MBBS V Surgery – Breast mass (tutorial)

Breast mass (PMH tutorial)

Approach to breast mass
 60-year old female
 Self-detected a mass over left breast
 Risk factors of breast cancer
o Congenital/non-modifiable
 Family history of breast cancer (de novo vs inherited)
 <50 years old
 E.g. BRCA1 usually present <30 years
 E.g. BRCA2 usually present later
 Other heterogeneous genetic mutations  breast cancer
 History of ovarian disease
 E.g. BRCA 1 and 2
 Other types of cancer associated with breast cancer
 Male: prostate cancer (hormonal sensitive)

o Acquired
 Endogenous estrogen exposure
 Obesity
 Early menarche and late menopause
 Nulliparity
 Breastfeeding
 Exogenous estrogen exposure (risk depends on duration + dose)
 OCP
 Hormonal replacement therapy
o Lifestyle
 Physical activity
 Obesity
 Alcohol
o Personal history of breast diseases
 History of benign breast disease or high risk breast disease
 Intra-ductal papilloma (S/S: serous/bloody discharge)
 Atypical hyperplasia (increases risk of DCIS)
 Follow-up and surveillance for previous breast CA cases
o P/E
 Ipsilateral side for recurrence (skin change, mass): still have recurrence
after mastectomy or BCT
 Contralateral side (much higher risk on the contralateral side)
o Investigation
 Surveillance mammogram (on contralateral side)
 Ipsilateral side: cannot be done if performed mastectomy
 Distant metastasis screening
MBBS V Surgery – Breast mass (tutorial)

 Physical examination
o Inspection and palpation of mass
 Size
 Consistency
 Fixed to chest wall
 Triple assessment:
o Clinical
o Radiological
o Pathological
 Mammogram
o Mammogram for young (low sensitivity: dense lobular breast tissue) and
elderly patient (breast components changes as ages: fatty tissue)
 Breast tissue: white
 Fat: black (easier to pick up abnormality)
 More sensitive for micro-calcifications
o CC view

 CC: view = no pect/axilla (MLO: see pectoralis major and axilla)

 Site: correlate with 2 views
 6 o’clock
 12 o’clock
 Behind nipple
 Irregular border
 Not too spiculated (edge is sharp)
o MLO view

 Mass is therefore at 12 o’clock

o Compression view (not for routine)
o *Previous imaging for comparison
o *Anatomy of MLO and CC view
MBBS V Surgery – Breast mass (tutorial)

o Malignant features on mammogram

1. Fine pleomorphic microcalcifications (different shapes)
2. Spiculated (sharp)
3. Amorphous (hazy in appearance, shape not determined)
4. Coarse heterogeneous (irregular, heterogeneous)
5. Fine linear branching (thin, line, irregular, <0.5mm calibre)
o Mammogram has reduced sensitivity in:
1. High breast density
2. Young patients
3. Invasive lobular CA (no classical micro-calcifications)
4. Hormonal replacement
5. Presence of breast implants (obscure view: request MRI)
 Breast ultrasound
o More sensitive for morphology
o Better to evaluate axillary lymph nodes
o Example of ultrasound = highly suspicious of malignancy
 Patient identifiers (date) and side of breast
 Location of ultrasound (at 12 o’clock – correlates with clinical findings)
 Taller than wide
 Irregular
 Hypoechoic
 Microcalcification in mass
 Irregular posterior shadowing (can be regular vs irregular)
 Heterogeneous mass: absorb different wavelengths
 Hypervascularity: increase Doppler signal
 No enlarged lymph nodes (>1cm and usually palpable) (US: sensitive)
 Morphology of lymph node
o Irregular margin
o Metastatic LN: round (vs normal = oval)
 Contents of lymph node
o Normal: clear cortex (outside) and hilum
o Metastatic: hilum disrupted
 *NOT cystic lesion: homogenous, hypo-echoic, regular border
MBBS V Surgery – Breast mass (tutorial)

o Malignant features on ultrasound

1. Taller than wide
2. Hypoechoic
3. Posterior acoustic shadowing
4. Microcalcification
5. Central vascularity
o Role of ultrasound
 Adjunct to MMG (MMG: better to pick up microcalcifications)
 Characterize discrete mass or architectural distortion on MMG
 Morphology
 Lymph node status
 Evaluate palpable breast lesion not seen on MMG
o Limitations of ultrasound
 Operator dependent
 Lack of scanning protocol
 False positive result
 Screening has limited value
 BIRADS: breast imaging reporting and data system
o Role of BIRADS
 Standardize assessment
 Standardize nature of abnormality
 Standardize protocol and management
o Grade 4 onwards requires tissue diagnosis (4B or above = worrying + URGENT)
MBBS V Surgery – Breast mass (tutorial)

 Pathological
o Core biopsy (can give additionally info to change management)
 Morphology: architectural (can differentiate DCIS vs invasive cancer)
 Grading of disease
 Immunohistochemical staining: ER, PR, HER2, C-erB2 (for chemo mx)
 16G needle
 Advantages
 Higher sensitivity and specificity
 Tumour biology: plan neoadjuvant therapy or palliative tx
 Allows placement of surgical clips and markers
 Disadvantages
 More invasive
 Higher risk of patients especially those on anti-platelets/anti-
coagulants
 More expensive
o FNAC:
 Role: cystic mass management, recurrence, if does NOT guide mx
 Only aspirate resulting in scattered morphology
 21-22G needle (anti-coagulant, if just need dx, may be enough)
 Advantages
 Cheaper
 Simpler
 Less invasive
o Excisional biopsy (depends on clinical scenario)
 Indication: usually perform for chest wall nodule
 C/I: mass
 Advantages
 Simple technique (minor OT)
 Diagnostic and therapeutic role
o *Note: Pi67 status (during surgery, affect prognosis + guide adjuvant chemo)

Management: this patient confirmed with invasive ductal carcinoma

 Multi-disciplinary assessment
o Tumour biology, tumour staging, patient’s condition, etc
 Some tumours are more sensitive to chemo (e.g. triple negative is more
sensitive to chemotherapy)
 vs Luminal A or luminal B disease (ER strong and HER2-ve) are less
sensitive to chemo
 BCT vs mastectomy (similar survival and local recurrence rate)
o Tumour to breast ratio
 If do not want severe cosmetic deformity: <20% of breast volume
MBBS V Surgery – Breast mass (tutorial)

o BCT requires radiotherapy (a MUST) due to higher local recurrence rate

 Absolute C/I to BCT
 Failure to achieve adequate margin ithout causing significant
breast deformity
 Inflammatory breast CA
 Multi-centric disease
 Contraindicated for RT
o Previous radiation to chest and H&N
o Connective tissue disease (SLE, vasculitis)
o Pregnant women
o *Local recurrence depends on tumour status, tumour biology, tumour burden
(rather than the surgical approach itself)
 Axillary dissection and SLNB (SLNB = gold standard to mx node negative disease)
o Objective
 Lymph node is most important indicator for prognosis
o Definition of SLN
 First LN drains the tumour along lymphatic pathway
o Indications of axillary dissection (axillary staging AND therapeutic)
1. Clinical +ve findings of axillary lymph nodes
2. SLNB +ve (first lymph node from tumour)
 All patients receiving mastectomy without radiation
 >2 +ve sentinel lymph nodes in patients receiving BCT with
radiation
3. Inflammatory breast cancer (T4d): tumour block lymphatic channel –
thus whatever injected in tumour cannot go to axilla
4. Prior hx of axillary/breast surgery (lymphatic channel damaged by
surgery from past surgery – risk of inability to find signal)
 E.g. ipsilateral recurrence = unable to find SLN
o High morbidity (similar survival, rate of recurrence of disease – therefore
node negative disease = SLNB is accurate enough to replace AD)
 Lymphaedema (30%)
 Shoulder stiffness
 Numbness
 Longer recovery
o Axillary dissection procedure
 Clear fatty tissue until floor of axilla: latissimus dorsi and lateral to
pectoralis minor and behind pectoralis minor
o SLNB procedure:
 Injection of agent
 Sub-areolar: 12 to 3 o’clock
 Peri-tumour area
 Detection of agent: gold standard is to use BOTH blue dye + isotope =
dual method (highest sensitivity to 95%)
 Blue dye: colour to recognise SLN (used alone – Sn: 85-90%)
 Radio-active isotope: 99-Technetium (half life: 6 hours)
o Use gamma probe to detect radio-active signal
 ICG (newer technique)
 SLN should have 1/10 of radioactivity of tumour (no definite for how
many SLN required; but more SLN detected = more sensitive
assessment would be thus multiple LN can be removed)
MBBS V Surgery – Breast mass (tutorial)

 Note: neoadjuvant therapy: chemo increase false negative rate (dual

agent and require at least 3 SLN obtained)
 Chemo needed?
o Neoadjuvant: BEFORE surgery
o Adjuvant: AFTER surgery
 Radiotherapy needed? (continuous for 25 days – need to be ambulatory)
o BCT performed
o Close margins
o Large tumour (T3 or above)
o Large number of positive nodes
o Extensive lymphovascular invasion
o Close margins
 (Note: new studies with neoadjuvant hormone therapy but less evidence based, do not
need to mention in exam)

Other important points

 Paget’s disease: variant of DCIS near nipple-areolar complex
o Nipple eczema or discharge
 Key points for reading mammogram
o Correct placement of film
o View: CC, MLO (need two views to confirm site)
 CC: laterality/centrality
 MLO: upper or lower breast
o Laterality/clock-face
o Quadrant/position
o Distance from nipple
o Nipple status
 No nipple retraction
o Axilla status
 MLO view: no obvious lymph nodes
 Mass does not invade into muscles