Case Presentation & Discussion on Breast Mass Oliver S. - PowerPoint PPT Presentation

Case Presentation & Discussion on Breast Mass Oliver S. Leyson, MD Surgery Resident Department of Surgery Ospital Ng Maynila Medical Center

General Data: M.L, 62 y/o, F Cavite City

Chief Complaint: Breast Mass, right

History of Present Illness: 8 months PTA breast mass, right size of a 2x2 cm no other signs & symptoms noted no consult done

3 weeks PTA Mass was noted increased in size prompted consult OMMC advised surgery CONSULT

Past Medical History: Hypertension HBP: 180/100 Meds: metoprolol Family History: no history of breast cancer in the family Personal Social History: non-smoker non-alcoholic beverage drinker

Physical Examination: Conscious, coherent, ambulatory , NICRD • BP:140/80 CR:85 RR:21 T:37ºC • Pink palpebral conjunctiva, anicteric sclerae • Supple neck, (-) cervical LAD • Symmetrical chest expansion, clear breath sounds

Physical Examination • Adynamic precordium, normal rate & regular rhythm • Flat, NABS, soft, nontender • (-) cyanosis, (-) pallor

Breast: 3x3cm,hard, movable, non-tender mass at lower inner quadrant no ulceration (+) palpable axillary (-) lymphadenopathy

Salient Features: • 62 y/o, F • 8 months history breast mass • 3x3cm, hard, movable, non-tender mass at lower inner quadrant R breast • no ulceration overlying the mass • (+) palpable right axillary lymphadenopathy • (-) supraclavicular lymph nodes

Pattern Recognition BREAST MASS Non-Inflammatory Inflammatory Benign Malignant Breast abscess mastitis

Tumor, Rubor Pattern Recognition BREAST MASS Calor, Dolor Non-Inflammatory Inflammatory Acute onset Benign Malignant Breast abscess mastitis

62 yo female Prevalence BREAST MASS Hard, nontender Non-Inflammatory Inflammatory Benign Malignant Breast abscess mastitis Breast carcinoma Fibroadenoma

66 yo female Prevalence BREAST MASS Hard, nontender Non-Inflammatory Inflammatory Benign Malignant Breast abscess mastitis Breast carcinoma Fibroadenoma

Clinical Diagnosis: Diagnosis Certainty Treatment Breast mass prob 80% Surgical malignant Breast mass prob 20% Surgical benign

Do I need a para-clinical diagnostic procedure? Yes, to increase the certainty of my primary diagnosis.

Recommendations In patients with palpable breast mass in which cancer is suspected BIOPSY is mandatory (Level I, Category A) Evidence- Evidence -based Clinical Practice Guidelines on the Diagnosis and based Clinical Practice Guidelines on the Diagnosis and Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999. 99. Management of Breast Cancer Part I. Early Breast Cancer. PCS 19

Goal of Paraclinical Diagnostic Procedure • Adequate tissue for diagnosis

TREATMENT OPTIONS BENEFIT RISK COST AVAILABILIT Y Accuracy Sensitivity Specificity Bleeding Pain 300 +++ 95% FNAB *92.8% 83% ** 900 + 95% *99% Core 94% ****** needle biopsy *Adolfo AR; Nuguid TP; Cipriano MC; del Mundo AG; de Leon G. Fine-needle aspiration biopsy in the diagnosis of breast masses: a prospective study. Philipp J Surg Spec. 1986. 41(1):26-31.

TREATMENT OPTIONS AVAILA BENEFIT RISK COST BILITY Accuracy Sensitivity Specificity Bleeding •Pain • Residual tumor 600 ****** +++ Excision >99% 97% 99% Biopsy Incision 600 +++ ****** biopsy 92.8% 97% 98%

Recommendations • Fine needle aspiration cytology (FNAC) is the initial diagnostic procedure in patients with a palpable breast mass in which cancer is suspected(Level I, Category A) Evidence- Evidence -based Clinical Practice Guidelines on the Diagnosis and based Clinical Practice Guidelines on the Diagnosis and Management of Breast Cancer Part I. Early Breast Cancer. PCS 1999. 99. Management of Breast Cancer Part I. Early Breast Cancer. PCS 19

FNAC Result: Smears show some groups of ductal cells exhibiting atypia with other individual cells showing the same features in the background. The individual cells exhibiting irregular nuclear contour and hyperchromatic nuclei. Diagnosis: Cell findings suggestive of malignant ductal cells

Pre-Treatment Diagnosis: Diagnosis Certainty Breast Ca, Right 99% Stage IIB (T2N1M0) Breast Mass probably Benign 1% (Fibroadenoma)

Goals of Treatment: • RESOLUTION of the mass • No complications • No recurrence

TREATMENT OPTIONS BENEFIT RISK COST AVAILABILI TY Resolution of Overall survival Local recurrence mass Bleeding 3000 Wide excision ++ • Pain +++ 65-78% **40% • Anesthetic risk • Residual tumor Bleeding Modified • Pain Radical 3500 +++ 66-79% **8-12% • Anesthetic Risk +++ Mastectomy • Ischemia of skin flaps • Injury to nerves • Lymphedema of the arm Breast Bleeding 7000 Conservation • Pain +++ 65-78% **13-20% ++ therapy • Anesthetic Risk • Residual tumor • Radiation exposure **RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.

TREATMENT OPTIONS BENEFIT RISK COST AVAILABILI TY Resolution of Overall survival Local recurrence mass Bleeding 3000 Wide excision ++ • Pain +++ 35-48% **40% • Anesthetic risk • Residual tumor Bleeding Modified • Pain Radical 3500 +++ 66-79% **8-12% • Anesthetic Risk +++ Mastectomy • Ischemia of skin flaps • Injury to nerves • Lymphedema of the arm Breast Bleeding 7000 Conservation • Pain +++ 65-78% **13-20% ++ therapy • Anesthetic Risk • Residual tumor • Radiation exposure **RANDOMIZED CLINICAL TRIAL TO ASSESS THE VALUE OF BREAST CONSERVING THERAPY IN STAGE I AND II BREAST CANCER, EORTC 10801 TRIAL.

• Adjuvant combination chemotherapy is recommended for pre-menopausal women with involved axillary nodes while adjuvant hormonal therapy seems to benefit post-menopausal node-positive women, particularly those with positive hormone receptor levels. • Multimodality treatment is necessary to improve survival rates and decrease local recurrence Cabaluna ND.Current management of breast cancer. Acta Med Philipp.1993; 29(1):1-6.

Pre-op preparation: • Informed consent secured • Psychosocial support provided • Optimized patient’s physical health • Patient screened for any health condition • Operative materials secured

Intra-op Management: • Patient placed under GA with R arm extended • Transverse elliptical incision • Superior & inferior flaps created • Breast tissue dissected from the pectoralis major fascia • Clavipectoral fascia opened • Axillary vein identified • Palpable axillary LNs dissected • Right breast and axillary LNs removed enbloc

• Washed with NSS • Hemostasis • Anterior & lateral drains placed, anchored with silk 3-0 • Correct instrument,needle and sponge count • Flaps apposed – Subcutaneous & dermis closed with vicryl 2-0 – Skin- subcuticular with vicryl 4-0 • Povidone-iodine paint • DSD • Drain in negative pressure

Intra-operative findings: • Right breast measured 10x15cm with a 3x3 cm hard gritty mass, movable at the upper outer quadrant. • (-) levels 1 and 2 axillary LNs, multiple, not matted, largest of which measured 1x1cm.

Final Diagnosis: Breast CA, Right Stage II B (T2N1M0) S/P Modified Radical Mastectomy Right

Post-operative Routine use of any combination of analgesics � resulting in a pain-free post-operative period Arm rehabilitation exercises � Discharge within 48 hours post-operation, with � tube drain, and with instructions on: • care of tube drain • intake of analgesics • arm rehabilitation exercises

FOLLOW-UP � First follow-up visit 5-7 days of discharge � Second follow-up is 30 days after the operation � Adjuvant treatment is started within 6 weeks of the operation � Frequency of follow-up: First 2 years – every 6 months After 2 years – yearly Patients are given instructions to consult earlier if with symptoms � Routine annual contralateral breast mammography � Symptom-directed metastatic work-up � Annual gynecologic evaluation is advised for patients on Tamoxifen

Follow-up plan: • TCB after 1 week for removal of lateral drain • Awaiting final histopath result • ER-PR determination Post-menopausal ER (+) Tamoxifen ER (-) Chemotherapy ER Unknown Tamoxifen

Follow-Up Care • After primary therapy, patients should be followed for life, – to detect recurrences – to observe the opposite breast for a second primary • First 3 years, patient is examined every 3-4 months • Thereafter, examination is done every 6 months until 5 years postoperatively • Then, every 6-12 months for the rest of the life

Outcome: • Resolution of the breast mass • Live patient • Discharged • Happy and contented with the outcome • No complications • Satisfied patient • No medico-legal suit

Sharing of Information:

STAGING TNM staging (AJCC 6 th edition) � � Staging Maneuvers • Routine contra lateral breast mammography for all patients with microscopic evidence of breast cancer • Routine bilateral breast mammography for patients in whom breast conservation treatment is contemplated • Individual organ investigation for metastatic work-up should be symptom-directed