

14. Peau d’orange
this is an example of peau d'orange. notice how the skin looks just like an orange peel. This finding is due to swelling in the skin. The hair-follicles are fixed and the skin swells in between the follicles, resulting in this appearance. Although this is a classic presentation of inflammatory breast cancer, post-treatment swelling of the breast, for example after surgery and/or radiation therapy, can cause the skin to look like this.

15. Diagnostic Imaging Mammogram Ultrasound MRI
Findings: calcifications, architectural distortion, masses
Ultrasound
Further characterization of masses or palpable findings
MRI
Adjunctive screening method useful in cases of extremely dense breast tissue, patients with elevated breast cancer risk (eg, hereditary breast and ovarian cancer syndromes)
Diagnostic imaging is used to further characterize findings on physical exam or screening mammogram.
Findings noted on mammogram include calcifications, architectural distortion, and masses.
Ultrasound is typically used for further characterization of masses or palpable findings. Note that ultrasound can not detect calcifications.
MRI is an adjunctive screening method useful in cases of extremely dense breast tissue, and in patients with elevated breast cancer risk, for example hereditary breast and ovarian cancer syndromes.

16. Breast Imaging Reporting And Data System (BIRADS)
Standard descriptors to identify findings including masses, calcifications, and associated changes 1 2 3 4 5
Incomplete assessment
Negative
Benign finding
Probably benign
Suspicious
Highly suggestive of
malignancy
Additional work up
Routine screening
Short term follow-up
Biopsy urged
Appropriate action to be taken
Category
Assessment
Recommendations
The Breast Imaging Reporting and Data System or BIRADS is a classification scheme with standard descriptors to identify findings including masses, calcifications and associated changes.
BIRADS-1 is normal
BIRADS-2 is definitely benign, for example, a simple cyst.
Routine screening is recommended for BIRADS-1 and 2 studies.
BIRADS-3 indicates that a finding is probably benign, and short interval follow up, typically in 6 months with repeat imaging, is recommended.
BIRADS-4 indicates that a lesion is suspicious and biopsy is recommended.
BIRADS-5 is highly suggestive of malignancy
BIRADS-0 is an incomplete assessment. An example is of a finding of new calcifications on a screening mammogram for which additional mammogram imaging is recommended (for example, magnification views, true lateral views, or an ultrasound).

17. Stellate Mass on Mammogram

18. Clustered Microcalcifications on Mammogram

19. Ultrasound Image of a Simple Cyst
here is an ultasound image of a simple cyst. Notice that the edges are very well circumscribed. The lesion is anechoic, or entirely black on ultrasound, which indicates that this is fluid. Posterior to the cyst, we see acoustic enhancement, which is the whiter area.

20. Methods of Diagnosis Palpable lesion Non-palpable lesion
fine needle aspiration (FNA)
Core/Tru-cut biopsy
excisional biopsy
Non-palpable lesion
stereotactic biopsy
ultrasound-guided core needle biopsy
wire/needle localized excisional biopsy
Abnormal Skin/Skin Lesion
Punch biopsy
Methods of diagnosis:
For a palpable lesion, you can perform a fine needle aspiration, a core or Tru-cut biopsy, or an excisional biopsy. In the majority of cases, breast lesions are sampled using a core needle biopsy. Our standard of care is to always perform a needle biopsy prior to surgical excision. A fine needle aspiration is performed in special situations, for example a patient with numerous co-morbidities on anticoagulation and we need a quick diagnosis. Or, if you suspect a lump is a cyst, a fine needle aspiration can be performed. Aspiration of non-bloody fluid and resolution of the mass is diagnostic. An excisional biopsy is typically reserved for cases when a needle biopsy is discordant with the physical exam findings, or a high-risk lesion is found on needle biopsy.
for a non-palpable lesion, stereotactic biopsies are performed for lesions only seen on mammogram. Ultrasound core needle biopsy is both easier for the patient as well as easier to perform, but of course, you can only perform an ultrasound guided biopsy if the lesion is visualized by ultrasound. A wire/needle/or radioactive seed localized excisional biopsy is performed when either a core needle biopsy is not technically feasible, or when a high-risk lesion is found on needle biopsy.
Abnormal skin lesions can be easily sampled using a punch biopsy device.

21. Ultrasound-Guided Core or Mammotome Biopsy

22. Stereotactic Breast Biopsy
Here is the set up for a stereotactic core needle biopsy. Again, this is typically performed for suspicious calcifications. The woman lies prone on the table and the breast is placed through an aperture. The breast is placed in compression and the needle is guided to the appropriate coordinates under direct mammographic imaging.

23. Benign Breast Diseases
Infections – mastitis, abscess
Fibrocystic Change
Proliferative –
Fibroadenoma
Radial scar
Intraductal papilloma
Atypical hyperplasia
LCIS
Benign breast disease include:
infections - mastitis, or abscess
fibrocystic changes
and proliferative lesions such as fibroadenomas, radial scars, intraductal papillomas, atypical hyperplasia and lobular carcinoma in situ

24. Infections Mastitis Breast abscesses
Generalized cellulitis of the breast
Treated with antibiotics
Breast abscesses
Present with point tenderness, erythema, and fever
Generally related to lactation
Non-lactational abscesses more frequent in smokers
Caused by Staph (usually require I&D) or Strep (often more diffuse, superficial infection treated with local wound care and abx)
Mastitis is generalized cellulitis of the breast and is typically treated with antibiotics.
Breast abscesses present with point tenderness, erythema and often fever. They are generally related to lactation. Non-lactational abscesses are more frequent in smokers.

25. Fibrocystic Disease
Term that describes a wide spectrum of breast changes
The “lumpy” breast—nodularity with or without pain
Hormonally mediated
Fibrocystic disease or fibrocystic change is a term that describes a wide spectrum of breast changes. Clinically, this is a lumpy breast, a lot of nodularity either with or without pain and tenderness. We believe that this is hormonally mediated, and symptoms are often exacerbated by intacke of methylxanthine-containing compounds (ie caffeine).

26. Cysts Can be drained with 21-gauge needle.
If fluid is non-bloody and mass resolves completely, fluid discarded
If bloody or solid component, fluid may be sent for cytology and biopsy may be warranted
Breast cysts usually present as a lump that fluctuates in size and becomes tender around the time of the menstrual cycle. Simple cysts have a classic appearance by ultrasound as we saw earlier. These can be easily drained with a 21 g needle. if the fluid is non-bloody and the mass resolves completely, this is diagnosic of a cyst and the fluid can be discarded. If the fluid is bloody or it does not resolve completely, fluid may be sent for cytology and biopsy may be warranted.

27. Fibroadenoma Well-circumscribed, mobile, rubbery nodule
Most common in women in their 20s
Biopsy will provide a diagnosis
Lesions may be removed or observed with serial ultrasound to assure stability
Fibroadenomas are well-circumscribed, mobile, rubbery nodules that are most common in women in their 20's. Biopsy will provide a diagnosis. Lesions may be removed or observed with serial ultrasound to assure stability.

28. Other Proliferative Lesions
Intraductal papilloma
Radial Scar
Atypical hyperplasia
4-5 fold increase risk of breast cancer
Chemoprevention with tamoxifen is an option
LCIS
Usually diagnosed after biopsy performed for other reasons – no specific imaging characteristics
Marker of increased risk of either ductal or lobular cancer, either breast
Other proliferative lesions:
An intraductal papilloma is a wart-like growth that occurs within a duct. These lesions often present with nipple discharge or as a mammographic nodule.
A radial scar is a proliferative lesion that, when diagnosed by needle biopsy, is then surgically excised. Histologically, it is difficult to rule out the presence of a cancer with a small needle biopsy showing a radial scar.
Atypical hyperplasia is process associated with a 4-5 fold increased risk of breast cancer. Chemoprevention with tamoxifen, a selective estrogen receptor modulator, is an option.
Lobular carcinoma in situ is usually diagnosed after a biopsy is performed for other reasons. There are no specific imaging characteristics associated with LCIS. This is actually NOT cancer but rather a marker of increased risk of either ductal or lobular cancer, in either breast. Chemoprevention with tamoxifen is an option.
When any of these diagnoses is obtained by needle biopsy, surgical excision is recommended to rule out associated, yet unsampled cancer.

29. Foundational Science – Histopathology

30. Non-invasive breast cancer (DCIS)
DCIS/intraductal carcinoma
Arises from duct epithelium in region of terminal ductal lobular unit
Malignant cells are confined to mammary ducts, basement membrane intact
Currently accounts for 15% of all breast cancers
Non-invasive breast cancer, Ductal carcinoma in situ (DCIS). This entity arises from the duct epithelium in the region of the terminal ductal lobular unit.
Malignant cells are confined to mammary ducts and the basement membrane remains intact.
This currently accounts for 15% of all breast cancers.
In the figures below, note how the abnormal cells fill the ducts entirely, but do not spill out of the ducts. In the figure on the right, the duct on the far right exhibits central necrosis.

31. Non-invasive breast cancer (DCIS)
Usually presents as an abnormal mammogram with clustered calcifications
Nodal metastases are rare (1%), likely associated with unrecognized microinvasion
After complete excision, 15% will develop a recurrence (1/2 invasive ca)
DCIS usually presents as an abnormal mammogram with clustered calcifications. Nodal metastases are rare, approximately 1%, and are likely associated with unrecognized microinvasion. After complete excision, approximately 15% will develop a recurrence, and half of recurrences will be invasive cancer.
The figure here illustrates the cribriform pattern of DCIS.

32. Management of Ductal Carcinoma in Situ (DCIS)
Usually a nonpalpable mammographic finding (i.e., microcalcifications)
Treatment  lumpectomy (negative margins) with radiation therapy or total mastectomy
Evaluation of the axillary lymph nodes is generally not necessary*
Tamoxifen reduces risk of recurrence and subsequent development of invasive cancer
After the diagnosis of DCIS is made, treatment consists of either
1. lumpectomy with negative margins followed by radiation therapy or
2. mastectomy
Evaluation of the axillary lymph nodes is generally not necessary. However, if a mastectomy is being performed for DCIS, sentinel lymph node biopsy is generally recommended because if an invasive cancer is found on final pathology, it is not possible to go back and perform a sentinel lymph node biopsy (because the breast is gone) and the patient will require an axillary lymph node dissection.
You may also consider performing a sentinel lymph node biopsy for DCIS in certain situations where there is an increased likelihood of an unsampled invasive cancer, such as a large area of calcifications, a mass on mammogram, high-grade DCIS and/or comedonecrosis, or microinvasion.
Tamoxifen therapy reduces the risk of recurrence and subsequent developement of invasive cancer.

33. Invasive breast cancer
Most common type is infiltrating ductal carcinoma (75%)
Less common variants of ductal
Medullary (6%)-better prognosis
Tubular (2%)-excellent prognosis
Colloid (1-2%)-better prognosis
Invasive lobular (10%)
Indistinct margins, extensive infiltration
Harder to detect mammographically
Significant incidence of multicentricity
Invasive breast cancer.
The most common type of invasive breast cancer is infiltrating ductal carcinoma. Less common variants of ductal carcinoma include medullary carcinoma, tubular carcinoma and colloid carcinoma.
Invasive lobular cancer accounts for approximately 10% of breast cancers and is characterized by indistinct margins, and extensive infiltration. It is harder to detect mammographically and there is a significant incidence of multicentricity.

34. Invasive Ductal Carcinoma
Grade 1
Modified Bloom Richardson Score:
Tubules 1-3 (yes tubules -> no tubules)
Nuclei 1-3 -> (less atypia-> more atypia)
Mitoses 1-3 (fewer mitoses -> more mitoses
Grade 2
Here are some examples of invasive ductal carcinoma. The modified Bloom Richardson score is used to grade breast cancers. There are three components to this, whether or not the tumor makes tubules, how atypical the nuclei are, and how many mitoses are present. Higher score = higher grade.
Grade 3

35. Invasive Lobular Carcinoma

36. Markers Estrogen and progesterone receptors Her-2/neu
70-80% of invasive and nearly all in situ cancers are ER positive
About 60% of ER positive tumor are also PR positive
Her-2/neu
Epidermal growth factor
Overexpressed in 20-30% of breast cancers
There are three markers that we look at for every breast cancer: ER/PR and Her2/neu. The receptor profile for breast cancer is very important for making treatment decisions.

37. Management of Invasive Breast Cancer
Surgery
To provide local control
To stage/identify those at higher risk for recurrence
Radiation Therapy
After BCT, 5000 cGy for 6 weeks ± boost to lumpectomy bed
Indicated after mastectomy when large tumor/≥4 nodes
Adjuvant Systemic Therapy
systemic chemotherapy
Endocrine therapy for ER positive tumors (tamoxifen, aromatase inhibitors)
Immunotherapy (traztuzumab for Her2/Neu + tumors)
Management of invasive breast cancer
Surgery:
lumpectomy vs mastectomy - for local control
sentinel lymph node biopsy - to stage/identify those at higher risk for recurrence
Radiation therapy:
Always after lumpectomy, 5000cGy for ~ 6 weeks +/- electron boost to lumpectomy cavity
Indicated after mastectomy in cases of larger tumors, four or more positive nodes.
Adjuvant systemic therapy:
chemotherapy (adriamycin/cytoxan followed by taxol is typical)
endocrine therapy for hormone receptor positive tumors (tamoxifen for premenopausal, aromatase inhibitor for post-menopausal)
immunotherapy - traztuzumab/pertuzumab for Her2/neu positive tumors
In general:
Triple-negative cancers > 5mm get chemo
Her2/neu positive cancers> 5 mm get chemo
for ER/PR tumors, >1cm, node negative, we will check an Oncotype DX, 21 gene assay that will give us a recurrence score, helps to determine who in this population will benefit from chemotherapy

38. Foundational Science – Breast and Axillary Anatomy

39. Surgical Management of Breast Cancer
Halsted’s Radical Mastectomy-1880’s through 1970’s
Removes breast, pectoralis major, level I-III axillary lymph nodes
Modified Radical Mastectomy – 1970s-80’s
Removes breast and level I-II axillary lymph nodes; NSABP B-04
Lumpectomy + Axillary Lymph Node Dissection – 1980’s -90’s
Removes tumor and level I-II axillary lymph nodes; NSABP-B-06

40. Radical mastectomy
Removes breast tissue, muscle, axillary and internal mammary lymph nodes
Very disfiguring—rarely performed

41. Modified Radical Mastectomy
Removes all breast tissue and axillary lymph nodes
Spares muscle
Currently used for node positive breast cancers not amenable to breast conserving therapy

42. Total (simple) mastectomy
Tissue in pink is removed. This represents all breast tissue
No effort is made to remove axillary lymph nodes
Can be used for treatment or prophylaxis

43. NSABP-B-04
1665 women with breast cancer, stratified by clinical nodal status
Radical mastectomy
Total mastectomy + radiation therapy
Total mastectomy (axillary nodes removed if patients had/developed clinically evident nodal disease)
No difference in treatment failure rates or survival in node negative patients
No difference in treatment failure rates or survival in node positive patients
Became acceptable to forego routine resection of pectoralis muscle and level III axillary lymph nodes

44. NSABP-B-04

45. NSABP-B-06 1976-1984 2163 women with invasive tumors < 4cm
Total mastectomy
Lumpectomy
Lumpectomy followed by breast irradiation
All women underwent axillary lymph node dissection routinely
No survival difference between the groups at 20 years of follow-up
Patients undergoing lumpectomy without radiation therapy to the breast had significantly increased local recurrence rates

46. NSABP-B-06

47. Introduction of the Sentinel Lymph Node Biopsy for Breast Cancer
First described by Morton in 1992 for melanoma
Applied to breast cancer in 1994 by Giuliano, et al
Identification and evaluation of the sentinel lymph node allows for avoidance of complete axillary lymph node dissection in node negative patients
In recent years, surgical therapy for breast cancer has continued to evolve such that we are becoming more directed and less invasive.
Prior to the mid 1990's, complete axillary lymph node dissection was the standard of care for all invasive breast cancers. the sentinel lymph node biopsy, removal of the first draining lymph node, was first described by Dr. Morton in 1992 as a part of the surgical management of melanoma.
This concept was applied to breast cancer by Dr. Giuliano in He and his colleagues showed that identification and evaluation of the sentinel lymph node allows for avoidance of complete axillary lymph node dissection in node negative patients.

48. Skin-sparing mastectomy
“Keyhole” incision (skin preserved)
Tissue removed at mastectomy
Allows for more natural reconstruction by preserving breast envelope
Similarly, during the perfomance of a mastectomy, surgical management has evolved such that we are able to spare increasing amounts of the skin envelope of the breast during a mastectomy, up to and including the nipple in some cases, which allows for a more natural appearing reconstruction without compromising the oncologic outcome.

49. Special Situations: Paget’s Disease
Intraepidermal adenocarcinoma
Usually associated with an underlying breast malignancy
Diagnosis made by biopsy of nipple skin
Treatment options
Simple mastectomy
Central lumpectomy + RT
Now on to some special situations.
Paget's disease is intraepidermal adenocarcinoma. The figure below shows that the patient's left nipple is red and scaly. Biopsy was performed that showed Paget's disease. Paget's disease is usually associated with an underlying breast malignancy, so a thorough work-up is necessary. As with any breast cancer, treatment options include mastectomy vs lumpectomy (in this case, central lumpectomy since the nipple is involved) plus radiation therapy.

50. Special Situations: Phyllodes tumor
Spectrum of lesions (benign, borderline, malignant)
Can be difficult to differentiate between fibroadenoma and phyllodes – consider diagnosis with fibroepithelial lesion > 2cm or growing
Axillary nodal mets generally do not occur
Treatment involves wide excision with at least 1 cm margin of normal-appearing breast or total mastectomy
Phyllodes tumors are fibroepithelial lesions that can either be benign, borderline or malignant. It can be difficult to differentiate between a fibroadenoma nd a phyllodes tumor on needle biopsy. It is important to consider the diagnosis when a fibroepitheliala lesion measures greater than 2cm or is growing
Axillary nodal metastases generally do not occur with this entity, even in the malignant subtype
Treatment involves wide excision with at least a 1cm margin of normal appearing breast tissue, or total mastectomy if necessary due to the size of the tumor

51. Special Situations: Inflammatory breast cancers
Account for <3% of breast cancers
Characterized by brawny induration, ertyhema, and edema of the skin (peau d’orange)
Dermal lymphatic involvement seen on skin biopsy
May be mistaken for bacterial infection
Treatment: up-front systemic therapy, modified radical mastectomy, post-mastectomy radiation therapy
Inflammatory breast cancers account for < 3% of all breast cancers. These are characterized by brawny induration, erythema, and edema of the skin (peau d'orange).
Dermal lymphatic involvement is seen on skin biopsy - but this is a clinical diagnosis!! Dermal lymphatic involvement does not necessarily = inflammatory breast cancer.
This entity may be mistaken for mastitis/bacterial infection.
Treatment for inflammatory breast cancer includes up front (ie neoadjuvant) chemotherapy, modified radical mastectomy and post mastectomy radiation therapy

52. Thank you for completing this module?
Questions? Contact me at:
I would like to thank you for completing this module. Please do not hesitate to contact me with any questions you may have!

53. References
Saslow D, Hannan J, Osuch J, et al: Clinical Breast Examination: Practical Recommendations for Optimizing Performance and Reporting. CA Cancer J Clin 2004:54: