Breast mass
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Breast Mass. Connie Lee, M.D. Michael Hong, M.D. UF Surgery. History for Breast Mass. HPI: Precise location of mass How was it identified How long has it been present Nipple discharge (unilateral or B/L, # ducts involved, color, spontaneity), nipple inversion

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Breast mass

Breast Mass

Connie Lee, M.D.

Michael Hong, M.D.

UF Surgery


History for breast mass

History for Breast Mass

  • HPI:

    • Precise location of mass

    • How was it identified

    • How long has it been present

    • Nipple discharge (unilateral or B/L, # ducts involved, color, spontaneity), nipple inversion

    • New or persistent skin changes

    • Size & change in size

    • Does the size change during the menstrual cycle

  • PMHx, PSHx, SHx, FHx

  • ROS (note: malaise, bony pain, weight loss)


Breast cancer risk factors

Breast Cancer Risk Factors

  • Risk factors to note during history:

    • Gender

    • Age

    • Prior breast cancer or breast biopsy (h/o ADH, ALH, LCIS increases risk)

    • FHx of cancer (relationship, age of onset, type of CA)

    • FHx of genetic mutations (BRCA1, BRCA2)

    • Age of menarche, first pregnancy, menopause

    • ETOH use, hormonal replacement therapy, DES exposure in utero

  • Risk calculated using the Gail model based on:

    • Age

    • Menarche

    • Reproductive history

    • FHx in 1st degree relatives

    • Prior biopsies


Pe for breast mass

PE for Breast Mass

  • Examine: neck, chest wall, breasts, and axillae – in upright and supine positions

  • Inspection: asymmetry, skin changes, nipples

  • Palpation: regional LN (cervical, supra/infraclavicular, axillary), breast exam (borders: clavicle, sternum, midaxillary line, rib cage)

  • Mass characteristics to note: size, shape, location, consistency, and mobility

  • Also, remember node levels: I (lateral to pec minor), II (deep to pec minor), III (medial to pec minor)


Workup

Workup

  • Initial breast mass workup:

    • Diagnostic mammogram (CC, MLO, magnification views)

    • U/S

    • Core biopsies +/- image guidance, FNA, excisional biopsy

  • Further evaluation based on stage:

    • Stages 1 & 2: lab studies

    • Stage 3 (locally advanced or inflammatory) or symptomatic: CXR or chest CT, CT of abdomen/pelvis, +/- tumor markers

    • Stage 4: PET scan

  • MRI


Breast mass

DDX

  • Non-tumor

    • Galactorrhea (increased prolactin)

    • Galactocele

    • Cyst

    • Fibroadenoma – MCC breast mass in young women, firm, rubbery

    • Fibrocystic disease – breast pain, nipple discharge, masses, cyclical size change

    • Mondor’s disease – superficial vein thrombophlebitis

    • Mastitis / Abscess

    • Intraductal papilloma – MCC bloody nipple discharge

    • Asymmetry – normal, Poland syndrome, fat necrosis

  • Benign Tumor

    • Cystosarcoma phyllodes

    • Fibromatosis


Carcinoma histology

Carcinoma Histology

  • In situ carcinoma

    • Ductal carcinoma in situ: comedo vs. noncomedo

    • Lobular carcinoma in situ: a biomarker of increased breast CA risk (note: no mass on PE)

  • Invasive carcinoma

    • Infiltrating ductal (75%)

    • Infiltrating lobular (10%)

    • Medullary (5%)

    • Mucinous (<5%)

    • Tubular (1-2%)

    • Papillary (1-2%)

    • Metaplastic breast cancer (<1%)

    • Mammary Paget disease (1-4%)

  • Locally advanced breast cancer

  • Inflammatory breast cancer


Prognostic predictive factors

Prognostic & Predictive Factors

  • Factors:

    • Axillary LN status

    • Tumor size

    • Lymphatic/vascular invasion

    • Age

    • Histologic grade

    • Histologic subtypes

    • Response to neoadjuvant therapy

    • ER/PR status (hormone-positive tumors have more indolent course & are responsive to hormonal therapy)

    • HER2/neu gene amplification and/or overexpression (HER2 overexpression a/w more aggressive tumor phenotype & worse prognosis)


Staging

Staging

  • Patients grouped into 4 stages based on:

    • Tumor size (T)

    • Lymph node status (N)

    • Metastasis (M)

  • Five-year survival rates a/w stage:

    • Stage 1: 99%

    • Stage 2: 86%

    • Stage 3: 57%

    • Stage 4: 20%


Treatment of in situ carcinoma

Treatment of In Situ Carcinoma

  • DCIS:

    • Lumpectomy + XRT for most

    • Mastectomy if comedo pattern on biopsy

    • Usually axillary dissection/SLN biopsy not recommended

    • Tamoxifen (SERM) is approved for adjuvant therapy in pts treated with breast-conserving therapy & radiation

  • LCIS:

    • Not premalignant itself, consider marker of future risk

    • Close observation

    • Chemoprevention w/SERM

    • B/L mastectomy +/- reconstruction


Treatment of invasive carcinoma

Treatment of Invasive Carcinoma

  • Tumor removal

    • Lumpectomy with radiation therapy (not for pregnant, 2+ primary tumors, prior XRT, large tumor in small breast, scleroderma)

    • Mastectomy

    • Modified radical mastectomy (includes level 1 LN)

  • Node dissection

    • Sentinel LN biopsy (for tumors >1cm), not for palpable LN

    • Axillary LN dissection (+sentinel node, palpable nodes)

  • Adjuvant Treatments

    • Postmastectomy radiation therapy

    • Adjuvant chemotherapy

    • Adjuvant therapy for HER2+ breast cancer with trastuzumab (Herceptin), a mAb targeting the extracellular domain of the receptor

    • Adjuvant hormonal therapy decrease estrogen’s ability to stimulate micro-metastases or dormant cancer cells

    • Aromatase inhibitors (aromatase converts other steroid hormones into estrogen)


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