Breast cancer case - Your approach please - Forum

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Alalo

Breast cancer case - Your approach please - Ärzteforum

Post#1 »

From today's clinic:

50 year old heavy "mama". Very large "prolapsing" breasts.

Mammogram- microcalcifications in a lesion-left breast -outer upper quadrant (non palpable)

Axilla- ; single large mobile lymph node.

Your approach please.


John Dissector

Re: Breast cancer case - Ärzteforum

Post#2 »

It depends--this is one of those cases that you must see the calcifications--a
small area of Ca's less than one cm in size, less than 10 flecks, are well
established as safe to watch, which we do very routinely-- a more suspicious
cluster should be removed by needle-localized excision. A middle step of
stereotactic biopsy would not be wise if it is suspicious as it has to come
out regardless in that case--waste of money--and if it is nonsuspicious, you
just watch--again stereotactic is wasted--the stereotactic biopsy may be
indicated for the miiddle-risk lesion--birads 3 or 4 having malignant risk of
20-50%. which isn't often seen with calcifications. We have learned NOT to
blindly follow the radiologist's "recommendation" as in the majority of cases
they are TOO liberal in their recommendations, and are ralatively uninformed
in this area, and just covering their own asses--they have no stake in the
patient's outcome.
Seldom do their "recommendation" and my action coincide--it's good for the
patient to have a rational clinicla perspective to counterbalance the
radiologist report. I have always been of the opinion that the radiologist
should stick to what they're trained to do--tell us what they see--they have
virtually no clinical experience or training, so should stay away from the
clinical recommendations.

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Alalo

Re: Breast cancer case - Your approach please - Ärzteforum

Post#3 »

I agree; but what about the large lonely mobile axillary node?

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Resident

Re: Breast cancer case - Your approach please - Ärzteforum

Post#4 »

I would do a FNA biopsy of the axillary node in the clinic.

Marcel

Re: Breast cancer case - Your approach please - Ärzteforum

Post#5 »

I would needle to LN for cytology in the clinic. If you can establish a dx of
Ca that will be very helpful. If you establish this, then the course is
obvious, needle loc. mammo
followed by wide excision, XRT, and axillary lymph node dissection.
If cytology is negative, then I would again do needle loc., and open up the
axilla. This might be the rare case in which I would do a frozen section of
the LN or a touch prep. If the dx of Ca can be established, then proceed with
a level 1+2 axillary dissection. If not, then close and await permanent
sections on the breast specimen.

Poland

Re: Breast cancer case - Your approach please - Ärzteforum

Post#6 »

If I were at your institution, I'd excise the breast lesion with the
ABBI machine, and if malignant, do a sentinal node biopsy and remove the
enlarged lymph node.

forceps

Re: Breast cancer case - Your approach please - Ärzteforum

Post#7 »

Mammographic needle localisation,and excisional biobsy. If infiltrating
Ca then Mastectomy and axillary clearance due to difficulty of radiation
therapy to large breast.If Lobular Ca in situ then nothing, If DCIS
answer is still not in ,ideally admit in a controlled clinical trial. If
not practical wide excision without radiation is only option, mastectomy
is to drastic.

John Dissector

Re: Breast cancer case - Your approach please - Ärzteforum

Post#8 »

Alalo wrote:I agree; but what about the large lonely mobile axillary node?


That depends too--a fine needle aspiration biopsy would be my next step for
that and if malignant, then the calcifications would come out--if the latter
are then benign, and the node malignant, an axillary dissection is
indicated--in most cases thogh a solitary node does not affect what I do in
the breast--they are so often benign

John Dissector

Re: Breast cancer case - Your approach please - Ärzteforum

Post#9 »

forceps wrote:If DCIS
answer is still not in ,ideally admit in a controlled clinical trial. If
not practical wide excision without radiation is only option, mastectomy
is to drastic.


You need to beef up your reading. The NSABP B-17 trial was published 5 years
ago, and clearly shows that breast conservation is as feasible for DCIS as for
invasive cancer, as long as the same criteria can be met--i.e. that a margin
of normal tissue can be achieved. Lumpectomy alone without radiation is even
an option for DCIS if the lesion is small enough (<1cm) Mastectomy only
indicated if breast conservation can not be carried out, usually due to too
extensive disease--just like for invasive Ca


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