There are three components of the treatment of breast cancer: (1) local treatment of the cancer in the breast, (2) treatment of the loco-regional draining nodes, principally in the axilla, and (3) systemic treatments to eradicate any disease which may be present outwith the breast and loco-regional nodal basins (Figures 9.1, 9.2). Breast cancer is uncommon in men and may present at a more advanced stage because of a smaller volume of breast tissue; however, the principles of management are the same in women and men.
Mammograms of a male patient showing an irregular opacity on the left due to a breast cancer.
A locally advanced male breast cancer.
Initial treatment of the primary breast tumour in an individual with early or operable breast cancer is usually surgical (Figures 9.3,9.4,9.5,9.6). Some patients with locally advanced breast disease and most with cancers involving underlying muscle are suitable for a primary surgical approach, as long as other features such as inflammatory changes or distant metastatic disease are not present. The primary surgical options for management of the breast are mastectomy and breast conservation. Breast conservation therapy consists of excision of the tumour with a 1 cm macroscopic margin of normal tissue (wide local excision) plus breast radiotherapy. Controversy has surrounded how much extra tissue should be removed and what constitutes an involved or positive margin. Current evidence suggests that microscopic margins of 1 mm or more are adequate and that increasingly wide margins will not reduce local recurrence rates but will adversely affect cosmetic outcomes. Local recurrence rates should be less than 1% per annum following wide excision and radiotherapy.
A: Specimen X-ray showing orientation clips and central tumour shadow; B: wide local excision specimen with corresponding central tumour; C: centre slice cut up showing block selection. Arrow points to tumour area.
Well healed scar following breast conservation therapy with wide excision of the breast cancer and radiotherapy.
Specimen X-ray showing satisfactory margins following excision of a screen-detected, impalpable breast cancer. The lesion has been localized using a hooked wire and the specimen has been orientated using clips.
DCIS (arrow) extending close to the inked margin in a wide local excision specimen. H&E, original magnification x4.