Breast Cancer - Bailey & Love's Short Practice of Surgery (28th Ed.)

1. Risk Factors

2. Pathology

• Milk ducts: 90% - ductal carcinoma
• Lobules: 10% - lobular carcinoma

• In situ disease = confined to epithelium, no breach in basement membrane
• Invasive/infiltrative = breach through basement membrane

1. Tubule formation
2. Nuclear pleomorphism
3. Mitoses per HPF

• Grade I: Total score 3-5
• Grade II: Total score 6-7
• Grade III: Total score 8-9

• Invasive NST (No Special Type): Most common
• Mucinous/colloid carcinoma: Better prognosis; cells produce abundant mucin
• Medullary carcinoma: Solid sheets of large cells, marked lymphocytic reaction
• Tubular carcinoma: Better prognosis
• Papillary carcinoma: Rare (0.5-1%), fibrovascular core, usually ER-positive, rarely spreads to lymph nodes

• ER, PR, HER2/neu, AR overexpression
• Ki-67 mitotic index reflects proliferation rate

3. Molecular Classification (Table 58.4)

4. Staging (AJCC TNM, 8th Edition)

• LCIS is classified as a high-risk benign lesion, not a cancer
• Multiple synchronous tumours: (m) modifier
• Post-neoadjuvant status: (y) prefix
• Pathological complete response (pCR) = absence of tumour in breast and nodes
• Inflammatory carcinoma stays classified as such even after complete remission on NACT
• T1mi = invasive foci ≤1.0 mm; tumours >1 mm but <2 mm rounded up to 2 mm

5. Metastatic Work-up

• Locally advanced BC (T3, T4 / N2, N3): Contrast-enhanced CT chest/abdomen/pelvis + isotope bone scan
• Early BC (T1, T2, N0, N1): Metastatic work-up only if symptomatic or raised ALP
• PET-CT (18F-FDG) may be used for metastatic staging

6. Treatment - Multimodal Approach

A. Neoadjuvant Systemic Therapy (NAST)

1. Locally advanced BC (T3, T4 / N2, N3): to downsize tumour
2. Selected early BC:
   • To facilitate BCS
   • HER2/neu-positive tumours
   • Triple-negative BC (TNBC)
   • Premenopausal women (<50 yrs)
   • Axillary node metastasis

B. Surgery

• Removes tumour + 1-cm margin of normal tissue
• Specimen orientation: long suture = lateral; short suture = superior
• Positive margins → "cavity shave" re-excision
• All BCS patients receive radiotherapy: BCS + RT = Breast Conservation Therapy (BCT)

• Multicentric tumour
• Diffuse microcalcifications on mammogram
• Large tumour-to-breast ratio
• Two positive surgical margins after re-excision
• Previous breast/chest wall radiation
• SLE or other collagen vascular disease
• Ankylosing spondylitis
• Severe orthopnoea (patient cannot lie on radiation table)

• Volume displacement (level 1): Local breast tissue rearrangement
• Volume replacement (level 2): Distant/local flap
• Goal: Maintain shape and symmetry after wide-margin excision

Figure 58.38 - Surgical options for breast conservation and reconstructive options after mastectomy (Bailey & Love 28th Ed.)

C. Axilla Management

• Standard of care for clinically node-negative axilla
• Uses dual tracers: radioisotope + blue dye (or fluorescein/ICG)
• If SLNB negative: no further axillary surgery needed
• If SLNB positive (1-2 nodes): axillary node dissection may be avoided in selected patients

• Level I and II nodes routinely removed
• Level III dissection reserved for enlarged level I and II nodes

• A metal clip or India ink is applied to a positive node before NAST
• At surgery, the clipped/tattooed node is removed with SLNB
• Reduces false-negative rate if ≥3 sentinel nodes removed

D. Breast Reconstruction

• Immediate: Patient wakes up with breast mound
• Delayed: 6-12 months post-adjuvant treatment

• Latissimus dorsi flap
• TRAM flap (transverse rectus abdominis myocutaneous)
• DIEP flap (deep inferior epigastric perforator) - most commonly used in the UK; requires microvascular skill; ~4 hours operative time
• Anterolateral thigh flap

E. Adjuvant Radiotherapy

• Locally advanced BC (T3, T4 / N1, N2, N3)
• Following all BCS
• After mastectomy if: tumour ≥5 cm; skin/chest wall involvement; LVI + grade 3; axillary LN positive

• Node-negative after BCS: 45-50.4 Gy in 25 fractions OR 40-42.5 Gy in 15-16 fractions (hypofractionation)
• Node-positive: locoregional RT covering chest wall, supraclavicular region, internal mammary nodes, and axilla
• Do not irradiate axilla after axillary node dissection - increases lymphoedema risk

• Women ≥50 years, T1 disease, negative margins (≥2 mm), invasive ductal carcinoma, no LVI, ER-positive

F. Adjuvant Systemic Therapy

• Anthracycline-based (AC/FAC) followed by taxane-based regimens
• HER2/neu-positive: add trastuzumab (targeted therapy)

• Tamoxifen (SERM): Used in premenopausal patients
  • Low risk: 5 years
  • High risk (node positive, tumour >5 cm, LVI): 10 years
• Aromatase inhibitors (anastrozole, letrozole, exemestane): Used in postmenopausal women
  • Better relapse-free and overall survival vs. tamoxifen
  • Associated with bone density loss; baseline bone scan required; bisphosphonates + Vit D + calcium given

7. Metastatic Breast Cancer (Stage IV)

• Hormone receptor-positive + bony/limited visceral mets: Endocrine therapy preferred
• Hormone receptor-negative / hormone-refractory / visceral crisis: Systemic chemotherapy
• Bony metastasis: Palliative RT to weight-bearing areas (vertebra, femur) + bisphosphonates
• Symptomatic pleural effusion: Intercostal drainage + pleurodesis
• Solitary visceral metastasis (good performance status): Surgical resection may be considered
• Oral metronomic chemotherapy: Cytostatic + antiangiogenic; helps quality of life

8. Hereditary Breast Cancer (HBC)

• HBC (identifiable mutation): 5-10% of all BCs
• Familial BC (no known mutation): 20-30% of all BCs
• HBC features: more aggressive, earlier onset, more often multicentric and bilateral

• 50-85% lifetime risk of breast cancer
• Up to 40% risk of ovarian cancer
• Breast cancers mostly TNBC

• 50-60% lifetime risk of breast cancer
• 20% risk of ovarian cancer
• Also associated with prostate, colon, gallbladder, bile duct, stomach, and pancreatic cancer
• More common in male breast cancer

• Bilateral risk-reducing mastectomy with immediate reconstruction: reduces BC risk by 90%
• Chemoprophylaxis (tamoxifen or anastrozole): reduces risk by ~50%
• Bilateral salpingo-oophorectomy: offered to premenopausal women after completing family (~35-40 years)

• Known pathogenic variant in family
• BC diagnosed ≤50 years
• TNBC diagnosed ≤60 years
• Two breast cancer primaries
• BC + relative with BC ≤50 yrs, ovarian cancer, male BC, pancreatic or high-grade prostate cancer
• BC with two or more affected relatives
• Male breast cancer

9. Breast Cancer in Pregnancy

• Associated with aggressive biology (TNBC)
• Imaging: USS, mammogram + chest X-ray with abdominal shielding; MRI without gadolinium if bone/brain mets suspected
• Avoid: CT and PET-CT (high radiation dose)
• Surgery can be performed in any trimester
• Genetic counselling should be offered

10. Follow-up of Operable Breast Cancer

• Annual mammogram for all
• Annual contrast breast MRI for: implant patients, BRCA/other genetic mutation carriers

11. Screening

• UK: All women aged 50-70 years invited for mammographic screening every 3 years
• Screen-detected tumours: 90-95% long-term survival in high-income countries
• India: National multidisease screening for women aged 30-65 years (mouth, breast, cervix)
• In LMICs: Clinical breast examination (CBE) by trained healthcare professional + breast self-examination
• Suspicious mammogram lesion: image-guided biopsy; metal clip inserted for impalpable lesions; wire-guided excision if malignant

Recent Evidence Note: A 2025 meta-analysis (PMID 39878175) found that SLNB after NACT in clinically node-positive patients carries a higher false-negative rate than previously appreciated, reinforcing the importance of the targeted/clipped-node technique described above. A 2024 systematic review and meta-analysis (PMID 39370318) on surgical treatment in older breast cancer patients found that age alone should not drive decision-making, aligning with the MDT-based approach in Bailey & Love.