Difference between a free TRAM vs. a pedicled TRAM flap

A free TRAM flap is separated from the body freeing it from the original blood vessels and re-attached to new blood vessels in the chest or axilla.

The pedicled TRAM flap derives its blood flow from the upper part of the rectus muscle and is rotated and tunneled into the chest.

Both have the transverse abdominal muscle, fat and skin transferred but the free TRAM has a stronger blood flow and could be a reasonable choice in patients with a potentially impaired blood supply such as smokers, diabetics, and obese patients.

More information regarding plastic surgery in Modesto for breast reconstruction.

Giant fibroadenoma of the Breast

Giant Fibroadenoma of the Breast

  • Rare and generally occur in women age 15-20 years old.
  • Rapid growth
  • Can exceed 5 cm
  • Observation is not recommended for some patients because the rapid growth can lead to further problems (infarction, deformities)
  • Giant Fibroadenoma should be excised also to exclude a phyllodes tumor in addition to preventing futher problems of infarction and deformities.

When is a galactogram done?

Galactogram = Ductogram

Usually done for spontaneous unilateral bloody nipple discharge.  Sometimes it is done for serous (clear) discharge.

90% of the women with unilateral bloody nipple discharge = benign intraductal papilloma, a solitary discrete intraductal mass.  However if multiple masses are discovered in the duct, the more likely the diagnosis will be ductal carcinoma in situ (DCIS).

Regardless of single mass or multiple mass, a surgical biopsy (excisional biopsy) is required for diagnosis.  Methylene blue dye can assist the surgeon in removing the duct in the OR.

Pregnancy and Breast Cancer

Pregnancy affects breast cancer risk

Pregnancy stops monthly menstrual cycles and shifts the hormone balance to progesterone instead of estrogen; thus women who become pregnant while they are young and have many pregnancies may have slightly lower risk of breast cancer later on because they are exposed to less estrogen.

Breast Cancer diagnosis while pregnant

  • Mammograms are considered fairly safe during pregnancy.
  • Breast biopsy – ie core needle biopsy can be done during pregnancy.
  • MRI without contrast can be done while pregnant.
  • Chest X-Rays can be done.

Treating Breast Cancer while Pregnant

  • Surgeries can be done; however, SLN might be limited.
  • Radiation is usually given after delivery.
  • Chemo can start in the second trimester.  Induction chemotherapy can start (ie. for tumors fixed to the skin – stage III)
  • Hormone therapy should not be used during pregnancy.


Facts about Phyllodes tumors

Phyllodes tumors of the breast:

  • Not easily distinguished from fibroadenomas on physical exam and even challenging on radiological studies
  • Rarely involve the nipple-areolar complex
  • Most are in the upper outer quadrant
  • Central phyllodes tumors may present with bloody nipple discharge or nipple retraction
  • Few have been reported in men
  • Primary goal for treatment of phyllodes tumor is to achieve a wide negative margin with a rim of at least 1 cm of uninvolved tissue.
  • Total mastectomy may be required for lesions too big to achieve a 1 cm margin without markedly deforming the breast or for repeated local recurrences


Is there a difference between BRCA 1 and BRCA 2?

BRCA are breast cancer genes

When working properly these are tumor supressors.  They protect against breast cancer.

But when they are abnormal and genetically inherited – these are called the BRCA1 and BRCA2 genetic mutations.

Both BRCA mutations (1 and 2) increase risk of breast cancer

Normally women have a 12 % lifetime risk of developing breast cancer.  Having a BRCA mutation raises the risk to 50-85% with a high likelihood for a recurrence or a second tumor. Risk is the same for BRCA1 or BRCA2

The differences are the risks of associated other cancers.

Both have the increased risk of ovarian and pancreatic cancers

BRCA1 mutations may have additional risk of these cancers

  • cervical
  • uterine
  • pancreatic
  • colon cancer

BRCA2 mutations may have additional risk of these cancers

  • pancreatic
  • stomach
  • gallbladder
  • bile duct
  • melanoma

Future research will discover more differences between BRCA1 and BRCA2.

More info about BRCA mutations and Angelina Jolie

What is T4 in Breast Cancer

Staging of Breast Cancer

T stands for primary Tumor in the staging of Breast Cancer.

A T4 tumor is a tumor of any size with direct extesion to the chest wall (a) or skin (b).

  • T4a = extension to chest wall
  • T4b = Edema or ulceration of the skin of the breast.  Includes peau d’orange look of the skin.
  • T4c = both a and b above.
  • T4d = inflammatory carcinoma

For interest here’s the other T staging designations for Breast Cancer:

  • T1 = < 2 cm
  • T2 = 2-5 cm
  • T3 = > 5 cm


Gail Model of Breast Cancer Risk Assessment

What are the 7 key risk factors for breast cancer used in the Gail Model?

  1. Age
  2. Age at first period (late is better)
  3. Age at the time of birth of first child (earlier is better)
  4. Family history of breast cancer (mother, sister or daughter)
  5. Number of past breast biopsies
  6. Number of breast biopsies showing atypical hyperplasia
  7. Ethnicity

The model calculates the risk of developing breast cancer over the next 5 years and also the risk over a lifetime.


What are the side effects of tamoxifen?

Side effects and Risks of tamoxifen

Tamoxifen acts like an anti-estrogen in some tissues and acts like estrogen in other tissues.

  • Hot flashes and night sweats
  • Cancer of the uterus (most were endometrial cancer, a few were uterine sarcoma).  The risk is not present in those patients who have had  a hysterectomy.
  • Blood clots (DVT, PE, and stroke)

Tamoxifen is contraindicated in patients who continue to smoke due to the increased risk of thromboembolic disease.

How is Digital Mammograms different from film mammograms?

Breast cancer is the second most common cancer in women in the US second only to skin cancer.

Regarding the different types of mammograms (digital vs. film) overall diagnostic accuracy for breast cancer screening was similar but digital mammo was more accurate in women under 50 – more radiographically dense breasts

Benefits of Digital Mammograms over Film mammograms

  • Lower average radiation dose.  They use 25% less radiation than film mammograms because smaller areas of the breast are imaged in each view.
  • More accurate readings in patients under 50 and those with radiographically dense breasts.

Drawbacks of Digital Mammograms

Costs more

What is a normal white blood cell count

Normal WBC (White blood cells)

Normal WBC ranges from 3.5-10.5 billion cells/L or cells per mm2

Thus anything above 11 could be considered elevated.  But there are levels considered such as mildly elevated or severely elevated.

Other normal values for part of the CBC (complete blood count)

Normal value for hematocrit

Hct = 35-50%

Normal Value for platelet count

Platelets = 150-450 billion/L

What are the different types of Breast Cancer?

Different Types of Breast Cancer

Non-invasive Breast Cancer

  • Ductal Carcinoma In Situ (DCIS) – preinvasive
  • Lobular Carcinoma In Situ

Invasive Breast Cancer

  • Invasive Ductal Carcinoma = Infiltrating Ductal Carcinoma – Most common breast cancer accounting for 50-75% of all breast cancers.
  • Invasive Lobular Carcinoma
  • Tubular Carcinoma
  • Mucinous (colloid) Carcinoma
  • Papillary Carcinoma
  • Medullary Carcinoma

Special forms of Breast Cancer

  • Inflammatory Breast Cancer (IBC)
  • Pagets disease of the Breast – those who present with a mass at time of diagnosis most often have more advanced breast cancer.
  • Metaplastic Breast Cancer

Source: http://ww5.komen.org/breastcancer/typesoftumors.html


What is Perjeta, a breast cancer drug?

Perjeta is Pertuzumab

Perjeta is Pertuzumab

  • It is a targeted therapy to be used before surgery and in combination with other HER2 postive breast cancer drugs such as Herceptin (trastuzumab).
  • Perjeta has a different way of working than the other HER2 positive breast cancer medications.
  • Pertuzumab is a monoclonal antibody (like trastuzumab). The first of its class in a line of agents called “HER dimerization inhibitors.”
  • Both Perjeta and Herceptin target HER2 but work in complementary ways.  The combination may increase the death of cancer cells.
  • Perjeta is contraindicated in pregnancy.
  • FDA approved for Genentech (makers of Herceptin, too) on September 12, 2013.
  • Before surgery usage is called neoadjuvant or now called primary systemic therapy.

What is Trastuzumab – a breast cancer drug?


Herceptin is Trastuzumab for breast cancer

  • Trastuzumab has a trade name of Herceptin.
  • It is a monoconal antibody that interferes with the HER2/neu receptor.
  • Her proteins stimulate cell proliferation.  In certain types of breast cancers, HER2 is over expressed and causes the cancer cell to reproduce uncontrollably.
  • Trastuzumab is associated with cardiac dysfunction in 2-7% of cases.  Regular cardiac screening with an echocardiogram or MUGA scan is commonly undertaken during the trastuzumab treatment duration.
  • Optimal treatment duration of Herceptin isn’t known but one year of treatment is generally accepted as the optimum length of therapy based on clinical trials.
  • FDA approval was received in 1998 by Genentech with UCLA.

HER2 positive breast cancers vs. HER-2 negative

HER2 positive breast cancers have a worse prognosis.  HER2 positive breast cancers are likely to have high proliferative rate, positive axillary lymph nodes, and decreased expression extrogen and progesterone receptors.

Of invasive breast cancers what percentage are HER2 positive?

15-20% of invasive breast cancers are HER2 positive.

What is BI-RADS in Breast Imaging?


  • BIRADS stands for breast imaging reporting and data systems.  It was created to standardize mammographic results.
  • Biopsy is not required for BI-RADS 1,2, and 3.
  • BI-RADS 0 indicates technical concerns.
  • Proceeding to biopsy without additional imaging is strongly indicated for BI-RADS 4 or 5.
  • Family history is not a part of the breast imaging reporting and data (BIRADS).


  • If a BI-RADS 4 lesion ends up being benign, it is most likely a fibrocystic process (rather than a fibroadenoma – which occurs more likely in BI-RADS 3 patients.
  • The frequency of carcinoma is 25-30% in BI-RADS 4 lesions associated with a mass.
  • Ductal carcinoma (DCIS) is the most common malignancy with BI-RADS 4 patients, then next common is invasive ductal carcinoma.  This order is reversed in BI-RADS 5 patients.
  • No additional imaging needed.

Invasive vs Noninvasive breast cancer

Some thoughts about the differences between Invasive and non-invasive breast cancer.

Invasive Breast Cancer

Invasive breast cancer is sometimes called infiltrating.  The cancers spread outside the membrances that lines the duct or lobule; thus can travel to other parts of the body.  Stage I, II, III, or IV breast cancer is invasive breast cancer.

Non-invasive is also called in-situ.

The cancer cells have remained within their place of origin.  DCIS (Ductal Carcinoma In-Situ) is considered a precancerous lesion.  LCIS (Lobular Carcinoma In-Situ) isn’t considered precancerous because it won’t eventually evolve itself into a invasive cancer; however, it doesn increase the risk of cancer in both breasts.  Thus LCIS can be considered a marker for increased breast cancer risk.

What is the most common type of Breast Cancer?

What is the most common Breast Cancer?

Ductal Carcinoma is the most common type of breast cancer.  There are two types:  Ductal Carcinoma In Situ (DCIS)which is considered a pre-malignancy of the breast and there is Invasive Ductal Carcinoma of the breast.

The ducts refer to milk ducts.  This type of cancer comes from the lining of a milk duct within the breast.  These ducts carry milk from the lobules where the milk is made.