Breast Lump- Dr Deepak Ghuliani- Prepladder (Presenter- Dr Keshav Garg, MAMC

2017)

Demographics

Mrs. XYZ
48/F
R/o Bihar
Daily wage labourer
Low class SES as per MKS
Informant – Self

DOE: 21-07-2021

Chief c/o

She presented to the OPD with chief c/o

1. Lump in the Left Breast x 5 months

HOPI

The patient was apparently well 5 months ago, when she first noticed a lump in her
left breast while bathing
It was insidious in onset and the size has increased rapidly in the last 5 months from 1
x 1 cm initially to 5 x 3 cm at present
Lump is Painless

- No h/o overlying skin changes, nipple retraction and nipple discharge

- No h/o left arm swelling [to detect edema of the limbs]
- No h/o back pain, headache, abnormal body movements, abdominal distention,
breathless, and haemoptysis
- No h/o weight loss
- No h/o similar complaints in the right breast
- No h/o radiation exposure or trauma
- No h/o change in size with menstruation

[Overlying skin changes

- Erythema
- Ulceration
- Peau d’orange
- Satellite nodules

Edema of the limbs – infiltration/metastasis of axillary lymph nodes due to malignant

lump blocks/obstructs lymphatics which can lead to lymphedema – swelling of limb

Nipple Discharge:
Benign Malignant
Bilateral Unilateral
Milky / serous discharge Bloody discharge
Multi-ductal Uni-ductal
On Expression Spontaneous
change in discharge with
menstruation
Past H/o

No H/o similar c/o in the past

No h/o previous surgery or biopsy in either of the breast
No h/o DM, HTN, TB, Asthma, drug allergy

Family H/o

Father has HTN x 20 years well controlled on medication

Mother has DM x 25 years on medication
No H/o breast CA or any other malignancy in any first degree relatives

Obstetrics H/o

- P1L1
- Male child via LSCS at the age of 35 years
- Breastfed up to 1 year of age

Menstrual H/o

- Menarche attained at 15 years

- Regular menstrual cycles, 28 days apart, with 4 days of flow
- LMP: 10-06-2021
- [H/o HRT in post-menopausal female – risk factor for Breast CA]

Personal H/o

- No h/o smoking, alcohol addiction

- Non-veg
- Appetite is reduced
- Sleep inadequate
- Bowel bladder habits normal

Summary of H/o

48 y/o lady presents with mass in left breast x 5 months, which is painless and rapidly
increasing in size to present size of 5 x 3 cm with no symptoms s/o local and distant
spread

D/d
- Breast CA
- Phylloides Tumour [35-50 years, rapid increase in size]
- Breast cyst [40-50 years – due to ANDI – abnormalities in normal development
and involution]

[Points in favour of CA Breast in H/o

- Age
- Painless and Rapidly Progressing
- Risk factor – 1st child at older age – 35 years

Factors that can increase the risk of CA Breast:

- Increased/prolonged duration of Exposure to Estrogen

 1. Early menarche < 12 years
2. Late menopause > 55 years
3. Nulliparity
4. Decreased duration/Absence of Breastfeeding
5. Age of Mother at first live birth/first pregnancy > 30 years

History to rule out Local/Distant spread

Local spread
- Skin involvement
- Lymphatic spread – No left limb swelling
Metastasis/Distant spread
- Vertebra – Backache (Bone Pain)
- Liver – hepatomegaly, jaundice, abdominal distention
- Lung – haemoptysis, dyspnea {malignant pleural effusion - dyspnea}
- CNS – headache, convulsions – due to increased ICT ]

EXAMINATION

GPE
- Examination done in well-lit room with patient sitting comfortably on bed,
- Patient is conscious, cooperative, well-oriented to time place and person
- Built- normal; Height – 157 cm; Weight – 52 Kg; BMI: 21.1 kg/m2

Vitals:
- PR: 79/min; BP: 125/78 mmHg; RR: 18/min; Temp: 37 degrees C; JVP not raised
- PICKLE [cervical LN, pedal edema] absent; axillary LN examination discussed in
local O/E

Local Examination

- Patient examined after due verbal informed consent, with adequate privacy, in
the presence of a female attendant, and exposed from neck to umbilicus

Inspection done with

- Arms by the side of the body [compare size and shape of both breasts, level of
nipples, nipple retraction, lump/fullness visible, skin changes, dilated veins,
puckering]
- Arms raised straight above her head [dimpling, infra-mammary area, axillary
tail]
- Patient bending forward from the waist [breast falling forward or not – fixity to
chest wall]
- Sitting with the arms on the waist and pressing on the waist [subtle
retraction/dimpling can become more evident, lumps not visible earlier become
prominent

- Position of both breasts is normal

- Both are symmetrical in shape
- Nipples are at the same level and symmetrical
- Left Breast has a visible lump of 5 x 3 cm in the lower inner quadrant
- with no overlying skin erythema, ulceration, peau d’orange, satellite nodules,
dilated veins
- Nipple areola complex is normal with no nipple retraction, ulceration, or
discharge
 - Right breast shows no fullness or lump, has normal skin and normal NAC
- On raising the arms, no visible puckering is present, no visible axillary swelling
and the infra-mammary area is normal.
- On bending forward, both breasts fall forward equally
- On keeping hands over the waist and pressing- no dimpling seen

Examination of supra-clavicular fossa – No swelling/fullness of SCL fossa, no upper

limb edema

Palpation
- Right Breast
o No local rise of temperature, no tenderness
o No lump felt in any quadrant
o No discharge from nipple present
- Left Breast
o No local rise in temperature, no tenderness
o Lump present in the Lower Inner quadrant, globular in shape, 5 x 3 cm in
size, hard in consistency, with irregular surface, irregular and ill-defined
margins
o Fixed to skin, no fixity to underlying muscle
o No nipple discharge present

Lymph node examination- B/L axillary LN are not palpable, Supraclavicular LN not
palpable
Spinal tenderness – Absent [to look for distant metastasis to spine]
[Left Arm – no edema, no restriction of movement at the shoulder joint]

[Texture and consistency of the breast variable in different females. Palpate the
apparently normal breast first for normal texture/consistency, then compare abnormal
with normal.]

[Methods of Breast Palpation

- Dial clock method
- Quadrant method
- Vertical stripe method
- Horizontal stripe method
- Spoke wheel method]

[Fixity to Muscles:

1. Pectoralis major:
- First, check the fixity of the lump to the muscle when the muscle is relaxed
- If the lump is mobile, ask the patient to press her hands against the waist/hips
- Feel the anterior axillary fold to see if it is taut to make sure that the muscle is
adequately contracting or not
- Check the movement of the lump parallel and perpendicular to the fibres of the
muscle

2. Serratus Anterior
- Look for fixity to serratus anterior in lumps in the Outer Quadrants of the breast
- Ask the patient to stand near a wall and push the wall to check for mobility
- First see mobility in a relaxed position, then in a contracted position

Lump fixity to chest wall:

 - On inspection, ask the patient to bend forward. If not falling forward, lump is
fixed to the chest wall
- On palpation- No mobility of the lump even when the muscle is relaxed

Fixed to the chest wall – T4a]

Systemic O/E
- CVS – S1S2 present, no murmur heard
- RS – B/L air entry present. Normal vesicular BS. No added sounds
- CNS- No FND
- P/A – soft, non-tender, no lump or organomegaly, no free fluid

Diagnosis

Provisional Diagnosis: Breast Lump, probably Breast CA with stage cT2N0M0 – Stage
2a. {I would like to do USG to confirm LN status as per 8 th AJCC}
D/d – Phyllodes tumour

[Why CA Breast
- H/o = Age- 48 years, painless, rapidly progressive lump, risk factor – older age
at first live child birth
- O/E – Hard lump, irregular margins, fixed to the skin

[T2: 2-5 cm. In our case, maximum dimension = 5cm

N0: no palpable LN
M0: no c/f s/o metastasis

III
B

Why not Phyllodes tumour – classical features of phyllodes tumour (distended veins)
missing and phyllodes tumour is not fixed to overlying skin
TRUCUT BIOPSY preferred over FNAC
- Basement membrane invasion – in situ vs invasive CA
- Hormonal status of tumour – ER, PR, HER2Neu status
- Grade of tumour
- 14G needle is used, and at least 6 cores of tissue should be taken

Triple assessment – PPV of 99.9%

Core needle biopsy – Invasive Ductal CA? How do you proceed

- Axillary LN status (in N0 patients) – USG Axilla and FNAC (if LN+), OR Sentinel
LN biopsy
- Metastatic workup

Metastatic workup
- Stage 1 and Stage 2 (Early Breast CA)– CBC and LFT
o CT chest + abdomen / Bone scan is needed only if patient is symptomatic
OR abnormality on CBC, LFT detected. E.g. increased ALP on LFT – Bone
scan
 - Stage 3 (LABC – risk of occult metastasis is more)
o 3a: CBC, LFT, CT chest + abdomen + pelvis
o 3b and 3c: CBC, LFT, FDG-PET-CT

TREATMENT

Surgery: Early Breast CA

- BCS – if tumour to breast ratio is favourable + sentinel LN Biopsy+ post-op
radiotherapy

C/I of BCS:
- Technical C/I
o Multicentric disease- M/L foci of malignancy involving >1 quadrant of
breast, two tumours/foci of malignancy in same quadrant at > 4 cm
distance
o Tumour breast ratio is not adequate – for adequate margins and cosmesis
o Persistently positive margins [BCS- tumour sent to pathologist – positive
margins – remove margins – again send – positive margins – MRM]
- C/I to radiotherapy:
o 1st and 2nd trimester of pregnancy. In T3, radiotherapy after delivery
o Previous history of radiation to chest wall
o Inflammatory breast CA
o Collagen vascular diseases

Alternatives to BCS
- If patient is N0 – sentinel LN biopsy + simple mastectomy
- N1 – modified radical mastectomy

Structures removed in MRM:

- Entire breast tissue + overlying skin + NAC
- Level 1 and 2 axillary LN +/- Level 3 LN – Minimum 10 LN have to be removed
- Pectoralis minor – either retracted (Aunschinlaus), divided (Scanlon), or removed
(Patey’s)

Adjuvant therapies
- Chemotherapy: Tumour > 1 cm, >0.5 cm with high risk factors, LN positive
o Stage 1, 2 EBC, ER/PR +ve, LN -ve: Gene recurrence score (Oncotype Dx)-
High
o Anthracycline – cyclophosphamide – taxanes sequentially
- Hormonal therapy
o ER/PR +
o Premenopausal – Tamoxifen (SERM); postmenopausal – Letrozole (AI)
- Targeted therapy
o HER2Neu +ve – Transtuzumab

Role of Radiotherapy after MRM

- T3, T4 disease
- > 4 out of 10 LN removed after axillary LN dissection are POSITIVE
- Margins are Positive
- LVI – lymphovascular invasion

All patients after BCS require radiotherapy

After Surgery – tumour removed is sent for HPE – margin status, ER/PR/HER2Neu
status; axillary LN removed are also sent for HPE – LN status (+ or -)

LABC
- Neoadjuvant CT – assessment of response – if response good/complete –
Surgery (MRM).
- If response not good/partial – 1 or 2 more cycles of NACT – MRM – adjuvant
therapy

Advantage of NACT
- Downstages the disease
- In vivo response to chemotherapy – response to CT drugs present or not – can
decide which CT drugs to give for adjuvant CT post MRM

Metastatic Breast CA
- Palliation of symptoms
- Hormonal therapy – ER/PR+
- CT: ER/PR-
- Bony metastasis – HT has good response, Visceral metastasis – CT has good
response
- Bony metastasis – Bisphosphonates can be given. In painful Bony mets. – RT
- Ulcerative/fungating mass – Simple/Toilet mastectomy to improve QoL (palliative
Sx)

Staging of Breast CA:

Stage 1: T1N0

Stage 2: 2A: T1N1, T2N0

2B: T2N1, T3N0

Stage 3: 3A: T3N1, any N2 (T1-3N2)

3B: any T4 (T4N0-2)
3C: any N3 (T1-4N3)

Stage 4: M1