Breast Surgery ABSITE
Jason: [00:00:00] Okay, behind the knife ab site review. Today is a very high yield topic that you're sure to get plenty of questions on let's
get right into it. We're talking about breasts today. As always, we'll start with some high yield anatomy. Kevin. The axillary lymph nodes
levels one, two, and three, what are the surgical boundaries and where do these axillary lymph nodes live?

Jason: Yeah, so level one is lateral to the pectoralis minor, level two is posterior to the pectoralis minor, and level three is medial to the
pectoralis minor. Okay, great. So yeah, just know that relationship to that pectoralis minor levels 3. And know when you're doing your
axillary lymph node dissection, you're doing levels 1 and 2 for breast cancer.

Jason: If you're doing a lymph node dissection, let's say for melanoma, Kevin, what levels do you do? I believe that's all three. That's all
three. So that's distinct from an axillary lymph node dissection for breast cancer, but know the boundaries and know where your lymph
nodes live. Okay other frequently tested things are nerves that can be injured during an axillary [00:01:00] dissection.

Jason: I'll name you a clinical scenario, and you tell me which nerve and which muscle are involved in this clinical scenario that you may
encounter if there is a nerve injury after an axillary dissection. Okay. Let's start with a winged scapula. Yeah. So that's the long thoracic
nerve and that innervates the serratus interior.

Jason: Perfect. Long thoracic, serratus anterior, wing scapula. Oh, okay. Let's say weakness in pull ups and ARB adduction. Yeah, so
that's the thoracodorsal nerve, which innervates the latissimus dorsi. Okay. Weak adduction, thoracodorsal nerve. thoracodorsal nerve
and latissimus dorsi. Okay.

Jason: And let's say this is the most, this is the most common thing that you might find after an axillary dissection, but you have some
sensory deficits to the medial arm. What what nerve was injured? Yes. That's the intercostal brachial nerve. Intercosteobrachial, and
again, that's the most commonly injured nerve during an axillary lymph node [00:02:00] dissection.

Jason: Which nerve innervates both the pec major and the pec minor? That's your medial pectoral nerve. Okay, how about one that
innervates only the pec major? That's your lateral pectoral nerve. Okay, so medial pectoral nerve, again, pec major and minor, lateral
pectoral nerve pec major only. Good. Okay, a little bit something more up your alley.

Jason: Blood supply. So what's the blood supply to the breast? Yeah, so you have your internal thoracic artery commonly known as the
mammary. You have your intercostals, you have your lateral thoracic, and your thoracochromial arteries. Great. So there's multiple
arteries that supply blood to the breast.

Jason: Venous drainage, sometimes we'll hear something called the Batson's plexus. What is Batson's plexus and what is its clinical
significance? Yeah, so this is a valveless venous plexus that allows for direct hematogenous spread to the spine. Okay, perfect. Yep. And
that's that's exactly right.

Jason: So that hematogenous spread to the spine through that valveless venous plexus called bats[00:03:00] and plexus. Okay. So we
talked about some, the axillary lymph nodes and some nerves that are injured during axillary dissection. What are the boundaries of the
of an axillary dissection?

Jason: Yeah. So superiorly, you have the axillary vein. Okay. medially, you have the chest wall laterally. You have the skin anteriorly.
You have the pectoralis major and minor and dorsi. Great. Yeah. Again, with those boundaries, you just have to imagine yourself sitting in
the axilla and look around and what are you going to see?

Jason: So again, superior axillary vein. medial chest wall, lateral skin, anterior pec major, minor and posterior latissimus dorsi. Perfect.
Okay. So moving away from some anatomy, let's start talking about some pathology. So most common or a common presentation is
breast pain. Something we don't frequently see as surgeons, but it is something certainly primary care deals with pretty frequently.

Jason: Talk to me a little bit about. Breast pain. What what are some causes and some[00:04:00] treatments? Yeah. So most commonly
this is self limited. It's most frequent during the late luteal phase of the menstrual cycle. So treatment for this you can have reassurance.
But if these patients have continued pain or severe pain you have some other options to include vitamins and dietary supplements
primrose oil.

Jason: And then for. patients with refractory you can use tamoxifen or danisol or bromocryptine. Yeah. So if it's just isolated breast pain
and there's no palpable masses and you're not, no concerning findings on mammography or ultrasound, then the answer is going to be
reassurance.

Jason: Potentially some of these dietary supplementations that evening primrose oil is one that's frequently tested and in extreme cases
some of those those others that you mentioned the tamoxifen bromocryptine mondor's disease. What is mondor's disease? And what's
the treatment? Yeah So this is a superficial thrombophlebitis of the lateral thoracic vein [00:05:00] or tributary Okay.

Jason: And when do we, how does this present? When do we see this? Yeah. Generally, these patients have had recent surgery or
trauma or have some other inflammatory process going on. And it's really, it's not associated with carcinoma or cancer or other places.
Okay, how does the patient present? Yeah, just like you see any other superficial thrombophlebitis, they're gonna have a tender palpable
subcutaneous cord.

Jason: Okay, and what's the treatment? Yeah, so just the NSAIDs and some people like warm compresses. Great. So that tender
palpable subcutaneous cord, that's gonna be the description for Mondor's disease and the treatment is NSAIDs and warm complexes as
you compresses as you say. Okay. So let's talk.

Jason: So we're, talking right now about benign breast disease and benign breast lesions. So in general that we have, we can categorize
benign breast lesions into three different categories, and that's associated with [00:06:00] their risk of harboring an underlying malignancy
or risk factor for malignancy.
Jason: So what are those three categories? Yeah, so you have your non proliferative with no increase risk of breast cancer, and then
your proliferative with atypia. Okay, so yeah, non proliferative that has so non proliferative benign breast lesions, those are things like
microcyst, macrocyst, ductal actasia, fibro, simple fibroadenomas, mastitis, squamous or apocrine metaplasia, and mild hyperplasia.

Jason: Those are all categorized as non proliferative, and those have no increased risk of breast cancer. Then we start thinking about
our proliferative with a mild increased risk of breast cancer. And those are things like a papilloma, sclerosing adenosis, moderate or
severe hyperplasia, and complex fibroadenomas.

Jason: And those carry a 1. 5 to 2 relative risk of breast cancer. So again, proliferative with a mild increase. Once we started seeing
[00:07:00] proliferative with atypia, those have a higher risk of breast cancer. And that makes sense. Atypia, right? So that's your atypical
ductal hyperplasia, atypical lobular hyperplasia.

Jason: If you see those carry about a four and a half to five times a relative risk of breast cancer. So that can be helpful because
sometimes you'll get a benign breast lesion. And they will ask you which of these carries the highest risk of of breast cancer. And the
answer would be one of those proliferative lesions with atypia.

Jason: So those atypical lobular hyperplasia and atypical ductal hyperplasia. Just keep those in mind, look over those, have a familiarity
with which of these have a risk, which don't, which have a small risk, which have a higher risk. So we're gonna talk a little bit more about
some of these and we'll start with fibrocystic disease.

Jason: So Kevin, tell me a little bit about fibrocystic disease. Who is this most common in? Yes, this is most common in perimenopausal
women. They can have breast pain, [00:08:00] nipple discharge and lumps that vary throughout the menstrual cycle. Okay, great. This is
very common. So you'll have a woman that presents with a, let's say they have a simple cyst.

Jason: So what's the, what do we do? How do we manage simple cysts of the breast? Generally, we can observe these. Okay. And
again, this is after if we're, when we talk about this, we're assuming that there's no worrisome findings on imaging. No mass and. A low by
red score. So we observed them with their asymptomatic and they have the characteristic appearance on imaging.

Jason: Now, what if they're symptomatic? Yeah. So this is when you'd aspirate it. Okay. And tell me, talk to me a little bit about more of
that. How does aspiration help? Yeah. So if the aspirate is bloody or recurrent you'd send it for cytology. In. When you have a bloody
aspirate, generally you're going to move on to a surgical excision.

Jason: And again, if it's recurrent, you're going to need to do a surgical excision if it recurs after the aspiration.[00:09:00] Perfect. Yeah.
Yeah. So you're looking for, again, if there's bloody aspirate, you're going to send that for cytology. If it's non bloody, you're not
necessarily going to do that. And then if it's recurrent or unresolved or bloody, you're going to move on to surgical excision.

Jason: Okay, great. So that's a simple cyst. Let's talk about a complex cyst. So these are cysts that have a solid component or have
internal vascularity on imaging. What do we need to do for those? Yeah, so you want to get a corneal biopsy of the solid component.
Okay, perfect. Is there a risk of cancer with cysts?

Jason: So if the cytology demonstrates atypical ductal or lobular hyperplasia, there is. Okay, great. So yeah, again, complex cyst with
solid component internal vascularity, you're gonna coordin needle those. If the aspirate is bloody, you're gonna send those for
Scientology. And again, look for that ayia, right?

Jason: That atypical lobular or ductal hyperplasia does increase the risk of of a cancer. Okay. Okay, next let's talk about fibroadenoma.
How do fibroadenomas present? Yeah, so these [00:10:00] generally present as a dominant mass in the breast. Okay. And how do we.
You have a, 30 year old female who presents with a dominant mass.

Jason: How do we work those patients up? So the younger women generally have the dense breast tissue. So this is best to image with
ultrasound. In the older, generally over 35 you'd get mammography.

Jason: Okay. Yeah. Good. So you have a dominant mass. You're going to get some, you're gonna start with some type of imaging and
the woman's age is pertinent to the X. As you say, women under 35 tend to have a denser breasts and mammography is not as useful.
So under 35 we'll typically get an ultrasound over 35 we'll get mammography.

Jason: And what we're looking for, what's characteristic of fibroadenome is a solid mass with lobulated margins on ultrasound. Okay. So
that's going to be what. The description is going to be on ultrasound, solid mass, lobulated margins. What if the, what do we do with
these? So let's say the findings are consistent.

Jason: Ultrasound is consistent with the benign fibroadenoma and the patient[00:11:00] has no risk factor. Yeah. So in this patient, you
just need to do surveillance. So generally a biannual ultrasound. Okay, so you can watch these if they're asymptomatic and, no risk
factors and characteristic findings on ultrasound as described.

Jason: But if there's any uncertainty very low threshold for obtaining a core needle biopsy as with any mass of the breast. So what if the
you're doing that and the mass is enlarging on your surveillance? So in that situation, you need to proceed with an excisional biopsy.
Okay. Great. So we have the mass growing excisional biopsy.

Jason: Now there's some variants of fibroadenoma there's giant fibroadenoma, complex fibroadenoma and tubular adenoma. So Kevin,
what can you tell me about what's a giant fibroadenoma? Yeah. So as it sounds it's large, so generally greater than six centimeters and it
can actually be difficult to distinguish from a phyloides tumor.

Jason: Okay, perfect. Yeah, we're going to talk about phyloides here in a minute. So yeah, giant fibroadenoma greater than six[00:12:00]
centimeters. Complex fibroadenoma. What do I mean by complex fibroadenoma? Yeah, so this is one of these fibroadenomas. It's
actually an increased risk for carcinoma. So it's a fibroadenoma with sclerosine adenosis, papillary apocrine hyperplasia, cysts, or
epithelial calcifications.
Jason: Okay, great. So then, if you go back to our broad categories of that proliferative with a mild increased risk of of cancer, that's
where these would fall. So that fibroadenoma with sclerosine adenosis, cysts, or epithelial calcifications. Okay, and finally, the last variant
of fibroadenoma, a tubular adenoma.

Jason: What is this? Yeah, so this is benign. This is a variant of pericunicular fibroadenoma with adenosis like epithelial proliferation.
Great. So that would fall into that non proliferative with no increased risk of breast cancer. Those tubular adenomas. Okay. Perfect. Okay.
So moving on, [00:13:00] you mentioned we talked or you mentioned phyloides tumor.

Jason: You said giant fibrinoma can be difficult to distinguish from a phyloides tumor. So what is a phyloides tumor? Yeah, so this is, a
breast mass that has subclassifications that include benign, borderline and malignant about 10 percent become malignant. And you can
diagnose this by if there's greater than five mitosis per high power field.

Jason: And these phyloides tumors will have tumor stains that are positive for vimentin and actin. Okay, great. Yeah, so phyloides tumor,
they, behave similar to, a sarcoma. So again, we have those class subclassifications, benign, borrel, and malignant. As you mentioned,
about 10 percent become malignant and we look at, the mitoses for high power fields for their malignant potential.

Jason: hematogenously.

Jason: Yeah, [00:14:00] again, so if you think of them, like a more consistent with a sarcoma these are going to spread hepatogenously
they rarely spread, but they do occasionally spread nonetheless. What's important to know there is there's no role for sentinel node
biopsy or axillary dissection with a phyloides tumor.

Jason: So what is the treatment for a phyloides tumor? Yeah, so you need to do a wide local excision with just negative margins. Okay,
wide local excision, negative margins for a phyloides. Okay. Moving on to more, benign breast. pathology. Another common presentation
is nipple discharge. So what's the most common cause of bloody nipple discharge?

Jason: So it's your intraductal papilloma. Yeah. So classically that's your intraductal papilloma. So these are not pre malignant lesions.
So what would be more concerning for a malignant, what types of findings with nipple discharge would be more concerning for
malignancy? Yeah. So if the discharge is bloody, if it's spontaneous, if it's persistent [00:15:00] or unilateral, great, so unilateral,
spontaneous, bloody persistent discharge would be concerning for potentially malignancy.

Jason: So how does women's age affect that risk? Yeah, so it greatly impacts it. So if they're greater than 60 years old, there's a much
higher risk of it being associated with cancer than in a younger woman under 40. Okay, great. So if less than 40, there's about 3 percent
chance of associated with cancer. And over 60, there's a greater than 30 percent association with malignancy.

Jason: Now, obviously, other risk factors, family history, all those things are going to affect that as well. But in general, younger women
much lower risk of malignancy with bloody nipple discharge than older women. How do you diagnose what's the diagnosis? Yes. You use
ductal fluid cytology and a contrast ductogram.

Jason: And some people can use ductoscopy also. Yeah, those are, I would say those are not all that helpful. Those can be done. I say
inductive fluid cytology, [00:16:00] Dr. Graham's, ductoscopy. But what's the best diagnostic test? Yeah, we have a patient that presents
with bloody nipple discharge. What's the best test for diagnosis?

Jason: You need a tissue biopsy. So you do a duct excision and then you'll really get what the answer is. Yep. Best diagnostic test for
bloody nipple discharge is a duct excision. Okay. We mentioned that intraductal papilloma is the most common. What's the treatment for
that? Yeah. So the treatment is a subareola resection of the involved duct and papilloma. Okay. Yeah. Again, that's, again, your duct
excision. Sub areolar resection of the involved duct with the papilloma.

Jason: Okay. Moving on to more. We're sticking with the benign breast pathology. Duct ectasia. What is duct ectasia? Yeah. This is a
dilation of the sub areolar duct in the peri and postmenopausal women. Okay. And symptoms? So these patients will have viscous nipple
discharge. Okay. What's the treatment?

Jason: So if [00:17:00] they're asymptomatic, you can observe these. If they're symptomatic you can perform a duct excision.

Jason: Okay, great. So you asymptomatic, you can observe these, 'cause remember this falls into that category of proliferative with no
risk of cancer, that duct ectasia no risk of cancer. So you can't observe them of asymptomatic if symptomatic you, you excise them. Okay.
How about some breast infections?

Jason: What's the most common bacteria to cause? Both breast abscesses as well as mastitis. Yeah, so that's your staph aureus. Okay,
great. Staph aureus is the most common organism involved in breast infections. So remember that. Okay, we frequently break down
breast infections, both mastitis and abscesses into two groups.

Jason: Those being lactational and non lactational. So let's stick with lactational. What caught, what's the pathophysiology behind breast
infection, breast infections and lactational infections? Yeah. So this is most likely from a blockage of the lactiferous [00:18:00] ducts. Okay.
And let's and then we break it down even further into if there's an abscess present or no abscess present.

Jason: So if there's no abscess with lactational breast infection, what's the treatment? So if there's no abscess, it's antibiotics alone and
you encourage them to continue breastfeeding. If there is an abscess, you do aspiration and antibiotics and continue breastfeeding also.
Okay. Excellent. That's a great point.

Jason: So again, if there's no abscess antibiotics and it's important to, to continue that breastfeeding. And if there is an abscess, we try to
avoid incisions on the breast especially in lactating women. And why is that? Yeah, because you can develop a milk fistula. Yeah, so you
can develop a milk fistula.

Jason: So we try to avoid incisions, and if possible, we'll try aspiration and antibiotics, again, continuing to breastfeed. Now if the, if that
doesn't work, if it does not resolve with aspiration, you may ultimately need an incision and [00:19:00] drainage of that abscess, but it
certainly does raise, increase the risk of development of a milk fistula.

Jason: Okay, so now let's move on to non lactational breast infections. What's the most common what's the pathophysiology and the
cause behind that? Yeah, so this is a periductal infection associated with smoking and ductal axasia. Okay, great. And treatment?
Antibiotics. And if there's an abscess?

Jason: Incision and drainage. Okay. So let's say you have a patient who presents with recurrent unresolving mastitis. Classic. What are
you concerned about? What do you need to do? Yeah, so you have to be concerned about a cancer, so you need to biopsy the skin to
rule out an inflammatory breast cancer.

Jason: Yeah, frequently tested, so don't forget about that inflammatory breast cancer, which we're going to talk a little bit more about
later. But certainly important, and you need a biopsy of the skin to rule that out. Okay. And again, with some more benign breast
pathology, benign breast lesions, [00:20:00] sclerosine adenosis.

Jason: How do these present? Yeah, so generally they're going to have a mammogram and they're going to see microcalcifications and
it's going to be diagnosed on a core needle biopsy. Okay, and treatment? If there's no atypia in the imaging that's concordant, you can
observe. Okay, and yeah, again, this is not a precursor to cancer.

Jason: Sclerosine adenosis, this falls back into, we're going to fall back to those categories with each one of these. This is that
proliferative with no increased risk of cancer. These can be observed. And again, when we say this, we're saying that these are
concordant findings. Of course, if there's a mass, And there is discordant findings on imaging that more needs to be done.

Jason: But when we talk about these risk for cancers we're assuming that imaging is concordant. Okay. Finally let's talk about a radial
scar. What is some, what's radial scar also known as, and how do you diagnose it? Yeah. So it can be known as sclerosing papillary.
[00:21:00] proliferations and benign sclerosine ductal proliferation.

Jason: Okay, sclerosine papillary proliferations, benign sclerosine ductal proliferation is something you might see it as described as, but
these are all synonymous with radial scar. And how do they appear on mammogram? Yeah, so these Generally appear similar to small
invasive cancers. Okay, so what's the treatment then?

Jason: Yeah, you have to do an excisional biopsy in these situations. So with radial scar, they need an excisional biopsy. It is associated
with a small increased risk of cancer. And the difference between invasive... Breast cancer may be difficult to determine on imaging and
corneal biopsy alone. So excisional biopsy for radial scar.

Jason: So let's talk about some of those atypical lesions. Atypical lobular hyperplasia. So tell me a little bit about that. Yeah, so this is
less well developed, but morphologically similar to LCIS.

Jason: Okay, is it premalignant? No, it's not premalignant, but it[00:22:00] is a marker of increased risk. Okay. Yeah. So these patients
with atypical lobular hyperplasia will have an 8 to 12 fold increased lifetime risk or approximately 1 percent per year of developing breast
cancer. How do we diagnose these with the corneal biopsy?

Jason: Yeah. So typically it will be seen on imaging and they'll get a corneal biopsy. And treatment. So treatment is an excisional biopsy
followed by chemo prophylaxis with tamoxifen and anastrozole.

Jason: Okay. Wait a minute. So we said that they're not pre-malignant. So why do we excise these if they're not pre-malignant? Yeah.
The concern here is there, there's a discordant finding as these lesions are often incidental to the radiographic abnormality that prompted
the biopsy. Yeah, so you're worried about sampling error with these.

Jason: Okay, good. And and these patients afters will typically need, after the excisional biopsy will typically need enhanced surveillance
with annual breast MRI. Annual breast MRI for these patients because of that 8 to 12 days.[00:23:00]

Jason: Okay, so that's a typical lobular hyperplasia. How about a typical ductal hyperplasia? A. D. H. What's the association with A. D. H.
and invasive cancer? Yeah, so these patients have a four to five fold increased risk of invasive cancer. Okay. And again, what's the
diagnosis for these corneal biopsy? Okay. And treatment.

Jason: Excisional biopsy. Okay. And these will have a relatively high risk of of upgrading or up staging to DCIS or invasive ductal
carcinoma with that excisional biopsy. 90, 39 to 30% re risk of finding DCIS. And about a 3 percent risk of finding invasive ductal
carcinoma. So excisional biopsy for atypical ductal hyperplasia.

Jason: Okay. So let's move next step up from that atypia is the carcinoma in situ. So the LCIS and the DCIS. Let's talk about LCIS,
[00:24:00] lobular carcinoma in situ first. So with LCIS Kevin how do these how do these present and what's the association with your
hormone receptors? Yeah. So these are generally multifocal and bilateral and these patients generally have a genetic predisposition. And
so 90 percent of these will be ER, PR positive and HER2 negative.

Jason: Okay. Okay. Good. And what is the malignancy risk with LCIS? Yes, this is the crucial point here. You have a 20 to 40 percent risk
of cancer development in either breast again. So this is not a, this is not a pre malignant legion, but it is a marker for the development of
invasive cancer. And it's a significant marker.

Jason: So 20 to 40 percent risk of cancer development. And again, in either breast, not necessarily the breast that the LCIS is found in.
And when they do develop cancer, what type of cancer do they, Okay. Do they develop? Yeah, they develop ductal carcinoma. Yeah,
important. Yeah, [00:25:00] LCIS is a risk factor for the development of ductal carcinoma.

Jason: Treatment? For this, you do a wire localized excision. Okay, and something that's frequently tested is you have a patient with
LCIS, and you do the right thing, you do the excisional localized excisional biopsy, and there's a positive margin. What do you want to do
there? Yeah, so you do not need to re excise it.

Jason: You just put them on adjuvant hormonal therapy. Okay, great. And that's because again, this is the lesion itself is not pre
malignant. But it's a marker for malignancy. So they do need advanced surveillance. And they do need adjuvant hormonal therapy, but
you do not need to re excise for positive margins with LCIS.

Jason: Now there is in contrast to DCIS, which we'll talk about here in a minute where you do need margins not so for LCS, but there is a
caveat there. So there is a form of LCIS that is treated like DCIS. And what is that? Yeah, so that's if they have the pleomorphic LCIS.
That's right. So watch for that.

Jason: If there's, that's the [00:26:00] we get into this mindset of LCIS positive margins. Oh, I know this one. We don't need to re excise
that. But if you have that pleomorphic LCIS, remember those are treated like DCIS and those do need margins. Okay. So let's talk about
DCIS. What is DCIS? Yeah, so this is when you have malignant cells of the ductal epithelium without invasion of the basement
membrane.

Jason: So it's a pre malignant lesion. So this one is pre malignant and what is that malignancy risk? So 50 percent in the ipsilateral breast
and 5 percent in the contralateral breast. Okay, 50 percent ipsilateral, 5 percent contralateral. How do these patients present? Generally
this is found on mammography and then diagnosed with corneal biopsy.

Jason: Yeah, so generally these are not palpable and they're seen on mammography as an abnormality of mammography and we get
the corneal biopsy. Treatment. So you can do breast conservation therapy here. So you can do a lumpectomy with two millimeter margins
with adjuvant radiation. Yeah, you need a excision with two millimeter margins. And often this [00:27:00] breast conservation therapy is an
option with Lumpectomy. And when you do breast conservation therapy, you need to add that adjuvant radiotherapy. The adjuvant
radiation. Hold, and that's hold breast radiation.

Jason: Because that hold breast radiation reduces the risk of a local recurrence by 50%. It's important to know that radiation does not
affect overall survival but it does reduce the risk of local recurrence. Now, what if there the lesion is large, it's multi quadrant or there's a
contraindication to breast conservation therapy?

Jason: Then what's the treatment in this situation, you do the simple mastectomy with a sentinel lymph node biopsy. Yeah, okay, so right,
large multi quadrant or for another reason the patient can't undergo breast conservation therapy or doesn't want breast conservation
therapy, a mastectomy, but remember if you're doing a mastectomy for DCIS, you need to add that sentinel lymph node biopsy because
there is an incidence of upstaging to invasive cancer and if you disrupted all of those lymphatics, it makes [00:28:00] it difficult to go back
later and do a sentinel node biopsy.

Jason: So don't forget that. And if you are doing mastectomy for these there are skin and nipple sparing procedures with immediate
reconstruction that are generally options for these patients. Now what about postoperatively, what's the adjuvant therapy? We mentioned
adjuvant radiotherapy. Is there anything else?

Jason: Yeah. So for premenopausal women, tamoxifen is. The adjuvant therapy and for postmenopausal women and aromatase
inhibitors such as anastrozole. And of course, this is assuming the their hormone receptor positive. But yeah, pre metaposal, tamoxifen,
post metaposal, aromatase inhibitors, such as anastrozole.

Jason: You may see some, pathologic descriptions that are indicators of a more aggressive subtype of DCIS. And so that's what you'd be
looking for there is that comedonecrosis. Comedonecrosis is a aggressive subtype of DCIS. And if you see that the treatment is simple
mastectomy again, with that sentinel lymph node and [00:29:00] adjuvant hormone therapy.

Jason: And once again, just to, to reiterate, so with LCIS, you don't need positive margins. With DCIS, you do need margins, and those
margins are two millimeters, two millimeter margins for DCIS. Okay, so stepping it up a little bit and let's talk a little bit about invasive
cancer, breast cancer. Let's start with some basics first, some generalities.

Jason: So when should we start screening for breast cancer with mammography? So if they're low risk, they should start screening at
age 40 and every two to three years followed by 50. Okay, so age 40 every two to three years and then annually after 50 for low risk, your
average risk women high risk when do we start screening those patients?

Jason: Yeah, so 10 years before the youngest age of diagnosis and a first degree relative. At first degree relative 10 years before the
youngest stage of diagnosis. There are some hereditary disorders with increased risk of breast cancer. What are some of those disorders
[00:30:00] Kevin? Yeah of course, you're BRCA, both 1 and 2.

Jason: You have Li Fraumeni Syndrome. You have Cowden Syndrome and Puth Jager Syndrome and CDH1. Okay, perfect. BRCA is
really the most the one we're most familiar with with the highest association. With BRCA 1 and 2 mutations, what is that increased risk?
Yeah, so it's 10 to 20 fold increased risk.

Jason: Yeah, so 30 to 60 percent risk by age 60. That's significant in your BRCA mutations. With these patients, we typically start
screening at a much younger age 25, with annual mammography and MRI. As well as it's important to include pelvic exams and CA 125
because of the gynecologic malignancies is also associated with BRCA1.

Jason: So again, BRCA mutations, 30 to 60 percent risk by age 60, that's a 10 to 20 fold increase. So a screen at age 25, mammography
with MRI and pelvic exam and CA 125. On with the screening [00:31:00] mammography, what are some things that are concerning for
malignancy? Yeah, so if you see irregular borders, if you see a speculated mass, if you see distortion of the breasts, or if you see a small,
thin, linear branching calcifications.

Jason: Okay when do we add that MRI for an additional screening? Yeah, so screening MRI is used in addition to traditional
mammography in high risk women. Yeah, and there's some prediction models again. Certainly those hereditary disorders people with first
degree relatives. And then those we have those risk calculators.

Jason: The gale model, the Tyler acute ic model to identify those women who are high risk and those are patients that may need MRI
added to their screening plan. Okay, so on mammography we hear a lot about birads. Okay, so we have BIRADS zero through six. So
let's just go through those.
Jason: So what's a BIRAD zero? So that's [00:32:00] an incomplete image and you need further imaging. Okay, good. Bi REDS 1? So
that is negative, and you just need routine follow up. Okay, Bi REDS 2? That is benign, and once again, you need routine follow up. Okay,
and Bi REDS 3? So it's probably benign and needs six month follow up.

Jason: Yeah, that's the one they always like to ask, because you have a patient who presents with a Bi REDS 3 lesion and so it's
probably benign, and the question will be, what does that patient need? And so they need repeat imaging at six months, okay? BIRADS
four. So that's suspicious for malignancy and you need to perform a biopsy.

Jason: Birads five, that's highly suggestive of malignancy and you need a biopsy. Okay, and Bio Birads six. So that's a biopsy confirmed
malignancy, and you need to do your excision. Okay, perfect. I had mentioned a couple of prediction models there. One of the ones I
mentioned was the Gale [00:33:00] model. What is the Gale model?

Jason: Yeah, so that's a prediction model that calculates a woman's risk of developing breast cancer within the next five years and within
her lifetime. And there's a bunch of different variables. Yeah. What are those variables? Yeah. So of course, age age at first period age at
the time of birth of the first child or if they have not given birth a family history of breast cancer, both in the mother, sister or daughter
number of press.

Jason: Number of past breast biopsies, number of breast biopsies showing atypical hyperplasia, and the race and ethnicity. Okay, so
what's important to know about the Gale model is it underestimates the risk for patients with strong family history. For instance, patients
with BRCA mutations. patients with a personal history of DCIS, LCIS, or a prior invasive cancer.

Jason: So there is a Tyler Kucic score risk model that is a more accurate prediction model for patients with a strong family history of
breast cancer. So talking about invasive [00:34:00] breast cancer, this is one of the ones where you really need to know the staging
unfortunately. So let's go through some. NCCN staging pearls.

Jason: So let's talk first about T stage. So T one, two, three, and four. What's, what can you break those down for me with breast cancer,
Kevin? What's T one? What's T two? What's T three? What's T four? Yeah. Okay. So T one less than two centimeters. T two is going to
be your two to five centimeters. T three is greater than five centimeters.

Jason: And then T four is when you have chest wall or skin involvement. Okay, perfect. Your nodal stages, we have N1, 2, and 3. What
are those? So N1 is 1 to 3 nodes involved, N2 is 4 to 9 nodes involved, and N3 is greater than or equal to 10 nodes or supra or
infraclavicular nodes involved. Okay. 4 to 9 greater or equal than 10.

Jason: And also that supra or infraclavicular [00:35:00] nodes makes you an N3. Of course metastasis is either M0 or M1. That's always
my favorite. It's always the easiest ones. Okay. It's, so let's Then break that down and go over what are some pearls with regards to
staging. So this is not meant to be comprehensive, but in general, what do we talk when we talk about stage one?

Jason: What is what stage one? Yes, this is a small tumor with no nodes. And so you have a T1, which we said for the T1, you're looking
at zero to two centimeters in zero. Okay, good. So stage one is a small tumor. So your T1 tumors and no nodes. What's the treatment for
a stage one invasive breast cancer?

Jason: Yeah. So that's surgery with adjuvant chemo radiation if indicated. Okay. And we'll talk about some of the indications for adjuvant
chemo radiotherapy here. So yeah, surgery. Okay. So what's stage two? So stage two is a larger tumor with minor node involvement. So
something like a T3N0 or a T2N1. [00:36:00] Okay. So yeah, with stage two, either you have a larger tumor or you have that, minor nodal
involvement.

Jason: So maybe your larger tumors, your T3N0s or maybe you have a few nodes, a T2N1. That's that one to three nodes and treatment
for that. Yeah. So that's surgery with adjuvant chemo radiation, if indicated. Okay. Okay. And of course, we're talking in generalities here,
right? If there's, some patients might get chemo or might get neoadjuvant therapy if you're trying to shrink down a tuber to make breast
conservation an option.

Jason: But these are, we're just talking in generalities. Of course, there's nuances and there's a little bit of variation here. And again,
we're going to talk about some of those indications for neoadjuvant as well as adjuvant therapy here in a minute. So try not to get too
hard, far ahead of ourselves.

Jason: Stage three, we have a stage three, a and three B. What's what are we looking at there? Yeah. So there's either local invasion
here or more nodes. So T4N0 or T3N2. Okay, so [00:37:00] these are your locally invasive lesions, these stage 3a, 3b's, and depending
on the clinical situation, these are patients that may get surgery or they may need neoadjuvant therapy first prior to surgery, okay?

Jason: And then stage 3c? Yeah, so the c is, if you have clavicular nodes, so NET and N3M0

Jason: is your stage 3c. Yeah, it's a great way of remembering it. 3C, those clavicular nodes, that's that N3 disease without any
metastasis. So these patients are generally going to get neoadjuvant therapy and then potentially surgery depending on the response
there. And then stage 4, everybody knows stage 4 generally involves distant metastasis.

Jason: And so those patients will get definitive chemotherapy. A new thing that if you're, if you A relatively new thing that's come up with
the treatment of breast cancer is the Oncotype DX score. You [00:38:00] may hear about this when, if you go to your institution's
multidisciplinary tumor board talking about the Oncotype DX scores.

Jason: What is an Oncotype DX score? Yes, what this does is it analyzes 21 genes to help predict the risk of recurrence and help
determine which patients will benefit from chemotherapy. Yeah what, when do we do this? When is this indicated? On what patients get
an AquaType DX score? Yeah, so it's validated for patients with ER positive HER2 negative tumors that are either stage 1, 2, or 3a.

Jason: Okay, so stage 1, 2, or 3a. ER positive, HER2 negative tumors is where we get this aqua type DX. The treatment of breast
cancer, it changes every year. It gets more complex. There's a lot of very exciting things happen which is great. The downside is it's hard
to keep up with. And this is something that you may see popping up on tests now is this aqua type DX score and how we use it.
Jason: So it's, it helps us determine, what patients are going to benefit from chemotherapy.[00:39:00] We're going to talk a little bit more
about that when it comes into our indications for chemotherapy here in a few minutes. But first, let's talk about the different categories of
breast cancer. So what's the most common type of breast cancer?

Jason: Ductal carcinoma. And what type of breast cancer is less common and does not typically form calcifications? Lobular. Yeah,
lobular carcinoma. What subtype of breast cancer has the worst prognosis? That's your signet ring cells. Okay, so you see signet ring
cells that, that, that carries a poor prognosis.

Jason: Okay we talked a little bit about it Earlier. So let's dive into it a little bit more here. That inflammatory breast cancer. So these again
are your patients who present with a breast infection that's refractory to treatment. And it's characterized by, rapid diffuse involvement in
the entire breath, breast.

Jason: With cutaneous erythema and peau d'orange. How do you say that? Peau d'orange? Peau d'orange. Do[00:40:00] you speak
French? I don't. Yeah. Changes in the breast skin. What do we see on biopsy? What's the hallmark biopsy result we see with
inflammatory breast cancer? So you're going to see your dermal lymphatic invasion.

Jason: Okay, perfect. That's what you're looking for. Dermal lymphatic invasion on your skin biopsy, right? These are skin biopsies that
we're getting. So these are tumor stage four by definition. So that makes it at least a stage 3b. So what's the treatment for inflammatory
breast cancer? Yes, for these patients you're going to start with neoadjuvant chemotherapy, followed by a modified radical mastectomy
with axillary lymph node dissection, and then adjuvant chemoradiation.

Jason: Yeah, so they're going to get it all. So you're going to get, so neoadjuvant chemotherapy, modified radical mastectomy with
axillary lymph node dissection and adjuvant chemo radiation. What's important with inflammatory breast cancer is there's no breast
conservation therapy, no skin or nipple sparing mastectomy.

Jason: Those are [00:41:00] contraindicated with inflammatory breast cancer.

Jason: Okay, Kevin, so let's say you have a patient who presents with some examinus changes and scaling and ulceration of the skin
and nipple. What are you concerned about with this presentation? Yes, I'm concerned about Paget's disease. Paget's disease. So this
often presents as a dermatitis of the nipple.

Jason: So what are tell me a little bit about this disease. What are some characteristics? Yeah. What you're going to see is you're going
to see cells with clear cytoplasm and enlarged nuclei. And there's a, it's a marker of underlying malignancy with 90 percent having an
associated DCIS or invasive ductal carcinoma.

Jason: Okay, yep, and those are generally ERPR negative and HER2 positive tumors. So as you say, you have those clear cells, clear
cytoplasm, enlarged nucleoli. This is one that you might actually see a slide of. So I would Google image what these cells look like. If you
get a biopsy and they show you a histology slide this, They may be going for [00:42:00] Paget's disease a marker of underlying
malignancy, 90% having an associated DCIS or invasive ductal carcinoma.

Jason: How do we work these patients up? Yeah. So you're going to do bilateral mammograms and ultrasounds. Bilateral mammogram
and ultrasound and in treatment. So you're gonna do a mastectomy including the nipple areolar complex with a sentinel lymph node
biopsy. Good. Mastectomy, again nipple sparing mastectomy, non option with these patients.

Jason: So you need to include that nipple areola complex and add that sentinel lymph node. Okay, perfect. So that's Paget's disease.
What about breast cancer in men? We've been talking about all these lesions in women. What about breast cancer in men? What's tell me
a little bit about that. Yeah, so it's very, rare less than 1 percent of all breast cancers and it's usually ductal.

Jason: Okay, and what are risk factors for breast cancer in men? So certainly family history if they have Klinefelter's, or BRCA2, which
accounts for 15 percent of breast cancer in men. Okay, great. So it's BRCA2, that's the [00:43:00] association with breast cancer, or that's
the associated gene mutation in breast cancer in men, so that's an important one to remember.

Jason: What BRCA2 mutation, are these patients getting prophylactic mastectomies? So men do not require prophylactic mastectomy if
they have BRCA2 mutations, but they do require prostate cancer screening. Okay, good. Yeah, so you got to remember those other
associations with those BRCA2 mutations and prostate cancer being one of them.

Jason: No prophylactic mastectomy for men with BRCA2, but they do require prostate cancer screening. But let's say they do you have a
male who does develop breast cancer, what's the treatment? So you're going to do a modified radical mastectomy. Yeah, modified radical
mastectomy. These generally have a pretty poor prognosis.

Jason: And that's related to the late presentation, stage for stage, they have a similar prognosis as women, but and men, these are
typically caught late. So for that reason, they have a poor prognosis. Okay. [00:44:00] So another unique scenario that may pop up is
breast cancer in pregnancy.

Jason: This The treatment or how you approach these is going to depend on what stage in the pregnancy the woman is in. So let's say
you have a patient in the first trimester of pregnancy. How do you want to treat their breast cancer? So in this situation, I would proceed
with a mastectomy with axillary lymph node staging.

Jason: Okay, and let's say a little bit later, second and third trimester. So in second and third trimester, breast conservation therapy is an
option.

Jason: Okay. Yeah, that's right. So those breast cancers that are identified in the first trimester, mastectomy with axillary lymph node
staging and then, later in pregnancy, second and third trimester, breast conservation therapy is an option. With an important thing to
remember there is some of those adjuvant therapies, notably the radiation therapy and the hormonal therapy must be, delayed until after
[00:45:00] delivery.
Jason: If you're earlier in the pregnancy, that's a little more difficult to do, and that's more feasible as you get, later in pregnancy,
interestingly, it was often thoughts. Or previously thought that chemotherapy was not safe during pregnancy. But recent data has showed
that some of these adjuvant chemotherapies can be used in later stages of pregnancy with and it is safe for the fetus.

Jason: For the outside, remember that first trimester mastectomy, axillary lymph node staging late second and third trimesters, you can
do breast conservation and delay some of those adjuvant therapies until after delivery. So you mentioned, axillary staging and lymph
node sentinel lymph nodes.

Jason: So we have two options for that, right? We have blue dyes, such as lymphazurin or methylene blue, and we also have our radio
tracer. So in a pregnant females, which of those are you going to use and which is contraindicated? Yeah, it's a little counterintuitive, but
you're actually going to use the isotope.

Jason: You're gonna do a modified isotope dosing for your sentinel lymph node biopsy, and you're not going to use the blue dye, such
[00:46:00] as lymphazurin or methylene blue. Yeah. Yeah. So the blue dyes are contraindicated during pregnancy. So you're going to go
with your isotope. I agree. I think it's a little counterintuitive.

Jason: But and it's, they love to ask that question. So make sure you got that straight. Okay. So with our invasive cancers what are our,
our treatment options? So let's talk first about breast conservation therapy. What is, what do we've mentioned it already, just a refresher.

Jason: What do we mean by breast conservation therapy? So lumpectomy with whole breast radiation. Okay. And what we're looking for
is a negative lumpectomy margin. So that's no ink on the tumor. And that's also a little counterintuitive. We talked about DCIS, we need a
two millimeter margin.

Jason: But now we're talking about an invasive cancer. And we just need no ink on the tumor. What are some contraindications for breast
conservation therapy? Yeah, so an absolute contraindication would be if you're pregnant and would require the radiation during your
pregnancy. Another [00:47:00] contraindication is if they have multicentric disease or if they have positive pathologic margins after the re
excision.

Jason: Okay, yeah, so those are your absolute contraindications. Pregnancy, we just talked about. Multicentric disease is not, that would
be very difficult to do breast conservation therapy, obviously. And then if you have, if you have one positive margin, you can go back and
go for negative margins, but on that re excision, if you still have positive margins then that, that patient needs a mastectomy.

Jason: Okay, what about relative contraindications to breast conservation therapy? Yes, if they've had previous radiation or they have an
active connective tissue disease or they have a very large tumor such as greater than five centimeters. Yeah, so one if they've had
previous radiation, right? They've already reached their max radiation dose.

Jason: Those patients aren't candidates for breast conservation. So they have those active connective diseases, those scleroderma,
those type of things or tumors greater than five centimeters. Those are all relative[00:48:00]

Jason: conjugations.

Jason: Okay, so Kevin, you have a patient that asked you oh my gosh, the cancer, I just, I want the most, I want the most definitive thing,
so what's between breast conservation therapy and simple mastectomy how do you counsel the patient as to what the, let's say the
survival rates are? Yeah, so breast conservation therapy is equivalent to a mastectomy.

Jason: Yeah so equivalent with regard to overall survival. So breast conservation therapy is equivalent to simple mastectomy. There are
higher recurrence rates with breast conservation therapy. That's significantly reduced with the addition of whole breast radiation, but yeah,
equivalent survival between the two.

Jason: So we've talked a lot about add these adjuvant therapies, chemotherapies. So who gets a chemotherapy after surgery for breast
cancer in general? Yeah. So if the tumor is greater than one centimeter If they have positive nodes, if they have triple negative tumors, or
they have a high Oncotype DX [00:49:00] recurrence score.

Jason: Okay, so those are the things you're going to look for. So tumors greater than one centimeter, and this is again, constantly
changing, a lot of controversy, a lot of nuances. But for the ab site in general, tumors over one centimeter, positive nodes, triple negative
tumors, and then patients with a high Oncotype DX score.

Jason: Now for those tumors that are hormone receptor positive, Node negative with a favorable aqua type characteristics. Those
patients can receive post operative hormone therapy without chemotherapy. But it's getting a little bit into the weeds for the ab site. So just
know those general things.

Jason: What is the common chemotherapy regimen for breast cancer? Yeah, so your TAC or T A C. And so you have your taxane your
adreomycin, and your cyclophosphamide. Okay. Something that's frequently tested is the adverse effects or, side effects from those
different agents. For your taxanes the docetaxel what's the side [00:50:00] effect for that?

Jason: Peripheral neuropathy. Peripheral neuropathy. Okay. Adromycin or doxorubicin? Cardiomyopathy. Okay. And cyclophosphamide?
Hemorrhagic cystitis. And what can you give to reduce the risk of hemorrhagic cystitis with cyclophosphamide? You can give mesna.
Mesna, okay. Okay, so those are your adjuvant therapies.

Jason: Okay, how about neoadjuvant chemotherapy? So who gets neoadjuvant chemotherapy? Yeah, so these are locally advanced or
inoperable tumors such as inflammatory N2, N3, or T4. Okay, and if, so if the tumor is too large, and we talked about this briefly, but if the
tumor is too large relative to the rest of the breast, and the patient desires breast conservation therapy, that these patients can also get.

Jason: Neoadjuvant chemotherapy to shrink, hopefully shrink that tumor down and make that patient a candidate for breast conservation
therapy. But otherwise, yeah, locally advanced inoperable tumors or locally advanced or inoperable tumors, [00:51:00] inflammatory
breast cancer N2, N3, T4 tumors will get neoadjuvant therapy as well as HER2 positive tumors that are over one centimeter is an
indication for neoadjuvant therapy.

Jason: Okay, we mentioned it before, but whole breast radiation does decrease the recurrence rates. So after a lumpectomy, a whole
breast radiation with a boost to the tumor bed is strongly recommended. How about after Matt? So that's after breast conservation
therapy. What about after mastectomy?

Jason: What are the indications for radiation therapy after mastectomy? Yeah, so for advanced nodal disease, if it's greater than four
nodes, or they have fixed nodes, or they have internal memory nodes, if they have skin or chest wall involvement, if they have positive
margins, or if they have T3, T4 tumors, which are greater than five centimeters.

Jason: Okay. Yeah. Those are the things to remember for the outside for for XRT after mastectomy, advanced nodal disease. Fixed
nodes skin, chest wall involvement, positive margins and a tumor over the five centimeters. Okay. And then [00:52:00] for a regional node
irradiation. Yeah. So for this, if they have greater than four positive lymph nodes, you're going to do XRT to the supraclavicular,
infraclavicular, and axillary lymph nodes, and the tumor is central to the inner area of the breast.

Jason: Then you're going to do the internal memory node radiation. And if they have one to three positive lymph nodes. The gray zone
depends on individual characteristics. Yeah. So those greater than four, four nodes you're going to get an XRT to the, to those to those
nodes, you have a central tumor, you may get XRT to the internal memory.

Jason: And then, like you say, there's one of three nodes, it's a little bit of a gray zone, and it depends on the individual characteristic as
to whether or not those patients are going to get regional node radiation. So radiation is given after chemotherapy, because,
chemotherapy sensitizes the tumor to or the cancer cells to radiation.

Jason: How about radiation in older adults? What does the NCCN say about The use of radiation in[00:53:00] older individuals after a
lumpectomy. Yeah. So it's not as critical. So they allow for the use of lumpectomy with negative margins plus hormonal therapy without
radiation in women greater than 70 with clinically negative nodes that are ER positive and T1 breast cancers.

Jason: Okay. So yeah clinically negative nodes, ER positive, T1 breast cancers in women over 70 can be treated with lumpectomy,
negative margins, and hormonal therapy without radiation. As we're seeing the more we can individualize as we're seeing, the treatment
of breast cancer is becoming more and more individualized, the more we learn about the different tumor biologies.

Jason: It makes it difficult for test taking granted, but it is great for the patients. Endocrine therapy. So these are for your estrogen,
progesterone, positive tumors. So which has a better prognosis receptor positive or receptor negative patients? The receptor positive
patients. [00:54:00] Okay, and these are more common in post menopausal women, so ER PR positivity does have a better prognosis.

Jason: Of those, ER or PR, which has the better prognosis? Yeah, so PR has the best prognosis, but having both positive is the best. So
if you had to choose one, you'd want to be PR positive, ideally you'd have to have both. You'd like to have be positive for both. And so
what is the adjuvant hormonal therapy?

Jason: So you're gonna do five years of tamoxifen for premenopausal women, or an aromatase inhibitor for postmenopausal women, for
ER, and or PR positive tumors. Yeah. So tamoxifen or your aromatase inhibitors or anastrozole, it's five years. That's your adjuvant
hormonal therapy for those erpr positive.

Jason: So what about her to we have some her to targeted therapies and it was monoclonal antibodies for that with their her to receptor
is the prognosis. Better or worse if we have this? [00:55:00] We said ER PR positive is a better prognosis. What about with HER2? Yes,
it's actually worse. It's a worse prognosis, but there is a targeted treatment.

Jason: And what is that targeted treatment? Yeah, so trastuzumab or Herceptin and you put them on this for one year. Yeah, one year of
Herceptin and trastuzumab. What's the side effect of trastuzumab? Cardiac toxicity. Yeah, so that can cause cardiac toxicity. Okay

Jason: okay, so let's move a little, let's talk a little, we're almost done talking about breast cancer, but we have to talk a little bit about
axillary staging. So what is the most important prognostic factor in the staging of breast cancer? Yes, that's your nodal status. Yeah, nodal
status is extremely important.

Jason: So if you have 0 positive nodes, you have a 75 percent 5 year survival. However, if you have 4 10 positive nodes, that drops it
down to a 40 percent 5 year survival. So nodal status is very important. [00:56:00] Sentinel lymph node biopsy is indicated for all invasive
tumors. Something that actually, came was done during my residency and is now commonplace on exams is the Z11 trial.

Jason: So Kevin, what is a Z11 trial? Yeah. So this, they were comparing sentinel lymph node biopsies to axillary dissections. Yes, it's a
randomized controlled trial component comparing sentinel lymph node to axillary dissection. In women over 18 years old with a T1, T2
tumor and less than three positive sentinel lymph nodes who get breast conservation therapy plus whole breast radiation, there
recurrence, disease free survival, overall survival at a median follow up of 6.

Jason: 3 years. So the, so Z11 is very important for for boards. So if you have a patient who is over 18, has T1, T2, less than three
positive sentinel lymph nodes, [00:57:00] and is going to receive whole breast radiation therapy as part of their treatment, there's no
benefit from an axillary dissection. So that has decreased the number of axillary dissections that are being done and the associated
morbidity that goes along with that.

Jason: So who is an axillary dissection then recommended for?

Jason: So if you have clinically positive nodes confirmed by FNA or corneal biopsy, or if you have sentinel lymph nodes that are not
identified during a sentinel lymph node. Okay. So yeah, so again, those clinically positive axillary nodes still get axillary lymph node
dissections. You want to confirm that with your F with an FNA or corneal biopsy.

Jason: And then if you're doing your sentinel node and you can't identify the sentinel node on your sentinel node biopsy that's usually
due to the lymphatics being blocked with tumors. So those patients it's still recommended to get an axillary dissection. When you do an
axillary dissection going back to the beginning of the discussion.

Jason: What levels do we take? Levels one and two. Okay, so that's it for invasive breast cancer. Take levels one to[00:58:00] two. We
mentioned it before, but, repetition is the key to adult learning. If we're doing a dissection for a melanoma, what levels do you take? One
to three. Perfect. Okay. That's a lot.

Jason: Review that several times. You will get answers. You will get questions on breast cancer for sure. More recently, they've been
asking about reconstruction options. Oncoplastics is becoming the standard of care. So you do need some level of familiarity with breast
reconstruction and in the setting of breast cancer.

Jason: First we have our implant based reconstructions and with those we either have saline or silicone filled implants. But let's talk with
regard to tissue flaps. So what are our types of flaps? Yeah, so you have one of the go tos is an abdominal wall flap. And typically this
would be a pedicle transverse rectus abdominus flap, also known as a tram flap.

Jason: And what's the [00:59:00] artery that supplies that? So your superior epigastric artery. Okay. What are some other abdominal wall
flaps? So you can do a free tram flap. Yeah, you have pedicled and free tram flaps. Okay. And what else? You have your deep inferior
epigastric perforator flap.

Jason: And you have your superficial inferior epigastric artery flap. Okay. So those are your abdominal wall flaps, are there other
autologous flaps? Yeah, so you have your gluteal artery perforator flap, also known as the gap. And then you have your transverse or
vertical upper gracilis flap. You have your superior gluteal artery perforator flap and your latissimus dorsi myocutaneous flap.

Jason: Okay. And what's the, so with these flaps sometimes you'll see some complications. Flap necrosis is one that's commonly tested.
What's the most common cause of flap necrosis? Yeah, believe it or not, it's actually venous thrombosis. Venous thrombosis is your most
common cause of flat necrosis and smokers as you would expect are at [01:00:00] a significantly increased risk of flat necrosis.

Jason: All these patients we were talking about are in breast conservation therapy and whole breast radiation. What type of
reconstruction is preferred in patients with previously radiated breast? You want to do your autologous reconstruction in the previous
rated.

Jason: Kevin, what about patients with inflammatory breast cancer? We mentioned previously that, these patients aren't candidates for
skin sparing or nipple sparing mastectomy. Are they a candidate then for immediate reconstruction? No, they're not a candidate for
immediate reconstruction.

Jason: It is contraindicated in inflammatory breast cancer. Yeah, so immediate reconstruction is contraindicated in inflammatory breast
cancer. Those patients will need to undergo a delayed reconstruction. And remember, those are the patients that are getting, a kitchen
sink throttum. They're getting neoadjuvant therapy.

Jason: They're getting modified radical mastectomies. They're getting adjuvant chemotherapy, adjuvant radiation. So those are,
unfortunately, are patients that will have to have their reconstruction down the [01:01:00] road. Okay. So one thing you may see come up
is something called breast implant associated anaplastic large cell lymphoma. So what is breast implant associated anaplastic large cell
lymphoma? Yeah, so this is a rare lymphoma associated with textured breast implants. Okay, and how do these patients present? So
they'll have enlarging breasts with fluid collections around the implants. Yeah, so you'll see a big fluid collection and often this is delayed,
right? So these are, years down the road and you get a big fluid collection around the implant.

Jason: So how do you diagnose them?

Jason: So you'll do an aspiration of the fluid collection. Yeah, so you aspirate the fluid collection around the implant and send it for
cytology and pathologic evaluation. So yeah, that if you see that patient who had a breast implant and they're years down the road and
they have this now this new big fluid collection, that's definitely what you got to think about.

Jason: So you will probably get some questions on reconstruction and onchoplastics. Fortunately, they know we're not[01:02:00] plastic
surgeons and those are just some, key points and some pearls that will help you get help. You get a few extra points. With that, we are
going to move into our quick hits, and wrap up our discussion of breasts.

Jason: You ready for it, Kevin? Hit me. Okay. You have a patient presents with a dominant breast mass. What's the next step? So you're
gonna start with imaging. You're gonna get a bilateral mammography and or ultrasound. Yeah, so you're gonna move on to your
diagnostic imaging, right? so diagnostic mammography and or ultrasound, okay, so you have a concerning lesion on Mammography and
the core so you say you have a bireds for okay And so you're gonna get a biopsy so you get a core needle biopsy and that return returns
normal Are you reassured by this?

Jason: No, at this point, you need to do an excisional biopsy due to the discordant findings. Yeah, so it's discordant findings, so you need
to do, you're worried about sampling error, so you need a excisional biopsy. That's a classic question. Okay. Patient with complete clinical
[01:03:00] response after neoadjuvant therapy for inflammatory breast cancer.

Jason: What do you do then? Yeah, so they need a mastectomy with axillary lymph node dissection. Yeah, again, even with a complete
clinical response for neoadjuvant therapy, these patients still need a mastectomy and axillary lymph node dissection. Not skin sparing, no
immediate reconstruction. Not nipple sparing.

Jason: Those are all contraindicated with inflammatory breast cancer. Most common site for breast cancer metastasis. Where does it go?
It goes to the bone, the lung, the brain, and the liver. Okay, sometimes you'll see something called, they'll say isolated tumor cell deposits.
Does that make a patient M1, does that upstage them to stage 4?

Jason: No, if it's an isolated tumor deposit less than 0. 2. millimeters. It does not constitute metastatic disease. Okay. Yeah. Less than 0.
2 millimeters are isolated tumor cell deposits and do not constitute metastatic disease. That's very important. Okay. So you have invasive
cancer on the core needle biopsy and a palpable axillary [01:04:00] lymph node.
Jason: What's next? And so in this situation, you do an axillary ultrasound with FNA aspiration of the suspicious nodes. Yeah, so you
want to confirm that those are clinically positive nodes and that there's with your axillary ultrasound and either FNA or corneal biopsy.
Okay, so you have a woman with multicentric disease with calcification, calcifications extending to the nipple.

Jason: What are your surgical options? You have a skin sparing mastectomy but tumors that extend to the nipple and microcalcifications
encroaching on the subareola region and nipple retraction are all contraindications to a nipple sparing mastectomy. If you have extension
into the nipple areola complex nipple sparing is not an option, but you can still do skin sparing mastectomy.

Jason: Okay. What's the name of the valvulous venous system responsible for bony metastasis to the spine in breast cancer? Batson's
plexus. Batson's plexus. Okay. The rationale for radiation therapy in breast conserving surgery. Yeah. So it reduces [01:05:00] the risk of
ipsilateral breast disease recurrence, but does not increase survival.

Jason: So it reduces the risk of recurrence, not overall survival. What's the risk of breast cancer as well as ovarian cancer in the BRCA1
and BRCA2 mutations. So BRCA1 was the risk of breast cancer and the risk of ovarian cancer. Yeah, so the cumulative risk is 65 percent
for breast and 40 percent for ovarian.

Jason: Okay, BRCA2? 45 percent cumulative for breast and 10 percent for ovarian. Great, okay. Side effects of tamoxifen? So you can
have thromboembolisms, you can have Increased risk of uterine cancer, but it also decreases osteoporosis. Yeah, so for tamoxifen
thromboembolism, increased risk of cancer, but it's protective for osteoporosis, whereas your aromatase inhibitors, on the other hand,
those do increase osteoporosis risk.

Jason: Okay, you have a patient with a chronic lymphedema for 10 years following an[01:06:00] axillary dissection. Again, the axillary
dissection can be relatively morbid, and now they have a dark purple lesion on the upper arm. What is this? Yeah, this is like straight from
the 2012 ab site. This is the Stewart Treeve syndrome.

Jason: Yeah, and what is Stewart Treeve syndrome? Lymphangiosarcoma. Yeah, lymphangiosarcoma. Perfect. Okay 55 year old
woman who has had trauma to the breast and then notes a mass under the bruise. So she had the trauma and she had a bruise and now
she's got a mass in her line that bruise. What's the next step?

Jason: Yeah. So you need to start with mammography and ultrasound. Yeah. Again. So don't assume that this is just a hematoma or fat
necrosis. Patients may have trauma to an area and that brings attention to it and that's when they first notice the mass, so you still need to
treat it seriously as if it could be a malignancy, so diagnostic mammography and ultrasound.

Jason: What is Poland's syndrome? [01:07:00] So this is a patient with hypoplasia of the chest wall. They'll have amastia. They'll have a
shoulder.

Jason: Okay, what do we call the nodes between the pectoralis major and minor? These are rotter's nodes. Rotter's nodes, okay. Okay,
so you have a patient with a history of breast conservation therapy for DCIS, and she develops a recurrence. a mastectomy of sentinel
lymph node biopsy.

Jason: This patient is not a candidate for breast conservation therapy because the breast cannot be re irradiated. Okay, perfect. Alright,
that does it for our Behind the Knife Abscite Breast Review. Thank you for listening.