I just wanted to mention ductal carcinoma in situ. This is a very controversial area in terms of management. The choices, I think, are mainly mastectomy with no axillary dissection. This is only in those cases where there is no invasive disease noted versus a lumpectomy and radiation versus a lumpectomy with no other therapy. There’s a randomized trial really looking at these three various options and the lumpectomy alone had an increased incidence of local recurrence. There are certainly places like Van Nuys, California and other places who are doing very careful pathology, requiring larger margins and with smaller tumors are able to do lumpectomy alone. I think you really have to recreate some of those pathologic techniques and surgical techniques to get those kind of results and so I would not probably apply a lumpectomy alone to all patients who have ductal carcinoma in situ.

Lobular carcinoma in situ I look at as just a marker for risk not much unlike family history or other risk factors and I think that diagnosis warrants closer surveillance. Only in those patients who have other high risk or have breasts that are really very difficult for surveillance, don’t mammogram well, are too dense for accurate mammography or ultrasound doesn’t work or whatever, they have lots of lumps and bumps, would I consider bilateral mastectomy.

Let’s talk a little bit about the approach to patients who have been diagnosed with invasive carcinoma, ductal carcinoma, medullary carcinoma, lobular carcinoma. Really the approach is the same. The two approaches to local control are either a modified radical mastectomy or a lumpectomy with radiation and an axillary sampling or dissection.

A caveat to that has been the sentinel node dissection. Usually a patient with a smaller tumor and a tumor that has been diagnosed by needle aspirate or biopsy but not been excised you can put dye or technetium or something into the tumor bed, trace it to the first axillary node, dissect that and in the appropriately selected patients, that should be 95% predictive as to what the axillary status is. So if it’s negative in the axillary nodes, it’s 95% that the rest of the nodes will be negative also and further dissection is not necessary. If it’s positive, there’s about a 3% chance that the rest of the next axillary nodes will be negative but it requires them to go and dissect the node if it’s positive.

This is a look at mastectomy versus lumpectomy radiation and axillary dissection. This is at eight year followup. The earliest publication with followup is now at 20 years. Similar studies have reproduced these exact results in Europe and it really shows that there’s no difference in overall survival in patients treated with these two different local options. The deal is that this is really an option for the woman in terms of how she wants to approach this and it shouldn’t make a difference in overall outcome.

There are a few reasons not to do a lumpectomy and radiation. If you’ve got a very large tumor in a small breast, you’re not going to get a very good cosmetic result and it probably isn’t the right thing to do. If there’s a multifocal tumor throughout the breast, doing lumpectomy is not really feasible. If the breast is very dense, a lot of other pathology in the breast, it may be that that won’t lend to good surveillance in the future of that radiated breast which will increase the fibrosis and density and perhaps mastectomy is the best thing to do. Very rarely there will be patients with such severe underlying heart disease or lung disease that you won’t think they can tolerate the radiation but that’s very rare.

If the patient does choose for mastectomy, it certainly should be discussed with the patient’s various reconstruction options. Most of this reconstruction is getting done at the time of initial surgery if the patient doesn’t appear to have advanced local disease.

Just to talk about staging a little bit because really everything we do is based on the predictive value of the staging and a few other predictive features. Staging is based on the tumor node and metastasis system. The tumor is divided between T1 through T4. A T1 lesion is less than 2 cm, T2 between 2 and 5 cm, T3 more than 5 cm and a T4 lesion is a lesion that extends into the muscle or into the skin. It also includes inflammatory breast cancer – breast cancer that presents as a red inflamed breast, has an erysipeloid kind of appearance and if you biopsy that, often their dermal lymphatics will show tumor cells within them.