Breast

• Important history includes: pain, family history, menstruation (early menarche or late menopause increase risk), age of 1st preganncy, previous breast cancer, previous breast procedures, or estrogen hormone replacement therapy (HRT).
• Risks include: female, menarche <12yo, menopause >50yo, previous breast cancer, HRT for >5yrs, family history, delayed pregnancy (>30yo), prior radiation, obesity.
• Physical exam includes: bilateral breast and skin exam, lymph basin exam, liver palpation.
• 12% lifetime risk in the normal population
• BRCA 1 increases breast and ovarian cancer risk
• BRCA 2 increases breast, ovarian, pancreatic, and male breast cancer risk

Breast Studies

• Fine needle aspiration (FNA)= 23G needle on a 10ml syringe on negative pressure, take approximately 6 passes through the lesion, stop suction, and withdrawl.
• Core biopsy= 14G needle
• Stereotactic biopsy= image guided biopsy for lesions only seen on mammogram. Patient lies prone with breast in mammogram unit. The unit moves to give a stereo view. The machine sets the axis for biopsy.
• Open biopsy= needed for
  • ADH
  • LCIS
  • Papillary lesion
  • BIRAD 5
  • pseudoangiomatosis hyperplasia
  • radial scar
  • phylloides tumor
• Bilateral mammogram (MMG)= 10% false negative and false positives.Concerning patterns include cluster calcifications (>4 microcalcifications in 1cm square area), calcifications along ducts, irregular calcifications.
  • Birad score:
    • 0= inconclusive
    • 1= normal
    • 2= benign finding
    • 3= probably benign
    • 4= suspicious finding
    • 5= suggestive of cancer
    • 6= known cancer
• Breast Ultrasoud= differentiates cyst versus solid lesions. Best for women < 30 years old due to dense breasts making mammogram difficult. Characteristcs of breast cancer on ultrasound include:
  • taller than fat
  • irregular
  • uneven echotexture
• MRI= good for evaluation of lesions with breast impants and for determining extent of cancer to help determine breast conservative therapy versus mastectomy.

Breast Conditions

Breast Cyst

• Dx: best evaluated with ultrasound
• Tx: needle aspiration for diagnosis and possible further treatment
  • Cyst with clear fluid that disappears after aspiration = observe, can repeat up to two times
  • Cyst with bood = fluid for cytology and excisional biopsy of lesion
  • Cyst with clear fluid that returns after aspiration more than twice = excisional biopsy

Fibroadenoma

• Tx: excision and follow up

Cystosarcoma phyllodes

• Tx: wide local excision with 1-2 cm margins. doxorubicine and ifosfamide for lesions >5 cm or stromal overgrowth

Fat necrosis and sclerosing adenosis

• Tx: local excision

Plasma cell mastitis, Duct ectasia, Subareolar chronic abscess

• Tx: antibiotics, drainage, elective subareolar duct excision

Fibrocystic disease

• Tx: reassurance
  • Open biopsy for dysplasia or papillomatosis
  • caffeine reduction
  • primrose oil 1000mg TID for 2-4 months
  • Danazol 100mg Qday
  • Bromocriptine 5mg Qday
  • Mastectomy only for severe unrelenting pain after other pathology rulled out

Palpable Breast Mass not seen on imaging studies

• Tx: can follow up in one menstrual cycle
  • if lesion persists get core or excisional biopsy

Bloody nipple discharge

• Dx: differentiate endocrine abnormality versus a lesion
  • bilateral clear discharge needs endocrine evaluation and treatment
  • try to milk areolar quadrants to localize the lesion
  • bilateral MMG
  • ductogram
• Tx: based on ability to localize a lesion
  • ID quadrant but no mass - subareolar wedge resection of ductal system
  • ID quadrant and a mass - subareolar wedge and excisional biopsy
  • no quadrant - observe for a cycle and ask patient to try to localize, if still unable to localize, do complete subareolar duct excision

Axillary lymph node

• Dx: ask about infection, neoplasm history, lymphoma symptoms
  • differential includes ipsilateral breast cancer, lymphoma, melanoma, lung cancer, GI cancer, ovarian cancer
  • examine chest, lymph nodes, lung, guiac/rectal, palpate abdomen
  • core biopsy (look for ER/PR for breast, negative mucin stain for melanoma/lymphoma)
  • If adenocarcinoma, need PSA, MMG, CXR, CT abdomen/pelvis, bone sca, pan endoscopy, CA-125
• Tx: if unable to localize adenocarcinoma, can do modified radical mastectomy

Breast Cancer

• Staging Overview: (IIb-IIIb is locally advanced)
  • I= <2cm, no nodes
  • IIa= 2-5cm, no node; or <2cm with +node
  • IIb= 2-5cm with +node; or >5cm no node
  • IIIa= >5cm with +node
  • IIIb= peu de orange, chest wall invasion
  • IV= metastatic
• LCIS= lobar carcinoma in-situ. Gives a 20-40% increased lifetime risk of cancer (bilateral risk)
  • Tx: Observe q6 months with MMG (bilateral)
    • prophylactic tamoxifen
    • genetic test if risk factors for BRCA
    • bilateral prophylactic mastectomy with reconstruction for BRCA+
• DCIS= ductal carcinoma in-situ. 50% risk of becoming invasive.
  • Dx: ask for size, mulitfocal/unifocal, comedo necrosis, differentiation
  • Tx: Breast conservation therapy (12% recurrence)
    • total mastectomy for diffuse disease
    • Sentinal Lymph Node Biopsy (SNLB) for high grade, comedo necrosis, or if plan mastectomy (disrupt lymph node drainage).
    • Tamoxifen decreases recurrence if ER+
• Invasive breast cancer
  • Dx: workup includes CBC, CMP, CXR, bilateral MMG
    • Bone scan if Alk Phos or calcium is elevated
    • CT abdomen/pelvis if LFTs are abnormal
    • CT chest for symptoms
  • Tx:
    • BCT= mobile, <4cm, not central, can get negative margins, good cosmetic result is likely
    • Total mastectomy with SLNB
    • Locally advanced --> neoadjuvent (TAC), SLNB (if node - after neoadjuvent tx ???), XRT postop
• Disseminatd breast cancer
  • ER/PR positive gets estrogen suppression (tamoxifen, Lupron, or aromatase inhibitor)
    • postmenopausal - aromatase inhibitor
    • premenopausal - lupron or oophorectomy (then treat as postmenopausal)
  • Breast cancer in pregnancy
    • Tx:
      • can do SNLB (no blue die, no SNLB before 30 weeks)
      • Chemotherapy (FAC) is ok after 1st trimester
• Paget's disease of the nipple
  • Dx: Exam with bilateral MMG to look for invasive cancer or DCIS
    • mass - gets excisional biopsy and full thickness biopsy of nipple areolar complex (NAC)
    • no mass - full thickness biopsy of NAC
  • Tx:
    • mass - simple mastectomy with SLNB or BCT with excision of NAC (only do SLNB with BCT if path shows invasive cancer)
    • no mass - simple mastectomy with SNLB
• Inflammatory breast cancer
  • Dx: differentiate from mondor's disease, mastitis, or abscess
    • Full thickness skin biopsy
    • metastatic workup
  • Tx:
    • neoadjuvant therapy
    • mastectomy with SLNB if good responce
    • XRT prior to toilet mastectomy for poor responce
    • Adjuvant XRT
    • Tamoxifen
• Local recurrance
  • Dx: Always start with rulling out distant mets (re-stage)
    • ask about previous cancer stage
    • ER/PR status
    • CBC, CMP, CT chest / abdomen / pelvis
    • FNA in the office
  • Tx:
    • Radiation (XRT) to chest wall for chest or axillary recurrance
    • small and mobile - resect (completion mastectomy for prior BCT), XRT, systemic therapy
    • large or fixed - core biopsy (with ER/PR status), systemic therapy, XRT, consider resection

Breast Treatments

• Breast conservation therapy (BCT)= resection of tumor with negative margins followed by radiation therapy.
  • Contraindications:
    • inability to get negative margins (1cm is optimal)
    • inability to get radiation (lumpectomy alone has 40% risk of recurrance, addition of radiation drecreases risk to 12%)
    • multicentric or multifocal
    • diffuse microcalcifications
    • inflammatory breast cancer
  • Relative contraindications
    • retroareolar tumor
    • collagen-vascular diseae
    • large tumor:breast ratio
    • pregnancy in 1st/2nd trimester
    • BRCA 1 or 2
    • Patient's choice
• Mastectomy= removal of breast tissue
  • modified radical mastectomy= removal of breast and axillary node dissection
  • Total mastectomy= simple mastectomy= removal of breast
• Postmastectomy radiation therapy indications:
  • >4 positive lymph nodes
  • Tumors that involve skin or chest wall
  • T3 tumor (>5cm)
• Neoadjuvant chemotherapy for: inflammatory cancer, adherance to chest wall, or possible candidate for BCT excpet for size.
  • 5FU, Adriamycin, Cyclophosphamide (FAC)
  • Herceptin for 1yr if HER2neu +
  • Tamoxifen for 5yrs in premenopausal for ER+ or PR+ (then consider Arimidex if menopausal)
  • Aromatase inhibitor (Arimidex) for 5 yrs in postmenopausal ER+ or PR+
• Adjuvant chemotherapy for: >2cm, >1cm if ER/PR negative, or positive lymph node
  • FAC for 6 months
  • Herceptin for 1yr if HER2neu +