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Case 32 | HR(−) HER2(−) Breast Cancer | 32.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and . cyclophosphamide + #4 cycles. of docetaxel) + Operation + Post-operative. radiation therapy + Adjuvant capecitabine.. . . . HR(−) HER2(−) Breast Cancer. 694. . . Operation. 242. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 2.7 cm (ypT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 20/10HPF).. 4. Intraductal component: absent.. 5. Skin: dermal involvement of tumor.. E. S. Lee et al.. 695. 6. Nipple: no involvement of tumor.. 7. Surgical margins:. . (a) Deep margin: 22 mm.. . (b) Superficial margin: 7 mm.. 8. Lymph nodes: no metastasis in 14 axillary. lymph nodes (ypN0) (sentinel LN: 0/1, non-. sentinel LN: 0/13).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: absent.. . 13. Pathological TN category (AJCC 2017):. ypT2N0.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 75%. of tumor cells. 33. | Important Radiologic. Findings. 234 235 236. 237. . HR(−) HER2(−) Breast Cancer. 692. . . . . . E. S. Lee et al.. 693. . After Neoadjuvant. Chemotherapy. 238 239 240. 241. 32.3. | Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected mass lesion on left breast.. Family history of breast cancer, aunt and. cousin (paternal).. Family history of prostate cancer, father.. Hyperthyroidism.. BRCA 1 and 2 mutation: Not detected.. 32.2. |
Case 32 | Local Recurrence | 32.1. . Courses of Treatment. Right breast DCIS → Operation → Adjuvant. therapy → Right breast recurrence (tubular. carcinoma + DCIS).. Primary Treatment. Operation. Aug. 2014 Right breast wide excision (outside).. Pathology Report. Ductal carcinoma in situ involving intraductal. papilloma. . 1. Nuclear grade: low.. . 2. Necrosis: absent.. . 3. Architectural pattern: papillary/cribriform.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 10.8% of tumor. cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence. 221. 222. Operation. 223. Pathology Report. Tubular Carcinoma. 1. Post-lumpectomy status.. 2. Size of invasive component: 0.2 cm (rpT1a).. 3. Size of intraductal component: 1.0 cm.. 4. Histologic grade: 1/3 (tubule formation: 1/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 5. Intraductal component: present, intratu. moral/extratumoral (90%) (nuclear grade:. low, necrosis: present, architectural pattern:. micropapillary/cribriform/comedo,. exten. sive intraductal component: present).. 6. Skin: no involvement of tumor.. Y. Kim et al.. 807. . . . . . 7. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: <1 mm from tubular car. cinoma (slide 5).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. rpT1a.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. Operation. . 224. Local Recurrence. 808. a. b. . Pathology Report. Ductal Carcinoma In Situ, residual. . 1. Post-excision status.. . 2. Size of tumor: 0.2 cm.. . 3. Nuclear grade: low.. . 4. Necrosis: present.. . 5. Architectural pattern: cribriform/solid/comedo.. . 6. Surgical margins:. . (a) Nipple margin: (see note).. . (b) Deep margin: 3 mm.. . (c) Superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification: absent.. Note: 1. Atypical ductal hyperplasia is present. in the section of Fro 1.. 33. | null | Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast. . 12 o’clock direction.. Outside result of lumpectomy: Ductal carci. noma in situ.. No family history.. No comorbidities.. BRCA 2 VUS (variant of uncertain).. 32.2. |
Case 32 | Metastatic Breast Cancer | Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. receptor. Intermediate. (4/7). 2. 10%–1/3. Progesterone. receptor. Strong (6/7). 3. 1/3–2/3–. C-erbB2. Positive (3+). Ki-67. Positive in. 20% of tumor. cells. Y. Kwon et al.. & Doxorubicin & Cyclophosphamide).. Post-operative radiation therapy to left breast. + Zoladex for 2 years + Tamoxifen 20 mg/day for. 5 years.. Treatments After Recurrence. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in. 14% of tumor. cells. Palliative Therapy. Palliative therapy # 37 cycles (Paclitaxel &. Trastuzumab).. Palliative therapy # 38 cycles (Trastuzumab) ~. Metastatic Breast Cancer | null | Patient History and Progress. Female/49 years old, peri-menopause.. No family history.. 32.2. |
Case 33 | Carcinoma In Situ | 33.1. . Courses of Treatment:. Operation. Operation. 155. 156. Pathology Report. <First operation>. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: positive (Fro 5) (see Note),. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 5.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 4% of tumor. cells. <Second operation>. Atypical ductal hyperplasia involving intra. ductal papilloma.. . 1. with a) foreign body reaction,. . 2. b) fat necrosis.. . (a) Post-excision status.. . . . . Carcinoma In Situ. 126. a. b. . a. b. . 34. | Important Radiologic. Findings. 153. 154. 33.3. | Patient History and Progress. Female/68 years old, post-menopause.. Bloody nipple discharge from right breast.. No family history.. S/P Hysterectomy.. 33.2. |
Case 33 | HR(+) HER2(+) Breast Cancer | Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab) + Operation + Post-. operative. radiation. ther. apy + Trastuzumab + Tamoxifen 20 mg/day.. 194. Pathology Report. Invasive ductal carcinoma, histologic grade 2.. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in four axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/4).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 46%. of tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 413. . HR(+) HER2(+) Breast Cancer. 414. . a. b. . S. Park et al.. 415. 34. | Important Radiologic. Findings. 190 191 192. 193. 33.3. | Self-detected palpable mass lesion on left. breast.. No family history.. No comorbidities.. 33.2. |
Case 33 | HR(+) HER2(-) Breast Cancer | Courses of Treatment. Operation + Post-operative radiation ther. apy + Tamoxifen 20 mg/day.. Y. Kim et al.. micropapillary/cribriform, extensive intra. ductal component: present).. 5. Skin: no involvement of tumor.. HR(+) HER2(−) Breast Cancer. . (e) deep margin: 3 mm.. . (f) superficial margin: 5 mm.. Y. Kim et al.. 279. 7. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/2). 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathological TN category (AJCC 2017):. pT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5% of. tumor cells. 34. | Important Radiologic. Findings. See Figs. 180, 181, 182, 183 and 184.. 33.3. | Restless legs.. 33.2. |
Case 33 | HR(−) HER2(+) Breast Cancer | 33.1. . tion therapy + Trastuzumab.. Operation. 228. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in four axil. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/4).. . (c) Microcalcification:. present,. tumoral/. non-tumoral.. . (d) Related slides: C21-518.. . 2. Intraductal papilloma.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 22%. of tumor cells. 34. | Important Radiologic. Findings. 221 222 223. 224. HR(−) HER2(+) Breast Cancer. . HR(−) HER2(+) Breast Cancer. 552. . 33.3. . After Neoadjuvant. Chemotherapy. 225 226. 227. Y. Kwon et al. | Patient History and Progress. Female/63 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 2 o’clock direction.. No family history.. Hypertension, chronic kidney disease, ven. tricular premature contraction.. 33.2. |
Case 33 | HR(−) HER2(−) Breast Cancer | 33.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy.. Operation. 251. Pathology Report. Atypical ductal hyperplasia, focal. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 61%. of tumor cells. E. S. Lee et al.. 697. . . . HR(−) HER2(−) Breast Cancer. 698. . . E. S. Lee et al.. 699. 34. | Important Radiologic. Findings. 243 244 245. 246. . . HR(−) HER2(−) Breast Cancer. 696. . . . . After Neoadjuvant. Chemotherapy. 247 248 249. 250. 33.3. | Patient History and Progress. Female/52 years old, post-menopause.. Screen detected mass lesion on left breast 11. o’clock direction.. No family history.. s/p cervical cancer (stage 0).. BRCA 1 and 2 mutation: Not detected.. 33.2. |
Case 33 | Local Recurrence | 33.1. . Courses of Treatmaent. Left breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Left breast. recurrence (IDC).. Primary Treatment. 225 226 227. 228. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #6 cycles of trastu. zumab and pertuzumab and docetaxel and. carboplatin.. Operation. . 229. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 3.5 cm, 1.4 cm (ypT2(2)).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 30/10HPF).. 4. Intraductal component: present, extratumoral. (10%) (nuclear grade: high, necrosis: pres. ent, architectural pattern: micropapillary/. solid/comedo, extensive intraductal compo. nent: absent).. 5. Skin: no involvement of tumor.. Y. Kim et al.. 809. . . . . . 6. Surgical margins:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 6 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: (see note 1).. . (e) Deep margin: 6 mm.. . (f) Superficial margin: <1 mm from inva. sive ductal carcinoma (slide 12).. 7. Lymph nodes: no metastasis in 3 axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular. invasion:. present,. . intratumoral/peritumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT2(2)N0(sn).. Local Recurrence. 810. . . . Note: 1. The lateral margin of the lumpec. tomy specimen (slide 16) is close to ductal car. cinoma in situ (1.5 mm), but this margin. submitted for frozen diagnosis (Fro 7) is free. of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 59%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Trastuzumab for 1 year.. Treatments After Recurrence. 230. Operation. 231. Pathology Report. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.8 cm (rpT1c).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 22/10HPF).. 4. Intraductal component: present, intratumoral. (5%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra. ductal component: absent).. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: positive for invasive. ductal carcinoma (slide 2).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: positive for invasive. ductal carcinoma (slide 4).. . (e) Deep margin: 1 mm from invasive ductal. carcinoma (slide 3).. . (f) Superficial margin: 5 mm.. Y. Kim et al.. 811. a. b. . . 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification: present, tumoral.. . 10. Pathological TN category (AJCC 2017):. rpT1cNx.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 27%. of tumor cells. Operation. 232. Pathology Report. Lateral Margin. Invasive Ductal Carcinoma, residual. . 1. Post-lumpectomy and excision status.. . 2. Size of tumor: 0.6 cm.. . 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 22/10HPF).. . 4. Intraductal component: present, intratumoral. (20%) (nuclear grade: high, necrosis: absent,. architectural pattern: solid, extensive intra. ductal component: absent).. . 5. Surgical margins:. . (a) Lateral margin: (see note).. . 6. Vascular invasion: absent.. . 7. Lymphatic invasion: absent.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: absent.. Inferior Margin. No residual tumor. . 1. Post-lumpectomy and excision status.. Note: The lateral margin of the lumpectomy. specimen (slide 4) is close to ductal carcinoma in. situ (4 mm), but this margin submitted for frozen. diagnosis (Fro 2) is free of tumor.. Adjuvant Therapy. Chemotherapy #14 cycles of T-DM1 (trastu. zumab emtansine).. Local Recurrence. 812. 34. | null | Patient History and Progress. Female/45 years old, pre-menopause.. Screen detected mass lesion on upper inner. portion of left breast.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, mother at her. 50 years old.. S/P. Hysterectomy,. s/p. bilateral. breast. augmentation.. 33.2. |
Case 33 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Bone metastasis.. Primary Treatment. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%–. 1/3. Result. Intensity. Positive %. C-erbB2. Equivocal (2+). Ki-67. Positive in 7%. of tumor cells. SISH. Positive. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy to right breast. +Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. invasion.. Palliative Therapy. Radiation therapy to L-spine & T-spine & sacrum.. Palliative Capecitabine & lapatinib (Jul. 2021) ~. Y. Kwon et al. | null | |
Case 34 | Carcinoma In Situ | 34.1. . Courses of Treatment:. Operation. Operation. 161. 162. Pathology Report. <First operation>. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Surgical margins:. E. S. Lee et al.. 127. . . . . a. b. . Carcinoma In Situ. 128. a. b. . . (a) superior margin: 15 mm,. . (b) inferior margin: 30 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 8 mm,. . (f) superficial margin: 8 mm.. . 6. Microcalcification: absent.. <Second operation>. Right.. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.7 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins: positive for lobular carci. noma in situ at the nearest resection margin. (slide 1).. . 6. Microcalcification: absent.. E. S. Lee et al.. 129. . . Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 1. 10%−1/3. Progesterone. receptor. Weak (4/8). 1. 10%−1/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 3% of tumor. cells. Left.. Intraductal papilloma.. 35. | Important Radiologic. Findings. 157 158 159. 160. 34.3. | Patient History and Progress. Female/53 years old, pre-menopause.. Screen detected mass lesion on upper outer of. right breast.. No family history.. S/P Total gastrectomy (gastric cancer), micro. papillary thyroid carcinoma (follow-up).. BRCA 1 and 2: Not examination.. 34.2. |
Case 34 | HR(+) HER2(+) Breast Cancer | 34.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab) + Operation + Post-. operative radiation therapy + Trastuzumab. and Pertuzumab + Letrozole 2.5 mg/day.. 201. Pathology Report. Invasive ductal carcinoma, histologic grade 2.. No residual tumor with stromal degeneration. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. Result. Intensity. Positive. %. Estrogen. receptor. Intermediate. (6/8). 3. 10%-. 1/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 61%. of tumor cells. . HR(+) HER2(+) Breast Cancer. 416. . . . S. Park et al.. 417. . . . HR(+) HER2(+) Breast Cancer. 418. a. b. . 35. | Important Radiologic. Findings. 195 196 197 198 199. 200. 34.3. | Patient History and Progress. Female/55 years old, post-menopause.. Self-detected palpable mass lesion on right. breast 9 o’clock direction.. No family history.. No comorbidities.. 34.2. |
Case 34 | HR(+) HER2(-) Breast Cancer | 34.1. . Courses of Treatment. Operation. Right nipple–areolar complex sparing mastec. tomy with immediate implant reconstruction,. sentinel lymph node biopsy, left nipple–areo. lar complex sparing mastectomy with immedi. ate implant reconstruction (Figs. 190, 191 and. 192).. Pathology Report. [Right]. Invasive Ductal Carcinoma. 1. Size of tumor: 1.8 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. noma in situ (slide 1).. . (b) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). 7. Arteriovenous invasion: absent.. Y. Kim et al.. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 14%. of tumor cells. [Left]. Fibrocystic change.. 35. | Important Radiologic. Findings. See Figs. 186, 187, 188 and 189.. 34.3. | Patient History and Progress. Female/43 years old, pre-menopause.. Screen for high risk for breast cancer.. Family history of breast cancer, mother.. Pancreatic cancer, maternal uncle.. No comorbidities.. BRCA 1 mutation carrier.. 34.2. |
Case 34 | HR(−) HER2(+) Breast Cancer | 34.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4 cycles. of. doxorubicin. +. cyclophosphamide). +. Operation + Trastuzumab.. Operation. 233. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c(Paget)).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 3. Intraductal component: absent.. 4. Nipple: Paget disease.. 5. Skin: no involvement of tumor.. Y. Kwon et al.. 557. a. b. . 6. Surgical margins: deep margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: present, intratu. moral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral/non-. tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1c(Paget)N0(sn).. HR(−) HER2(+) Breast Cancer. 558. . Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 25%. of tumor cells. 35. | Important Radiologic. Findings. 229 230 231. 232. . HR(−) HER2(+) Breast Cancer. 556. . . . . 34.3. | Patient History and Progress. Female/54 years old, post-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. S/P. unilateral. salpingo-oophorectomy,. dyslipidemia.. HR(−) HER2(+) Breast Cancer. 554. a. b. . Y. Kwon et al.. 555. 34.2. |
Case 34 | HR(−) HER2(−) Breast Cancer | 34.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#1. cycles of docetaxel and cyclophosphamide,. stop d/t mucositis).. Operation. 255. Pathology Report. Invasive Ductal Carcinoma associated with. paraffinoma. 1. Size of tumor: 3.0 cm (pT2).. . . E. S. Lee et al.. 701. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 8/10HPF).. 3. Intraductal component: absent.. 4. Skin and nipple: no involvement of tumor.. 5. Surgical margins:. . (a) Deep margin: 10 mm.. . (b) Superficial margin: 21 mm.. 6. Lymph nodes: no metastasis in five axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 23%. of tumor cells. 35. | Important Radiologic. Findings. 252 253. 254. . . HR(−) HER2(−) Breast Cancer. 700. 34.3. | Patient History and Progress. Female/79 years old, post-menopause.. Screen detected mass lesion on left breast 12. o’clock direction.. No family history.. S/P paraffin injection, s/p appendectomy, s/p. hysterectomy, s/p hemicolectomy (colon cancer).. S/P radical total gastrostomy (advanced gas. tric cancer).. BRCA 1 and 2 mutation: Not detected,. BARD1 VUS (variant of uncertain).. 34.2. |
Case 34 | Local Recurrence | 34.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. 233 234. 235. Operation. 236. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive component: 0.7 cm (pT1b).. 2. Size of intraductal component: 1.0 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10HPF).. 4. Intraductal component: present, extratumoral. (60%) (nuclear grade: low, necrosis: present,. architectural pattern: papillary/cribriform,. extensive intraductal component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 28 mm.. . (b) Inferior margin: 12 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 30 mm.. . . . Y. Kim et al.. 813. a. b. . . . (e) Deep margin: <1 mm from ductal carci. noma in situ (slide 7).. . (f) Superficial margin: 13 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1b.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 53%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 1.8 years.. Treatments After Recurrence. 237. 238. Operation. . 239. Pathology Report. Invasive Ductal Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 2.1 cm, multifocal (rpT2).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 4/1HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (50%) (nuclear grade:. high, necrosis: present, architectural pattern:. papillary/micropapillary/cribriform/solid/. comedo, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. Local Recurrence. 814. . (a) Deep margin: <1 mm from ductal carci. noma in situ (slides 1 and 3).. . (b) Superficial margin: positive for invasive. ductal carcinoma (slide 5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT2.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in 51%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #4 cycles of doxorubicin. and cyclophosphamide.. Trastuzumab for 1 year.. Letrozole 2.5 mg/day.. . . Y. Kim et al.. 815. 35. | null | Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of right breast.. Family history of ovarian cancer mother.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 34.2. |
Case 34 | Metastatic Breast Cancer | Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Right pleural, liver, right adrenal. gland, bone metastasis → Brain metastasis.. Primary Treatment. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Equivocal. (2+). Ki-67. Positive. in 46% of. tumor. cells. SISH. Positive. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel & trastu. zumab #4).. Post-operative radiation therapy to left breast.. Concurrent Trastuzumab #13.. Treatments After Recurrence. Palliative Therapy. Radiation therapy to brain.. Palliative therapy #6 (Pertuzumab & trastu. zumab & Docetaxel) ~. 35. | null | No family history.. 34.2. |
Case 35 | Carcinoma In Situ | 35.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 165. 166. Pathology Report. Lobular carcinoma in situ, pathological TN. category (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 2% of tumor. cells. Carcinoma In Situ. 130. a. b. . a. b. . . 36. | Important Radiologic. Findings. 163. 164. 35.3. | Patient History and Progress. Female/59 years old, post-menopause.. Screen detected ductal dilatation on left breast. 12 o’clock direction.. No family history.. S/P Hysterectomy and bilateral salpingo-. oophorectomy, S/P total thyroidectomy (thyroid. cancer), hypertension.. 35.2. |
Case 35 | HR(+) HER2(+) Breast Cancer | 35.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. S. Park et al.. 209. 210. Pathology Report. Invasive ductal carcinoma, histologic grade 3.. No residual tumor with stromal degeneration.. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in seven axillary. lymph nodes (ypN0) (axillary LN (Fro 4): 0/4,. axillary LN: 0/3).. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%-1/3. Progesterone. receptor. Intermediate. (6/8). 2. 10%-1/3. C-erbB2. Positive (3+). Ki-67. Positive in. 49% of tumor. cells. . S. Park et al.. 421. . HR(+) HER2(+) Breast Cancer. 422. . . . . . S. Park et al.. 423. a. b. . a. b. . HR(+) HER2(+) Breast Cancer. 424. 36. | Important Radiologic. Findings. 202 203 204 205 206 207. 208. 35.3. | Patient History and Progress. Female/39 years old, pre-menopause.. Self-detected skin change and palpable mass. lesion on right breast 9:30 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 35.2. |
Case 35 | HR(+) HER2(-) Breast Cancer | 35.1. . cribriform/solid/comedo, extensive intra. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 15 mm.. . (b) inferior margin: 15 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . (f) superficial margin: 2 mm.. 7. Lymph nodes:. . (a) metastasis in two out of five axillary. lymph nodes (ypN1a(sn)) (sentinel LN:. 2/2, axillary LN: 0/3). HR(+) HER2(−) Breast Cancer. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (7/8). 2. >2/3. Progesterone receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8% of tumor cells. HR(+) HER2(−) Breast Cancer. 286. 36. | Important Radiologic. Findings. See Figs. 193, 194, 195, 196 and 197.. Y. Kim et al. | Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on left breast 4. o’clock direction.. Family history of breast cancer, maternal aunt.. No comorbidities.. BRCA 1 and 2 mutation: no examination.. 35.2. |
Case 35 | HR(−) HER2(+) Breast Cancer | 35.1. . Courses of Treatment. Neoadjuvant chemotherapy (#5 cycles of. docetaxel. and. trastuzumab. and. pertu. zumab) + Operation + Post-operative radiation. therapy + Trastuzumab and pertuzumab.. Operation. 242. Pathology Report. Microinvasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: <0.1 cm. (ypT1mi).. 3. Size of intraductal component: 0.8 cm.. 4. Histologic grade: not applicable.. . HR(−) HER2(+) Breast Cancer. 562. moral/extratumoral (99%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo. nent: present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: positive for microinva. sive ductal carcinoma (Fro 3) (see note),. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in three axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/3).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1miN0(sn).. Note: 1. Microinvasive ductal carcinoma is. focally present only in the permanent section of. Fro 3.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 48% of. tumor cells. 36. | Important Radiologic. Findings. 234 235 236. 237. Y. Kwon et al.. 559. . . . HR(−) HER2(+) Breast Cancer. 560. . . Y. Kwon et al.. 561. 35.3. . After Neoadjuvant. Chemotherapy. 238 239 240. 241. 35.4. | Patient History and Progress. Female/73 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, cousin. (maternal).. s/p cholecystectomy, s/p unilateral salpingo-. oophorectomy, hypertension, diabetes mellitus.. BRCA 1 and 2 mutation: Not detected.. 35.2. |
Case 35 | HR(−) HER2(−) Breast Cancer | 35.1. . Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4 cycles of doxorubicin and cyclophospha. mide) + Post-operative radiation therapy.. Operation. 259. Pathology Report. Invasive Ductal Carcinoma with apocrine. differentiation. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 6/10HPF).. 3. Intraductal component: present, extratumoral. (10%) (nuclear grade: high, necrosis: pres. ent, architectural pattern: cribriform/solid/. comedo, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 13 mm.. . (c) Medial margin: (see note).. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 15 mm.. 6. Arteriovenous invasion: absent.. 7. Lymphovascular invasion: absent.. 8. Tumor border: infiltrative.. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. pT1cNx.. Note: 1. The medial margin of the lumpec. tomy specimen (slide 5) is close to ductal carci. noma in situ (2 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 7% of. tumor cells. HR(−) HER2(−) Breast Cancer. 702. . . . . E. S. Lee et al.. 703. . 36. | Important Radiologic Findings. 256 257. 258. 35.3. | Patient History and Progress. Female/75 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Hypertension, Hyperlipidemia, s/p hysterec. tomy, arrhythmia (s/p operation).. 35.2. |
Case 35 | Local Recurrence | 35.1. . Courses of Treatment. Right breast IDC → Neoadjuvant chemotherapy. → Operation → Adjuvant therapy → Right. breast recurrence (DCIS).. Primary Treatment. Operation. First Operation (Aug. 2004) Left breast conserv. ing surgery, sentinel lymph node biopsy.. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive carcinoma: 0.4 cm (pT1a).. 2. Size of intraductal carcinoma: 4 cm.. 3. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count: 2/3).. 4. Ductal carcinoma in situ: present, intratu. moral/extratumoral (95%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform and comedo, extensive intraductal. component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 10 mm.. 7. Lymph nodes: no metastasis in 3 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3,. axillary LN: 0/0).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic staging: pT1aN0(sn).. Note: Ductal carcinoma in situ is noted only in. the permanent section of nipple margin (Fro 4). and inferior margin (Fro 5).. Result. Intensity Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Operation. Second Operation (Sep. 2004) Left breast wide. excision.. Pathology Report. No residual carcinoma with foreign body. reaction.. . 1. Post-lumpectomy status.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence. 240. 241. Local Recurrence. 816. Operation. . 242. 243. Pathology Report. . 1. Ductal Carcinoma In Situ. . (a) Size of tumor: 2.0 cm (pTis).. . (b) Nuclear grade: low.. . (c) Necrosis: absent.. . (d) Architectural pattern: cribriform.. . (e) Surgical margins:. • Deep margin: 7 mm.. • Superficial margin: 6 mm.. . (f) Microcalcification:. present,. tumoral/. non-tumoral.. . (g) Pathologic stage (AJCC 2010): pTisNx.. . 2. Sclerosing adenosis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 17%. of tumor cells. . . . Y. Kim et al.. 817. . . Adjuvant Therapy. Tamoxifen. 20. mg/day. for. 0.3. year. (self-cessation).. 36. | null | Patient History and Progress. Female/53 years old, peri-menopause.. Screen detected mass lesion on left breast. subareola.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 35.2. |
Case 35 | Metastatic Breast Cancer | 35.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Bone metastasis.. Primary Treatment. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in. 16% of tumor. cells. Oncotype Dx test: 23 (Recurrence Score).. Adjuvant Therapy. Post-operative radiation therapy to right breast. zoladex for 2 years +Tamoxifen 20 mg/day for. 5 years.. Treatments After Recurrence. See Figs. 112 and 113.. Sep. 2017 PET-CT: R/o metastasis to C2. vertebra.. Palliative Therapy. Bilateral salpingo-oophorectomy.. Radiation therapy to C-spine + Letrozole &. Palbociclib & zometa (2017-11-03~).. Metastatic Breast Cancer | null | Patient History and Progress. Female/51 years old, pre-menopause.. No family history.. S/p. hysterectomy. &. Left. salpingo-. oophorectomy (benign), s/p total hip replacement. arthroplasty.. 35.2. |
Case 36 | Carcinoma In Situ | 36.1. . Courses of Treatment:. Operation. Operation. 169. 170. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 0.5 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 5 mm,. E. S. Lee et al.. 131. . . a. b. . . Carcinoma In Situ. 132. . (c) medial margin: 20 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. 37. | Important Radiologic. Findings. 167. 168. 36.3. | Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast. 11 o’clock direction.. No family history.. No comorbidities.. 36.2. |
Case 36 | HR(+) HER2(+) Breast Cancer | 36.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide and. trastuzumab) + Post-operative radiation ther. apy + Trastuzumab + Tamoxifen 20 mg/day.. 215. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. b. . 3. Intraductal component: present, intratu. moral/extratumoral (5%) (nuclear grade:. high, necrosis: absent, architectural pattern:. solid, extensive intraductal component:. absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: <1 mm from invasive duc. tal carcinoma (slide 2),. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Weak (3/8). 2. <1%. C-erbB2. Equivocal (2+). Ki-67. Positive in 54%. of tumor cells. SISH. Tumor. heterogeneity. S. Park et al.. 427. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_7 | Important Radiologic. Findings. 211 212 213. 214. 36.3. | Patient History and Progress. Female/42 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast 5:30 o’clock direction.. No family history.. S/P Right pneumonectomy (lung cancer).. BRCA 1 and 2 mutation: Not examination.. 36.2. |
Case 36 | HR(+) HER2(-) Breast Cancer | 36.1. . Courses of Treatment. Operation + Post-operative radiation ther. apy + Tamoxifen 20 mg/day.. Operation. Right breast conserving surgery, sentinel lymph. micropapillary/cribri. form, extensive intraductal component:. present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm.. . (b) inferior margin: 25 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: 20 mm.. . (e) deep margin: <1 mm from invasive duc. tal carcinoma (slide 1).. . (f) superficial margin: 5 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1,. non-sentinel LN: 0/1). pT1bN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (7/8). 3. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 9% of. tumor cells. HR(+) HER2(−) Breast Cancer | Important Radiologic. Findings. See Figs. 199, 200, 201, 202 and 203.. 36.3. | Patient History and Progress. Female/50 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. No family history.. s/p endometrial curettage.. 36.2. |
Case 36 | HR(−) HER2(+) Breast Cancer | 36.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab) + Operation + Post-. operative radiation therapy + Trastuzumab.. 245. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in four axil. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/4).. . (c) Microcalcification:. present,. tumoral/. non-tumoral.. . 2. Intraductal papilloma.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 22% of. tumor cells. Y. Kwon et al.. 565. F. i. g. 243. (mSUV = 1.3). HR(−) HER2(+) Breast Cancer. 566. . . 37. | Important Radiologic. Findings. 243. 244. 36.3. | Patient History and Progress. Female/63 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Hypertension, chronic renal failure, ventricu. lar premature contraction.. S/P cholecystectomy (due to stone).. 36.2. |
Case 36 | HR(−) HER2(−) Breast Cancer | 36.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and . cyclophosphamide + #4 cycles. of docetaxel) + Operation + Post-operative. radiation therapy.. Operation. 267. Pathology Report. . 1. No residual tumor with foamy histiocytic. collection.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in two axil. lary lymph nodes (ypN0(sn)) (sentinel. LN: 0/2).. . (c) Related slides: S21–10541, S21–10544.. . 2. Adenomyoepithelial. hyperplasia. with. microcalcification.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 66%. of tumor cells. E. S. Lee et al.. 707. . . . HR(−) HER2(−) Breast Cancer. 708. 37. | Important Radiologic Findings. 260 261 262. 263. HR(−) HER2(−) Breast Cancer. 704. . . . . E. S. Lee et al.. 705. . HR(−) HER2(−) Breast Cancer. 706. . After Neoadjuvant Chemotherapy. 264 265. 266. 36.3. | Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass lesion on left. axillary.. Family history of breast cancer, aunt. (maternal).. Hepatitis B virus carrier.. BRCA 1 and 2 mutation: Not detected, RET. VUS (variant of uncertain).. 36.2. |
Case 36 | Local Recurrence | 36.1. . Courses of Treatment. Right breast DCIS → Operation → Left breast. recurrence (DCIS).. Primary Treatment. 244. Operation. 245. Pathology Report. Ductal Carcinoma In Situ. . 1. Post mammotome biopsy status.. Local Recurrence. 818. . a. b. . . 2. Size of tumor: 0.2 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent/present.. . 5. Architectural pattern: cribriform.. . 6. Surgical margins:. . (a) Superior margin: (see note).. . (b) Inferior margin: 7 mm.. . (c) Medial margin: 4 mm from ductal carci. noma in situ.. . (d) Lateral margin: 8 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 7. Microcalcification: absent.. Note: 1. The superior margin of the lumpec. tomy specimen (slide 4) is close to ductal carci. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 1) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 29%. of tumor cells. Treatments After Recurrence. 246. Operation. 247. 248. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 3.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform/. solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathological TN category (AJCC 2017): pTis.. Axillary Tail: Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform.. . 5. Surgical margin: involvement of superficial. margin.. Y. Kim et al.. 819. . a. b. . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 51%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 5 years.. 37. | null | Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. Outside result of biopsy: Papillary carcinoma. in situ.. No family history.. s/p bilateral breast augmentation.. BRCA 1 and 2 mutation: Not detected.. 36.2. |
Case 36 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. Result. Intensity. Positive %. C-erbB2. Equivocal. (2+). Ki-67. Positive in. 10% of tumor. cells. SISH. Negative. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operation radiation to right breast +. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Negative (0). Ki-67. Positive in. 22% of tumor. cells. Palliative Therapy. Clinical trial: Capecitabine #19: Progressive. disease.. Nov. 2018 Bilateral salpingo-oophorectomy.. Palliative therapy: Letrozole +Palbociclib. (Dec. 2018) ~. 37. | null | mellitus.. 36.2. |
Case 37 | Carcinoma In Situ | 37.1. . Courses of Treatment:. Operation. Operation. 173. 174. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 2.0 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: positive (Fro 1),. . (b) inferior margin: 4 mm,. . (c) medial margin: positive (Fro 3),. . (d) lateral margin: positive (Fro 4),. . (e) deep margin: <1 mm (slide 6),. . (f) superficial margin: 10 mm.. . 7. Microcalcification: absent.. Result. Intensity. Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. . E. S. Lee et al.. 133. . a. b. . a. b. . . Carcinoma In Situ. 134. 38. | Important Radiologic. Findings. 171. 172. 37.3. | Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast. 12 o’clock direction.. Outside result of biopsy: Lobular carcinoma. in situ.. No family history.. No comorbidities.. 37.2. |
Case 37 | HR(+) HER2(-) Breast Cancer | Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of docetaxel & cyclophosphamide) +. Post-operative radiation therapy + Tamoxifen. 20 mg/day.. Operation. Left breast conserving surgery, sentinel lymph. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm.. . (b) inferior margin: 15 mm.. . (c) medial margin: 10 mm.. . (d) lateral margin: (see note).. . (e) deep margin: 4 mm.. . (f) superficial margin: <1 mm from ductal. 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Note: 1. The lateral margin of the lumpec. tomy specimen (slide 6) is close to ductal. carcinoma in situ (<1 mm) but this margin. submitted for frozen diagnosis (Fro 9) is free. of tumor.. Y. Kim et al.. 3. 10%–1/3. C-erbB2. Negative (1+) IDC. Positive (3+) DCIS. Ki-67. Positive in 47% of tumor cells. 38. | Important Radiologic. Findings. See Figs. 205, 206, 207 and 208.. 37.3. | 4–5 o’clock direction.. No family history.. Hypertension,. s/p. Lumbar. spine. disc. operation.. 37.2. |
Case 37 | HR(−) HER2(+) Breast Cancer | 37.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab. and pertuzumab) + Operation + Post-. operative radiation therapy + Trastuzumab.. 253. Pathology Report. Ductal Carcinoma In Situ. 1. Post-chemotherapy status.. 2. Size of tumor: 0.5 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: solid/comedo.. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 30 mm,. HR(−) HER2(+) Breast Cancer. 570. . . (d) lateral margin: 20 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 9. Microcalcification:. present,. tumoral/. non-tumoral.. . 10. Pathological TN category (AJCC 2017):. ypTisN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 39% of tumor. cells. 38. | Important Radiologic. Findings. 246 247. 248. Y. Kwon et al.. 567. . . . HR(−) HER2(+) Breast Cancer. 568. 37.3. . After Neoadjuvant. Chemotherapy. 249 250 251. 252. . Y. Kwon et al.. 569. . . . 37.4. | Patient History and Progress. Female/63 years old, post-menopause.. Self-detected nipple discharge on left breast.. No family history.. S/P Total hysterectomy, s/p right lung lobec. tomy (benign), diabetes mellitus.. 37.2. |
Case 37 | HR(−) HER2(−) Breast Cancer | 37.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy + Adjuvant. capecitabine.. Operation. 276. Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of invasive component: up to 0.3 cm,. multifocal (ypT1a).. 3. Size of intraductal component: 2.0 cm.. 4. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 3/HPF).. 5. Intraductal component: present, intratu. moral/extratumoral (80%) (nuclear grade:. high, necrosis: present, architectural pattern:. papillary/micropapillary/cribriform/solid/. comedo, extensive intraductal component:. absent/present).. 6. Skin: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: (see note).. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Lymph nodes:. . (a) metastasis in two out of six axillary lymph. nodes (ypN1a) (sentinel LN: 1/1, axillary. LN: 0/4, intramammary LN: 1/1),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 4 mm.. 9. Arteriovenous invasion: absent.. HR(−) HER2(−) Breast Cancer. 710. . . . . E. S. Lee et al.. 711. . 10. Lymphovascular invasion: present, intratu. moral/peritumoral.. . 11. Tumor border: infiltrative.. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. ypT1aN1a.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1%–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 29%. of tumor cells. . . HR(−) HER2(−) Breast Cancer. 712. 38. | Important Radiologic. Findings. 268 269 270. 271. . . . . . E. S. Lee et al.. 709. . After Neoadjuvant. Chemotherapy. 272 273 274. 275. 37.3. | Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass lesion on right breast.. Family history of breast cancer, aunt (maternal).. s/p myomectomy.. BRCA 1 and 2 mutation: Not detected.. 37.2. |
Case 37 | Local Recurrence | 37.1. . Courses of Treatment. Left breast DCIS→ Operation → Adjuvant ther. apy → Left breast recurrence (DCIS).. Primary Treatment. 249 250. 251. Operation. 252. Local Recurrence. 820. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 3.0 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri. form/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Nipple margin: positive for atypical duc. tal hyperplasia (Fro 1) (see note 1).. . (b) Superior margin: (see note 2).. . (c) Inferior margin: 20 mm.. . (d) Medial margin: 5 mm.. . (e) Lateral margin: 15 mm.. . (f) Deep margin: 2 mm.. . (g) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathologic stage (AJCC 2010): pTis.. Note: 1. Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. 2. The superior margin of the lumpectomy. specimen (slide 1) is positive for ductal carci. noma in situ, but this margin submitted for frozen. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 36%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 253. 254. Operation. 255. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.5 cm (rpTis).. . 3. Nuclear grade: high.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. micropapillary/. cribriform.. . 6. Skin and nipple: Paget’s disease.. . 7. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. Local Recurrence. 822. . . . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017):. rpTis(Paget).. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 58%. of tumor cells. 38. | null | Patient History and Progress. Female/43 years old, pre-menopause.. Screen detected mass lesion on left breast 7. o’clock direction.. Outside result of biopsy: ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 37.2. |
Case 37 | Metastatic Breast Cancer | 37.1. . Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Intermediate. (6/8). 2. 1/3–2/3. C-erbB2. Positive (3+). Ki-67. Positive in. 27% of tumor. cells. Metastatic Breast Cancer. 920. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel & trastu. zumab #4).. Post-operative radiation therapy to right. breast.. Concurrent Trastuzumab # 4 + Tamoxifen. 20 mg/day for 85 days.. Treatments After Recurrence. See Figs. 117 and 118.. Feb. 2014 PET>R/O metastasis to lung, lymph. node, and right pleural effusion.. Palliative Therapy. Palliative therapy: Letrozole & trastuzumab (Feb. | null | Patient History and Progress. Female/59 years old, post-menopause.. No family history.. Hypertension, s/p right vertebral artery, tran. sient ischemic attack.. 37.2. |
Case 38 | Carcinoma In Situ | 38.1. . Courses of Treatment. Neoadjuvant chemotherapy #6 cycles (Docetaxel. and. Carboplatin. and. Trastuzumab. and. Pertuzumab) + Operation + Postoperative radia. tion therapy + Tamoxifen 20 mg/day for 5 years. + Trastuzumab for 1 year.. Operation. 180. 181. Pathology Report. Right.. Lobular carcinoma in situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: 1.5 cm.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) superior margin: (see note),. . (b) inferior margin: 4 mm,. . (c) medial margin: 20 mm,. . (d) lateral margin: (see note),. . (e) deep margin: <1 mm (MG2),. . (f) superficial margin: 2 mm.. . 7. Microcalcification: present, non-tumoral.. Note: 1. The superior and lateral margins of. the lumpectomy specimen (slides MG1and 5). are close to lobular carcinoma in situ (1 mm). but these margins submitted for frozen diagno. sis (Fro 1 and Fro 4) are free of tumor.. Left.. Ductal carcinoma in situ. . 1. Post-chemotherapy status.. . 2. Size of tumor: up to 0.5 cm (ypTis).. . 3. Nuclear grade: high.. . 4. Necrosis: present.. . 5. Architectural pattern: papillary/cribriform/. solid/comedo.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 17 mm,. . (b) inferior margin: 10 mm,. . . . E. S. Lee et al.. 135. . . . . . a. b. . Carcinoma In Situ. 136. a. b. c. d. . . . (c) medial margin: 40 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 3 mm,. . (f) superficial margin: 14 mm.. . 8. Lymph nodes: no metastasis in five axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/5).. . 9. Microcalcification: present.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 15% of tumor. cells. 39. | Important Radiologic. Findings. 175 176 177 178. 179. 38.3. | Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass and microcalcification. on upper outer left breast.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected, POLE. VUS (variant of uncertain).. 38.2. |
Case 38 | HR(+) HER2(-) Breast Cancer | 38.1. . Courses of Treatment. Operation + Post-operative radiation ther. apy + Letrozole 2.5 mg/day.. HR(+) HER2(−) Breast Cancer. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 20 mm.. . (b) inferior margin: 7 mm.. . (c) medial margin: 15 mm.. . (d) lateral margin: 10 mm.. . (e) deep margin: 2 mm.. . (f) superficial margin: 5 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). Y. Kim et al.. %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in 19%. of tumor cells. HR(+) HER2(−) Breast Cancer | Important Radiologic. Findings. See Figs. 210, 211, 212, 213 and 214.. 38.3. | Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. No family history.. Diabetes mellitus, dyslipidemia, s/p cataract. operation.. 38.2. |
Case 38 | HR(−) HER2(+) Breast Cancer | 38.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of docetaxel and cyclophosphamide) +. Post-operative. radiation. therapy. +. Trastuzumab.. 258. Y. Kwon et al.. 571. . . . HR(−) HER2(+) Breast Cancer. 3. Intraductal component: present, intratu. moral/extratumoral (60%) (nuclear grade:. high, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra. ductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 15 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 10 mm,. . (e) deep margin: 10 mm,. . (f) superficial margin: 7 mm.. Y. Kwon et al.. 573. 6. Lymph nodes: no metastasis in nine axillary. lymph nodes (pN0) (sentinel LN: 0/4, axil. lary LN: 0/5).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0.. Result. Intensity Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. positive. (3+). Ki-67. Positive. in 59%. of tumor. cells. HR(−) HER2(+) Breast Cancer. 575 | Important Radiologic. Findings. 254 255 256. 257. 38.3. | Patient History and Progress. Female/55 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. Family history of breast cancer, sister.. Dyslipidemia.. BRCA 1 and 2 mutation: Not detected,. MUTYH. and. RAD50 VUS. (variant. of. uncertain).. 38.2. |
Case 38 | HR(−) HER2(−) Breast Cancer | 38.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy.. Operation. . 285. 286. Pathology Report. No residual tumor with stromal degeneration. . 1. Post-chemotherapy status.. . 2. Lymph nodes: no metastasis in one axillary. lymph node (ypN0(sn)) (sentinel LN: 0/1).. . 3. Microcalcification: present.. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 62%. of tumor cells. HR(−) HER2(−) Breast Cancer. 714. . . . E. S. Lee et al.. 715. . . HR(−) HER2(−) Breast Cancer. 716. . E. S. Lee et al.. 717 | Important Radiologic. Findings. 277 278 279. 280. . . . . E. S. Lee et al.. 713. . After Neoadjuvant. Chemotherapy. 281 282 283. 284. 38.3. | Patient History and Progress. Female/52 years old, post-menopause.. Self-detected palpable mass lesion on right. breast.. No family history.. s/p bilateral salpingo-oophorectomy.. BRCA 1 mutation carrier.. 38.2. |
Case 38 | Local Recurrence | 38.1. . Courses of Treatment. Right breast IDC→ Operation → Adjuvant ther. apy → Right breast DCIS.. Primary Treatment. Operation. Jun. 2012 Right breast conserving surgery, senti. nel lymph node biopsy (outside).. Pathology Report. Invasive Ductal Carcinoma. . 1. Size of tumor: 0.9 cm (pT1b).. . 2. Lymph nodes: no metastasis in four axillary. lymph nodes (pN0(sn)).. . 3. Pathological TN category: pT1bN0.. Result. Intensity. Positive %. Estrogen. receptor. Positive (6/8). Progesterone. receptor. Positive (6/8). C-erbB2. Equivocal (2+). Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of cyclophos. phamide and methotrexate and fluorouracil.. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 256. Operation. 257. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform/solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 2 mm (slides 3 and 4).. . . . Local Recurrence. 824. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathological TN category (AJCC 2017): pTis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day.. 39. | null | Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of Lumpectomy: Invasive duc. tal carcinoma.. No family history.. Y. Kim et al.. 823. 38.2. |
Case 38 | Metastatic Breast Cancer | Courses of Treatment. Both breasts cancer → Operation → Adjuvant. therapy → Liver metastasis.. Primary Treatment. See Figs. 119 and 120.. Operation. Dec. 2008 Bilateral breast conserving surgery,. axillary lymph node dissection.. Pathology:. Right breast> Invasive ductal carcinoma, stage. pT2N2a, size of tumor: 4.5 cm, lymph node: 6/9. (12 mm).. Result. Intensity Positive %. Estrogen. receptor. Weak(2/7). 1. <10%. Progesterone. receptor. Negative. (0/7). 0. 0. Result. Intensity Positive %. C-erbB2. Positive. (3+). Ki-67. Positive in. 15% of. tumor cells. Left breast> Ductal carcinoma in situ, stage. pTisN0, size of tumor: 2.0 cm, lymph node: 0/7.. Metastatic Breast Cancer. receptor. Negative (0/7). 0. 0. C-erbB2. Positive(3+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Post-operative radiation therapy to right breast. & supraclavicular lymph node + Letrozole for. 5 years, concurrent Trastuzumab #18.. Treatments After Recurrence | null | |
Case 39 | Carcinoma In Situ | 39.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 6 months.. Operation. 184. 185. Pathology Report. Lobular carcinoma in situ. . 1. Size of tumor: 2.0 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. E. S. Lee et al.. 137. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: <1 mm (slide 2),. . (b) inferior margin: <1 mm (slide 5),. . (c) medial margin: 1 mm (slide 4),. . (d) lateral margin: <1 mm (slide 6),. . (e) deep margin: <1 mm (slide 3),. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 6%. of tumor cells. . . a. b. . Carcinoma In Situ. 138. a. b. . . . . . 40. | Important Radiologic. Findings. 182. 183. 39.3. | Patient History and Progress. Female/47 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: lobular carcinoma in. situ.. No family history.. Hypertension.. 39.2. |
Case 39 | HR(+) HER2(-) Breast Cancer | Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4 cycles of docetaxel & cyclophospha. mide) + Tamoxifen 20 mg/day.. Operation. Right nipple–areolar complex sparing mastec. tomy with immediate implant reconstruction, left. breast mass excision (Figs. 220, 221 and 222).. Pathology Report. [Right]. Invasive Lobular Carcinoma. 1. Size of tumor: 2.5 cm (pT2).. Y. Kim et al.. 295. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10 HPF). 3. In situ component: present, intratumoral/. extratumoral (70%).. 4. Skin: no involvement of tumor.. 5. Surgical margins: (see note).. . (a) deep margin: <1 mm from invasive lobu. lar carcinoma (slides 1 and 9).. . (b) superficial margin: <1 mm from invasive. lobular carcinoma (slide 1).. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1). 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N0(sn).. Note: 1. Lobular carcinoma in situ is pres. ent only in the permanent sections of Fro 9. and Fro 10.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 5% of. tumor cells. [Left] | Important Radiologic. Findings. See Figs. 216, 217, 218 and 219.. 39.3. | No comorbidities.. 39.2. |
Case 39 | Local Recurrence | 39.1. . Courses of Treatment. Left breast IDC→ Operation → Adjuvant ther. apy → Left breast recurrence (IDC).. Primary Treatment. 258 259 260. 261. Operation. 262. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive tumor: 3 cm (pT2).. 2. Size of intraductal component: 4.5 cm.. 3. Histologic grade: 1/3 (tubule formation: 3/3,. nuclear pleomorphism: 1/3, mitotic count:. 1/3, 7/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . . . Y. Kim et al.. 825. . . . Local Recurrence. 826. . (a) Deep margin: 13 mm.. . (b) Superficial margin: 16 mm.. 7. Lymph nodes:. . (a) Metastasis in 1 out of 10 axillary lymph. nodes (pN1mi) (sentinel LN: 1/3, axil. lary LN: 0/7).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 2 mm.. 8. Vascular invasion: absent.. 9. Lymphatic invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: absent.. . 12. Pathologic stage (AJCC 2010): pT2N1mi.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 26%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 2.6 years with. goserelin.. Treatments after Recurrence. 263. 264. Operation. 265. Pathology Report. Invasive Ductal Carcinoma. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 0.3 cm, residual (see note).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 7/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (10%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 5 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. Note: 1. In the previous biopsy specimen. (S18–12629), invasive ductal carcinoma mea. sures at least 0.4 cm in greatest dimension.. . . Y. Kim et al.. 827. . . Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%-1/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 14%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day for 5 years.. 40. | null | Patient History and Progress. Female/42 years old, post-menopause.. Bloody discharge from left nipple.. No family history.. 39.2. |
Case 39 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Neoadjuvant chemother. apy → Operation → Adjuvant therapy → Left. breast and lung metastasis.. Primary Treatment. Estrogen. receptor. Negative(0/7). 0. 0. Progesterone. receptor. Negative(0/7). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 10% of tumor. cells. SISH. Negative. Adjuvant Therapy. Post-operative radiation to right breast.. Treatments After Recurrence. (0/8). 0. 0. Progesterone. receptor. Negative(0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 43% of tumor. cells | null | Patient History and Progress. Female/51 years old, peri-menopause.. No family history.. BRCA 1 & 2 mutation: Not detected.. Hepatitis B virus carrier, hypertension.. 39.2. |
Case 4 | Benign and Proliferative | 4.1. . Courses of Treatment. → 2021-12-14 Excision, Lt.. Benign and Proliferative Case Series. 22. . 4.3.1. . Pathology Report. Diagnosis. • Breast, left, excision:. –. – Intraductal papilloma.. 5. | Important Radiologic. Findings. 6. 4.3. | Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on left breast. 12 o’clock direction.. Family history of pancreatic cancer, mother.. Hypertension, dyslipidemia (taking medication).. 4.2. |
Case 4 | Carcinoma In Situ | 4.1. . Courses of Treatment. Operation + Postoperative radiation therapy (left. side) + Tamoxifen 20 mg/day for 5 years.. 4.3.1. . Operation. 19. 20. 4.3.2. . Pathology Report. Right.. <First operation>. Lobular carcinoma in situ. . 1. Size of tumor: 0.2 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/. non-tumoral.. <Second operation>. Lobular carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 0.2 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . . . . . . Carcinoma In Situ. 60. d. . (c) medial margin: 10 mm,. . (d) lateral margin: 30 mm (see Note 1),. . (e) deep margin: 10 mm,. . (f) superficial margin: 5 mm.. . 7. Microcalcification: present, non-tumoral.. Note: 1. Atypical ductal hyperplasia is pres. ent only in the permanent section of Frozen 10.. Left.. <First operation>. E. S. Lee et al.. 61. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural. pattern:. micropapillary/. cribriform.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8%. of tumor cells. <Second operation>. Ductal carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 0.4 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural. pattern:. micropapillary/. cribriform.. . 6. Surgical margins:. . (a) superior margin: 5 mm (see Note 1),. . (b) inferior margin: 5 mm,. . (c) medial margin: (see Note 2),. . (d) lateral margin: 30 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification: present, tumoral.. Note: 1. Atypical ductal hyperplasia is. present only in the permanent section of Fro 1. 2. The medial margin of the lumpectomy. specimen (slide 4) is close to ductal carci. noma in situ (2 mm) but this margin submit. ted for frozen diagnosis (Fro 3) is free of. tumor. F. i. g. . 20_1 | Important Radiologic. Findings. 15 16 17. 18. 4.3. | Patient History and Progress. Female/46 years old, pre-menopause.. Self-detected palpable mass on right breast 8. and 9 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2: No detected mutation,. RAD51C VUS (variant of uncertain).. 4.2. |
Case 4 | HR(+) HER2(+) Breast Cancer | 4.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha. mide). +. Post-operative. radiation. ther. apy + Letrozole 2.5 mg/day.. 23. 4.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.6 cm (pT1b).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 10/10 HPF).. HR(+) HER2(+) Breast Cancer. 310. . . . 3. Intraductal component: present, extratumoral. (50%) (nuclear grade: high, necrosis: pres. ent, architectural pattern: micropapillary/. cribriform/comedo, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 15 mm,. . (d) lateral margin: 25 mm,. . (e) deep margin: 1.5 mm from ductal carci. noma in situ (slide 3),. . (f) superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10% to. 1/3. C-erbB2. Positive (3+). Ki-67. Positive in 27%. of tumor cells. S. Park et al.. 311. . . HR(+) HER2(+) Breast Cancer. 312. a. b. . 5. | Important Radiologic. Findings. 19 20 21. 22. 4.3. | Patient History and Progress. Female/56 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. S/P Thyroid radiofrequency ablation.. 4.2. |
Case 4 | HR(+) HER2(-) Breast Cancer | high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 10 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. 6. Lymph nodes:. . (a) metastasis in one out of five axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 1/1, axillary LN: 0/4),. . (b) perinodal extension: present,. . (c) size of metastatic carcinoma: 23 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Strong (8/8). 3. >2/3. Progesterone receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+) (SISH negative). Ki-67. Positive in 6% of tumor cells. Y. Kim et al. | Important Radiologic. Findings. See Figs. 15, 16, 17 and 18.. HR(+) HER2(−) Breast Cancer | Dyslipidemia.. 4.2. |
Case 4 | HR(−) HER2(+) Breast Cancer | 4.1. . Courses of Treatment. Neoadjuvant chemotherapy (#6 cycles of. docetaxel and carboplatin and trastuzumab and. pertuzumab) + Operation + Post-operative radia. tion therapy.. 4.4.1. . Operation. 35. 4.4.2. . Pathology Report. . 1. No residual tumor with stromal fibrosis.. . (a) Post-chemotherapy status.. . (b) Lymph nodes: no metastasis in nine axil. lary lymph nodes (ypN0) (sentinel LN:. 0/4, non-sentinel LN: 0/5).. . 2. Fibroadenomatous change.. Note: Histologic mapping has been done.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 35%. of tumor cells. . HR(−) HER2(+) Breast Cancer. 446. . 5. | Important Radiologic. Findings. 27 28 29. 30. . Y. Kwon et al.. 443. . . . F. ig. 30. 34. . . . . . . Y. Kwon et al.. 445. 4.4. | Patient History and Progress. Female/58 years old, post-menopause.. Self-detected mass lesion on left breast 3:30. o’clock direction.. No family history.. No comorbidities.. 4.2. |
Case 4 | HR(−) HER2(−) Breast Cancer | 4.1. . Courses of Treatment. Operation + adjuvant chemotherapy (#4 cycles. of docetaxel and cyclophosphamide) + Post-. operative radiation therapy.. 4.3.1. . Operation. 26. 4.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 40/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 16 mm.. . (b) Inferior margin: 20 mm.. . (c) Medial margin: 18 mm.. . (d) Lateral margin: 26 mm.. . (e) Deep margin: 6 mm.. . (f) Superficial margin: 8 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 25%. of tumor cells. HR(−) HER2(−) Breast Cancer. 588. . 5. | Important Radiologic. Findings. 22 23 24. 25. HR(−) HER2(−) Breast Cancer. 586. . . . E. S. Lee et al.. 587. . 4.3. | Patient History and Progress. Female/52 years old, post-menopause.. Self-detected palpable mass lesion on left. breast 1–2 o’clock direction.. No family history.. Hyperthyroidism.. 4.2. |
Case 4 | Local Recurrence | 4.1. . Courses of Treatment. Left breast Invasive cribriform carcinoma →. Operation → Adjuvant therapy → Left chest. wall recurrence (IDC).. 4.2.1. . Primary Treatment. 22 23. 24. Operation. . 25. 26. Pathology Report. Invasive Cribriform Carcinoma. 1. Size of invasive component: 1.5 cm and. 0.5 cm (pT1c).. 2. Size of intraductal component: 7.0 cm.. Local Recurrence. 726. . . . . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (90%) (nuclear grade:. low, necrosis: present, architectural pattern:. papillary/cribriform/solid/comedo, extensive. intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from ductal carci. noma in situ (slides 4 and 15).. . (b) Superficial margin: positive for ductal. carcinoma in situ (slides 5 and 10).. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2). 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, tumoral.. . 12. Pathologic stage (AJCC 2010): pT1c(m). N0(sn).. Y. Kim et al.. 727. a. b. c. d. . . Invasive Lobular Carcinoma. . 1. Size of tumor: 0.4 cm.. . 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. . 3. In situ component: present, extratumoral (30%).. . 4. Arteriovenous invasion: absent.. . 5. Lymphovascular invasion: absent.. . 6. Tumor border: infiltrative.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Strong (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 18%. of tumor cells. Adjuvant Therapy. Tamoxifen 20 mg/day for 1.2 years.. 4.2.2. . Treatments After Recurrence. 27. 28. Operation. 29. Pathology Report. Invasive Ductal Carcinoma. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 0.7 cm (rpT1b).. Local Recurrence. 728. . . . 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. 4. Intraductal component: present, intratumoral. (10%) (nuclear grade: low, necrosis: present,. architectural pattern: cribriform/comedo,. extensive intraductal component: absent).. 5. Skin and nipple: no involvement of tumor.. 6. Surgical margins: deep margin: 3 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT1b.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 15%. of tumor cells. Adjuvant Therapy. Plan for tamoxifen with goserelin.. 5. | null | Patient History and Progress. Female/41 years old, pre-menopause.. Screen detected mass lesion on left breast 1. and 2 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 4.2. |
Case 4 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Left breast and pleural effusion. recurrence.. 4.2.1. . Primary Treatment. Operation. Oct. 2008 Right breast conserving surgery, axil. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. T1(m)N1 (2/25).. Size of tumor: 1.7 * 1.5 * 1 cm and. 0.5 * 0.4 cm, lymph node: 2/25, size of metastatic. carcinoma: 19 mm.. Result. Intensity. Positive %. Estrogen. receptor. Positive. N.A.. N.A.. Progesterone. receptor. Positive. N.A.. N.A.. C-erbB2. Negative (1+). Ki-67. Positive in. 63.51% of. tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles → Post-. operative radiation therapy + Tamoxifen 20 mg/. day for 5 years.. 4.2.2. . Treatments After Recurrence. Left breast and pleural effusion recurrence.. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 74% of. tumor cells. Clinical. stage:. cT4N3M1. (pleural. effusion).. Palliative Chemotherapy. Palliative chemotherapy #12 cycles (paclitaxel. #12 & Cisplatin #9): controlled disease.. Palliative Operation. Feb. 2022 Left total mastectomy, sentinel lymph. node biopsy (palliative operation).. Pathology: No residual tumor with foamy his. tiocytic collection.. . 1. Post-chemotherapy status. . 2. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)). (sentinel LN: 0/1). Palliative radiation therapy.. Post-operative radiation therapy. | null | BRCA 1 mutation: detected.. s/p Appendectomy, s/p myomectomy.. 4.2. |
Case 40 | Carcinoma In Situ | 40.1. . Courses of Treatment:. Operation. Operation. 189. 190. Pathology Report. Lobular carcinoma in situ. . 1. Post-stereotactic excision status.. . 2. Size of tumor: 1.0 cm, residual.. . 3. Nuclear grade: low.. E. S. Lee et al.. 139. . 4. Necrosis: absent.. . 5. Architectural pattern: solid.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 20 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. . a. b. . a. b. . Carcinoma In Situ. 140. . . . Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 1%. of tumor cells. 41. | Important Radiologic. Findings. 186 187. 188. 40.3. | Patient History and Progress. Female/47 years old, post-menopause.. Screen detected mass and microcalcification. on right breast 10 o’clock direction.. No family history.. No comorbidities.. 40.2. |
Case 40 | Local Recurrence | 40.1. . Courses of Treatment. Right breast DCIS→ Operation → Right breast. recurrence (microinvasive ductal carcinoma).. Primary Treatment. 266. Local Recurrence. 828. . . Operation. 267. Pathology Report. Ductal Carcinoma In Situ. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid/cribriform.. . 5. Surgical margins:. . (a) Superior margin: 7 mm.. . (b) Inferior margin: 6 mm.. . (c) Medial margin: 1 mm from ductal carci. noma in situ (slide 1).. . (d) Lateral margin: 45 mm.. . (e) Deep margin: <1 mm from ductal carci. noma in situ (slide 1).. . 6. Microcalcification:. present,. tumor/. non-tumor.. . 7. Pathologic stage (AJCC 2010): pTisNx.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 25%. of tumor cells. Treatments After Recurrence. 268 269. 270. Operation. . 271. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1 cm. (pT1mi).. 2. Size of intraductal component: 0.6 cm.. Y. Kim et al.. 829. . . . . Local Recurrence. 830. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (99%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform/solid/comedo, extensive intra. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic stage (AJCC 2010): pT1miN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 22%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day for 3.3 years, then tamoxi. fen 20 mg/day.. 41. | null | Patient History and Progress. Female/60 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock and 9 o’clock direction.. Outside result of biopsy: right breast 12. o’clock, Atypical ductal hyperplasia.. Right breast 9:30 o’clock, Fibrocystic change.. Family history of breast cancer, older sister. and younger sister.. Hepatitis C virus carrier, Facet Joint Syndrome. lumbosacral region, Dyspnea disorder.. BRCA 1 VUS (variant of uncertain).. 40.2. |
Case 40 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Neoadjuvant chemother. apy → Operation → Adjuvant therapy → Lung. metastasis.. Primary Treatment. 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 76% of tumor. cells. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel #4).. Y. Kwon et al.. 925. Operation. Apr. 2015 Right breast conserving surgery, axil. lary lymph node dissection.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1mi.. Size of tumor: 1.4 cm, lymph node 2/9 (2 mm).. Adjuvant Therapy. Post-operative radiation to right breast +. Tamoxifen 20 mg/day for 2 years.. Treatments After Recurrence | null | |
Case 41 | Carcinoma In Situ | 41.1. . Courses of Treatment. 194. 195. Operation + Tamoxifen 20 mg/day for 5 years.. Operation. 194. 195. Pathology Report. <First operation>. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 1.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: <1 mm from ductal carci. noma in situ (slide 3),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. 16% of tumor. cells. <Second operation>. E. S. Lee et al.. 141. Ductal carcinoma in situ. . 1. Post-excision status.. . 2. Size of tumor: 1.5 cm, residual.. . 3. Nuclear grade: low.. . 4. Necrosis: present.. . 5. Architectural. pattern:. cribriform/solid/. comedo.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) inferior margin: (see Note 1),. . (b) medial margin: (see Note 2).. . 8. Microcalcification: present, non-tumoral.. Note: 1. The inferior margin of the lumpec. tomy specimen (slides 2 and 3) is close to. ductal carcinoma in situ (<1 mm) but this. margin submitted for frozen diagnosis (Fro 1). is free of tumor.. . . a. b. . Carcinoma In Situ. 142. a. b. c. d. . 2. The medial margin of the lumpectomy speci. men (slide 1) is positive for ductal carcinoma. in situ but this margin submitted for frozen. diagnosis (fro 2) is free of tumor.. 42. | Important Radiologic. Findings. 191 192. 193. 41.3. | Patient History and Progress. Female/46 years old, pre-menopause.. Screen detected mass lesion on left breast. 2 o’clock direction.. Outside result of biopsy: R/O Atypical ductal. hyperplasia or ductal carcinoma in situ.. No family history.. No comorbidities.. 41.2. |
Case 41 | Local Recurrence | 41.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant ther. apy → Right breast recurrence (DCIS).. Primary Treatment. 272 273. 274. Operation. 275. Pathology Report. Invasive Ductal Carcinoma. 1. Size of invasive tumor: 1.2 cm (pT1c).. 2. Size of ductal carcinoma in situ: 3.5 cm.. 3. Histologic grade: 2 (tubule formation: 2/3,. nuclear pleomorphism: 3/3, mitotic count:. 1/3, 3/10HPF).. . . Y. Kim et al.. 831. 4. Intraductal component: present, intratumoral. and extratumoral (80%) (nuclear grade: high,. necrosis: present, architectural pattern: pap. illary and cribriform, extensive intraductal. component: present).. 5. Skin: no involvement of tumor.. 6. Nipple: involvement of lactiferous duct by. ductal carcinoma in situ.. 7. Surgical margins:. . (c) Deep margin: 2 mm.. . (d) Superficial margin: 12 mm.. 8. Lymph nodes: no metastasis in 4 axillary. lymph nodes (pN0) (sentinel LN: 0/1, axil. lary LN: 0/3).. 9. Vascular invasion: absent.. . 10. Lymphatic invasion: absent.. . 11. Tumor border: infiltrative.. . 12. Microcalcification: present, tumoral.. . 13. Pathologic stage (AJCC 2010): pT1cN0.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Intermediate. (5/7). 3. 10%-1/3. C-erbB2. Negative (0). Ki-67. Positive in 35%. of tumor cells. a. b. . . . Local Recurrence. 832. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Tamoxifen 20 mg/day for 2.3 years.. Treatments After Recurrence. 276 277. 278. Operation. 279. Pathology Report. . 1. Ductal Carcinoma In Situ, residual involving. sclerosing adenosis.. . (a) Size of tumor: 3.5 cm.. . (b) Nuclear grade: low.. . (c) Necrosis: present.. . (d) Architectural pattern: papillary/cribri. form/comedo.. . (e) Skin and nipple: no involvement of tumor.. . (f) Surgical margins:. • Deep margin: 3 mm.. • Superficial margin: 6 mm.. . (g) Lymph nodes: no metastasis in two axil. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/1, axillary LN: 0/1).. . (h) Microcalcification:. present,. tumoral/. non-tumoral.. . 2. Sclerosing adenosis with microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 20%. of tumor cells. Adjuvant Therapy. Anastrozole 1 mg/day.. . Y. Kim et al.. 833. . . . Local Recurrence. 834. 42. | null | Patient History and Progress. Female/62 years old, post-menopause.. Screen detected mass lesion on left breast sub. areolar and retraction of left nipple.. No family history.. No comorbidities.. 41.2. |
Case 41 | Metastatic Breast Cancer | Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung, liver, and bone metastasis.. Primary Treatment. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. weak (4/8). 2. 1–10%. C-erbB2. Positive. (+3). Ki-67. Positive in. 19% of. tumor cells. Adjuvant Therapy. Adjuvant chemotherapy # 8 cycles (Doxorubicin. & cyclophosphamide #4 → Docetaxel &. Trastuzumab #4).. Post-operative radiation to left breast +. Tamoxifen 20 mg/day for 2.5 years.. Concurrent Trastuzumab # 14.. Treatments After Recurrence. See Figs. 128 and 129.. Oct. 2018 PET-CT> R/O multiple metastasis. in both lungs, bone, and liver.. Palliative Therapy. Palliative therapy # 23 cycles (Docetaxel &. Trastuzumab & Pertuzumab). | null | Patient History and Progress. Female/52 years old, peri-menopause.. No family history.. S/p Tuberculosis.. 41.2. |
Case 42 | Carcinoma In Situ | 42.1. . Courses of Treatment. Operation + Postoperative radiation therapy.. Operation. 200. 201. Pathology Report. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTisNx. . 1. Size of tumor: 1.5 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary/cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 20 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. E. S. Lee et al.. 143. . . . . . . a. b. . Carcinoma In Situ. 144. a. b. . . . . 7. Lymph nodes: not submitted (pNx).. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (5/8). 2. 10%-1/3. C-erbB2. Negative (1+). Ki-67. Positive in 7%. of tumor cells. 43. | Important Radiologic. Findings. 196 197 198. 199. 42.3. | Patient History and Progress. Female/57 years old, post-menopause.. Screen detected microcalcification on left. breast 6 o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. Diabetes mellitus.. 42.2. |
Case 42 | Local Recurrence | 42.1. . Courses of Treatment. Left breast ILC → Operation → Adjuvant ther. apy → Right breast recurrence (IDC).. Primary Treatment. 280. Operation. Aug. 2017 Left nipple-areolar complex sparing. mastectomy with transverse rectus abdominis. muscles flap reconstruction (outside).. Pathology Report. Invasive Lobular Carcinoma. . 1. Size of invasive tumor: 0.2 cm (pT1a).. . 2. Pathologic stage: pT1aNx.. Result. Intensity. Positive %. Estrogen. receptor. Positive. Progesterone. receptor. Negative. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Adjuvant therapy.. Tamoxifen 20 mg/day for 0.7 year.. Treatments After Recurrence. 281 282. 283. Operation. . 284. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 1/3 (tubule formation: 1/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 5/10HPF)/. . . Y. Kim et al.. 835. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 1. 1/3–2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Letrozole 2.5 mg/day with leuprolide.. . . . Local Recurrence. 836. 43. | null | Patient History and Progress. Female/52 years old, pre-menopause.. Screen detected mass lesion on right breast 10. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, younger sister. at her 44 years old.. s/p Left breast Nipple sparing mastectomy. (invasive lobular carcinoma).. BRCA 1 and 2 mutation: Not detected.. 42.2. |
Case 42 | Metastatic Breast Cancer | . Courses of Treatment. Left breast cancer → Operation → Adjuvant. therapy → Lung metastasis.. Primary Treatment. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 5%. of tumor cells. FISH. Negative. Adjuvant Therapy. Adjuvant chemotherapy # 6 cycles (Fluorouracil-5. & Doxorubicin & Cyclophosphamide).. Post-operation radiation to left breast +. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 2022) ~. Y. Kwon et al. | null | Patient History and Progress. Female/57 years old, post-menopause.. No family history.. Arrhythmia (taking on medicine).. 42.2. |
Case 43 | Brief Overview of Breast Cancer Treatment | Brief Overview of Breast Cancer Treatment. 150. . (b) Multicentric or multifocal lesions or with. an extensive intraductal component of. 25% or greater and tumor size that is sig. nificantly reduced after neoadjuvant. therapy.. . (c) A lesion significantly reduced in size. after neoadjuvant therapy that is a T1 or. partial T2 tumor located deep in the breast. parenchyma.. Nipple–areolar complex (NAC) spar. ing mastectomy has also begun to improve. the cosmetic effect. The risk of cancer. cell infiltration or recurrence in the nip. ple–areola complex is an issue that. requires consideration. Selecting target. patients based on preoperative findings is. very important. Patients with inflamma. tory breast cancer and stage III locally. advanced breast cancer are generally not. recommended for this surgery.. . 2. Surgical technique.. Several incision techniques are used: the. peri-areolar incision, a separate dilated inci. sion around the areola, a separate previous. biopsy site incision, a modified oval incision. that includes the nipple and areola area and. the previous biopsy site, and an incision using. the inframammary fold. Surgeons should. carefully choose the type of skin incision, tak. ing into account various factors. When per. forming. a. nipple–areola. complex. and. skin-. sparing mastectomy, a radial incision. that minimizes the blockage of blood flow in. the areola can be used. The first priority is that. the tumor must be completely resected. The. technique for removing the skin during a skin-. sparing mastectomy, similar to a classical. mastectomy, avoids the breast tissue and. removes skin from the subcutaneous tissue. and dermis to the surface of the superficial. fascia. With the skin flap lifted, the breast tis. sue is detached from the chest wall together. with the pectoralis major fascia from top to. bottom. After the skin flap is completely lifted. and most of the mastectomy is done, the. breast is detached from the pectoralis major. muscle and pulled outward to facilitate access. for sentinel lymph node biopsy or axillary. lymph node dissection. It is necessary to. remove as much breast tissue as possible and. satisfy the two conditions so that necrosis. does not occur in the remaining nipple. The. best technique to use depends on the patient’s. skin thickness, areola size, presence or. absence of inverted nipples, vascular distribu. tion, breast size, age, and breast tightness.. Surgeons must accumulate techniques through. a lot of experience [23, 24].. . 3. Breast reconstruction.. Immediate breast reconstruction is per. formed by various methods depending on the. characteristics of the patient. An artificial. implant can be inserted, or the patient’s own. tissue can be used. For implant placement, a. tissue expander is placed between the pectora. lis major and pectoralis minor muscles under. the resected breast to gradually increase the. volume. Another method to make a breast that. uses autologous tissue is a myocutaneous flap. surgery. The skin and muscles are transferred. from the patient’s back (latissimus dorsi flap),. lower abdomen (deep inferior epigastric artery. perforator flap or transverse rectus myocutane. ous flap), or buttocks or thighs [25–29].. . 4. Local recurrence.. When the indications are carefully. selected, performing breast reconstruction. immediately after a skin-sparing mastectomy. has a better cosmetic effect than other options. and has a similar local recurrence rate. Local. recurrence is not difficult to detect because it. recurs mostly on the chest wall. Therefore,. skin-. sparing mastectomy is oncologically. safe and cosmetically superior to traditional. mastectomy when performed selectively.. There are not many reports of long-term fol. low-up for nipple–areola complex and skin-. sparing mastectomy, and an excision of. nipple–areola complex might be performed. during surgery depending on the results of. frozen section tests. Therefore, it is impor. tant to fully explain all the possibilities to the. patient and proceed with surgery only after. that consultation.. J. Y. You et al.. 151. 1.3. . Axillary Lymph Node Surgery. 1.3.1. . Sentinel Lymph Node Biopsy. and Intraoperative Evaluation. of the Sentinel Lymph Node. . 1. Method using dye.. Among the dyes, isosulfan blue is the most. widely used. In combination with albumin, it. selectively enters the lymph vessels and stains. them and the sentinel lymph nodes blue.. Methylene blue, indigo carmine, Paten blue V,. indocyanine green, etc., have also been used. and shown similar success rates. Among the. methods for injecting dye for a sentinel lymph. node biopsy, an intradermal injection around. the areola is reported to have a higher detec. tion rate of sentinel lymph nodes than a sub. cutaneous injection, intradermal injection,. subareolar injection, or tumor site parenchy. mal injection. Some researchers argue that. parenchymal injections around the tumor. have a high detection rate. Gently massage the. breast for about 5 min after injecting the dye. to allow it to enter the lymph vessels well.. Precise timekeeping is important because. starting a biopsy too early after the injection. might not result in staining, and waiting until. too late to start could result in staining of non-. sentinel lymph nodes with excessive stain.. The time it takes for the dye to reach the sen. tinel lymph nodes becomes shorter as the. tumor becomes closer to the axilla. It has been. reported that massaging the breast after injec. tion increases the sensitivity of finding the. sentinel lymph nodes [30].. After that, the clavipectoral fascia is found. by making a 2–3-cm skin incision in front of. the midaxillary line about 1 cm below the. axillary hair line, and the axillary adipose tis. sue can be found. Look for stained lymph ves. sels in the area where the pectoral node is. located along the margin of the pectoralis. major muscle. If no lymph node is found. there, look for lymph nodes at levels I and II,. such as the external breast lymph node and the. sub-shoulder central lymph node. All sentinel. lymph nodes can only be found only by trac. ing both the proximal and distal parts of the. stained lymph vessels and looking for the sen. tinel lymph nodes. After the sentinel lymph. nodes are removed, the axilla should be re-. examined, and any suspicious palpable lymph. nodes should be removed and included in the. sentinel lymph nodes. It is important to be. careful not to cut or damage the stained lymph. vessels because they play a role in the area. where the sentinel lymph nodes can be found.. . 2. Method using radioactive isotopes.. Among the radioactive isotopes, colloidal. radioisotopes are most commonly used. because they move quickly into the lymph. vessels and are transported to the sentinel. lymph nodes, where they remain long enough. to be found during surgery.. Currently, 99mTc-sulfur, 99mTc-human. serum albumin, 99mTc-antimony sulfur col. loid, 99mTc-dextran, 99mTc-tin, etc. are used.. Other ideal radio colloids should be inexpen. sive, free from radiation exposure, and easy to. handle. Radioactive isotopes can be injected. around the tumor, subcutaneously, intrader. mally, subareolar, and around the areola, but. many studies have shown that subareolar or. around the areola injections are effective for. sentinel lymph node detection. Preoperatively,. sentinel lymph node locations can be deter. mined by taking frontal and lateral lymphos. cintigraphy images 15 min after injection.. That also has the advantage of locating senti. nel lymph nodes outside the axilla before sur. gery. Conversely, some reports indicate that it. does not help the detection rate or false nega. tive rate of the sentinel lymph nodes [31].. Before starting surgery, a gamma-ray. detector is used to confirm and display the. exact locations of the sentinel lymph nodes.. A minimal incision window is made at that. location, and a gamma-ray detector is used to. find hotspots with high radiation doses and. remove those sentinel lymph nodes. There is. no dispute that the stained lymph nodes. should be considered as sentinel lymph. nodes when dyes are used, but there is no. standard for how many nodes should be con. sidered sentinel lymph nodes when radioiso. topes are used. One standard is that the. Brief Overview of Breast Cancer Treatment. 152. absolute value of the radiation dose be 25 or. more for 10 s, but another is that the radia. tion dose be 10 times or more than that of the. surrounding tissue. Furthermore, once the. sentinel lymph node with the highest radia. tion dose is excised, there is an increased risk. of false negatives if the remaining lymph. nodes, which exhibit a radiation dose of 10%. or more of that value, are not removed by. measuring the radiation dose as a sentinel. lymph node. There is also a report that the. standard can be lowered even further. Breast. cancer usually shows the highest amount of. metastasis to the sentinel lymph nodes with. the highest radiation dose. But once metasta. sized tumor cells have completely replaced. the lymph nodes, the lymph nodes might. have very low or undetectable radiation. doses, so all suspicious lymph nodes should. be removed at the time of biopsy. The greater. the number of sentinel lymph nodes resected,. the higher the accuracy. According to the. NSABP B-32 study, the false negative rate. was 17.7% in one node, 10% in two nodes,. 6.9% in three nodes, 3.3% in four nodes, and. 1% in five nodes.. . 3. Combination of dyes and radioactive isotopes.. It has been reported that combining dyes. and radioactive isotopes for sentinel lymph. node biopsy increases the meaningful sentinel. lymph node detection rate and average num. ber of sentinel lymph nodes and lowers the. false negative rate. Therefore, for surgeons. who are not experienced with these proce. dures, it is easy to use both formulations. together to shorten the learning curve [32].. . 4. Side effects and complications.. Isosulfan blue dyes rarely cause urticaria. and anaphylaxis. The administration of ste. roids and antihistamines improves urticaria in. a short time. Hypotensive anaphylaxis, how. ever, requires aggressive and immediate treat. ment and 24-h intensive observation. In. addition, the use of isosulfan blue during sur. gery can interfere with the measurement of. intraoperative oxygen saturation by pulse. oximetry, causing it to be measured as lower. than the actual value. Other side effects that. stain the epidermis can occur, but they usually. disappear in a few weeks to a few months [17,. 18].. It is well known that sentinel lymph node. biopsy has fewer complications than axillary. lymphadenectomy. When only the sentinel. lymph node procedure is performed, effects. such as postmastectomy pain syndrome,. lymphedema, axillary pain, abnormal sensa. tion in the surgical site, upper extremity. movement on the affected side, cosmetic. aspects of the axillary wound, postoperative. wound infection, and seroma were held at sat. isfactory levels.. . 5. Sentinel lymph node evaluation.. With the advent of sentinel lymph nodes, a. thorough and detailed examination of the axil. lary lymph nodes has become possible.. According to the American Society of. Pathology’s draft recommended method, the. sentinel lymph nodes are first cut in half in the. longitudinal direction and then cut at intervals. of 1.5–2 mm to make continuous sections. [32]. It is recommended to make three sec. tions for each block. If metastases are found,. the pathologist should record whether they are. macrometastases or micrometastases found. by immunohistochemical staining or reverse. transcription polymerase chain reactions. Due. to controversy over the significance of senti. nel lymph node metastases found by immuno. histochemical. staining,. the. American. Pathology Society does not recommend the. basic use of immunohistochemical staining.. According to the ACOSOG Z0010 trial,. sentinel node metastases deemed positive by. H&E staining had a significant effect on the. 5-year overall survival rate, but sentinel node. metastases deemed positive by immunohis. tochemical staining did not affect the sur. vival rate. The clinical significance of. micrometastasis is also still controversial.. Some results show that micrometastases. found by H&E staining indicate a difference. in disease-free survival, but other reports. persist that this is not [33, 34].. According to the seventh edition of the. AJCC, isolated tumor cells or isolated clusters. J. Y. You et al.. 153. of tumor cells (ultra-micrometastases) are. defined as a cell colony size of 0.2 mm or less,. single tumor cells, or fewer than 200 colonies. in a single histological cross-section, and they. are classified as pN0.. 1.3.2. . Axillary Lymph Node Dissection. The presence or absence of axillary lymph node. metastasis is one of the most important single. prognostic factors in breast cancer. Axillary. lymph node dissection is a local axillary treat. ment used to stage breast cancer and determine. the direction of advanced treatment.. . 1. Indications.. . (a) A sentinel lymph node biopsy shows. metastasis.. . (b) Contraindications for sentinel lymph. node biopsy or if no sentinel lymph node. is found.. . (c) Inflammatory breast cancer or surgery. after neoadjuvant chemotherapy.. . (d) Cases of locoregional recurrence of axil. lary lymph nodes after sentinel lymph. node resection.. . 2. Surgical anatomy.. The axilla is divided into three levels, I, II,. and III, depending on the positional relation. ship with the pectoralis minor muscle. Level I. is the lateral portion of the pectoralis minor. muscle, including the lateral border, and con. tains the lateral lymph nodes, the subscapu. laris, and the lateral axillary veins. Level II is. situated between the lateral and medial bor. ders of the pectoralis minor muscle, essentially. just inferior to the pectoralis minor. This. region is where the central lymph node group. is located. The common axillary dissection. involves a level I and II lymphadenectomy.. Level III is the area inside the medial border of. the pectoralis minor and contains the subcla. vian lymphoid group. Dissection is not gener. ally considered except in cases in which the. lymph nodes of level III are palpable, or when. a level III dissection is required because metas. tasis to level I or II is clinically clear. Rotter’s. nodes mean the lymph nodes located between. the pectoralis major and pectoralis minor.. . 3. Preoperative considerations and surgical. steps.. The patient’s arms should be placed on the. arm supports, with the affected arm at 90° or. less, and the skin of the axilla is prepared for. standard methods. From preparation for sur. gery until the end of surgery, the arm should. not be hyperextended. It is important to place. a pad on the arm struts to prevent shoulder. dislocation and brachial plexus tension during. surgery. To prevent infection, a wide range of. antibiotics, including against Gram-positive. bacteria, is given intravenously just before. surgery. During anesthesia, avoid the use of. long-acting muscle relaxants to make it easier. to recognize the motor nerves during surgery.. When performing a modified radical mas. tectomy, use the mastectomy line without a. separate skin incision. In mastectomy, surgery. is performed through a new axillary incision. line. The anterior edge of the skin incision. extends to the lateral aspect of the pectoralis. major muscle, while the posterior edge. reaches the anterior border of the latissimus. dorsi muscle. In most cases, the incision is. made parallel to the wrinkles of the skin, but. in some cases, it can be made vertically or. diagonally to the chest wall. The cutaneous. flap is bordered by the axillary vein above, the. chest wall below, the lateral edge of the pecto. ralis major muscle in the anterior, and the. anterior edge of the distribution muscle in the. posterior. At this time, attention should be. paid to the external thoracic nerve that runs. along the posterior side of the pectoralis major. muscle and the internal thoracic nerve that. runs in a Y shape on the inferolateral sides of. the pectoralis major muscle.. The surgeon dissects along the pectoralis. minor muscle. When the axillary vein is iden. tified, the fat layer covering it should be sepa. rated from top to bottom. At this time, thorough. removal of the tissue around the vein induces. lymphedema. When the axillary vein is. exposed, the lower part of the vein is separated. from the inside to the outside, and the upper. part of the vein is not dissected. Rather than. separating just below the vein, separating it at. Brief Overview of Breast Cancer Treatment. 154. intervals of about 5 mm can prevent side holes. from forming in the vein. When separating and. ligating the branches of the axillary vein, the. anterior thoracic branch of the axillary vein is. ligated, and the thoracic vein just below is. checked. Axillary lymph node dissection. involves en bloc resection to prevent damage. to the axillary lymphatic vessels and pro. gresses in stages from medial to lateral. At this. time, the thoracic neurovascular bundle is the. first deep branch to be found. Detachment. along the lateral and anterior sides of the latis. simus dorsi muscle can prevent damage to the. thoracodorsal nerve. The thoracodorsal nerve. is located mainly inside the vein, slightly pos. terior, and can be pressed lightly to check the. contraction of the latissimus dorsi muscles and. the movement of the shoulder. Along with this,. the long thoracic nerve must be found and pre. served. The long thoracic nerve returns inferi. orly and posteriorly along the thoracic wall. from the fat layer at the intersection of the. axillary vein and the thoracic wall, with the. subscapular lymphatic group sample pulled. downward and outward. Pressing it lightly. allows the surgeon to check the movement of. the serratus anterior. If it is not found along the. chest wall, check that it is not pulled outward. along the axillary tissue being exfoliated. If it. has been pulled outward, it should be sepa. rated and placed on the chest wall. To safely. preserve the long thoracic nerve, the surgeon. should keep an eye on it and immediately dis. sect the anterior nerve, taking care not to dis. sect the inside of the nerve. Then, the surgeon. dissects downward until the nerve enters the. serratus anterior muscle, taking special care. not to injure the nerves at this point because. they run slightly outward just before entering. the serratus anterior. It can be confirmed that. the intercostal brachial nerve enters the chest. wall through the third intercostal nerve during. the separation of the long thoracic nerve. It. runs about 1 cm below the axillary vein.. Intermediate axillary adipose tissue is sepa. rated until the nerves are free. Preservation of. the intercostal brachial nerve is not essential if. the axilla is lymph node positive when viewed. with the naked eye.. . 4. Postoperative management and complications.. When the 24-h drainage volume is 30 mL. or less, the axillary drainage tube can be. removed, and most of the time, it is removed. 4–7 days after surgery. During this time, oral. antibiotics are not usually required. Arm. movements should begin the day after surgery. and should be managed carefully until the. range of movement returns to normal.. Excessive exercise can increase drainage.. Lymphedema can appear at various times. after surgery and must be diagnosed early in. the condition and treated appropriately.. Axillary cord syndrome, often known as. Mondor’s disease, involves a string of tender. subcutaneous tissues extending from the lat. eral axilla to the upper and medial aspects of. the arm, manifesting in a cord-like structure. beneath the skin. It typically occurs 1–8 weeks. after axillary dissection and appears when the. axillary veins and lymphatic vessels were. damaged proximally during surgery. It gener. ally improves spontaneously and must be dis. tinguished from lymphedema.. When the thoracic nerve is injured, the. abduction of the arm is restricted, and when. the long thoracic nerve is injured, the wing. scapula and shoulders are affected. When the. intercostobrachial nerve is injured, paresthe. sia of the upper medial part of the arm, axil. lary, and superior laterality of the chest. appears. Complications such as upper arm. movement range limitation can occur, but. movement can be recovered by steady exer. cise and rehabilitation.. 2. . Local Therapy: Radiotherapy. 2.1. . History. Radiation began to be used in the treatment of. cancer shortly after Roentgen discovered X-rays.. Since then, radiation therapy has played an impor. tant role in improving the local remission rate and. survival rate in breast cancer. Radiation therapy is. also given to patients with distant metastases to. relieve symptoms. After the Curie couple discov. ered a radioisotope called radium, radium needles. J. Y. You et al.. 155. were primarily used to treat breast cancer, but in. the 1930s, low-energy external radiation therapy. was used. However, much of the radiation from. low-energy radiation therapy was absorbed into. the skin and did not sufficiently irradiate the. actual cancer tissue, which caused acute skin. damage and chronic sequelae. In 1951, a radiation. therapy device using cobalt was put into operation. to reduce the amount of radiation absorbed by the. skin. Thus, medical linear accelerators that gener. ate high-energy X-rays and electron beams have. been developed since the early 1950s, and they. now play a major role in radiation therapy for. breast cancer. Linear-. accelerated radiotherapy. equipment began to be used after the development. of computer-based three-dimensional radiother. apy technology in the 1990s [35, 36].. Subsequently, intensity-modulated radiation ther. apy technology was developed, and now, respira. tory gated radiation that treats patients according. to their breathing has also been developed. Thanks. to these advancements, side effects can be mini. mized and the target can be irradiated uniformly,. thereby enhancing clinical effectiveness. In addi. tion to radiation using electromagnetic waves. such as X-rays and γ-rays, medium-particle radio. therapy devices for neutrons, protons, and carbon. ions have also been developed, but they are still. used in a limited manner for breast cancer.. Recently, breast conserving surgery has become. widespread, and radiation therapy is an important. part of that breast cancer treatment. In recent. years, the convenience and accessibility of radia. tion therapy have become the main concerns.. Therefore, various methods for optimizing radio. therapy, such as reducing the number of sessions. and performing partial radiotherapy, have been. developed and tested [37–39].. 2.2. . Radiation Therapy After. Breast-Conserving Surgery. 2.2.1. . Range of Radiation Therapy. and Radiation Dose. The scope of radiation therapy for patients who. undergo axillary lymph node dissection at the. same time as breast conservation surgery includes. the remaining total breast tissue, adjacent skin. and subcutaneous tissue, and chest wall. It can be. found by dividing up to 50 Gy over 25–28 days.. The divided survey dose is thus 1.8–2 Gy and is. administered once a day, 5 times a week.. Subsequently, an electron beam is directed to the. site of the surgical scar and previous tumor loca. tion, or brachytherapy is performed within the. tissue. In some cases, additional irradiation is. performed by three-dimensional modeling treat. ment using a photon beam and electron beam.. Radiation therapy is usually available as outpa. tient treatment, and each treatment takes about. 15 min. The total duration of radiation therapy is. usually 6 weeks. If there is a tumor in the resec. tion margin, the recurrence rate is high. In that. situation, additional irradiation of 15–20 Gy is. applied to the primary lesion site, for a total irra. diation dose of 60–65 Gy. To evaluate the useful. ness of additional irradiation, an EORTC study. was conducted in patients with lesions of 3 cm or. smaller and confirmed tumor-free excision.. According to that study, 5-year survival did not. change with additional radiation therapy of. 16 Gy, but the local recurrence rate was signifi. cantly reduced. However, the researchers reported. that the additional radiation had a negative effect. on the cosmetic results [40, 41]. At the same. time, the effect of an additional 10 Gy of irradia. tion was studied in France. That study reported. that the local recurrence rate was significantly. reduced without causing a difference in the cos. metic results [42].. The standard treatment to date has been radia. tion therapy to the whole breast, but partial treat. ment has been attempted in some studies. Holland. et al. (1985) [43] reported that in the case of a. tumor of 2 cm or smaller, the probability that a. new tumor would be found at a site 2 cm or more. away from the primary tumor was 28%. Therefore,. they reported that the entire breast had to be. treated. However, according to reports since 1990,. most local recurrences occur around the surgical. site, even when radiotherapy is not administered. after surgery, and the recurrence rate in other. lesions is not significantly different from the inci. dence of secondary tumors in the contralateral. breast. This suggests the possible feasibility of. Brief Overview of Breast Cancer Treatment. 156. partial treatment ([44, 45], Veronesi et al. [5]).. Furthermore, such conservative treatment can be. retried if cancer recurs in the breast after local. treatment. Unlike whole breast therapy, partial. treatment can be completed within 1 week using. methods such as external radiation therapy, inter. stitial. brachytherapy,. balloon. intracavitary. brachytherapy, or low-energy radiation therapy.. Therefore, it has the advantage of having little. effect on the timing of systemic anticancer che. motherapy. Most studies conducted to date report. that local recurrence rates and survival rates do. not differ from those with existing treatments.. However, the follow-up period is still short, so it. is difficult to conclude the usefulness of partial. radiotherapy.. 2.2.2. . Timing of Radiation Therapy. . 1. Timing of radiotherapy after surgery.. It has never been established when radia. tion therapy should be started after surgery. It. usually takes 4–6 weeks for the surgical scar. to heal. Delaying radiation therapy for more. than 8 weeks after surgery does not increase. the local recurrence rate compared with radia. tion therapy given within 4 weeks after sur. gery. One study by Vujovic et al. reported that. for axillary lymph node-negative patients,. delaying radiation therapy for more than. 16 weeks did not affect the local recurrence. rate. However, that is not the case for patients. aged 40 years or younger who have close. resection margins (≤ 2 mm) or benign resec. tion margins. In those cases, the local recur. rence rate tended to increase, though not in a. statistically significant way, when radiation. therapy was given 8 or 12 weeks or more after. surgery. In general, patients who are not eli. gible for systemic anticancer chemotherapy. should receive radiation therapy within. 8 weeks after surgery [46].. . 2. Timing of systemic chemotherapy and radia. tion therapy.. For patients who are not eligible for sys. temic chemotherapy, radiation therapy begins. after surgical scarring, generally 3–4 weeks. after surgery. The order of treatment for. patients who must receive both systemic che. motherapy and radiation therapy is still con. troversial. An analysis of 11 studies with 1927. patients showed a high local recurrence rate of. 16% in the group of patients who received. chemotherapy first and radiation therapy later.. The local recurrence rate in the group of. patients who received radiation therapy first. was 6% [47]. However, a large retrospective. study reported that delaying radiation therapy. did not increase local recurrence rates. A. study of 718 axillary lymph node-positive. patients reported no difference in the local. recurrence rate between the group who. received radiation therapy immediately after. breast-conserving surgery and the group who. received radiation therapy after 3 or 6 chemo. therapy sessions.. 2.2.3. . Irradiation Method. The breast and surrounding tissues are irradiated. through an internally and externally symmetrical. tangential irradiation field. The treatment should. be designed so that the whole target volume. receives radiation in as uniform a dose as possi. ble while minimizing the amount of lung tissue. contained in the treatment area. When designing. the internally and externally symmetrical tan. gential irradiation field, sufficiently treat the. chest wall. At the same time, when treating lung. tissue on the left side, the volume of radiation to. which normal organs, such as the heart, are. exposed should be minimized. Because the fre. quency of radiation pneumonia is proportional to. the volume of exposed lung tissue, it is important. to reduce the exposed area. Recently, 3-dimen. sional treatment plans using CT images to adjust. the irradiation intensity have been proposed.. Intensity-modulated radiation therapy, which. irradiates tumors intensively, has been intro. duced, and makes it possible to reduce the. amount of radiation applied to normal tissues.. It can also be helpful to fix the patient’s body. and induce postural changes to facilitate the set. ting of the radiation field. Various fixation devices. are used to consistently maintain the patient’s. therapeutic posture for each fractionated irradia. tion. For breast treatment, low-density cradle-. type fixing devices are commonly used.. J. Y. You et al.. 157. 2.3. . Radiation Therapy After. Radical Total Mastectomy. 2.3.1. . Indications. The local recurrence rate after radical mastec. tomy has been reported to be 9–36%, varying. with the size of the primary lesion and the pres. ence and degree of metastasis to the axillary. lymph nodes. That is, in the absence of axillary. lymph node metastasis, the local recurrence rate. is only 5%, but in the presence of metastasis, the. local recurrence rate is about 25%. The recur. rence rate is about 10% with 3 or fewer lymph. node metastases and 36% with 4 or more lymph. node metastases. In patients with T1–2 breast. cancer and lymph node metastasis (4 or more if. the primary tumor is 2 cm or more), vascular. lymphatic invasion of the tumor, or a primary. tumor that is clinically palpable, the frequency. of lymph node metastasis is significantly. increased [48]. Therefore, patients with 4 or. more lymph node metastases or other risk fac. tors for recurrence should receive radiation ther. apy after mastectomy. For T3 and T4 tumors. without lymph node metastases, radiation ther. apy is given after radical mastectomy, which. reduces the local recurrence rate to 5%. Even. when chemotherapy was performed as adjuvant. therapy, local recurrence increased as the pri. mary disease site and number of axillary lymph. nodes affected became larger. Specifically, when. the primary lesion is 5 cm or larger and 4 or. more axillary lymph nodes have metastases, the. local recurrence rate is reported to be 30% or. more, so radiation therapy is absolutely neces. sary [49].. 2.3.2. . Method. Radiation therapy after radical mastectomy is. usually split treatment once a day, 5 days a week,. for about 5 weeks (25–28 sessions). A total dose. of 45–50 Gy of radiation should be irradiated to. the supraclavicular lymph node on the ipsilateral. chest wall from which the tumor has been. removed. According to the US Treatment Method. Study [50], this irradiation dose has become uni. versal, and it is the irradiation dose that is com. monly prescribed in South Korea. The treatment. area is based on the chest wall and some axillary. lymph nodes. The supraclavicular lymph nodes. on that side can also be included as dictated by. the patient’s risk factors. Because there is no evi. dence to recommend radiation therapy for inter. nal mammary lymph nodes, it is performed only. when lymph node metastases are clinically diag. nosed by CT or MRI or confirmed by pathologic. findings after surgery. Because recurrence often. occurs in the skin or subcutaneous tissue within. 3 cm above and below the wound site, it is neces. sary to ensure that the skin is exposed to a suffi. cient amount of radiation when the chest wall is. irradiated. Treatment with electron beams ensures. that the skin surface receives a high dose. When. treating a tangential field using X-rays, the skin is. covered with a tissue-equivalent substance for. treatment. Because the depth varies depending on. the anatomical position of the irradiation volume. and major organs such as the lungs and heart are. near the affected area, care must be taken to per. form radiation therapy without complications.. 2.4. . Axillary Lymph Node. Radiation Therapy. Axillary lymphadenopathy is performed to stage. the disease, assess the risk, and prevent recur. rence in the axillary lymph nodes. It is well. known that the local control rate offered by sur. gery improves the survival rate, but side effects. such as edema, pain, paresthesia, and restricted. shoulder movement are problematic. For early-. stage breast cancer, sentinel lymph node biopsy. can significantly reduce these side effects.. Furthermore, this procedure can provide similar. outcomes to axillary lymph node dissection,. while lowering the incidence of complications.. The NSABP B-04 study at the Curie Institute. demonstrated that axillary lymph node radiation. therapy after breast conserving surgery had the. same effect as lymphadenectomy, and many ret. rospective analyses have shown similar results. [51]. If lymph node metastasis is confirmed by. sentinel lymph node biopsy, further axillary. lymph node dissection is performed. However,. radiation therapy can be given instead of surgery. Brief Overview of Breast Cancer Treatment. 158. to reduce lymphedema of the arm. Prospective. studies, such as the AMAROS study, are under. way to find the best treatment protocol. Some. researchers have argued that if the sentinel lymph. node are positive, radiation therapy could be a. viable option if additional axillary lymphadenop. athy is unlikely to change the chemotherapy. treatment regimen [33, 39].. 2.5. . Breast Reconstruction. and Radiation Therapy. Many women desire breast reconstruction after. mastectomy. If patients have to undergo radiation. therapy, they will face various problems and. require close cooperation among specialists in. breast surgery, orthopedics, and radiation oncol. ogy. Breast reconstruction uses artificial prosthe. ses and autologous tissue. It can be performed at. the time of the initial surgery or after a certain. period of time, usually after radiation therapy.. Immediate reconstruction has advantages in terms. of skin sensation and cosmetology, but when radi. ation therapy is used, those advantages disappear,. and it becomes difficult to establish a treatment. plan. Geometric problems arise, especially for. transplanted prostheses, and radiation is difficult. without specially planned treatments, such as. intensity-controlled radiation therapy. In many. cases, fibrosis, constriction, etc., cause poor cos. metic results. Even when using autologous tissue,. it is generally recommended to perform recon. struction after radiation therapy [23, 24].. 2.6. . Radiation Therapy. for Palliative Purposes. Breast cancer patients, unlike other cancer. patients, can survive for a long time even if they. have a local recurrence or distant metastasis. To. improve the patient’s quality of life, long-term. control of the pain, fractures, spinal cord com. pression, etc., that can be caused by distant metas. tases must be ensured. Extensive distant. metastases can cause a short survival time, but. metastasis confined to one organ, especially if the. time to metastasis is long, can permit long-term. survival. Therefore, radiation therapy more. aggressive than that required for short-term symp. tom-relieving radiation therapy, such as palliative. radiation therapy for general cancer, is required.. 3. . Neoadjuvant Therapy. Neoadjuvant chemotherapy has two purposes:. First, in patients (N2–3 or T4) who have diffi. culty with definitive surgery, it can induce a reac. tion in the tumor or metastasized lymph nodes. that will facilitate local treatment such as surgery. or radiation therapy. Second, in patients who can. undergo definitive surgery (T3N1M0), it can. make breast conserving possible. In addition, it. has the advantage of revealing the susceptibility. of the tumor to chemotherapy and, at least in the. ory, provides early treatment of micrometastases. [52]. Most studies have shown similar clinical. courses and prognoses with neoadjuvant chemo. therapy and adjuvant chemotherapy, and both. protocols are thus widely used as standard thera. pies. In addition, pathological complete remis. sion (pCR) can be used as a prognostic factor for. long-term survival. Whether adjuvant chemother. apy should be given before or after surgery. depends on the stage, histology, hormone recep. tor, and HER2 receptor status of the invasive. breast cancer. The choice must be made by com. prehensively judging the state of expression and. the possibility of breast preservation. Neoadjuvant. chemotherapy can be performed for locally. advanced breast cancer and (when surgery is pos. sible) to reduce the surgical range for large breast. cancers. Patient planning for advanced chemo. therapy requires a core biopsy of the primary. tumor. If axillary lymph node metastasis is clini. cally suspected, a biopsy or cell aspiration cytol. ogy of the lymph nodes is also recommended.. 3.1. . Chemotherapy. In principle, the drugs used for adjuvant chemo. therapy can also be used for neoadjuvant chemo. therapy. Combined therapy based on doxorubicin. J. Y. You et al.. 159. has mainly been performed, but since adjuvant. chemotherapy including taxane showed superior. ity in the survival rate, taxane has also been used. in neoadjuvant chemotherapy. Various other ther. apies have also been studied and reported better. pCR rate. In the NSABP B-27 study of 2300. patients, pCR rates were higher in the group that. received docetaxel after AC (doxorubicin, cyclo. phosphamide) than in the group that did not. receive docetaxel (26% vs. 13%) [53]. In the. Aberdeen study of 162 patients, the CVAP. (cyclophosphamide, vincristine, doxorubicin,. prednisolone) response group who received. docetaxel after conversion had a higher pCR rate. than the group who continued to receive CVAP. therapy (34% vs. 16%). In the GEPARDUO. study of 913 patients, AC (doxorubicin, cyclo. phosphamide) followed by DOC (docetaxel). sequential therapy had a better pathological com. plete remission rate than 2-week interval (dose. dense) ADOC (doxorubicin, docetaxel) simulta. neous combination therapy (14.3% vs. 7%) [54].. Following a neoadjuvant chemotherapy study. with taxane, phase II or III studies on nanoparti. cle. albumin-bound. (nab)-paclitaxel. were. reported. The GeparSepto study compared epiru. bicin/cyclophosphamide (EC) administration. after nab-paclitaxel or paclitaxel and found pCR. rates of 38% and 29%, respectively [55]. In addi. tion, after 4 years of follow-up, invasive disease-. free survival was superior in the nab-paclitaxel. group, though there was no difference in the. overall survival rate. In contrast, the ETNA study. did not show the superiority of nab-paclitaxel,. with a pCR rate of 22.5% vs. 18.6% [56]. In dif. ferent large studies, nab-paclitaxel did not show. consistent results, but it did show a pCR rate sim. ilar to paclitaxel, so long-term follow-up results. need to be collected.. In a study of the number of neoadjuvant che. motherapy treatments, the pCR rate with ED. (epirubicin, docetaxel) was higher after 6 cycles. than after 3 cycles. In the GeparTrio study of. 2000 people, 2 doses of TAC (docetaxel, doxoru. bicin, cyclophosphamide) were administered. first, and then 4 or 6 additional doses of TAC. were administered to 1390 responders [57]. The. study reported no differences in the pCR rate. between the two groups. The 2006 International. Expert Panel recommendation is for a combina. tion therapy that includes anthracycline or taxane. to be administered at least 6 cycles for 4–6 months. before surgery in eligible breast cancer patients.. The recent GeparQuinto study of 1509 patients. given 4 cycles of EC (epirubicin, cyclophospha. mide) therapy compared the addition of docetaxel. monotherapy (EC-T), docetaxel + capecitabine. combination therapy (EC-TX), and docetaxel →. capecitabine sequential therapy (EC-T-X). It. reported no difference in the pCR rate or breast-. conserving surgery, so it is not recommended to. increase the duration of anthracycline-taxane. therapy or add capecitabine.. After completing 2–3 neoadjuvant chemother. apies, a clinical evaluation and response evalua. tion by imaging study must be performed. Then,. the decision to continue the planned chemother. apy, switch to a new therapy, or administer local. treatment must be made based on the results of. those assessments. If trastuzumab or hormone. therapy is indicated after surgery, it can be given. in parallel with radiation therapy.. 3.2. . Endocrine Therapy. Studies of neoadjuvant endocrine therapy in pre. menopausal women who are hormone receptor. positive are very restrictive. Reports have shown. 3% complete pathological observation and 42%. breast preservation from combination therapy. with GnRH agonists and letrozole. According to. several studies of neoadjuvant endocrine therapy. in postmenopausal women, tamoxifen plus anas. trozole, anastrozole alone, and letrozole mono. therapy offer the best breast-conserving surgery. and objective response rates [58]. Based on those. studies, aromatase inhibitors are suitable neoad. juvant endocrine therapy for postmenopausal. women with hormone receptor positive breast. cancer. The appropriate duration of neoadjuvant. endocrine therapy is 4–6 months, and co-. administration of chemotherapy and aromatase. inhibitors is not desirable. In addition, neoadju. vant therapy with a CDK4/6 inhibitor combined. with endocrine therapy has recently been tested. Brief Overview of Breast Cancer Treatment. 160. in clinical studies.. According to the CORALLEEN. phase 2 clinical study comparing 6 months of. ribociclib + letrozole and prior endocrine therapy. with doxorubicin/cyclophosphamide and pacli. taxel, both therapies have the same low risk-of-. relapse score [59].. 4. . Systemic Therapy: Adjuvant. Setting. 4.1. . Chemotherapy. 4.1.1. . Adjuvant Chemotherapy. Adjuvant chemotherapy should be determined by. the histological type of tumor, presence or. absence of hormone receptor and HER2 overex. pression,. and. lymph. node. metastasis.. Chemotherapy and endocrine therapy should be. given sequentially, not simultaneously. CMF and. radiation therapy can be given at the same time,. but except in special cases, all other chemother. apy is given prior to radiation therapy.. The first randomized studies of adjuvant che. motherapy in breast cancer demonstrated that adju. vant CMF chemotherapy significantly reduced the. treatment failure rate. Four cycles of doxorubicin. and cyclophosphamide have the same effect as six. cycles of CMF chemotherapy. There is no benefit. to be gained by increasing the dose of doxorubicin. or cyclophosphamide above the standard dose. The. comparison of 4 cycles of AC and 6 cycles of FEC. for lymph node-negative breast cancer in the. NSABP B-36 study found no difference in disease-. free survival or overall survival between the two. groups, but toxicity was higher with FEC therapy. [60]. High-dose epirubicin-. based CEF therapy for. lymph node-positive breast cancer improved dis. ease-free survival compared with CMF therapy. [61]. The FASG-05 study comparing two epirubi. cin doses (high versus low doses) observed a sig. nificant improvement in survival with high-dose. epirubicin-based CEF therapy [62].. Various studies have also been conducted on. the role of taxane in adjuvant therapy. Sequential. administration of docetaxel or paclitaxel for. lymph node-positive breast cancer showed. improved survival over FEC monotherapy. The. addition of taxane to anthracycline-based therapy. has been shown to improve the clinical course of. lymph node-positive breast cancer and reduce the. risk of recurrence in even high-risk lymph node-. negative patients in several phase III studies [63].. The EBCTCG meta-analysis also showed a sig. nificant reduction in breast cancer related mortal. ity with the addition of 4-cycle taxane to treatment. with fixed doses of anthracyclines. The E1199. study by the Eastern Cooperative Oncology. Group compared schedules of paclitaxel and. docetaxel given after AC chemotherapy [64]. In a. 12-year follow-up analysis, docetaxel therapy. every 3 weeks showed a significant prolongation. of disease-free survival compared with paclitaxel. therapy every 3 weeks. Therefore, weekly pacli. taxel or every 3-week docetaxel therapy is rec. ommended for sequential administration after. 4 cycles of AC [65]. The USON 9735 study com. pared docetaxel with cyclophosphamide (TC),. doxorubicin, and cyclophosphamide (AC) and. showed significantly longer disease-free survival. with TC therapy. The CALGB 9741 study com. pared dose-. intensive therapy with standard. sequential chemotherapy and found that dose-. dense therapy improved survival [66]. A meta-. analysis. also. reported. that. dose-dense. chemotherapy significantly improved both over. all survival and disease-free survival. A meta-. analysis restricted to clinical trials using. equivalent doses demonstrated that dose-dense. chemotherapy significantly improved survival. without increasing chemotherapy-related side. effects. In the meta-analysis results of 26 studies. in EBCTCG, dose-dense chemotherapy signifi. cantly lowered the 10-year recurrence rate from. 31.4% to 28.0% and lowered the 10-year breast. cancer mortality rate from 21.3% to 18%, com. pared with the control group. From the viewpoint. of improving the survival rate, dose-dense che. motherapy with prophylactic G-CSF assistance is. preferred [67].. 4.1.2. . Chemotherapy in Elderly. Patients. Chemotherapy may be recommended for all age. groups younger than 70 years. The benefits of. post-surgery chemotherapy are most pronounced. J. Y. You et al.. 161. in women younger than 50 and diminish with. age above that. For patients older than 70, it is. difficult to offer general clinical guidelines. because clinical trial materials for adjuvant che. motherapy are rare. However, in the CALGB. 49907 study, patients, especially those with. ER-negative breast cancer, who were treated. with capecitabine did more poorly than those. who received AC or CMF standard therapy [68].. In other words, evidence suggests that it is better. for older breast cancer patients to receive the. same standard therapy as younger breast cancer. patients. In a random-distribution open clinical. trial comparing trastuzumab monotherapy with. trastuzumab plus chemotherapy in patients aged. 70–80 years with HER2-positive breast cancer. who underwent surgical resection, 3-year dis. ease-free survival was reported to be 85.9% in. the trastuzumab monotherapy group and 93.8%. in the trastuzumab/chemotherapy combination. therapy group, demonstrating the noninferiority. of trastuzumab monotherapy. Therefore, in prin. ciple, systemic adjuvant therapy for patients. aged 70 years or older should be standard ther. apy, but decisions should be made individually. in consideration of accompanying diseases and. general condition.. 4.1.3. . Adjuvant Systemic Therapy. for histology of Breast Cancer. with Good Prognosis. For invasive cancer of good histological subtypes. such as tubular carcinoma or mucinous carci. noma, adjuvant systemic therapy is not required. in the absence of lymph node involvement or. lymph node involvement of less than 2 mm when. the tumor is less than 1 cm. With lymph node. involvement less than 2 mm and a tumor of 1 cm. or more and less than 3 cm, endocrine therapy. can be considered if the hormone receptor is pos. itive, and if the tumor is 3 cm or more, endocrine. therapy should be performed irrespective of the. hormone receptor status. The chemotherapy may. be considered as an alternative to endocrine ther. apy when lymph node metastasis is 2mm or. greater, regardless of tumor size. If the hormone. receptor is negative after retesting, chemotherapy. based on common histological types can be con. sidered [69, 70].. 4.2. . Endocrine Therapy. All breast cancer patients should be confirmed. for ER and PR expression [71]. If one of them is. positive, adjuvant endocrine therapy is given. regardless of the patient’s age, axillary lymph. node metastasis, adjuvant chemotherapy, or. HER2 overexpression. Adjuvant endocrine ther. apy may be omitted in some cases because the. prognosis after surgery is very good if the size is. 0.5 cm or less and there is no lymph node metas. tasis. However, in an ER-positive patient, adju. vant endocrine therapy is recommended because. it reduces the risk of developing secondary can. cer in the contralateral breast [72].. 4.2.1. . Endocrine Therapy for Breast. Cancer in Premenopausal. Women. For hormone receptor-positive premenopausal. women, oral administration of 20 mg of tamoxi. fen daily is a priority, and the recommended. duration of use is at least 5 years. The SOFT and. TEXT trial found that the addition of ovarian. suppression therapy to tamoxifen significantly. improved disease-free survival and overall sur. vival compared with the use of tamoxifen alone. [73]. In addition, ovarian suppression therapy. was used to induce menopause, and when an aro. matase inhibitor was administered, the disease-. free. survival. rate. improved.. Therefore,. premenopausal women can undergo ovarian sup. pression therapy for 5 years with tamoxifen and. aromatase inhibitors. Ovarian suppression ther. apy is more beneficial if anticancer treatment is. required because of a high risk of recurrence or if. the risk of other clinicopathological recurrence is. high (35 years or younger, high tumor grade, N2. stage or higher, etc.). However, the decision must. be made in consideration of the side effects that. can occur due to ovarian suppression therapy and. drug adaptability.. If tamoxifen is used for 5 years and meno. pause occurs, it can be replaced with an aroma. tase inhibitor and administered for another. 5 years or more. Also, based on the ATLAS study,. 10 years of endocrine therapy plus tamoxifen for. another 5 years can be given with or without. menopause. Because aromatase inhibitors are. Brief Overview of Breast Cancer Treatment. 162. ineffective in women with ovarian action, serum. LH, FSH, and estradiol (E2) concentrations. should be checked every 3–6 months when con. sidering aromatase inhibitor treatment in this. group of patients.. When a GnRH agonist and an aromatase. inhibitor are administered in combination to pre. menopausal patients, it has been reported that the. administration of zoledronic acid significantly. prolongs disease-free survival. It also delays. bone density loss and helps to restore bone den. sity after treatment is interrupted [74].. 4.2.2. . Endocrine Therapy for Breast. Cancer in Postmenopausal. Women. In general, the postmenopausal condition indi. cates one of the followings:. –. – Bilateral oophorectomy was performed.. –. – The patient is older than 60 years.. –. – The patient is younger than 60 years but has. been amenorrheic (with FSH and E2 in the. postmenopausal. range). for. at. least. 12 months without treatment with antican. cer drugs (tamoxifen, etc.) or ovarian func. tion suppressants.. –. – Among patients younger than 60 years who are. taking tamoxifen and started adjuvant chemo. therapy before menopause, when FSH and E2. were in the premenopausal range, menopause. status after chemotherapy cannot be judged as. amenorrhea. Therefore, treated amenorrheic. patients can receive an aromatase inhibitor. only if menopause is confirmed by regular fol. low-up of FSH and E2 levels [75, 76].. For postmenopausal patients with hormone. receptor-positive breast cancer, we recommend. upfront therapy as the initial adjuvant therapy.. Initial administration of an aromatase inhibitor. instead of tamoxifen for 5 years has been shown. to reduce the risk of local recurrence, contralat. eral breast cancer development, and distant. metastasis without affecting overall survival. In. addition, after taking tamoxifen for 2–3 years,. it can be changed to an aromatase inhibitor and. administered for a total of 5 years (switch ther. apy as sequential with tamoxifen), or after tak. ing tamoxifen for 5 years, the aromatase. inhibitor can be used for 5 more years (extended. therapy). Due to the absence of comparative. studies determining the optimal duration of. tamoxifen administration before initiating aro. matase inhibitors, no specific duration can be. recommended at this time. But patients who. have been taking tamoxifen for 2–3 years are. recommended to switch to an aromatase inhibi. tor. Based on the results of the ATLAS study, it. is possible to use tamoxifen for 5 years and. then administer the same drug for up to. 10 years. However, no studies have yet shown. whether either method is more effective than. changing to an aromatase inhibitor. The deci. sion between tamoxifen and aromatase inhibi. tors is best made in consultation with the. patient, considering the benefits and potential. side effects of each medication. Therefore, if. aromatase inhibitors are contraindicated or. unsuitable, tamoxifen is recommended for. 5 years. Even in those cases, tamoxifen can be. optionally used for 10 years [77].. Until now, it has not been recommended to. maintain aromatase inhibitors for more than. 5 years. Recently, a study of adjuvant endo. crine therapies after surgery reported results. from using an initial aromatase inhibitor for. 5 years and then extending that therapy with. an additional aromatase inhibitor for up to. 10 years. Some results showed a tendency to. improve disease-free survival, but the differ. ence was not large, and no results showed an. improvement in overall survival. However,. given the results of studies showing the long-. term recurrence potential of breast cancer and. the effect of aromatase inhibitors in reducing. secondary breast cancer, their use can be. extended to 10 years in patients at high risk of. recurrence. Other considerations are drug. resistance and side effects [73].. To reduce the risk of osteoporosis, it is. advisable to measure bone mineral density. before using aromatase inhibitors. If necessary,. appropriate physical exercise, calcium prepara. tions, vitamin D, and zoledronic acid can be. administered. The ABCSG-18 study reported. that subcutaneous injections of denosumab. J. Y. You et al.. 163. (60 mg every 6 months) in postmenopausal. patients taking aromatase inhibitors as adjuvant. endocrine therapy significantly delayed the. development of clinical fractures [78].. 4.2.3. . CDK4/6 Inhibitor Combination. Therapy as Adjuvant Therapy. In the MONARCHE study, patients diagnosed. with hormone receptor-positive/HER2-negative. breast cancer and having 4 or more lymph node. metastasis or high risk with 1–3 lymph node. metastasis were administered abemaciclib for a. duration of 2 years alongside adjuvant endocrine. therapy. The study reported that the drug combi. nation improved the 2-year invasive disease-free. survival rate from 88.7% with adjuvant endocrine. therapy alone to 92.2%. In contrast, the PALLAS. study, which added 2 years of palbociclib admin. istration to adjuvant endocrine therapy in stage. 2–3 patients, failed to show significant differ. ences in 3-year invasive disease-free survival. [79]. Although the MONARCHE study showed. positive results, the follow-up period was rela. tively short, so we must wait for future long-term. follow-. up results [80]. Likewise, we have to wait. to judge the results of the NATALEE research. into ribociclib, another CDK4/6 inhibitor.. 4.3. . HER2-Targeted Therapy. Targeted treatment focuses on substances that play. crucial roles in the development and progression of. cancer, aiming to inhibit their actions and achieve. therapeutic effects. As a general rule, targeted. treatment is administered specifically to patients. with identified targets, in contrast to conventional. chemotherapy. This approach helps reduce side. effects and enhances treatment efficacy. Targeted. treatments are expected to play a major role in can. cer treatment in the future. There are four human. epidermal growth factor receptor (HER) families:. epidermal growth factor receptor (EGFR), HER2,. HER3, and HER4. These receptors are present. throughout the cell membrane; are composed of. extracellular, cell membrane, and intracellular. regions; and have a morphological structure that. transmits signals related to cell proliferation to the. nucleus. GFR, HER3, and HER4, but not HER2,. possess a structure capable of specific binding to. the extracellular ligand of the receptor. This ligand. binding initiates the signal generation process and. its transmission into the cell. EGFR, HER2, and. HER4, but not HER3, possess a structure that. activates the intracellular tyrosine kinase domain.. Upon receptor dimerization, the phosphorylation. of intracellular tyrosine kinase enzymes trans. mits the received signal into the nucleus. HER2 is. expressed in 20–30% of all breast cancers and can. not bind to ligands, but it plays an important role in. amplifying and transmitting the signals generated. by forming dimers with other receptors. Therefore,. much effort has been made to develop a therapeutic. agent that can suppress the action of HER2 [81].. 4.3.1. . Trastuzumab. In current clinical practice, the representative. HER2 inhibitor used in patients with HER2-. overexpressing breast cancer is trastuzumab, a. humanized monoclonal antibody that has four. functions. First, by binding to the extracellular. space of the HER2 receptor near the cell mem. brane and preventing it from shedding the extra. cellular space construct, it prevents signal. activation via the remaining HER2 construct,. p95 HER2. Second, it interferes with polymer. . formation between HER family receptors and. suppresses signal transduction. Third, it induces. antibody-dependent, cell-mediated cytotoxic. effects. Fourth, the bound HER2 receptor is. introduced into the cell to reduce the HER2. receptor. Trastuzumab is effective as a mono. logic in patients with HER2-overexpressing. breast cancer. It also showed improved survival. when used as a first-line treatment along with. existing chemotherapeutic agents in patients. with metastatic breast cancer [82]. Recent clini. cal studies have confirmed that trastuzumab. improves disease-free survival and overall sur. vival when used in combination or sequentially. with existing chemotherapy drugs, even as post. operative adjuvant chemotherapy [83].. 4.3.2. . Lapatinib. Lapatinib is a low molecular-weight oral tyro. sine kinase inhibitor that competitively binds to. the intracellular ATP binding pockets of HER1. and HER2 and blocks receptor autophosphoryla. Brief Overview of Breast Cancer Treatment. 164. tion. It regulates cell differentiation and survival. by blocking receptor activity and blocking signal. transduction of the MAPK and PI3K/AKT path. ways below it [84]. Currently, lapatinib has been. shown to have a therapeutic effect on breast can. cer and is being applied clinically [85]. In par. ticular, it is effective in the treatment of p95. HER2-active breast cancer in which the extracel. lular construct of the HER2 receptor is shed and. does not respond to treatment with trastuzumab.. Its role as a therapeutic agent for trastuzumab-. resistant cancer is well known. Currently, large-. scale clinical studies are underway on its. usefulness as a first-. line treatment for early-stage. breast cancer and its usefulness as neoadjuvant. chemotherapy.. 4.3.3. . Pertuzumab. Pertuzumab is a monoclonal antibody that binds. to the binding site of trastuzumab (domain IV). and another site (domain II) and inhibits the. HER2–HER3 disconjugate [86]. Trastuzumab. suppresses ligand-independent HER2 signals,. whereas. pertuzumab. suppresses. ligand-. dependent HER2 mediation signals and HER2–. HER3 signals, which are heterodimerizations. that send the strongest mitotic signaling [87].. Pertuzumab has limited efficacy as a monother. apy, but the results of the CLEOPATRA study. show that it has a synergistic effect when used in. combination with trastuzumab. The combination. of trastuzumab and pertuzumab is currently being. clinically applied, especially in trastuzumab-. resistant patients [88].. 4.3.4. . Trastuzumab Emtansine. (T-DM1). T-DM1 combines trastuzumab with the anti. cancer drug DM1 (maytansine). After the. trastuzumab portion of T-DM1 binds to HER2,. the endocytosis of HER2–T-DM1 complex is. occurred, where the DM1 portion is released by. proteolytic degradation in lysosomes to exert an. tumor-suppressive effect. DM1 is a maytansine. derivative and is an anti-microtubule agent such. as vinca alkaloid. It is clinically known to sup. press mitosis 20–100 times more than vincristine.. The EMILIA study compared T-DM1 mono. therapy with the lapatinib and capecitabine com. bination in HER2 overexpressing metastatic. breast cancer previously treated with taxane and. trastuzumab [89]. The excellent event-free and. overall survival of the T-DM1 monotherapy. group indicates its value as a second-line HER2. targeted treatment for patients with HER2-. overexpressing breast cancer who have failed. with trastuzumab. The ongoing MARIANNE. study is intended to confirm the effect of T-DM1. as a first-line treatment, and if it succeeds in. obtaining that result, T-DM1 might be the most. effective target treatment for HER2 overexpress. ing metastatic breast cancer.. 4.3.5. . Pan-HER Inhibitors. Pan-HER inhibitors simultaneously block other. EGFR family members, including HER2.. Neratinib and afatinib are currently being studied. as oral, irreversible, low molecular-weight sub. stances that simultaneously block EGFR, HER2,. and HER4 [90].. 4.4. . Immunotherapy. 4.4.1. . Antiangiogenic Agents. Angiogenesis is an essential step in tumor growth. and metastasis that involves a variety of factors,. including vascular endothelial growth factor. (VEGF). Bevacizumab is a monoclonal antibody. against VEGG-A. As a first-line treatment for. HER2-negative breast cancer patients, the com. bination of paclitaxel and bevacizumab showed a. significant improvement in event-free survival. compared with paclitaxel monotherapy. It was. approved in 2008 as a treatment for HER2-. negative metastatic breast cancer. However, since. then, some meta-analyses have shown no. improvement in the survival rate, and it is found. to have a low gain compared with its toxicity,. such as hypertension, bleeding, and intestinal. perforation. In 2011, the US FDA revoked its. approval for the treatment of metastatic breast. cancer. It is still approved for use with paclitaxel. or capecitabine in Europe, but it is used in only a. J. Y. You et al.. 165. few patients because of its limited therapeutic. effect, large side effects, and high price [91, 92].. Sunitinib and sorafenib were studied as multi-. targeted tyrosine kinase inhibitors, including. VEGFR. However, in HER2-negative metastatic. breast cancer, sunitinib monotherapy was less. effective than capecitabine monotherapy. There. was no improvement in event-free survival com. pared with the monotherapy group when it was. combined with docetaxel as the first-line treat. ment or administered as a combination therapy. with capecitabine to previously treated HER2-. negative metastatic breast cancer patients.. Sorafenib in combination with capecitabine. showed improved event-free survival in patients. with advanced or metastatic HER2-negative. breast cancer compared with capecitabine alone,. but further research is needed.. 4.4.2. . PI3K/AKT/mTOR Pathway. Inhibitors. The PI3K-AKT-mTOR pathway regulates cell. proliferation and survival, making it a critical. player in tumor development and progression. [93]. It is also known to be associated with trastu. zumab resistance and hormone therapy resistance. [94]. Everolimus acts as an allosteric inhibitor of. mTOR complex 1 with a rapamycin analog and. suppresses tumors. As a clinical study to confirm. the effects of everolimus, the BOLERO-1,2,3 trial. was advanced, and the results were reported. In. BOLERO-2, [95] the event-free survival rate of. everolimus and exemestane combination therapy. was significantly higher than that with exemes. tane monotherapy [96, 97]. The BOLERO-3. study compared vinorelbine, trastuzumab, and. everolimus combination therapies with non-. everolimus combinations in patients who failed. with taxane and trastuzumab [98]. It found that. the event-free survival rate was improved in the. everolimus-using groups, but it was reported that. the decision should be made in consideration of. the toxicity of everolimus [99].. 4.4.3. . PARP Inhibitor. Poly-ADP-ribose polymerase (PARP) is one of. the most well-known enzymes that maintain gene. stability. PARP-1 activation is one of the early. cellular reactions that occur when a DNA strand. is destroyed, and if a DNA single strand is defec. tive, it is detected and immediately recovered.. The BRCA1,2 gene is responsible for repairing. double-stranded DNA damage by means of. homologous recombination. If a mutation in. BRCA1 or BRCA2 causes a loss of its function,. a PARP inhibitor can be used to induce DNA. single-strand defects. In that situation, single-. stranded DNA damage progresses from the repli. cation process to double-stranded damage, which. eventually leads to cell death due to chromo. somal instability because repair using homolo. gous recombination is difficult. There are many. molecular pathological similarities between. triple-. negative breast cancer and BRCA-deficient. breast cancer, suggesting that PARP inhibitors. (olaparib, iniparib, etc.) could play a role as tar. geted therapeutic agents in triple-negative breast. cancer [100].. 4.5. . Bone-Directed Therapy. Bone remodeling is the process by which bone is. generated through osteoblasts and reabsorbed. through osteoclasts. Osteoblasts secrete the. RANK (receptor activator of nuclear factor kappa. B) ligand (RANKL), which activates RANK in. the cell membrane of the osteoclast precursor and. activates osteoclasts. Integrin in the osteoclast. membrane and proteins such as osteopontin. secreted from osteoblasts interact with each other. to activate osteoclasts. Osteoprotegerin secreted. by bone lining cells binds to RANKL and inhibits. RANK activity. Through this series of processes,. balance is achieved between bone resorption. (osteoblasts). and. remodeling. (osteoclasts).. Cancer cells secrete substances that allow the. stimuli necessary for their growth to occur and. thus increase the activity of osteoclasts [101].. Bisphosphonate adjuvant therapy has shown. the potential to reduce recurrence rates and. improve survival, but it is difficult to apply to all. patients. The therapeutic effect is good when it is. used as an adjunct therapy in hormone treatment. or anticancer treatment for female patients with. early-stage breast cancer who have a low estrogen. Brief Overview of Breast Cancer Treatment. 166. environment after menopause or whose ovarian. function is suppressed. The mechanism of action. of the bisphosphonates is to prevent bone resorp. tion by activating osteoblasts and suppressing. bone metabolism. Additionally, they contribute. to reduced lifespan by inhibiting the replacement,. adhesion, and activity of osteoclasts. Furthermore,. they hinder the growth of macrophages respon. sible for generating osteoclasts, thereby curtailing. the lifespan of osteoclasts. Indigestion is the most. common side effect, and other side effects include. heat sensation, arthralgia, myalgia, hypocalcemia,. and decreased renal function. A pretreatment den. tal examination is essential as they can also cause. osteonecrosis of the jaw [102].. References. 1. Halsted WS. The results of operations for the cure. of cancer of the breast performed at the Johns. Hopkins hospital from June, 1889, to January,. 1894. Ann Surg. 1894;20(5):497–555. https://doi.. org/10.1097/00000658-189407000-00075.. 2. Patey DH, Dyson WH. 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Case 43 | Carcinoma In Situ | 43.1. . Courses of Treatment. Operation + Postoperative radiation therapy (left).. E. S. Lee et al.. 145. . . . . Operation. 206. 207. Pathology Report. Right.. Lobular carcinoma in situ. . 1. Size of tumor: 0.3 cm.. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: solid.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 2 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. Left.. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 1.0 cm (pTis).. . 2. Nuclear grade: high.. . 3. Necrosis: present.. . 4. Architectural pattern: micropapillary/cribri. form/comedo.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 10 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 7. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. . 8. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 8%. of tumor cells. Carcinoma In Situ. 146. a. b. . a. b. . E. S. Lee et al.. 147. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_4. Brief Overview of Breast Cancer. Treatment. Ji Young You, Soojin Park, and Eun Sook Lee. 1. . Local Therapy: Surgery. 1.1. . History. In 1984, Halsted and Meyer reported the first radi. cal mastectomy [1]. Under the concept that breast. cancer metastasizes locally along the lymphatic. vessels, the procedure removed the breast, the skin. of the breast, the pectoralis major muscle, and the. axillary lymph nodes. This technique became a. technically feasible but not wholly effective local. treatment for most breast cancers, especially. advanced cases, found in the early twentieth cen. tury. However, many patients still had expired due. to breast cancer metastasis after radical mastec. tomy, and it was found that about 25% of the breast. cancer metastasis into the internal mammary. lymph nodes. Therefore, in addition to the radical. mastectomy, an extended radical mastectomy that. included the internal mammary lymph nodes was. performed. However, even with that technique, the. survival could not be extended, and the limits of. the Halsted theory became clear. In 1948, Patey. and Dyson [2] reported that many patients would. continue to die of breast cancer after surgery. unless effective breast cancer treatments could be. developed. They designed a modified radical mas. tectomy that preserved the pectoralis major mus. cle. In the 1970s, radical mastectomy was the most. commonly performed procedure, but oncologists. acknowledged that local-segmental treatment. alone could not completely prevent recurrence. In. other words, the theory emerged that cancer cells. had already spread throughout the body at the time. of surgery, rather than being inadequately surgi. cally resected. Fisher et al. found no difference in. survival between patients who received postmas. tectomy radiation therapy and those who under. went radical mastectomy, according to the. National Surgical Adjuvant Breast and Bowel. Project (NSABP) B-04 study [3, 4]. They pro. posed that given the heterogeneous nature of. malignant tissues, metastasis to surrounding. organs can occur concurrently with systemic. spread via lymphatic and blood vessels. This prop. osition marked a paradigm shift, underlining the. significance of both local and systemic treatment. modalities. Radiation therapy along with surgery. plays a decisive role in reducing the scope of sur. gery in the local treatment of breast cancer. A mas. tectomy under the name quadrantectomy was first. attempted by Veronesi [5]. In 1969, the World. J. Y. You (*). Division of Breast and Endocrine, Department of. General Surgery, Korea University Medical Center,. Seoul, Republic of Korea. e-mail: [email protected]. S. Park. Department of Surgery, Wonkwang University. Sanbon Hospital, Gunpo, Republic of Korea. E. S. Lee. Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: [email protected]. 148. Health Organization approved a clinical study of. breast preservation surgery, and several prospec. tive studies on breast preservation surgery were. conducted. All those studies consistently reported. no difference in survival between the group that. received radiation therapy after breast preservation. surgery and the group that underwent mastectomy. [6]. Now that its safety has been proven, breast. preservation surgery is accepted as the standard. surgery for early-stage breast cancer and is under. gone by many patients [7–12].. Axillary lymph node surgery is almost always. performed during surgery for breast cancer. For. patients with invasive breast cancer, the purpose of. axillary lymph node surgery is the reduction of. local recurrences and prolongation of survival, as. well as obtaining disease information valuable to. prognosis, selection of postoperative adjuvant che. motherapy, and staging. However, many patients. suffer from complications and sequelae such as. lymphedema. In addition, only about one-third of. patients who underwent axillary lymph node dis. section were reported to have lymph node metasta. ses. As a result, new methods have emerged that. are less invasive, have fewer complications, and. provide appropriate treatment whether or not a. patient has axillary lymph node metastases. The. sentinel lymph node is the first lymph node that. metastasizes through the lymph vessels. In 1977,. Cabanas et al. used supervised lymphadenectomy. for the first time for penile cancer [13]. In 1992,. Morton et al. [14] began using it for lymphadenec. tomy of melanoma, laying the foundation for the. theory. The sentinel lymph node biopsy was intro. duced to reduce possible complications during. axillary lymphadenopathy in breast cancer. Based. on the initial experience, Guiliano et al. conducted. research to standardize monitored lymph node. biopsies in breast cancer and announced that the. monitoring lymph node detection rate was 93.5%,. with a false negative rate of 0% and sensitivity and. specificity of 100% [15, 16]. A significant differ. ence in the incidence of complications was. observed between the two procedures: a 3% inci. dence when only sentinel lymph node resection. was performed, versus a 35% incidence when axil. lary lymph node dissection was conducted [17,. 18]. However, no such difference was observed in. terms of local recurrence. Presently, sentinel. lymph node biopsies are extensively utilized to. evaluate the metastatic status of lymph nodes. [19–22].. 1.2. . Breast Surgery. 1.2.1. . Radical Mastectomy. . 1. Indications.. . (a) Breast cancer stage III or higher, a lesion. fixed in the pectoralis major muscle that. is resistant to chemotherapy or radiation. therapy.. . (b) Inflammatory breast cancer that do not. respond to chemotherapy or radiation. therapy.. . (c) Advanced breast cancer with a fixed. lesion in the pectoralis major that has. recurred after a partial mastectomy.. . (d) A lesion fixed to the muscle and accom. panied by a peripheral lesion near the. clavicle and sternum.. . 2. Surgical technique.. The skin incision takes an oval shape con. taining the primary lesion and the nipple–are. ola complex. At this time, it is better to lift the. outer circumference of the breast to secure an. appropriate boundary. If the diagnosis was. previously confirmed by histological exami. nation, it is advisable to include the biopsy. site in the oval display if technically possible.. The superior border of the resection is the. inferior surface of the clavicle, the lateral bor. der is the anterior surface of the latissimus. dorsi, the medial border is the midline of the. sternum, and the inferior border is the mam. mary fold over the extended tendon of the rec. tus abdominis.. After retracting the skin flap, identify the. insertion point of the pectoralis major muscle. on the humerus. Subsequently, dissect the. pectoralis major muscle towards its central. and superior medial portions to expose the. underlying pectoralis minor muscle. The pec. toralis major muscle insertion to the humerus. J. Y. You et al.. 149. rotates inward after the incision. During the. dissection, the pectoralis major nerve and. blood vessels that enter the pectoralis major. muscle are cut and ligated. Separation of the. pectoralis major from the medial edge of the. costosternal junction causes the pectoralis. major and breast to emerge away from the. chest wall. The pectoralis minor muscle is cut. with the coracoid process of the scapula and. then separated inwardly.. 1.2.2. . Modified Radical Mastectomy. . 1. Indication.. It could be applied to patients diagnosed. with breast cancer in the breast or axilla with. out tumor infiltration in the pectoralis major. muscle or fascia.. . 2. Surgical technique.. The techniques employed for anesthesia,. surgical positioning, skin incision, and skin. flap dissection in a modified radical mastec. tomy are similar to those used in a radical. mastectomy. The Auchincloss method is. used to pull the pectoralis minor muscle. upward and medially for level I and level II. axillary lymphadenopathy without removal. of the pectoralis minor muscle. Using the. Patty method, axillary lymph node dissec. tion is performed by making an incision from. near the origin of the pectoralis minor mus. cle to the region external to the pectoralis. major nerve branch to remove the pectoralis. minor muscle and level III lymph nodes.. 1.2.3. . Breast Conserving Surgery. . 1. Indications.. Breast Conserving Surgery are commonly. used techniques. If a mass is newly palpated,. there is a negative or ectopic breast cancer on. imaging study, or there is a shadow (microcal. cification) on visual inspection that cannot be. not touched, these techniques can be per. formed with an axillary lymphadenopathy for. breast preservation. They are suitable for non-. invasive or early stage breast cancer.. These techniques may not include lesions. in the dissected tissue. When dealing with a. tumor, it’s essential to verify the cut surface. using frozen section histology during sur. gery. Similarly, in the case of microcalcifi. cations, the excised tissue must be confirmed. via mammographic examination.. . 2. Surgical extent.. For palpable masses, an incision is made. directly on the skin above the mass, or an inci. sion is made to include a portion of the skin. above the mass. It is towed by the other hand. and peeled off, but depending on the situation,. 1–2 cm of normal surrounding tissue is usu. ally removed. If the border is unclear, espe. cially if the mass is close to the axillary tail. side, it is better to pass through the pectoralis. major fascia and remove some of the axillary. subcutaneous fat.. In the case of a mass shadow that cannot be. touched or is suspected to be a microcalcifica. tion, it is advisable to preliminarily select the. position under preoperative mastectomy,. ultrasound guidance, or ultrasound guidance. during surgery. The wire localization is placed. at the suspicious lesion site, and the normal. breast tissue around the lesion is excised. based on the tip of the lead wire.. . 3. Surgical technique.. The incision must be located within the. mastectomy incision line because it can be. enlarged by mastectomy after histologic. examination. The most cosmetically effective. incision is the circumareolar incision. The. tumor excision extent contains 1–2 cm of. normal surrounding tissue, excises the tumor,. and bleeding control using electrocautery.. The resected specimen is generally labeled. with a knot, clip, or stain as cranio-caudal,. medial-. lateral, superficial-deep and then sent. for a pathological examination or imaging.. 1.2.4. . Skin-Sparing Mastectomy. . 1. Indications.. . (a) AJCC (American Joint Committee on. Cancers) stage 0, I, and II cancers for. which a primary mastectomy is required. and breast reconstruction can be per. formed immediately. | Important Radiologic. Findings. 202 203 204. 205. 43.3. | Patient History and Progress. Female/67 years old, post-menopause.. Screen detected mass lesion on left breast 4. o’clock direction.. Outside result of biopsy: Ductal carcinoma in. situ.. No family history.. Diabetes mellitus, hypertension.. 43.2. |
Case 43 | Local Recurrence | 43.1. . Courses of Treatment. Right breast ILC→ Operation → Adjuvant ther. apy → Left breast recurrence (microinvasive. ductal carcinoma).. Primary Treatment. 285. 286. Operation. . 287. Pathology Report. Invasive Lobular Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 2/10HPF).. 3. In situ component: present, extratumoral. (40%).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 27 mm.. . (c) Medial margin: positive for lobular car. cinoma in situ (Fro 6) (see note).. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 9 mm.. 6. Lymph nodes: no metastasis in three axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/3).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Note: 1. Lobular carcinoma in situ is present. only in the permanent section of Fro 6.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 11%. of tumor cells. . . Y. Kim et al.. 837. . . . Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day for 5 years.. Treatments After Recurrence. 288 289 290. 291. Operation. 292. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1 cm. (pT1mi).. 2. Size of intraductal component: 4.0 cm.. 3. Histologic grade: not applicable.. 4. Intraductal component: present, intratu. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pattern:. micropapillary/cribriform/solid/comedo,. extensive intraductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: (see note).. . (d) Lateral margin: 5 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. Local Recurrence. 838. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1miN0(sn).. Note: 1. The inferior margin of the lumpec. tomy specimen (slide 3) is close to ductal carci. noma in situ (<1 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. The medial margin of the lumpectomy. specimen (slide 10) is close to ductal carcinoma. in situ (2 mm), but this margin submitted for fro. zen diagnosis (Fro 4) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 20%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. . . . . Y. Kim et al.. 839. 44. | null | Patient History and Progress. Female/64 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Invasive ductal. carcinoma.. Family history of breast cancer, older sister.. Diabetes mellitus, fatty liver, dyslipidemia.. BRCA 1 and 2 mutation: Not detected, ATM. VUS (variant of uncertain).. 43.2. |
Case 43 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Operation → Adjuvant. therapy → Brain metastasis.. Primary Treatment. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative. (1+). Ki-67. Positive in. 8% of tumor. cells. Adjuvant Therapy. Post-operation radiation to right breast +. Tamoxifen 20 mg/day for 3 years.. Concurrent Zoladex for 1 year.. Treatments After Recurrence. | null | BRCA 1 & 2 mutation: Not detected.. S/p bilateral salpingo-oophorectomy.. 43.2. |
Case 44 | Local Recurrence | 44.1. . Courses of Treatment. Left breast microinvasive ductal carcinoma →. Operation → Adjuvant therapy → Right breast. recurrence (IDC).. Primary Treatment. 293 294 295. 296. . . . . . . Local Recurrence. 840. Operation. . 297. Pathology Report. Microinvasive Ductal Carcinoma. 1. Size of invasive component: <0.1 cm. (pT1mic).. 2. Size of intraductal component: 1.2 cm.. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 3/10HPF).. 4. Intraductal component: present, extratumoral. (99%) (nuclear grade: low, necrosis: absent,. architectural pattern: solid, extensive intra. ductal component: present).. 5. Surgical margins:. . (a) Superior margin: 7 mm.. . (b) Inferior margin: 17 mm.. . (c) Medial margin: positive for ductal carci. noma in situ (Fro 4) (see note).. . (d) Lateral margin: <2 mm from ductal car. cinoma in situ (slide 6).. . (e) Deep margin: 4 mm.. . (f) Superficial margin: <1 mm from ductal. carcinoma in situ (slide 1).. 6. Lymph nodes: no metastasis in one axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Venous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathologic. stage. (AJCC. 2010):. pT1micN0(sn).. Note: 1. Ductal carcinoma in situ is present. only in the permanent section of Fro 4.. Result. Intensity. Positive %. Estrogen. receptor. Weak (3/8). 1. 1–10%. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in 17%. of tumor cells. Operation. Second Operation (Mar. 2014) Left breast wide. excision.. Pathology Report. . 1. No residual tumor with foreign body. reaction.. . (a) Post-lumpectomy status.. . 2. Atypical ductal hyperplasia, focal (see note).. Note: Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 298 299 300. 301. . Y. Kim et al.. 841. . . . . . Operation. . 302. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 3/3, 22/10HPF).. 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: present,. architectural pattern: micropapillary/cribri. form/comedo, extensive intraductal compo. nent: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: (see note).. . (c) Medial margin: 5 mm.. . (d) Lateral margin: 30 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: <1 mm from inva. sive ductal carcinoma (slides 2 and 3).. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(i+)(sn)) (sentinel LN:. 0/2).. 7. Arteriovenous invasion: absent.. Local Recurrence. 842. . 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(i+)(sn).. Note: 1. The inferior margin of the lumpec. tomy specimen (slide 3) is close to invasive duc. tal carcinoma (3 mm), but this margin submitted. for frozen diagnosis (Fro 3) is free of tumor.. 2. A few isolated tumor cells are present only. in the permanent section of Fro 6 for immunohis. tochemical staining (pN0(i+)).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative (2/8). 1. <1%. C-erbB2. Equivocal (2+). (SISH equivocal). Ki-67. Positive in 28%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. 45. | null | Patient History and Progress. Female/54 years old, post-menopause.. Screen detected mass lesion on left breast 2. o’clock direction.. Outside result of biopsy: Ductal carcinoma.. No family history.. No comorbidities.. 44.2. |
Case 44 | Metastatic Breast Cancer | 44.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive in. 57% of. dissection.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1a.. Size of tumor: 2.0 cm, lymph node: 3/7. (2 mm).. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Negative(0/8). 0. 0. C-erbB2. Equivocal (2+). Ki-67. Positive in. 66% of tumor. cells. SISH. Negative. Palliative therapy: Capecitabine (Sep. 2019 ~. Dec. 2019): Progressive disease.. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative. (1+). Ki-67. Positive in. 2% of tumor. cells. Palliative therapy: DS-8201aU 303 # 8:. Progressive disease (liver).. Concurrent proton therapy: radiation to liver.. Palliative therapy: Albumin-bound Paclitaxel. # 8: Progressive disease.. Palliative. therapy:. Fluorouracil-5. &. Doxorubicin & cyclophosphamide # 5.. Palliative therapy: Eribulin. | null | Patient History and Progress. Female/49 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy.. 44.2. |
Case 45 | Local Recurrence | 45.1. . Courses of Treatment. Right breast LCIS→ Operation → Right breast. recurrence (DCIS).. Primary Treatment. 303. Operation. 304. 305. Pathology Report. <Right>. Y. Kim et al.. 843. . 1. Lobular Carcinoma In Situ. . (a) Size of tumor: up to 0.4 cm, multifocal. (pTis).. . (b) Surgical margins:. • Superior margin: 5 mm.. • Inferior margin: 5 mm.. • Medial margin: 5 mm.. • Lateral margin: (see note).. • Deep margin: 5 mm.. • Superficial margin: 5 mm.. . (c) Microcalcification: present, non-tumoral.. . (d) Pathologic stage (AJCC 2010): pTisNx.. . 2. Atypical ductal hyperplasia.. . . . Local Recurrence. 844. Note: 1. The lateral margin of the lumpectomy. specimen (slide 5) is close to lobular carcinoma. in situ (<1 mm), but this margin submitted for. frozen diagnosis (Fro 5) is free of tumor.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in. 1% of. tumor cells. <Left>. . 1. Atypical ductal hyperplasia involving intra. ductal papilloma. . 2. Fibroadenoma.. Treatments After Recurrence. 306. Operation. 307. Pathology Report. Ductal Carcinoma In Situ. . 1. Post-lumpectomy status.. . 2. Size of tumor: 0.3 cm (pTis).. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: cribriform/solid.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) Deep margin: 2 mm.. . (b) Superficial margin: 2 mm.. . 8. Microcalcification:. present,. tumoral/. non-tumoral.. . 9. Pathological TN category (AJCC 2017): pTis.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 2%. of tumor cells. . Y. Kim et al.. 845. . 46. | null | Patient History and Progress. Female/57 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. Outside result of biopsy: Lobular carcinoma. in situ.. Family history of breast cancer, older sister.. Panic disorder.. BRCA 1 and 2 mutation: Not detected.. 45.2. |
Case 45 | Metastatic Breast Cancer | Courses of Treatment. Left breast cancer with lung and bone metas. tasis → Palliative therapy.. See Figs. 137, 138, and 139.. Left invasive ductal carcinoma, stage IV. (metastasis in lung, bone).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Equivocal. (2+). Ki-67. Result. Intensity Positive %. Estrogen. receptor. Weak (4/8). 2. 1–10%. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in. 8% of tumor. cells. Palliative therapy: fluorouracil & Doxorubicin. & cyclophosphamide # 6.. Post-op radiation to left breast & subclavicu. lar lymph node + Tamoxifen 20 mg/day (Apr.. 2015 ~ Jul. 2018).. Jul. 2018 Chest CT> increased nodule in lung,. hepatic metastasis.. Palliative therapy: Trastuzumab emtansine # 5. cycles: Progressive disease.. Palliative therapy: Lapatinib & Capecitabine #. 39 cycles: Progressive disease.. Palliative therapy: Gemcitabine & Cisplatin. (Feb. 2021) ~. 46. | null | |
Case 46 | Local Recurrence | 46.1. . Courses of Treatment. Right breast papillary carcinoma in situ →. Operation → Adjuvant therapy → Right breast. recurrence (IDC).. Primary Treatment. Operation. 308. Pathology Report. Papillary Carcinoma In Situ in background of. multiple papilloma (see note). . 1. Size of intraductal carcinoma: 0.5 cm. (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: papillary.. . 5. Skin: no involvement of tumor.. Local Recurrence. 846. . . . 6. Surgical margins:. . (a) Superior margin: 18 mm.. . (b) Inferior margin: positive for intraductal. papilloma.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 2 mm.. . 7. Microcalcification:. present,. tumoral/. non-tumoral.. . 8. Pathologic staging: pTis.. Note: The in situ component is mainly present. in the needle biopsy specimen.. Adjuvant Therapy. Tamoxifen 20 mg/day for 3.6 years.. Treatments After Recurrence. 309 310 311. 312. Operation. . 313. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 3. Intraductal component: present, intratu. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary/cribriform, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Nipple margin: (see note 1).. . (b) Superior margin: 5 mm.. . (c) Inferior margin: (see note 2).. . (d) Medial margin: (see note 3).. . (e) Lateral margin: 20 mm.. . (f) Deep margin: 2 mm.. . (g) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. Y. Kim et al.. 847. . . . . . 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1bN0(sn).. Note: 1. Atypical ductal hyperplasia is present. only in the permanent section of Fro 1.. 2. The inferior margin of the lumpectomy. specimen (slide 8) is close to ductal carcinoma in. situ (2 mm), but this margin submitted for frozen. diagnosis (Fro 3) is free of tumor.. 3. The medial margin of the lumpectomy. specimen (slide 6) is close to ductal carcinoma in. situ (2 mm), but this margin submitted for frozen. diagnosis (Fro 4) is free of tumor.. Local Recurrence. 848. . . . Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 10%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. 47. | null | Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on upper outer. portion of right breast.. No family history.. No comorbidities.. 46.2. |
Case 46 | Metastatic Breast Cancer | 46.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. See Figs. 140 and 141.. Metastatic Breast Cancer. 934. Right invasive ductal carcinoma, Stage IV. (R/O metastasis in bone, T-spine 10).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 43%. of tumor cells. SISH. Negative. Palliative therapy: Letrozole & Palbociclib # 29.. Dec. 2021 Right breast conserving surgery,. sentinel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1bN0 (sn).. Size of tumor: 0.9 cm, lymph node: 0/2.. Result. Intensity Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 34% of. tumor cells. Palliative. chemotherapy. #4. cycles. (Doxorubicin & Cyclophosphamide).. Post-op radiation to right breast & T-spine 10.. 47. | null | Patient History and Progress. Female/61 years old, post-menopause.. No family history.. s/p appendectomy, hypertension.. 46.2. |
Case 47 | Local Recurrence | 47.1. . Courses of Treatment. Right breast Infiltrating ductal carcinoma→. Operation → Adjuvant therapy → Left breast. recurrence (IDC).. Primary Treatment. 314. 315. Operation. Aug. 2003 Right breast conserving surgery, axil. lary lymph node dissection.. Pathology Report. Infiltrating ductal carcinoma.. 1. Size of tumor: 2 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count: 2/3).. 3. Ductal carcinoma in situ: present, intratu. moral (5%) (nuclear grade: low, necrosis:. absent, architectural pattern: solid, extensive. intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins: clear:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 35 mm.. . (c) Medial margin: 35 mm.. . (d) Lateral margin: 25 mm.. . (e) Deep margin: 10 mm.. 6. Lymph nodes:. . (a) Metastasis in 2 out of 22 axillary lymph. nodes (pN1a) (sentinel LN: 1/2, axillary. LN: 1/20).. . (b) Perinodal extension: absent.. . (c) Size of metastatic carcinoma: 6 mm.. Y. Kim et al.. 849. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: absent.. . 11. Pathologic staging: pT1cN1a.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/7). 2. 1/3–2/3. Progesterone. receptor. Weak (2/7). 1. <10%. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Postoperative radiation therapy.. Tamoxifen 20 mg/day 1.6 years, anastrozole. 1 mg/day for 1 year, tamoxifen 20 mg/day for. 2.3 years.. Treatments After Recurrence. 316 317. 318. Operation. . 319. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.1 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3, 11/10HPF).. 3. Intraductal component: present, intratumoral/. extratumoral (20%) (nuclear grade: low, necro. sis: absent, architectural pattern: cribriform,. extensive intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . Local Recurrence. 850. . . . . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity Positive %. Estrogen receptor. Weak. (4/8). 2. 1–10%. Progesterone. receptor. Weak. (4/8). 2. 1–10%. C-erbB2. Negative. (0). Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. Y. Kim et al.. 851. 48. | null | Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 1. o’clock direction.. No family history.. Diabetes mellitus.. BRCA 1 and 2 mutation: Not detected, ATM. VUS (variant of uncertain).. POLE VUS (variant of uncertain).. 47.2. |
Case 47 | Metastatic Breast Cancer | 47.1. . Courses of Treatment. Right breast cancer → Neoadjuvant chemother. apy → Operation → Adjuvant therapy → Ipsilateral. breast recurrence → Lung metastasis.. Primary Treatment. receptor. Negative 0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in 5%. Operation. Aug. 2013 Left breast conserving surgery, senti. nel lymph node biopsy.. Pathology: Ductal carcinoma in situ (resid. ual), stage yp TisN0 (sn).. Size of tumor: up to 0.5 cm, lymph node: 0/3.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. 0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 19% of. tumor cells. Adjuvant Therapy. Post-operative radiation to left breast & subcla. vicular lymph node.. Concurrent Trastuzumab # 18.. Treatments After Recurrence. Ipsilateral Breast Recurrence. Progesterone. receptor. Negative 0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 84% of tumor. cells. Adjuvant Chemotherapy. Adjuvant chemotherapy #8 cycles (Paclitaxel &. Trastuzumab # 8).. Operation. Nov. 2016 Left simple mastectomy with implant. reconstruction.. Pathology: Invasive ductal carcinoma, stage. rpT2.. Size of tumor : 2.5 cm.. Adjuvant Therapy. Adjuvant therapy: Paclitaxel & Trastuzumab # 32. cycles.. Lung Metastasis. Clinical trial: PF-06804103 #1: withdraw due. to side effects.. Palliative therapy: Irinotecan & Cisplatin # 6:. Partial response.. Rest for 3 months.. Palliative therapy: Trastuzumab & Eribulin #2.. Radiation to lung.. Palliative therapy: Abraxane #2: Progressive. disease.. Palliative therapy: Mitomycin #2: Progressive. disease.. 48. | null | Patient History and Progress. Female/46 years old, pre-menopause.. No family history.. 47.2. |
Case 48 | Local Recurrence | 48.1. . Courses of Treatment. Left breast Mucinous carcinoma → Operation. → Adjuvant therapy → Left breast recurrence. (mucinous carcinoma).. Primary Treatment. 320. 321. Operation. 322. Pathology Report. Mucinous Carcinoma. 1. Size of invasive carcinoma: 0.6 cm (pT1b).. 2. Size of intraductal carcinoma: 1.5 cm.. 3. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3).. 4. Ductal carcinoma in situ: present, intratu. moral/extratumoral (50%) (nuclear grade:. low, necrosis: absent, architectural pattern:. cribriform, extensive intraductal component:. present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 8 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: 1 mm from mucinous. carcinoma (slide 9) and.. . (d) Positive for atypical ductal hyperplasia. (Fro 5) (see note).. . (e) Lateral margin: 10 mm.. . (f) Deep margin: 1 mm.. 7. Lymph nodes: no metastasis in 1 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 8. Vascular invasion: absent.. 9. Lymphatic invasion: present, intratumoral.. . 10. Tumor border: pushing.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathologic staging: pT1bN0(sn).. . . . . Local Recurrence. 852. Note: Atypical ductal hyperplasia is focally. present only in the permanent section of Fro 5.. Result. Intensity. Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (5/7). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 10%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. Treatments After Recurrence. 323 324. 325. Operation. . 326. 327. Pathology Report. Mucinous Carcinoma. 1. Post-lumpectomy status.. 2. Size of tumor: 1.1 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 1/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Deep margin: <1 mm from mucinous. carcinoma (slide 1).. . (b) Superficial margin: 14 mm.. 7. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1,. axillary LN: 0/0).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: pushing.. . 11. Microcalcification: absent.. . 12. Pathologic stage (AJCC 2010): rpT1cN0(sn).. . . . Y. Kim et al.. 853. . . Result. Intensity. Positive %. Estrogen. receptor. Strong (7/8). 2. >2/3. Progesterone. receptor. Weak (4/8). 2. 1–10%. C-erbB2. Negative (0). Ki-67. Positive in 6%. of tumor cells. Adjuvant Therapy. Tamoxifen 10 mg/day for 2.2 years.. 49. | null | Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on left breast 9. o’clock direction.. Outside. result. of. biopsy:. Mucinous. carcinoma.. No family history.. No comorbdities.. 48.2. |
Case 48 | Metastatic Breast Cancer | 48.1. . Courses of Treatment. Right breast cancer with mediastinum and. bone metastasis → Palliative therapy.. Progesterone. receptor. Intermediate. (5/8). 2. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in. 54% of tumor. cells. Neoadjuvant. chemotherapy. #8. cycles. (Doxorubicin + Cyclophosphamide #4 →. Docetaxel #4).. Dec. 2014 Right breast conserving surgery.. Pathology: Invasive ductal carcinoma, stage. ypT2N2a.. Size of tumor: 3.0 × 1.5 cm, lymph node: 4/4. (10 mm).. Result. Intensity Positive %. Estrogen. receptor. Intermediate. (6/8). 2. 1/3–2/3. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (0). Ki-67. Positive in 1%. of tumor cells. Post-operative radiation to right breast &. internal mammary lymph node + Tamoxifen. 20 mg/day & zoladex.. Mar. 2015 Bilateral salpingo-oophorectomy.. Tamoxifen 20 mg/day only.. Mar. 2016 PET-CT> metastasis in multiple. bone.. Palliative therapy: Letrozole (Mar. 2016 ~. Nov. 2017: Progressive disease).. Palliative therapy: Exemestane & Everolimus.. Oct. 2018 Chest CT> metastasis in liver.. Palliative therapy: Paclitaxel & Cisplatin #21:. Progressive disease.. Palliative therapy: Fulvestrant & Abemaciclib. (Feb. 2020)~. 49. | null | Patient History and Progress. Female/45 years old, post-menopause.. No family history.. BRCA 1 & 2 mutation: Not detected.. S/p bilateral salpingo-oophorectomy.. 48.2. |
Case 49 | Local Recurrence | 49.1. . Courses of Treatment. Right breast IDC→ Operation → Adjuvant ther. apy → Left breast recurrence (IDC).. Primary Treatment. 328. 329. Operation. Apr. 2004 Right breast conserving surgery, senti. nel lymph node biopsy.. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 2/3).. 3. Ductal carcinoma in situ: present, intratu. moral/extratumoral (30%) (nuclear grade:. low, necrosis: present, architectural pattern:. cribriform and comedo, extensive intraductal. component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 15 mm.. . (b) Inferior margin: 25 mm.. . (c) Medial margin: 20 mm.. . (d) Lateral margin: 20 mm.. . (e) Deep margin: 5 mm.. 6. Lymph nodes: no metastasis in 1 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/1).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic staging: pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (6/7). 3. 1/3–2/3. Progesterone. receptor. Intermediate. (4/7). 2. 10%-1/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 5%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Treatments After Recurrence. 330 331. 332. Operation. 333. . . Y. Kim et al.. 855. . . . . . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.6 cm (pT1c).. 2. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 4/10HPF).. 3. Intraductal component: present, intratumoral. (5%) (nuclear grade: low, necrosis: present,. architectural pattern: solid, extensive intra. ductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 19 mm.. . (b) Inferior margin: 11 mm.. . (c) Medial margin: 15 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 4 mm.. . (f) Superficial margin: 15 mm.. 6. Lymph nodes: no metastasis in 2 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. Local Recurrence. 856. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. 11) Pathological TN category (AJCC 2017):. pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 12%. of tumor cells. Adjuvant Therapy. Postoperative radiation therapy.. Anastrozole 1 mg/day.. 50. | null | Patient History and Progress. Female/63 years old, post-menopause.. Self-detected mass lesion on right breast. . 2 o’clock direction.. No family history.. No comorbidities.. BRCA 1 and 2 mutation: No examination.. Local Recurrence. 854. 49.2. |
Case 49 | Metastatic Breast Cancer | 49.1. . Courses of Treatment. Right breast cancer with bone metastasis →. Palliative therapy.. See Figs. 148 and 149.. Right invasive ductal carcinoma, stage IV. (metastasis in bone).. Metastatic Breast Cancer. Strong(8/8). 3. >2/3. C-erbB2. Negative. (1+). Ki-67. Positive in. 75% of. tumor cells. Clinical trial: Tamoxifen 20 mg/day &. Goserelin 3.6 mg (Dec. 2014 ~ Jan. 2017):. Progressive disease.. Jan. 2017 Palliative right breast conserving. surgery & bilateral salpingo-oophorectomy.. Pathology: Invasive ductal carcinoma, stage. yp T1p.. Size of tumor: 1.4 cm.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Weak (4/8). 3. <1%. C-erbB2. Negative. (1+). Ki-67. Positive in. 30% of. tumor cells. Palliative therapy: Letrozole & Palbociclib. (Jan. 2017) ~. Post-operative radiation to pelvic bone.. Y. Kwon et al.. 939. 50. | null | Patient History and Progress. Female/55 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy, s/p Left. pelvis cementoplasty.. 49.2. |
Case 5 | Benign and Proliferative | 5.1. . Courses of Treatment. →2021-12-17 Excision, Lt. (11H, 1H).. 5.3.1. . Pathology Report. • Breast, left, excision:. –. – Atypical ductal hyperplasia (#1. 1 o’clock. & #2. 11 o’clock) involving intraductal. papilloma with microcalcification.. C. W. Lee et al.. 23. . . 6. | Important Radiologic. Findings. 7. 8. 5.3. | Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected microcalcification on upper. outer portion of left breast.. Family history of breast cancer, mother and. sister.. No comorbidities.. BRCA 1 and 2 mutation: Not detected.. 5.2. |
Case 5 | Carcinoma In Situ | Courses of Treatment. Operation + Postoperative radiation therapy.. 5.3.1. . Operation. 25. 26. 5.3.2. . Pathology Report. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural pattern: cribriform.. . 5. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: <1 mm from ductal carci. noma in situ (slide 12),. . (d) lateral margin: 10 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 6. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Weak (4/8). 1. 10%–1/3. C-erbB2. Negative (0). Ki-67. Positive in. <1% of tumor. cells. E. S. Lee et al.. 63. . . . . Carcinoma In Situ. 64. . 6. | Important Radiologic. Findings. 21 22 23. 24. 5.3. | Screen detected mass lesion on left breast 11,. 3 and 2 o’clock direction.. Outside result of biopsy:. Left breast 11 o’ clock: Intraductal prolifera. tive lesion.. Left breast 3 o’ clock: Adenosis and fibrocys. tic change.. Left breast 2 o’clock: Fibrocystic change.. No family history.. No comorbidities.. 5.2. |
Case 5 | HR(+) HER2(+) Breast Cancer | 5.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles. of. docetaxel. and. cyclophospha. mide). +. Post-operative. radiation. ther. apy + Trastuzumab + Tamoxifen 20 mg/day.. 28. 5.3.1. . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 1.5 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 3/3, 3/HPF).. S. Park et al.. 313. . . . 3. Intraductal component: present, intratu. moral/extratumoral (20%) (nuclear grade:. high, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo. nent: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: (see note),. . (c) medial margin: 5 mm,. . (d) lateral margin: (see note),. . (e) deep margin: <1 mm from invasive duc. tal carcinoma (slide 4),. . (f) superficial margin: 2 mm.. 6. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT1cN0(sn).. Note: 1. The inferior and lateral margins of the. lumpectomy specimen (slides 9 and 10, respec. tively) are close to ductal carcinoma in situ. (<1 mm) but these margins submitted for frozen. diagnosis (Fro 3 and Fro 5, respectively) are free. of tumor.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Intermediate. (6/8). 3. 10%-. 1/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 39%. of tumor cells. SISH. Positive. HR(+) HER2(+) Breast Cancer. 314. . . S. Park et al.. 315. a. b. . 6. | Important Radiologic. Findings. 24 25 26. 27. 5.3. | Patient History and Progress. Female/53 years old, peri-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. Hypothyroidism, dyslipidemia, s/p cold knife. conization of cervix.. 5.2. |
Case 5 | HR(+) HER2(-) Breast Cancer | Courses of Treatment. Operation. +. Adjuvant. chemotherapy. (#4 cycles of docetaxel & cyclophospha. mide). +. Post-operative. radiation. ther. apy + Letrozole 2.5 mg/day.. 5.3.1. . Operation (1st, Dec. 2020). Right breast conserving surgery, sentinel lymph. low, necrosis: present, architectural pattern:. micropapillary/cribriform/comedo,. exten. sive intraductal component: absent).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) superior margin: (see note 2),. . (b) inferior margin: 5 mm,. . (c) medial margin: positive for invasive duc. tal carcinoma (Fro 6),. . (d) lateral margin: (see note 3),. . (e) deep margin: positive for invasive ductal. carcinoma (slide 1),. . (f) superficial margin: 2 mm.. 1. <1%. C-erbB2. Negative (1+). Ki-67. Positive in 4% of tumor cells. . (a) metastasis in two out of three axillary. lymph nodes (pN1a(sn)) (sentinel LN:. 2/3),. . (b) perinodal extension: absent,. . (c) size of metastatic carcinoma: 2.5 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular. invasion:. present,. intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. pT2N1a(sn).. Note: 1. Micrometastasis is present in the. frozen section of Fro 2.. 2. The superior margin of the lumpectomy. specimen (slide 6) is close to invasive ductal. carcinoma (<1 mm) but this margin submit. ted for frozen diagnosis (Fro 4) is free of. tumor.. 3. The lateral margin of the lumpectomy. specimen (slide 8) is close to invasive ductal. carcinoma (<1 mm) but this margin submit. ted for frozen diagnosis (Fro 7) is free of. tumor.. Y. Kim et al.. nuclear pleomorphism: 2/3, mitotic count:. 1/3).. . 4. Intraductal component: absent.. . 5. Surgical margins: 9 mm.. . 6. Arteriovenous invasion: absent.. . 7. Lymphovascular. invasion:. present,. extratumoral.. . 8. Tumor border: infiltrative.. . 9. Microcalcification: present, non-tumoral.. HR(+) HER2(−) Breast Cancer. 188. 6. | Important Radiologic. Findings. See Figs. 20, 21, 22 and 23.. 5.3. | o’clock direction.. No family history.. No comorbidities.. 5.2. |
Case 5 | HR(−) HER2(+) Breast Cancer | 5.1. . Courses of Treatment. Operation + Post-operative radiation therapy.. 5.3.1. . Operation. 40. 5.3.2. . Pathology Report. . 1. Invasive ductal carcinoma.. . (a) Size of invasive component: 0.2 cm. (pT1a).. . (b) Size of intraductal component: 2.0 cm.. . (c) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 2/3, 10/10HPF).. . (d) Intraductal component: present, intratu. moral/extratumoral (99%) (nuclear grade:. high, necrosis: present, architectural pat. tern: cribriform/solid/comedo, extensive. intraductal component: present).. . (e) Skin: no involvement of tumor.. . (f) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 40 mm,. • medial margin: 15 mm,. • lateral margin: 15 mm,. • deep margin: 2 mm,. • superficial margin: 30 mm.. . (g) Lymph nodes: no metastasis in four axil. lary lymph nodes (pN0(sn)) (sentinel LN:. 0/4).. . (h) Arteriovenous invasion: absent.. . (i) Lymphovascular invasion: absent.. . (j) Tumor border: infiltrative.. . (k) Microcalcification:. present,. . tumoral/. non-tumoral.. . (l) Pathological TN category (AJCC 2017):. pT1aN0(sn).. . 2. Intraductal papilloma.. . 3. Mucocele-like lesion.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 28% of tumor. cells. Y. Kwon et al.. 449. F. ig. 40 | Important Radiologic. Findings. 36 37 38. 39. Y. Kwon et al.. 447. . . . HR(−) HER2(+) Breast Cancer. 448. . 5.3. | Patient History and Progress. Female/58 years old, post-menopause.. Screen detected mass lesion on upper inner. portion of left breast 8 o’clock.. No family history.. S/P myomectomy, dyslipidemia.. 5.2. |
Case 5 | HR(−) HER2(−) Breast Cancer | 5.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy + Adjuvant. capecitabine (refuse).. 5.3.1. . Operation. 35. 5.3.2. . Pathology Report. Invasive Ductal Carcinoma. 1. Post-chemotherapy status.. 2. Size of tumor: 0.3 cm (ypT1a).. 3. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count:. 2/3, 11/10HPF).. 4. Intraductal component: absent.. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 13 mm.. . (b) Inferior margin: 11 mm.. . (c) Medial margin: 25 mm.. . (d) Lateral margin: 15 mm.. . (e) Deep margin: 5 mm.. . (f) Superficial margin: 6 mm.. 7. Lymph nodes: no metastasis in two axillary. lymph nodes (ypN0(sn)) (sentinel LN: 0/2).. 8. Arteriovenous invasion: absent.. 9. Lymphovascular invasion: absent.. . 10. Tumor border: infiltrative.. . 11. Microcalcification: present, non-tumoral.. . 12. Pathological TN category (AJCC 2017):. ypT1aN0(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 26%. of tumor cells. E. S. Lee et al.. 591. . . . . HR(−) HER2(−) Breast Cancer. 592. . . . E. S. Lee et al.. 593. 6. | Important Radiologic. Findings. 27 28 29. 30. E. S. Lee et al.. 589. . . . HR(−) HER2(−) Breast Cancer. 590. . 5.2.1. . After Neoadjuvant. Chemotherapy. 31 32 33. 34. 5.3. | Patient History and Progress. Female/57 years old, post-menopause.. Screen detected a mass lesion on left breast 9. o’clock direction.. Family history of breast cancer, sister and. niece.. Family history of ovarian cancer, mother.. S/P. Hysterectomy,. s/o. bilateral. salpingo-oophorectomy.. BRCA 1 mutation carrier.. 5.2. |
Case 5 | Local Recurrence | 5.1. . Courses of Treatment. Left breast IDC → Operation → Adjuvant ther. apy → Right breast recurrence (IDC).. 5.2.1. . Primary Treatment. 30 31. 32. Operation. 33. Y. Kim et al.. 729. . . . . . Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 2.0 cm (pT1c).. 2. Histologic grade: 3/3 (tubule formation: 3/3,. nuclear pleomorphism: 3/3, mitotic count: 2/3). 3. Ductal carcinoma in situ: present, intratumoral/. extratumoral (30%) (nuclear grade: high, necro. sis: present, architectural pattern: comedo,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 30 mm.. . (c) Medial margin: 30 mm.. . (d) Lateral margin: 40 mm.. . (e) Deep margin: 2 mm.. 6. Lymph nodes: no metastasis in 4 axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/4).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic staging: pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/7). 0. 0. Progesterone. receptor. Negative (0/7). 0. 0. C-erbB2. Negative (1+). Ki-67. Positive in 20%. of tumor cells. Local Recurrence. 730. Adjuvant Therapy. Adjuvant chemotherapy #6 cycles of fluorouracil. and doxorubicin and cyclophosphamide.. Postoperative radiation therapy.. 5.2.2. . Treatments After Recurrence. 34 35. 36. Operation. . 37. Pathology Report. Invasive Ductal Carcinoma. 1. Size of tumor: 0.8 cm (pT1b).. 2. Histologic grade: 2 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, <1/10HPF).. 3. Intraductal component: absent.. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 30 mm.. . (b) Inferior margin: 40 mm.. . (c) Medial margin: 35 mm.. . (d) Lateral margin: 35 mm.. . (e) Deep margin: 16 mm.. . (f) Superficial margin: 20 mm.. 6. Lymph nodes: no metastasis in two axillary. lymph nodes (pN0(sn)) (sentinel LN: 0/2).. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification: present, non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1bN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Negative (8/8). 3. >2/3. Progesterone. receptor. Negative (7/8). 2. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 15%. of tumor cells. . . . . Y. Kim et al.. 731. a. b. . . . . Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. 6. | null | Patient History and Progress. Female/69 years old, post-menopause.. Screen detected mass lesion on left breast. . 2 o’clock direction.. No family history.. No other history of disease, operation, or. medication.. BRCA 1 VUS (variant of uncertain).. 5.2. |
Case 5 | Metastatic Breast Cancer | Courses of Treatment. Left breast cancer → Neoadjuvant chemother. apy → Operation → Adjuvant therapy → Lung. and liver metastasis.. 5.2.1. . Primary Treatment. Jun. 2015 breast, left, needle biopsy:. Invasive ductal carcinoma, histologic grade 2. with apocrine differentiation.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 24% of tumor. cells. See Figs. 15 and 16.. Neoadjuvant Chemotherapy. Neoadjuvant. chemotherapy. #8. cycles. (Adriamycin. +. Cyclophosphamide. #4. →. Docetaxel #4).. Operation. Dec. 2015 Left breast conserving surgery, senti. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1cN1mi (sn).. Size of tumor: 1.5 cm, lymph node: 1/3, size. of metastatic carcinoma: 1.8 mm.. Result. Intensity. Positive %. Estrogen. receptor. Intermediate. (5/8). 2. 10%–1/3. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Negative. (1+). Ki-67. Positive in. 2% of tumor. cells. Adjuvant Therapy. Post-operative radiation therapy + Letrozole. 2.5 mg/day for 4.9 years.. Metastatic Breast Cancer. 870. 5.2.2. . Treatments After Recurrence. Lung and Liver Metastasis. Nov. 2020 CT chest: metastasis to lung, liver.. Liver biopsy: Metastatic ductal cancer.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. Result. Intensity. Positive %. C-erbB2. Positive. (3+). Ki-67. N.A.. Palliative Therapy (Enrolled in Clinical Trial). → Clinical trial enrolled (ZW25 + Docetaxel #6. cycles → ZW25 ~). | null | 5.2. |
Case 50 | Local Recurrence | 50.1. . Courses of Treatment. Right breast IDC → Operation → Adjuvant. therapy → Right breast recurrence (IDC).. Primary Treatment. 334 335. 336. Operation. 337. 338. Pathology Report. <Right>. . 1. Invasive Ductal Carcinoma. . (a) Size of tumor: 1.8 cm (pT1c).. . (b) Histologic grade: 2/3 (tubule formation:. 2/3, nuclear pleomorphism: 2/3, mitotic. count: 2/3, 10/10HPF).. . (c) Intraductal component: present, intratu. moral/extratumoral (30%) (nuclear grade:. low,. necrosis:. absent,. architectural. . pattern: solid, extensive intraductal com. ponent: present).. . (d) Surgical margins:. • Deep margin: 3 mm.. • Superficial margin: 10 mm.. . (e) Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . (f) Arteriovenous invasion: absent.. . (g) Lymphovascular invasion: absent.. . (h) Tumor border: infiltrative.. . (i) Microcalcification: present, non-tumoral.. . (j) Pathologic. stage. (AJCC. 2010):. pT1cN0(sn).. . 2. Intraductal Papilloma with usual ductal. hyperplasia.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (0). Ki-67. Positive in 23.8%. of tumor cells. <Left>. Intraductal papilloma with usual ductal. hyperplasia.. Adjuvant Therapy. Letrozole 2.5 mg/day for 2.8 years.. Treatments After Recurrence. 339. 340. Operation. 341. Y. Kim et al.. 857. . . . . Local Recurrence. 858. . a. b. . Y. Kim et al.. 859. Pathology Report. Invasive. Ductal. Carcinoma,. clinically. recurrent. 1. Post-nipple-sparing mastectomy status.. 2. Size of tumor: 1.1 cm (rpT1c).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: absent.. 5. Skin: dermal involvement of tumor.. 6. Nipple: no involvement of tumor.. 7. Surgical margins:. . (a) Superior margin: 10 mm.. . (b) Inferior margin: 10 mm.. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 80 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 8. Lymph nodes: no metastasis in one axillary. lymph node (rpN0(sn)) (sentinel LN: 0/1).. 9. Arteriovenous invasion: absent.. . 10. Lymphovascular. invasion:. present,. intratumoral.. . 11. Tumor border: infiltrative.. . . . Local Recurrence. 860. . 12. Microcalcification:. present,. tumoral/. non-tumoral.. . 13. Pathological TN category (AJCC 2017):. rpT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). (SISH negative). Ki-67. Positive in 31%. of tumor cells. Adjuvant Therapy. Exemestane 25 mg/day.. Y. Kim et al.. 861. © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023. E. S. Lee (ed.), A Practical Guide to Breast Cancer Treatment,. https://doi.org/10.1007/978-981-19-9044-1_10 | null | Patient History and Progress. Female/72 years old, post-menopause.. Screen detected mass lesion on right breast 12. o’clock and 8 o’clock direction, left breast 12. o’clock direction.. No family history.. Hypertension, hepatitis B virus carrier,. claustrophobia.. 50.2. |
Case 50 | Metastatic Breast Cancer | 50.1. . Courses of Treatment. Left breast cancer with lung metastasis →. Palliative therapy.. See Figs. 150 and 151.. Left invasive ductal carcinoma, stage IV. (metastasis. in. ovary,. s/p. bilateral. salpingo-oophorectomy).. Result. Intensity Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Weak (3/8). 1. 1–10%. C-erbB2. Negative (1+). Ki-67. Positive in. 52% of tumor. cells. Palliative therapy: Letrozole & Palbociclib. #11.. Jan. 2021 Left breast conserving surgery.. Pathology: Invasive ductal carcinoma, stage. ypT2N1a.. Size of tumor: 2.5 cm, lymph node: 1/7. (6 mm).. Result. Intensity Positive %. Estrogen. receptor. Negative. (02/8). 1. <1%. Progesterone. receptor. Negative. (2/8). 1. <1%. C-erbB2. Negative. (0). Ki-67. Positive in. 59% of. tumor cells. Palliative chemotherapy # 4 cycles (Docetaxel. & cyclophosphamide #4).. Post-operative radiation to left breast & sub. clavicular lymph node + Tamoxifen 20 mg/day. • Breast cancer treatment is highly affected by. the patient’s status of illness, overall health,. and socioeconomic condition, but it is also. influenced by the insurance policy of the soci. ety to which the patient belongs and the politi. cal and economic situation of the country.. • South Korea receives a relatively high-level,. guideline-compliant treatment because the. entire population is under the national health. insurance system, but there is a slight gap in. E. S. Lee (*). Center for Breast Cancer, National Cancer Center,. Goyang, Kyonggi-do, Republic of Korea. e-mail: [email protected]. . 942. the immediate adoption of newly developed. therapeutics such as immune checkpoint. inhibitors, antibody-drug conjugate, and many. other agents.. • For primary breast cancers, most patients are. treated well according to the guidelines, but. there is still a shortage in patients with meta. static cancer.. • Fortunately, we are actively involved in many. global clinical trials and patients who have. metastasis and are heavily treated are benefit. ing from many new treatments, but globally,. the health disparity is clearly an ongoing. problem.. E. S. Lee. | null | Patient History and Progress. Female/47 years old, post-menopause.. No family history.. S/p bilateral salpingo-oophorectomy, diabetes. mellitus.. 50.2. |
Case 6 | Benign and Proliferative | 6.1. . Courses of Treatment. → 2021-12-31 excision, both.. Benign and Proliferative Case Series. 24. . . 6.3.1. . Pathology Report. • Breast, right, excision:. –. – Intraductal papilloma with (1) usual ductal. hyperplasia, (2) microcalcification.. • Breast, left, excision:. –. – Intraductal papilloma with (1) usual ductal. hyperplasia, (2) microcalcification.. 7. | Important Radiologic. Findings. 9. 10. 6.3. | Patient History and Progress. Female/48 years old, pre-menopause.. Bloody discharge from right nipple.. No family history.. Hypertension.. 6.2. |
Case 6 | Carcinoma In Situ | 6.1. . Courses of Treatment. Operation + Tamoxifen 20 mg/day for 5 years.. E. S. Lee et al.. 65. 6.3.1. . Operation. 28. 29. 6.3.2. . Pathology Report. <First operation>. Ductal carcinoma in situ, pathological TN cat. egory (AJCC 2017): pTis. . 1. Size of tumor: 0.3 cm (pTis).. . 2. Nuclear grade: low.. . 3. Necrosis: absent.. . 4. Architectural. pattern:. micropapillary/. cribriform.. . 5. Skin: no involvement of tumor.. . 6. Surgical margins: positive.. . 7. Microcalcification:. present,. tumoral/non-. tumoral.. Result. Intensity Positive %. Estrogen. receptor. Strong (7/8). 3. 1/3–2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Equivocal (2+). Ki-67. Positive in 2%. of tumor cells. <Second operation>. No residual tumor with foreign body reaction.. . 1. Post-excision status.. . . . Carcinoma In Situ. 66. . . . 7. | Important Radiologic. Findings. 27. 6.3. | Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected microcalcification on left. breast upper outer.. No family history.. s/p Lt mammotome biopsy in 2018 (result:. benign).. 6.2. |
Case 6 | HR(+) HER2(+) Breast Cancer | 6.1. . Courses of Treatment. Operation + Adjuvant chemotherapy (#4. cycles of doxorubicin and cyclophospha. mide). +. Post-operative. radiation. ther. apy + Trastuzumab + Tamoxifen 20 mg/day.. 35. 6.3.1. . Pathology Report. . 1. Invasive ductal carcinoma.. . (a) Size of tumor: 1.5 cm (pT1c).. . (b) Histologic grade: 3/3 (tubule formation:. 3/3, nuclear pleomorphism: 3/3, mitotic. count: 3/3, 5/HPF).. HR(+) HER2(+) Breast Cancer. 316. . . . (c) Intraductal component: present, intratu. moral/extratumoral (10%) (nuclear grade:. high, necrosis: present, architectural pat. tern: solid/comedo, extensive intraductal. component: absent).. . (d) Skin: no involvement of tumor.. . (e) Surgical margins:. • superior margin: 10 mm,. • inferior margin: 10 mm,. • medial margin: 20 mm,. • lateral margin: 10 mm,. • deep margin: 2 mm,. • superficial margin: 2 mm.. . (f) Lymph nodes: no metastasis in seven. axillary lymph nodes (pN0) (sentinel LN:. 0/4, non-sentinel LN: 0/3).. . (g) Arteriovenous invasion: absent.. . (h) Lymphovascular invasion: absent.. . (i) Tumor border: infiltrative.. . (j) Microcalcification:. present,. tumoral/. non-tumoral.. . (k) Pathological TN category (AJCC 2017):. pT1cN0.. . 2. Intraductal papilloma with (1) myoepithelial. hyperplasia usual ductal hyperplasia.. Result. Intensity. Positive. %. Estrogen. receptor. Strong (7/8). 3. 1/3-2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Positive (3+). Ki-67. Positive in 52%. of tumor cells. S. Park et al.. 317. . F. ig. 32. . S. Park et al.. 319. a. b. . 7. | Important Radiologic. Findings. 29 30 31 32 33. 34. 6.3. | Patient History and Progress. Female/42 years old, pre-menopause.. Screen detected mass lesion on right breast 12. o’clock direction.. No family history.. Hypertension.. 6.2. |
Case 6 | HR(+) HER2(-) Breast Cancer | 6.1. . Courses of Treatment. Operation + Post-operative radiation ther. apy + Tamoxifen 20 mg/day.. 6.3.1. . Operation. Right breast conserving surgery, sentinel lymph. moral/extratumoral (60%) (nuclear grade:. low, necrosis: present, architectural pattern:. solid/comedo, extensive intraductal compo. nent: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) superior margin: 5 mm,. . (b) inferior margin: 5 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 5 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 1 mm from ductal. carcinoma in situ (slide 12).. 9. Lymphovascular. invasion:. present,. intratumoral.. . 10. Tumor border: infiltrative.. . 11. Microcalcification:. present,. tumoral/. non-tumoral.. . 12. Pathological TN category (AJCC 2017):. pT1cN1a(sn).. Result. Intensity. Positive %. Estrogen receptor. Intermediate (6/8). 2. 1/3–2/3. Progesterone receptor. Intermediate (6/8). 2. 1/3–2/3. C-erbB2. Negative (1+). Ki-67. Positive in 8% of tumor cells. HR(+) HER2(−) Breast Cancer | Important Radiologic. Findings. See Figs. 26, 27, 28 and 29.. 6.3. | Patient History and Progress. Female/51 years old, pre-menopause.. Screen detected mass lesion on right breast 2. o’clock direction.. No family history.. S/P Thyroid benign mass, excision.. 6.2. |
Case 6 | HR(−) HER2(+) Breast Cancer | Courses of Treatment. Neoadjuvant. chemotherapy. (#1. cycle. of. docetaxel and carboplatin and #6 cycles of trastu. zumab and pertuzumab) + Operation + Post-. operative radiation therapy + Trastuzumab +. Letrozole 2.5 mg.. 6.4.1. . Operation. 47. 6.4.2. . Pathology Report. . 1. No residual tumor with stromal degeneration.. . (a) Post-chemotherapy status.. a. b. . Y. Kwon et al.. 453. . (b) Lymph nodes: no metastasis in ten axil. lary lymph nodes (ypN0) (sentinel LN:. 0/3, axillary LN: 0/7).. . 2. Atypical ductal hyperplasia, focal with. microcalcification.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 2. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 22% of. tumor cells. 7. | Important Radiologic. Findings. 41 42. 43. HR(−) HER2(+) Breast Cancer. . Y. Kwon et al.. 451. 6.3. . After Neoadjuvant. Chemotherapy. 44 45. . HR(−) HER2(+) Breast Cancer. 452. 6.4. | S/P. cholecystectomy,. hypertension,. dyslipidemia.. BRCA 1 and 2 mutation: Not detected.. 6.2. |
Case 6 | HR(−) HER2(−) Breast Cancer | 6.1. . Courses of Treatment. Neoadjuvant chemotherapy (#4 cycles of. doxorubicin and cyclophosphamide + #4. cycles of docetaxel) + Operation + Post-. operative radiation therapy + Letrozole. 2.5 mg + Adjuvant capecitabine.. 6.3.1. . Operation. 43. . E. S. Lee et al.. 597. . 6.3.2. . Pathology Report. Ductal Carcinoma In Situ associated with. fibroadenoma. 1. Post-chemotherapy status.. 2. Size of tumor: 3.0 cm and 2.2 cm (ypTis).. 3. Nuclear grade: high.. 4. Necrosis: present.. 5. Architectural pattern: cribriform/comedo.. 6. Nipple: involvement of lactiferous duct.. 7. Skin: no involvement of tumor.. 8. Surgical margins:. . (a) Superior margin: 80 mm.. . (b) Inferior margin: 80 mm.. . (c) Medial margin: 60 mm.. . (d) Lateral margin: 40 mm.. . (e) Deep margin: 3 mm.. . (f) Superficial margin: 10 mm.. 9. Lymph nodes:. . (a) Metastasis in three out of five axillary lymph. nodes (ypN1a(sn)) (axillary LN: 3/5),. . (b) Perinodal extension: present,. . (c) Size of metastatic carcinoma: 4 mm.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. ypTisN1a(sn).. Result. Intensity. Positive. %. Estrogen. receptor. Negative (2/8). 1. <1%. Progesterone. receptor. Negative (2/8). 1. 0. C-erbB2. Negative. (1+)-metastasis. Equivocal (2+)-in. situ. Ki-67. Positive in 46%. of tumor cells. 7. | Important Radiologic. Findings. 36 37 38. 39. . HR(−) HER2(−) Breast Cancer. 594. . . . E. S. Lee et al.. 595. . . . . 6.2.1. . After Neoadjuvant. Chemotherapy. 40 41. 42. HR(−) HER2(−) Breast Cancer. 596. 6.3. | Patient History and Progress. Female/49 years old, pre-menopause.. Self-detected palpable mass lesion on left. breast.. No family history.. Panic disorder, lumbar spine disc.. 6.2. |
Case 6 | Local Recurrence | 6.1. . Courses of Treatment. Both breasts IDC→ Operation → Adjuvant. therapy → Left breast recurrence (IDC).. 6.2.1. . Primary Treatment. 38 39 40 41 42. 43. Operation. . 44. 45. Local Recurrence. 732. . . . . . . . Pathology Report. <Right>. Invasive Ductal Carcinoma. 1. Size of tumor: 1.2 cm (pT1c).. 2. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. Y. Kim et al.. 733. a. b. . 3. Intraductal component: present, intratu. moral/extratumoral (40%) (nuclear grade:. low, necrosis: present, architectural pattern:. micropapillary, cribriform, and comedo,. extensive intraductal component: present).. 4. Skin: no involvement of tumor.. 5. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 4 mm from ductal carci. noma in situ (slide 2).. . (c) Medial margin: 10 mm.. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. 6. Lymph nodes: no metastasis in 2 axillary. lymph nodes (pN0) (sentinel LN: 0/2).. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1cN0(sn).. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 20%. of tumor cells. <Left>. Invasive Ductal Carcinoma. 1. Size of invasive carcinoma: 0.3 cm (pT1a).. 2. Size of intraductal carcinoma: 3.0 cm.. 3. Histologic grade: 1/3 (tubule formation: 2/3,. nuclear pleomorphism: 1/3, mitotic count:. 1/3, 5/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (90%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary and cribriform, extensive intra. ductal component: present).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 20 mm.. . (b) Inferior margin: 15 mm.. . (c) Medial margin: Positive for ductal carci. noma in situ (Fro 3).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. 7. Vascular invasion: absent.. 8. Lymphatic invasion: present, intratumoral.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathologic stage (AJCC 2010): pT1a.. Result. Intensity. Positive %. Estrogen. receptor. Strong (7/7). 3. >2/3. Progesterone. receptor. Strong (7/7). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in 5%. of tumor cells. Operation. 46. Local Recurrence. 734. . . . . Pathology Report. No residual tumor with foreign body reaction.. . 1. Post-lumpectomy status.. . 2. No metastasis in 1 lymph node (pN0(sn)) (left. sentinel LN: 0/1).. Adjuvant Therapy. Postoperative radiation therapy.. Tamoxifen 20 mg/day for 5 years.. 6.2.2. . Treatments After Recurrence. 47 48. 49. Operation. . 50. Pathology Report. Invasive Ductal Carcinoma associated with. papillary carcinoma in situ. 1. Post-lumpectomy status.. 2. Size of tumor: 0.6 cm (rpT1b).. 3. Histologic grade: 2/3 (tubule formation: 3/3,. nuclear pleomorphism: 2/3, mitotic count:. 1/3, 6/10HPF).. 4. Intraductal component: present, intratu. moral/extratumoral (30%) (nuclear grade:. low, necrosis: absent, architectural pattern:. papillary/cribriform, extensive intraductal. component: absent).. 5. Skin: no involvement of tumor.. 6. Surgical margins:. . (a) Superior margin: 5 mm.. . (b) Inferior margin: 10 mm.. Y. Kim et al.. 735. a. b. . . (c) Medial margin: (see note 2).. . (d) Lateral margin: 10 mm.. . (e) Deep margin: 2 mm.. . (f) Superficial margin: 2 mm.. 7. Arteriovenous invasion: absent.. 8. Lymphovascular invasion: absent.. 9. Tumor border: infiltrative.. . 10. Microcalcification:. present,. tumoral/. non-tumoral.. . 11. Pathological TN category (AJCC 2017):. rpT1b.. Note: 1. Invasive ductal carcinoma is present. only in the permanent section of Fro 4.. 2. The medial margin of the lumpectomy. specimen (slide 9) is close to invasive ductal car. cinoma (1 mm), but this margin submitted for. frozen diagnosis (Fro 3) is free of tumor.. Result. Intensity Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. 1/3–2/3. C-erbB2. Negative. (1+) (IDC). Equivocal. (2+) (DCIS). Ki-67. Positive in 1%. of tumor cells. Operation. Second Operation (Apr. 2022) Left sentinel. lymph node biopsy.. Pathology Report. No metastasis in two axillary lymph nodes (sen. tinel LN: 0/1, non-sentinel LN: 0/1).. . 1. Post-lumpectomy status.. Adjuvant Therapy. Letrozole 2.5 mg/day for 5 years.. 7. | null | Patient History and Progress. Female/60 years old, post-menopause.. Bloody nipple discharge on left breast.. Screen detected mass lesion on right breast 6. o’clock direction and left breast 12 o’clock. direction.. No family history.. Hypertension.. 6.2. |
Case 6 | Metastatic Breast Cancer | Courses of Treatment. Right breast cancer → Neoadjuvant chemother. apy → Operation → Adjuvant therapy →. Ipsilateral breast and chest wall recurrence →. Palliative therapy → Progression on the skin. and contralateral axillary lymph nodes.. 6.2.1. . Primary Treatment. Aug. 2017 breast, left, needle biopsy:. Invasive ductal carcinoma, histologic grade 2.. Result. Intensity. Positive %. Estrogen. receptor. Negative (0/8). 0. 0. Progesterone. receptor. Negative (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 35% of tumor. cells. Clinical stage: cT3N1M0.. See Figs. 20 and 21.. Neoadjuvant Chemotherapy. Neoadjuvant chemotherapy #6 cycles (Docetaxel. & Carboplatin & Trastuzumab & Pertuzumab).. Operation. Jan. 2018 Right breast conserving surgery, senti. nel lymph node biopsy.. Pathology: Invasive ductal carcinoma, stage. ypT1aN1mi (sn).. Size of tumor: 0.2 cm, lymph node: 1/1, size. of metastatic carcinoma: 2 mm.. Result. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive (3+). Ki-67. Positive in. 21% of. tumor cells. Adjuvant Therapy. Post-operative radiation therapy + Trastuzumab. for 1 year.. 6.2.2. . Treatments After Recurrence. Ipsilateral breast and chest wall recurrence →. Progression on the skin and contralateral axillary. lymph nodes.. Intensity. Positive %. Estrogen. receptor. Negative. (0/8). 0. 0. Progesterone. receptor. Negative. (0/8). 0. 0. C-erbB2. Positive. (3+). Ki-67. Positive in. 40% of. tumor cells. Palliative Therapy. Clinical trial enrolled (ZW25 #20 cycles +. Docetaxel #6 cycles): Progressive disease on. skin, axillary lymph node.. → Docetaxel & Trastuzumab & Pertuzumab. #6: Progressive disease.. → Trastuzumab emtansine ~ | null | 6.2. |
Case 7 | Benign and Proliferative | 7.1. . Courses of Treatment. →2021-10-29 Rt upper, stereotactic biopsy.. 7.3.1. . Pathology Report. Diagnosis. • Breast, right upper, stereotactic biopsy:. –. – Atypical ductal hyperplasia (#1. Ca++). with microcalcification.. –. – Flat epithelial atypia (#2. no Ca++) with. microcalcification.. →2021-11-26 excision, Rt.. Diagnosis. • Breast, right, excision:. –. – Atypical. ductal. hyperplasia. with. microcalcification.. Post-stereotactic biopsy status.. C. W. Lee et al.. 25. . 8. | Important Radiologic. Findings. 11. 7.3. | Patient History and Progress. Female/58 years old, post-menopause.. Screen detected microcalcification on upper. portion of right breast.. No family history.. No comorbidities.. 7.2. |
Case 7 | Carcinoma In Situ | 7.1. . Courses of Treatment. Operation + Postoperative radiation therapy +. Tamoxifen 20 mg/day for 5 years.. 7.3.1. . Operation. 32. 33. 7.3.2. . Pathology Report. Ductal carcinoma in situ. . 1. Post-mammotome excision status.. . 2. Size of tumor: 0.3 cm, residual.. . . . Carcinoma In Situ. 68. . 3. Nuclear grade: low.. . 4. Necrosis: absent.. . 5. Architectural pattern: papillary/cribriform.. . 6. Skin: no involvement of tumor.. . 7. Surgical margins:. . (a) superior margin: 10 mm,. . (b) inferior margin: 10 mm,. . (c) medial margin: 5 mm,. . (d) lateral margin: 15 mm,. . (e) deep margin: 2 mm,. . (f) superficial margin: 2 mm.. . 8. Lymph nodes: no metastasis in one axillary. lymph node (pN0(sn)) (sentinel LN: 0/1).. . 9. Microcalcification:. present,. tumoral/. non-tumoral.. Result. Intensity. Positive %. Estrogen. receptor. Strong (8/8). 3. >2/3. Progesterone. receptor. Strong (8/8). 3. >2/3. C-erbB2. Negative (1+). Ki-67. Positive in. <1% of. tumor cells. 8. | Important Radiologic. Findings. 30. 31. E. S. Lee et al.. 67. 7.3. | Patient History and Progress. Female/48 years old, pre-menopause.. Screen detected mass lesion on right breast 1. and 9 o’clock direction.. Outside result of mammotome excision:. Right breast 1 o’clock, DCIS.. Right breast 9 o’clock, intraductal papilloma. with atypical ductal hyperplasia.. No family history.. No comorbidities.. 7.2. |
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