Transcript Mass Carcinoma

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
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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
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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
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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 Diagnosis
Based on History and Presentation
Differential Diagnosis
Consider the following
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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 Tissue
Breasts: 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 nodes
Chest: CTA
ABD: No Hepatosplenomegaly or mass
Genitorectal: Uterus retroflexed, no mass, no adnexal mass,
guaiac – stool, no mass
Extremities: 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 ?
PET SCAN ?
Breast MRI ?
Other:
Studies, Mrs. Trainor
Breast Ultrasound
Screening Mammogram ?
PA/Lat Chest ?
Diagnostic Mammogram
CT Scan of Chest ?
PET SCAN ?
Breast MRI ?
Other:
Mammogram
Comparison 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)
2)
3)
4)
5)
6)
Breast Cancer
Fibrocytic Mass
Fat necrosis
Radial Scar
Fibroadenoma
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/ pretreatment
What next?
1.
2.
3.
4.
5.
Additional Imaging?
Observation ?
Biopsy ?
OR?
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
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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 Options
Immediate
 Staged Implant reconstruction/ tissue expander
 TRAM Flap
 Latissimus Dorsi Flap
 Free Flaps
Delayed
 Staged Implant reconstruction/ tissue expander
 TRAM Flap
 Latissimus Dorsi Flap
 Free Flaps
Additional Treatment
Considerations
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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.
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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
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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
mass
nodes
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?
Mammogram
Comparison 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
Acknowledgment
The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we
welcome your comments/ suggestions at:
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