Breast

 

  • Important history includes: pain, family history, menstruation (early menarche or late menopause increase risk), age of 1st preganncy, previous breast cancer, previous breast procedures, or estrogen hormone replacement therapy (HRT).
  • Risks include: female, menarche <12yo, menopause >50yo, previous breast cancer, HRT for >5yrs, family history, delayed pregnancy (>30yo), prior radiation, obesity.
  • Physical exam includes: bilateral breast and skin exam, lymph basin exam, liver palpation.
  • 12% lifetime risk in the normal population
  • BRCA 1 increases breast and ovarian cancer risk
  • BRCA 2 increases breast, ovarian, pancreatic, and male breast cancer risk

Breast Studies

  • Fine needle aspiration (FNA)= 23G needle on a 10ml syringe on negative pressure, take approximately 6 passes through the lesion, stop suction, and withdrawl.
  • Core biopsy= 14G needle
  • Stereotactic biopsy= image guided biopsy for lesions only seen on mammogram. Patient lies prone with breast in mammogram unit. The unit moves to give a stereo view. The machine sets the axis for biopsy.
  • Open biopsy= needed for
    • ADH
    • LCIS
    • Papillary lesion
    • BIRAD 5
    • pseudoangiomatosis hyperplasia
    • radial scar
    • phylloides tumor
  • Bilateral mammogram (MMG)= 10% false negative and false positives.Concerning patterns include cluster calcifications (>4 microcalcifications in 1cm square area), calcifications along ducts, irregular calcifications.
    • Birad score:
      • 0= inconclusive
      • 1= normal
      • 2= benign finding
      • 3= probably benign
      • 4= suspicious finding
      • 5= suggestive of cancer
      • 6= known cancer
  • Breast Ultrasoud= differentiates cyst versus solid lesions. Best for women < 30 years old due to dense breasts making mammogram difficult. Characteristcs of breast cancer on ultrasound include:
    • taller than fat
    • irregular
    • uneven echotexture
  • MRI= good for evaluation of lesions with breast impants and for determining extent of cancer to help determine breast conservative therapy versus mastectomy.

Breast Conditions

 

Breast Cyst

  • Dx: best evaluated with ultrasound
  •  Tx: needle aspiration for diagnosis and possible further treatment
    • Cyst with clear fluid that disappears after aspiration = observe, can repeat up to two times
    • Cyst with bood = fluid for cytology and excisional biopsy of lesion
    •  Cyst with clear fluid that returns after aspiration more than twice = excisional biopsy
Fibroadenoma 
  • Tx: excision and follow up
 
Cystosarcoma phyllodes
  • Tx: wide local excision with 1-2 cm margins. doxorubicine and ifosfamide for lesions >5 cm or stromal overgrowth
Fat necrosis and sclerosing adenosis
  • Tx:  local excision
 
Plasma cell mastitis, Duct ectasia, Subareolar chronic abscess
  • Tx: antibiotics, drainage, elective subareolar duct excision
Fibrocystic disease
  • Tx: reassurance
    • Open biopsy for dysplasia or papillomatosis
    • caffeine reduction
    • primrose oil 1000mg TID for 2-4 months
    • Danazol 100mg Qday
    • Bromocriptine 5mg Qday
    • Mastectomy only for severe unrelenting pain after other pathology rulled out
Palpable Breast Mass not seen on imaging studies
  • Tx:  can follow up in one menstrual cycle
    • if  lesion persists get core or excisional biopsy
  • Bloody nipple discharge
    • Dx: differentiate endocrine abnormality versus a lesion
      • bilateral clear discharge needs endocrine evaluation and treatment
      • try to milk areolar quadrants to localize the lesion
      • bilateral MMG
      • ductogram
    • Tx: based on ability to localize a lesion
      • ID quadrant but no mass - subareolar wedge resection of ductal system
      • ID quadrant and a mass - subareolar wedge and excisional biopsy
      • no quadrant - observe for a cycle and ask patient to try to localize, if still unable to localize, do complete subareolar duct excision
    Axillary lymph node
    • Dx: ask about infection, neoplasm history, lymphoma symptoms
      • differential includes ipsilateral breast cancer, lymphoma, melanoma, lung cancer, GI cancer, ovarian cancer
      • examine chest, lymph nodes, lung, guiac/rectal, palpate abdomen
      • core biopsy (look for ER/PR for breast, negative mucin stain for melanoma/lymphoma)
      • If adenocarcinoma, need PSA, MMG, CXR, CT abdomen/pelvis, bone sca, pan endoscopy, CA-125
    • Tx: if unable to localize adenocarcinoma, can do modified radical mastectomy

    Breast Cancer

    • Staging Overview: (IIb-IIIb is locally advanced)
      • I= <2cm, no nodes
      • IIa= 2-5cm, no node; or <2cm with +node
      • IIb= 2-5cm with +node; or >5cm no node
      • IIIa= >5cm with +node
      • IIIb= peu de orange, chest wall invasion
      • IV= metastatic
    • LCIS= lobar carcinoma in-situ. Gives a 20-40% increased lifetime risk of cancer (bilateral risk)
      • Tx: Observe q6 months with MMG (bilateral)
        • prophylactic tamoxifen
        • genetic test if risk factors for BRCA
        • bilateral prophylactic mastectomy with reconstruction for BRCA+
    • DCIS= ductal carcinoma in-situ. 50% risk of becoming invasive.
      • Dx: ask for size, mulitfocal/unifocal, comedo necrosis, differentiation
      • Tx: Breast conservation therapy (12% recurrence)
        • total mastectomy for diffuse disease
        • Sentinal Lymph Node Biopsy (SNLB) for high grade, comedo necrosis, or if plan mastectomy (disrupt lymph node drainage).
        • Tamoxifen decreases recurrence if ER+
    • Invasive breast cancer
      • Dx: workup includes CBC, CMP, CXR, bilateral MMG
        • Bone scan if Alk Phos or calcium is elevated
        • CT abdomen/pelvis if LFTs are abnormal
        • CT chest for symptoms
      • Tx:
        • BCT=  mobile, <4cm, not central, can get negative margins, good cosmetic result is likely
        • Total mastectomy with SLNB
        • Locally advanced --> neoadjuvent (TAC), SLNB (if node - after neoadjuvent tx ???), XRT postop
    • Disseminatd breast cancer
      • ER/PR positive gets estrogen suppression (tamoxifen, Lupron, or aromatase inhibitor)
        • postmenopausal - aromatase inhibitor
        • premenopausal - lupron or oophorectomy (then treat as postmenopausal)
    • Breast cancer in pregnancy
      • Tx:
        • can do SNLB (no blue die, no SNLB before 30 weeks)
        • Chemotherapy (FAC) is ok after 1st trimester
    • Paget's disease of the nipple
      • Dx: Exam with bilateral MMG to look for invasive cancer or DCIS
        • mass - gets excisional biopsy and full thickness biopsy of nipple areolar complex (NAC)
        • no mass - full thickness biopsy of NAC
      • Tx:
        • mass - simple mastectomy with SLNB or BCT with excision of NAC (only do SLNB with BCT if path shows invasive cancer)
        • no mass - simple mastectomy with SNLB
    • Inflammatory breast cancer
      • Dx: differentiate from mondor's disease, mastitis, or abscess
        • Full thickness skin biopsy
        • metastatic workup
      • Tx:
        • neoadjuvant therapy
        • mastectomy with SLNB if good responce
        • XRT prior to toilet mastectomy for poor responce
        • Adjuvant XRT
        • Tamoxifen
    • Local recurrance
      • Dx: Always start with rulling out distant mets (re-stage)
        • ask about previous cancer stage
        • ER/PR status
        • CBC, CMP, CT chest / abdomen / pelvis
        • FNA in the office
      • Tx:
        • Radiation (XRT) to chest wall for chest or axillary recurrance
        • small and mobile - resect (completion mastectomy for prior BCT), XRT, systemic therapy
        • large or fixed - core biopsy (with ER/PR status), systemic therapy, XRT, consider resection

    Breast Treatments

    • Breast conservation therapy (BCT)= resection of tumor with negative margins followed by radiation therapy.
      • Contraindications:
        • inability to get negative margins (1cm is optimal)
        • inability to get radiation (lumpectomy alone has 40% risk of recurrance, addition of radiation drecreases risk to 12%)
        • multicentric or multifocal
        • diffuse microcalcifications
        • inflammatory breast cancer
      • Relative contraindications
        • retroareolar tumor
        • collagen-vascular diseae
        • large tumor:breast ratio
        • pregnancy in 1st/2nd trimester
        • BRCA 1 or 2
        • Patient's choice
    • Mastectomy= removal of breast tissue
      • modified radical mastectomy= removal of breast and axillary node dissection
      • Total mastectomy= simple mastectomy= removal of breast
    • Postmastectomy radiation therapy indications:
      • >4 positive lymph nodes
      • Tumors that involve skin or chest wall
      • T3 tumor (>5cm)
    • Neoadjuvant chemotherapy for: inflammatory cancer, adherance to chest wall, or possible candidate for BCT excpet for size.
      • 5FU, Adriamycin, Cyclophosphamide (FAC)
      • Herceptin for 1yr if HER2neu +
      • Tamoxifen for 5yrs in premenopausal for ER+ or PR+ (then consider Arimidex if menopausal)
      • Aromatase inhibitor (Arimidex) for 5 yrs in postmenopausal ER+ or PR+
    • Adjuvant chemotherapy for: >2cm, >1cm if ER/PR negative, or positive lymph node
      • FAC for 6 months
      • Herceptin for 1yr if HER2neu +