Breast Lump
- Any lump / mass noted on clinical exam or by pt
1 Given a well woman with concerns about breast disease, during a clinical encounter (annual or not):
a) Identify high-risk patients by assessing modifiable and non-modifiable risk factors
b) Advise regarding screening (mammography, breast self-examination) and its limitations.
c) Advise concerning the woman’s role in preventing or detecting breast disease (breast self examination, lifestyle changes).
Breast Cancer – Risk Factors (prolonged estrogen exposure)
- Gender (99% female), Age (80% >50yo) – the biggest risk factor!
- Prior Hx of breast Ca or prior breast biopsy (regardless of pathology)
- 1o relative with breast cancer (greater risk if premenopausal)
- BRCA relative
- Increased risk with high breast density
- Unopposed estrogen:
- nulliparity, first pregnancy >30yo,
- menarche <12yo, menopause >55yo
- Radiation exposure (mantle radiation for Hodgkin’s dz), >5yr of HRT
- Hx benign brest dz
- Atypical hyperplasia – 4x > moderate/florid hyperplasia – 2x > sclerosing adenosis / papilloma – 1.5x
- Modifiable:
- OCP use / Alcohol / sedentary lifestyle / obesity (wt) / pregnancy
Decreased risk with
- early childbirth, Lactation
- early menopause
Breast Cancer Risk Calculator: http://www.cancer.gov/bcrisktool/
Breast Cancer Screening: CTFPHC 2011:
Screening Mammography
- 74 do not routinely screening with mammography.
- 50–74 years, routinely screening with mammography every 2 to 3 years.
- Start 10 yr earlier of first age of breast cancer in first degree relative
- Risk of mammography: radiation exposure, pain, anxiety, false +
Diagnostic Mammography
- Post surgical biopsy / bening core biopsy
- Breast implants
- Pregnant or breastfeeding
- Breast cancer survivors
- women <40yo
Magnetic resonance imaging
-
We recommend not routinely screening with MRI scans. (Weak recommendation; no evidence)
Clinical breast examination
-
We recommend not routinely performing clinical breast examinations alone or in conjunction with mammography to screen for breast cancer. (Weak recommendation; low-quality evidence)
Breast self-examination
-
We recommend not advising women to routinely practice breast self-examination. (Weak recommendation; moderate-quality evidence)
They do not apply to women at higher risk due to
- personal history of breast cancer
- history of breast cancer in first degree relative
- known BRCA1/BRCA2 mutation
- BRCA1/2 are tumor supressor genes
- increase risk of breast, ovarian, colon, cervical, and uterine cancer
- prior chest wall radiation
Genetic Screening – High risk groups in women
- >1 first degree relative with breast cancer
- at risk of mutations in BRCA1 or BRCA2
- A woman with a sister or mother with bilateral breast ca – 4x risk if the case were postmenopausal & 9x if premenopausal & higher risk if
- Also a family hx of ovarian ca or male breast ca
- Ashkenazi Jewish heritage
Higher Risk Screening: women 30-69yo (OBSP) – annual mammography / MRI
- carriers of a deleterious gene mutation (e.g. BRCA1, BRCA2) o
- the first degree relative of a mutation carrier (e.g. BRCA1, BRCA2) and have declined genetic testing
- at ≥ 25% lifetime risk of breast cancer — must have been assessed using risk assessment tools, preferably at a genetics clinic
- Have received chest radiation before age 30 and at least 8 years previously.
2 Given a woman presenting with a breast lump (i.e., clinical features):
a) Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated.
b) Ensure adequate support throughout investigation of the breast lump by availability of a contact resource.
c) Use diagnostic tools (e.g., needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump.
PEx suggestive of benign breast dz:
- Smooth, discrete, well circumscribed
- Rubbery, mobile, nontender
- hormone dependent (cyclic) ad young age
- No skin or nipple changes
PEx suggestive of breast cancer
- Firm, fixed
- Indistinct / not well circumscribed
- skin of nipple changes (retraction) / peau d’orange
- Increasing size
Any palpable dominant breast mass requires further investigation
- Dx mammography (>30yo) is indicated in all pt, includes women
- indicative of malignancy:
- mass that is poorly defined, spiculated border
- microcalcifications
- architectural distortion
- interval mammographic changes
- normal mammogram doesn’t r/o suspicion of cancer based on clinical findings
- U/S: differentiate btw cystic & solid
- Test of choice for women
- MRI: high sensitivity, low specificity
- if very dense breast
- Galactogram / ductogram (for nipple discharge): identifies lesions in ducts
Metastatic w/u after surgery or if clinical suspicion of metastatic dz:
- CT chest/abdomen/pelvis / or bone scan, abdominal u/s ,CXR /
- head CT only if specific neurological symptoms
Tissue Sampling – dx:
- Needle aspiration (use a bigger needle prn):
- for palpable cystic lesions – send fluid for cytology if blood or cyst doesn’t completely resolve
- Otherwise, can discard the fluid (controversial, but recommended by the guideline)
- FNA – for solid mass – often low yield
- U/S or mammography guided core needle biopsy (most common)
- FNA is preferable for palpable, low malignancy-risk lesions. However, for potential malignancies, CNB is advantageous with respect to prognostication and prediction and is likely cost- effective in the long-term.
- Excisional biopsy: second choice to core needle biopsy – shouldn’t be done for dx if possible
Genetic Screening – Test for BRCA1/2 if
- Pt dx with breast and ovarian ca
- strong family hx of breast/ovarian ca or male breast ca
Benign Breast Lesions (fibrocystic change, chronic cystic mastitis, mammary dysplasia)
- no increased risk of breast ca
- age 30 to menopause (after if HRT used)
Clinical Features
- Breast pain, focal areas of nodularity or cysts often in the upper outer quadrant
- Frequently bilateral, mobile, varies with menstrual cycle
- nipple discharge: straw-like, brown or green
Tx
- Evaluation of breast mass and reassurance
- if >40yo: mammography q3yr
- No strong evidence for avoidance of xanthine-containing products (coffee, tea, chocolate, cola)
- Analgesia: ibuprofen, ASA
- Severe symptoms: OCP, danazol, bromocriptine
Proliferative Lesions – No Atypia
Fibroadenoma
- Most common benign breast tumor <30yo
- Increase breast ca risk if fibroadenoma is complex, adjacent atypia or a strong family hx of breast ca
Clinical features:
- Nodules: smooth, rubbery, discrete, well-circumscribed, nt, mobile, hormone depedent
- Not a cyst – FNA yields no fluid
Ix
- Core / excisional biopsy required
- U/S and FNA alone cann’t differentiate fibroadenoma from Phyllodes tumour
Tx
- Generally conservative: serial observation
- Consider excision if size 2-3cm and growing on serial u/s (Q6mo x 2 yr), symptomatic or pt preference
Intraductal Hyperplasia
- Solitary intraductal benign polyp
Clinical Features:
- Nipple discharge – most common cause of spontaneous, unilateral, bloody nipple discharge
- breast mass – nodule on u/s
- Can harbour areas of atypia or DCIS
Tx: Excision of involved duct to ensure no atypia
Ductal Hyperplasia Without Atypia
- Increased number of cells within the ductal space – cells retain benign cytology
- No Tx required, slightly increased cancer risk if moderate or florid hyperplasia
Proliferative Lesions + Atypia: Atypical Hyperplasias
- Can involve ducts (ductal hyperplasia with atypia) or lobules (lobular hyperplasia with atypia)
- Cells lose apical-basal orientation – increased risk of breast cancer
Dx: Core / excisional biopsy
Tx: Complete resection, risk modification (avoid exogenous hormones), close f/u
DCIS (Ductal carcinoma in situ)
- neoplasm contained within breast ducts – 80% non-palpable & detected by screening
LCIS (Lobular carcinoma in situ)
- neoplasm contained within breast lobule – nonpalpable, not seen on mammography, usually found on biopsy
Infiltrative ductal carcinoma (most common 80%)
- Hard scirrhous, infiltrating tentacles, gritty on cross section
Invasive lobular carcinoma, 20% bilaterally
- originates from lobular epithelium, hard to detect
Paget’s dz
- Ductal carcinoma that invades the nipple with scaling + eczema
Inflammatory Breast Cancer
- Aggressive cancer defined by dermal lymphatic invasion
- May or may not be associated with a mass
- skin hot, red, painful, peau d’orange
- Generally have normal WBC and no fever
- If concerned, arrange for urgent mammography & obtain at least 2 skin punch biopsies
Other Lesions
Fat Necrosis
- result of trauma, after breast Sx
- Firm, ill-defined mass with skin / nipple retraction ± tenderness
- Regress spontaneously, but complete imaging ± biopsy to r/o carcinoma
Mammary Duct Ectasia
- Obstruction of a subareolar duct leading to duct dilation, inflammation, fibrosis
- may present with nipple discharge, bluish mass under nipple, local pain
- Risk of secondary infection (abscess, mastitis)
- Resolves spontaneously
Montgomery Tubercle
- Papular projections at the edge of the areola
- Obstruction of these glands can lead to inflammation / cystic collection (cyst of Montgomery – retroareolar cyst)
- If s/s of 2o infection, start Tx for mastitis
- Resolves spontaneously in weeks to years
Abscess
- Lactational vs periductal/subareolar
- Unilateral localized pain, tenderness, erythema, subareolar mass, nipple discharge, nipple inversion
- r/o inflammatory carcinoma
Tx: initially broad-spectrum abx and I&D, if persistent total duct excision (definitive)
- If mass doesn’t resolve, U/S to assess for presence of abscess, core biopsy to exclude cancer, consider MRI
3 In a woman who presents with a malignant breast lump and knows the diagnosis:
a) Recognize and manage immediate and long-term complications of breast cancer.
b) Consider and diagnose metastatic disease in the follow-up care of a breast cancer patient by appropriate history and investigation.
c) Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support).
Tx of breast ca
- Lumpectomy + radiation
- Masectomy + sentinel node biopsy
- Nodal status is the most important prognostic factor
- Node dissection
- Hormone therapy
- Chemotherapy
Post-Treatment Follow-up
- visits q3-6mo x 2 yr and annually thereafter (frequency is controversial)
- annual mammography; no other imaging unless clinically indicated
- psychosocial support and counseling
Complications of breast Cancer
- Sx
- Lymphedema – nodal metastasis or node dissection
- cellulitis, phantom pain
- Generalized aches and pains
- S/E from XRT
- weakness / paresthesia, CAD, valvular dz) /
- S/E from chemoTx
- premature ovarian failure, dilated cardiomyopathy, secondary cancer, cognitive dysfunction)
- Mets:
- bone > lung > liver > brain
- Meds:
- Estrogen : VTE
- Estrogen antagonists: hot flashes, vaginal dryness
- Progestin: wt gain, nausea, fluid retention
- Aromatase inhibitors: somnolence, skin rash
Local/Regional Recurrence
- recurrence in treated breast or ipsilateral axilla
- 1% per year up to maximum of 15% risk of developing contralateral malignancy
- 5x increased risk of developing metastases
Metastasis
- bone > lungs > pleura > liver > brain
- treatment is palliative: hormone therapy, chemotherapy, radiation
References:
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