Distant metastasis with ipsilateral supraclavicular nodes

SURGICAL. The goal of surgery is control of cancer in the breast and the axillary nodes. Most women have a choice of surgical procedures, but it depends on the clinical stage, tumor location, contraindications to radiation (pregnancy, collagen disease, prior radiation, multifocal tumors), and the presence of other health problems. Several types of surgical therapy are commonly available, as follows.

MODIFIED RADICAL MASTECTOMY (TOTAL MASTECTOMY). The most common surgical procedure for mastectomy removes the entire breast and some or all of the axillary nodes, as well as the lining over the pectoralis major muscle. At times, the pectoralis minor muscle is removed.

BREAST-PRESERVING SURGERIES. The breast-preserving surgeries combined with radiotherapy are recognized to be equivalent to modified radical mastectomy for stages I and II breast cancer for survival rates and local control.

Sentinel lymph node biopsy, a procedure using a radioactive tracer to determine which lymph nodes need to be removed during a mastectomy, is under investigation. This procedure will allow fewer lymph nodes to be removed, decreasing the uncomfortable side effect of lym-phedema that can occur with surgery.

COMPLICATIONS OF SURGERY. The complications of breast surgery may be infection, seroma (fluid accumulation at the operative site), hematoma, limited range of motion (ROM), sensory changes, and lymphedema. A seroma is usually prevented with the placement of a gravity drainage device (Hemovac, Jackson-Pratt) in the site for up to 7 days postoperatively. Drains are usually removed when drainage has decreased to about 30 cc per day. ROM for the lower arm is begun within 24 hours postoperation, and full ROM and other shoulder exercises are ordered by the surgeon after the drains are removed. Sensory changes include numbness, weakness, skin sensitivity, itching, heaviness, or phantom sensations that may last a year.

152 Breast Cancer

RADIATION THERAPY. Radiotherapy is routinely given 2 to 4 weeks after breast-preserving surgery for stages I and II breast cancer. Sometimes, it is indicated after modified radical surgery if four or more nodes are positive. The incision needs to be healed, and ROM of the shoulder should be restored. Radiotherapy may consist of an external beam to the breast for 4 to 6 weeks or by an experimental method called brachytherapy (interstitial iridium-192 implants) directly to the tumor site, or both. Radiation can be given at the same time as chemotherapy.

CHEMOTHERAPY/HORMONAL THERAPY. Combination chemotherapy is recommended for pre- and postmenopausal patients with positive nodes. Hormonal therapy is used to change the levels of hormones that promote cancer growth and increase survival time in women with metastatic breast cancer. Tumors with a positive ER assay (tumors that need estrogen to grow) have a response rate to hormonal therapy of 65% compared with a 10% response rate with negative ER assay. PR assays that are also positive enhance endocrine therapy response even more. There is a 77% response rate if both ER and PR are positive, as compared with a 5% response rate if both are negative.

AUTOLOGOUS BONE MARROW TRANSPLANT (ABMT). Certain patients (with chemosen-sitive tumors) with stage III cancer are being treated with high-dose chemotherapy preceded by removal of the patient's bone marrow, which is then restored after chemotherapy.

RECONSTRUCTION. Approximately 30% of women who have mastectomies choose to have breast reconstruction (Table 5).

• TABLE 5 Types of Breast Reconstructive Surgery
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