what percent of patients who present with a palpable breast mass have an underlying malignancy?
what is your Ddx for a palpable breast mass? (4)
cyst, fibroadenoma, fat necrosis, carcinoma
what are five benign changes of the breast that can result in a palpable breast mass?
fibrocystic changes, prominent breast lobules, focal dense breast tissue, lipoma, concentric thickening of the inframammary crease
what are the most common benign breast lesions and how do they present?
fibroadenomas: well-circumscribed, firm, rubbery, mobile, painless, single or multiple nodules, up to 5cm in size
how do breast cysts present? what is the underlying pathophysiology?
round, well-circumscribed, smooth, mobile, result of obstruction and dilation of intramammary ducts, can fluctuate with the menstrual cycle
how do fibrocystic changes of the breast present?
bilateral, poorly localized, thickened, symmetrical plaques of glandular parenchyma. Prominent in upper outer quadrants, cause cyclical pain that radiates to axilla, fluctuate with the menstrual cycle
how does fat necrosis of the breast present?
firm, smooth, irregular mass, occasionally tender, a/w h/o trauma, reduction mammoplasty, prior breast surgery. also a/w inflammation, pain, skin thickening, and nipple retraction
how does breast carcinoma present?
firm mass with poorly defined margins a/w skin retraction, asymmetric, and discrete compared to surrounding parenchyma and contralateral breast
what are the steps of the clinical breast exam when evaluating a breast mass?
Inspection: +/- erythema, skin/nipple retraction, dimpling, nipple discharge, asymmetry, or previous scars Assessment: fibroglandular consistency, discrete/distinct masses that are asymmetrical, nipple/areolar abnormalities
what are the differences in palpation when evaluating a clinically benign vs clinically worrisome lesion?
clinically benign lesions tend to be smooth, well-circumscribed, and mobile. Clinically worrisome masses are firm, poorly defined, fixed to the chest wall, and a/w skin changes
what are two ways to communicate to the radiologist the location of a worrisome breast mass that requires diagnostic imaging?
clockface location and distance from nipple
what is the first line diagnostic imaging for a woman with a palpable breast mass under and over age 30
Under 30: directed ultrasound; over 30: diagnostic bilateral mammogram + directed US
what is the comparative sensitivity of an FNA compared to core needle bx or excisional bx for a suspicious breast mass? why the discrepancy?
93% on FNA compared to 98-99% on CNB/excisional bx b/c CNB provides histologic architecture
why are image-guided breast biopsies preferred over surgical breast biopsies?
equally accurate, less risk and lower cost, less long-term implications on cosmetics and radiographic surveillance
what percent of breast biopsies following diagnostic imaging of a palpable breast mass are benign?
what is the "triple test" for diagnosing a benign breast lesion and what is the accuracy when all three are negative?
clinical breast exam, imaging, cytology - almost 100% accuracy of diagnosis of benign breast lesion
what is the next step when a palpable breast mass has dx mammogram/US findings = complex cyst with internal echoes
US-guided FNA --> if discordant with imaging --> excisional biopsy
what is the next step when a palpable breast mass has dx mammogram/US findings = simple cyst + symptomatic
therapeutic aspiration --> f/u with clinical breast exam and mammogram at appropriate interval
what is the next step when a palpable breast mass has dx mammogram/US findings = suspicious, solid, or indeterminate mass
US-guided core needle bx --> if discordant with imaging --> repeat CNB or excisional bx
what is the next step when a palpable breast mass has dx mammogram/US findings = normal findings & negative imaging + high clinical suspicion
surgical assessment with core needle bx/FNA
what is the next step when a palpable breast mass has dx mammogram/US findings = indeterminate clinical suspicion
consider: 1) FNA/core needle bx; 2) MRI; 3) 2-3mo f/u with clinical breast exam and repeat imaging
what is the next step when a palpable breast mass has dx mammogram/US findings = simple cyst + asymptomatic
f/u with clinical breast exam and mammogram at appropriate interval
what is the next step when a palpable breast mass has dx mammogram/US findings = normal findings & negative imaging + low clinical suspicion
2-3 mo f/u with clinical breast exam and imaging
what should you do in a patient with a breast mass for preop staging of the axilla? What is the benefit of this preop staging?
US of axillary LNs --> if suspicious features, perform FNA --> if positive, avoids unnecessary SLNB
what imaging is indicated to evaluate for suspected metastatic breast cancer?
PET scan or CT scan
what is the timing and duration of postop radiation after breast conserving therapy for breast cancer?
start 3-4 weeks after BCT, lasts 4-6 weeks with whole breast irradiation
what are the two subtypes of drugs used for neoadjuvant chemotherapy for breast cancer?
systemic cytotoxic therapy or hormonal therapy
what is the surgical benefit of neoadjuvant chemotherapy when treating breast cancer?
in 81% of patients who were candidates for only mastectomy, they became eligible for BCT after neoadjuvant chemotherapy
should you perform an ALND if a SLNB for breast cancer is negative?
which two subtypes of carcinomas require axillary staging?
invasive ductal or lobular carcinomas should be considered for axillary staging = lymphatic mapping, SLNB
what are the three locations for injection of agents used for lymphatic mapping for breast cancer?
subareolar, peritumoral, or intradermal over the lesion. After injection, massage the breast for five minutes.
what are the two agents used for lymphatic mapping for breast cancer?
1) radiolabeled colloid; 2) dilute methylene blue or isosulfan blue
what are the incisions for SLNB when performing a mastectomy vs. lumpectomy?
mastectomy: use the same incision; lumpectomy: separate small curvilinear incision two fingerbreadths below the hair-bearing line in the ipsilatareal axilla; take it down to the clavipectoral fascia
how do you find a sentinel lymph node when using blue dye alone?
look for a blue lymphatic channel - ID and trace to the corresponding LN. clip the lymphatic channel and remove the SLN, search for any additional SLNs
what are the criteria for a sentinel lymph node according to radiolabeled colloid?
LNs with counts > or = 10% of the hottest node; be sure to check background radioactivity so that there are no remaining hot spots
what are the three criteria for a sentinel node when performing a SLNB with radiolabeled colloid + blue dye
lymphatic channel leading to the node, gamma probe with LN counts > or = 10% of the hottest node, or when its a big palpable LN
how many SLNs are removed (on average) during SLNB? why?
average 2-3 SLNs identified, if only one removed, have a higher false negative rate, so palpate for more. Usually safe to stop at 5 if the hottest node has been removed.
Name the five key technical steps of axillary SLNB
1) dual agent mapping; 2) meticulous dissection once through the clavipectoral fascia to identify the blue channel; 3) trace blue channel to SLN or guided by gamma probe if blue channel not visualized; 4) deliberately use gamma probe to guide exact location and limit unnecessary dissection; 5) remove all hot/blue/suspicious LNs (5 max)
Describe the surgical pitfall associated with making the axillary SLNB incision too high
risks leaving behind a low-lying SLN and adds difficulty in finding SLN due to "shine through" from the injected breast b/c gamma probe points to the breast
describe the surgical pitfall associated with the number of SLNs obtained during axillary SLNB
stopping at the first SLN without searching for additional SLNs
describe the surgical pitfall associated with aggressive dissection during axillary SLNB
aggressive dissection leads to disruption of numerous lypmhatic channels OR en bloc removal of cluster of LNs will increase risk of lymphedema
What are you looking for / what are the goals at a postoperative visit s/p mastectomy or lumpectomy?
Review pathology; evaluate for cellulitis, SSI, seroma, hematoma, flap necrosis, and early lymphedema of the breast or arm
what are the three presentations of breast cancer (based on pathologic findings) for which postmastectomy radiation can improve survival and decrease recurrence risk?
patients with greater than or equal to 4 metastatic LNs, extracapsular extension, or primary tumor is > or = 5cm in size
How frequently do you perform mammograms & CBEs after BCT?
baseline mammogram of the breast, then 6 months after irradiation, then annually thereafter, with CBE scheduled q4-6mo
How frequently do you perform mammograms and CBEs after mastectomy with or without reconstruction
chest wall exam and CBE of unaffected breast q4-6mo and mammogram annually of unaffected breast
what step must be performed after excising a breast mass to assist pathology in identifying margins?
must orient the breast specimen! (short superior, long lateral)