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TREATMENT varies on trimester
Surgical: mastectomy or breast conservation: mastectomy preferred due to limitations of radiation during pregnancy.
Sentinel lymph node biopsy: safe to use with lymphoscintigraphy
Chemotherapy: appropriate in 2nd and 3rd trimesters, trastuzumab contraindicated
RT: Avoid until after delivery.
INPATIENT CONSIDERATIONS
Discharge Criteria
Postmastectomy
- Complications: seroma, phantom breast syndrome, cellulitis, chest wall/axilla/arm pain, long thoracic nerve damage leading to winged scapula sign
- Lymphedema; avoid having BP taken on side of surgery
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Every 4 to 6 months for 5 years, then annually
- No evidence to support the use of routine CBC, LFTs, "tumor markers", bone scan, CXR, liver ultrasound, CT scans, MRI, PET
- Mammogram/imaging 1 year after initial mammogram but 6 to 12 months postradiation, then annually
- Annual gynecologic exam for women on tamoxifen; bone mineral density at baseline and follow-up for women on aromatase inhibitors or with ovarian failure secondary to treatment
PROGNOSIS (5)
View LargeStage5-year Relative Survival Rate0100%I100%II93%III72%IV22%
COMPLICATIONS
- Hypercalcemia, metastatic disease, lymphedema
- Emotional issues(depression, body-image alteration)
REFERENCES
11 American Cancer Society. Breast Cancer Facts & Figures 2015-2016. Atlanta, GA: American Cancer Society; 2015. http://www.cancer.org.22 National Comprehensive Cancer Network. NCCN Guidelines: Breast Cancer (Version 3.2015) © 2015. Breast Cancer National Comprehensive Cancer Network, Inc. http://www.nccn.org.33 U.S. Preventive Services Task Force. Breast Cancer: Screening 2009. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening?ds=1&s=breast cancer.44 Lyman GH, Barron RL, Natoli JL, et al. Systematic review of efficacy of dose-dense versus non-dose-dense chemotherapy in breast cancer, non-Hodgkin lymphoma, and non-small cell lung cancer. Crit Rev Oncol Hematol. 2012;81(3):296-308.55 American Cancer Society. Breast Cancer Survival by stage. http://www.cancer.org.
ADDITIONAL READING
Rothwell PM, Wilson M, Price JF, et al. Effect of daily aspirin on risk of cancer metastasis: a study of incident cancers during randomised controlled trials. Lancet. 2012;379(9826):1591-1601.
CODES
ICD10
- C50.919 Malignant neoplasm of unsp site of unspecified female breast
- D05.90 Unspecified type of carcinoma in situ of unspecified breast
- Z12.31 Encntr screen mammogram for malignant neoplasm of breast
- D05.80 Oth type of carcinoma in situ of unspecified breast
- C50.811 Malignant neoplasm of ovrlp sites of right female breast
- C50.612 Malignant neoplasm of axillary tail of left female breast
- C50.611 Malignant neoplasm of axillary tail of right female breast
- C50.619 Malignant neoplasm of axillary tail of unsp female breast
- C50.81 Malignant neoplasm of overlapping sites of breast, female
- C50.812 Malignant neoplasm of ovrlp sites of left female breast
- C50.819 Malignant neoplasm of ovrlp sites of unsp female breast
- C50.911 Malignant neoplasm of unsp site of right female breast
- C50.61 Malignant neoplasm of axillary tail of breast, female
- D05.00 Lobular carcinoma in situ of unspecified breast
- C50.419 Malig neoplasm of upper-outer quadrant of unsp female breast
- D05.10 Intraductal carcinoma in situ of unspecified breast
- Z12.39 Encounter for oth screening for malignant neoplasm of breast
- C50.912 Malignant neoplasm of unspecified site of left female breast
- C50.212 Malig neoplasm of upper-inner quadrant of left female breast
- C50.011 Malignant neoplasm of nipple and areola, right female breast
- C50.012 Malignant neoplasm of nipple and areola, left female breast
- C50.019 Malignant neoplasm of nipple and areola, unsp female breast
- C50.111 Malignant neoplasm of central portion of right female breast
- C50.112 Malignant neoplasm of central portion of left female breast
- C50.511 Malig neoplm of lower-outer quadrant of right female breast
- C50.211 Malig neoplm of upper-inner quadrant of right female breast
- C50.519 Malig neoplasm of lower-outer quadrant of unsp female breast
- C50.219 Malig neoplasm of upper-inner quadrant of unsp female breast
- C50.311 Malig neoplm of lower-inner quadrant of right female breast
- C50.312 Malig neoplasm of lower-inner quadrant of left female breast
- C50.411 Malig neoplm of upper-outer quadrant of right female breast
- C50.412 Malig neoplasm of upper-outer quadrant of left female breast
- C50.51 Malignant neoplasm of lower-outer quadrant of breast, female
- C50.512 Malig neoplasm of lower-outer quadrant of left female breast
- C50.119 Malignant neoplasm of central portion of unsp female breast
ICD9
- 174.9 Malignant neoplasm of breast (female), unspecified
- 233.0 Carcinoma in situ of breast
- V76.10 Breast screening, unspecified
- 174.8 Malignant neoplasm of other specified sites of female breast
- 174.2 Malignant neoplasm of upper-inner quadrant of female breast
- 174.1 Malignant neoplasm of central portion of female breast
- 174.0 Malignant neoplasm of nipple and areola of female breast
- 174.6 Malignant neoplasm of axillary tail of female breast
- 174.5 Malignant neoplasm of lower-outer quadrant of female breast
- 174.4 Malignant neoplasm of upper-outer quadrant of female breast
- 174.3 Malignant neoplasm of lower-inner quadrant of female breast
SNOMED
- 254837009 malignant tumor of breast (disorder)
- 189336000 Carcinoma in situ of breast
- 268547008 Screening for malignant neoplasm of breast
- 373176000 pTis: Ductal carcinoma in situ (breast) (finding)
- 188153009 Malignant neoplasm of lower-inner quadrant of female breast
- 403946000 Paget's disease of nipple (disorder)
- 448952004 Infiltrating duct carcinoma of female breast (disorder)
- 188156001 Malignant neoplasm of axillary tail of female breast
- 188154003 Malignant neoplasm of upper-outer quadrant of female breast
- 188152004 Malignant neoplasm of upper-inner quadrant of female breast
- 188151006 Malignant neoplasm of central part of female breast
- 188147009 Malignant neoplasm of nipple and areola of female breast
- 188155002 Malignant neoplasm of lower-outer quadrant of female breast
CLINICAL PEARLS
- BC is most common CA death in U.S. women, lifetime risk of 1 in 8.
- High alcohol use, high body mass index (BMI), and physical inactivity are modifiable risk factors.
- Pursue/refer all abnormal breast physical examination/imaging findings.
- If patient ≥30 years of age with palpable mass, obtain mammogram, if <30 years of age obtain ultrasound.
- Normal mammography does not exclude possibility of CA with a palpable mass.