Case Study: Breast Surgery Flashcards
***DDx of Breast lump
Benign:
- Fibroadenoma
- Breast cysts
- Phyllodes tumour (Benign / Borderline)
Malignant:
- In-situ breast cancer
- Invasive breast cancer
- Phyllodes tumour (Malignant)
Uncommon:
- Idiopathic granulomatous mastitis (with / without inflammatory signs)
- Fat necrosis (history of trauma)
History taking in Breast lump
- Characterisation of lump
- Duration
- Change in size - Associated symptoms
- Nipple discharge
- Mastalgia - Risk factor
- Family history of Breast / Ovarian cancer
- Hormonal: Early menarche, Late menopause, Nulliparity, Exogenous hormone (OC pills, HRT)
- Personal history of Breast cancer / Pre-malignant conditions: Atypical ductal hyperplasia - Surgical history
- Previous breast surgery - Past medical history
- Drug history
Triple assessment
Triple assessment:
- Clinical
- History + P/E
- S/S - Radiological
- Mammography
- USG
- MRI - Pathological
- FNAC
- Core biopsy
- Incisional biopsy
- Excisional biopsy
—> sensitivity 99.6% + specificity 93%
Mammogram / USG interpretation
Mammogram: 1. Patient name 2. Date 3. View (MLO / CC view) 4. Striking feature of lesion - Size - Shape - Density - Location: Right / Left, Upper / Lower, Medial / Lateral quadrant - Look for: —> ***Architectural distortion —> ***Spiculation —> ***Suspicious (Micro)calcification (***Pleomorphic: different size / shape, in cluster / segment) —> Mass lesion —> Relation with skin / underlying muscle —> Any LN involvement 5. Compare to other side
USG: 1. Striking feature of lesion - Size - Shape - Look for: —> ***Irregular hypoechoic mass —> ***Posterior shadowing —> ***Taller than wide —> ***Microcalcification (within the mass) —> ***Hypervascularity (Doppler USG) —> ***Dilated duct (for Nipple discharge) - Compare to other side
FNAC vs Core needle biopsy (CNB)
FNAC:
Pros:
- Less invasive than CNB
- Good specificity (96%)
Con:
- Only give cytology assessment
- Without architectural assessment (don’t know invasive or not)
- Less accurate than CNB
- Not allow good immunohistochemical assessment
- Poor sensitivity (74%)
CNB (Trucut: brand name):
Pros:
- Allow histological diagnosis
- High sensitivity (90%) + specificity (~100%)
Cons:
- More invasive
Management of Breast cancer (Any cancer in general)
- Confirm diagnosis
- Stage disease
- Assessment of co-morbidities
- Nutritional assessment + optimisation
- Definitive treatment
Staging disease
Radiological: 1. PET-CT Alternatives: 2. CT thorax / abdomen 3. Bone scans
(Cheap options:
- CXR (Lung)
- Liver USG (Liver)
- Bone scan (Bone))
Pathological:
1. TNM staging
(Classification of 4 molecular subtypes of breast cancer)
Luminal A: ER+, PR+/-, HER2-, Ki-67 <14% (Low proliferation), Good prognosis (most common type)
Luminal B: ER+, PR+/-, HER2+/-, Ki-67 = 14% (High proliferation)
HER2+: ER-, PR-, HER2+
Triple negative: ER-, PR-, HER-, Poor prognosis
Neoadjuvant systemic treatment
Neoadjuvant therapy:
- Chemotherapy (for HER2 +ve, Triple negative)
- Hormonal therapy (for Hormonal +ve)
Indication:
- Better locoregional control (for advanced / LN +ve disease)
- Downstage disease (shrink tumour) to enable Breast Conserving Surgery (esp. in Large size tumour)
- Special circumstance
- **HER2 +ve breast cancer (respond well to chemo) —> Targeted therapy needed —> Neoadjuvant + Targeted therapy
- **Triple negative breast cancer (respond well to chemo)
(Hormonal +ve breast cancer —> respond to hormonal therapy, less respond to chemotherapy)
Surgery for Breast cancer
- Breast management
- Simple Mastectomy (SM) —> Always offer Breast reconstruction as an option
- Breast Conserving Surgery (BCS (Lumpectomy)) - Axillary management
- Sentinel LN biopsy (for N0 disease) (SLNB) (preferred unless large tumour load in axillary region)
- Axillary LN dissection (AD)
4 combinations:
- BCS + SLNB
- BCS + AD
- SM + SLNB
- SM + AD (aka ***Modified radical mastectomy (Radical mastectomy: Remove pectoralis as well))
Consideration:
- Size of tumour
- Size of breast
- Multicentric lesions (rule out Breast Conserving Surgery)
- Patient wish
Case 1:
- 45 yo lady
- Self-detected right breast lump for 6 months
- Mass increase in size gradually
History: - No pain / nipple discharge - No family history of breast / ovarian cancer - Hormonal history: —> Menarche 13 yo —> Premenopausal —> G1P1 —> Never on OCP - Unremarkable past medical history apart from chronic Hep B carrier
P/E: - General: Unremarkable - Breast: —> No scars suggestive of previous breast surgery —> Slight bulge over R12-2 o’clock position —> 2cm tumour, periareolar in location - LN: —> No palpable axillary LN —> No palpable supraclavicular LN
Investigations: - CNB —> Invasive ductal carcinoma —> ER positive (Allred score 8/8) —> PR positive (Allred score 8/8) —> HER2 score 0 —> Ki-67 index 8% (Proliferative index: show how fast cell divide + grow)
- Metastatic workup
—> PET-CT: no evidence of distant metastasis / suspicious local lymphadenopathy
Diagnosis:
- T1N0M0 disease
- Luminal A disease (ER+, PR+, HER2-, Low proliferative index)
Treatment:
- Neoadjuvant not needed
- SM + SLNB without immediate reconstruction
- Pathology
—> 18mm Invasive ductal carcinoma grade 1
—> ER positive (Allred score 8/8)
—> PR positive (Allred score 8/8)
—> HER2 score 0
—> Ki-67 index 8%
—> Margins all clear
—> Sentinel LN: 3 harvested, none involved by metastatic carcinoma
Pathological staging:
- T1cN0M0 disease
Subsequent management - Multidisciplinary: Surgeon + Oncologist + Radiologist + Pathologist - Prognostic tools (e.g. Gene signature) —> High risk: Adjuvant chemotherapy —> Low risk: Adjuvant hormonal therapy
DDx for Nipple discharge
Benign (more common):
- Intraductal papilloma (Bloody)
- Ductal ectasia (Serous)
Malignant:
- In-situ breast cancer (Bloody)
- Invasive breast cancer (Bloody)
General:
- Physiological lactation (Milky)
- Hyperprolactinaemia (Milky)
History taking in Nipple discharge
- Characterisation of nipple discharge
- Unilateral / Bilateral
- Blood / Serous / Milky / Yellow discharge
- Spontaneous (stain on underwear) vs Manual expression of nipple - Associated breast symptoms
- Mass
- Mastalgia - Risk factor
- Family history of Breast / Ovarian cancer
- Hormonal: Early menarche, Late menopause, Nulliparity, Exogenous hormone (OC pills, HRT)
- Personal history of Breast cancer / Pre-malignant conditions: Atypical ductal hyperplasia - Surgical history
- Previous breast surgery - Past medical history
- Drug history
P/E in Nipple discharge
- Breast mass
- Inspection
- Palpation - Nipple discharge
- Ask patient to express discharge
- Unilateral / Bilateral (Bilateral: **Visual field examination)
- Blood / Serous / Milky / Yellow discharge
- **Single ductal (more pathological) / Multiductal (more physiological / systemic)
- Sampling for cytology
Investigations in Nipple discharge
Radiological 1. USG (high frequency linear probe, adjust depth of scan, radial placement of probes, try to identify any intraductal lesions should there be any dilated ducts) - ***Dilated duct (for Nipple discharge) - Mass lesion within duct
-
**Ductogram (Mammogram / MR ductogram)
- Mammogram: Cannulate diseased nipple —> **Contrast mammogram —> Dilated duct + **Filling defect
- MR ductogram: Performed with heavily T2-weighted sequence, non-invasive, no radiation —> Dilated duct
—> **Distance of filling defect from nipple orifice
—> Mass lesion within duct - Ductoscopy
Histological
- Core biopsy
- can be difficult for small intraductal lesions —> may result in sampling error
