Download Breast Mass

Case Presentation and Discussion
BREAST MASS
Gemma Uy, MD
General Surgery Resident, Year III
CASE:
This is a case of a 61 yr old female who consulted for a breast mass.
The mass was first noted 8 mos prior to consult on the right breast, movable, firm, nontender.
Px has no other systemic complaints except for the mass. On consultation at the Out-patient
Dept, an FNAB was done which showed ductal carcinoma, hence Px was advised admission.
On physical exam :
(+) R breast mass - 6 x 5 cm, firm,
movable, nontender , non-erythematous ,
with poorly defined borders located beneath
the skin
no skin changes
no nipple retraction or discharge
(+) axillary lymph node 2x1 cm,
not mated
(-) supraclavicular nodes bilateral
(-) breast mass, L
(-) axillary LN, left
Dx: Breast CA, R St. IIIA T3N1M0
PLAN: Modified Radical Mastectomy, R
DISCUSSION:
With a patient consulting for a breast mass and confirmed by the physician that there was
indeed a mass on the right breast by physical examination, the diagnosis can be obtained by
first knowing the tissue of origin.
Based on the location, the mass can arise from:
SKIN
SUBCUTANEOUS TISSUE – lipoma, sebaceous cyst
BREAST
MUSCLE
RIB
But given the following characteristics of the mass – firm, movable, no skin changes, the
mass is unlikely to arise from the ribs, skin or muscle. A mass arising from the muscle is more
deeply located and with the relatively thin anterior chest muscles, it is not that movable.
A lipoma or sebaceous cyst may arise over the area but by prevalence, it is more common
to arise from the breast tissue that from the subcutaneous tissue. Also the presence of the axillary
lymph node is not usually associated with a subcutaneous tissue origin.
After considering that the mass is most likely of breast tissue origin, then the next step is
to differentiate whether it is benign, malignant or inflammatory . The more common benign
breast masses are fibroadenoma and fibrocystic disease. A phylloides tumor may also occur.
CHARACTERISTICS
FIBROADENOMA
firm, movable, nontender with well defined borders,
my be multiple
More common in young females
FIBROCYSTIC DISEASE
firm, borders poorly delineated, assoc w/
pain/tenderness especially during menses
PHYLLOIDES TUMOR
firm, usually large and multicystic, not assoc w/
axillary lymph node
MASTITIS
tender, erythematous
More common in lactating women
BREAST
CA
PATIENT – 61 y.o./ F
firm – hard, movable or fixed, may be assoc
with skin changes – peau-de-orange, nipple
retaction, and axillary lymph nodes
more common in older women
firm, movable, borders poorly define, nontender,
nonerythematous
Presence of axillary lymph node
Given the following characteristics, our patient is most likely to be having a malignant
breast mass because of her age, the character of the mass and the presence of the axillary lymph
node.
Primary diagnosis : Breast CA, R
Secondary diagnosis:
benign breast mass
PARACLINICAL DIAGNOSTIC PROCEDURE
Since no definite diagnosis can be arrived from the history and physical examination
alone and since the management of a benign breast mass- which is excision differs from a
malignant breast mass – modified radical mastectomy which is mutilating, then a paraclinical
diagnostic procedure is warranted prior to treatment planning.
The diagnostic procedure to be used is fine needle aspiration and biopsy. Compared to
other procedures it is the least invasive and is commonly available.
OPTIONS:
BENEFIT
FNAB
RISK
high sensitivity and
COST
low
cheap
Specificity , can diff.
Benign vs malig
Least invasive
Can be done quickly,
No need for OR facilities
TRU-CUT
AVAILABILITY
available
(~P60.00) in most
hospitals
higher yield than FNAB more more expensive
available
Painful than FNAB
but needs
(~1,000)
Special needle
INCISION can give definite
BIOPSY diagnosis
higher risk
high
available
for tumor
(~P2,000
but needs OR
Spread
& up)
facilities
EXCISION
( Same as incision biopsy)
BIOPSY added benefit – definitive treatment for benign disease
Risk – may be difficult especially for larger masses
Our patient underwent FNAB and results showed ductal carcinoma cells.
TREATMENT OPTIONS;
Before presenting the treatment options, it is necessary o have a clinical staging og the
disease because options may vary. For our patient, the mass is 6 x 5 cm with no skin
involvement. There was axillary lymph node, not matted.. To screen for the presence of systemic
spread, symptoms that may point to a metastasis should be inquired during consultation. These
include recurrent cough, dyspnea, bone pains, sensorial changes. Presence of these warrant
further work-up .A complete physical exam is needed and supported by ancillary procedures
such as chest xray . Our patient has no jaundice, no supraclavicular nodes and no other systemic
complaints. A chest xray was done which showed no evidence of metastasis. Our patient is
therefore Stage IIIA T3N1M0.
For locally advanced breast CA such as this case, the treatment option is primarily
surgical. A modified radical mastectomy is warranted. Adjuvant treatment in the presence of
positive axillary lymph nodes depends on the age of the patient. For pxs <50 yrs old chemotherapy or bilateral oophorectomy. For Pxs >50 yrs old and such as the case of our
patient, , hormonal therapy with tamoxifen for 5 yrs is recommended. Radiotherapy will be
done only when the histopath of the specimen from MRM will show positive margins of
resection
BENEFIT
RISK COST AVAILABILITY
MRM
improves survival
mutilating
~ P 20,000
arm lymphedema
tamoxifen
improves survival
low side effects
risk of endometrial
CA
commonly
done
P60.00/
available
day x 5 yrs
TREATMENT PLAN : Modified Radical Mastectomy, R, under general anesthesia
PRE-OPERATIVE PREPARATION:
1) Establish rapport with the patient and relatives, explain the diagnosis and the treatment plan.
Advise relatives regarding their increased risk for CA and therefore a more vigilant
screening is needed. Provide psychosocial support .
2) Optimize the Px’s medical condition. Treat any coexisting disorder that may affect outcome
of surgery.
3) Secure needs for the operation.
INTRAOPERTIVE MANAGEMENT:
The objective of the surgery is to remove all the breast tissue and the axillary lymph
nodes without doing harm to the patient.
OR Technique:
Transverse elliptical incision over R breast area with at least 2 cm margin from
the tumor down to subcutaneous tissue
Superior and inferior flaps develop with the ff borders;
SUPERIOR – clavicle
INFERIOR – rectus abdominis muscle
MEDIAL - sternla border
LATERAL – Latissimus dorsi muscle
Mastectomy down to pectoralis fascia
Axillary dissection with identification and preservation of:
Axillary vein
Thoracodorsal nerve
Long thoracic nerve
Hemostasis
Jackson-Pratt drain
Skin closure with Vicyl 4-O subcuticular
POST-OPERATIVE CARE
1)
2)
3)
4)
5)
adequate pain control
monitor JP drain daily , remove drain if output <50 cc/day
active range of motion exercises over R upper extremity
wound care
if axillary node is grossly malignant, start on Tamoxifen 20 mg tab OD, if not conclusive,
then wait for the histopath
FOLL0W-UP PLAN:
Histopath should be noted
If (+) axillary LNs – ensure good compliance with Tamoxifen for at least 5 yrs
If (+) margin of resection – refer to Radio-Onco for post-op radiotherapy
Surveillance for recurrence of disease
Schedule of ff-up : monthly for the 1st 3 mos then every 6 months
Physical examination to be done every ff-up - note for local recurrence or distal spread
Symptom directed investigation
Mammography of the contralateral breast yearly
OUTCOME OF MANAGEMENT
1) Most cost-effective treatment
2) Resolution of the health problem which is breast CA with prolongation of the survival rate
3) Live and satisfied patient
4) No complication
5) No medicolegal suit