04-1 Gen Surg: Breast Flashcards
An 18-year-old woman has a firm, rubbery mass in the left breast that moves easily with palpation.
What is it? Fibroadenoma.
Management.The underlying concern in all breast masses is cancer, and the best predictor of the likelihood of malignancy is age. At age 18, the chances of malignancy are very remote; thus, the least invasive way to make the diagnosis is, in order, either sonogram, fine-needle aspirate (FNA) or core needle biopsy, or surgical excision. Sonogram happens to be quite diagnostic for fibroadenomas (more so than for other conditions). Reassurance alone would not be a good choice! Do not order a mammogram either. At age 18, mammograms are useless (breast too dense). Sonogram is the only imaging technique suitable for the very young breast. Once diagnosis is confirmed, excision is optional.
A 14-year-old girl has a firm, movable, rubbery mass in her left breast that was first noticed 1 year ago and has since grown to be about 6 cm in diameter.
What is it? Giant juvenile fibroadenoma.
Management. At age 14 chances of cancer are virtually zero. That avenue does not have to be explored. But the rapid growth requires resection to avoid cosmetic deformity.
A 27-year-old immigrant from Mexico has a 12- × 10- × 7-cm mass in her left breast. It has been present for 7 years, and has been slowly growing to its present size. The mass—firm, rubbery, completely movable—is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
What is it? Cystosarcoma phyllodes, a benign condition that can turn into an outright malignant sarcoma.
Management. After tissue diagnosis, proceed with margin-free resection.
A 35-year-old woman has a 10-year history of tenderness in both breasts, related to menstrual cycle, with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle. She now has a firm,
round, 2-cm mass that has not gone away for 6 weeks.
What is it? Palpable cyst in fibrocystic disease (cystic mastitis, mammary dysplasia).
Management. Start with mammogram to see if there are other nonpalpable lesions. Once we can zero in on this one, tissue diagnosis (i.e., biopsy) becomes impractical when there are lumps every month. Aspiration of the cyst is the answer here (this is not FNA, this is aspiration of fluid to empty a cyst, not aspiration of a solid mass to get cells). If the mass goes away and the fluid aspirated is clear, that’s all. If the fluid is bloody it goes to cytology. If the mass does not go away, or recurs, she needs biopsy
A 34-year-old woman has been having bloody discharge from the right nipple, on and off for several months. There are no palpable masses
What is it? Intraductal papilloma.
Management. Although cancer is a concern with bloody nipple discharge, the most common cause of this complaint happens to be benign intraductal papilloma. The concern over cancer must be ruled out; the way to detect cancer that is not palpable is with mammogram. That should be the first choice. If negative, one may still wish to find and resect the intraductal papilloma to provide symptomatic relief and further exclude malignancy given the bloody discharge. Resection can be guided by galactogram, sonogram, or done as a retroareolar exploration.
A 26-year-old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender mass in the breast, along with fever and leukocytosis.
What is it? Sounds like an abscess—and in this setting it is. Usually, only lactating breasts are entitled to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.
Management. No point on doing a mammogram on a lactating breast (even if she were older). Incision and drainage is the treatment for all abscesses, this one included. But, if an option includes drainage with biopsy of the abscess wall, go for that one.
A 49-year-old woman has a firm, 2-cm mass in the right breast, which has been present for 3 months.
What is it? This could be anything. Age is the best determinant for risk for cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign.
Management. Mammogram to explore for other non-palpable lesions (don’t want to miss anything) and then multiple core biopsies of the known 2-cm mass are needed.
A 34-year-old woman in month 5 of pregnancy reports a 3-cm firm, ill-defined mass in her right breast that has been present and growing for 3 months.
The diagnosis of possible breast cancer in the pregnant patient is done the same way as if she had not been pregnant. Yes, you can do the mammogram and appropriate biopsies; but the radiologist will probably use sonogram to guide the biopsies, and no, you do not need to terminate the pregnancy.
I. A 69-year-old woman has a 4-cm hard mass in the right breast with ill-defined borders, movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted and has an “orange peel” appearance.
II. A 69-year-old woman has a 4-cm hard mass in the right breast under the nipple and areola with ill-defined borders, movable from the chest wall but not movable within the breast. The nipple became retracted 6 months ago.
III. A 72-year-old woman has a red, swollen breast. The skin over the area looks like orange peel. She is not particularly tender, and it is debatable whether the
area is hot or not. She has no fever or leukocytosis.
IV. A 62-year-old woman has an eczematoid lesion in the areola. It has been present for 3 months, and it looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions and ointments.
These are all classic presentations of breast cancer. The hard masses are likely invasive breast adenocarcinoma. The red, orange peel skin is likely inflammatory breast cancer, and the eczematoid areolar lesion is likely Paget’s disease of the breast (a rare form of breast cancer). They
all need mammograms for further evaluation and multiple core biopsies of suspicious breast lesions. The suspicious skin lesions (e.g. orange peel, eczematoid) can be confirmed with dermal biopsies.
A 42-year-old woman hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and 1 week later the lump is still there. She has a 3-cm hard mass deep inside the affected breast, and some superficial ecchymosis over the area.
What is it? A classic trap for the unwary. It is cancer until proven otherwise. Trauma often brings the area to the attention of the patient—but is not the cause of the lump. Proceed as with the others.
A 58-year-old woman discovers a mass in her right axilla. She has a discrete, hard, movable, 2-cm mass. Physical examination of her breast is negative, and she has no enlarged lymph nodes elsewhere.
What is it? A tough one, but another potential presentation for cancer of the breast. It could be
lymphoma but also may be lymph node metastasis from an occult primary. She needs a mammogram (we are now looking for an occult primary in the breast) and possible ultrasound. The node will eventually have to be biopsied. MRI of the breast is now in the work-up for occult primary breast cancer, as many are lobular cancers which are not always visualized by mammogram or even ultrasound.
A 60-year-old woman has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present 2 years ago on a previous mammogram.
Management. You will not be asked to read difficult x-rays (particularly mammograms), but you should recognize the description of a malignant radiologic image—which this one is. Thus, we go back to our old issue: we need tissue diagnosis. The mammographer will obtain multiple core biopsies.
A 44-year-old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows infiltrating ductal carcinoma. The mass is freely movable, and her breast is of normal, rather generous size. She has no palpable axillary nodes, and the mammogram showed no other lesions.
Treatment of operable breast cancer begins (but does not end) with surgery. With a small tumor far away from the nipple, the standard option is segmental resection (lumpectomy) and axillary node sampling (i.e. sentinel node biopsy) to help determine the need for adjuvant
systemic therapy. Why go after the axillary nodes when they are not palpable? Because palpation is notoriously inaccurate in detecting microscopic metastasis to the lymph nodes which may be present in the early stages of an invasive breast cancer. Afterward, radiation therapy
has to be given to the breast (otherwise, lumpectomy would have an unacceptably high rate of local recurrence).
A 62-year-old woman has a 4-cm hard mass under the nipple and areola of her smallish left breast. A core biopsy has diagnosed infiltrating ductal carcinoma. There are no palpable axillary nodes, and the mammogram shows no other lesions.
Lumpectomy is an ideal option when the tumor is small (in relation to the size of the breast), is located where most of the breast can be spared, and can be performed in a way that maintains the cosmetic appearance of the breast. A total mastectomy (also called simple mastectomy) is the choice here. Axillary sampling of sentinel nodes is also required (i.e. sentinel node biopsy if no palpable nodes). Radiation is typically not needed when the whole breast is removed unless in rare
circumstances where the mass is very large (e.g., ≥5 cm) or if the lymph nodes contain metastasis. The old (unmodified) radical mastectomy is no longer done.
I. A 44-year-old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows lobular cancer.
II. A 44-year-old woman has a 2-cm palpable mass in the upper outer quadrant of her right breast. A core biopsy shows medullary cancer of the breast.
If they tease you with breast cancers that are not the standard infiltrating ductal carcinoma, here are the rules: lobular has a higher incidence of bilaterality (but not enough to justify bilateral mastectomy), and inflammatory has terrible prognosis. All the other variants of invasive
cancer have a little better prognosis than infiltrating ductal, and they are all treated the same way anyway.
