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
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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
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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
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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
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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
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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
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Tumor removal
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Node dissection
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Sentinel LN biopsy (for tumors >1cm), not for palpable LN
Axillary LN dissection (+sentinel node, palpable nodes), cx-lymphedema, nerve injury
Adjuvant Treatments
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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