1. Linda M. Barney M.D. Wright State University
Breast Mass
Linda M. Barney M.D.
Wright State University

2. Mrs. Trainor
Mrs. Trainor is a 57-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

3. History
What other points of the history do you want to know?

4. History, Mrs. Trainor Consider the following:
Associated signs/symptoms
Pertinent PMH
ROS
MEDS
Relevant Family Hx.
Characterization of Symptoms:
Temporal sequence
Alleviating / Exacerbating factors:

5. Characterize Symptoms
3 week history of left breast lump.
1st noticed in the shower
Bean sized and nontender
May have increased in size slightly

6. Associated Signs & Symptoms
Denies pain, skin change, nipple discharge
Prior history of Fibrocystic breasts, no biopsies
LMP 6 years ago
Last mammogram 11 months ago, routine mammography since 40’s
Denies trauma

7. Pertinent PMH Healthy, married, mother of 4 (3 girls 1 boy)
1st pregnancy age 21, Breast fed 3 of 4
Menarche age 11, OCP’s x 20 years total,
Menopause at 51, HRT w/ prempro x 7 years
Denies smoking, social alcohol only,no drugs
No chronic medical problems

8. Aleviating/ Exacerbating factors
No change with activity
Uses Ibuprofen for headache with no change in the lump
Drinks decaffeinated tea and sodas only

9. Family History
Maternal grandmother with breast cancer at age 62, maternal grandfather w/colon CA at 71
Mother and sister with breast cancer, mother at age 52, Sister at 47
2 maternal aunts with ovarian cancer, 1 maternal uncle with colon cancer

10. Differential Diagnosis Based on History and Presentation

11. Differential Diagnosis Consider the following
Fibrocystic Mass
Breast Cancer
Fibroadenoma
Cyst
Fat necrosis

12. Physical Examination
What would you look for?

13. Physical Examination, Mrs
Physical Examination, Mrs. Trainor Relevant Exam findings for a problem focused assessment
Skin & Soft Tissue
Breasts: Symmetrical, no skin changes, nipples everted/ no discharge. Right breast w/no dominant findings. Left breast with 1-2cm firm mass with ill-defined margins at 12’oclock, non-tender,
Nodes: No axillary or supraclavicular nodes
Chest: CTA
ABD: No Hepatosplenomegaly or mass
Genitorectal: Uterus retroflexed, no mass, no adnexal mass, guaiac – stool, no mass
Extremities: No edema, Right-handed, neuro intact
Remaining Examination findings non-contributory

14. Studies
What further studies would you want at this time?

15. Studies, Mrs. Trainor Breast Ultrasound ? Screening Mammogram ?
PA/Lat Chest ?
Diagnostic Mammogram ?
CT Scan of Chest ?
Breast MRI ?
PET SCAN ?
Other:

16. Studies, Mrs. Trainor Breast Ultrasound Screening Mammogram ?
PA/Lat Chest ?
Diagnostic Mammogram
CT Scan of Chest ?
Breast MRI ?
PET SCAN ?
Other:

17. Mammogram Comparison CC ViewL

18. Mammogram Comparison MLO Views
 Marker palpable

19. US Breast
L Breast

20. Studies – Results
Focused L Breast US demonstrates a 1.7 cm poorly defined, heterogeneous, hypoechoic nodule, with abnormal shadowing
Taller than wide orientation(violates tissue planes)
No additional abnormalities are noted
Mammogram reveals a 1.8cm spiculated mass, upper central L breast corresponding to palpable abnormality.
Dense parenchyma with no other abnormalities
What is the differential diagnosis at this point?

21. Revised Differential Diagnosis
Breast Cancer
Fibrocytic Mass
Fat necrosis
Radial Scar
Fibroadenoma
Cyst

22. Discuss Mrs. Trainor’s Breast Cancer Risk Factors
Are there any tools to help determine her risk?

23. Risk Factors NEGATIVE Menarche/Menopause? Hormone Exposure
Family with 1st degree relatives w/ BCA
Genetic predisposition profile?
Age
POSITIVE
Menarche/Menopause?
Parity
Lactation
Age at 1st pregnancy
No hx. of at risk pathology
Discuss Gail Model & other risk assessment options

24. Laboratory
What would you obtain?

25. Lab Discussion No labs indicated at this point
Patient has no clinical signs of infection and no suggestion of any systemic disease
Screening labs may be indicated for pre-op/ pre-treatment

26. What next?
Additional Imaging?
Observation ?
Biopsy ?
OR?
Other?

27. Observation
Not reasonable in a post-menopausal high risk patient with a suspicious palpable mass,abnormal imaging and a strong family history.

28. Interventions at this point?

29. Discuss options for tissue diagnosis

30. Biopsy Techniques Needle Core Biopsy FNA Excisional Biopsy
Image Guided Biopsy
Ultrasound
Stereotactic

31. Biopsy Options Which techniques are applicable for Mrs. Trainor?
What are the advantages/disadvantages of each?
What information is needed from the biopsy specimen?

32. Biopsy Options
FNA is a minimally invasive technique best suited for clearly benign or clearly malignant lesions & less suited for indeterminate lesions. It provides small volume cellular material for cyto-pathologic diagnosis.
CORE BX is also minimally invasive, but provides a # of tissue cores for histo-pathologic diagnosis. Volume of specimen usually permits analysis of hormone receptors and Her-2-neu.

33. Biopsy Options
Image guided technique can be utilized with FNA but is most often used with CORE needle biopsy. Appropriate for non-palpable lesions identified by either mammography or US (CT & MRI too)
A number of devices are available and enable consecutive biopsies, varying sizes, marker clip deployment & localization wire placement.

34. US Directed Biopsy

35. Pathology
Invasive Ductal Adenocarcinoma Grade II
ER+/PR+ Her2neu -

36. What next?

37. Treatment Considerations
Unilateral vs Bilateral Disease or Risk including genetic predisposition
Extent of Disease/ Clinical Stage
Comorbidities
Breast Conservation
Patient Preference***

38. Surgical Treatment Options
Lumpectomy w/ SLN sampling +/-axillary dissection & post-op Radiation Therapy
Mastectomy w/ SLN sampling +/-axillary dissection +/- reconstruction
Modified Radical Mastectomy +/- reconstruction

39. Breast Reconstruction Options
Immediate
Staged Implant reconstruction/ tissue expander
TRAM Flap
Latissimus Dorsi Flap
Free Flaps
Delayed

40. Additional Treatment Considerations
Neoadjuvant Chemotherapy?
Adjuvant Chemotherapy?
Adjuvant Hormonal Therapy?
Ablative therapies?
Clinical Trials participation +/-

41. Management What would you advise for Mrs. Trainor?
She wants to know more about Sentinel Lymph Node Sampling.
Can you explain how it’s done and how it works?
She’s leaning toward breast conservation surgery but is worried the tumor might come back.
What would you tell her regarding her risk and prognosis?
Will pre-operative genetic testing influence her treatment decision?

42. Discuss Surgical Risks & Potential Complications

43. Risks & Expected Course
Anesthetic
Peri-operative
Medications
Antibiotic?
Lymphazurin reaction*
Incisions/ Dressings/ Drains
Need for re-excision for margins or nodes

44. Complications Wound Infection Breast Lymphedema Arm Lymphedema
Seroma/Hematoma
Nerve Injury
Flap Necrosis
Poor Cosmetic Result

45. Treatment, Mrs.Trainor
She elects Lumpectomy w/ SLN sampling & post-op RT
Pre-op Chem profile, and Chest X-ray are NL
No metastatic imaging was performed
She decides NOT to pursue genetic testing
Final Pathology
1.9cm Invasive Ductal GrII with minor component of DCIS
3 SLN’s negative by H&E and IHC
ER+/PR+ Her2Neu-

46. Pathology, Mrs. Trainor

47. Stage & Prognosis
Mrs. Trainor comes back to the office for her 1st post-op visit, doing well with no post-operative issues.
Discuss her pathology,
Disease stage & prognosis
Any further treatment recommendations?

48. Staging & Additional Treatment
Stage T1c pN M0
Tumor >1cm <2cm,
Nodes – by IHC/H&E
No evidence of metastatic disease
What Next?
Referral to medical oncologist for adjuvant therapy considerations
Referral to radiation oncologist for completion of post-op RT
Discuss long term follow-up recommendations

49. What if your patient is:
A 41-year-old female with a 6 week history of generalized fullness of her right breast and skin dimpling.
Exam demonstrates a 5 cm irregular fixed right breast mass with skin dimpling and palpable R axillary nodes.

50. Right Breast Skin Dimpling & Nipple Retraction

51. Right Breast Skin Dimpling & Nipple Retraction

52. Mammogram Right Breast

53. Pathology
Invasive Lobular Carcinoma Gr III, w/ lymphovascular invasion, minor component of DCIS
ER-/PR-, Her-2-Neu +
FNA R Axillary node= Metastatic Lobular Carcinoma

54. CT Chest
mass
nodes
What might this study add?

55. Breast MRI
What might this study add ?

56. How would her treatment differ?
Discuss pre-operative staging of locally advanced tumors
Discuss neoadjuvant chemotherapy options

57. What if your patient is:
A 47-year-old female with a 2 mo history of generalized breast tenderness fullness of her left breast, erythema and skin dimpling.

58. Left Breast Image

59. Breast Erythema & Satellite Lesion
Describe this finding 
Describe this finding

60. Clinical Findings Erythema with Peau d’orange skin change
Satellite lesion
Fixation of lesion to skin and chest wall?

61. Mammogram Comparison CC View

62. Pathology Inflammatory Breast Cancer
Invasive Ductal adenocarcinoma by core needle biopsy of largest lesion
Skin Biopsy demonstrates tumor infiltration of dermal lymphatics
How will her evaluation and management differ from Mrs. Trainor?

63. What if your patient is:
A 71-year-old female with a 1 year hx of recurrent scaling rash of right nipple-areolar complex. No discharge. Has tried creams without relief. Last mammogram at age 60 was normal.

64. Mammogram

65. Image

66. Pathology
Core Biopsy of mammographic lesion shows invasive ductal adenocarcinoma
ER+/PR+ Her2Neu -
Skin biopsy of nipple rash shows
Paget’s disease
How will her management differ?

67. QUESTIONS ??????

68. Summary
Identify key clinical,pathologic and radiographic features of breast cancer
Recognize risk factors, treatment implications and relevant prognostic variables of various stages & types
Understand complexity of treatment decision making and appropriate patient counseling

69. Acknowledgment
The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials we welcome your comments/ suggestions at: