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