Breast Mass

Linda M. Barney M.D.Wright State University

Mrs. Trainor

Mrs. Trainor is a 57-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

History

What other points of the history do you want to know?

History, Mrs. Trainor Consider the following:

Characterization of Symptoms:

Temporal sequence

Alleviating / Exacerbating factors:

Associated signs/symptoms

Pertinent PMH ROS MEDS Relevant Family Hx.

Characterize Symptoms

3 week history of left breast lump. 1st noticed in the shower Bean sized and nontender May have increased in size slightly

Associated Signs & Symptoms

Denies pain, skin change, nipple discharge Prior history of Fibrocystic breasts, no biopsies LMP 6 years ago Last mammogram 11 months ago, routine

mammography since 40’s Denies trauma

Pertinent PMH

Healthy, married, mother of 4 (3 girls 1 boy) 1st pregnancy age 21, Breast fed 3 of 4 Menarche age 11, OCP’s x 20 years total, Menopause at 51, HRT w/ prempro x 7 years Denies smoking, social alcohol only,no drugs No chronic medical problems

Aleviating/ Exacerbating factors

No change with activity Uses Ibuprofen for headache with no change in

the lump Drinks decaffeinated tea and sodas only

Family History

Maternal grandmother with breast cancer at age 62, maternal grandfather w/colon CA at 71

Mother and sister with breast cancer, mother at age 52, Sister at 47

2 maternal aunts with ovarian cancer, 1 maternal uncle with colon cancer

Differential DiagnosisBased on History and Presentation

Differential DiagnosisConsider the following

Fibrocystic Mass Breast Cancer Fibroadenoma Cyst Fat necrosis

Physical Examination

What would you look for?

Physical Examination, Mrs. Trainor Relevant Exam findings for a problem focused assessment

Skin & Soft TissueBreasts: Symmetrical, no skin changes, nipples everted/ no

discharge. Right breast w/no dominant findings. Left breast with 1-2cm firm mass with ill-defined margins at 12’oclock, non-tender,

Nodes: No axillary or supraclavicular nodesChest: CTAABD: No Hepatosplenomegaly or massGenitorectal: Uterus retroflexed, no mass, no adnexal mass,

guaiac – stool, no massExtremities: No edema, Right-handed, neuro intact

Remaining Examination findings non-contributory

Studies

What further studies would you want at this time?

Studies, Mrs. Trainor

Breast Ultrasound ? Screening Mammogram ?

PA/Lat Chest ? Diagnostic Mammogram ?CT Scan of Chest ? Breast MRI ?PET SCAN ? Other:

Studies, Mrs. TrainorStudies, Mrs. Trainor

Breast Ultrasound Screening Mammogram ?

PA/Lat Chest ? Diagnostic Mammogram CT Scan of Chest ? Breast MRI ?PET SCAN ? Other:

MammogramComparison CC View

R L

Mammogram Comparison MLO Views

R L

Marker palpable

US Breast

L Breast

Studies – Results Focused L Breast US demonstrates a 1.7 cm poorly

defined, heterogeneous, hypoechoic nodule, with abnormal shadowing• Taller than wide orientation(violates tissue planes)• No additional abnormalities are noted

Mammogram reveals a 1.8cm spiculated mass, upper central L breast corresponding to palpable abnormality.• Dense parenchyma with no other abnormalities

What is the differential diagnosis at this point?

Revised Differential Diagnosis

1) Breast Cancer 2) Fibrocytic Mass3) Fat necrosis 4) Radial Scar5) Fibroadenoma6) Cyst

Discuss Mrs. Trainor’s Breast Cancer Risk Factors

Are there any tools to help determine her risk?

Risk Factors NEGATIVE Menarche/Menopause? Hormone Exposure Family with 1st degree

relatives w/ BCA Genetic predisposition

profile? Age

POSITIVE Menarche/Menopause? Parity Lactation Age at 1st pregnancy No hx. of at risk

pathology

Discuss Gail Model & other risk assessment options

Laboratory

What would you obtain?

Lab Discussion

No labs indicated at this point Patient has no clinical signs of infection and no

suggestion of any systemic disease Screening labs may be indicated for pre-op/ pre-

treatment

What next?

1. Additional Imaging?2. Observation ?3. Biopsy ?4. OR?5. Other?

Observation

Not reasonable in a post-menopausal high risk patient with a suspicious palpable mass,abnormal imaging and a strong family history.

Interventions at this point?

Discuss options for tissue diagnosis

Biopsy Techniques

Needle Core Biopsy FNA Excisional Biopsy Image Guided Biopsy

• Ultrasound• Stereotactic

Biopsy Options

Which techniques are applicable for Mrs. Trainor?

What are the advantages/disadvantages of each?

What information is needed from the biopsy specimen?

Biopsy Options

FNA is a minimally invasive technique best suited for clearly benign or clearly malignant lesions & less suited for indeterminate lesions. It provides small volume cellular material for cyto-pathologic diagnosis.

CORE BX is also minimally invasive, but provides a # of tissue cores for histo-pathologic diagnosis. Volume of specimen usually permits analysis of hormone receptors and Her-2-neu.

Biopsy Options

Image guided technique can be utilized with FNA but is most often used with CORE needle biopsy. Appropriate for non-palpable lesions identified by either mammography or US (CT & MRI too)

A number of devices are available and enable consecutive biopsies, varying sizes, marker clip deployment & localization wire placement.

US Directed Biopsy

Pathology

Invasive Ductal Adenocarcinoma Grade II ER+/PR+ Her2neu -

What next?

Treatment Considerations

Unilateral vs Bilateral Disease or Risk including genetic predisposition

Extent of Disease/ Clinical Stage Comorbidities Breast Conservation Patient Preference***

Surgical Treatment Options

Lumpectomy w/ SLN sampling +/-axillary dissection & post-op Radiation Therapy

Mastectomy w/ SLN sampling +/-axillary dissection +/- reconstruction

Modified Radical Mastectomy +/- reconstruction

Breast Reconstruction OptionsImmediate Staged Implant reconstruction/ tissue expander TRAM Flap Latissimus Dorsi Flap Free FlapsDelayed Staged Implant reconstruction/ tissue expander TRAM Flap Latissimus Dorsi Flap Free Flaps

Additional Treatment Considerations

Neoadjuvant Chemotherapy? Adjuvant Chemotherapy? Adjuvant Hormonal Therapy? Ablative therapies? Clinical Trials participation +/-

Management What would you advise for Mrs. Trainor?1) She wants to know more about Sentinel Lymph

Node Sampling.• Can you explain how it’s done and how it works?

2) She’s leaning toward breast conservation surgery but is worried the tumor might come back.

• What would you tell her regarding her risk and prognosis?

3) Will pre-operative genetic testing influence her treatment decision?

Discuss Surgical Risks & Potential Complications

Risks & Expected Course

Anesthetic Peri-operative

Medications• Antibiotic? • Lymphazurin reaction*

Incisions/ Dressings/ Drains Need for re-excision for margins or nodes

Complications

Wound Infection Breast Lymphedema Arm Lymphedema Seroma/Hematoma Nerve Injury Flap Necrosis Poor Cosmetic Result

Treatment, Mrs.Trainor

She elects Lumpectomy w/ SLN sampling & post-op RT• Pre-op Chem profile, and Chest X-ray are NL• No metastatic imaging was performed• She decides NOT to pursue genetic testing

Final Pathology• 1.9cm Invasive Ductal GrII with minor component of DCIS• 3 SLN’s negative by H&E and IHC• ER+/PR+ Her2Neu-

Pathology, Mrs. Trainor

Stage & Prognosis

Mrs. Trainor comes back to the office for her 1st post-op visit, doing well with no post-operative issues.

Discuss her pathology, Disease stage & prognosis Any further treatment recommendations?

Staging & Additional Treatment

Stage 1 T1c pN0 M0 Tumor >1cm <2cm, Nodes – by IHC/H&E No evidence of metastatic disease

What Next? Referral to medical oncologist for adjuvant therapy

considerations Referral to radiation oncologist for completion of

post-op RT Discuss long term follow-up recommendations

What if your patient is:

A 41-year-old female with a 6 week history of generalized fullness of her right breast and skin dimpling.

Exam demonstrates a 5 cm irregular fixed right breast mass with skin dimpling and palpable R axillary nodes.

Right Breast Skin Dimpling & Nipple Retraction

Right Breast Skin Dimpling & Nipple Retraction

Mammogram Right Breast

Pathology

Invasive Lobular Carcinoma Gr III, w/ lymphovascular invasion, minor component of DCIS

ER-/PR-, Her-2-Neu + FNA R Axillary node= Metastatic Lobular

Carcinoma

CT Chest

nodes

mass

What might this study add?

Breast MRI

What might this study add ?

How would her treatment differ?

Discuss pre-operative staging of locally advanced tumors

Discuss neoadjuvant chemotherapy options

What if your patient is:

A 47-year-old female with a 2 mo history of generalized breast tenderness fullness of her left breast, erythema and skin dimpling.

Left Breast Image

Breast Erythema & Satellite Lesion

Describe this finding

Describe this finding

Clinical Findings

Erythema with Peau d’orange skin change Satellite lesion Fixation of lesion to skin and chest wall?

MammogramComparison CC View

Pathology

Inflammatory Breast Cancer Invasive Ductal adenocarcinoma by core needle

biopsy of largest lesion Skin Biopsy demonstrates tumor infiltration of

dermal lymphatics

How will her evaluation and management differ from Mrs. Trainor?

What if your patient is:

A 71-year-old female with a 1 year hx of recurrent scaling rash of right nipple-areolar complex. No discharge. Has tried creams without relief. Last mammogram at age 60 was normal.

Mammogram

Image

Pathology

Core Biopsy of mammographic lesion shows invasive ductal adenocarcinoma

ER+/PR+ Her2Neu - Skin biopsy of nipple rash shows Paget’s disease

How will her management differ?

QUESTIONS ??????

Summary Identify key clinical,pathologic and

radiographic features of breast cancer Recognize risk factors, treatment implications

and relevant prognostic variables of various stages & types

Understand complexity of treatment decision making and appropriate patient counseling

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