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

2. 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)

3. 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

4. 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)

5. 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

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

7. 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

8. 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)

9. 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%

10. 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

11. 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)