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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
slide6
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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