Development and Physiology

1. Development and Physiology During adolescence, the breast is composed primarily of dense fibrous stroma and scattered ducts lined with epithelium.In the breast, this hormone-dependent maturation (thelarche) entails increased deposition of fat, formation of new ducts by branching and elongation, and the first appearance of lobular units. The postpubertal mature or resting breast contains fat, stroma, lactiferous ducts, and lobular units. During phases of the menstrual cycle or in response to exogenous hormones, the breast epithelium and lobular stroma undergo cyclic stimulation. In the late luteal (premenstrual) phase, there is an accumulation of fluid and intralobular edema. It is probable that this edema produces both pain and breast engorgement. With pregnancy, there is diminution of the fibrous stroma to accommodate the hyperplasia of the lobular units. This formation of new acini or lobules is termed the adenosis of pregnancy and is influenced by high circulating levels of estrogen and progesterone and by levels of prolactin that steadily increase during gestation. After birth, there is a sudden loss of the placental hormones. A continued high level of prolactin is the principal trigger for lactation.

2. Investigation of breast diseasesFine-Needle Aspiration It can be done with a 22-gauge needle, an appropriate size syringe. Its main utility is the differentiation of solid from cystic masses, but it may be done whenever a new dominant, unexplained mass is found in the breast. A cytologic examination of the aspirated material is performed This simple procedure is postponed only if mammography is necessary and there is worry that a small hematoma, resulting from needle puncture, might confuse the radiographic evaluation. Carcinoma will not be missed if a surgical biopsy is done when (1) needle aspiration produces no cyst fluid and a solid mass is diagnosed, (2) the cyst fluid produced is thick and blood tinged, and (3) fluid is produced but the mass fails to resolve completely. (4)rapid accumulation of fluid after initial aspiration (<2 weeks).

4. BREAST IMAGING • Breast radiographic imaging is used to detect small, nonpalpable breast abnormalities, to evaluate clinical findings, and to guide diagnostic procedures. • Mammography is the most sensitive and specific imaging test currently available, though 10% to 15% of clinically evident breast cancers have no mammographic correlate. • Screening mammography is performed in efforts to detect breast cancer that is not clinically evident. • Ultrasonography is not used as a screening tool or in the evaluation of mammographic microcalcifications, but in a directed fashion to evaluate a breast mass and characterize it as cystic or solid. • Computed tomography appears to be the best way to image internal mammary nodes and to evaluate the chest and axilla after mastectomy. • Magnetic resonance imaging (MRI) is the imaging method of choice to evaluate implant rupture. It may be used in (occult breast cancer). MRI sensitivity for invasive cancers approaches 100% but is only 60% at best for DCIS.

5. Mammogram

7. Magnetic resonance imaging (MRI) is of increasing interest tobreast surgeons in a number of settings: • It can be useful to distinguish scar from recurrence in women who have had previous breast conservation therapy for cancer (although it is not accurate within 9 months of radiotherapy because of abnormal enhancement). • It is the best imaging modality for the breasts of women with implants. • It has proven to be useful as a screening tool in high-risk women (because of family history). • It is less useful than ultrasound in the management of the axilla in both primary breast cancer and recurrent disease Magnetic resonance imaging scan of the breasts showing carcinoma of the left breast (arrows). (a) Pre-contrast; (b) postgadolinium contrast; (c) subtraction image.

8. Large-Core Needle Biopsy • LCNB increasingly is the diagnostic method of choice to histologically evaluate nonpalpable mammographic abnormalities. In experienced centers, it is considered the standard of care

9. Triple assessment In any patient who presents with a breast lump or other symptoms suspicious of carcinoma, the diagnosis should be made by a combination of clinical assessment, radiological imaging and a tissue sample taken for either cytological or histological analysis the so called triple assessment.

10. ABNORMAL DEVELOPMENT • Absence of breast tissue (amastia) and absence of the nipple (athelia) are rare anomalies. • Unilateral rudimentary breast development is much more common, as is adolescent hypertrophy of one breast with lesser development of the other. In contrast, accessory breast tissue (polymastia) and accessory nipples (supernumerary nipples) are both common. Supernumerary nipples are usually rudimentary and occur along the milk line from the axilla to the pubis in both males and females. They may be mistaken for a small mole. However, accessory nipples are removed only for cosmetic reasons. • True polythelia refers to more than one nipple serving a single breast, which is rare. • Accessory breast tissue is commonly located above the breast in the axilla. Rudimentary nipple development may be present, and lactation is possible with more complete development. Accessory breast tissue, which may present as an enlarging mass in the axilla during pregnancy, is treated by surgical removal if it is large or cosmetically deforming, or it is removed to prevent enlargement during future pregnancy.

11. Supernumerary Nipples • More common than supernumerary breasts • Found along milk line • May darken during pregnancy • Not dangerous

12. Inverted Nipples • Often will evert with stimulation • Mostly a cosmetic issue • Successful breastfeeding is usually possible.

13. Andi

14. Fibrocystic Changes • Fibrocystic condition (FCC), previously referred to as fibrocystic disease in up to 90% of women. • FCC appears to represent an exaggerated response of breast stroma and epithelium to anormal level of variety of circulating and locally produced hormones and growth. • Symptomatically, the condition presents as premenstrual cyclical mastalgiawith pain and tenderness to touch. • Breast examinations range from mild, bilaterally symmetrical alterations in texture ,to nodularity and dense, firm breast tissue with palpable lumps, to the frequent appearance of gross cysts. • Mammographically, FCC is usually seen as bilaterally symmetrical diffuse or focal radiologically dense tissue. • Ultrasonography alone may be used in women under 30 years of age. • By ultrasound, cysts exist in up to one third of women 35 to 50 years of age, with most of these being nonpalpable. • Because a mass due to fibrocystic condition may be difficult to distinguish from carcinoma on the basis of clinical findings, suspicious lesions should be biopsied.

15. Clinical presentation of FCC Painful, often multiple, usually bilateral masses in the breast. Rapid fluctuation in the size of the masses is common. Frequently, pain occurs or worsens and size increases during premenstrual phase of cycle. Most common age is 30–50. Rare in postmenopausal women not receiving hormonal replacement.

16. Treatment • Breast pain associated with generalized fibrocystic condition is best treated by avoiding trauma and by wearing a good, supportive brassiere during the night and day. • Hormone therapy is not advisable similarly, tamoxifen because of their side effects. • Oil of evening primrose (OEP), a natural form of gamolenic acid, has been shown to decrease pain in 44–58% of users. • Aspiration of a discrete mass suggestive of a cyst is indicated to alleviate pain and, more importantly, to confirm the cystic nature of the mass. The patient is reexamined at intervals thereafter. If no fluid is obtained by aspiration, if fluid is bloody, if a mass persists after aspiration, or if at any time during follow-up a persistent or recurrent mass is noted, biopsy should be performed.

17. Breast Cysts • Cysts within the breast are fluid-filled, epithelium-lined cavities that may vary in size from microscopic to large, palpable masses . • Cysts are generally discovered by physical examination and confirmed by ultrasound or needle aspiration. • Most women with new cyst formation are first seen after the age of 35 and rarely before the age of 25 years. Cyst fluid can be straw colored, opaque, dark-greenish, and even contain flecks of debris. • The only reliable indication for submitting fluid for cytology is the presence of a residual mass after aspiration of the fluid. If the cyst recurs multiple times (more than two times is a reasonable rule), cytology is justified. Finally, surgical removal of a cyst may be indicated if the cytology is suspicious or the cyst recurs multiple times.

18. Galactocele • A galactocele is a milk-filled cyst, well circumscribed. It usually occurs after the cessation of lactation or when feeding frequency has been curtailed significantly. • The pathogenesis of galactocele is not known, but it is thought that inspissated milk within ducts is responsible. The lump is usually located in the central portion of the breast or under the nipple. Needle aspiration produces thick, creamy material that may be tinged dark-green or brown. • Although it appears purulent, the fluid is sterile. • Treatment is needle aspiration. Withdrawal of thick milky secretion confirms the diagnosis; operation is reserved for cysts that cannot be aspirated or that become infected.

19. Fibroadenoma Fibroadenoma (adenofibroma) is a benign tumor composed of stromal and epithelial elements. Fibroadenomas appear in teenage girls and women during their early reproductive years. Clinically, they present as firm well circumscribed ,highly mobile within the breast tissue , solitary tumors that may increase in size over several months of observation. At operation, fibroadenomas appear to be well-encapsulated masses that may easily detach from the surrounding breast tissue. Ultrasound usually clearly shows the difference between cysts and fibro adenomas. The treatment of fibroadenoma follows that for any unexplained solid mass within the breast. Most patients undergo excisional biopsy to remove the tumor and establish the diagnosis. Cryoablation is not appropriate for all fibroadenomas because some are too large to freeze or the diagnosis may not be certain.

20. Phyllodes tumor • Phyllodes tumor :It may reach a large size and, if inadequately excised, will recur locally. The lesion can be benign or malignant. If benign, phyllodes tumor is treated by local excision with a margin of surrounding breast tissue. The treatment of malignant phyllodes tumor is more controversial, but complete removal of the tumor with a rim of normal tissue avoids recurrence. Because these tumors may be large, simple mastectomy is sometimes necessary. Lymph node dissection is not performed, since the sarcomatous portion of the tumor metastasizes to the lungs and not the lymph nodes.

21. Milk engorgement Lactational mastitis and Breast abscess Milk engorgement presented with dull aching pain associated with mild pyrexia , breast is enlarged with no signs of inflammation Mastitis describes a generalized cellulites of breast tissue that may involve a large area of the breast but may not form a true abscess. Mastitis presents with erythema of the overlying skin, pain, and tenderness to palpation. There is induration of the skin and underlying breast parenchyma. Mastitis commonly complicates lactation, possibly as a result of bacteria( staph. Aurieus) ascending in ductal tree of the breast through the nipple. Predisposing factors includes : milk engorgement ,nipple retraction , cracked nipple ,bad hygiene , DM Local measures such as application of heat, or use of a mechanical breast pump on the affected side, administration of broad-spectrum antibiotics. In many situations, the differential diagnosis of acute mastitis includes inflammatory carcinoma. Breast abscess present with , thropping pain associated with hectic fever ( never wait for fluctuation ) Treatment of breast abscise is drainage

23. Non lactating breast abscess and duct ectasia • Commonly occurs in the subareolar breast tissue and may be recurrent. Subareolar duct ectasia and obstruction of major ducts may lead to proliferation of bacteria and subsequent abscess. Further destruction of the normal ductal openings leads to fistula formation and chronic recurrent abscess. • Mammary duct ectasia, is an inflammatory condition that causes distortion and dilation of the lactiferous sinuses under the nipple. It is a common entity and is frequently responsible for nipple inversion in older women. • The treatment is major duct excision .

24. Duct ectasia

25. Breast pain • Breast pain is common symptom.Usually it is of functional origin and uncommonly is it a symptom of breast cancer. • For those women with breast pain and an associated palpable mass, the presence of the mass should be the focus of evaluation and treatment. • For patients without a mass, the evaluation should be guided by whether the pain is cyclical or noncyclical. • Normal ovarian hormonal influences on breast glandular elements frequently produce cyclical mastalgia. It is predominantly experienced in the luteal phase of the menstrual cycle and abates with menstruation. • Noncyclical mastalgiais more likely to be the result of a non breast etiology or of a specific significant breast condition. A careful history and physical examination should eliminate musculoskeletal causes such as cervical radiculopathy, costochondritis, or intercostal muscle strain. Gastroesophageal reflux disorder, symptomatic gallstones, cardiovascular disease, and pulmonary pathology are fairly obvious after a brief patient interview. • Breast cellulitis (mastitis), inflammatory breast cancer causes breast pain.

26. Investigation • Women 30 years of age and older with cyclical or noncyclical mastalgia should undergo mammography. The exception to this rule is when the clinical breast examination reveals focal tenderness and breast ultrasound detects a simple cyst. In this instance the work-up can be terminated with reassurance and without a mammogram. • If the mammogram is abnormal or the ultrasound reveals a complex cyst or solid lesion, further evaluation of the mass should commence. • For patients younger than 30 years of age without focal breast pain, the initial management should be symptomatic.

27. Treatment • If the clinical breast examination and mammography are normal, 85% of women respond to reassurance that mastalgia is a common, benign condition. • For the 15% of women who do not, wearing a supportive brassiere and taking ibuprofen 600 to 800 mg every 8 hours during symptomatic days may be adequate to relieve symptoms. • Primrose oil results in symptomatic relief in 58% of patients with cyclical and 38% of patients with noncyclical mastalgia. • More aggressive therapies include danazol, a synthetic androgen that decreases ovarian function . • Bromocriptine, a longacting dopaminergic drug that suppresses prolactin. • Tamoxifen provided symptomatic relief in 75% of

28. Nipple Discharge • Nipple discharge is common and is rarely associated with an underlying carcinoma. • It is important to establish whether the discharge comes from one breast or from both breasts, whether it comes from multiple duct orifices or from just one, and whether the discharge is grossly bloody or contains blood. • A milky discharge from both breasts is termed galactorrhea. In the absence of lactation or history of recent lactation, galactorrhea may be associated with increased production of prolactin. Serum prolactin is diagnostic. • Unilateral, non milky discharge coming from one duct orifice is surgically significant and warrants special attention . However, the underlying cause is rarely a breast malignancy. The most common cause of spontaneous nipple discharge from a single duct is a solitary intraductal papilloma in one of the large subareolar ducts directly under the nipple. If an occult cancer is found, it is usually an intraductal carcinoma. • Fibrocystic change, or cystic mastopathy, typically produces multiple-duct discharge and is another commonly associated finding. • Subareolar duct ectasia, producing inflammation and dilation of large collecting ducts under the nipple, is a common finding that usually produces multiple-duct discharge.

29. Gynicomastia Hypertrophy of normal male breast tissue; can be divided into 2 categories: pubertal hypertrophy (ages 13–17), senescent hypertrophy (age >50) Associated with some recreational and therapeutic drugs: digoxin, thiazides, estrogens, phenothiazines, theophylline marijuana Symptoms and signs include unilateral or bilateral breast enlargement Surgery is indicated if enlargement is primary and does not regress and breast is cosmetically unacceptable What is the secondary causes

30. Fat Necrosis Fat necrosis is a rare lesion of the breast but is of clinical importance because it produces a mass (often accompanied by skin or nipple retraction) that is indistinguishable from carcinoma even with imaging studies. Trauma is presumed to be the cause, though only about 50% of patients give a history of injury. Ecchymosis is occasionally present. If untreated, the mass effect gradually disappears. The safest course is to obtain a biopsy. Needle biopsy is often adequate, but frequently the entire mass must be excised, primarily to exclude carcinoma. Fat necrosis is common after segmental resection, radiation therapy, or flap reconstruction after mastectomy.

31. Risk Factors for Breast Cancer • Age: is probably the most important risk factor that clinicians use in everyday clinical practice. Breast cancer is rare in persons younger than 20 years of age. Thereafter, the incidence increases to 1 in 93 by age 40, 1 in 50 by age 50, 1 in 24 by age 60, 1 in 14 by age 70, and 1 in 10 by age 80. • Gender is also an important risk factor. Males are at risk for breast cancer, although the incidence in males is less than 1% of the incidence in females • Histologic Risk Factors ■ Aytpia or Cancer on Previous Biopsy ■ Atypical ductal hyperplasia (ADH) ■ Atypical lobular hyperplasia (ALH) ■ Lobular carcinoma in situ (LCIS) ■ Previous history ductal carcinoma in situ (DCIS) ■ Previous history of invasive breast cancer • Thoracic Radiation Before Age 30 ■ Infant thymus radiation ■ Frequent fluoroscopy for TB ■ Multiple x-rays for scoliosis • Family History—Three Generations Maternal and Paternal ■ Known or suspected gene mutation(BRCA1 and BRCA 2) ■ Early age onset <40 ■ Bilateral breast cancer ■ Breast and/or ovarian cancer ■ Male breast cancer ■ Ethnicity , e.g., Jewish ancestry with family history ■ Cluster of rare tumors in a biological family • Reproductive Risk Factors ■ >5 years of combined estrogen/ progesterone hormone replacement therapy ■ Age at menarche <12 ■ Nulliparity ■ Age at firstborn >30 ■ Age at menopause >55

32. Clinical picture • Painless breast lump • Early findings: Single, nontender, firm to hard mass with ill-defined margins; or mammographic abnormalities and no palpable mass. • Later findings: Skin or nipple retraction; axillary lymphadenopathy; breast enlargement, erythema, edema, pain; fixation of mass to skin or chest wall.

36. INVESTIGATIONS • FNAC: Most experienced clinicians would not leave a suspicious dominant mass in the breast even when FNA cytology is negative unless the clinical diagnosis, breast imaging studies, and cytologic studies were all in agreement, such as a fibrocystic lesion or fibroadenoma. • • Ultrasound: best for young women/ dense breasts. Ultrasonography is performed primarily to differentiate cystic from solid lesions but may show signs suggestive of carcinoma. • Mammography • Biopsy (‘Trucut’/open surgical): usually provides definitive histology (may be radiologically guided if lump is small or impalpable bdetected by mammography as part of breast screening programme). • As an alternative in highly suspicious circumstances, the diagnosis may be made on frozen section of tissue obtained by open biopsy under general anesthesia. If the frozen section is positive, the surgeon can proceed immediately with the definitive operation. This one-step method is rarely used today except when a cytologic study has suggested cancer but is not diagnostic and there is a high clinical suspicion of malignancy in a patient well prepared for the diagnosis of cancer and its treatment options. In general, the two-step approach—outpatient biopsy followed by definitive operation at a later date—is preferred in the diagnosis and treatment of breast cancer, because patients can be given time to adjust to the diagnosis of cancer, can consider alternative forms of therapy, and can seek a second opinion if they wish. There is no adverse effect from the short delay of the two-step procedure.

37. Biomarkers • The ER and PR status and HER-2/neu status of the tumor should be determined at the time of initial biopsy. • PR status may be more sensitive than ER status in determining which patients are likely to respond to hormonal manipulation. • The presence of HER-2/neuamplification predicts the response to trastuzumab(Herceptin), a monoclonal antibody that binds to the HER-2/neu receptors. • Other studies such as proliferation indices may be performed. • These markers may be obtained on core biopsy specimens, which will be necessary to institute neoadjuvant therapy.

38. Once tissue diagnosis is reached we should stage the patient with • CBC, LFT’s, CXR bone scan and abdominal ultrasound

40. PATHOLOGY OF BREAST CANCER (Spread) • Local (direct) Breast ,skin, pectoral fascia ,muscle ,rips • Lymphatic to (axillary ,internal mammary ) lymph node Embolization Permeation • Blood

41. PATHOLOGY OF BREAST CANCER Classification of Primary Breast Cancer • Noninvasive Epithelial Cancers Lobular carcinoma in situ (LCIS) Ductal carcinoma in situ (DCIS) or intraductal carcinoma Papillary, cribriform, solid, and comedo types • Invasive Epithelial Cancers (percentage of total) Invasive lobular carcinoma (10–15) Invasive ductal carcinoma • Invasive ductal carcinoma, NOS (50–70) NOS, nothing otherwise specified • Tubular carcinoma (2–3) • Mucinous or colloid carcinoma (2–3) • Medullary carcinoma (5) • Invasive cribriform (1–3) • Invasive papillary (1–2) • Adenoid cystic carcinoma (1) • Metaplastic carcinoma (1) • Mixed Connective and Epithelial Tumors Phyllodes tumors, benign and malignant Carcinosarcoma Angiosarcoma .

42. American Joint Committee on Cancer Staging System for Breast Cancer, 2002 • (p)T (Primary Tumor) • Tis Carcinoma in situ (lobular or ductal) • T1 Tumor ≤2 cm • T1a Tumor ≥0.1 cm; ≤0.5 cm • T1b Tumor >0.5 cm; ≤1 cm • T1c Tumor >1 cm; ≤2 cm • T2 Tumor >2 cm; ≤5 cm • T3 Tumor >5 cm • T4 Tumor any size with extension to chest wall or skin • T4a Tumor extending to chest wall (excluding pectoralis) • T4b Tumor extending to skin with ulceration, edema, satellite nodules • T4c Both T4a and T4b • T4d Inflammatory carcinoma

43. TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ Tis (DCIS) Ductal carcinoma in situ Tis (LCIS) Lobular carcinoma in situ Tis (Paget) Paget disease of the nipple with no tumor

44. American Joint Committee on Cancer Staging System for Breast Cancer, 2002 • (p)N (Nodes) • N0 No regional node involvement, no special studies • N1 Metastasis to 1–3 axillary nodes and/or int. mammary positive by biopsy • N1(mic) Micrometastasis (>0.2 mm, none >2.0 mm) • N1a Metastasis to 1–3 axillary nodes • N1b Metastasis in int. mammary by sentinel biopsy • N1c Metastasis to 1–3 axillary nodes and int. mammary by biopsy • N2 Metastasis to 4–9 axillary nodes or int. mammary clinically positive, without axillary metastasis • N2a Metastasis to 4–9 axillary nodes, at least 1 >2.0 mm • N2b Int. mammary clinically apparent, negative axillary nodes • N3 Metastasis to ≥10 axillary nodes or combination of axillary and int. mammary metastasis • N3a ≥10 axillary nodes (>2.0 mm), or infraclavicular nodes • N3b Positive int. mammary clinically with ≥1 axillary node or >3 positive axillary nodes with int. mammary positive by biopsy • N3c Metastasis to ipsilateral supraclavicular nodes

45. American Joint Committee on Cancer Staging System for Breast Cancer, 2002 • M (Metastasis) • M0 No distant metastasis • M1 Distant metastasis

47. American Joint Committee on Cancer Stage Grouping • Stage TNM • 0 Tis, N0, M0 • I T1, N0, M0 • IIA T0, N1, M0 T1, N1, M0 T2, N0, M0 • IIB T2, N1, M0 T3, N0, M0 • IIIA T0, N2, M0 T1, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 • IIIB T4, N0, M0 T4, N1, M0 T4, N2, M0 • IIIC Any T, N3, M0 • IV Any T, any N, M1

48. MODERN TREATMENT FOR EARLY BREAST CANCER • Shift from radical mastectomy to modified radical mastectomy to procedures that preserve the breast conservative breast surgery . Large size is only a relative contraindication to breast conservation. Subareolar tumors, also difficult to excise without deformity, are not contraindications to breast conservation. Clinically detectable multifocality is contraindication to breast-conserving surgery. The patient—not the surgeon—should be the judge of what is cosmetically acceptable. • The approach to the axillary nodes is also evolving. Many specialists are becoming more selective about the need for axillary dissection to axillary staging , and the use of sentinel node biopsy is replacing routine axillary dissection for women with clinically negative lymph nodes. • Whole-breast radiation after surgical removal of the primary tumor. Radiotherapy after partial mastectomy consists of 5–7 weeks of five daily fractions to a total dose of 5000–6000 cGy. • Adjuvant Chemotherapy: In practice, most medical oncologists are currently using systemic adjuvant therapy for patients with either node-negative or node-positive breast cancer. • Targeted Therapy Her-2/Neu Overexpression :Trastuzumab (Herceptin), a monoclonal antibody that binds to the HER-2/neu receptors, when studied in the metastatic setting, has proved effective in combination with chemotherapy in patients with HER-2/neu overexpression. Vascular Endothelial Growth Factor (VEGF) Bevacizumab (Avastin) is a monoclonal antibody directed against VEGF. • Hormonal :decrease recurrence and mortality by 25% in women with ER-positive tumors regardless of menopausal status. • Neoadjuvant Chemotherapy The use of chemotherapy or hormonal therapy prior to resection of the primary tumor (neoadjuvant) is gaining popularity.

49. EARLY INVASIVE BREAST CA • Discuss options with patient, based on pathology, size of the tumor, size of the breasts, and patient desire . • Must: 1. Treat the entire breast and 2. Either assess (with SLN biopsy , and treat if positive) or prophylactically treat / sample the axillary nodes. • The breast can be treated by lumpectomy (with a clearly negative margin) and 5,000 cGy breast radiotherapy(XRT). Breast XRT doesn’t impact survival, but it decreases local recurrence by 20%. This breast-conserving treatment is best if the tumor is < T3 (no extension and < 5 cm), it is unifocal, and the breast is not too small for an acceptable cosmetic result. • Total mastectomy w/ or w/out immediate reconstruction is also acceptable. • The axillary nodes can be staged with axillary dissection of level 1 and 2 nodes or SLN biopsy (s) SNL Bx is inappropriate for multiple CA's. • Add 5,000 cGy chest wall/axillary XRT for patients with > 3 positive nodes • Adjuvant Chemotherapy, Targeted Therapy ,. Hormonal Neoadjuvant Chemotherapy • All patients get routine flow up with CXR, exam for local recurrence, and bi- or contra- lateral mammography

50. Treatment of Locally Advanced and Inflammatory Breast Cancer The treatment of locally advanced breast cancer has been changing. The disease is heterogeneous and defies a uniform treatment approach. Prior to the 1970s, treatment included surgery and radiation, with little effect on survival. When surgery is used alone, local relapse rates in the range of 30% to 50% can be anticipated and the long-term cure rates rarely exceed 30%. Similar results are reported when radiation therapy is the sole modality of treatment. These poor results suggest that locally advanced disease is actually metastatic in most patients, emphasizing the role of chemotherapy in these patients. A trimodality approach with the addition of chemotherapy improved both disease-free and overall survivals. Inflammatory breast cancer was once a uniformly fatal disease that claimed its victims after a median survival of 9 to 12 months. Current approaches emphasize aggressive use of combined modality treatment, which includes chemotherapy, mastectomy, and radiation therapy