Medical therapy for breast cancer can be divided into 3 categories: chemoprevention, neo-adjuvant, and adjuvant therapy. Ductal excision: Ductal excision may be indicated for suggestive nipple discharge without an associated palpable or radiographic lesion. Bloody discharge and spontaneous clear discharge from a single duct are findings with an increased risk of malignancy. Ductal excision can be performed using a small (4.0) lacrimal duct probe to localize the draining duct. A cone-shaped sample of tissue then should be excised around the probe. The most common histologic findings in this setting are intraductal papilloma or ductal ectasia (approximately 80%). Most of the remaining lesions demonstrate intraductal or infiltrating carcinoma.
Excisional biopsy or lumpectomy: This should be performed for palpable lesions with suggestive or malignant findings on needle biopsy. Benign or inconclusive findings on needle biopsy also may prompt excisional biopsy in the presence of high clinical suspicion (eg, large mass fixed to the chest wall, atypical epithelial hyperplasia)
Lumpectomy or wide local excision: Most often performed along with some form of lymph node dissection as part of a breast conservation procedure, lumpectomy involves excision of a palpable malignant breast lesion with adequate margins. In the case of nonpalpable lesions, a needle-localization procedure may precede lumpectomy. This is performed with ultrasonographic or mammographic assistance for nonpalpable, radiographically identified lesions. Following placement of a fine J wire under radiographic guidance, the lesion can be excised surgically. Care must be taken to obtain a solid core of breast tissue around the tip of the wire with margins of at least 1 cm. The specimen should be reevaluated radiographically to confirm excision of the intended lesion prior to completion of the operation.
Quadrantectomy:
Sentinel lymph node biopsy (SLNB): The sentinel lymph nodes (SLN) are the first nodes that receive drainage from tumors. The technique involves injecting radiocolloid, blue dye, or both in the tissues of the breast. Several techniques of injection are available, including subareolar, peritumoral, intradermal, or intraparenchymal. After injection, an incision is made with consideration of the potential need for subsequent completion lymph node dissection (see next paragraph). Therefore, the incision can be elongated easily if the SLN is positive for metastasis.
Completion Lymph Node Dissection (CLND): If an SLN is found to be positive on histologic evaluation, a CLND is indicated to assess the degree of lymph node involvement. This can have a significant impact on staging as well as adjuvant treatment.
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