Welcome to First Incision. the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. Welcome to this extremely special episode of First Incision, where we are lucky enough to be joined by Ashwinnie Pondicherry, who is the current Breast Fellow at Christchurch Hospital, where I'm working this year as a Colorectal Fellow.
This episode is incredible. We are covering a number of cases and Ashwinnie is going to give you the royal tour of breast cancer management. Also, Ashwinnie is my first New Zealand guest, which is an extra special moment for this podcast. I'm sure you're going to learn heaps from this episode. So without further ado, Ashwini, could you start us off by telling us a little bit about yourself?
Hi everyone, I'm Ashwini as Amanda's just said. I am a current breast fellow in Christchurch Hospital and working with Amanda, who I've gotten to know quite well this year. Outside of work, I like doing a lot of creative things like painting, dressmaking, and I'm trying to keep up with Amanda with her running. Struggling a little bit right now, but enjoying it overall.
So today I've asked Ashwinnie to come onto the podcast to talk through a series of cases relating to breast surgery to try to cover a range of different topics and also talk a little bit about sort of exam presentation and viva presentation we're talking about. different cases. There's going to be some photos on the Instagram page that we will refer to different imaging photos but other than that we're just going to chat through some cases.
Okay, so our first case is a 57-year-old female. She's had a screen detected right breast abnormality and has been referred to you in clinic. Her past medical history is that she's had a previous left-sided, so the other side, wide local excision and radiotherapy for high-grade DCIS. Say you're in the exam, how would you go about talking through your history and exam?
I think both in an exam and real life setting with your history, it's really important to be systematic about it just to make sure that you don't miss any key aspects. I would start by just asking my patients some demographic details, like what do they do, who do they live with, what they usually do with their time to get a reasonable...
understanding of their functional status. And it's also a really nice way to establish rapport before you delve into sensitive things like a breast history and exam. Next, I'd focus on the actual problem at hand and I'd group this into the... Presenting complaint issues. So given this is a screen detected problem, you want to know whether they've been screened in the past and whether they've had any previous screen detected abnormalities other than what you already know with the left side.
and if they'd noticed any symptoms. So even if it is screen detected, some people do have symptoms that they haven't addressed or brought forward to medical attention. And then I'd move through the background risk factors for breast cancer. So that's both personal factors such as hormonal exposure, such as hormone replacement therapy, smoking history. what their treatment for their previous cancer included, how they coped with it and what their views around that are.
their family history most importantly you want to get an idea of whether there is a family history and what risk category that puts them in and you ask broadly about both breast and ovarian cancer history and some of the more uncommon cancer such as pancreatic and prostate cancer then I'd move into sort of social history you glean that a little bit when you're establishing rapport but I would ask specifically about smoking
alcohol, any other drug use. And I actually also do a brief anaesthetic history to see if they've had any previous problems with their general anaesthetic, what their past medical history is, their medications, their allergies, if there aren't any relatives. medications such as anticoagulants or immunosuppressants. And then with the breast exam, really important regardless of the gender of the clinician to have a chaperone there.
and explain to the patient what's going to happen prior to doing any of the exam. So I... start with saying we need to do an exam of both your breasts and also of your armpits and the neck region and that's really important to know whether there's any lymph nodes so that people have an understanding before you start doing it.
And then you tell them that ideally, I'd like you to be exposed down to the level of the waist. And then you give them a little bit of time to process that, get into the particular position. You have your nurse there who is a chaperone, but also an emotional support for the patient if they want.
a family member there that's completely reasonable as well and then as with any other exam you start with inspection palpation and then move through that and do it at a pace that's comfortable both for yourself and also for the patient
How do you systematically do a breast exam? So I'd start with having them exposed sitting up initially just to get a fair understanding of the size of their breasts, the level of ptosis, and this is important when you're thinking about reconstruction options in the future. or during the same operation. And then if there's any visual abnormalities that you can see, then I'd get them lying down and I'd start in a clockwise fashion using the palm of both my hands for my palpation of both.
and then also bilateral axilla and also supraclavicular nodal basins and document my findings as I go. So a little bit more in terms of history for this 57-year-old lady. She had DCIS in the left breast in 2014, which was 8mm in size and was high grade. It was excised with wide local excision and she had radiotherapy post. operatively to the left breast with no endocrine therapy. Her past medical history is she had a right partial nephrectomy in 2016. She went through menopause at age of 31.
not on any hormone replacement therapy, and she has osteoporosis. She's a non-insulin-dependent diabetic on glyclozide, and she's got high cholesterol on rosuvastatin. On family history, both of her parents had lung cancer, but there's no history of breast or ovarian cancer. And she's an ex-smoker having quit eight years ago. On examination, she's got A cup breasts. And there's no palpable mass or abnormality seen, but she does have a well-heeled left-sided breast scar from her previous surgery.
So having completed your history and exam and knowing that there is this screen detected abnormality in the right breast, what would you want to do next for this lady? So with any breast abnormality, you want to do triple assessment, which is imaging. And the standard imaging is a mammogram and an ultrasound, and depending on the findings, biopsy. So we'll put some pictures up on the Instagram page, but I have here some mammographic images for this lady.
In general, when you're looking at a mammogram, what are the sort of things you look at and what sort of system do you have for talking about mammograms? So with mammograms, there are two standard views that you obtain, which is a cranial caudal view and a... medial lateral oblique view.
So firstly you want to make sure that you have adequate images with the cranial caudal that you have the entirety of the breast on display and with the medial lateral oblique that you can see the pec muscle clearly and again that the borders of your breasts are visible. The next thing to note is if there's any obvious abnormalities that you can see and also which quadrant of the breast that you're dealing with.
So counterintuitively, it's the medial lateral oblique view that allows you to know whether this is a superior or inferior abnormality. And then it's the cranial caudal that helps you determine whether it's medial or lateral. So putting those two pictures together, you know. which quadrant of the breasts that you're dealing with. And then you want to comment on the actual abnormalities that you can see.
And the last thing with the mammogram is also getting a fair idea of the density of the breast. And there is a standardised way of scoring this, which is a BioRID system. This is useful because in very dense breasts, mammograms are less accurate. And so you may want to add an MRI to your imaging modalities preoperatively. And most units would comment on the density of the breasts.
on their report. So with this lady you can see that she has a area of architectural abnormality in the upper outer quadrant of the right breast with associated non-linear calcs. Posterior to this is also a rounded lesion that you can see, which is indeterminate at this stage, but given its rounded density, it could be benign.
Excellent. And on an ultrasound that was also performed as part of the assessment, they didn't find a corresponding lesion in that area where the calcifications were, but they did see that that circular lesion is most likely an intramammary lymph. node and that has been seen on previous imaging and has not changed in size or morphology.
And she's also had an axillary ultrasound bilaterally, which doesn't demonstrate any axillary lymphadenopathy. So now that they've found this abnormality on the mammogram, what would be the next step? So the next step with this lady would be to do an image-guided core biopsy of the breast lesion. If it is visible on ultrasound, this is a preferred method, but sometimes there is no imaging abnormality that can...
be found on the ultrasound so they might need a stereotactic guided biopsy. A core biopsy is preferred and that's because you'd want hormonal status off the abnormality. FNA is not performed routine. other than on lymph nodes. On lymph nodes, you can do a core or an FNA depending on unit preference, but definitely for the breast, you'd want to do a core biopsy.
So a core biopsy was performed stereotactically on this right breast area of calcifications, and that's demonstrated ductal carcinoma in situ, which is high grade. It's got a solid architecture, focal comedonecrosis. And the immunohistochemistry for the hormone receptors is that it's negative for estrogen receptor and weakly positive for progesterone receptor. So Ashwini, can you tell us what is DCIS?
So DCIS is ductal carcinoma in situ, which is a pre-malignant condition of ductal epithelium. And the characterising feature is that there is no invasion into the basement membrane of the cell, which distinguishes this from invasive. cancer so it has no propensity to spread outside of the breast but it can progress into invasive malignancy the rate of which is contentious but it is treated surgically. with DCIs, especially high-grade DCIs.
And so for this patient in particular, she's got a area of high-grade DCIS in the right breast. What are the management options that exist for this patient and how do you decide what would be the best management for this patient? So when we're thinking about breast surgery in any patient, let's start with any patient, there are two broad categories for treatment of the breast, which is breast conserving surgery and mastectomy.
and there are loads of factors that play into this so firstly the breast size to abnormality ratio which is quite important because if you've got a small breast to begin with
then removing a large amount of abnormality leaves you with too less tissue to leave them with an acceptable cosmetic outcome. And then there's a big factor of... patient preference and the psychology behind all of this and there are a cohort of patients that would request a mastectomy for DCIS and that's fueled by anxiety relating to surveillance. And so it's really important that this decision is a joint decision. Coming back to the patient at hand.
So she's got size A breasts, as we've previously mentioned, and she's got about 47 millimeters of calcifications, which is what we want to remove. And so that in itself is a lot of disease in a very small breast. So it would be difficult to do a breast conserving option for her. So I'd be counseling this patient for a mastectomy. But I'd also speak to the patient about whether or not she'd want to speak about reconstruction, whether in the immediate phase or the delayed phase.
But she does have a few comorbidities that would play a role into this decision making, especially this smoking. In terms of central lymph node biopsy, if you were doing a breast conserving option for DCIS, Unless there's a really high suspicion of invasive malignancy, such as mass associated with it, central lymph node biopsy is not routine in breast conserving surgery for DCIS. However, if you are doing a mastectomy for DCIS, you will...
want to stage the axilla with a central lymph node because if you do not do this and you've removed the breast, you've lost your opportunity to adequately stage the axilla. If the pathology comes back and it's a cancer. Correct. And what's the role of endocrine treatment and radiotherapy in patients with DCIS? In terms of radiation therapy for DCIS, there is a nomogram that can be used, which is the MSK nomogram.
that can be used to determine whether a patient will benefit from radiation therapy. In general, as it depends on the size, amount of low to intermediate grade DCIS, radiation therapy may be omittable. But they should all go through an MDM setting. The reason that we don't offer radiation for DCIs as a blanket rule is because DCIs in general has very good survival. We're talking 98% 10-year survival.
There's actually morbidity and compliance issues that come with adjuvant therapy, and this applies to both radiation therapy and endocrine therapy. And in general, endocrine therapy for DCIs is not standard treatment. With endocrine therapy for DCIS in the patient that we're discussing at the moment, her original hormonal status was ER negative and PR weekly positive. So it would be very low benefit to give this patient endocrine therapy. So moving on to our second case. Case two.
is a 95-year-old female. She's from a high-level care nursing home and she's been referred in by her GP with a palpable left-sided breast mass. She has a significant past medical history with multiple strokes in the past, type 2 diabetes, atrial fibrillation on apixaban. What would your workup be for this palpable left breast mass? So, as we've spoken earlier, the standard workout would be a comprehensive history and exam.
triple assessment with imaging and a biopsy of the palpable breast mass. And if there was any lymph nodes that were seen on imaging and an FNA or a core biopsy of the lymph nodes as well. Talking a little bit about imaging, there's going to be a picture for this case on Instagram, both of her mammogram and of her ultrasound findings.
As we talk through what you can see on this mammogram and ultrasound, can you also talk about which features are suspicious for malignancy? In general, in mammograms, the features that would raise suspicions of malignancy would be a speculated mass. with architectural distortion, any skin in drawing associated calcifications with this. The ultrasound features of a breast mass that should be commented on are the shape, the margin.
the orientation, whether it's taller than wide, the echo pattern and posterior enhancement or shadowing and associated calcifications. So usually you would see architectural distortion, duct changes, skin thickening, retraction, crossing of tissue planes, vascularity, so either absent or internal or rim enhancing, and posterior acoustic shadowing.
as part of your suspicious features on an ultrasound. And so looking at this lady's mammogram and ultrasound, can you describe what you can see? So on the left breast, there's two lesions at... The six o'clock position and the three o'clock position. The largest one is the deep-seated one at the six o'clock position, and the smaller one is the three o'clock position, which is closer to the nipple.
Excellent. And these lesions both look pretty suspicious for malignancy. And just a little bit more information, they didn't see any abnormal auxiliary lymph nodes. So on biopsy, they found invasive ductal carcinoma of no special type, which is BRE grade 2 with associated intermediate to high grade DCIS. In terms of the immunohistochemistry, the tumor is ER3 plus positive in more than 95% of cells, PR2 plus positive in 20% of cells, and HER2 is negative.
For this lady, what would your management recommendation be and why? So this lady is a 95-year-old core morbid patient with poor functional status. So it's really important to take a pragmatic approach with this. It is reasonable to use endocrine therapy in this lady as her primary cancer treatment, given that she's got a luminal A cancer.
So I would speak to the patient and their next of kin or if they have an EPOA about the options. She would be high risk for morbidity and mortality if we operated on her. given her age, her functional status, her comorbidities. So I'd make that very clear. And if the patient and the family member were willing, start endocrine therapy. as first line and then have short interval follow-up to make sure that they are responding to this and you can do this with a three to six month ultrasound scan.
to see what's happening with the size of the lesion and how the patient's tolerating endocrine treatment. In postmenopausal women, the first sign is always an aromatase inhibitor. Given her osteoporosis history, you'd want to get a baseline bone scan to ensure that we don't need to give her bisphosphonate treatment prior to this. And she would probably require another bone scan in two to three years time if she...
mains on endocrine therapy. So you've mentioned that an aromatase inhibitor would be appropriate for this lady. What's the other main type of endocrine treatment that we need to know for the exam and when would you use it? So the other main type of endocrine treatment that's used is a selective estrogen receptor modulator. And the most common one that we use in Australasia is tamoxifen. And that's used in the pre-menopausal women. So letrozole is our first line.
aromatase inhibitor in New Zealand. If its side effects are intolerable by the patient then we can use eczemestane and then as an addition in premenopausal women we can also use gosaralin which is an ovarian suppression treatment. So let's take a moment away from the cases. I thought we could do a little operative fiver. So...
In this operative viva, I want you to tell me how you would perform a left-sided simple mastectomy and the patient has already been consented and is prepped and draped on the table. And do it in a sort of what you would do in the exam situation.
Okay, in the exam situation, even though your stem has been the patient's prep and drape, I would still cover the preoperative steps that you would take. So in breast surgery, it's really important to mark the patient when they're awake, when they're sitting up, so you want to get a fair eye. idea of where their inframammary fold lies when they're sitting up and the borders of the breasts. So I do this in the preoperative setting prior to the patient going to sleep.
Once the patient's asleep, then I would make my definitive markings initially, which is where I would place my incisions. Important things to note is that you don't want to cross midline with the extent of your medial skin incision. and also laterally a lot of women have excess skin and tissue so you'd want to incorporate this to make sure that you don't leave them with a large dog ear.
There's multiple ways of marking your mastectomy skin flaps and there are... lots of different techniques that have been described so i would go with a technique that you do most commonly and you want to achieve a aesthetic flat closure that is the primary aim of a simple mystique to me
Give the patient a nice flat closure and the wound at the end isn't in a place where it would cause irritation either with the prosthesis or with the bra that they're going to wear. So that's why it's important to know where your inframemory fold lies. and the borders of the breast because you want to give the patient the best sort of cosmetic outcome, even in a mastectomy setting. In an operative vibe, I would say that I would then open my skin flaps using a...
15 blade. Then I would use retracting instruments to raise the skin flaps and create a mastectomy plane using diathermy down to the chest wall. Once I've reached the chest wall superiorly, I would then change positions with my assistants to then do the inferior skin flap. and then dissect the breast off the chest wall, leaving pec fascia in situ unless I was worried about invasion into the chest wall.
In that case, sometimes it is useful to take fascia with a margin off muscle overlying the mass. Once the breast is then... detach from the chest wall, then it's really important to check for hemostasis. And I would do this methodically in a clockwise fashion, moving from superior skin flap at the 12 o'clock position right around and take my time and use energy devices if appropriate.
Once this is done, then I would place a 15 French Blake drain into the wound cavity and then close my wound in layers with Vicral and Monocral as a subcuticular stitch. So nice.
Is that what you wanted? Yeah, it's great. And I was just saying to Ashwini before we started recording that it can be really hard to find examples of people actually talking through surgeries. So I try to do a little bit of that on the podcast because I think that's really handy leading up to your... operative vivas so you've heard it from a professional okay so we're going to go into the third case now
Our third case is a 54-year-old female. She's presented with right-sided self-detected breast lump. She's had a mammogram and an ultrasound that's demonstrated extensive right-sided breast malignancy with multiple abnormal auxiliary lymph nodes on that right side. She's had a core biopsy of the breast, which has demonstrated invasive breast cancer, which is BRE grade three. In terms of immunohistochemistry, this is ER negative.
PR2 plus positive and HER2 positive on CISH. She's had an FNA of her axilla, which is positive for metastatic malignancy. So what would be your next steps in the workup of this patient? This lady has node positive extensive malignancy in her breast. An important thing to note with her is that she's HER2 positive. So these...
two reasons that she would be appropriate for neoadjuvant chemotherapy up front, which is node positivity and also HER2 positive cancer. So the next steps with her would be... to adequately stage her. And the way that we would do this is a bone scan to make sure that there's no menesthetic disease and secondary a CT chest, abdomen, pelvis.
And also it's routine in our unit to do an MRI of the breast for patients undergoing neuroadjuvant chemotherapy because that then becomes imaging modality to check for response to treatment. The patient also needs a clip placed into the primary breast abnormality and also a clip placed into her positive lymph node.
And again, this is important because if she has a complete radiological response post chemotherapy, then we need to know which area of the breast to resect to ensure that she has pathological response as well as just radiological. And there is a move towards doing less in the axilla with a node-positive patient who shows response post-cineoadjuvant therapy in the axilla as well, which is why it's important to clip the lymph node.
So this lady gets systemic staging and she doesn't have any evidence of metastatic disease. So what would usually be the treatment recommendation for this patient? So they get AC, Paclitaxel and Herceptin in the new adjuvant setting. The treatment period usually lasts six months and they get a post-treatment MRI scan to check for treatment response.
Depending on treatment response, then you speak to the patient about surgical options. Post-operatively, you want to know whether they've had a complete pathological response or if there's any residual cancer. If they had a complete radiological response or a significant radiological response, then it's reasonable to offer breast conserving surgery to a patient with localised wide local excision and the methods are...
wire or non-wire technology that's available right now. The factors that you would usually take into account between choosing breast conserving and mastectomy still apply to the size of the breast, the area of the abnormality. And then the real nuance these days is what to do about the axilla in a post neoadjuvant setting.
Given that they had a positive lymph nodes preoperatively, the standard practice is to do an axillary clearance regardless of the response to treatment in the axilla. However, more recently, there's been a push towards doing targeted axillary dissection. which the technical definition is removal of the clipped node as well as doing a sentinel lymph node biopsy instead of a complete clearance if they had a complete response on imaging.
And the way that you would do this, again, defers with different surgeons, but you would do your central lymph nodes with dual mapping with technetium and blue dye and removal of the clip node, either by localizing it using a non-wire localizer. or x-raying the specimen of your central lymph node to see if the clip node's in there. But the principle of it is removal of the clip node and doing a central lymph node biopsy.
And so if the patient has a complete pathological response in the breast and the axilla, do they get any more ongoing treatment with oncology? So they will complete Herceptin treatment. In most centres for 12 months, although that duration is changing in some centres,
but they don't require any ongoing chemotherapy. And then dependent on their hormonal status, so estrogen and progesterone status, they might also add endocrine therapy into the mix here. And if they have... not had a complete pathological response, so there's still viable tumour cells in the postoperative specimen, do they get any different treatments?
So if there is residual cancer in the specimen, then they would switch over to TDM1, which is a version of trastuzumab, which has a chemotherapy agent that's combined with trastuzumab, which is a targeted. So in essence, it's chemotherapy that's delivered via the trastuzumab directly to the cancer cells. So that's what oncology would switch them to.
And I think that's a new thing since the first round of podcasts that I did on breast cancer. There was the Catherine trial that came out that showed that there was a survival benefit for those patients who had not had a complete pathological response and switched. them to TDM1. So just something to note that's a new thing since I last talked about breast on first incision. So let's say this lady does not have a complete
radiological response. And so you decide to go ahead with an auxiliary clearance. Can you talk us through an auxiliary clearance as an operative viva? Sure. So I'd make sure that the patient had their arm free draped because it's important to have mobility of that arm for your auxiliary clearance. And then I would make a right auxiliary lazy S type incision.
about a centimetre to below the hair-bearing part of the axillary skin. Once I do this, I would then dissect down through claviopectoral fascia to enter axilla proper. So principles of an axillary clearance is to remove all fatty lymphatic tissue between the borders of the axilla. up to level two of the axilla. So just to refresh people, so the axilla is divided into level one, two and three based on its relationship to pec minor.
So you want to clear any tissue that's lateral to pec minor and behind pec minor or posterior to pec minor, but there's no benefit in doing level three clearance unless you've got evidence of disease in that level. The next step would be to identify the important anatomical landmarks of an axilla and the borders of an axilla.
So the borders of the axilla laterally would be the fascia overlying the lat dorsi. Medially, it would be the fascia overlying serratus anterior and pec minor. And then inferiorly, it would be where the angular vein. drains into the thoracodorsal vein. Superiorly, it is at the level of the auxiliary vein. Important steps. So I start with defining the border medially and then defining my border laterally.
There are multiple ways of finding your auxiliary vein, which is finding a venous tributary more distally and then following that up to the auxiliary vein. But my preferred method is to find the pectoral bundle, which would be at the most superior aspect of my medial. dissection and then follow that as it drains into the axillary vein. Once you've identified your axillary vein, that then becomes your superior extent if you were doing a level 1-2 clearance.
The next step would be to identify the important neurovascular structures which is the long thoracic nerve and the thoracodorsal nerve. Again, a tip would be these nerves tend to run in the same... plane so once you find one of the nerves then in terms of the anterior posterior depth of where that nerve lies the other nerve lies in the same plane
I find the long thoracic nerve easier to dissect out, overlying the fascia of the serratus anterior. And once I find this, then I use a peanut to sweep it away and ensure that it remains on the side of the chest wall. them being retracted into my specimen. The most common place of injury of this nerve is actually more superiorly. When you are getting that tissue between the chest wall and the medial aspect of the axillary veins, it's really important to continue that sweeping method superiorly.
And then once I do this, then I then go on to identify my thoracodorsal bundle. Usually you have a central vein of the axilla that's more superficial to the true thoracodorsal bundle. I wouldn't take this vein until I've identified the proper bundle. And once I've identified that, then I take the more superficial central vein of the axilla using Ligoclip. and an energy device, whatever your preference is.
and then sweep down all of the lymphatic tissue that is in between these two structures, and then complete my lateral dissection, which is all the lymphatic tissue between the thoracodorsal and the lat dorsi, down to my inferior extent. check for hemostasis and then I'd actually palpate in my level three just to make sure that there isn't any palpable nose because if they are you want to remove them.
And then I'd leave a 15 French Blake drain into the axilla. In really slim patients, sometimes I would have to drop that down to a 10 French. Then again, I would close the wounded layers with Vicro and then monoclonal to skin. So for our final case, we're going to talk about a patient. She's 51 years old. She's premenopausal. She has a one-month history of a heavy, painful breast with new nipple inversion.
The GP initially treated her with antibiotics and eventually sent her to a breast surgeon when there was no improvement. She has no family history of significance, no other risk factors for breast cancer, and she's otherwise fit and well apart from depression. And her last mammogram was five years ago. So on examination, you find a diffusely swollen edematous and red right breast with nipple inversion. There's two palpable lymph nodes in the right axilla.
But no definite mass in the right breast and the left breast, axillas and supraclavicular fosses are all normal. So again, I'll put the images up onto the Instagram page, but Ashwini, could you tell us what you can see on these mammographic images for this patient? So on this... mammographic image the most distinct feature is the skin thickening that is diffused around that right breast and also a
generally edematous spress. There are some microcalcifications associated with this mammographic image but they are actually very difficult to note. The other thing to know is that she's got quite dense breasts, but other than that, there isn't much else that you can comment on in these pictures.
And then this patient goes on to have an ultrasound. On ultrasound, a small area of abnormality is seen that looks abnormal and a core biopsy is performed. This initial core biopsy on this right breast lesion at the 10 o'clock position demonstrates invasive. breast carcinoma but it's too small to perform immunohistochemistry although clinically there's a suspicion for inflammatory breast cancer so she also has skin punch biopsies performed and this demonstrates
dermal lymphatic invasion with malignant breast cancer. And the immunohistochemistry on these punch biopsies demonstrates that the tumor is ERPR negative as well as HER2 negative. So what would you do next for this lady? So with this patient, the important things to note, and you can actually use this technique in an exam setting where it allows you a moment to just compose yourself and then reflect to the examiners that you have actually picked up.
on the important bits. So this is a lady who's got both biopsy and clinical suspicion of inflammatory breast cancer. And the other important thing is that it's a triple negative breast cancer. So again, she's got two reasons why she would be eligible for neoadjuvant chemotherapy. And the next steps are similar in the sense that you would want to stage her appropriately with a CT and a bone scan and get an MRI scan. It's really important to have a good handle on inflammatory breast cancer.
Inflammatory breast cancer is a clinical diagnosis. So this includes rapid onset of erythema, edema, poterage. which occupies at least a third of the breast, duration of no more than six months, with or without an underlying breast mass. Pathologically, what you're looking for is the presence of tumour within dermal lymphatics.
but it's not required to make the actual diagnosis. So that's why it remains a clinical diagnosis. So inflammatory breast cancer is something I really struggled to get my head around when I was studying for the exam. Can you talk a little bit about... the pathophysiology of this condition and why it actually happens? So the pathophysiology is assumed to be tumor microemboli that cause obstruction of dermal lymphatics, which then causes increase
pressure in the lymphatic system that causes lymphedema of the skin, thickening, erythema. It may involve any subtype of invasive breast cancer. But it's usually ductal compared to lobular. And more frequently is ERPR negative HER2 positive, which is about 50% of the cases. And it's high grade. And from what I understand, it has a really terrible overall prognosis. So a lot of the treatment that... we give these patients is pretty aggressive because of that.
Yeah, correct. So the quoted figures are up to a third of patients who present with inflammatory breast cancer have metastatic disease at presentation, which is why the treatment tends to be systemic in nature first. And this lady unfortunately has the double whammy of also having a triple negative breast cancer. Triple negative breast cancers are also quite poor prognosis compared to the other types of breast cancer.
Yeah, correct. So again, a second hat of why she really needs systemic chemotherapy first, which would again be an anthraciclin and taxane. In this patient, she wouldn't require her to target a therapy, so it would just be AC and paclitexel. So this lady has a staging CT chest abdopelvis and a bone scan that don't show any evidence of metastatic disease.
Would she be a candidate to be sent for genetic testing? So currently, as part of the New Zealand guidelines, she wouldn't. But if she was to have triple negative breast cancer diagnosed under the age of 50, she would.
Obviously, family history plays a part in this, but again, as we heard before, this lady does not have any family history of note, so in this setting, no. Just talking about indications for genetic testing, which I actually always struggle to get my head around while studying for the exam. Broadly speaking, there's breast cancer history. So if you had a known family mutation off a cancer predisposition gene, then that would make you eligible.
In terms of personal history, you'd have triple negative breast cancer diagnosed under the age of 50, high-grade, non-mucinous, epithelial, ovarian, fallopian tube or primary peritoneal cancer. Lobular breast cancer and a family history of either lobular or diffused type gastric cancer. Just in general, any type of breast cancer under the age of 40. Any males with breast cancer.
Or if you had two primary cancers, so breast and ovarian. Or if you had two primary breast cancers where one of them was under the age of 50, regardless of hormonal type. And breast cancer... plus a personal family history of those syndromes that we spoke about earlier. There's also a separate category for family history. So you have two first degree... all second degree relatives diagnosed with breast ovarian cancer plus one or more of the following on the same side. So a third relative.
If one of those relatives were diagnosed under the age of 50, breast or ovarian cancer in the same woman again, Ashkenazi Jewish heritage or male breast cancer? So we've talked about how she would be a prime candidate for some neoadjuvant chemotherapy and you would restage her with an MRI after she completed her neoadjuvant chemotherapy. What would be the treatment intent for surgery for this patient? So with inflammatory breast cancer, the standard treatment would be a mastectomy.
And skin or nipple sparing mastectomy is also contraindicated because you already have dermal invasion of the lymphatic. So it's considered high risk to do a skin sparing mastectomy. Most of these patients then require post-mystectomy radiotherapy as well. And in most units, then immediate recon is also out of the question because people don't... routinely offer immediate reconstruction when there is radiotherapy planned.
However, this is not in every single surgeon's hand. So in the exam setting, I would just say that in this patient, their standard treatment would be a mastectomy and an axillary clearance. So this lady has her mastectomy and her auxiliary clearance, and although she has had some response to her neoadjuvant chemotherapy, there is residual cancer in the specimen. Would she be eligible for any adjuvant therapies?
Yes, she would. Because she's HER2 negative, she doesn't qualify for the TDM1 amphibus that we spoke about previously, so she requires systemic chemotherapy. And the agent of choice with... these patients is oral capcitabine, which is an anti-metabolite. And this is another...
new things since my last range of breast podcast episodes. So there was a trial that came out that I think was published in the New England Journal of Medicine that showed that adjuvant capsidabine for patients with residual disease, post neoadjuvant chemotherapy. who have triple negative breast cancer, does have a survival benefit. So these patients should get adjuvant capcitabine.
Yeah, correct, because they, by proxy of what they've had previously shown, progression on the taxane and the anthracycline, so that's why you change the agent to capcitamine. So say this lady had not had inflammatory breast cancer. Say we've got a patient who's got a mass in the breast and that's been diagnosed as a triple negative breast cancer but no evidence of inflammatory breast cancer.
Would all patients get neoadjuvant therapy with triple negative breast cancer or would there only be particular patients that would get neoadjuvant chemo? I think with the triple negative breast cancer... most patients would get upfront neoadjuvant chemotherapy. There's always caveats to this. So if it's a very small lesion in a patient that is unlikely to tolerate neoadjuvant chemotherapy, then surgery...
may still happen in an upfront setting. Again, this just hits home the importance of an MDT. So my exam answer would be for triple negative breast cancers. It is always important to discuss it in an MDT setting because most patients benefit from upfront neodrivent chemotherapy, but there is a small subset of patients where upfront surgery may be reasonable.
And you mentioned that this lady would probably get radiotherapy postoperatively. What is the role of radiotherapy post-mastectomy? Who gets it? So the indications for post-mastectomy radiation therapy are... node positive disease so this means that they would get radiation therapy to both the chest wall but also the axillary nodal basin. In terms of breast cancer characteristics, so inflammatory breast cancer is an indication for post-mystectomy radiotherapy, locally advanced breast cancer.
and then chest wall involvement or closed margins. These are the high risk features that could be considered for post-mystectomy radiation therapy. all of which should be discussed in MDM, but sometimes extensive LVI in itself would tip the balance towards post-mystectomy radiation therapy. And in general for breast cancer, what is the sort of surveillance protocols that these patients go on post-treatment?
For post-treatment in general for breast cancer, you would do annual mammograms. In New Zealand or in Christchurch currently would be, depending on age at diagnosis, for minimum of 10 years post. and also a clinical review yearly.
And if it's a high-risk cancer for the first two years, this can be as frequent as six monthly. In terms of the length of clinical review, most people would get reviewed in a clinic setting between two to five years, depending on... the original cancer characteristics and the implied prognosis associated with this.
If they are in endocrine treatment and they're postmenopausal, as I've mentioned before, it's also important to take into account their bone health and add that into their surveillance as well, which would be a bone density scan at baseline. and then usually at around the three-year mark. And then depending on the length of treatment, which tends to be five years, but sometimes 10 years, then you can do a repeat one at the eight-year mark.
All that completes the cases for today. Thanks so much for coming on to the program. No problem. It's been amazing having you. I'm sure everyone's going to learn so much from listening to this episode and hopefully we'll have you on again soon. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!