A 63-year-old woman with a screen-detected abnormality

Published on 10/04/2015 by admin

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Problem 9 A 63-year-old woman with a screen-detected abnormality

A 63-year-old woman underwent a screening mammogram which demonstrated an abnormal opacity in the left breast. There is no previous history of breast problems. Her sister was diagnosed with breast cancer at the age of 64 years 2 years previously. Current medications include combined oestrogen and progesterone hormone replacement therapy (HRT) that she has been taking for 12 years. Menarche was at the age of 10. She is married with two adult children aged 34 and 32 years.

Q.1

What risk factors place this patient at increased breast cancer risk?

The mammogram is reviewed (Figure 9.1).

Figure 9.1

Q.2

What abnormal features would you look for? What are the abnormal features in the image?

Q.3

What should be done next?

An ultrasound examination is performed and shows a hypoechoic lesion with irregular margins, distorting and invading the surrounding breast tissue.

A fine needle aspiration (FNA) is arranged. In the outpatient clinic and with ultrasound guidance a 23 gauge needle is passed several times through the lesion. The aspirate is spread on a microscope slide and examined immediately. Benign cells with atypia are seen, but there is no evidence of malignancy.

Q.4

What should be the next step in management?

A core biopsy is arranged. This procedure requires the use of an automated biopsy gun and 12–18 G biopsy needle. The biopsy is performed under local anaesthesia using ultrasound guidance. A core of architecturally intact breast tissue is removed and invasive ductal carcinoma of intermediate nuclear grade is confirmed.

Q.5

What will you tell the patient at this stage?

In this particular case, staging investigations (liver function tests, CT scan chest and abdomen, whole body bone scan) did not reveal any evidence of metastatic disease.

Q.6

What treatment options for the breast cancer are available? What factors influence which are preferred?

A surgical procedure is planned for the patient. The following investigation is performed immediately before the operation (Figure 9.2).

Figure 9.2

Q.7

What is this investigation, how is it performed, and what does it show? What treatment options are available for management of the axilla?

The patient undergoes wide local excision, specimen X-ray and sentinel node biopsy. Histopathology demonstrates a 22 mm grade II ductal carcinoma with focal vascular invasion. Tumour excision is complete with the closest resection margin being 5 mm from the inferior edge. Of the three sentinel lymph glands removed, two demonstrated metastatic tumour deposits. The patient subsequently underwent completion axillary dissection. Histopathology of the axillary fat demonstrated 1/13 further lymph glands with metastatic tumour. The cancer stained strongly for oestrogen receptor and progesterone receptor but was negative for HER-2 (human epidermal growth factor receptor-2).

Q.8

What is the patient’s prognosis? What factors determine prognosis and what additional treatments are recommended? How are these recommendations made?

The patient underwent chemotherapy followed by sequential breast radiotherapy and hormone treatment using an aromatase inhibitor. Regular follow-up was arranged to include clinical examination and annual mammography.

Answers

A.1 The two most obvious risk factors are that the patient is female and over the age of 50 years. Breast cancer is a disease almost exclusively affecting women although approximately 1% of all breast cancers affect men.

Family history is an important breast cancer risk factor. The nature of the family history is important whereby closely related relatives, bilaterality, age of onset and the number of affected relatives all play a role in determining breast cancer risk. The presence of other organ-specific cancers (i.e. ovarian, soft tissue malignancies) is also important and may indicate a hereditary form of the disease involving breast cancer-specific genes such as BRCA1 or BRCA2.

Hormonal factors also affect breast cancer risk. Women who start menstruating early in life, have a late menopause or have a late age of first pregnancy are at increased risk of developing breast cancer. Current users of hormone replacement therapy (especially combined preparations using both oestrogen and progesterone) are also at increased risk of breast cancer. The risk increases with longer duration of hormone replacement therapy use. The risks associated with HRT disappear 5 years after stopping this treatment.

A.2 The following features on the mammogram would suggest malignancy:

• a mass of increased density

• ill-defined margins

• spiculated stellate architecture

• distortion of adjacent breast architecture

• the presence of associated pleomorphic microcalcifications.

The following features are more suggestive of a lesion being benign:

• well-defined lesion

• smooth border.

This woman’s mammogram shows:

• Fatty involution of breast, consistent with the patient’s age.

• A 2 cm dense, ill-defined solitary mass with spicules extending into the surrounding tissue in the upper outer quadrant.

• No areas of calcification.

• No other abnormal tissue.

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