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

This patient Noticed the lump 2 weeks ago Painless No discharge PMH: Unremarkable FH: Unremarkable MH: Menopausal, 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

Investigations Hematology, Biochemical (u/e, LFT) Imaging: Mammography, US, MRI, Tissue diagnosis: Core biopsy (palpation/ image guided) Biopsy: Type, OR/PR status, Her2neu Staging: CXR, CT, bone scan, PET scan

TNM staging of breast cancer Stage Description Tumor TX Primary tumor not assessable T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor ≤2 cm in greatest dimension T1 mic Microinvasion ≤0.1 cm in greatest dimension T1a Tumor >0.1 cm but not >0.5 cm T1b Tumor >0.5 cm but not >1 cm T1c Tumor >1 cm but not >2 cm T2 Tumor >2 cm but <5 cm in greatest dimension T3 Tumor >5 cm in greatest dimension T4 Tumor of any size with direct extension into the chest wall or skin T4a Extension to chest wall (ribs, intercostals, or serratus anterior) T4b Peau d'orange, ulceration, or satellite skin nodules T4c T4a + b T4d Inflammatory breast cancer Regional lymph nodes NX Regional lymph nodes not assessable N0 No regional lymph node involvement N1 Metastasis to movable ipsilateral axillary lymph nodes N2 Metastases to ipsilateral axillary lymph nodes fixed to one anotheror to other structures N3 Metastases to ipsilateral internal mammary lymph node with or without axillary lymph node involvement, or in clinically apparent clavicular lymph node. Distant metastases MX Presence of distant metastases not assessable M0 No distant metastases M1 Existent distant metastases (including ipsilateral supraclavicular nodes)

Management Benign lump: Observation/ surgery Cysts: incomplete resolution/ recurrent Malignant lump: Loco-regional therapy BCT+ SLNB/ALND + Radiotherapy Mastectomy + SLNB/ALND Systemic therapy: Chemotherapy/ hormone/ monoclonal antibody

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 OF INVASIVE BREAST CANCER Local Therapy Breast-conserving treatment (BCT): Wide local excision (lumpectomy) + RT Suitable for tumor <4cm Excision of tumor with 1cm margin of normal tissue+ sentinel node biopsy± node clearance. Postoperative radiotherapy (RT) Modified radical mastectomy: Large tumor, widespread disease or those who choose this treatment. Whole breast with axillary surgery (SLB ± clearance) RT: high risk- >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- when given after surgery/ radiotherapy. 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- when 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

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: Diagnose by core biopsy. <4cm- Reassurance and follow up. >4cm- excision.

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.

Duct papilloma Bloody discharge from the nipple. Treated by duct excision- microdochectomy.

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