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Breast Mass

Breast Mass

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Breast Mass

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  1. Breast Mass Connie Lee, M.D. Michael Hong, M.D. UF Surgery

  2. 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)

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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

  8. 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)

  9. 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%

  10. 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

  11. 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)