Download How will you approach the 35-year old, with a 2x2x2cm, firm, mobile

How will you approach the 35year old, with a 2x2x2cm, firm,
mobile, well-circumscribed nontender mass on her R breast?
Approach
• History
• Physical Examination
– breast exam
- Evaluation of breast mass
• Breast imaging
– Mammography
– Ultrasound
Role of imaging modality
• Imaging methods are complements to, and not
substitutes for, a thorough history and PE
• MAMMOGRAPHY
– Screening mammography: used to detect unexpected
breast cancer in asymptomatic women. In this regard,
it supplements history and P.E.
– Diagnostic mammography: used to evaluate women
with abnormal findings such as breast mass. It may
use views that better define the nature of any
abnormalities.
– Although sensitive, not specific
• Ultrasound:
– Most useful feature is the ability to distinguish
between cystic and solid masses
– Not an effective screening test for cancer
(cannot detect microcalcifications or small
lesions
– May help to confirm the diagnosis of a cyst or
support a clinical impression of fibroadenoma
• Premenopausal
– Evaluation of breast masses between age 30
and menopause is problematic ( presence of
functional, cycling glandular tissue combined
with a progressively increasing incidence of
cancer
– Bilateral mammograms to look for
concurrent nonpalpable disease
– Definitive diagnostic procedure
A mammogram was taken as seen
in the picture. Is this benign or
malignant
benign
Benign vs Malignant
• RADIOLOGIC FINDINGS
• BENIGN
– Round or oval smooth-edged masses. The
outline of the mass will be clearly defined, not
blurry
• MALIGNANT
– Sine qua non: spiculated density with illdefined margins
Features suggestive but not
diagnostic of cancer
•
•
•
•
Clustered microcalcifications
Asymmetric density
Ductal asymmetry
Distortion of skin, nipple and normal breast
architecture
• Should the patient have a
mother who is a breast
cancer survivor, how would
that information change
your management?
Family History
• Institute of Public
Health UK
2nd degree
relative
1st degree
Relative Risk
of Cancer
1.5
2.1
mother
2.0
sister
2.3
Mother and
sister
3.6
Individuals at increased breast
cancer risk
• Close surveillance with Consultation breast
examination (CBE), mammography, and
possibly breast MRI – Self-breast exam at age
18; semi-annual CBE at age 25, annual
mammography beginning age 25 or 10 years
prior to earliest age of onset of a family member
• Chemoprevention using Tamoxifen (estrogen
antagonist)
• Bilateral prophylactic mastectomies – reduces
the chance of breast cancer in high risk women
by 90%
How will you approach the 55
year old menopausal patient with
a 2cm diameter, mobile, firm,
non-tender mass on her R
breast? Imaging modality in this
case?
Postmenopausal
• Evaluation relatively straightforward
• Patients most prone to carcinoma
• After obtaining bilateral mammograms (to
screen for concurrent, clinically
unappreciated lesions) – biopsy of the
palpable mass is indicated
• Cannot observe only
Diagnosis
• SIMPLE CYSTS
– A cyst is a little pocket of fluid in the breast.
– Occurs when a milk duct becomes blocked,
preventing the normal breast fluid to flow
through the ducts
– Round, moveable lump that may be tender to
touch
– Appear on a mammogram as a round or oval
gray structure. Ultrasound can provide an
accurate diagnosis of cysts
FNAC reveals NEGATIVE FOR
MALIGNANT CELLS. How would
you now manage the patient?
• Preoperative procedure and counseling
definitive procedure
• Negative findings does not rule out cancer,
especially in women older than 50 years of age.
• In any case, the involved duct- and a mass,
should be excised.
• Many clinicians will not leave a dominant mass
in the breast even if the FNAC is negative,
unless perhaps the fine-needle aspiration shows
fibroadenoma.