tommyk
05-20-2006, 11:44 AM
Now you encounter a 60-year-old woman with a 5-cm, hard mass under the nipple and areola of her rather small left breast. The mass occupies most of the breast, but the breast is freely movable from the chest wall. There is no dimpling or ulceration of the skin over the mass, and careful palpation of the axilla is completely negative. A core biopsy of the breast mass has established a diagnosis of infiltrating ductal carcinoma, and the mammogram showed no other lesions in that breast or the other one. A chest x-ray film and liver function tests are normal. She has no symptoms suggestive of brain or bone metastasis. What is the best USMLE Step 1 answer choice?
1- Lumpectomy only
2- Lumpectomy with axillary sampling and post-op radiation
3- Fine need aspiration
4- A handshake and a return visit in 6 months
5- Ask the pt to monitor and see if the tumor becomes immovable.
6- Total mastectomy
7- Modified radical mastectomy, w/ a sample of axilla tissue
8- Radical mastectomy (including complete axillary dissection)
9- Start chemotherapy right away
Ans) #7. The mass is too large, in a breast that is too small, to allow an adequate lumpectomy. Local control of the tumor requires mastectomy. However, mastectomy alone is not sufficient. We need to know what is happening in the axilla to make a decision regarding postoperative systemic therapy. The physical examination was negative, but the reliability of that finding is not much better than flipping a coin. Lumpectomy alone cannot be done here, and it would not be the appropriate management even if the cancer had been smaller. Lumpectomy, axillary sampling, and post-op radiation would have been the correct answer for a smaller tumor in a larger breast. Total mastectomy alone would have been a wise palliative choice if she had had evidence of distant metastasis. She does not. We have to go for cure. We need the standard potentially curative operation: modified radical mastectomy, which includes axillary sampling. Same explanation goes true for chemotherapy. Radical mastectomy is no longer used for the treatment of breast cancer. It offers no survival advantage over the less mutilating modified radical, plus, you are psychologically damaging the women. Is THAT worth it? That would be like chopping off my nuts…
1- Lumpectomy only
2- Lumpectomy with axillary sampling and post-op radiation
3- Fine need aspiration
4- A handshake and a return visit in 6 months
5- Ask the pt to monitor and see if the tumor becomes immovable.
6- Total mastectomy
7- Modified radical mastectomy, w/ a sample of axilla tissue
8- Radical mastectomy (including complete axillary dissection)
9- Start chemotherapy right away
Ans) #7. The mass is too large, in a breast that is too small, to allow an adequate lumpectomy. Local control of the tumor requires mastectomy. However, mastectomy alone is not sufficient. We need to know what is happening in the axilla to make a decision regarding postoperative systemic therapy. The physical examination was negative, but the reliability of that finding is not much better than flipping a coin. Lumpectomy alone cannot be done here, and it would not be the appropriate management even if the cancer had been smaller. Lumpectomy, axillary sampling, and post-op radiation would have been the correct answer for a smaller tumor in a larger breast. Total mastectomy alone would have been a wise palliative choice if she had had evidence of distant metastasis. She does not. We have to go for cure. We need the standard potentially curative operation: modified radical mastectomy, which includes axillary sampling. Same explanation goes true for chemotherapy. Radical mastectomy is no longer used for the treatment of breast cancer. It offers no survival advantage over the less mutilating modified radical, plus, you are psychologically damaging the women. Is THAT worth it? That would be like chopping off my nuts…