Case scenario- Breast Lump M K ALAM

Case scenario A 50-year old female presented with a breast lump. What would you do?

History Self introduction Permission, privacy, chaperone Basic information: Name, age, nationality, gender

History When noticed (duration)? How noticed? Any change in the lump since first noticed? Any change in the breast/ nipple? Any associated symptom ? Pain, discharge Any relationship with menstrual cycle? Any history of trauma?

Past medical/ surgical history Breast problem Mammogram Breast biopsy Exposure to radiation (face, chest)- risk factor Other medical/ surgical history

Menstrual history History of pregnancy

The patient Age: 50 years Noticed the lump 2 weeks ago Painless No discharge PMH: Unremarkable FH: Unremarkable MH: Menopause, 2 children, menarche at 14 Breast fed her children No medication, Allergies- nil

Examination GE: unremarkable Local Examination: ? Position & exposure Normal side Affected side: Inspection- NAD Palpation: Mass in UOQ, 2.5 cm, firm to hard, No skin/ deep attachment Axilla: NAD both side What next?

Differential diagnosis ? Malignant mass Benign neoplasm Other benign lesions Cyst ? Most likely diagnosis ?What next Triple assessment ?

Investigations Hematology, Biochemical (u/e, LFT) Imaging: Mammography, US, MRI, Tissue diagnosis: Core biopsy (palpation/ image guided) Biopsy report: Type, OR/PR status, Her2neu Invasive duct carcinoma, HR +ve., Her2 neu –ve. Staging: CXR, CT, bone scan, PET scan

Management Benign: Observation/ surgery

MANAGEMENT OF BREAST CANCER- DCIS Localized disease (<4cm): Wide local excision with normal healthy tissue all round the margins + Radiotherapy ( except for very small lesions) Larger (>4cm) or widespread disease: mastectomy

MANAGEMENT OF INVASIVE BREAST CANCER Operable: T1-T3, N0,N1,M0 Loco-regional therapy+ systemic therapy.

Management Loco-regional therapy 1.BCT+ SLNB/ALND + Radiotherapy 2.Mastectomy + SLNB/ALND Systemic therapy: Chemotherapy/ hormone/ monoclonal antibody

MANAGEMENT OF INVASIVE BREAST CANCER Local Therapy Breast-conserving treatment (BCT): Suitable for tumor <4cm Excision of tumor with 1cm margin of normal tissue Sentinel node biopsy± node clearance. Postoperative radiotherapy (RT)

MANAGEMENT OF INVASIVE BREAST CANCER Local Therapy Modified radical mastectomy: Larger tumor, widespread disease or those who choose this treatment. Mastectomy with axillary surgery (SLB ± clearance) Radiotherapy only if: >3 LN involvement, Lymphatic/vascular invasion, Grade3 tumor, >4cm tumor, Tumor attached to pectoral fascia or close surgical margin <5mm

SYSTEMIC THERAPY Chemotherapy, hormone therapy, immunotherapy Adjuvant chemotherapy: given after surgery/ RT. For all except- tumor <1cm & grade 1 Common regimens: FAC (5-fluouracil,adriamycin, cyclophosphamide) 6cycles/ 21 days. AC ( adriamycin, cyclophosphamide), FEC (5-fluouracil,epirubicin, cyclophosphamide). Neoadjuvant chemotherapy: given before surgery/ radiotherapy to shrink larger tumors.

Hormone therapy Tamoxifen (partial estrogen agonist): 20 mg / day for 5 years for pre and postmenopausal Aromatase inhibitors (blocks conversion of androgens to estrogen): letrozole, anastrozole, exemestane. Postmenopausal women, hormone receptor +ve tumors Oophorectomy: Women <50, ER +ve tumors, metastatic disease ( surgical or radiation)

Anti-HER 2 therapy 15-20% tumor express HER2 Worse prognosis than HER2 negative tumors. Humanized monoclonal antibody- Trastuzumab

Case 2 A 20- year old female with a painless breast lump. Examination: Right breast: Normal Left breast: well defined, mobile, 3cmx 2cm firm mass in the lower part of the breast. No LAP Investigations: U/S, core biopsy

Fibroadenoma 15-25 years age group. ? Neoplasm, ? Aberration of development Well-circumscribed, smooth, firm, mobile mass. May be multiple or bilateral. Some may increase in size. > 5cm- giant fibroadenoma. 1/3rd may regress spontaneously. U/S- smooth outline mass. Management: Core biopsy. <4cm- Reassurance and follow up. >4cm- excision.

Case 3 45-year female A painless mass in left breast Examination: A 6x6 cm mass, non-tender, firm, well defined with smooth surface Investigations: Mammogram, U/S- cyst

Cysts Distended involuted lobules. Perimenopausal women. Smooth discrete lump, usually painless. U/S confirms cyst. Treatment: Aspiration of clear fluid & no residual mass- discharge patient. Aspiration of hemorrhagic fluid or cysts relapse- excision to rule out malignancy.

Case 4 History: Bloody discharge from the nipple. Examination: 0.5x0.5 firm sub-areolar mass, bloody discharge from nipple on pressure Investigations: mammogram, U/S, ductogram Duct papilloma Treated by duct excision- microdochectomy.

Case 5 40-year old female Large mass left breast, painless Examination: large, bosselated mass, non-tender, no skin or deep attachment. No axillary LAP U/S, mammogram, core biopsy Phyllodes tumour

Phyllodes tumor Fibroepithelial tumor Most are benign, some malignant. Usually large, bosselated, no attachment. Malignant may metastasize by blood Treatment : Wide local excision. Mastectomy for very large lesions. No axillary lymph node clearance needed