Symptoms:
- Mass, nipple discharge, skin changes, pain
Triple Assessment:
- H&P
- Imaging
- Pathology
- Any red flags in one or discordance between them -> take pt for excisional biopsy
BIRADS:
Is grading of the breast mass (not staging):
- BIRADS 2 -> likelihood of it being benign 100%
- BIRADS 3-> likelihood of being benign 98% + 2% malignant -> follow up every 6 mo for 2 yrs
- BIRADS 4-> likelihood of being malignant 2-95%
- 4A: 2-20% -> if biopsy is benign -> treat as BIRADS 3 (follow up every 6 mo for 2 yrs)
- 4B: 20-50% -> mostly likely will require excisional biopsy
- 4C: 50-95%v-> need excisional biopsy
- BIRADS 5-> likelihood of being malignant 95%
Tissue Diagnosis:
- Histopathology: core needle biopsy -> excisional biopsy if not conclusive
- Cytology: FNA
CASE:Â A 20 yo pt w\ a 2-cm breast mass, what’s next?
- Do US
- If BIRADS 2 or 3 -> do FNA -> most likely fibroadenoma -> follow up every 6 mo
Indications for excisional biopsy for fibroadenoma:
- Larger than 4 cm
- Increasing in size
- Radiological indicated (BIRADS 4B and above)
- Clinically looks hard and not benign
- Radiology pathology discordance
- If you do core needle and it shows -> atypical ductal\lobular hyperplasia, florid epithelial hyperplasia, flat epithelial atypia, fibro-epithelial lesion, papillary lesion
- Why we prefer to remove it? It might be phyllodes tumour (sarcoma of the breast but on FNA\core biopsy it resembles fibroadenoma morphologically)
CASE: A 35 yo pt w\ a 4-cm breast mass for the past 4 yrs, what’s next?
- Do mammogram followed by US (b\c she’s above 30 yo)
- If cyst -> only needs aspiration
- If solid mass -> grade it:
- If BIRADS 2 -> do core needle biopsy -> then do excisional (indicated b\c a 4-cm mass)
- Why core needle biopsy if you’re doing to do excisional anyways? B\c you need a pre-op dx; if it’s phyllodes -> need margins
- If it’s 1-cm mass + BIRADS 2\3\4A + core needle is benign -> counsel the pt and follow up
- If BIRADS 2 -> do core needle biopsy -> then do excisional (indicated b\c a 4-cm mass)
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CASE:Â A 25 yo pt w\ a 6-cm breast mass, what’s next?
- Do US
- If BIRADS is 3 or 4a -> core needle biopsy -> then excisional biopsy based on size
Nipple Discharge:
- Differentiate between pathological and physiological
- Colour of the discharge doesn’t guide management
- Bloody usually means intraductal papilloma
- Malignant can be associated with both, but most are serous
- If imaging shows no findings or duct ectasia -> still do US for ductal system -> if negative -> do MRI
- If MRI shows intraductal lesion -> do second-look US -> if intraductal papilloma -> do biopsy or vacuum
- If MRI is negative -> microductectomy (the only time take to OR without biopsy, where the pt has pathological nipple discharge w\out apparent imaging findings)
Skin Changes:
- Inflammatory (mastitis) -> give appropriate abx (Clindamycin and Augment -> cover staph and strept + good penetration + appropriate duration) -> if doesn’t improve -> do skin biopsy (imaging will show skin thickening w\out mass)
- Neoplastic: locally advanced: direct infiltration to skin
- Paget disease: sometimes considered DCIS -> needs treatment like Ca (missed by GP -> giving cortisone on the basis of eczema)
Download the PDF version: here
References:
- Dr Alriyees’s lecture
- Monte Reid