Transcript Breast Mass
Breast Mass Lori F Gentile, MD UF Surgery History for Breast Mass • HPI: • Location of mass • How was it identified • How long has it been present • Nipple changes - discharge (unilateral or B/L, # ducts involved, color, spontaneity), nipple inversion • New or persistent skin changes • Change in size or tenderness • Do symptoms vary with menstrual cycle • History of other breast complaints • PMHx (including reproductive hx), PSHx, SHx, FHx • ROS (note: malaise, bony pain, weight loss) 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/menopause, first full term pregnancy, parity • 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 Abnormal Mammogram • Abnormal screening mammogram is the most common initial presentation for women with breast cancer • 5% to 10% of all screening mammograms are abnormal • BIRADS – – – – – – 0 Additional imaging evaluation required 1 Negative finding; routine screening 2 Benign finding Negative mammogram, routine screening 3 Probably benign finding, short-interval follow-up 4 Suspicious abnormality; conisder bx 5 Abnormality highly suggestive of malignancy High probability of cancer; appropriate action should be taken PE for Breast Mass • Inspection: asymmetry, skin changes (dimpling, rashes), nipples (discharge, retraction, inversion). Perform sitting upright. • Palpation: regional LN (cervical, supra/infraclavicular, axillary), breast exam (borders: clavicle->infra-mammary fold, sternum,>posterior axillary line), nipple exam for discharge – Supine one arm raised • Mass characteristics to note: size, shape, location, consistency, and mobility – Hard, immobile, fixed, irregular borders are more likely malignant • Also, remember node levels: I (lateral to pec minor), II (deep to pec minor), III (medial to pec minor) Workup • Imaging • Bilateral diagnostic mammogram • U/S – solid vs cystic • MRI-can detect implant leaks, S&S still being assessed • Biopsy – Palpable – FNA or CNB – Non-palpable - stereotactic or ultrasound-guided percutaneous core biopsy Remember to correlate imaging findings with pathology results Management Algorithm http://www.aafp.org/afp/2005/0501/p1731.html DDX • Benign Breast Disease – Fibroadenoma – MCC breast mass in young women, firm, rubbery, smooth, mobile (hypoechoic mass on US) – Cyst – aspirate, if does not completely disappear then bx – Galactorrhea - increased prolactin, OCPs, TCAs, etc – Galactocele – breast cyst filled with milk – Fibrocystic disease – breast pain, nipple discharge, masses, cyclical size change – Mondor’s disease – superficial vein thrombophlebitis – Mastitis / Abscess-usually associated with breast feeding, s.aureus most common – Intraductal papilloma – MCC bloody nipple discharge – Asymmetry – normal, Poland syndrome, fat necrosis • Benign Tumor – Phyllodes tumor- mimics fibroadenoma, <5% metastisize, tend to recur locally, resect with 1 cm margins Carcinoma Histology • In situ carcinoma • Ductal carcinoma in situ: comedo vs. noncomedo • Lobular carcinoma in situ: increased risk of invasive ductal CA in bilateral breasts • Invasive carcinoma • Infiltrating ductal (75%) • Infiltrating lobular (10%) • Medullary (5%) - favorable • Mucinous (<5%) - favorable • Tubular (3%)-better prognosis • Papillary (1-2%) • Metaplastic breast cancer (<1%) • Mammary Paget disease (1-4%) • Locally advanced breast cancer – neoadjuvent chemo • Inflammatory breast cancer 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 • • 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% • Further evaluation based on stage: • Stages 1 & 2: lab studies- cbc, Lfts • Stage 3 (locally advanced or inflammatory) or symptomatic: CXR or chest CT, CT of abdomen/pelvis, +/- tumor markers, bone scan • Stage 4: PET scan Treatment of In Situ Carcinoma • DCIS: • Lumpectomy + XRT for most • Mastectomy if comedo pattern on biopsy or >5 cm • SLN bx in pts with palpable lesions, high grade DCIS, mastectomy • 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 • Tumor removal – – • Node dissection – – • Sentinel LN biopsy (for tumors >1cm), not for palpable LN Axillary LN dissection (+sentinel node, palpable nodes), cx-lymphedema, nerve injury Adjuvant Treatments – – – – – – • Lumpectomy with radiation therapy (not for pregnant, prior XRT, large tumor in small breast, scleroderma, tumor greater than 5 cm) Mastectomy 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) Tamoxifen, raloxifen in ER+ cancers Preventative Treatment Tamoxifen/raloxifen decrease risk of breast cancer if high risk pts