Breast Surgery JC076: Breast Mass: Breast Cancer, Benign Breast Diseases, Mammography, Breast Cancer Screening Flashcards
Management of Breast disease
Triple assessment:
1. Clinical
- History + P/E
- S/S
- Radiological
- Mammography
- USG
- MRI - Pathological
- FNAC
- Core biopsy
- Incisional biopsy
- Excisional biopsy
—> Combined: sensitivity 99.6% + specificity 93%
- Triple assessment is positive if ***ANY of above is positive
- negative if ***ALL 3 negative
- if findings not correlate —> further investigations / monitoring necessary
History taking of Breast disease
- HPI / Breast symptoms
- **Lump
- **Pain (Mastalgia)
- ***Discharge from nipple (Unilateral / Bilateral, Single / Multiple ducts, Nature) - Symptoms characterisation
- **Duration
- **Changes of symptoms (e.g. change with menstrual cycle, analgesia)
- Unilateral / Bilateral
- Characteristics (SSSTCM: Site, Size, Shape, Tenderness, Consistency, Mobility) - Family history
- 1st / 2nd degree
- ***Age of onset (correlate with familial risks) - ***Hormonal risk (esp. Steroid receptor +ve breast cancer)
- Early menarche / Late menopause
- Gestational history (Nulliparity)
- Breast feeding history (↓ risk)
- OC pills (exogenous estrogen)
- Hormonal replacement therapy (exogenous estrogen) - Previous breast disease / screening
P/E of Breast disease
Position + Exposure (at least clavicle to abdomen)
- Inspection (end of bed)
- Asymmetry
- Scar (esp. inframammary fold)
- Mass
- Skin changes - Palpation (along clock face)
- Breast mass
- Nipple discharge
- Axillary LN
Nipple discharge
Types:
1. Blood stained
- mostly pathological
- Serous
- pathological / physiological - Milky
- lactation
Skin changes
- Eczematous change
- scaling of skin + areola
- if scaling / involvement of **nipple —> **Paget’s disease of nipple —> need incisional biopsy for Paget’s cells - Peau d’orange
- **skin tethering + **SC lymphedema changes —> associated with underlying cancer
(from wiki: hair follicles become buried in edema) - Inverted nipple
- ask how long its been there
- underlying tumour causing retraction of nipple
***DDx of Breast mass
Benign (Mobile, Round, Smooth):
1. Fibroadenoma
2. Breast cyst
3. Fat necrosis
4. Skin / SC lesions (Sebaceous cyst, Lipoma)
Other DDx of Benign breast lump
1. Galactocele (if lactating)
2. **Lipoma
3. **Fat necrosis
4. Diabetic mastopathy
5. Infective causes: Mastitis, ***Breast abscess, Chronic recurrent subareolar infections e.g. from ductal ectasia
(6. Skin lesions: Sebaceous cysts
7. Postpartum engorgement)
Malignant (Irregular shape, Diffuse / Poorly defined border, Rapidly growing, Harder):
1. In-situ cancer
- DCIS
- LCIS
2. Invasive cancer
- Invasive Ductal
- Invasive Lobular
- Special types
3. Malignant phyllodes tumour (indeterminate)
***Histological types of Breast cancer
In-situ carcinoma:
1. **DCIS (Low / Intermediate / High grade)
(2. **LCIS (Lobular carcinoma-in-situ): a premalignant condition / risk factor rather than cancer, commonly bilateral —> only surveillance needed)
Invasive carcinoma:
1. **Invasive Ductal (80%) (now called **Invasive carcinoma of no special type (NST))
2. **Invasive Lobular (3%)
3. **Special types (unimportant, better prognosis)
- Tubular / Cribriform
- Papillary (Malignant form of Intraductal papilloma)
- Mucinous
- Medullary
- Paget’s (Nipple areolar complex involvement)
- Inflammatory (Skin infiltration)
***5 Steps in treating ANY cancer
- Confirm diagnosis (by biopsy / triple assessment)
- Metastatic workup (know extent of disease)
- Assessment of co-morbidities
- Nutritional assessment
- Definitive treatment
***Treatment options of Breast cancer
Curative treatment:
1. Surgery
- Mastectomy (Simple / Skin sparing / Nipple-Areolar sparing)
- Breast conserving surgery (BCS) (Wide local excision) (Need RT)
Adjuvant treatment (↓ recurrence risk + improve survival):
1. Chemotherapy
2. RT
3. Hormonal therapy
4. Targeted therapy
***Choice of treatment in Breast cancer
Patient factor:
1. Age / Menopause status
Tumour factor:
1. Tumour size
2. Tumour grade
3. No. of involved LN
4. ER / PR status
5. HER2 gene amplification (gene signatures)
***Surgical treatment option of Breast cancer
Aim:
- Oncological outcome vs Cosmetic outcome
1. Loco-regional control
2. Cosmesis
- Breast surgery
- **Mastectomy
- **BCS - Axillary surgery
- **Sentinel LN biopsy (SLNB) (+ Frozen section)
- **Axillary dissection (AD) - Reconstruction (additional option)
- Autologous (Flap reconstruction)
- Implant
CI to BCS
Absolute CI:
1. Tumor size **too large (Large Tumour to Breast size ratio)
- BCS will not result in a good cosmetic result
2. **Multicentric cancer (across quadrants)
3. Where ***RT is contraindicated (e.g. Pregnancy, SLE, previous radiation, ipsilateral breast recurrence)
Relative CI:
1. Multifocal (within same quadrant)
2. Cancer underneath nipple or nipple involvement (can perform lumpectomy if large breasts)
- Mastectomy
- Simple mastectomy
- removal of whole breast + some skin
- most of the cases - Skin sparing mastectomy
- leave a lot more skin behind for future ***reconstruction - Nipple / Areolar sparing mastectomy
- reserved for selective low risk patients with **no nipple involvement of cancer
- **prophylactic mastectomy
- Axillary surgery (SLNB / AD)
Landmark of LN: Pectoralis ***minor muscle (NOT major!!!)
- Level 1: Lateral
- Level 2: Posterior
- Level 3: Medial
Axillary dissection (AD):
- Clear ***Level 1 + 2 LN
- 20% lymphedema rate
NOT remove everything ∵ avoid lymphedema
Sentinel LN biopsy (SLNB):
- **First LN which drains the tumour
- **Dye / Radioisotope (Dual tracer: injection of **methylene blue dye + **99Tc colloid in the sub-areolar area —> identify dyed or radioactive LN using gamma probe (“hot and blue”)
—> travel along lymphatics to Sentinel LN
—> biopsy for **frozen section (done **intra-operatively)
—> -ve: no need AD, +ve: need AD
Aim of SLNB:
- Suitable for **early stage cancers to avoid unnecessary AD
- Avoid **complications related to AD
- Do less surgery without compromising **oncological outcome (e.g. early breast cancer often not involve LN)
- AD may not be necessary in patients with **minimal tumor load in axillary LN + receiving BCS and RT
***Complications of AD
Early complication:
1. Nerve damage
- **Thoracodorsal bundle (i.e. artery + vein + nerve) —> **Latissimus dorsi —> Unable to raise trunk with upper limb e.g. climbing
- **Long thoracic nerve —> **Serratus anterior —> Pain, weakness, limitation of shoulder elevation, scapular winging
- **Intercostobrachial nerve —> **Sensory nerve to Triceps area
- Brachial plexus (uncommon ∵ more upward (area around level 3 LN))
- Vessel damage
- **Thoracodorsal bundle
- **Axillary vein
Late complication:
3. ***Lymphedema
***Surgical strategy for Breast cancer
4 combinations (2 Breast surgery + 2 Axillary surgery):
1. Mastectomy + SLNB
2. Mastectomy + AD (i.e. ***MRM: Modified radical mastectomy)
3. Breast conserving + SLNB
4. Breast conserving + AD
Choice of breast surgery (Mastectomy vs BCS?):
1. **Tumour response / size
2. **Breast size
3. Tumour **location + **Multiplicity
4. Patient’s preference
(Modified Radical vs Radical mastectomy:
- Modified Radical: Mastectomy + Level 1+2 LN
- Radical: Remove pectoralis as well)
- Reconstruction
Types:
1. Implant based
- saline / silicon gel
- temporary / permanent
- one stage / two stage
- placed behind pectoralis muscle
- advantages: simpler procedure, **no donor site morbidity (i.e. no additional scar)
- disadvantages: **↑ risk of infection, questionable ***durability, asymmetry more common
- Autologous tissue based
- **Latissimus dorsi (LD)
- **Transverse rectus abdominis myocutaneous (TRAM) —> Pedicle flap / Free flap / Deep inferior epigastric perforator flap (DIEP flap) (only skin + vessel, no muscle —> avoid herniation in future)
- advantages: better cosmetic result
- disadvantages: need ***additional scar / wound, may cause complications e.g. hernia in abdomen, ↑ chance of wound infection, longer surgery, more complex procedures - Mixture of both types
Nipple-Areola reconstruction
- Final touch up procedure (i.e. 2nd stage procedure)
- Usually performed >=6 months after initial operation
- Under local anaesthesia as day case
- Use of ***local flaps to recreate nipple projection
- Expect 50% reduction in height
- Nipple sharing nearly obsolete
- ***Tattoo to restore natural colour
Adjuvant therapy: RT
Indications:
1. >=4 LNs involved
2. Large tumours
3. Multifocal tumours
4. High grade
5. Lymphovascular permeation
6. ***BCS
Method:
- Whole breast RT / Partial breast RT / Intraop RT
Complications from radiation:
Early:
1. **Skin burn (preventable with radiogel)
2. **Infection
Late:
3. **Lung fibrosis
4. **Cardiomyopathy
5. **Lymphedema —> **Lymphangiosarcoma (Stewart-Treves syndrome) (Resection + RT / CT)
6. Skin discolouration
7. ***Sternal necrosis (in bilateral breast cancer)
Adjuvant therapy: Chemotherapy
Types:
1. Adjuvant: Kill of microscopic disease
2. Neoadjuvant: Pre-surgery control
3. Palliative / Salvage: At recurrence
Indications:
1. LN involvement
2. High risk (e.g. young age)
3. High grade
4. Large tumour
SE:
- N+V
- Injection site reaction, extravasation
- Hair loss
- **Bone marrow suppression (infection risk: Neutropenic fever)
- Allergic reaction
- Cardiotoxicity
- **Neuropathy —> Numbness
- Nephrotoxicity
- Hepatotoxicity
- Amenorrhoea —> Infertility
- Hepatitis B flare up
Adjuvant therapy: Hormonal therapy
- SERM (Selective estrogen receptor modulator) (e.g. Tamoxifen)
- Suitable in **Pre + Postmenopausal patients
- Increase **endometrial cancer risk, ***clotting disorders
- Beneficial effect in blood lipids (lower LDL) - Aromatase inhibitor (e.g. Letrozole)
- Only in **Postmenopausal patients
- Type I: Enzyme inactivator (steroidal)
—> Exemestane
- Type II: Competitive antagonist (non-steroidal)
—> Anastrozole
—> **Letrozole
- **Decrease bone density
- **Dyslipidaemia
- ***Multiple joint pain - Estrogen receptor antagonist (e.g. Fulvestrant)
Others:
4. Oophorectomy
5. Ovarian irradiation
6. Endocrine therapy (GnRH analogue) (Zoladex)
Adjuvant therapy: Targeted therapy
Based on HER2 overexpression:
- Trastuzumab
- Pertuzumab
- Lapatinib
SE:
- Cardiotoxicity (Trastuzumab)
- Skin rash (Lapatinib)
Other new emerging drugs:
- CDK4/6 inhibitors
- Parp inhibitors
- Everolimus
Neoadjuvant therapy
- Reduce size of tumour —> increase ***BCS rate
- Improve **local control + **long term outcome
Benign breast disease
- A spectrum of diseases
- 90% of clinical presentation
- ANDI (Aberrations of Normal Development and Involution of the breast) (—> now known as **Fibrocystic disease???)
—> all encompassing term to describe a wide spectrum of benign breast diseases: **Cysts to ***Fibroadenoma
—> allow better description of benign disease vs normal breast
S/S:
- Nodularity
- Tenderness
- Mobile
***Fibrocystic disease: Physiological cyclical swelling + tenderness
**Fibrocystic disease (aka **Fibroadenosis)
- ***NOT a disease but general term that refers to a group of anomalies / symptoms
- main benign diagnosis in 30-40 yo
S/S:
1. **Cyclical mastalgia, **Lumpiness, **Nodularity
- areas of pronounced nodularity can mimic a lump
- **premenstrual breast tenderness with mild swelling (engorgement of breast during menstrual period) —> result from variation in plasma concentration of gonadotrophic + ovarian hormones
- Breast can be nodular with ***no definitive mass —> Not considered abnormal breast
***Fibroadenoma
- A disease entity
- most common benign breast tumour
Onset:
- any time after puberty
- most frequently 20-30 yo
S/S:
- **Painless (記住!)
- **Well-circumscribed
- ***Freely movable tumours with rounded lobulated / discoid configuration —> “Breast mouse”
- Multiple in 10-15%
- Can become quite large
Prognosis:
- **NOT regress with time but tends to grow slowly
- Estimated incidence of malignancy: 0.12-0.3%
- **Giant Fibroadenoma (>5 cm): may rapid growth
—> require excision (usually in young girls)
—> ∵ triple assessment not 100% accurate
—> have to rule out ***Phyllodes tumour
Treatment options:
1. Surveillance (USG)
2. Surgery (Excision)
3. HIFU
- can be used to treat various solid tumours (e.g. Fibroadenoma, Thyroid adenoma)
Cyst
- A disease entity
- Commonest breast lump in 30-50 yo
Types:
1. **Simple cysts: Accumulation of fluid
2. **Complex cysts: contain debris (solid components) —> need to rule out ***cystic tumour by Triple assessment
Treatment:
1. Aspiration to confirm nature (to rule out cystic tumour), also therapeutic to relieve symptom
2. **Fluid for cytology
3. **Excision for suspicious lesions (e.g. complex cysts with solid components)
Mastalgia
- ***Cyclical
- ***Non-cyclical
- Muscular pain
- Costochondritis
- Non-specific
Nipple discharge
- Unilateral vs Bilateral
- ***Unilateral: pathological likely (involving single site)
- Bilateral: physiological likely (e.g. lactation (but can be prolactinoma)) - Single ductal vs Multiductal
- ***Single duct: pathological likely (involving single site)
- Multiductal: physiological likely - Nature of discharge
- Milk (Galactorrhoea): Lactation, Prolactinoma
- ***Blood / Brown (Suspicious): Intraduct papilloma, Malignancy
- Yellowish / Green: Infection, Ductal ectasia
- Serous / Colourless: Physiological, Ductal ectasia
Investigations:
Triple assessment
- +/- **Ductogram (inject contrast into diseased duct to look for filling defect —> identify cause of nipple discharge + location of lesion)
- +/- **Ductoscopy (allow direct visualisation of lining of lactiferous ducts via a small fibreoptic scope)
Other benign breast disease
- ***Sclerosing adenosis
- Radial scars and complex sclerosing lesions
- ***Papillomas
- Intraductal papilloma (usually only involves single duct) -
**Atypical lesions
- **Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Atypical columnar cell hyperplasia
- etc.
—> Atypia ↑ risk of breast cancer —> whenever see this in biopsy —> **excise (*surveillance NOT an option)
Investigations: Imaging
- Mammography
- used for screening
- for older female - USG
- for younger female (denser breast: USG better penetration) - MRI breast
- Mammography
Malignant features on mammogram
1. **Clustered + **Pleomorphic microcalcifications
- apoptosis of dead cells (a normal phenomenon, but if ↑ cell turnover —> clustered instead of scattered)
- different size and shape (∵ some cells die quickly / slowly)
- Coarse calcifications: likely ***benign
- ***Spiculated border, High density mass
- Architectural distortion
- ***tethering of skin
- involvement of muscles etc. - ***Asymmetrical density
- compare both breasts + both views
- USG
Benign features:
1. **Regular border
2. **Oval in shape (grow along anatomical plane) (Width > Height)
3. Lobulated (sometimes)
4. **Posterior enhancement (indicate fluid in lesion) (Solid tumour: posterior shadowing)
5. **Homogeneous
Malignant features:
1. **Irregular outline
2. **Height > Width (i.e. grow across anatomical planes: invading up / down)
3. ***Posterior shadowing (Acoustic shadowing)
4. Echogenic halo
- MRI breast
Not routinely done
- very sensitive but not specific
Indications:
1. Screening women at high risk of breast cancer (e.g. BRCA carriers)
2. Patients with **breast implants / augmentation (obscure view on USG)
3. Evaluate questionable suspicious lesions seen on mammography / USG (conflicting between imaging and histology)
4. Identify patients with clinical **occult tumour presenting with positive axillary LN
5. Monitor result of neoadjuvant therapy
6. Identify extent of residual disease after excision which show positive margins
Pathological exam (Biopsy)
Indication:
1. Evaluation of a palpable breast mass
2. Evaluation of a non-palpable breast mass
3. Evaluation of nipple discharge
4 techniques:
1. FNAC
2. Core biopsy
3. Incisional biopsy
4. Excisional biopsy
FNAC vs Core biopsy
FNAC:
Advantages:
- safe, simple, inexpensive
- immediately distinguishes ***cysts from solid masses (tumour)
Disadvantages:
- cannot reliably distinguish **DCIS from invasive cancer
- cannot perform **immunohistochemical staining
Core biopsy:
Advantages:
- distinguishes DCIS from invasive cancer
- allow **immunohistochemical staining for **ER / PR / C-erbB2 (HER2) status
Disadvantages:
- relatively ***more invasive, require local anaesthesia
- small stab incision
Evaluation of a non-palpable breast mass
- Imaging
- USG
- Mammogram
- MRI - Biopsy (depends on which imaging picked up the lesion)
- USG picked up —> USG guided FNAC / Core biopsy
- Mammogram picked up —> Mammogram-guided biopsy (aka **Stereotactic guided biopsy —> for **microcalcifications)
- MRI picked up —> MRI guided biopsy
Biopsy techniques:
1. FNAC / Core biopsy (when clinical suspicion)
2. Vacuum assisted core biopsy (***larger bore, more traumatic, vacuum to suck lesion, can achieve complete removal of small lesion)
3. Hookwire guided excisional biopsy (can do specimen mammogram / radiology / USG)
4. Radio-guided occult lesion localisation (ROLL)
Excisional vs Incisional biopsy:
Incisional:
- **Fungating / **Ulcerative tumour
- take out a strip of tissue directly from skin surface from **fungating edge (because **rapidly-growing area)
- cannot be done on a breast lump ***without ulceration
Excisional:
- when conflict between radiological vs core biopsy —> to be **100% sure
- cannot be done on a breast lump **without ulceration
Breast cancer screening
- Aim to detect cancer as an asymptomatic + curable stage
- Already proven decrease mortality rate in international studies
- Problems: Psychological impact / over-diagnosis, Cost effectiveness
Why suitable for screening?
- Common disease / high prevalence
- Significant impact to population
- Detectable in early phase
- Low cost
- Accurate
- Specific
- Critical point before clinical diagnosis
- Short lag phase
- Tool is acceptable / tolerable to population
- Treatment available after diagnosis
- Treatment acceptable to population
“Standard” screening guidelines:
30s:
- ***Yearly breast examination
- Monthly self-breast examination
40s:
- Mammogram every ***2 years
- Yearly breast examination
- Monthly self-breast examination
50s:
- Mammogram every ***1 year
- Yearly breast examination
- Monthly self-breast examination
Interactive tutorial: Management of breast cancer
Breast cancer screening
Pros:
- Decreased breast cancer mortality + total mortality
- Decreased morbidity from breast cancer (Reduction of late-stage breast cancer)
Cons:
- Radiation exposure
- False-positive and false-negative mammography results, additional imaging + biopsies
- Anxiety, distress, psychological responses
World:
- Variation in different countries depending on resources
- Voluntary: Not population screening
- Privately / Charity funded
- Means of screening: Mammography
- USG as part of screening (but lack evidence)
- Age 40: every 1-2 years
- Age 50: every 2 years
- Can consider screening earlier if family history
HK:
Past: Voluntary breast screening
Last year (2021):
***Risk based breast screening:
- Starting at age 44 based on risk calculation model
- Screening every 2 years
Signs of Breast cancer on Mammogram
-
**Microcalcifications
- **Clustered / Segmental
- **Pleomorphic (有大有細)
- **Stellate patterns (星狀) - ***Spiculated, high density mass
- ***Architectural distortion
- ***Asymmetrical density
**BiRADS score: Mammogram reporting (now for USG + MRI as well)
Category 0: Need further investigations (without any clinical examinations)
Category 1: Normal
Category 2: **Benign
Category 3: Probably benign (<2% malignant)
Category 4: Suspicious of malignancy
Category 5: Highly suggestive of malignancy >=95%
Category 6: Malignancy proven with biopsy
Limitations of mammography
- Breast implant
- Dense breast
- Paraffin calcification
USG
- Mammography still most sensitive test for breast cancer detection
- USG used in conjunction with mammography
- USG is commonly used in our locality to add diagnosis of breast lesion
Cons:
- USG not as sensitive for macrocalcification detection
- Less useful in fatty breast
Pros:
- Good at: mass lesions, cysts
- Easy to use, fast, cheap
- Useful in breasts with dense parenchyma
Reading USG:
- R93N: Right, 9 o’clock , 3 cm from nipple
MRI breast indications
- Screening women at ***high risk of breast cancer e.g. strong family history, hereditary cause
- Evaluate ***questionable suspicious lesions seen on mammography / USG
- Identify patients with **clinically occult (i.e. **non-palpable) tumour presenting with positive axillary nodes
- Monitor result of ***neoadjuvant therapy
- Exclude ***multifocal lesions when planning breast conservation surgery
MRI breast kinetic curve:
- leaky neovascularisation —> type 3 kinetic curve —> contrast concentration drops rapidly (vs benign disease will hold contrast)
Staging of Breast cancer
Purpose (ALWAYS answer in exam):
1. Stage to plan treatment
2. Prognostication
Methods:
1. PET-CT / PET-MR
Alternative ways:
2. Bone scan
3. CT thorax / abdomen
4. USG
(AJCC TNM staging:
T stage:
T0: no evidence of primary tumour
Tis: Carcinoma in Situ
T1: Tumour **<2cm
- T1a: 0.1-0.5cm
- T1b: 0.5-1.0cm
- T1c: 1.0-2.0cm
T2: Tumour **>2cm but <5cm
T3: Tumour **>5cm
**T4: Tumour with **direct extension to
- T4a: chest wall (ribs, IC, serratus)
- T4b: skin (Peau d’orange, ulceration, satellite skin nodule)
- T4c: T4a + T4b
- T4d: inflammatory breast cancer
N stage (**Clinical / **Pathological):
N0: no lymph node involvement
N1: mets to movable ipsilateral level I, II axillary LN
N2: mets to ipsilateral level I,II axillary LN – clinically fixed or matted or mets to ipsilateral mammary LN in absence of axillary LN
N3: mets to ipsilateral infraclavicular (level III) lymph nodes, ipsilateral mammary LN, ipsilateral supraclavicular LN (with or w/o level I & II axillary LN)
M stage:
M0: no distant mets
M1: distant detectable metastasis (histologically proven > 0.2mm))
Biopsy of Breast lumps
- FNAC
- Core biopsy (e.g. Vacuum assisted core biopsy)
- Excisional biopsy
If **palpable —> **Direct / Free hand
If **non-palpable —> **Image-guided
- USG guided
- Mammogram (Stereotactic) guided
- MRI guided
(others: Wire guided, Radio-guided occult lesion localisation (ROLL))
Cytology Reporting Categories
C1: Inadequate
C2: Benign
C3: Atypia, probably benign
C4: Suspicious of malignancy
C5: Malignant
***Risk factors of Breast cancer
Hormonal factors:
1. Early menarche <12
2. Late menopause >55
3. Pregnancy after age 30
4. Nulliparity
5. Use of OC pills / HRT
6. Obesity
Non-hormonal factors:
7. Family history of breast cancer (BRCA1, 2)
8. History of breast biopsy showing a premalignant condition, atypical ductal hyperplasia, proliferative fibrocystic changes, LCIS, DCIS
9. Smoking, Alcohol
10. Diet
11. Lack of exercise
12. Advanced age
BRCA1, BRCA2
BRCA1:
- Breast cancer
- Ovarian cancer
- Prostate cancer
- Colon cancer
BRCA2:
- Breast cancer
- Male breast cancer
- Ovarian cancer
- Prostate cancer
- Laryngeal cancer
- Bile duct cancer
- Stomach cancer
- Colon (minimal) melanoma
- Pancreatic cancer
Infertility issues
Pre-surgery / Pre-chemotherapy egg harvesting + storage can be offered
