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Any questions? When an abnormality is detected during a physical examination or by a screening procedure , testing is required to differentiate benign lesions from cancer.

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Because early detection and treatment of breast cancer improves prognosis, this differentiation must be conclusive before evaluation is terminated. If advanced cancer is suspected based on physical examination, biopsy should be done first; otherwise, the approach is the same as evaluation for a breast mass , which typically includes ultrasonography. All lesions that could be cancer should be biopsied. A prebiopsy bilateral mammogram may help delineate other areas that should be biopsied and provides a baseline for future reference.

However, mammogram results should not alter the decision to do a biopsy if that decision is based on physical findings. Mammogram results should not alter the decision to do a biopsy if that decision is based on physical findings. Percutaneous core needle biopsy is preferred to surgical biopsy. Core biopsy can be done guided by imaging or palpation freehand.

Routinely, stereotactic biopsy needle biopsy guided by mammography done in 2 planes and analyzed by computer to produce a 3-dimensional image or ultrasound-guided biopsy is being used to improve accuracy. Clips are placed at the biopsy site to identify it. If core biopsy is not possible eg, the lesion is too posterior , surgical biopsy can be done; a guidewire is inserted, using imaging for guidance, to help identify the biopsy site.

Any skin taken with the biopsy specimen should be examined because it may show cancer cells in dermal lymphatic vessels. The excised specimen should be x-rayed, and the x-ray should be compared with the prebiopsy mammogram to determine whether all of the lesion has been removed. If the original lesion contained microcalcifications, mammography is repeated when the breast is no longer tender, usually 6 to 12 weeks after biopsy, to check for residual microcalcifications. If radiation therapy is planned, mammography should be done before radiation therapy begins.

After cancer is diagnosed, a multidisciplinary evaluation is usually done to plan further testing and treatment. The core multidisciplinary team typically includes a breast surgical oncologist, medical oncologist, and radiation oncologist plus other experts in cancer tumor board. Part of a positive biopsy specimen should be analyzed for estrogen and progesterone receptors and for HER2 protein.

The cancer does not have estrogen or progesterone receptors or overexpression of HER2 protein triple negative breast cancer. Some experts recommend that genetic testing be offered to all patients with breast cancer 1. For these tests, the best approach is to refer patients to a genetic counselor, who can document a detailed family history, choose the most appropriate tests, and help interpret the results.

Breast Cancer

Chest x-ray, a complete blood count CBC , liver function tests, and measurement of serum calcium levels should be done to check for metastatic disease. An oncologist should be consulted to determine whether to measure serum carcinoembryonic antigen CEA , cancer antigen CA , or CA and whether bone scanning should be done. MRI is often used by surgeons for preoperative planning; it can accurately determine tumor size, chest wall involvement, and number of tumors.

Grading is based on histologic examination of the tissue taken during biopsy. Tumor grade describes how abnormal tumor cells and tissue look under a microscope. Because clinical examination and imaging have poor sensitivity for nodal involvement, staging is refined during surgery, when regional lymph nodes can be evaluated. However, if patients have palpably abnormal axillary nodes, preoperative ultrasonography-guided fine needle aspiration or core biopsy may be done:. If results are positive, axillary lymph node dissection is typically done during the definitive surgical procedure.

If results are negative, a sentinel lymph node biopsy, a less aggressive procedure, may be done instead. CA Cancer J Clin 67 4 , Spread to ipsilateral low or midaxillary nodes that are fixed or matted, detected by clinical examination cN2. Spread to internal mammary nodes but not axillary nodes as detected by clinical examination or imaging. Spread to ipsilateral internal mammary nodes plus axillary nodes as detected by clinical examination or imaging.

Springer New York, Inc. Patients with breast cancer should not become pregnant while being treated for breast cancer.

However, all patients who wish to preserve fertility should be referred to a reproductive endocrinologist to discuss fertility preservation before systemic therapy is initiated. Assisted reproductive techniques ART with ovarian stimulation and oocyte and embryo cryopreservation. Ovarian suppression eg, with leuprolide to minimize the destruction of ova by chemotherapy. Type of breast cancer, anticipated treatment, and patient preferences affect the type of fertility preservation that can be used.

ART may have adverse effects in patients with estrogen -receptor positive tumors. The American Society of Breast Surgeons : Official statement consensus guideline on genetic testing for hereditary breast cancer. Long-term prognosis depends on tumor stage.

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Nodal status including number and location of nodes correlates with disease-free and overall survival better than any other prognostic factor. Young age: Prognosis appears worse for patients diagnosed with breast cancer during their 20s and 30s than for patients diagnosed during middle age. Larger primary tumor: Larger tumors are more likely to be node-positive, but they also confer a worse prognosis independent of nodal status. Patients with progesterone receptors on a tumor may also have a better prognosis.

Patients with both estrogen and progesterone receptors on a tumor may have a better prognosis than those who have only one of these receptors, but this benefit is not clear. Presence of BRCA gene mutations: For any given stage, patients with the BRCA1 gene mutation appear to have a worse prognosis than those with sporadic tumors, perhaps because they have a higher proportion of high-grade, hormone receptor—negative cancers.


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Patients with the BRCA2 gene mutation probably have the same prognosis as those without the mutation if the tumors have similar characteristics. For most types of breast cancer, treatment involves surgery, radiation therapy, and systemic therapy. Choice of treatment depends on tumor and patient characteristics see table Treatment by Type of Breast Cancer. Recommendations for surgery are evolving and include early referral to a plastic or reconstruction surgeon for oncoplastic surgery which combines cancer removal with reconstruction of the breast.

Possible Treatments. Tamoxifen or, for some postmenopausal women, raloxifene or aromatase inhibitors to reduce risk of invasive cancer. Chemoprevention with tamoxifen or raloxifene for some patients. If cancer is symptomatic and multifocal, hormone therapy, ovarian ablation therapy, or chemotherapy.

Grading and Staging In Cancer

For brain metastases, local skin recurrences, or isolated symptomatic bone metastases, radiation therapy. Mastectomy or surgical resection if mastectomy has already been done , sometimes preceded by chemotherapy or hormone therapy.

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Skin-sparing mastectomy: Spares the pectoral muscles and enough skin to cover the wound, making breast reconstruction much easier, and spares axillary lymph nodes. Nipple-sparing mastectomy: Same as skin-sparing mastectomy plus spares the nipple and areola.

Modified radical mastectomy: Spares the pectoral muscles and removes some axillary lymph nodes. Breast-conserving surgery involves determining the size of the tumor and the required margins based on the tumor's size relative to the volume of the breast , then surgically removing the tumor with its margins. Various terms eg, lumpectomy, wide excision, quadrantectomy are used to describe how much breast tissue is removed. For patients with invasive cancer, survival and recurrence rates with mastectomy do not differ significantly from those with breast-conserving surgery plus radiation therapy as long as the entire tumor can be removed.

Thus, patient preference can guide choice of treatment within limits. The main advantage of breast-conserving surgery plus radiation therapy is less extensive surgery and opportunity to keep the breast. However, the need for total removal of the tumor with a tumor-free margin overrides cosmetic considerations. Some physicians use preoperative chemotherapy to shrink the tumor before removing it and applying radiation therapy; thus, some patients who might otherwise have required mastectomy can have breast-conserving surgery.