Breast Cancer
In Situ Carcinomas
DCIS (Ductal Carcinoma In Situ)
DCIS is commonly identified in association with micro-calcifications seen on a mammogram. These lesions are often not palpable and may be identified commonly during routine screening breast imaging.
Cells are similar to those of invasive carcinomas but are confined to ductal structures within the breast parenchyma. Such lesions may be located within areas of Invasive carcinoma, however can be identified as in situ lesions only.
Characterised as low, intermediate or high grade.
Treatment requires complete excision (with clear margins) in addition to adjuvant radiation therapy (for breast conserving surgery).
LCIS (Lobular Carcinoma In Situ)
Considered a marker of increased risk of breast cancer.
Pleomorphic LCIS
May actually progress into invasive Lobular Carcinoma and therefore is treated with surgical excision.
Invasive Breast Cancer
Invasive Breast Cancer may be diagnosed after a patient has noted a clinical concern, or routinely on surveillance breast imaging. The presentations are varied from small non-palpable tumours to large locally advanced disease.
The workup of a breast cancer requires a thorough history and examination, appropriate breast imaging, usually including mammography and ultrasound scan bilaterally. In addition histology (tissue from the cancer) is required for diagnosis. This is usually gained from a core biopsy or FNA (Fine-needle aspiration).
The most commonly diagnosed breast cancers are Invasive Carcinoma NST (no specific type, previously Invasive Ductal Carcinoma), and Invasive Lobular Carcinoma.
Appropriate management of Breast Cancer depends on the cancer stage based on the tumour, node, metastases (TNM) system.
Most patients will progress to surgical excision for their breast cancer as the first step in their treatment. However some patient require other initially therapy eg chemotherapy prior to surgical intervention.
The important reminder in regards to a patient’s Breast Cancer journey is that each patient is treated individually based on their tumour characteristics. Not every patient will receive exactly the same treatment regime.
Surgical management of Breast Cancer
Breast Conserving Surgery (Wide Local Excision)
Most small (<3cm) breast cancers can be managed with Breast conserving surgery where the tumour mass is excised with a clear margin of normal tissue surrounding the tumour. However, whether this is possible will be dependent on breast size and tumour features eg involvement of skin.
If the breast cancer is not palpable then a pre-operative procedure (Hook-wire localisation) is required in order to mark the operative site.
Dr Geere offers Oncoplastic surgical techniques for Breast conserving surgery with the aim to improve post-operative cosmesis.
Mastectomy may be required for large breast cancers or certainly if this is the patient’s preference. This requires complete excision of the breast tissue leaving the chest wall muscle intact beneath the skin.
Patient’s who have Invasive Breast Cancers will also require management of the Axillary Lymph Nodes.
Mastectomy
Patients with large volume Breast Cancer or multicentric disease may require a Mastectomy to remove their disease. This involves removal of the whole breast and in some cases be offered in combination with an immediate Breast Reconstruction. This is dependent on each patient’s individual Breast cancer as there are cases in which immediate breast reconstruction is not appropriate.
Sentinal Lymph Node Biopsy
This technique is used for small <3cm Breast cancers when there is no evidence of spread of cancer cells to the Lymph Nodes in the axilla pre-operatively. Patient’s undergo an injection into the affected breast pre-operatively with a radioactive tracer. This allows the Sentinal Lymph Node (first draining lymph nodes of the axilla) to be identified and excised. These lymph nodes are sent to the pathologist and examined under the microscope to identify any cancer spread to the lymph nodes.
Dr Geere also performs a second injection of Patent Blue V dye to the breast when her patient’s are under general anaesthetic. This injected dye also maps the lymphatic channels towards the axilla and gives a second method of identification of the Sentinal Lymph Nodes at the axilla.
If the Sentinal Lymph Node does contain cancer cells then Dr Geere will usually discuss with her patients the potential need for re-excision of further lymph nodes at the axilla (Axillary clearance) to ensure there is no further cancer within the axilla lymph nodes.
Axillary Clearance
This technique for management of the Lymph nodes of the axilla removes about 2/3rds of the lymph nodes from the axilla. This technique is performed in patients who have been diagnosed with Breast cancer which has spread to the lymph nodes pre-operatively (usually diagnosed with a pre-op biopsy of the lymph nodes). The Axillary Clearance is also usually performed for large Breast cancers >4-5cm) and also for multifocal breast cancer (multiple cancers within the breast).
The removal of these lymph nodes gains important information about the further management required for the patient. It also gives important information in regards to prognosis.
Post-operatively the results of the excised Breast cancer will be discussed with the patient and a plan for further therapy developed.
Many patients will require additional (adjuvant) therapy which may include chemotherapy, radiation therapy to the breast and hormone therapy (hormone tablets to reduce the risk of further hormone sensitive breast cancer).
Dr Geere will arrange referral to Medical and Radiation Oncologists as required for each individual patient through a Multidisciplinary process.
Dr Geere is very aware that a Breast Cancer diagnosis can be a very emotional journey and she aims to ensure each patient is well supported. Her patient’s are met and reviewed by Breast Care Nurses at both the Wesley and Mater Hospitals during their admission as well as receiving post-op support.
Dr Geere is also happy to discuss particular needs with patients and refer on to Psychologist or other required specialists as needed.
Neoadjuvant Chemotherapy
Some Invasive Breast Cancer patients may require chemotherapy treatment prior to surgery required for their diagnosed disease. If this is the case Dr Geere will arrange an urgent referral to a Medical Oncologist for their chemotherapy management.