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

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

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

4. DCIS

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

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

8. Breast Lymph Nodes
Rotor node: inter-pectoral

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

10. BI-RADS

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

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

13. Case Presentation

14. Chief Complaint:
Painful and erythematous L. axillary mass

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

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

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

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

19. 4/22/2016
Bilateral screening mammogram

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

21. 7/25/2016
Left breast U/S

22. 7/25/2016
Left breast U/S:
Indication: Abnormal mammogram (from April)
Left breast axillary tail at 1 O’clock, 2.1 x 1.7 cm pathological adenopathy with irregular vascularities and increase in thickness of the cortex
Bi-RADS 4: suspicious abnormality, biopsy should be considered

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

24. 9/12/2016
Lymphadenectomy (excisional biopsy)
Pathology of L axillary mass:

25. 9/12/2016
Lymphadenectomy (excisional biopsy)
Pathology of L axillary mass:
Invasive ductal carcinoma, Nottingham grade 3 of 3, with necrosis and perineural invasion
Ductal carcinoma in situ, high grade, cribriform and comedo necrosis types  

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

27. 9/30/2016
MRI Bilateral breasts
MRI NEGATIVE

28. 9/30/2016
MRI Bilateral breasts
No findings of occult breast malignancy
Site of left axillary tail previous resection did not show any abnormal enhancement or mass
Bi-RADS 6: known bx, proven malignancy
 Occult breast malignancy that is not even delineated by breast MRI or mammogram

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

30. 10/10/2016
Left modified radical mastectomy
Left axillary lymph node dissection
Excision of left axillary biopsy scar site

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

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

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

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

35. Henri Matisse