1. Case scenario- Breast Lump
M K ALAM

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

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

4. 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?

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

6. Menstrual history
History of pregnancy

7. 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

8. 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?

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

10. 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

12. Management
Benign: Observation/ surgery

13. 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

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

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

16. 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)

17. 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

18. 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.

19. Hormone therapy
Tamoxifen (partial estrogen agonist): 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)

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

21. 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

22. 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.

23. 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

24. 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.

25. 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.

26. 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

27. 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