Case scenario- Breast Lump

M K ALAM

Case scenario

• A 50-year old female presented with a breast lump.

• What would you do?

• Self introduction

• Permission, privacy, chaperone

• History • Basic information: Name, age, nationality, gender

History

When noticed (duration)?

How noticed?

Any change in the lump since first noticed?

Any change in the breast/ nipple?

Any associated symptom ? Pain, discharge

Any relationship with menstrual cycle?

Any history of trauma?

Past medical/ surgical history

• Breast problem

• Mammogram

• Breast biopsy

• Exposure to radiation (face, chest)- risk factor

• Other medical/ surgical history

• Menstrual history

• History of pregnancy

This patient• Noticed the lump 2 weeks ago• Painless• No discharge• PMH: Unremarkable• FH: Unremarkable• MH: Menopausal, 2 children, menarche at 14• Breast fed her children• No medication, • Allergies- nil

Examination• GE: unremarkable• Local Examination: • ? Position & exposure• Normal side• Affected side: • Inspection- NAD• Palpation: Mass in UOQ, 2.5 cm, firm to hard,

No skin/ deep attachment• Axilla: NAD both side

• What next?

Differential diagnosis

• ? Malignant mass

• Benign neoplasm

• Other benign lesions

• Cyst

• ? Most likely diagnosis

• ?What next

Investigations

• Hematology, Biochemical (u/e, LFT)

• Imaging: Mammography, US, MRI,

• Tissue diagnosis: Core biopsy (palpation/ image guided)

• Biopsy: Type, OR/PR status, Her2neu

• Staging: CXR, CT, bone scan, PET scan

TNM staging of breast cancerStage Description

Tumor

TX Primary tumor not assessable

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor ≤2 cm in greatest dimension

T1 mic Microinvasion ≤0.1 cm in greatest dimension

T1a Tumor >0.1 cm but not >0.5 cm

T1b Tumor >0.5 cm but not >1 cm

T1c Tumor >1 cm but not >2 cm

T2 Tumor >2 cm but <5 cm in greatest dimension

T3 Tumor >5 cm in greatest dimension

T4 Tumor of any size with direct extension into the chest wall or skin

T4a Extension to chest wall (ribs, intercostals, or serratus anterior)

T4b Peau d'orange, ulceration, or satellite skin nodules

T4c T4a + b

T4d Inflammatory breast cancer

Regional lymph nodes

NX Regional lymph nodes not assessable

N0 No regional lymph node involvement

N1 Metastasis to movable ipsilateral axillary lymph nodes

N2 Metastases to ipsilateral axillary lymph nodes fixed to one anotheror to other structures

N3 Metastases to ipsilateral internal mammary lymph node with or without axillary lymph node involvement, or in clinically apparent clavicular lymph node.

Distant metastases

MX Presence of distant metastases not assessable

M0 No distant metastases

M1 Existent distant metastases (including ipsilateral supraclavicular nodes)

Management

• Benign lump: Observation/ surgery

• Cysts: incomplete resolution/ recurrent

• Malignant lump:

• Loco-regional therapy

BCT+ SLNB/ALND + Radiotherapy

Mastectomy + SLNB/ALND

• Systemic therapy:

Chemotherapy/ hormone/ monoclonal antibody

MANAGEMENT OF BREAST CANCER- DCIS

• Localized disease (<4cm)- Wide local excision with

normal healthy tissue all round the margins +

Radiotherapy ( except for very small lesions)

• Larger (>4cm) or widespread disease-

mastectomy

MANAGEMENT OF INVASIVE BREAST CANCER

• Operable: T1-T3, N0,N1,M0

• Loco-regional therapy+ systemic therapy.

MANAGEMENT OF INVASIVE BREAST CANCER

Local Therapy• Breast-conserving treatment (BCT): Wide local excision (lumpectomy) + RT

• Suitable for tumor <4cm

• Excision of tumor with 1cm margin of normal tissue+ sentinel node biopsy±

node clearance.

• Postoperative radiotherapy (RT)

• Modified radical mastectomy: Large tumor, widespread disease or those who

choose this treatment.

• Whole breast with axillary surgery (SLB ± clearance)

• RT: high risk- >3 LN involvement, lymphatic/vascular invasion, grade3 tumor,

>4cm tumor, tumor attached to pectoral fascia or close surgical margin <5mm

SYSTEMIC THERAPY

• Chemotherapy, hormone therapy, immunotherapy• Adjuvant chemotherapy- when given after surgery/

radiotherapy.• For all except- tumor <1cm & grade 1• Common regimens: FAC (5-fluouracil,adriamycin, cyclophosphamide) 6cycles/ 21

days. AC ( adriamycin, cyclophosphamide), FEC (5-fluouracil,epirubicin, cyclophosphamide).

• Neoadjuvant chemotherapy- when given before surgery/ radiotherapy to shrink larger tumors.

Hormone therapy

• Tamoxifen (partial estrogen agonist):

20 mg / day for 5 years for pre and postmenopausal

• Aromatase inhibitors (blocks conversion of androgens to

estrogen): letrozole, anastrozole, exemestane.

Postmenopausal women, hormone receptor +ve tumors

• Oophorectomy: Women <50, ER +ve tumors, metastatic

disease ( surgical or radiation)

Anti-HER 2 therapy

• 15-20% tumor express HER2

• Worse prognosis than HER2 negative tumors.

• Humanized monoclonal antibody- Trastuzumab

Fibroadenoma

• 15-25 years age group.• ? Neoplasm, ? Aberration of development• Well-circumscribed, smooth, firm, mobile mass.• May be multiple or bilateral.• Some may increase in size. > 5cm- giant fibroadenoma.

• 1/3rd may regress spontaneously.• U/S- smooth outline mass.• Management: Diagnose by core biopsy.• <4cm- Reassurance and follow up.• >4cm- excision.

Cysts

• Distended involuted lobules.• Perimenopausal women.• Smooth discrete lump, usually painless.• U/S confirms cyst.• Treatment: Aspiration of clear fluid & no

residual mass- discharge patient.• Aspiration of hemorrhagic fluid or cysts

relapse- excision to rule out malignancy.

Duct papilloma

• Bloody discharge from the nipple.

• Treated by duct excision- microdochectomy.

Phyllodes tumor

• Fibroepithelial tumor

• Most are benign, some malignant.

• Usually large, bosselated, no attachment.

• Malignant may metastasize by blood

• Treatment : Wide local excision.

Mastectomy for very large lesions.

• No axillary lymph node clearance needed