Lump Investigation & Management

Question 1

What is the triple test apprach?

Answer 1

1. Clinical History and Examination
2. Imaging – Mammogram &/or Ultrasound
3. Pathology – FNA cytology & core biopsy

Question 2

What imaging would you do?

Answer 2

Mammography in >35, can detect:

i. Mass lesions
ii. Asymmetric densities (spiculated/stellate)
iii. Architectural disturbances
iv. Calcifications (pleomorphic, branching a/w DCIS)

Ultrasound

i. In women <35 years, pregnant or lactating women
ii. Also used surgically for guidance of biopsy, drainage, hookwire insertion

MRI
i. Very sensitive but NOT specific (lots of red herrings)

Question 3

What are the pros and cons of cytology

Answer 3

a. Cytology looks at cell morphology not tissue architecture, cannot distinguish insitu from invasive, where as core biopsy shows both

Question 4

If any of these tests are positive, what would you do?

Answer 4

If positive – HER2: HER2-positive breast cancers tend to be more aggressive than other types of breast cancer. They’re also LESS RESPONSIVE TO HORMONE TREATMENT. However, treatments that specifically target HER2 are very effective. They include: (Herceptin)

& ER/PR testing (tamoxifen) : The expression of the hormone receptors ER and PR in a patient’s breast cancer is an example of a weak prognostic but strong predictive biomarker. If a patient’s tumor expresses ER and/or PR, as seen in approximately 70% of invasive breast cancers, we can predict that this patient will likely benefit from endocrine therapy such as tamoxifen.

Question 5

Explain surgical treatment

Answer 5

Excision of Primary Tumour

• Breast conservation = wide local excision (+ breast radiotherapy)
• Mastectomy

Regional LN Staging with Sentinel Node Biopsy

• Identifying the first draining lymph node from the breast using patent blue dye + lymphoscintography
• Node sliced into multiple sections & examined by H&E and IHC
• If nodal involvement → axillary dissection

Excision: Axillary Dissection

• Removal of axillary fat pad containing lymph nodes
• Potential complications: lymphedema (20-30%), shoulder stiffness, seroma, numbness, infection.

Question 6

WHAT KIND OF ADJUVENT TREATMENTS are available?

Answer 6

Adjuvant treatment is additional therapy given to a patient with no known residual or metastatic disease, with the aim of decreasing the likelihood of recurrence (local or distal)

Local
o Adjuvant breast radiotherapy in post breast conservation & in high risk mastectomy patients

Systemic
o Based on risk benefit analysis, includes chemo, immunotherapy, hormonal etc
o Tamoxifen (selective OR modulator), Aromatase inhibitors, Trastuzumab (Herceptin), oopherectomy