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. 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

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

10. 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

11. 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)

12. 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

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 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

16. 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.

17. 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)

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

19. 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.

20. 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.

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

22. 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