Case Presentation & Discussion on Breast Mass Oliver S. - - PowerPoint PPT Presentation

Case Presentation & Discussion on Breast Mass

Oliver S. Leyson, MD Surgery Resident Department of Surgery Ospital Ng Maynila Medical Center

General Data:

M.L, 62 y/o, F Cavite City

Chief Complaint:

Breast Mass, right

History of Present Illness:

8 months PTA breast mass, right size of a 2x2 cm no other signs & symptoms noted no consult done

3 weeks PTA Mass was noted increased in size prompted consult OMMC advised surgery CONSULT

Past Medical History: Hypertension HBP: 180/100 Meds: metoprolol Family History: no history of breast cancer in the family Personal Social History: non-smoker non-alcoholic beverage drinker

Physical Examination:

Conscious, coherent, ambulatory, NICRD

• BP:140/80 CR:85

RR:21 T:37ºC

• Pink palpebral conjunctiva, anicteric sclerae
• Supple neck, (-) cervical LAD
• Symmetrical chest expansion, clear breath

sounds

Physical Examination

• Adynamic precordium, normal rate &

regular rhythm

• Flat, NABS, soft, nontender
• (-) cyanosis, (-) pallor

Breast:

3x3cm,hard, movable, non-tender mass at lower inner quadrant no ulceration (+) palpable axillary lymphadenopathy (-)

Salient Features:

• 62 y/o, F
• 8 months history breast mass
• 3x3cm, hard, movable, non-tender mass

at lower inner quadrant R breast

• no ulceration overlying the mass
• (+) palpable right axillary

lymphadenopathy

• (-) supraclavicular lymph nodes

BREAST MASS Inflammatory Non-Inflammatory Breast abscess mastitis Benign Malignant

Pattern Recognition

BREAST MASS Inflammatory Non-Inflammatory Breast abscess mastitis Benign Malignant Tumor, Rubor Calor, Dolor Acute onset

Pattern Recognition

BREAST MASS Inflammatory Non-Inflammatory Breast abscess mastitis Benign Malignant Fibroadenoma Breast carcinoma

Prevalence

62 yo female Hard, nontender

BREAST MASS Inflammatory Non-Inflammatory Breast abscess mastitis Benign Malignant Fibroadenoma Breast carcinoma

Prevalence

66 yo female Hard, nontender

Clinical Diagnosis:

Surgical 20% Breast mass prob benign Surgical 80% Breast mass prob malignant Treatment Certainty Diagnosis

Do I need a para-clinical diagnostic procedure?

Yes, to increase the certainty of my primary diagnosis.

Recommendations

In patients with palpable breast mass in which cancer is suspected BIOPSY is mandatory (Level I, Category A)

Evidence Evidence-

• based Clinical Practice Guidelines on the Diagnosis and

based Clinical Practice Guidelines on the Diagnosis and Management of Breast Cancer Part I. Early Breast Cancer. PCS 19 Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999. 99.

Goal of Paraclinical Diagnostic Procedure

• Adequate tissue for diagnosis

TREATMENT OPTIONS

94% 83% Sensitivity Bleeding Pain Specificity Accuracy + 900

******

95% *99% Core needle biopsy +++ 300

**

95% *92.8% FNAB AVAILABILIT Y COST RISK BENEFIT

*Adolfo AR; Nuguid TP; Cipriano MC; del Mundo AG; de Leon G. Fine-needle aspiration biopsy in the diagnosis of breast masses: a prospective study. Philipp J Surg Spec. 1986.

41(1):26-31.

TREATMENT OPTIONS

97% 97% Sensitivity Bleeding

• Pain
• Residual tumor

Specificity Accuracy

+++

600

******

98% 92.8% Incision biopsy

+++

600

******

99% >99% Excision Biopsy

AVAILA BILITY

COST RISK BENEFIT

Recommendations

• Fine needle aspiration cytology (FNAC) is

the initial diagnostic procedure in patients with a palpable breast mass in which cancer is suspected(Level I, Category A)

Evidence Evidence-

• based Clinical Practice Guidelines on the Diagnosis and

based Clinical Practice Guidelines on the Diagnosis and Management of Breast Cancer Part I. Early Breast Cancer. PCS 19 Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999. 99.

FNAC Result:

Smears show some groups of ductal cells exhibiting atypia with other individual cells showing the same features in the background. The individual cells exhibiting irregular nuclear contour and hyperchromatic nuclei. Diagnosis: Cell findings suggestive of malignant ductal cells

Pre-Treatment Diagnosis:

1% Breast Mass probably Benign (Fibroadenoma) 99% Breast Ca, Right Stage IIB (T2N1M0) Certainty Diagnosis

Goals of Treatment:

• RESOLUTION of the mass
• No complications
• No recurrence

TREATMENT OPTIONS

+++

3500

Bleeding

• Pain
• Anesthetic Risk
• Ischemia of skin

flaps

• Injury to nerves
• Lymphedema of

the arm

**8-12% 66-79% +++

Modified Radical Mastectomy

65-78% 65-78%

Overall survival Local recurrence Resolution of mass

++

7000

Bleeding

• Pain
• Anesthetic Risk
• Residual tumor
• Radiation

exposure

**13-20% +++

Breast Conservation therapy ++

3000

Bleeding

• Pain
• Anesthetic risk
• Residual tumor

**40% +++

Wide excision

AVAILABILI TY

COST RISK BENEFIT

**RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.

TREATMENT OPTIONS

+++

3500

Bleeding

• Pain
• Anesthetic Risk
• Ischemia of skin

flaps

• Injury to nerves
• Lymphedema of

the arm

**8-12% 66-79% +++

Modified Radical Mastectomy

65-78% 35-48%

Overall survival Local recurrence Resolution of mass

++

7000

Bleeding

• Pain
• Anesthetic Risk
• Residual tumor
• Radiation

exposure

**13-20% +++

Breast Conservation therapy ++

3000

Bleeding

• Pain
• Anesthetic risk
• Residual tumor

**40% +++

Wide excision

AVAILABILI TY

COST RISK BENEFIT

**RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.

Cabaluna ND.Current management of breast cancer. Acta Med Philipp.1993; 29(1):1-6.

• Adjuvant combination chemotherapy is

recommended for pre-menopausal women with involved axillary nodes while adjuvant hormonal therapy seems to benefit post-menopausal node-positive women, particularly those with positive hormone receptor levels.

• Multimodality treatment is necessary

to improve survival rates and decrease local recurrence

Pre-op preparation:

• Informed consent secured
• Psychosocial support provided
• Optimized patient’s physical health
• Patient screened for any health condition
• Operative materials secured

Intra-op Management:

• Patient placed under GA with R arm extended
• Transverse elliptical incision
• Superior & inferior flaps created
• Breast tissue dissected from the pectoralis major

fascia

• Clavipectoral fascia opened
• Axillary vein identified
• Palpable axillary LNs dissected
• Right breast and axillary LNs removed enbloc

• Washed with NSS
• Hemostasis
• Anterior & lateral drains placed, anchored with

silk 3-0

• Correct instrument,needle and sponge count
• Flaps apposed

– Subcutaneous & dermis closed with vicryl 2-0 – Skin- subcuticular with vicryl 4-0

• Povidone-iodine paint
• DSD
• Drain in negative pressure

Intra-operative findings:

• Right breast measured 10x15cm with a 3x3 cm

hard gritty mass, movable at the upper outer quadrant.

• (-) levels 1 and 2 axillary LNs, multiple, not

matted, largest of which measured 1x1cm.

Final Diagnosis:

Breast CA, Right Stage II B (T2N1M0) S/P Modified Radical Mastectomy Right

Post-operative

• Routine use of any combination of analgesics

resulting in a pain-free post-operative period

• Arm rehabilitation exercises
• Discharge within 48 hours post-operation, with

tube drain, and with instructions on:

• care of tube drain
• intake of analgesics
• arm rehabilitation exercises

FOLLOW-UP

First follow-up visit 5-7 days of discharge Second follow-up is 30 days after the operation Adjuvant treatment is started within 6 weeks of the

• peration

Frequency of follow-up: First 2 years – every 6 months After 2 years – yearly Patients are given instructions to consult earlier if with symptoms Routine annual contralateral breast mammography Symptom-directed metastatic work-up Annual gynecologic evaluation is advised for patients

• n Tamoxifen

Follow-up plan:

• TCB after 1 week for removal of lateral drain
• Awaiting final histopath result
• ER-PR determination

Post-menopausal ER (+) Tamoxifen ER (-) Chemotherapy ER Unknown Tamoxifen

Follow-Up Care

• After primary therapy, patients should be followed for

life, – to detect recurrences – to observe the opposite breast for a second primary

• First 3 years, patient is examined every 3-4 months
• Thereafter, examination is done every 6 months until

5 years postoperatively

• Then, every 6-12 months for the rest of the life

Outcome:

• Resolution of the breast mass
• Live patient
• Discharged
• Happy and contented with the outcome
• No complications
• Satisfied patient
• No medico-legal suit

Sharing of Information:

STAGING

• TNM staging (AJCC 6th edition)
• Staging Maneuvers
• Routine contra lateral breast mammography for

all patients with microscopic evidence of breast cancer

• Routine bilateral breast mammography for

patients in whom breast conservation treatment is contemplated

• Individual organ investigation for metastatic

work-up should be symptom-directed

TREATMENT

Goals of Treatment

• CURE – for Stage I to Stage IIIA
• PALLIATION – for stage IIIB, IIIC and Stage IV

Stage I – II

Definitive treatment: MRM or Breast conservation + RT

Contraindications for Breast Conservation + RT:

• Patient’s refusal for the procedure
• pregnancy
• relatively small size of breast
• inaccessibility or unavailability of RT
• multicentricity of tumor

ADJUVANT TREATMENT

N0 No adjuvant treatment N(+) Pre-menopausal ER (+) Chemotherapy OR Surgical oophorectomy + Tamoxifen ER (-) Chemotherapy ER Unknown Chemotherapy Post-menopausal ER (+) Tamoxifen ER (-) Chemotherapy ER Unknown Tamoxifen

Tamoxifen is given 20 mg daily for a period of 5 years

Invasive Ductal CA

• accounts for about 80% of all breast cancers.

Ducts Lobules Nipple

Invasive Ductal CA

Invasive Ductal CA

• Most common type of breast CA occurring as an

irregular hard nodule

• Histologically, composed of malignant ductal cells

disposed in cords, solid cell nests, tubules, anastomosing sheets, and various mixtures of all these

• Cells are dispersed in a dense stromal reaction

responsible for the hard consistency of the tumor.

• Robbins SL, Cotran RS, Kumar V, Pathologic Basis of
• Disease. Pp1436,2003.

Risk factors for Breast Cancer

• White race
• Increased age
• Family history in mother, sister or daughter
• BRCA1 or BRCA2 mutation
• Previous history of endometrial cancer, some

forms of mammary dysplasia and cancer in the

• ther breast
• Early menarche or late menopause
• Nulliparous or late first pregnancy

Diagnosis

• Out-patient breast biopsy permits:

– Diagnosis based on permanent section rather than on quick sections – Further consultation, if necessary, and staging procedures before treatment when cancer is found – Discussion of treatment based on a firm diagnosis

• The trauma involved in biopsy or a short delay

between biopsy and definitive treatment does not adversely affect the prognosis

Nora PF, Operative Surgery Principles and Techniques

Staging

>1.0cm – 2.0cm T1c >0.5cm – 1.0cm T1b >0.1cm – 0.5cm T1a Microinvasion 0.1cm or less in greatest dimension T1 mic Tumor 2cm or less in greatest dimension T1 Paget’s disease of the nipple with no tumor Note: Paget’s disease associated with a tumor is classified according to the size of the tumor Tis (Paget) Lobular carcinoma in situ Tis (LCIS) Ductal carcinoma in situ Tis (DCIS) Carcinoma in situ Tis No evidence of primary tumor T0 Primary tumor cannot be assessed TX Assessment Primary Tumor (T)

Staging

Inflammatory carcinoma T4d Both T4a and T4b T4c Edema (including peau d’ orange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast T4b Extension to the chest wall, not including the pectoralis muscle T4a Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below T4 >5cm T3 >2cm – 5cm T2 Assessment Primary Tumor (T)

Staging

Metastasis only in clinically apparenta ipsilateral internal mammary nodes and in the absence of clinically evident axillary lymph node metastasis N2b Metastasis in ipsilateral axillary lymph nodes fixed to

• ne another (matted) or to other structures

N2a Metastasis in ipsilateral axillary lymph nodes fixed or matted, or in clinically apparent a ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastasis N2 Metastasis in movable ipsilateral axillary lymph nodes N1 No regional lymph node metastasis N0 Regional lymph nodes cannot be assessed (eg. Previously removed) NX Assessment Regional Lymph Nodes (N)

Staging

Metastasis in ipsilateral supraclavicular lymph node(s) N3c Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) N3b Metastasis in ipsilateral infraclavicular lymph node(s) and axillary lymph node(s) N3a Metastasis in ipsilateral infraclavicular lymph node(s),

• r in clinically apparenta ipsilateral internal mammary

lymph node(s) and in the presence of clinically evident axillary lymph node metastasis; or metastasis in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement N3 Assessment Regional Lymph Nodes (N)

Staging

Distant metastasis M1 No distant metastasis M0 Distant metastasis cannot be assessed MX Assessment Distant metastasis (M)

Staging

M1 Any N Any T IV M0 N3 Any T IIIC M0 M0 M0 N0 N1 N2 T4 T4 T4 IIIB M0 M0 M0 M0 M0 N2 N2 N2 N1 N2 T0 T1a T2 T3 T3 IIIA M0 M0 N1 N0 T2 T3 IIB M0 M0 M0 N1 N1 N0 T0 T1a T2 IIA M0 N0 T1a I M0 N0 Tis Stage grouping

Modified Radical Mastectomy

• modified radical mastectomy removes the entire breast

and includes axillary dissection, in which axillary lymph nodes are also removed.

A pink highlighted area indicates tissue removed at mastectomy B axillary lymph nodes: levels I C axillary lymph nodes: levels II D axillary lymph nodes: levels III

Chemotherapy

BSA = squareroot [(wt. in kg x Ht in cm)/ 3600] = m2 CMF every 21-28 days

• Cyclophosphamide

100mg/m2 day 1-14 (50mg/tab)

• Methotrexate

40mg/m2 day 1 and 8 (50mg/2ml)

• 5FU

600mg/m2 day 1 and 8 (500mg/10ml) 6 cycles

Prognosis

• The stage of the breast cancer is the single most

reliable indicator of prognosis.

• Stage

Five years Ten years

• 95

90

• I

85 70

• IIA

70 50

• IIB

60 40

• IIIA

55 30

• IIIB

30 20

• IV

5-10 2

• All

65 30

REFERENCES:

Matsuda ML, Laudico AV, et al. Evidence-based clinical practice guidelines on the diagnosis and management of breast cancer Part

• I. Early Breast Cancer. PJSS 2001; 56(1):7-30.

Cabaluna ND. Current management of breast cancer. Acta Med Philipp.1993; 29(1):1-6. [Herdin] Patawaran E; del Rosario R. Modified radical mastectomy: a prospective randomized study of the lymph node salvage compared to classical radical mastectomy. PhilippJ Surg Spec: 1980;35(3):217-228.

References:

Newman LA, Washington TA, New trends in breast conservation therapy. Surg Clin N Am 2003; 83:841-883. Adolfo AR; Nuguid TP; Cipriano MC; del Mundo AG; de Leon G, Fine- needle aspiration biopsy in the diagnosis of breast masses: a prospective study. PJSS 1986; 41(1):26-31.[Herdin] Galut AG; Lasala AL. Treatment experience for breast carcinoma: a local

• verview. Philipp J Surg Spec. 1986.41(1):7-10 . [Herdin]

Nora PF, Operative Surgery Principles and Techniques, 3rd ed. WB Saunders; 1990;5:223-276. Schwartz SL, et al. Principles of Surgery, 7th ed. McGraw-Hill; 1998;14: 533-97. Robbins SL, Cotran RS, Kumar V, Pathologic Basis of Disease, 5th ed. WB Saunders; 1995;20:430-435.

• “For practicing Filipino surgeon some light

and direction for the dilemma that besets him.

• As he or she continues or moves on his

surgical experience, he will realize that in the impossibility of his ideals, there is still an alternative: a good surgical acumen, a wise judgement.

• He has to make the most out of what the local

set-up can afford to offer in terms of surgical and technological expertise.”

Galut AG; Lasala AL. Treatment experience for breast carcinoma: a local overview Philipp J Surg Spec. 1986.41(1):7-10 . [Herdin]

Salamat Po……..

Questions

1. A breast condition is generally classified as a pre- cancerous condition among the following non-invasive breast cancers. a. Lobular carcinoma in situ b. Ductal carcinoma in situ c. Pagets disease on the nipple d. a and b only e. all

Questions

1. A breast condition is generally classified as a pre- cancerous condition among the following non-invasive breast cancers. a. Lobular carcinoma in situ b. Ductal carcinoma in situ c. Pagets disease on the nipple d. a and b only e. all

• 2. Based on the PCS clinical practice guideline,

what is the initial diagnostic procedure in patients with palpable breast mass? a. Fine needle aspiration cytology b. Core needle biopsy c. Excision biopsy d. Incision biopsy

• 2. Based on the PCS clinical practice guideline,

what is the initial diagnostic procedure in patients with palpable breast mass? a. Fine needle aspiration cytology b. Core needle biopsy c. Excision biopsy d. Incision biopsy

• 3. In the PCS clinical practice guideline for early breast

cancer, frozen section is advised during what condition? (Level III, Category A). a. In advanced stage b. In doubt of the diagnosis c. In early stage d. Patient’s request

• 3. In the PCS clinical practice guideline for early breast

cancer, frozen section is advised during what condition? (Level III, Category A). a. In advanced stage b. In doubt of the diagnosis c. In early stage d. Patient’s request

• 4. Which among the following risk factors for

breast cancer are related to prolonged exposure to estrogen ?

a. starting menstruation at a young age b. taking menopause hormone therapy for over five years with estrogen alone c. going through menopause at a late age d. never having had a full-term pregnancy

• 4. Which among the following risk factors for

breast cancer are related to prolonged exposure to estrogen ?

a. starting menstruation at a young age b. taking menopause hormone therapy for over five years with estrogen alone c. going through menopause at a late age d. never having had a full-term pregnancy

• 5. In women with early breast cancer, preoperative

mammography is recommended in the following? a. To detect subclinical diseased in the contralateral breast b. Women greater than 40 years of age c. Ipsilateral breast for those patients who will undergo breast conservation treatment d. Bilateral breast for high risk patient

• 5. In women with early breast cancer, preoperative

mammography is recommended in the following? a. To detect subclinical diseased in the contralateral breast b. Women greater than 40 years of age c. Ipsilateral breast for those patients who will undergo breast conservation treatment d. Bilateral breast for high risk patient