Connie Lee, M.D. UF Surgery Breast Mass Connie Lee, M.D. UF Surgery

History for Breast Mass HPI: Precise location of mass How was it identified How long has it been present Nipple discharge (unilateral or B/L, # ducts involved, color, spontaneity), nipple inversion New or persistent skin changes Size & change in size Does the size change during the menstrual cycle PMHx, PSHx, SHx, FHx ROS (note: malaise, bony pain, weight loss)

Breast Cancer Risk Factors Risk factors to note during history: Gender Age Prior breast cancer or breast biopsy (h/o ADH, ALH, LCIS increases risk) FHx of cancer (relationship, age of onset, type of CA) FHx of genetic mutations (BRCA1, BRCA2) Age of menarche, first pregnancy, menopause ETOH use, hormonal replacement therapy, DES exposure in utero Risk calculated using the Gail model based on: Menarche Reproductive history FHx in 1st degree relatives Prior biopsies ADH = atypical ductal hyperplasia, ALH = atypical lobular hyperplasia, LCIS = lobular carcinoma in situ A separate model is available for AA women. Model may be less accurate in other ethnicities. BRCA1 a/w breast & ovarian > colon, prostate CA BRCA2 a/w prostate, pancreatic, fallopian tube, bladder, non-Hodgkin lymphoma, and basal cell CA

PE for Breast Mass Examine: neck, chest wall, breasts, and axillae – in upright and supine positions Inspection: asymmetry, skin changes, nipples Palpation: regional LN (cervical, supra/infraclavicular, axillary), breast exam (borders: clavicle, sternum, midaxillary line, rib cage) Mass characteristics to note: size, shape, location, consistency, and mobility Also, remember node levels: I (lateral to pec minor), II (deep to pec minor), III (medial to pec minor)

Workup Initial breast mass workup: Diagnostic mammogram (CC, MLO, magnification views) U/S Core biopsies +/- image guidance, FNA, excisional biopsy Further evaluation based on stage: Stages 1 & 2: lab studies Stage 3 (locally advanced or inflammatory) or symptomatic: CXR or chest CT, CT of abdomen/pelvis, +/- tumor markers Stage 4: PET scan MRI

DDX Cyst Fibroadenoma Galactocele Fibrocystic disease Cancer Mondor’s disease Intraductal papilloma Abscess Cystosarcoma phyllodes Radial scar Fibromatosis Granular cell tumors Fat necrosis

Carcinoma Histology In situ carcinoma Ductal carcinoma in situ: comedo vs. noncomedo Lobular carcinoma in situ: a biomarker of increased breast CA risk (note: no mass on PE) Invasive carcinoma Infiltrating ductal (75%) Infiltrating lobular (10%) Medullary (5%) Mucinous (<5%) Tubular (1-2%) Papillary (1-2%) Metaplastic breast cancer (<1%) Mammary Paget disease (1-4%) Locally advanced breast cancer Inflammatory breast cancer

Prognostic & Predictive Factors Axillary LN status Tumor size Lymphatic/vascular invasion Age Histologic grade Histologic subtypes Response to neoadjuvant therapy ER/PR status (hormone-positive tumors have more indolent course & are responsive to hormonal therapy) HER2/neu gene amplification and/or overexpression (HER2 overexpression a/w more aggressive tumor phenotype & worse prognosis)

Staging Patients grouped into 4 stages based on: Tumor size (T) Lymph node status (N) Metastasis (M) Five-year survival rates a/w stage: Stage 1: 99% Stage 2: 86% Stage 3: 57% Stage 4: 20%

Treatment of In Situ Carcinoma DCIS: Surgical resection +/- radiation Usually axillary dissection/SLN biopsy not recommended Tamoxifen (SERM) is approved for adjuvant therapy in pts treated with breast-conserving therapy & radiation LCIS: Chemoprevention w/SERM B/L mastectomy +/- reconstruction Close observation

Treatment of Invasive Carcinoma Modified radical mastectomy Breast-conserving therapy with radiation therapy Mastectomy Sentinel LN dissection Axillary LN dissection Postmastectomy radiation therapy Adjuvant chemotherapy Adjuvant therapy for HER2+ breast cancer with trastuzumab (Herceptin), a mAb targeting the extracellular domain of the receptor Adjuvant hormonal therapy decrease estrogen’s ability to stimulate micro-metastases or dormant cancer cells Aromatase inhibitors (aromatase converts other steroid hormones into estrogen)