Breast Cases (Pestana) Flashcards
An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.
What is it? - Fibroadenoma.
How is the diagnosis made? - The underlying concern in all breast masses is cancer. The only safe answer, even if the presentation favors benign disease, is to get tissue diagnosis. In this case it should be done in the least invasive way possible: If offered, FNA (fine needle aspirate for cytology). If not, core biopsy or if it is the only choice, excisional biopsy. Reassurance alone would not be a good choice! Mammogram alone is not the way to go, either. Mammogram is primarily for screening, not for diagnosis. At age 18, mammograms are useless (breast to dense).
Sonogram is the only imaging technique suitable for the very young breast.
A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been present for seven years, and slowly growing to it’s present size. The mass is 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.
Management: Tissue diagnosis is needed (some of these become outright malignant sarcomas), given the size best done with core or incisional biopsy. Margin-free resection will follow.
A 35 year old lady has a ten 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. Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks.
What is it? - Fibrocystic disease (cystic mastitis, mammary dysplasia, with a palpable cyst.
Management: tissue diagnosis (i.e: biopsy) becomes impractical when there are lumps every month. Aspiration of the cyst is the answer here. 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. Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only choice.
A 34 year old lady 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.
What is to be done? - The old concern over cancer is the issue, and the way to detect cancer that is not palpable is with a mammogram. That should be the first choice. If negative, one may still wish to find an resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, 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. However, only lactating breasts are “entitled” to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.
Management: Incision and drainage is the Rx. 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 has a firm, 2cm. mass in the right breast, that has been present for 3 months.
What is it? - This could be anything. Age is the best determinant for Cancer of the breast. If she had been 72, you go for cancer. At 22, you favor benign. But they will not ask you what this is, they will ask what do you do.
Management: You have to have tissue. Core biopsy is OK, but if negative you don’t stop there: only excisional biopsy will rule out cancer.
A 69 year old lady 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…or the nipple became retracted six months ago.
What is it? - Classical cancer of the breast.
What do you do? - Establish the diagnosis with tissue: Core biopsy is OK, but if negative you don’t stop there: only excisional biopsy will rule out cancer.
A 72 year old lady 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.
What is it? - Another classic for cancer of the breast.
Management: get that tissue diagnosis (here a punch biopsy of the skin is an option. It probably is permeated with cancer).
A 62 year old lady has an eczematous 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.
What is it? - Another sneaky way for cancer of the breast to show up. If you get this one in an extended matching set, the answer is Paget’s disease of the breast-which is a cancer under the areola.
Management: Get tissue! A full thickness punch biopsy of the skin would be OK, but core biopsy or incisional biopsy of the tissue underneath would be OK also.
A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a lump in that area at the time, and one 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 classical trap for the unwary. It is cancer until proven otherwise. Trauma often brings the area to the attention of the patient…but is not because of the lump.
A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2 cm. mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere.
What is it? - A tough one, but another potential presentation for cancer of the breast. In a younger patient you would think lymphoma. It could still be lymphoma on her. She needs a mammogram (we are now looking for an occult primary), and the node will eventually have to be biopsied.
A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular area of increased density, with fine microcalcifications, that was not present two year ago on a previous mammogram.
What do you do? - You will not be asked to read X-Rays (particularly mammograms), but you should recognize the description of a malignant radiological image – which this one is. Thus, we go back to our old issue: we need tissue diagnosis. In this case the first attempt should be stereotactic radiologically guided core biopsy. If unsatisfactory, the next move would be needle localized excisional biopsy.
A 44 year old lady 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.
The question is obviously what to do. The standard option here is segmental resection (lumpectomy), to be followed by radiation therapy to the remaining breast, as well as axillary node dissection to help determine the need for adjuvant systemic therapy.
A 62 year old lady has a 4 cm. hard mass under the nipple and areola of her rather smallish left breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable axillary nodes.
Again, a management question. Lumpectomy is an option only when the tumor is small (in absolute terms and in relation to the breast) and located where most of the breast can be spared.
A modified radical mastectomy is the choice here. Why go after the axillary nodes when they are not palpable?: Because palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis.
A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”. Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly attached to the chest wall. The patient maintains that the mass has been present for only “a few weeks”, but a relative indicates that it has been there at least two years, maybe longer.
What is it? – An all too frequent tragic case of neglect and denial. Obviously a far advanced cancer of the breast.
Management: the tissue diagnosis is still needed, and either a core or an incisional biopsy is in order, but the likely question here is what to do next. This is an inoperable, and incurable as well…but palliation can be offered. Chemotherapy is the first line of treatment. In many cases the tumor will shrink enough to become operable.
