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
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
- Birad score:
- 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 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
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+
- Tx: Observe q6 months with MMG (bilateral)
- 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
- Dx: workup includes CBC, CMP, CXR, bilateral MMG
- 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
- Tx:
- ER/PR positive gets estrogen suppression (tamoxifen, Lupron, or aromatase inhibitor)
- 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
- Dx: Exam with bilateral MMG to look for invasive cancer or DCIS
- 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
- Dx: differentiate from mondor's disease, mastitis, or abscess
- 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
- Dx: Always start with rulling out distant mets (re-stage)
Breast Treatments
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
- Contraindications:
- 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 +