This 53 year old postmenopausal lady presented with 4 cm diameter breast lump superior to the nipple.
It was firm and irregular. It was not fixed to the skin or muscles and there was no evidence of axillary
lymphadenopathy. On clinical assessment it appeared to be a carcinoma (P5). Mammography was
performed and this showed a spiculated mass consist with a carcinoma (R5). Fine needle aspiration cytology
showed irregular, pleomorphic cells diagnostic of a carcinoma (C5). All aspects of the triple assessment
were in agreement, the diagnosis was discussed with the patient and treatment planned.
Several studied have shown that the local recurrence rate, disease-free and overall survival rates are
similar when breast tumours are excised with either breast conserving surgery (usually wide local excision) or
mastectomy. Breast conserving surgery does however need to be followed by breast radiotherapy. Not
all tumours are however suitable for breast conserving surgery. This lady had a large tumour in relation
to the size of the breast. In view of its central location mastectomy was advised. She underwent a
mastectomy and level III axillary clearance. All women with invasive breast cancer require axillary
surgery. This is needed to stage the disease to provide important prognostic information. Depending
on the extent of the surgery the procedure may also be considered therapeutic if the lymph nodes are
subsequently shown to contain metastatic tumour. The axilla can be adequately staged by a four-node
axillary sampling procedure. The role of sentinel node biopsy in stageing the axilla is currently the
subject of ongoing trials . A level III axillary clearance would be considered both a staging and
therapeutic procedure. Except for a wound seroma she made an uncomplicated recovery from her
operation. On histological assessment the tumour was shown to be a 4 cm in diameter, poorly differentiated
(grade 3) with evidence of lymphovascular invasion. The tumour was oestrogen receptor negative and 5 out
of 10 axillary nodes contained metastatic tumour.
All women with invasive breast cancer, both pre- and postmenopausal, should be started on tamoxifen on
completion of there other adjuvant therapies. This anti-oestrogen has been shown to reduced the risk of
local recurrence, improve survival and reduce the risk of developing contralateral breast cancer even in
patients who have oestrogen receptor negative tumours. The drug is well tolerated by most women and it has
few side effects - hot flushes are the most troublesome. With a large, high grade node-positive tumour
with evidence of lymphovascular invasion the patient is at increased risk of local recurrence.
Consideration should be given to radiotherapy to the mastectomy skin flaps. Having had a level III
axillary clearance she does not require axillary radiotherapy. Axillary radiotherapy after a full axillary
clearance is associated with an unacceptable rate of arm lymphoedema. Despite being postmenopausal, in
view of her age and node-positive status she should be offered chemotherapy. In the United Kingdom, the
most likely regimen that she would received in cyclophosphamide, methotrexate and 5-flurourocil given at monthly
intervals for 6 months. She underwent both adjuvant radiotherapy and chemotherapy.
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surgery in the management of breast cancer. Curr Pract Surg 1996; 8: 17 - 21.