Breast Lump – CTFPHC 2011

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
  1. Sx
    • Lymphedema – nodal metastasis or node dissection
    • cellulitis, phantom pain
  2. Generalized aches and pains
  3. S/E from XRT
    • weakness / paresthesia, CAD, valvular dz) /
  4. S/E from chemoTx
    • premature ovarian failure, dilated cardiomyopathy, secondary cancer, cognitive dysfunction)
  5. Mets:
    • bone > lung > liver > brain
  6. 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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Posted in 11 Breast Lump, 99 Priority Topics, FM 99 priority topics, Gyne

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