How will you approach the 35- year old, with a 2x2x2cm, firm, mobile, well-circumscribed non- tender...

How will you approach the 35-year old, with a 2x2x2cm, firm, mobile, well-circumscribed non-tender mass on her R breast?

Approach

• History

• Physical Examination – breast exam- Evaluation of breast mass

• Breast imaging– Mammography– Ultrasound

Role of imaging modality

• Imaging methods are complements to, and not substitutes for, a thorough history and PE

• MAMMOGRAPHY– Screening mammography: used to detect unexpected

breast cancer in asymptomatic women. In this regard, it supplements history and P.E.

– Diagnostic mammography: used to evaluate women with abnormal findings such as breast mass. It may use views that better define the nature of any abnormalities.

– Although sensitive, not specific

• Ultrasound:– Most useful feature is the ability to distinguish

between cystic and solid masses– Not an effective screening test for cancer

(cannot detect microcalcifications or small lesions

– May help to confirm the diagnosis of a cyst or support a clinical impression of fibroadenoma

• Premenopausal– Evaluation of breast masses between age 30

and menopause is problematic ( presence of functional, cycling glandular tissue combined with a progressively increasing incidence of cancer

– Bilateral mammograms to look for concurrent nonpalpable disease

– Definitive diagnostic procedure

A mammogram was taken as seen in the picture. Is this benign or

malignant

benign

Benign vs Malignant

• RADIOLOGIC FINDINGS

• BENIGN– Round or oval smooth-edged masses. The

outline of the mass will be clearly defined, not blurry

• MALIGNANT– Sine qua non: spiculated density with ill-

defined margins

Features suggestive but not diagnostic of cancer

• Clustered microcalcifications

• Asymmetric density

• Ductal asymmetry

• Distortion of skin, nipple and normal breast architecture

• Should the patient have a mother who is a breast cancer survivor, how would that information change your management?

Family History

• Institute of Public Health UK

Relative Risk of Cancer

2nd degree relative

1.5

1st degree 2.1

mother 2.0

sister 2.3

Mother and sister

3.6

Individuals at increased breast cancer risk

• Close surveillance with Consultation breast examination (CBE), mammography, and possibly breast MRI – Self-breast exam at age 18; semi-annual CBE at age 25, annual mammography beginning age 25 or 10 years prior to earliest age of onset of a family member

• Chemoprevention using Tamoxifen (estrogen antagonist)

• Bilateral prophylactic mastectomies – reduces the chance of breast cancer in high risk women by 90%

How will you approach the 55 year old menopausal patient with

a 2cm diameter, mobile, firm, non-tender mass on her R

breast? Imaging modality in this case?

Postmenopausal

• Evaluation relatively straightforward

• Patients most prone to carcinoma

• After obtaining bilateral mammograms (to screen for concurrent, clinically unappreciated lesions) – biopsy of the palpable mass is indicated

• Cannot observe only

Diagnosis

• SIMPLE CYSTS– A cyst is a little pocket of fluid in the breast. – Occurs when a milk duct becomes blocked,

preventing the normal breast fluid to flow through the ducts

– Round, moveable lump that may be tender to touch

– Appear on a mammogram as a round or oval gray structure. Ultrasound can provide an accurate diagnosis of cysts

FNAC reveals NEGATIVE FOR MALIGNANT CELLS. How would

you now manage the patient?• Preoperative procedure and counseling

definitive procedure • Negative findings does not rule out cancer,

especially in women older than 50 years of age.• In any case, the involved duct- and a mass,

should be excised.• Many clinicians will not leave a dominant mass

in the breast even if the FNAC is negative, unless perhaps the fine-needle aspiration shows fibroadenoma.