Main Glossary       Alphabetized List of Topics

Breast cancer: A cancer from the glandular portion of the breast. In addition to the glandular breast tissue, the breast is formed by the skin and a layer fat under the skin (subcutaneous fat) that is superficial to the glandular breast tissue. Although breast cancer starts from the glandular breast tissue, it may spread and invade the subcutaneous fat layer below the skin. The skin is less commonly invaded and typically occurs in more advanced breast cancers. Although breast cancer can invade adjacent tissues, spreading or metastasis to other parts of the body can occur through the blood stream. Another way that breast cancer can spread is through the lymphatic circulation. Small lymph vessels within the breast drain either to axillary (underarm) lymph nodes or to lymph nodes under the sternum (breast bone). The axillary nodes drain the majority of the breast with the exception of the inner aspect of the breast which also drains to the sternal lymph nodes. Typically, breast cancer cells will spread lymphatically to the axillary nodes for tumors located in the lower (inferior), outer (lateral) and upper (superior) portions of the breast. Tumors of the inner (medial) portion of the breast will spread lymphatically to both sternal and axillary lymph nodes. The main risk of breast cancer comes from its potential to spread to other parts of the body. This process of spread through the blood stream is called systemic metastasis. The risk is reduced by effectively treating the disease locally (within the breast) and systemically (other parts of the body). Effective eradication (removal) of cancer within the breast is important because the initial tumor (or any future recurrence) within the breast will be a continuing source of breast cancer cells that will spread through the blood stream to other parts of the body. Systemic treatment with chemotherapy is important because small nests of cells may already be in transit from the breast to other parts of the body. Systemic spread is likely in large high risk cancers which have positive lymph nodes or in cancers that recur because they are inadequately treated. Initial effective treatment is extremely important if the patient is to be cured of her disease. There are different cell types of cancer which are important to understand. Ductal cancer (or intraductal cancer) originates from the milk duct and lobular cancer originates from the gland portion that produces the milk.

Diagnosis: The identification of a disease. This identification process may involve Physical diagnosis in which a physician (or a patient) detects an abnormal physical change in the body. Detection is performed by the senses of the observer i.e., by vision, by hearing or by feeling. For example, a breast lump is felt. Diagnosis is also facilitated but not established with a breast x-ray (mammogram). Patients should be aware that mammograms will not detect breast cancer in a  significant percentage of patients. For most palpable breast lumps that do not disappear over time, the presence (or absence) of breast cancer must be established with microscopic examination of tissue that is obtained form a  breast biopsy.

Breast self examination: The physical examination of both breasts on a routine monthly schedule. The woman palpates or feels for lumps in her own breasts. The best time for BSE is 2 days after the woman's menstrual period.

Palpation: The physical examination of the breasts is performed by manually feeling for breast lumps.

Palpable breast mass: A breast lump that is felt by the patient or by her physician. Palpable breast masses that are smooth and loosely attached to the overlying soft tissue are usually benign ( non cancerous). Irregular breast masses that are tightly attached are more indicative of a malignant tumor that is invading (and attaching) into the normal adjacent tissue.

Non palpable breast mass: A breast mass that cannot be felt (by palpation). Instead, the breast mass or tumor that is detected by another diagnostic means other than palpation. Typically, the non-palpable breast mass is detected at an earlier stage by mammography (X-ray) or sonography (Ultrasound). Usually, the small breast mass is detected as an area of calcification or distortion of the glandular tissue before it becomes palpable. Early diagnosis is the main advantage of mammography when tumors distort the breast tissue before they become palpable. However, some tumors do not distort the breast tissue at an early stage which may lead to a false sense of security. See Mammogram, False Negative and Lobular breast cancer. A surgical biopsy of a non-palpable breast mass will require a J wire localization because the mass cannot be palpated by the surgeon. Stereotaxic breast biopsy can also be employed in the diagnosis of a non-palpable breast mass.

Mammogram: A low dose x-ray of the breast that is modified to see the soft tissues within the breast. A particular pattern of distortion with calcification is diagnostic for breast cancer. Most but not all ductal cancers can be diagnosed with mammography. However, many early breast cancers are not diagnosed until they have grown enough to distort the local tissue. Less commonly, ductal cancers do not distort nor do they calcify. Mammographic diagnosis is difficult to establish in these patients and will more frequently lead to false negative diagnosis. Lobular carcinoma is less likely to distort or calcify until the tumor has grown to a larger size. For this reason, mammography is less reliable for making an early diagnosis of lobular carcinoma. Although, mammography is an effective diagnostic tool it is not the Rosetta stone of breast diagnosis. Followup mammographic monitoring may be difficult in patients who have elected breast conservation with radiation. Radiation scarring within the remaining breast tissue may obscure or mimic the mammographic patterns that are seen with a recurrent breast cancer.

False negative: A diagnostic study that does not indicate the presence of a breast cancer (negative test) even though a cancer is actually present in the breast (false negative test). For a mammogram, a negative mammogram is no assurance that a breast cancer is not present. Mammography is not sensitive enough as a diagnostic tool to rule out breast. The problem of false negatives with mammography is especially prevalent with lobular carcinoma which can grow extensively without any changes in the mammogram. A mammogram is only reliable as a diagnostic test when a positive diagnosis of breast cancer is made.

False positive: A diagnostic study that indicates the presence of a breast cancer when a cancer is not actually present in the breast. False positives typically occur in overly sensitive tests. Blood tests such as  CEA (carcinoembryonic antigen) are overly reactive in certain conditions that are not associated with breast cancer.

Breast biopsy: The surgical procedure that removes diseased breast tissue for evaluation by a pathologist. The procedure is usually done on an out patient basis with a local anesthetic.

Standard breast biopsy: The surgical incision for the breast biopsy is placed on the skin of the breast. Placing the biopsy incision on the breast skin complicates breast reconstruction with additional scarring.

Periareolar breast biopsy: The surgical incision for the breast biopsy is made within the margin of the areola. Breast reconstruction is facilitated because a skin preservation mastectomy can be performed if there is no involvement of the skin with the breast cancer.

Needle biopsy: As the name implies, the use of a needle to obtain a small amount of tissue for evaluation by the pathologist. This type of biopsy is most reliable when positive (when the pathologist has enough tissue to confirm the diagnosis of breast cancer). When a patient has a suspicious breast mass, a negative result (when the pathologist does not have enough tissue to confirm the diagnosis of breast cancer) is unreliable and a surgical breast biopsy is required to remove the entire mass for a more through evaluation by the pathologist.

Stereotaxic breast biopsy: A newer type of needle biopsy that uses X-ray (mammography) to locate the breast mass. Stereotaxic breast biopsies are useful for non-palpable (cannot feel the lump) tumors that are only detectable with mammography. This type of biopsy is only meaningful when a positive diagnosis of breast cancer is made. When a patient has a suspicious appearing breast mass and the result of the stereotaxic biopsy is negative, a surgical biopsy is required that removes the breast mass for more thorough evaluation by the pathologist. In this circumstance, removal of the breast mass for evaluation is required before a diagnosis of a benign (non-cancerous) tumor can be reliably made.

J wire localization: The use of a J shaped wire to locate a suspicious appearing breast mass that is not palpable (cannot feel the breast lump). During mammography, the wire is guided and temporarily left in the breast mass. The inserted J wire (within the breast) functions as a guide to the surgeon for removal of the non-palpable breast mass. During the surgical biopsy, the surgeon removes the J wire with the breast mass.

Pathology: The evaluation of diseased tissue that has been removed from a patient. The evaluation includes a visual inspection or gross evaluation of the removed (excised) tissue. The diseased tissue is also evaluated microscopically. During this evaluation process, a microscopic slide is made out of a thin slice of that tissue. The tissue is then stained with chemicals that will highlight the difference between the different components of that tissue. Differences that are highlighted include normal structures and diseased tissues such as cancer. Further differentiation (determining the difference) is possible between the different cell types of breast cancer (ductal and lobular) and their invasiveness. Invasiveness can be differentiated microscopically between non invasive and invasive. The appearance of the cancer cells, regardless of cell type, can also be discerned microscopically. Qualitative descriptions of the microscopic appearance of cancer cells is important in predicting their tendency to spread (metastasis) to other parts of the body. The term low grade dysplasia implies a reduced probability of spread. Well differentiated also implies a lower probability of systemic( metastatic) spread. Descriptive terms such as high grade, anaplastic or undifferentiated indicate a higher probability of metastatic spread.

Frozen section: A means to make a microscopic diagnosis during surgery. The tissue specimen that is removed during surgery is frozen and thinly sliced before placing it on a microscopic slide. The prepared slide is then stained. The pathologist then examines the slide under a microscope while the surgery is being performed. Although less precise than a permanent section, a "real time" analysis is possible which will provide a preliminary diagnosis including the adequacy of surgical margins of resection. An adequate margin of resection is seen by the pathologist under the microscopic as a buffer of normal tissue between the cancer and the surgical incision that removes the malignant tumor. An inadequate or involved margin of resection is the absence of a buffer of normal tissue. This condition implies that the cancer extends beyond the margin of resection (surgical removal).

Permanent section: The microscopic evaluation of diseased tissue that is completed after surgery. A permanent section diagnosis typically requires 48 hours to complete the more involved staining process that provides a more detailed and more accurate pathological diagnosis than a frozen section diagnosis. A permanent section diagnosis represents the highest level of pathological diagnosis of a disease. For breast cancer patients, the permanent section provides a confirmation of the initial frozen section diagnosis. After mastectomy or lumpectomy with radiation, the permanent section diagnosis determines the presence of residual cancer and the adequacy of surgical margins of resection. It is especially important (for breast conservation) that gross tumor is not left in the remaining breast tissue. Also determined with the permanent section is the presence or absence of axillary lymph node metastasis (cancer in the underarm lymph nodes). Qualitative description of the cancer cells appearance is also possible with a permanent section diagnosis. See dysplasia, anaplasia, well differentiated, poorly differentiated under the definition of pathology.

Clear margins: A pathological description that a surgical resection (removal) has an adequate buffer of normal tissue surrounding the breast cancer. In certain types of breast cancer, the determination of clear margins can be difficult.  With Ductal carcinoma insitu (DCIS), a clear margin seen on one microscopic slide does not necessarily mean that all margins are clear. Because DCIS can spread widely within multiple ducts, tumor margins cannot be clearly defined by microscopic examination of the removed tissue. Instead, poorly defined margins between involved and uninvolved breast tissue may not be detected by the pathologist who can only examine a limited number of microscopic slides. In this instance, the patient has an involved margin with tumor present in her residual breast tissue even though the pathology report states that the margins are "clear".

Involved margins: When the breast cancer extends beyond the surgical margin of removal. This condition indicates that additional cancer is still present in the breast.  Patients who have involved margins and who are treated with with lumpectomy and radiation, will have a much higher rate of local recurrence than patients who are treated with mastectomy.

Angiolymphatic invasion: A microscopic term that describes th e appearance of cancer cells inside blood vessels or lymphatic vessels. Angiolymphatic invasion is typically described in the initial breast biopsy that establishes the diagnosis of breast cancer. It is an indicator that systemic spread is more likely.

Estrogen receptor sites:A pathololgy test of breast cancer tissue that is typically performed at the time of the original breast biopsy. A positve estrogen receptor site test indicates that the breast cancer will be stimulated to grow in the presence of estrogen. This finding is important if estrogen suppression therapy with tamoxifin medication is to be used. Positive estrogen receptor sites are also an indication that the breast cancer is well differentiated (the cancer cells respond as normal breast tissue to the presence of estrogen) and will be less likely to spread to other parts of the body (metastasis) even though it is stimulated to grow by estrogen. A negative estrogen receptor site test is an indication that the breast cancer maybe poorly differentiated (and more likely to metastasize) because it does not respond to the presence of estrogen.

Unifocal: Only one cancer in the breast is present.

Multifocal: More than one cancer is present in the breast. Mutifocal breast cancers can either be the same cell type or they may be comprised of different cell types (see ductal and lobular breast cancer). Multifocal breast cancers are important if the patient chooses breast conservation with radiation. An undetected second cancer in the remaining breast tissue may lead to an early recurrence.

Intraductal Breast Cancer: See Ductal Breast Cancer.

Ductal breast cancer: Also referred to as intraductal cancer, this type of breast cancer is the most common form. Ductal cancer typically occurs in single breast only and is the most detectable with palpation (to feel for breast lumps) and mammography. More recently, ductal cancer has become multifocal in increasing minority of patients. Multifocal refers to the presence of multiple separate cancers in a single breast ie, the ductal cancer is unilateral (present in a single breast) and multifocal (multiple tumors in a single breast). The presence within a breast of a separate nondetected breast cancer with a detected breast cancer has serious implications if breast conservation with radiation is elected as the method of treatment. The non detected breast cancer is also referred to as an occult primary. For these patients who choose breast conservation with radiation, local recurrence is likely because they keep their residual breast tissue which contains the occult breast cancer. Mastectomy will effectively treat an occult primary that is associated with a detected cancer because the residual breast tissue is removed. Instead of remaining in the patient as an occult primary, the undetected cancer is removed during mastectomy and becomes detected when the pathologist subsequently examines the breast tissue specimen.

Lobular breast cancer: This type of breast cancer originates from the gland portion of the breast that produces the milk. Although less common than ductal cancer, the incidence of lobular cancer is increasing. Lobular cancer tends to be multifocal (more than one breast cancer in a single breast) and bilateral (present in both breasts) in a higher percentage of tumors than ductal cancer. Detection with lobular cancer is more difficult because the tumor grows without distortion of the involved breast tissue. Lobular cancers can grow to large size before detection with either palpation( to feel the breast lump) or with mammography. A negative mammogram is no assurance that a lobular breast cancer is not present.

Invasive breast cancer: Breast cancer is subdivided into invasive components and non invasive components. Regardless of cell type (ductal or lobular), invasive breast cancer describes the invasion or growth of the cancer into normal adjacent tissue. The normal adjacent tissue can consist of breast tissue, fatty tissue or underlying pectoralis muscle. Invasive breast cancers can also spread through the blood stream to other parts of the body by a process termed systemic metastasis.

Non invasive breast cancer: The presence of a breast cancer that grows but does not invade normal adjacent tissues. With this non invasive component, breast cancer cells are present microscopically but they have not yet become invasive. Most non invasive breast cancers will become invasive over a variable period of time. Non invasive breast cancers may become quite extensive before detection. This type of non invasive breast cancer is termed EDC or extensive ductal cancer. Non invasive cancer is detected with either palpation( to feel the breast lump) or with mammography. With non invasive ductal cancer(DCIS), calcium deposits are seen on mammography that appear as calcified ducts. Non invasive breast cancer can be described as one less step in the evolution to an invasive breast cancer. For this reason, non invasive breast cancer is frequently seen surrounding an invasive cancer. Another term for non invasive breast cancer is carcinoma in situ.

Carcinoma in situ: Synonymous with non invasive breast cancer. Carcinoma in situ is subdivided into ductal carcinoma in situ and lobular carcinoma in situ.

Ductal carcinoma in situ: A non invasive type of breast cancer of ductal cell origin. Although non invasive (into normal adjacent tissue), this type of non invasive cancer will grow. Surgical removal is required. Progression to invasive breast cancer is common.

Lobular carcinoma in situ: A non invasive type of breast cancer of lobular (milk producing component) cell origin. This type of carcinoma instu does not grow or invade but is used as an indicator that more aggressive forms of cancer may also be present. Careful monitoring without surgical removal is acceptable. Patients need to know that an undetected cancer may be present if careful watching and waiting is elected by the patient. This type of non invasive cancer is more frequently bilateral (present in both breasts) than ductal carcinoma in situ.

Unilateral: Refers to one breast only

Bilateral: Refers to both breasts. For example, lobular breast cancer tends to be bilateral in a higher percentage of patients.

Metastatic workup: The use of blood tests and bone scans to determine the presence of established metastatic disease throughout the body. However, these tests will rarely indicate the presence of early metastatic disease that is not well established.

Bone scan: An X-ray survey of the skeleton to determine the presence or absence of established bony metastases.

CEA: A blood test that determines the level of an antigen (a detectable protein on the surface of a cell) that is generally present in cancer tissues. CEA is used to detect the presence of metastatic (systemic spread of cancer) disease before and after treatment.

Prognosis: A prediction of the future health of the patient. For breast cancer patients, Prognosis relates to the probability that a patient will be free of her disease after a period of time. Short term Prognosis is usually stated in terms of 5 and 10 years. Long term prognosis is stated in terms of 15 and 20 years..

Low risk: Refers to the probability that a disease will be cured. Low risk usually implies an excellent prognosis.

Intermediate risk:Refers to an equal probability between cure and continuation of the disease. The prognosis is unclear.

High risk: Refers to a low probability that a disease will be cured. Continuation of the disease is likely. The prognosis is guarded or poor.

TMN staging: A grading system for cancer severity that is based on a) tumor (T) size in centimeters b) presence of metastasis (M). Metastasis refers to the spread of cancer to other parts of the body. c) spread of cancer to the lymph nodes (N). Higher risk tumors with a guarded prognosis are associated with large tumors over 5 centimeters that are present with positive lymph. The presence of metastatic disease usually indicates a poor prognosis. TMN is staged 1,2 or 3 with stage 1 implying the best prognosis and stage 3 implying the worst prognosis.

Lymph nodes: Small oval shaped structures that are connected to lymph vessels that function as biological filters of bacteria, foreign material and cancer. The breast is drained by the axillary (underarm) chain of lymph nodes.

Positive lymph nodes: Breast cancer spreads initially through the lymph vessels of the breast to the Axillary ( underarm) lymph nodes. Spread to the sternal ( breast bone) lymph nodes may also occur for tumors that are present on the inner aspect of the breast. Three or less positive lymph implies a better prognosis than several positive lymph nodes. The presence or absence of positive nodes is determined surgically with an axillary lymph node dissection ( Lymph node removal) that is performed either at the time of mastectomy or at the time of lumpectomy. Although an important therapeutic benefit occurs with the removal of positive lymph nodes, determination of lymph node status is important diagnostically. Positive lymph nodes will usually indicate the need for systemic chemotherapy. Chemotheraphy with positive lymph nodes is recommended more frequently in younger premenopausal patients than post menopausal patients. Premenopausal patients tend to have higher risk tumors that are more likely to spread systemically even if tumor size is small. The determination of the presence or absence of positive sternal nodes is more difficult to the limited accessibility of these nodes under the sternum. This is a diagnostic problem when a cancer is present in the inner aspect of the breast and the axillary lymph nodes are negative. The presence of positive sternal lymph nodes is more likely in a cancer located in the inner portion of the breast than a cancer located in the outer portion. The need for chemotherapy is then made on the basis of tumor size and age of the patient. Removal of sternal nodes is rarely performed due to the surgical difficulty in removing them. Instead, radiation therapy to the sternal nodes may be used if risk for spread to these nodes is high.

Negative lymph nodes: The absence of positive lymph nodes after performing a lymph node dissection implies a good prognosis. For breast cancer patients, this typically refers to the axillary (underarm) lymph nodes.

Size of tumor: The diameter ( in centimeters ; there are 2.54 cm per inch) of the tumor is measured by the pathologist after removal of the breast cancer. The diameter usually refers to the size of the invasive component as prognosis is determined mainly by this component.

Size of invasive component: The diameter (in centimeters) of the cancer that is actively growing into the adjacent breast tissue.

Size of non invasive component: The size of the tumor may be also be determined by a type of a breast cancer that does not actively invade into the adjacent breast tissue. This type of non invasive component typically surrounds the invasive component and will usually convert to an invasive component. In some patients, the non invasive component of breast cancer can be quite extensive and involve most of the breast. Non invasive cancer is also refer to as carcinoma in situ.

Metastasis: The blood borne spread of breast cancer cells to tissues outside the breast. Breast cancer can also metastasize through the lymph system, but this rarely impacts the long-term prognosis of the patient directly. Instead, the presence of cancer containing (positive) axillary lymph nodes is used as a predictor of systemic spread through the blood stream.

oncologic: Relating to cancer

Premenopausal: A physiological condition of women who are still having menstrual periods. This condition implies that the ovaries are producing a higher level of estrogen that may vigorously stimulate the growth and systemic spread (metastasis) of breast cancer cells. This condition is especially significant in pre-menopausal women who have larger cancers that are estrogen receptor site positive. These patients should seriously consider ovariectomy as a means to reduce the stimulation of their breast cancer.

Postmenopausal: A physiological condition in which ovarian production is inadequate to produce menstrual periods. However, a low-level production below the level to produce menstrual periods may be adequate to stimulate the growth of breast cancer cells. This is the rational for the treatment of postmenopausal patients with tamoxifen which functions as an estrogen suppressor. Estrogen suppression is especially indicated in post menopausal women who have breast cancers that test positive for estrogen receptor sites

Treatment: The medical means by which a beneficial change is effected in the course of a disease. For breast cancer, a mastectomy removes the diseased tissue which will stop the continuing growth of the tumor in the breast. Chemotherapy kills breast cancer cells that have spread to other parts of the body and will prevent the establishment of breast cancer tumors in other parts of the body. Mastectomy and breast conservation with radiation are the two major ways to treat breast cancer which may result in patient outcomes that are entirely different. This initial choice by the patient is the most significant because it sets in motion a sequence events that are entirely different between the two types of treatment. It is of paramount importance that the patient completely understands the short term and long term effects of each type of treatment.

Radical mastectomy: The surgical removal of all glandular tissue in a breast. This performed through a large elliptically shaped incision that includes the nipple and a variable amount of breast skin. Removal of the Pectoralis muscle is rarely performed. See modified radical mastectomy

Skin-sparing mastectomy: Synonymous with a skin preservation mastectomy

Breast conservation therapy: A recently developed method of breast cancer treatment that "conserves" the breast. This method of treatment is limited to the surgical removal of the breast cancer tumor without removal of the remaining breast tissue. During this surgical procedure, The axillary (underarm) lymph nodes draining the breast are removed. Within a one month period, radiation therapy is used to treat cancer cells that may be in the remaining breast tissue. The course of radiation therapy is administered over a 6 week period. The usually dose of radiation is between 5,000 and 7,000 Rads. Breast conservation is also referred to as "lumpectomy with radiation". Breast conservation can also be combined with chemotherapy if the risk of spread (systemic metastasis) to other parts of the body is likely. Breast conservation assumes that only one cancer is present in the breast and that radiation therapy will adequately treat any additional cancer cells in the remaining breast tissue. Of singular importance is the the initial surgical treatment with an adequate lumpectomy that creates a clear margin of resection. An inadequate lumpectomy with involved tumor margins will frequently lead to an early local recurrence of the patient's breast cancer. With Ductal Carcinoma insitu (DCIS), clear margins of the resection may be very difficult to determine (by the pathologist). Commonly described to patients as "keeping your breast", this method of treatment can also be associated with severe radiation deformities that are difficult to correct. These radiation induced deformities are more likely to occur with larger lumpectomies that leave the overlying breast skin unsupported i.e., after radiation, severe tightening and distortion of the unsupported breast skin may occur.

Residual breast tissue: The remaining glandular breast tissue that is left in the treated breast following breast conservation (lumpectomy with radiation). The residual breast tissue is the main source of concern with this method of treatment.

Radiation: The presence of high energy nuclear particles and waveforms that are produced from radiation therapy machines, nuclear reactors and the natural decay of uranium in the environment.

Radiation therapy: The application of a high energy beam of radiation to a patient. This may also involve the temporary insertion of radioactive materials into the patient. Radiation therapy is typically used to treat cancer.

Primary radiation therapy: For breast cancer patients, the application of radiation following lumpectomy or local removal of the cancer without mastectomy. The remaining breast tissue is irradiated on a daily schedule over a 6 week period of time. Primary radiation with lumpectomy is also described as 'breast conservation".

Adjuvant radiation therapy: For breast cancer patients, the use of radiation therapy with mastectomy. Adjuvant radiation therapy is used in patients who have advanced breast cancers that are more likely to recur even with mastectomy.

Recurrence: A term that describes the return of the breast cancer. The breast cancer can return locally in the breast or it can return systemically throughout the body. Local recurrence rates can be described as short term (10 years or earlier) or as long term (over 10 years). Although short-term recurrence rates are similar for mastectomy and breast conservation, long term recurrence rates may be significantly different. Very little data is available to alleviate the long-term concern that is associated with breast conservation with radiation.

Local recurrence after mastectomy: The recurrence of breast cancer after a mastectomy will typically involves the superficial soft tissues under the remaining breast skin. Because of the superficial location of the local recurrence, earlier diagnosis is likely for post mastectomy patients. Although short term local recurrence rates are similar to breast conservation with radiation, long term recurrence rates may be significantly lower for mastectomy that removes the residual breast tissue.

Radiation induced local recurrence: A local return of the breast cancer in the residual breast tissue that is due to the carcinogenic(cancer causing) effect of radiation.

Mastectomy: The removal of essentially all breast tissue within a breast. Most patients will require removal of the nipple because it drains the breast tissue. In the past, breast skin was routinely removed with a long elliptically shaped incision across the breast that included the nipple. More recently, studies have shown that breast skin removal does not need to be done routinely. Although less than one percent of residual breast tissue may be present following mastectomy, this small amount will rarely be the source of future breast cancers. This low risk of recurrence from the residual breast tissue is in contrast to breast conservation in which a patient keeps the majority of her breast tissue. Although mastectomy has also been described to patients as "losing your breast", newer methods of breast reconstruction will avoid this" loss" in the majority of patients.

Skin preservation mastectomy: synonymous with skin-sparing mastectomy. A type of mastectomy that does not remove skin. Because the majority of breast cancers do not have involve the breast skin, preservation of the breast skin envelope during mastectomy is possible. This preferred method of mastectomy facilitates breast reconstruction because patients are no longer skin short in relation to the opposite breast. With this method, a circular incision is made around the border of the areola. Removal of all breast tissue including the nipple is performed through this circular incision.

Skin invasion: The growth of a breast cancer into the skin. Skin invasion is relatively uncommon and usually occurs with larger advanced cancers or with smaller cancers that are initially located under to the skin. Skin invasion or skin involvement requires the removal of the involved skin. However, routine skin removal is rarely indicated unless there is direct invasion.

Skin resection mastectomy: synonymous with skin removal mastectomy. A type of mastectomy in which breast skin is removed with the breast tissue and nipple. A longer elliptically shaped incision is used that results in the typical mastectomy scar. Patients will be skin short in relation to the opposite breast. This method of mastectomy is now reserved for the minority of patients who may have skin involvement.

Modified radical mastectomy: Identical to a skin resection mastectomy in which a large ellipse of breast skin is removed which includes the nipple and the remaining breast tissue. Removal of the Pectoralis chest muscle is rarely performed unless there is direct invasion of the cancer into the muscle.

Chest wall invasion: The growth of a breast cancer deeply into the underlying Pectoralis muscle. Chest wall invasion typically occurs with larger advanced cancers or with smaller cancers that were initially located next to the muscle.

Subcutaneous mastectomy: The removal of the glandular breast tissue only. The nipple is not removed with this method. Subcutaneous mastectomy is performed prophylactically in patients who do not have breast cancer but who are at risk for developing breast cancer in the future.

Lymph node dissection: The surgical removal of lymph nodes. For breast cancer patients, the lower group of axillary (underarm) lymph nodes are removed for therapeutic and diagnostic purposes. Between 15 and 20 lymph nodes are removed. Although there is some disagreement among physicians, the removal of cancer containing lymph nodes should improve the prognosis of the patient. For diagnostic purposes, the determination of lymph node status is important if systemic therapy is warranted. The presence or absence of cancer containing lymph nodes will determine the need for chemotherapy.

Sentinel node biopsy: The identification and biopsy of the first lymph node within a chain of lymph nodes. Axillary (underarm) sentinel node biopsy is being employed on a trial basis as an alternative to an axillary lymph node dissection. An assumption is made that the identified Lymph node is actually the first sentinel lymph node within the chain of draining lymph nodes.

Chemotherapy: For breast cancer patients, the administration of drugs that either suppress or kill cancer cells that have spread (systemic metastatsis) to other parts of the body. Chemotherapy is used prophylactically when the risk of metastasis is high or therapeutically when metastatic spread has been established in other parts of the body. If required, breast cancer patients will typically undergo a 6 month period of chemotherapy. Chemotherapy can be used in combination with mastectomy or lumpectomy with radiation.

Bone marrow transplant: An aggressive form of chemotherapy that is used in high risk patients or patients with established metastatic disease. The drugs are administered at high enough doses to kill established cancer cells but also destroy needed bone marrow cells. Bone marrow cells are needed to form white blood cells which fight infection. Following the high dose chemotherapy, patients are then transfused additional bone marrow cells that have been previously obtained from the patient or from another individual (donor). The transfusion replenishes the bone marrow cells that have been destroyed during chemotherapy.

Stem cell support: A less aggressive form of high level chemotherapy in which patients are either given back their own stem cells or are given additional medications that stimulate the formation of white blood cells.

Tamoxifen: A medication that is used to suppress the effects of estrogen. Estrogen is the main female hormone that is made in the ovary which may also stimulate the growth of breast cancer cells.

Nupagen: A medication that is used commonly during chemotherapy to stimulate the growth of white blood cells.

Adjuvant therapy: Any form of therapy that is used in combination with either mastectomy or lumpectomy with radiation.

Adjuvant chemotherapy: The administration of drugs that suppress or kill cancer cells that is used in combination with either mastectomy or lumpectomy with radiation (breast conservation).

Adjuvant radiation therapy after mastectomy: The use of radiation in combination with mastectomy to treat advanced forms of breast cancer.

Follow-up care: Following treatment with either breast conservation/radiation or treatment with mastectomy, the patient is followed by her physicians with set schedule of examinations, mammography and blood tests

Surveillance: Essentially the same as Followup care

Algorithm: A specific pathway or system of medical procedures that is used to treat a disease. The algorithm may be subdivided into specific diagnostic and treatment components.

Risk benefit ratio: A commonly cited relationship that describes the risk of surgical complications in reference to the potential of improvement that the surgical procedure offers.

Path compromised: The treatment does not follow an optimal pathway. Additional scarring may occur.

Path not compromised: The treatment follows an optimal pathway. Less scarring will occur.

Reconstruction

Breast reconstruction: The surgical methods by which the natural contour of the breast is restored. These methods are most frequently employed with post mastectomy or post radiation deformities. Breast reconstruction can be performed immediately (at the time of mastectomy) or delayed (following mastectomy). A total and immediate breast reconstruction is a single stage procedure that is performed at the time of mastectomy in which all components of the breast, including the nipple, are surgically recreated. Staged reconstruction involves more than a single operation to recreate the three dimensional components of the breast. A first stage of a staged reconstruction can be performed either at the time of mastectomy or at a later date. Breast reconstruction is complicated with excessive removal breast skin during mastectomy. The preservation of the breast skin envelope during mastectomy will greatly facilitate reconstruction.

Breast reconstruction in the presence of radiation therapy is extremely difficult. The quality of the breast reconstruction will be severely compromised in most patients with radiation. Deformities of the breast following large lumpectomies with radiation are also very difficult to correct. In these patients, the overlying breast skin is no longer supported by the (removed) breast tissue. Subsequent radiation therapy will cause severe shrinkage and indentation of this unsupported breast skin. Patients who have been previously treated with breast conservation and radiation will frequently require additional breast biopsies to diagnosis suspicious areas of the remaining breast tissue. A progressive deformity with indentation of the breast skin can develop in these patients after each subsequent breast biopsy. This deformity, like all radiation-induced deformities, can be extremely difficult to correct.

There are two basic methods for breast reconstruction. Tissue flaps from the abdomen or back are commonly used. Methods of flap reconstruction are described to patients as "using their own tissue". These procedures are more involved because the patient herself is providing the tissue from a separate part of her body. Implant methods of reconstruction are less involved because the patient does not provide the additional flap tissue. Even though less extensive than tissue flap, an implant method of reconstruction usually involves two procedures or "stages". The initial stage involves the surgical placement of a breast expander implant into a tissue pocket that is created under the mastectomy scar and the chest wall muscle (Pectoralis muscle). The expander implant prepares the remaining breast tissues by stretching or expanding those tissues. During this expansion process, fluid is injected into the expander through a special valve that is present in the implant. This type of implant allows a progressive expansion of the breast skin envelope during and after the completion of the surgery. Expansion of the breast skin envelope is important if the natural contour of the breast is to be restored. The second or final stage involves the insertion of the permanent implant with creation of the nipple and areola (the pigmented skin around the nipple). Repositioning or uplifting of the opposite breast may also be required for symmetry because the reconstructed breast is typically skin short even though it has been expanded.

Flap reconstruction: The use of a patient's own tissue that is moved from a donor site where the tissue is obtained to a recipient site where the flap tissue is used to reconstruct a deformity. Flap tissues must have an inherent circulation (or vascular pedicle) to survive as transferred tissue. For breast reconstruction with flap tissue, the vascular pedicle is the vessel that are in the muscle component of the flap. For an abdominal flap, the muscle that provides the vascular pedicle is the rectus abdominis muscle. A large elliptical skin flap of abdominal tissue that has been transferred with the pedicle circulation of the rectus muscle is called the TRAM flap. Although this large elliptical flap of skin may recreate the natural "droop" of the breast, the transfer of a large ellipse of skin to the breast results in a prominent double tier scar on the surface of the reconstructed breast. There may also be a pigmentary discrepancy between the remaining breast skin and the elliptically shaped TRAM flap that is transferred to the reconstructed breast. The Rectus PEG Flap that is also based on the circulation of the rectus muscle avoids the double tier scarring and pigmentary discrepancy of the TRAM flap. This is accomplished by confining the Rectus Peg scar to the circular border of the reconstructed nipple. In a similar fashion, the double tier scar and pigmentary discrepancy of a standard latissimus Dorsi flap (of the back) is avoided with a Latissimus Dorsi PEG flap.

Implant reconstruction: The use of breast implants to modify and replace tissues that have been removed during a mastectomy. See reconstruction. With a standard modified radical mastectomy with elliptical removal of breast skin, the reconstructive process will require additional expansion of the remaining breast skin envelope. Additional expansion (with a breast expander) of the remaining skin is required to obtain a similar cross sectional area to the opposite breast. The more skin that is removed during mastectomy, the greater the skin surface discrepancy that must be replaced for symmetry. For implant reconstruction, the correction of the discrepancy is achieved with a breast expander. For flap reconstruction, the skin surface discrepancy is corrected with the added skin surface area of the flap. A skin preservation mastectomy limits the surface area discrepancy by restricting the removal of the remaining breast skin envelope to the excised (removed) nipple areolar complex. The breast skin envelope, as the most valuable component of a good reconstruction, is not unnecessarily depleted.

Breast implant: A medical device that designed for implantation into the female breast for aesthetic enlargement or for purposes of breast reconstruction. Most breast implants are comprised of a solid silicone envelope that contains a filling solution of saline or a filling material of silicone gel. Most breast implants are pre-sterilized at the factory. For saline implants, the filling solution of saline is added at the time of surgery from a sterile intravenous bag. The solution is instilled into the implant through a special self-sealing valve. To avoid contamination, the solution should be added to the implant through a closed system of tubing that does not allow air contact with the saline solution. Silicone gel breast implants are pre-filled at the factory in a sterile environment. Breast implants may also be smooth or textured. Texturing of the implant envelope may reduce scarring which may result in a softer breast.

Silicone gel breast implant: A type of breast implant that is pre-filled with a silicone gel that mimics the consistency of breast tissue. Earlier gel implants had a higher incidence of rupture due to progressive degradation of the implant envelope. Another drawback of the earlier gel implant was the phenomenon of gel bleed in which there was a leakage of gel through the implant envelope without rupture. More recently gel implants are much longer lasting because the implant envelope is more durable. In addition to being more durable, newer gel implants are much less porous which has greatly reduced gel bleed. Over the past six years, silicone gel implants have been accused of causing a variety of arthritic conditions in patients due to an immune reaction to the silicone gel. Recent studies that compare the incidence of these arthritic conditions in patients with implants to patients without implants do not show any statistical difference between these two groups of women. What these studies do not show is the possible aggravation of symptoms in patients who have a pre-existing predilection to these arthritic autoimmune diseases. Although the incidence of autoimmune disease is much rarer than initially feared, patients with a family history of autoimmune disease should avoid a variety of implant materials including breast implants. The average patient without a family history of these diseases has extremely low risk to develop these diseases as a result of breast implants.

Saline breast implant: A breast implant with an external shell of silicone that is filled with an IV solution of saline. The implant is filled with saline (a salt water solution that is similar to our own body fluid) at the time of breast implantation. An advantage of a saline implant is the diminished reaction to the body because the problem of "silicone gel bleed" is not present. Another advantage of a saline implant is the ability to customize the volume of the breast implant at the time of surgery. Asymmetries of breast volume can be more easily corrected with a saline implant than a silicone gel implant that is pre-filled at the factory. A disadvantage of the saline implant is total deflation of the implant if a small leak develops. Although the patient is not at any risk for the internal leakage of a saline solution, replacement of the deflated implant will be necessary to regain the lost breast volume. Another disadvantage of a saline breast implant is the fluid waviness that may be apparent at the skin surface in patients who are very thin. This is especially true in mastectomy patients who have had the breast surgically thinned. Newer saline implants have at least partially addressed this problem of waviness by contouring the implant itself.

Breast expander: A type of saline breast implant that is used to progressively stretch the remaining breast skin after a mastectomy. Expansion or stretching of the remaining breast skin is accomplished through a special valve that is part of the breast expander. Even though the expander is placed in a surgically created pocket under the remaining breast skin, fluid can be added through this valve to progressively stretch the remaining breast skin after the mastectomy. The expansion process is typically performed in the plastic surgeon's office over a two to four month period of time. The second and final stage surgery is performed after the expansion process. This typically involves the creation of the nipple with exchange of the expander with a permanent implant. This second surgery is more limited in scope and can usually be accomplished in an outpatient surgery center.

Autoimmune disease: A description of a disease process in which the patients produces antibodies against their own tissues. Medically, autoimmune disease is termed rheumatic disease. The medical specialist who treats patients with rheumatic disease is called a Rheumatologist. The most common rheumatic diseases are Rheumatoid arthritis, Lupus erythematosus and Scleroderma. It has been speculated that patients with silicone gel breast implants would be more likely to develop these diseases. Recently completed studies have not supported these speculations.

Rheumatoid disease: Essentially the same as Autoimmune disease.

Lupus: A type of rheumatoid disease that commonly causes skin rashes and joint symptoms. More severe forms may involve other organ systems such as the kidneys.

Scleroderma: A more severe rheumatoid disease that can involve the intestines, lungs and major vessels.

Fibromyalgia: A more obscure combination of arthritic symptoms of unknown cause. Fibromyalgia may be a type of rheumatoid disease although a consensus among Rheumatologists has not been formed.

Cause and effect: A scientifically proven relationship between the cause of disease and the effect that disease has upon a patient.

Anecdotal: An unproven relationship of cause and effect that is made by an observer with inadequate information. Limited personal observations by a physician is an example of an anecdotal relationship that has not been proven. For example, it is the author's suspicion that breast implants (as with any food, medication, vaccination or implant material) can aggravate an established case of rheumatoid disease. However, this anecdotal suspicion remains unproven.

Statistically significant: A scientifically proven relationship that is the result of an objective analysis in a large group of patients.

Flap: A term used in Plastic Surgery to describe the transfer of skin and soft tissue to correct a deformity. In most instances the flap is attached to the body by its blood supply for nourishment. The place where the flap is taken from (harvested) is called the donor site. The place on the body where the flap is transferred is called the recipient site. The recipient site is typically where the deformity is located.

Random cutaneous flap: A tenuous flap of skin and fatty tissue that has a fragile blood supply. The breast skin after a mastectomy has a fragile blood supply and is a type of random cutaneous flap.

Myocutaneous flap: A flap of tissue that consists of skin, fatty and muscle tissue. The muscle tissue component provides a more robust blood supply that increases the survival of the flap when it is transferred over a longer distance to a recipient deformity. The rectus flap is safely transferred to the mastectomy recipient site due its enhanced circulation. The Latissimus Dorsi flap is another example of a myocutaneous flap that is used in breast reconstruction.

Neovascular flap: A type of myocutaneous flap that occurs after the growth of new vessels from a muscle into an area of skin. The Pectoralis Peg is a Neovascular flap that is formed after mastectomy when new vessels from the Pectoralis muscle grow into the remaining breast skin.

Autologous flap: Another name for a flap that is used to entirely reconstruct a deformity. The TRAM flap is an example of a large autologous flap that is used to reconstruct a typical mastectomy deformity.

Patient's own tissue: A synonymous term for an autologous flap.

Free flap: A flap that is completely detached from its donor site and is transferred to the recipient (deformity) site by reattaching the nutrient vessels of the flap to vessels of the recipient site.

Microvascular flap: A synonymous term to a free flap that describes the technique that reattaches the small vessels of the flap to the small recipient site vessels.

Standard breast flap: Any flap that transfers a large ellipse of skin to a recipient deformity site. The TRAM flap has been used extensively in the past for breast reconstruction. Although the missing skin of typical mastectomy is replaced with a TRAM flap, a double tier scar is created on the reconstructed breast as a result.

Peg flap: A peg flap uses the same circulation as a standard flap with the exception that a large ellipse of skin is not transferred to the recipient breast. Instead, a circle of skin is used to recreate the nipple and the areola. The fatty and muscle tissue under the circular PEG of skin is used to replace the missing tissue that was removed during the mastectomy. In other words, a round PEG is used to fill a round hole at the mastectomy recipient site.

Pectoralis Peg flap: This technique also employs a round PEG into a round hole, but achieves this result without the transfer of flap tissue from a distant flap donor site. The Pectoralis PEG is a Neovascular flap that relies on the reestablished circulation of the Pectoralis muscle to the overlying breast skin.

Nipple: The central conduit of milk that projects from the breast. The nipple is mainly comprised of skin and ductal breast tissue. The probability of cancer involvement is fairly high because the nipple functions as the primary conduit of the entire breast.

Areola: The pigmented portion of the skin around the nipple. A fairly dense layer of ductal breast tissue is attached to the under surface of the areola. A fairly high probability of cancer involvement also exists for this structure.

Nipple-areolar reconstruction: Because the nipple and the areola function as the main conduit of the breast, involvement with any breast cancer is fairly likely. Removal of this structure is typically required during mastectomy. Reconstruction of the normal esthetic contours of the nipple areolar complex is an essential part of any method of breast reconstruction. Because accurate placement is important, creation of the nipple areolar complex is performed as the last part of the breast reconstruction.

Standard nipple-areolar reconstruction: Previous methods of nipple areolar reconstruction failed to restore the unique contours of this aesthetic structure. Most standard techniques resulted in an artificially flattened contour. With these standard techniques, skin grafts from the thigh are typically required to complete the areolar portion of the reconstruction.

Bowtie nipple-areolar reconstruction: The most recently developed method of nipple areolar reconstruction that restores the natural projection of the nipple areolar complex. Areolar reconstruction is achieved without he need of skin grafting from other parts of the body. Although the Bowtie Nipple Areolar reconstruction has been incorporated as an integral part of the Peg procedures, this technique can be employed with any method of breast reconstruction.

Complications: This term generally refers to the occurrence of an untoward event that complicates the normal coarse of recovery from surgery. Surgical complications usually refer to bleeding, infection, severe scarring. For breast reconstruction, a severe complication is flap loss.

Hypertrophic scarring: Commonly referred to as a keloid, this type of scar is seen frequently after a surgical incision. In most patients there is a raised appearance of the scar that fades over a 6 to 12 month period of time. A keloid is a very severe form of a scar that actually grows into normal uninvolved skin. Keloids typically do not resolve over a period of time. Although relatively uncommon, keloids are relatively uncommon and are seen in more deeply pigmented patients. However, keloids can occur in lighter complexion patients when an incision is made on the upper sternum (breastbone). A note of caution is given to patients who desire removal of benign moles in the upper sternum for an improved appearance. Instead of an improved appearance, a severe keloid scar may occur that is more unsightly than the original benign mole.

TRAM flap: The name given for a commonly performed flap method of breast reconstruction that transfers a large elliptically shaped flap of skin and fatty tissue from the abdomen to the mastectomy deformity. The TRAM flap includes the rectus muscle as the source of circulation to the flap. See double tier scarring.

Double tier scarring: A description of a standard flap scar that appears on the breast after breast reconstruction. A TRAM flap is a large ellipse of skin that has two levels of scarring when transferred to the breast for reconstruction of a mastectomy deformity. Standard elliptically shaped flaps will frequently have a different pigmentation with the adjacent breast skin that is visibly apparent. Although used less frequently than in the past, a TRAM or Latissimus Dorsi Flap is indicated in patients that require mastectomy after a radiation failure.

Skin pigment discrepancy: See pigmentary discrepancy

Pigmentary discrepancy: A color difference that is seen between the breast skin and a standard skin flap that is used in breast reconstruction. The PEG flap avoids a pigmentary discrepancy by confining the flap to the border of the reconstructed nipple which is normally pigmented.

Flap donor sites: The location on the patients body that a flap of tissue is taken. The flap of tissue is then moved to the deformed area on the patients body. The deformed area that is being reconstructed is called the flap recipient site. For example, the TRAM flap was taken from the abdomen and transferred to the recipient mastectomy site.

Flap loss: The transfer of living flap tissue requires an intrinsic blood supply for the survival of the transferred tissues. Thrombosis or clotting of that pedicle blood supply will result in the death of that tissue. The flap dies due to a lack of circulation. Fortunately this significant complication is fairly rare with breast reconstruction and occurs most frequently in the presence of radiation therapy.

Revision: A secondary surgery that is needed to fine-tune the results of the original breast reconstruction.

Contour deformity: A deformity in three dimensions that is a departure from the normal aesthetic contours of the body. Contour deformities are caused by a deficiency (or excess) of soft tissue under the skin and by a deficiency (or excess) of the skin envelope that covers a body structure.

Symmetry: The three dimensional similarity of a soft tissue structure to an another. The achievement of symmetry is a visual process that is frequently mislead by the more objective parameters of volume and weight.

Breast skin envelope: A term that describes the surface area of the breast skin. The term's usefulness is in the comparison that it provides to the remaining breast. Components the breast skin envelope include the breast skin and the nipple areolar complex. The achievement of a similar surface area between both breasts is essential for the achievement of symmetry.

Inframammary fold: The lower breast fold that attaches the lowest portion of the breast to the rib cage. Preservation or recreation of the inframammary fold is important for a natural appearing reconstruction.

Ptosis: The natural droop of the breast over the inframammary fold.

Breast repositioning: The surgical uplifting of the breast. During breast repositioning, the redundant breast skin is removed and the nipple is raised to a level above the inframammary fold. Breast repositioning can be indicated for esthetic enhancement of breasts that are excessively droopy or for symmetry in patients who are having breast reconstruction. The remaining breast is repositioned to equalize the breast skin envelope with the reconstructed breast.

Mastopexy: Synonymous with breast repositioning for esthetic purposes.

Nipple-areolar pigmentation: The process by which a combination of different skin pigments are instilled (tattooed) into the reconstructed nipple areolar complex. For the most part, an experienced esthetician that is trained in this process will provide the best color match to the natural pigmentation of the opposite nipple areolar complex.

Pectoralis muscle: The main chest wall muscle that is underneath the breast tissue. After a mastectomy, this muscle becomes attached to the remaining breast skin envelope by a process called neovascularization. This process of neovascularization is essential to the Pectoralis PEG method of reconstruction. Th