Breast Lump – CTFPHC 2011

Breast Lump

• Any lump / mass noted on clinical exam or by pt

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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/

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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.

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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

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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

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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

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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

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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

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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

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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

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References:

• TN2014
• http://canadiantaskforce.ca/ctfphc-guidelines/2011-breast-cancer/patient-algorithm/
• UpToDate