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Breast Mass

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?. Characterization of Symptoms :

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Breast Mass

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  1. Breast Mass Linda M. Barney M.D. Wright State University

  2. Mrs. Trainor • Mrs. Trainor is a 57-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

  3. History What other points of the history do you want to know?

  4. Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/symptoms Pertinent PMH ROS MEDS Relevant Family Hx. History, Mrs. TrainorConsider the following:

  5. Characterize Symptoms • 3 week history of left breast lump. • 1st noticed in the shower • Bean sized and nontender • May have increased in size slightly

  6. Associated Signs & Symptoms • 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

  7. Pertinent PMH • 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

  8. Aleviating/ Exacerbating factors • No change with activity • Uses Ibuprofen for headache with no change in the lump • Drinks decaffeinated tea and sodas only

  9. 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

  10. Differential DiagnosisBased on History and Presentation

  11. Differential DiagnosisConsider the following • Fibrocystic Mass • Breast Cancer • Fibroadenoma • Cyst • Fat necrosis

  12. Physical Examination What would you look for?

  13. 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

  14. Studies What further studies would you want at this time?

  15. Studies, Mrs. Trainor

  16. Studies, Mrs. Trainor

  17. MammogramComparison CC View R L

  18. MammogramComparison MLO Views R L  Marker palpable

  19. US Breast L Breast

  20. 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?

  21. Revised Differential Diagnosis • Breast Cancer • Fibrocytic Mass • Fat necrosis • Radial Scar • Fibroadenoma • Cyst

  22. Discuss Mrs. Trainor’s Breast Cancer Risk Factors Are there any tools to help determine her risk?

  23. 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 Risk Factors Discuss Gail Model & other risk assessment options

  24. Laboratory What would you obtain?

  25. 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/ pre-treatment

  26. What next? • Additional Imaging? • Observation ? • Biopsy ? • OR? • Other?

  27. Observation • Not reasonable in a post-menopausal high risk patient with a suspicious palpable mass,abnormal imaging and a strong family history.

  28. Interventions at this point?

  29. Discuss options for tissue diagnosis

  30. Biopsy Techniques • Needle Core Biopsy • FNA • Excisional Biopsy • Image Guided Biopsy • Ultrasound • Stereotactic

  31. Biopsy Options • Which techniques are applicable for Mrs. Trainor? • What are the advantages/disadvantages of each? • What information is needed from the biopsy specimen?

  32. 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.

  33. 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.

  34. US Directed Biopsy

  35. Pathology • Invasive Ductal Adenocarcinoma Grade II • ER+/PR+ Her2neu -

  36. What next?

  37. Treatment Considerations • Unilateral vs Bilateral Disease or Risk including genetic predisposition • Extent of Disease/ Clinical Stage • Comorbidities • Breast Conservation • Patient Preference***

  38. Surgical Treatment Options • Lumpectomy w/ SLN sampling +/-axillary dissection & post-op Radiation Therapy • Mastectomy w/ SLN sampling +/-axillary dissection +/- reconstruction • Modified Radical Mastectomy +/- reconstruction

  39. 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

  40. Additional Treatment Considerations • Neoadjuvant Chemotherapy? • Adjuvant Chemotherapy? • Adjuvant Hormonal Therapy? • Ablative therapies? • Clinical Trials participation +/-

  41. Management What would you advise for Mrs. Trainor? • She wants to know more about Sentinel Lymph Node Sampling. • Can you explain how it’s done and how it works? • She’s leaning toward breast conservation surgerybut is worried the tumor might come back. • What would you tell her regarding her risk and prognosis? • Will pre-operative genetic testing influence her treatment decision?

  42. Discuss Surgical Risks & Potential Complications

  43. Risks & Expected Course • Anesthetic • Peri-operative • Medications • Antibiotic? • Lymphazurin reaction* • Incisions/ Dressings/ Drains • Need for re-excision for margins or nodes

  44. Complications • Wound Infection • Breast Lymphedema • Arm Lymphedema • Seroma/Hematoma • Nerve Injury • Flap Necrosis • Poor Cosmetic Result

  45. 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-

  46. Pathology, Mrs. Trainor

  47. 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?

  48. 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

  49. 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.

  50. Right Breast Skin Dimpling & Nipple Retraction

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