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