Skill Checkup: A Menopausal Woman With a Lump in Her Right Breast

Pavani Chalasani, MD, MPH

Disclosures

January 18, 2022

Lumpectomy usually includes a sentinel lymph node dissection to identify and examine the first lymph node to which a breast mass may have spread. When that lymph node is found to contain cancer cells, surgery will usually expand to include an axillary lymph node dissection to identify additional nodes positive for tumor cells. In the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology—Breast Cancer, algorithms for patients with four or fewer lymph nodes differ from those with more than four positive nodes because of the long-recognized association of positive lymph nodes and higher risk for disease recurrence. Research indicates that the ratio of positive lymph nodes as a proportion of the total number of nodes examined is also important.

In contrast to the number of positive lymph nodes, which is one of the ways that risk for disease recurrence is calculated, a diagnosis of infiltrating ductal carcinoma refers only to the anatomical location of the milk duct cells in which the cancer arose. Neither the designation as a ductal carcinoma nor the location of the tumor in the upper right quadrant of the breast provides any information about level of risk.

One of the risks of lumpectomy vs mastectomy is the potential need for re-excision. In terms of survival, the two surgeries are associated with comparable outcomes. However, if ink-negative margins are not achieved with lumpectomy, an evaluation may be required to determine whether additional surgery is required. However, ink-negative margins do not shed light on disease recurrence risk.

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