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7 Breast Cancer inPregnancy
23
risk of preterm delivery and spontaneous abortion compared
to the third trimester. However, the timing of surgery should
be individualized based on patient characteristics, tumor
biology, gestational age, and patient preference.
• Two surgical approaches are available for consideration:
modied radical mastectomy (MRM) and breastconserving surgery (BCS). BCS consists of lumpectomy
with sentinel lymph node biopsy (SLNB) or axillary
lymph node dissection (ALND). The decision regarding
which surgical procedure should be chosen depends on
the need for post-operative radiation in BCS, which is
contraindicated during pregnancy.
– In the rst trimester, BCS is less preferable due to the
extended delay in radiotherapy. Thus, MRM is preferred. In such cases, breast reconstruction remains an
option but is typically deferred until after delivery.
– In the second and third trimesters, BCS is more feasi-
ble, given the possibility of delaying radiation until
after childbirth if chemotherapy is administered in the
interim (Shachar etal. 2017).
– BCS does not appear to have a negative impact on sur-
vival (Kuerer etal. 2002; Annane etal. 2005).
Sentinel Lymph Node Surgery
• Although the American Society of Clinical Oncology
(ASCO) clinical practice guideline from 2016 does not
recommend SLNB during pregnancy (Lyman etal. 2017),
the National Comprehensive Cancer Network (NCCN)
and recent studies show it can be safely performed and
should be considered over axillary clearance when indicated (Alfasi and Ben-Aharon 2019; Gropper etal. 2014;
Gentilini etal. 2004).
• Use of blue dye mapping with methylene blue is contraindicated in pregnancy. However, technetium-99 sulfur colloid can be safely used in the second and third
trimesters.
• If preoperative biopsy indicates the presence of metastasis in any axillary node, the recommended course of
action is to proceed with axillary lymph node dissection
(ALND) without sentinel lymph node biopsy (SNLB)
(Chung etal. 2021).
Chemotherapy/Trastuzumab/Hormonal Therapy
• Indications for chemotherapy remain the same for cancer
in pregnant and non-pregnant women; however, it should
be avoided in the rst trimester.
• Chemotherapy is recommended from week 14 to ensure
a safe window following organogenesis (Mcgrath and
Ring 2011). To avoid myelosuppression, it should not be
given after week 35 of pregnancy or within 3weeks of
planned delivery.
• Systemic chemotherapy (with anthracyclines and alkylating agents) can be safely administered during the second
through most of the third trimester.
– Taxanes should be used cautiously, as the data regard-
ing their safety is limited. If used, weekly administration of Paclitaxel is preferred (Gainford and Clemons
2006; Gonzalez-Angulo etal. 2004).
• Trastuzumab is contraindicated in pregnancy due to its
association with oligohydramnios/anhydramnios (Watson
2005; Bader etal. 2007). Nevertheless, neoadjuvant che-
motherapy regimens in pregnancy should remain the
same as for non-pregnant patients.
• Endocrine therapy is also contraindicated during pregnancy.
Radiotherapy
• Adjuvant radiation is contraindicated throughout the
duration of pregnancy.
• If a patient opts for breast conservation therapy, this is
typically completed post-partum.
Other Considerations
• Termination of pregnancy has no demonstrated impact on
prognosis or survival rates (Johansson etal. 2011; Poggio
et al. 2020). However, it may be considered during the
rst trimester for advanced stages, primarily due to the
potential risk associated with administering chemotherapy in the rst trimester (Poggio et al. 2020; Sánchez
Martínez and Ruiz Simón 2010).
• Before reaching the viability threshold at 24weeks gestation, fetal heart tone dopplers should be conducted pre
and post operatively. After viability, it should be performed with neonatal services, with dedicated OB staff
responsible for fetal heart rate monitoring.
• Invasive Breast Cancer should be treated in a multidisciplinary approach, with involvement of surgery, medical
oncology, radiation oncology, and maternal-fetal-medicine.
Case conclusion The patient had a staging work up performed, which included a chest radiograph and abdominal
and liver ultrasonography. No suspicious lesions were found.
The patient was discussed in a multidisciplinary tumor board
setting involving the breast surgeon, medical oncology, radiation oncology, and maternal-fetal-medicine. Following discussion with the patient, the decision was made to proceed to
the operating room for a right mastectomy with axillary
lymph node dissection early in her second trimester. Surgical
pathology demonstrated a 2.1cm invasive ductal carcinoma
and 3/22 lymph nodes. Chemotherapy was started approximately 6 weeks after surgery and discontinued prior to a
scheduled cesarean section delivery. Post-partum, the patient
resumed adjuvant chemotherapy and chest wall radiation.
24
L. M. de La Cruz et al.
Clean Kills
• Failure to execute a thorough, bilateral examination of the
entire breast and axilla.
– Pregnancy increases breast density, making clinical
examination more difcult. Be aware that a breast
lump in a pregnant patient may be associated with a
cancer diagnosis. Thus, perform imaging and biopsy
without delay.
• Performing therapeutic abortion.
• Failure to ask about receptors in pathology.
• Antihormonal therapy is contraindicated during pregnancy and breastfeeding.
• Radiation therapy is contraindicated during pregnancy.
Bonus Points
• Chemotherapy is safe during the second and third
trimesters.
• If lumpectomy is offered during the second or third trimester, patients should be offered neoadjuvant chemotherapy followed by breast-conserving surgery and
radiation after delivery.
Bibliography
Ahn BY, Kim HH, Moon WK, Pisano ED, Kim HS, Cha ES, Kim JS,
Oh KK, Park SH.Pregnancy- and lactation-associated breast cancer.
J Ultrasound Med. 2003;22:491–7.
Alfasi A, Ben-Aharon I.Breast cancer during pregnancy-current para-
digms, paths to explore. Cancers (Basel). 2019;11:1669. https://doi.
org/10.3390/CANCERS11111669.
Amant F, Von Minckwitz G, Han SN, etal. Prognosis of women with
primary breast cancer diagnosed during pregnancy: results from an
international collaborative study. J Clin Oncol. 2013;31:2532–9.
Annane K, Bellocq JP, Brettes JP, Mathelin C.Inltrative breast can-
cer during pregnancy and conservative surgery. Fetal Diagn Ther.
2005;20:442–4.
Bader AA, Schlembach D, Tamussino KF, Pristauz G, Petru
E. Anhydramnios associated with administration of trastuzumab
and paclitaxel for metastatic breast cancer during pregnancy. Lancet
Oncol. 2007;8:79–81.
Boere I, Lok C, Poortmans P, Koppert L, Painter R, Vd Heuvel-Eibrink
MM, Amant F.Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities.
Best Pract Res Clin Obstet Gynaecol. 2022;82:46–59.
Chung HL, Sun J, Leung JWT. Breast cancer skip metastases: fre-
quency, associated tumor characteristics, and role of staging nodal
ultrasound in detection. AJR Am J Roentgenol. 2021;217:835–44.
Dwyer M. NCCN clinical practice guidelines in oncology (NCCN
guidelines
Patients
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) Breast Cancer NCCN.org NCCN Guidelines for
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. 2023. www.nccn.org/patients.
Gainford MC, Clemons M. Breast cancer in pregnancy: are taxanes
safe? Clin Oncol (R Coll Radiol). 2006;18:159.
Gentilini O, Cremonesi M, Trirò G, et al. Safety of sentinel node
biopsy in pregnant patients with breast cancer. Ann Oncol.
2004;15:1348–51.
Gonzalez-Angulo AM, Walters RS, Carpenter RJ, Ross MI, Perkins
GH, Gwyn K, Theriault RL. Paclitaxel chemotherapy in a pregnant patient with bilateral breast cancer. Clin Breast Cancer.
2004;5:317–9.
Gropper AB, Calvillo KZ, Dominici L, et al. Sentinel lymph node
biopsy in pregnant women with breast cancer. Ann Surg Oncol.
2014;21:2506–11.
Han SN, Amant F, Michielsen K, De Keyzer F, Fieuws S, Van Calsteren
K, Dresen RC, Gziri MM, Vandecaveye V.Feasibility of whole- body
diffusion-weighted MRI for detection of primary tumour, nodal and
distant metastases in women with cancer during pregnancy: a pilot
study. Eur Radiol. 2018;28:1862–74.
Johansson ALV, Andersson TML, Hsieh CC, Cnattingius S, Lambe
M.Increased mortality in women with breast cancer detected during pregnancy and different periods postpartum. Cancer Epidemiol
Biomarkers Prev. 2011;20:1865–72.
Kuerer HM, Gwyn K, Ames FC, Theriault RL.Conservative surgery
and chemotherapy for breast carcinoma during pregnancy. Surgery.
2002;131:108–10.
Lyman GH, Somereld MR, Bosserman LD, Perkins CL, Weaver DL,
Giuliano AE.Sentinel lymph node biopsy for patients with earlystage breast cancer: American Society of Clinical Oncology clinical
practice guideline update. J Clin Oncol. 2017;35:561–4.
Mcgrath SE, Ring A.Chemotherapy for breast cancer in pregnancy:
evidence and guidance for oncologists. Ther Adv Med Oncol.
2011;3:73–83.
Middleton LP, Amin M, Gwyn K, Theriault R, Sahin A.Breast car-
cinoma in pregnant women: assessment of clinicopathologic and
immunohistochemical features. Cancer. 2003;98:1055–60.
Poggio F, Tagliamento M, Pirrone C, Soldato D, Conte B, Molinelli
C, Cosso M, Fregatti P, Del ML, Lambertini M. Update on the
management of breast cancer during pregnancy. Cancers (Basel).
2020;12:1–17.
Robbins J, Jeffries D, Roubidoux M, Helvie M.Accuracy of diagnostic
mammography and breast ultrasound during pregnancy and lactation. AJR Am J Roentgenol. 2011;196:716–22.
Sabate JM, Clotet M, Torrubia S, Gomez A, Guerrero R, De Las Heras
P, Lerma E. Radiologic evaluation of breast disorders related to
pregnancy and lactation. Radiographics. 2007;27:S101. https://doi.
org/10.1148/RG.27SI075505.
Sánchez Martínez MC, Ruiz Simón A.Breast cancer during pregnancy.
Breast Cancer Res Treat. 2010;123(Suppl 1):55–8.
Shachar SS, Gallagher K, McGuire K, Zagar TM, Faso A, Muss HB,
Sweeting R, Anders CK.Multidisciplinary management of breast
cancer during pregnancy. Oncologist. 2017;22:324–34.
Vashi R, Hooley R, Butler R, Geisel J, Philpotts L.Breast imaging of the
pregnant and lactating patient: imaging modalities and pregnancyassociated breast cancer. AJR Am J Roentgenol. 2013;200:321–8.
Watson WJ. Herceptin (trastuzumab) therapy during pregnancy:
association with reversible anhydramnios. Obstet Gynecol.
2005;105:642–3.
Invasive Lobular Breast Cancer
MicheleFantazzio
8
Risks
• Older age
• Hormone replacement therapy
• Prior high risk breast biopsies, ALH, LCIS, radial scar
• Genetic abnormalities
Diagnosis
• ALWAYS examine both breasts and axilla and look at
nipple
• Thickening or fullness
• Texture differences
• Newly inverted nipple
• On ultrasound hypoechoic mass with spiculated or illdened borders
• On mammogram does not present as mass (44–65%)
• Always core biopsy usually with ultrasound guidance, if
high suspicious and mammogram and ultrasound are negative can do MRI of breast which is overly sensitive not
specic
• MRI can identify multifocal disease or help with preoperative planning
Treatment
• Can do lumpectomy and XRT (breast conservation) same
recurrence as long as margins are clear
• Sometimes more mastectomies in ILC due to inltrative
nature of cells and usually larger at time of diagnosis
since the patient does not “always feel a dened lump”
• Usually require endocrine therapy Tamoxifen in pre-
menopausal and Aromatase Inhibitors if post
menopausal
• Their sensitivity to chemotherapy is always in question
since they are usually sensitive to hormones
• Pathologic complete response after neoadjuvant chemotherapy is low (14%)
Pleomorphic Lobular Carcinoma
• 1% of invasive breast cancers
• Less sensitive to estrogen and progesterone
• More aggressive than classic invasive lobular carcinoma
M. Fantazzio (*)
Department of Breast Surgery, MD Anderson at Cooper Hospital,
Camden, NJ, USA
e-mail: fantazzio-michele@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_8
25
Hereditary Breast Cancer (BRCA1/2)
CarlyWareham andSalvatoreNardello
9
Breast Cancer Gene 1 and2 (BRCA1/2)
• Most BRCA1/2 associated cancers are invasive ductal
carcinomas and are more aggressive than sporadic breast
cancers.
• BRCA1 mutation is associated with breast and ovarian
cancers.
– BRCA1 mutation confers an 87% lifetime risk of
developing breast cancer (for comparison, the general
public lifetime risk is ~12%), and a 40–60% risk of
ovarian cancer.
– BRCA1 associated breast cancers are typically triple
negative and poorly differentiated.
• BRCA2 mutation is associated with breast, ovarian, prostate, and pancreatic cancers.
– BRCA2 mutation confers an ~80% lifetime risk for
developing breast cancer and a 15–20% risk of ovarian
cancer.
– BRCA2 associated breast cancers are typically well
differentiated and express hormone receptors.
A 22-year-old female, with a strong family history of
breast cancer, presents to your clinic for screening recommendations. Her mother was diagnosed with breast cancer
at 35years old and her maternal aunt had ovarian cancer at
40years old. She asks for your recommendations going forward. How do you begin her work up?
• With any breast concern, always obtain a thorough history
and physical examination.
– Don’t forget these breast-specic questions: age of
menarche and menopause, age during rst pregnancy,
C. Wareham
Department of Surgery, Tufts Medical Center, Boston, MA, USA
e-mail: Carly.Wareham@tuftsmedicine.org
S. Nardello (
Division of Surgical Oncology and Breast Surgery, Department of
Surgery, Tufts Medical Center, Boston, MA, USA
e-mail: salvatore.nardello@tuftsmedicine.org
*)
hormone use, previous cancer/radiation, presence of
breast lump, nipple discharge, nipple inversion,
detailed family history (including breast/ovarian cancers and age of diagnosis).
– Don’t forget to do a bilateral breast examination in
both the seated and supine positions with attention to
bilateral axillae and lymph node basins.
• You can begin with the below screening tools to determine her lifetime risk for developing breast cancer.
– Tyrer-Cuzick Risk Assessment: If lifetime risk is
>20%, she is eligible for additional screening such as
alternating yearly mammograms and MRIs.
– Gail Model (includes age, race, age of menarche and
rst birth, family history, personal history of breast
cancer/breast biopsies).
• She should be offered genetic testing, with a referral to a
genetic counselor for pretest and posttest counseling. Other
patients who qualify for genetic testing are those with a:
– History of breast cancer in a rst-degree family mem-
ber <50years old
– Known BRCA mutation in a family member
– Personal history of any breast cancer <50years old, or
triple negative breast cancer <60years old, or personal
history of ovarian/fallopian/primary peritoneal cancer
– Personal history of male breast cancer
• In this specic patient, she should begin screening for
breast cancer at age 25 (10years before the age of onset
of the youngest rst degree relative with breast cancer, or
at age 40, whichever is sooner). MRI can begin at age 25,
while mammograms can begin at age 30.
Alternate Scenario
The above patient is found to be a BRCA1 carrier. She would
like to know what her surgical risk reduction options are.
• The decision to undergo risk reduction surgery is personal
preference and should be customized for each patient
with their informed consent, keeping in mind the level of
risk reduction for each strategy.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_9
27
28
C. Wareham and S. Nardello
• She should be offered bilateral prophylactic mastectomy which can be considered at any age and reduces the
risk of breast cancer by over 90% but does not reduce
all-cause mortality.
– If this is pursued, she should be referred to a plastic
surgeon for reconstructive options.
• She should be offered risk reduction bilateral salpingo-
oophorectomy (rrBSO), which reduces the risk of breast
cancer up to 50%, reduces the risk of ovarian and fallo-
pian tube cancer by ~80%, and reduces mortality.
– It is recommended at the completion of childbearing,
or age 35–40 for BRCA1+ carriers and age 40–45
for BRCA2+ carriers (BRCA2 carriers tend to
develop ovarian cancer 10years later than BRCA1
carriers).
– Women who undergo rrBSO will likely experience the
side effects of surgically induced menopause.
– She should also be referred for reproductive counsel-
ing, as there is a 50% chance her offspring will inherit
the mutation.
Alternate Scenario
The above patient is found to be a BRCA1 carrier but is not
interested in surgery at this time. What are other risk reduction strategies?
• She should be offered tamoxifen (20mg/day×5years).
– It has been shown to reduce breast cancer by 62% in
BRCA2 carriers, but not in BRCA1. However, it has
been shown to decrease contralateral breast cancers by
50% in both BRCA1 and BRCA2.
• Aromatase inhibitors should be offered to post- menopausal
women.
How should she be surveilled if she decides against risk
reduction surgery?
• Clinical breast exams every 6–12months starting at age
25.
• Annual MRIs beginning at 25years old, alternating with
annual mammograms beginning at 30years old.
• Annual ovarian cancer screening with pelvic exams
and transvaginal ultrasound +/-serum CA-125 beginning
at 30years old.
Alternate Scenario
What if your patient is a 35-year-old male, who is found to be
a BRCA2 carrier?
• There are no proven risk reduction strategies for male carriers, but surveillance strategies include:
– Annual clinical breast exam, beginning at age 35.
– Annual mammogram beginning at age 50 or 10years
before the earliest known male breast cancer in the
family.
– Prostate cancer screening at age 40.
– Tamoxifen is not recommended for BRCA1/2 male
carriers.
Clean Kills
• Failing to know the screening recommendations for breast
cancer.
• Failing to offer bilateral prophylactic mastectomy and
salpingo-oophorectomy in BRCA1/2+ carriers.
Bonus Points
• Be aware of the other hereditary syndromes that
increase risk for breast cancer:
– CHEK2: breast, colorectal, bladder
– p53 (Li-Fraumeni Syndrome): breast, brain, sarcoma,
leukemia, lung
– CDH1 (Hereditary Diffuse Gastric Cancer): breast,
gastric
– PTEN (Cowden Syndrome): breast, thyroid, renal cell
– STK1 (Peutz Jeghers Syndrome): hamartomatous GI
tract polyps, mucocutaneous pigmentation, breast,
colorectal
Words ofWisdom
Genetic testing may not always provide a straightforward
answer for patients and a negative test does not necessarily
mean patients are not at increased risk for developing breast
cancer. Genetic testing may reveal variants of uncertain signicance (VUS) which are DNA sequences that are not clinically actionable. The American Society of Breast Surgeons
recommends that no clinical treatment plan or risk management plan should be inuenced by a VUS, and patients
should be managed based on their other personal factors that
inuence breast cancer risk.
Bibliography
American Society of Breast Surgeons. Consensus guideline for genetic
testing for hereditary breast cancer. https://www.breastsurgeons.
org/docs/statements/Consensus- Guideline- on- Genetic- Testing- forHereditary- Breast- Cancer.pdf.
NCCN Clinical Practice Guidelines in Oncology. Genetic/familial
high-risk assessment: breast, ovarian, and pancreas. https://www.
nccn.org/login?ReturnURL=https://www.nccn.org/professionals/
physician_gls/pdf/genetics_colon.pdf.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=138328.
UpToDate. https://www- uptodate- com.ezproxy.library.tufts.edu/con-
tents/cancer- risks- and- management- of- brca1- 2- carriers- without-
cancer?search=brca&source=search_result&selectedTitle=1~150&
usage_type=default&display_rank=1.
Locally Advanced Breast Cancer
AdrianLopez andJennaMancinelli
10
Concept
Locally advanced breast cancer refers to either large tumors
(T3 or T4), involvement of multiple lymph nodes or a combination of both without evidence of carcinoma in distant
organs. These patients are situated in stage II or III with
prognosis being extremely variable, including 5-year overall
survival from 60 to 99% depending on type of treatment
received and tumor response to such treatment.
Locally advanced breast cancer is a very likely scenario
on the Oral Board (OB). It usually allows the evaluator to
assess not only the surgical management, but also the knowledge of the different adjuvant therapies needed in these cases
and part of the multidisciplinary team necessary to take care
of breast cancer patients, such as chemotherapy, radiation,
biologic therapy, immunotherapy, genetics, and physical
therapy.
It is important to know that staging breast cancer not only
depends on the standard TNM classication but that it also
incorporates the receptor status and grade of the tumor, since
these two factors often dramatically change the response to
the different therapies and affect the prognosis as well.
Full History andPhysical
History
Same as almost every question on the OB, a full history and
physical is the best rst step. Important points to focus when
doing the interrogation are:
• Characteristics of the tumor: size, time of progression or
growth, skin or nipple changes that might indicate tumor
eroding through the skin or skin metastasis (T4b) or a rash
that might indicate inammatory breast cancer (T4d).
• Any symptoms that suggest distant organ involvement:
cough, back pain, extremity pain, headaches, focal neurologic symptoms.
• Risk factors
– Family history is very important, particularly in
women younger than 50 since this usually is an indication to strongly consider genetic testing.
– Tobacco, alcohol, obesity.
Physical
Oral Board Scenario
A 42-year-old premenopausal female noticed a lump in her
right breast 2 days “after a fall”, and she did not look for
medical help thinking that it will go away; however, after
4months, she now notices that the lump is larger, and she has
pain in her right axilla. She is coming to your ofce for
consultation.
A. Lopez (*) · J. Mancinelli
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: lopez-adrian@cooperhealth.edu;
mancinelli-jenna@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_10
• Breast exams should focus on size of the mass given that
tumors that are large enough to preclude breast conservation should be considered for neoadjuvant chemotherapy
that could potentially decrease the size of the tumor.
• Mobile or xed mass: A mass that is xed to the chest
wall/pectoralis major muscle generally means a nonresectable breast cancer and neoadjuvant chemotherapy is
usually the best initial therapy.
• Nipple involvement: retraction or pathologic discharge
usually means the nipple is involved by carcinoma and
its resection is needed. This can be done via mastectomy or less commonly a central lumpectomy (it generally has a poor cosmetic outcome, so most patients
choose mastectomy with reconstruction when nipple
needs to be removed)
29
30
A. Lopez and J. Mancinelli
• Lymph nodes assessment: axillary, infra/supra clavicular
area as well as internal mammary lymph nodes should be
assessed on the physical exam and palpation of any of
these nodes on the exam should trigger a needle biopsy
(core needle preferred) of them to rule out involvement by
carcinoma (in the scenario presented above, the evaluator
likely will tell you that there is two or three lymph nodes
that are palpable in the axillary region).
Diagnostic Imaging
• Diagnostic mammogram (screening mammogram is not
used since these scenarios involve a symptomatic patient)
• Breast and Axillary ultrasound: This imaging modality is
extremely useful to not only characterize the tumor in the
breast but also assessment of the regional lymph nodes and
recommend biopsy if found to have abnormal appearance.
• MRI of the breast: This is the gold standard to assess
breast tumor response before and after neoadjuvant
chemotherapy.
• Staging imaging: CT of chest, abdomen, and pelvis +
Bone scan is the gold standard imaging when there is suspicion of distant organ involvement by patient’s symptoms which is currently the main indication to consider
staging imaging. (PET scan can be considered when CT
or bone scans are indeterminate).
Labs
• Basic Labs: CBC and CMP are usually all that is needed.
(elevated alkaline Phosphatase is suggestive of bone
involvement, and elevated ALT/AST could be a sign of
liver metastasis)
Tissue Diagnosis
• Core needle biopsy of the breast: Important to ask for ER/
PR and HER-2 receptor status when given a diagnosis of
invasive carcinoma since this will determine type of chemotherapy, biologic therapy, immunotherapy, or a combination of them will be needed.
• Core needle biopsy of the axillary lymph node: it is necessary to prove with tissue sampling the involvement of
lymph nodes when they are suspicious on physical exam
or imaging prior to the start of the treatment.
Multidisciplinary Conference/Tumor Board
Discussion of challenging cases (most of locally advanced
breast cancers are) on a Tumor Board is something that the
evaluators want to hear about. Discussion among other specialties emphasizes the importance you give to the cooperative approach breast cancer requires, and how surgeons
function as leaders in such groups.
When mentioning a case should be brought up for a multidisciplinary conference/discussion, do not expect that the
evaluators will give you an answer on what is best done in
that situation. Instead, the idea is to mention the need for this
type of discussion and then lay out the plan you think ts
best for the situation the patient is facing.
Treatment
• Neoadjuvant chemotherapy (NAC): This is usually the
initial step inlocally advanced breast cancer (e.g., posi-
tive lymph nodes regardless of the receptor status or non-
resectable tumors showing involvement of chest wall,
skin, or both). Although, there is no proven survival
advantage to this approach, NAC has the potential bene-
ts of:
– Reducing the size of the tumor which increases the
chances of negative margins and allows the patient to
be a candidate for breast conservation.
– Could allow the patient to be spared from a com-
plete axillary dissection: This is true in patients
with limited lymph node involvement (<3 or 4 axillary only lymph nodes prior to starting NAC) that
have complete pathologic response (PCR) after
NAC (see below the surgical management of the
axilla)
– Assess response of the Tumor to NAC with potential
modications to the adjuvant therapy required depending on such response (e.g., triple negative breast cancers that have PCR after NAC generally do not require
any additional chemotherapy after surgery, however,
presence of residual invasive carcinoma is an indication for adjuvant Capecitabine (Xeloda) or immunotherapy in the adjuvant setting.
• Surgical management: As of the day of writing this book
chapter, surgery after NAC is the standard of care even
when imaging has shown PCR.There is a relatively high
false negative rate with current imaging modality when
trying to predict PCR after NAC.
10 Locally Advanced Breast Cancer
31
– Surgical management of the breast after NAC:
Lumpectomy vs. mastectomy are still the two options
available and similarly when surgery is offered upfront,
the decision depends on: size of breast, size of tumor,
involvement of nipple, genetic mutation, and patient
preference.
– Surgical management of the Axilla after NAC: This
portion of the test will be challenging to answer since
there is not full consensus on all the different situations; however, it is safe to say that: If the patient has
shown to have a complete clinical response in the
axilla after NAC (whether by physical exam or imaging) offering the patient a Targeted Axillary Dissection
(TAD) + Sentinel Lymph Node biopsy (SLN) will
comply with the National guidelines and be the best
answer. This procedure involves placing a localizer
(wire, Savi, Tag, radioactive seed, etc.) in the previously known positive LN and removing that lymph
node in addition to any sentinel node that can be identied. Complete Axillary dissection should be done if:
clinically the nodes have not shown response to NAC
or if TAD + SLN is done, and residual carcinoma is
found on any of those nodes (this can be seen during
the procedure when sending frozen section analysis of
those lymph nodes or at the time nal pathology is
reported)
– Reconstruction: This is low yield for the OB and you
only need to know that patients should have immediate
vs. delayed reconstruction offered to them.
• Adjuvant Radiation: Most patients with locally advanced
breast cancer will meet criteria for adjuvant radiation.
– Tumor >5cm.
– Tumor involving skin or chest wall.
– Positive margin (re-excision is the preferred approach)
– Positive lymph node (even if the patient shows PCR
after NAC).
– Breast conservation.
• Medical Oncology assessment: Referral to medical
oncology for additional therapy is usually all the answer
the evaluators are looking for given that adjuvant management from the medical perspective is very variable and
beyond the scope of the exam. It is important, however, to
know and be able to answer if asked, that all estrogen
positive breast cancers will meet criteria for anti-estrogen
therapy for 5–10years and all HER-2 positive breast cancers will meet criteria for maintenance anti-HER2 medications (trastuzumab, Pertuzumab) for 1year.
Surgical Procedure
Complete Axillary Dissection
• Axillary incision (Lazy “S” or transverse if not done
through a mastectomy incision)
• Dissect through the clavi-pectoral fascia
• Identify and preserve:
– Axillary vein
– Thoracodorsal nerve
– Long thoracic nerve
• Resection of the axillary content in between these
structures
• Hemostasis and drain placement.
• Close of the incision
Common Curveballs
• Young patients or strong FH (genetics need to be
ordered since BRCA + patients will meet criteria for
contralateral prophylactic mastectomy at the time of
initial surgery)
• Persistent suspicious/enlarged lymph nodes after NAC
(that is criteria for a complete axillary dissection and not
TAD + SLN)
• Advanced age or poor performance status (some patients
might not be suitable for chemotherapy at all, and they
might be better served with upfront surgery or at the very
least, discussion at a multidisciplinary conference/Tumor
board)
• Progression through NAC (Discussion at Tumor
Board is necessary and strong consideration for interrupting chemotherapy and performing surgery is
needed. Switching therapies is also an option but
likely not what the SURGERY Board wants to talk
about)
Clean Kills
• Failing to perform appropriate work up for distant metastasis when given systemic symptoms in a patient with
breast cancer or performing surgery in a patient with distant metastasis (There is no prospective data showing
improved survival in patients that receive surgery with
metastatic disease).
32
A. Lopez and J. Mancinelli
• Performing a Complete Axillary Dissection when given
the right scenario for TAD + SLN (complete clinical
response in the axilla/breast after NAC in a patient with
limited axillary involvement). This might not be enough
to make someone fail the case depending on how the decision process is justied; however it could deduct points
from the case.
• Not performing genetic testing on the right patient and
missing a BRCA 1 or 2 mutation which could lead to
undertreating the patient.
• Not recommending adjuvant radiation in a patient that
meets criteria for it (see above).
• Failing to give NAC to a non-resectable tumor (xed to
the chest wall).
Summary
Locally advanced breast cancer is one of the most common scenarios in the OB and it requires the surgeon to
have an organized thought process that would allow a
comprehensive management to happen without missing
key steps. It also opens the door to the necessary interaction and cooperation from a diverse group of specialties
in order to offer optimal treatment and the best possible
outcomes.
Bibliography
Surveillance Research Program, National Cancer Institute.
SEER*Explorer. Breast cancer—SEER 5-year relative survival
rates, 2013–2019, by stage at diagnosis, female, all races/ethnicities, all ages. 2023. https://seer.cancer.gov/explorer/. Accessed 26
Apr 2023.
Boughey JC, Suman VJ, Mittendorf EA, etal. Sentinel lymph node sur-
gery after neoadjuvant chemotherapy in patients with node-positive
breast CancerThe ACOSOG Z1071 (Alliance) clinical trial. JAMA.
2013;310(14):1455–61.
Kuehm T, Bauerfeind I, Fehm T, Fleige B, etal. Sentinel lymph node
biopsy in patients with breast cancer before and after neoadjuvant
chemotherapy (SENTINA): a prospective, multicentre cohort study.
Lancet Oncol. 2013;14(7):609–18.
National Comprehensive Cancer Network. NCCN clinical practice
guidelines in oncology: breast cancer, version 4.2023. 2023. http://
www.nccn.org.
Overgaard M, Nielsen HM, Tramm T, et al. Postmastectomy radio-
therapy in high-risk breast cancer patients given adjuvant systemic therapy. A 30-year long-term report from the Danish breast
cancer cooperative group DBCG 82bc trial. Radiother Oncol.
2022;170:4–13.
National Cancer Institute. BRCA1 and BRCA2: cancer risks and
management (PDQ
www.cancer.gov/about- cancer/causes- prevention/genetics/
brca- genes- hp- pdq#_589.
Malone KE, Begg CB, Haile RW, et al. Population-based study of
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®
)—health professional version. 2023. https://
Metastatic Breast Cancer
KahyunYoon-Flannery andCandiceN.Ford
11
Metastatic Breast Cancer
Concept
It is estimated that approximately 154,000 women in the
United States have metastatic breast cancer. In fact, de novo
metastatic breast cancer accounts for approximately 6% of
all breast cancer diagnoses. The expected survival for
patients with stage IV breast cancer is variable based on
tumor biology and individual response to treatment. The
most common site of distant metastatic spread is the bone.
Other common sites include the lungs, pleura, brain, liver,
soft tissues, adrenal glands, and lymph nodes.
Way Question May BeAsked?
“A 44-year-old female presents to your ofce with a selfdetected breast mass for further investigation and treatment.
Approximately 1month ago, she discovered a rm mass in
her right breast while showering. The mass has not gone
away and seems to be associated with swelling in her right
axilla. During this time, she has also developed back pain.
What would you do next?”
How toAnswer?
History
• Risk Factors for Breast Cancer
– Age of menarche
– History of breastfeeding
– Family history of breast and/or ovarian cancer
– Number of children
– Age at rst pregnancy
– Previous breast biopsies and results (if applicable)
– Previous history of breast cancer
– Age of menopause
– History of birth control or hormone replacement ther-
apy use
– History of chest radiation
• Symptoms
– Change in breast appearance
– Relationship between mass and patient’s menstrual
cycle (if appropriate)
– Bone pain
– Abdominal discomfort
– Headaches
– Weight loss
– Fevers
– Chills
Physical Examination
• Examine both breasts in the sitting and supine positions
– Assess for symmetry, dimpling, erythema, edema, nip-
K. Yoon-Flannery
Breast Surgery, Janet Knowles Breast Cancer Center, Cooper
Medical School of Rowan University, Camden, NJ, USA
e-mail: Yoon-Flannery-Kay@CooperHealth.edu
C. N. Ford (
General Surgery, Christiana Care Health System,
Newark, DE, USA
e-mail: Candice.N.Ford@christianacare.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_11
*)
ple retraction
– Determine characteristics of the primary mass (i.e.,
size, mobility, border regularity, relationship to nippleareolar complex, quadrant location)
• Check surrounding nodal basins including axillary, infra-
and supraclavicular, cervical, and submandibular
33