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

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

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

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

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

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

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

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

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

Differential Diagnosis Based on History and Presentation

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

Physical Examination What would you look for?

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

Studies What further studies would you want at this time?

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

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

Mammogram Comparison CC View L

Mammogram Comparison MLO Views  Marker palpable

US Breast L Breast

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?

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

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

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

Laboratory What would you obtain?

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

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

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

Interventions at this point?

Discuss options for tissue diagnosis

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

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

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.

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.

US Directed Biopsy

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

What next?

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

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

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

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

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?

Discuss Surgical Risks & Potential Complications

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

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

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-

Pathology, Mrs. Trainor

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?

Staging & Additional Treatment Stage 1 T1c pN0 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

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.

Right Breast Skin Dimpling & Nipple Retraction

Right Breast Skin Dimpling & Nipple Retraction

Mammogram Right Breast

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

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

Breast MRI What might this study add ?

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

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.

Left Breast Image

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

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

Mammogram Comparison CC View

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?

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.

Mammogram

Image

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?

QUESTIONS ??????

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

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: feedbackPPTM@surgicaleducation.com