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Case Presentation& Discussion on
Breast Mass
Oliver S. Leyson, MDSurgery Resident
Department of SurgeryOspital Ng Maynila Medical Center
General Data:
M.L, 62 y/o, FCavite City
Chief Complaint:
Breast Mass, right
History of Present Illness:
8 months PTA breast mass, right size of a 2x2 cm
no other signs & symptoms noted
no consult done
3 weeks PTA Mass was notedincreased in sizeprompted consult OMMCadvised surgery
CONSULT
Past Medical History: Hypertension HBP: 180/100 Meds: metoprolol
Family History: no history of breast cancer in the family
Personal Social History: non-smokernon-alcoholic
beverage drinker
Physical Examination:Conscious, coherent, ambulatory, NICRD• BP:140/80 CR:85 RR:21 T:37ºC• Pink palpebral conjunctiva, anicteric sclerae• Supple neck, (-) cervical LAD• Symmetrical chest expansion, clear breath
sounds
Physical Examination
• Adynamic precordium, normal rate & regular rhythm
• Flat, NABS, soft, nontender• (-) cyanosis, (-) pallor
Breast:3x3cm,hard, movable,non-tender mass at lowerinner quadrantno ulceration(+) palpable axillarylymphadenopathy (-)
Salient Features:• 62 y/o, F• 8 months history breast mass• 3x3cm, hard, movable, non-tender mass
at lower inner quadrant R breast• no ulceration overlying the mass • (+) palpable right axillary
lymphadenopathy• (-) supraclavicular lymph nodes
BREAST MASS
Inflammatory Non-Inflammatory
Breast abscessmastitis
Benign Malignant
Pattern Recognition
BREAST MASS
Inflammatory Non-Inflammatory
Breast abscessmastitis
Benign Malignant
Tumor, RuborCalor, Dolor
Acute onset
Pattern Recognition
BREAST MASS
Inflammatory Non-Inflammatory
Breast abscessmastitis
Benign Malignant
Fibroadenoma Breast carcinoma
Prevalence62 yo femaleHard, nontender
BREAST MASS
Inflammatory Non-Inflammatory
Breast abscessmastitis
Benign Malignant
Fibroadenoma Breast carcinoma
Prevalence66 yo femaleHard, nontender
Clinical Diagnosis:
Surgical20%Breast mass probbenign
Surgical80%Breast mass probmalignant
TreatmentCertaintyDiagnosis
Do I need a para-clinical diagnostic procedure?
Yes, to increase the certainty of my primary diagnosis.
Recommendations
In patients with palpable breast mass in which cancer is suspected BIOPSY is mandatory (Level I, Category A)
EvidenceEvidence--based Clinical Practice Guidelines on the Diagnosis andbased Clinical Practice Guidelines on the Diagnosis andManagement of Breast Cancer Part I. Early Breast Cancer. PCS 19Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999.99.
Goal of Paraclinical Diagnostic Procedure
• Adequate tissue for diagnosis
TREATMENT OPTIONS
94%
83%
Sensitivity BleedingPain
SpecificityAccuracy
+900
******95%*99%Core needle biopsy
+++300
**95%*92.8%FNAB
AVAILABILITY
COSTRISKBENEFIT
*Adolfo AR; Nuguid TP; Cipriano MC; del Mundo AG; de Leon G. Fine-needle aspiration biopsy in the diagnosis of breast masses: a prospective study. Philipp J Surg Spec. 1986. 41(1):26-31.
TREATMENT OPTIONS
97%
97%
Sensitivity Bleeding•Pain• Residual tumor
SpecificityAccuracy
+++600******98%92.8%Incision biopsy
+++600******99%>99%Excision Biopsy
AVAILABILITY
COSTRISKBENEFIT
Recommendations
• Fine needle aspiration cytology (FNAC) is the initial diagnostic procedure in patients with a palpable breast mass in which cancer is suspected(Level I, Category A)
EvidenceEvidence--based Clinical Practice Guidelines on the Diagnosis andbased Clinical Practice Guidelines on the Diagnosis andManagement of Breast Cancer Part I. Early Breast Cancer. PCS 19Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999.99.
FNAC Result:Smears show some groups of ductal cells exhibiting atypia
with other individual cells showing the same features in the background. The individual cells exhibiting irregular nuclear contour and hyperchromatic nuclei.
Diagnosis: Cell findings suggestive of malignant ductalcells
Pre-Treatment Diagnosis:
1%Breast Mass probably Benign(Fibroadenoma)
99%Breast Ca, RightStage IIB (T2N1M0)
CertaintyDiagnosis
Goals of Treatment:
• RESOLUTION of the mass
• No complications
• No recurrence
TREATMENT OPTIONS
+++3500
Bleeding•Pain•Anesthetic Risk•Ischemia of skin flaps•Injury to nerves•Lymphedema of the arm
**8-12%66-79%+++Modified Radical Mastectomy
65-78%
65-78%
Overall survival Local recurrenceResolution of mass
++
7000Bleeding•Pain•Anesthetic Risk •Residual tumor•Radiation exposure
**13-20%+++Breast Conservation therapy
++3000Bleeding
•Pain•Anesthetic risk •Residual tumor
**40%+++Wide excision
AVAILABILITYCOSTRISKBENEFIT
**RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.
TREATMENT OPTIONS
+++3500
Bleeding•Pain•Anesthetic Risk•Ischemia of skin flaps•Injury to nerves•Lymphedema of the arm
**8-12%66-79%+++Modified Radical Mastectomy
65-78%
35-48%
Overall survival Local recurrenceResolution of mass
++
7000Bleeding•Pain•Anesthetic Risk •Residual tumor•Radiation exposure
**13-20%+++Breast Conservation therapy
++3000Bleeding
•Pain•Anesthetic risk •Residual tumor
**40%+++Wide excision
AVAILABILITYCOSTRISKBENEFIT
**RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.
Cabaluna ND.Current management of breast cancer. Acta Med Philipp.1993; 29(1):1-6.
• Adjuvant combination chemotherapy is recommended for pre-menopausal women withinvolved axillary nodes while adjuvant hormonal therapy seems to benefit post-menopausal node-positive women, particularly those withpositive hormone receptor levels.
• Multimodality treatment is necessaryto improve survival rates and decrease local recurrence
Pre-op preparation:
• Informed consent secured• Psychosocial support provided• Optimized patient’s physical health• Patient screened for any health condition• Operative materials secured
Intra-op Management:
• Patient placed under GA with R arm extended• Transverse elliptical incision• Superior & inferior flaps created• Breast tissue dissected from the pectoralis major
fascia• Clavipectoral fascia opened• Axillary vein identified• Palpable axillary LNs dissected • Right breast and axillary LNs removed enbloc
• Washed with NSS• Hemostasis• Anterior & lateral drains placed, anchored with
silk 3-0• Correct instrument,needle and sponge count• Flaps apposed
– Subcutaneous & dermis closed with vicryl 2-0– Skin- subcuticular with vicryl 4-0
• Povidone-iodine paint• DSD• Drain in negative pressure
Intra-operative findings:
• Right breast measured 10x15cm with a 3x3 cm hard gritty mass, movable at the upper outer quadrant.
• (-) levels 1 and 2 axillary LNs, multiple, not matted, largest of which measured 1x1cm.
Final Diagnosis:
Breast CA, RightStage II B (T2N1M0)
S/P Modified Radical Mastectomy Right
Post-operative
Routine use of any combination of analgesics resulting in a pain-free post-operative periodArm rehabilitation exercisesDischarge within 48 hours post-operation, with tube drain, and with instructions on:
• care of tube drain• intake of analgesics• arm rehabilitation exercises
FOLLOW-UP
First follow-up visit 5-7 days of dischargeSecond follow-up is 30 days after the operationAdjuvant treatment is started within 6 weeks of the operationFrequency of follow-up:
First 2 years – every 6 monthsAfter 2 years – yearly
Patients are given instructions to consult earlier if with symptoms
Routine annual contralateral breast mammographySymptom-directed metastatic work-upAnnual gynecologic evaluation is advised for patients on Tamoxifen
Follow-up plan:
• TCB after 1 week for removal of lateral drain• Awaiting final histopath result• ER-PR determination
Post-menopausalER (+) TamoxifenER (-) ChemotherapyER Unknown Tamoxifen
Follow-Up Care
• After primary therapy, patients should be followed for life,– to detect recurrences– to observe the opposite breast for a second
primary• First 3 years, patient is examined every 3-4 months• Thereafter, examination is done every 6 months until
5 years postoperatively• Then, every 6-12 months for the rest of the life
Outcome:
• Resolution of the breast mass • Live patient• Discharged • Happy and contented with the outcome• No complications• Satisfied patient• No medico-legal suit
Sharing of Information:
STAGING
TNM staging (AJCC 6th edition)
Staging Maneuvers• Routine contra lateral breast mammography for
all patients with microscopic evidence of breast cancer
• Routine bilateral breast mammography for patients in whom breast conservation treatment is contemplated
• Individual organ investigation for metastaticwork-up should be symptom-directed
TREATMENT
Goals of Treatment
CURE – for Stage I to Stage IIIA
PALLIATION – for stage IIIB, IIIC and Stage IV
Stage I – II
Definitive treatment: MRM or Breast conservation + RT
Contraindications for Breast Conservation + RT:Patient’s refusal for the procedurepregnancyrelatively small size of breastinaccessibility or unavailability of RTmulticentricity of tumor
ADJUVANT TREATMENT
N0 No adjuvant treatment
N(+) Pre-menopausalER (+) Chemotherapy OR
Surgical oophorectomy+ Tamoxifen
ER (-) ChemotherapyER Unknown Chemotherapy
Post-menopausalER (+) TamoxifenER (-) ChemotherapyER Unknown Tamoxifen
Tamoxifen is given 20 mg daily for a period of 5 years
Invasive Ductal CA• accounts for about 80% of all breast cancers.
Ducts
Lobules
Nipple
Invasive Ductal CA
Invasive Ductal CA• Most common type of breast CA occurring as an
irregular hard nodule
• Histologically, composed of malignant ductal cells disposed in cords, solid cell nests, tubules, anastomosing sheets, and various mixtures of all these
• Cells are dispersed in a dense stromal reaction responsible for the hard consistency of the tumor.
- Robbins SL, Cotran RS, Kumar V, Pathologic Basis of Disease. Pp1436,2003.
Risk factors for Breast Cancer
• White race• Increased age• Family history in mother, sister or daughter• BRCA1 or BRCA2 mutation• Previous history of endometrial cancer, some
forms of mammary dysplasia and cancer in the other breast
• Early menarche or late menopause• Nulliparous or late first pregnancy
Diagnosis• Out-patient breast biopsy permits:
– Diagnosis based on permanent section rather than on quick sections
– Further consultation, if necessary, and staging procedures before treatment when cancer is found
– Discussion of treatment based on a firm diagnosis
• The trauma involved in biopsy or a short delay between biopsy and definitive treatment does not adversely affect the prognosis
Nora PF, Operative Surgery Principles and Techniques
Staging
>1.0cm – 2.0cmT1c>0.5cm – 1.0cmT1b>0.1cm – 0.5cmT1aMicroinvasion 0.1cm or less in greatest dimensionT1 micTumor 2cm or less in greatest dimensionT1
Paget’s disease of the nipple with no tumorNote: Paget’s disease associated with a tumor is
classified according to the size of the tumor
Tis (Paget)Lobular carcinoma in situTis (LCIS)Ductal carcinoma in situTis (DCIS)Carcinoma in situTisNo evidence of primary tumorT0Primary tumor cannot be assessedTXAssessmentPrimary Tumor (T)
Staging
Inflammatory carcinomaT4dBoth T4a and T4bT4c
Edema (including peau d’ orange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast
T4b
Extension to the chest wall, not including the pectoralis muscle
T4a
Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below
T4>5cmT3>2cm – 5cmT2AssessmentPrimary Tumor (T)
Staging
Metastasis only in clinically apparenta ipsilateral internal mammary nodes and in the absence of clinically evident axillary lymph node metastasis
N2b
Metastasis in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures
N2a
Metastasis in ipsilateral axillary lymph nodes fixed or matted, or in clinically apparent a ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis
N2
Metastasis in movable ipsilateral axillary lymph nodes
N1No regional lymph node metastasisN0
Regional lymph nodes cannot be assessed (eg. Previously removed)
NX
AssessmentRegional Lymph Nodes (N)
Staging
Metastasis in ipsilateral supraclavicular lymph node(s)
N3c
Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3b
Metastasis in ipsilateral infraclavicular lymph node(s) and axillary lymph node(s)
N3a
Metastasis in ipsilateral infraclavicular lymph node(s), or in clinically apparenta ipsilateral internal mammary lymph node(s) and in the presence of clinically evident axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement
N3
AssessmentRegional Lymph Nodes (N)
Staging
Distant metastasisM1
No distant metastasisM0
Distant metastasis cannot be assessedMX
AssessmentDistant metastasis (M)
Staging
M1Any NAny TIVM0N3Any TIIIC
M0M0M0
N0N1N2
T4T4T4
IIIB
M0M0M0M0M0
N2N2N2N1N2
T0T1a
T2T3T3
IIIA
M0M0
N1N0
T2T3
IIB
M0M0M0
N1N1N0
T0T1a
T2
IIAM0N0T1aIM0N0Tis0
Stage grouping
Modified Radical Mastectomy• modified radical mastectomy removes the entire breast
and includes axillary dissection, in which axillary lymph nodes are also removed.
A pink highlighted area indicates tissue removed at mastectomyB axillary lymph nodes: levels IC axillary lymph nodes: levels IID axillary lymph nodes: levels III
ChemotherapyBSA = squareroot [(wt. in kg x Ht in cm)/ 3600] = m2
CMF every 21-28 days• Cyclophosphamide 100mg/m2 day 1-14
(50mg/tab)• Methotrexate 40mg/m2 day 1 and 8
(50mg/2ml)• 5FU 600mg/m2 day 1 and 8
(500mg/10ml)
6 cycles
Prognosis• The stage of the breast cancer is the single most
reliable indicator of prognosis.
• Stage Five years Ten years• 0 95 90• I 85 70• IIA 70 50• IIB 60 40• IIIA 55 30• IIIB 30 20• IV 5-10 2
• All 65 30
REFERENCES:
Matsuda ML, Laudico AV, et al. Evidence-based clinical practice guidelines on the diagnosis and management of breast cancer PartI. Early Breast Cancer. PJSS 2001; 56(1):7-30.
Cabaluna ND. Current management of breast cancer. Acta Med Philipp.1993; 29(1):1-6. [Herdin]
Patawaran E; del Rosario R. Modified radical mastectomy: a prospective randomized study of the lymph node salvage compared to classical radical mastectomy. PhilippJ Surg Spec: 1980;35(3):217-228.
References:Newman LA, Washington TA, New trends in breast conservation therapy.
Surg Clin N Am 2003; 83:841-883.
Adolfo AR; Nuguid TP; Cipriano MC; del Mundo AG; de Leon G, Fine-needle aspiration biopsy in the diagnosis of breast masses: a prospective study. PJSS 1986; 41(1):26-31.[Herdin]
Galut AG; Lasala AL. Treatment experience for breast carcinoma: a local overview. Philipp J Surg Spec. 1986.41(1):7-10 . [Herdin]
Nora PF, Operative Surgery Principles and Techniques, 3rd ed. WB Saunders; 1990;5:223-276.
Schwartz SL, et al. Principles of Surgery, 7th ed. McGraw-Hill; 1998;14: 533-97.
Robbins SL, Cotran RS, Kumar V, Pathologic Basis of Disease, 5th ed. WB Saunders; 1995;20:430-435.
• “For practicing Filipino surgeon some light and direction for the dilemma that besets him.
• As he or she continues or moves on his surgical experience, he will realize that in the impossibility of his ideals, there is still an alternative: a good surgical acumen, a wise judgement.
• He has to make the most out of what the local set-up can afford to offer in terms of surgical and technological expertise.”
Galut AG; Lasala AL. Treatment experience for breast carcinoma: a local overviewPhilipp J Surg Spec. 1986.41(1):7-10 . [Herdin]
Salamat Po……..
Questions1. A breast condition is generally classified as a pre-
cancerous condition among the following non-invasive breast cancers.
a. Lobular carcinoma in situb. Ductal carcinoma in situc. Pagets disease on the nippled. a and b onlye. all
Questions1. A breast condition is generally classified as a pre-
cancerous condition among the following non-invasive breast cancers.
a. Lobular carcinoma in situb. Ductal carcinoma in situc. Pagets disease on the nippled. a and b onlye. all
2. Based on the PCS clinical practice guideline, what is the initial diagnostic procedure in patients with palpable breast mass?
a. Fine needle aspiration cytologyb. Core needle biopsyc. Excision biopsyd. Incision biopsy
2. Based on the PCS clinical practice guideline, what is the initial diagnostic procedure in patients with palpable breast mass?
a. Fine needle aspiration cytologyb. Core needle biopsyc. Excision biopsyd. Incision biopsy
3. In the PCS clinical practice guideline for early breast cancer, frozen section is advised during what condition? (Level III, Category A).
a. In advanced stageb. In doubt of the diagnosisc. In early staged. Patient’s request
3. In the PCS clinical practice guideline for early breast cancer, frozen section is advised during what condition? (Level III, Category A).
a. In advanced stageb. In doubt of the diagnosisc. In early staged. Patient’s request
4. Which among the following risk factors for breast cancer are related to prolonged exposure to estrogen ?
a. starting menstruation at a young age b. taking menopause hormone therapy for over five years
with estrogen alonec. going through menopause at a late aged. never having had a full-term pregnancy
4. Which among the following risk factors for breast cancer are related to prolonged exposure to estrogen ?
a. starting menstruation at a young age b. taking menopause hormone therapy for over five years
with estrogen alonec. going through menopause at a late aged. never having had a full-term pregnancy
5. In women with early breast cancer, preoperative mammography is recommended in the following?
a. To detect subclinical diseased in the contralateralbreast
b. Women greater than 40 years of agec. Ipsilateral breast for those patients who will undergo
breast conservation treatment d. Bilateral breast for high risk patient
5. In women with early breast cancer, preoperative mammography is recommended in the following?
a. To detect subclinical diseased in the contralateralbreast
b. Women greater than 40 years of agec. Ipsilateral breast for those patients who will undergo
breast conservation treatmentd. Bilateral breast for high risk patient
Recommended