Presentation on theme: "Linda M. Barney M.D. Wright State University"— Presentation transcript:
1 Linda M. Barney M.D. Wright State University Breast MassLinda M. Barney M.D.Wright State University
2 Mrs. TrainorMrs. Trainor is a 57-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.
3 HistoryWhat other points of the history do you want to know?
4 History, Mrs. Trainor Consider the following: Associated signs/symptomsPertinent PMHROSMEDSRelevant Family Hx.Characterization of Symptoms:Temporal sequenceAlleviating / Exacerbating factors:
5 Characterize Symptoms 3 week history of left breast lump.1st noticed in the showerBean sized and nontenderMay have increased in size slightly
6 Associated Signs & Symptoms Denies pain, skin change, nipple dischargePrior history of Fibrocystic breasts, no biopsiesLMP 6 years agoLast mammogram 11 months ago, routine mammography since 40’sDenies trauma
7 Pertinent PMH Healthy, married, mother of 4 (3 girls 1 boy) 1st pregnancy age 21, Breast fed 3 of 4Menarche age 11, OCP’s x 20 years total,Menopause at 51, HRT w/ prempro x 7 yearsDenies smoking, social alcohol only,no drugsNo chronic medical problems
8 Aleviating/ Exacerbating factors No change with activityUses Ibuprofen for headache with no change in the lumpDrinks decaffeinated tea and sodas only
9 Family HistoryMaternal grandmother with breast cancer at age 62, maternal grandfather w/colon CA at 71Mother and sister with breast cancer, mother at age 52, Sister at 472 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 MassBreast CancerFibroadenomaCystFat necrosis
13 Physical Examination, Mrs Physical Examination, Mrs. Trainor Relevant Exam findings for a problem focused assessmentSkin & Soft TissueBreasts: 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 nodesChest: CTAABD: No Hepatosplenomegaly or massGenitorectal: Uterus retroflexed, no mass, no adnexal mass, guaiac – stool, no massExtremities: No edema, Right-handed, neuro intactRemaining Examination findings non-contributory
14 StudiesWhat further studies would you want at this time?
20 Studies – ResultsFocused L Breast US demonstrates a 1.7 cm poorly defined, heterogeneous, hypoechoic nodule, with abnormal shadowingTaller than wide orientation(violates tissue planes)No additional abnormalities are notedMammogram reveals a 1.8cm spiculated mass, upper central L breast corresponding to palpable abnormality.Dense parenchyma with no other abnormalitiesWhat is the differential diagnosis at this point?
21 Revised Differential Diagnosis Breast CancerFibrocytic MassFat necrosisRadial ScarFibroadenomaCyst
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/ BCAGenetic predisposition profile?AgePOSITIVEMenarche/Menopause?ParityLactationAge at 1st pregnancyNo hx. of at risk pathologyDiscuss Gail Model & other risk assessment options
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 OptionsFNA 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 OptionsImage 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.
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?
43 Risks & Expected Course AnestheticPeri-operativeMedicationsAntibiotic?Lymphazurin reaction*Incisions/ Dressings/ DrainsNeed for re-excision for margins or nodes
44 Complications Wound Infection Breast Lymphedema Arm Lymphedema Seroma/HematomaNerve InjuryFlap NecrosisPoor Cosmetic Result
45 Treatment, Mrs.TrainorShe elects Lumpectomy w/ SLN sampling & post-op RTPre-op Chem profile, and Chest X-ray are NLNo metastatic imaging was performedShe decides NOT to pursue genetic testingFinal Pathology1.9cm Invasive Ductal GrII with minor component of DCIS3 SLN’s negative by H&E and IHCER+/PR+ Her2Neu-
47 Stage & PrognosisMrs. Trainor comes back to the office for her 1st post-op visit, doing well with no post-operative issues.Discuss her pathology,Disease stage & prognosisAny further treatment recommendations?
48 Staging & Additional Treatment Stage T1c pN M0Tumor >1cm <2cm,Nodes – by IHC/H&ENo evidence of metastatic diseaseWhat Next?Referral to medical oncologist for adjuvant therapy considerationsReferral to radiation oncologist for completion of post-op RTDiscuss 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.
62 Pathology Inflammatory Breast Cancer Invasive Ductal adenocarcinoma by core needle biopsy of largest lesionSkin Biopsy demonstrates tumor infiltration of dermal lymphaticsHow 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.
68 SummaryIdentify key clinical,pathologic and radiographic features of breast cancerRecognize risk factors, treatment implications and relevant prognostic variables of various stages & typesUnderstand complexity of treatment decision making and appropriate patient counseling
69 AcknowledgmentThe preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATIONIn order to improve our educational materials we welcome your comments/ suggestions at: