A breast lump
This 53 year old postmenopausal lady presented with this breast lump. 1. How would you assess the lump? 2. If a breast carcinoma what would be your recommended surgical approach? 3. What adjuvant therapy might she require?
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This 53 year old postmenopausal lady presented with 4 cm diameter breast lump superior to the nipple. It was firm and irregular. It was not fixed to the skin or muscles and there was no evidence of axillary lymphadenopathy. On clinical assessment it appeared to be a carcinoma (P5). Mammography was performed and this showed a spiculated mass consist with a carcinoma (R5). Fine needle aspiration cytology showed irregular, pleomorphic cells diagnostic of a carcinoma (C5). All aspects of the triple assessment were in agreement, the diagnosis was discussed with the patient and treatment planned. Several studied have shown that the local recurrence rate, disease-free and overall survival rates are similar when breast tumours are excised with either breast conserving surgery (usually wide local excision) or mastectomy. Breast conserving surgery does however need to be followed by breast radiotherapy. Not all tumours are however suitable for breast conserving surgery. This lady had a large tumour in relation to the size of the breast. In view of its central location mastectomy was advised. She underwent a mastectomy and level III axillary clearance. All women with invasive breast cancer require axillary surgery. This is needed to stage the disease to provide important prognostic information. Depending on the extent of the surgery the procedure may also be considered therapeutic if the lymph nodes are subsequently shown to contain metastatic tumour. The axilla can be adequately staged by a four-node axillary sampling procedure. The role of sentinel node biopsy in stageing the axilla is currently the subject of ongoing trials . A level III axillary clearance would be considered both a staging and therapeutic procedure. Except for a wound seroma she made an uncomplicated recovery from her operation. On histological assessment the tumour was shown to be a 4 cm in diameter, poorly differentiated (grade 3) with evidence of lymphovascular invasion. The tumour was oestrogen receptor negative and 5 out of 10 axillary nodes contained metastatic tumour. All women with invasive breast cancer, both pre- and postmenopausal, should be started on tamoxifen on completion of there other adjuvant therapies. This anti-oestrogen has been shown to reduced the risk of local recurrence, improve survival and reduce the risk of developing contralateral breast cancer even in patients who have oestrogen receptor negative tumours. The drug is well tolerated by most women and it has few side effects - hot flushes are the most troublesome. With a large, high grade node-positive tumour with evidence of lymphovascular invasion the patient is at increased risk of local recurrence. Consideration should be given to radiotherapy to the mastectomy skin flaps. Having had a level III axillary clearance she does not require axillary radiotherapy. Axillary radiotherapy after a full axillary clearance is associated with an unacceptable rate of arm lymphoedema. Despite being postmenopausal, in view of her age and node-positive status she should be offered chemotherapy. In the United Kingdom, the most likely regimen that she would received in cyclophosphamide, methotrexate and 5-flurourocil given at monthly intervals for 6 months. She underwent both adjuvant radiotherapy and chemotherapy. Recent papersFalk S J. Radiotherapy and the management of the axilla in early breast cancer. Br J Surg 1994; 81: 1277 - 81. Galea M H, Blamey R W, Elston C E, Ellis I O. The Nottingham prognostic index in primary breast cancer. Breast Cancer Research and Treatment 1992; 22: 207-219. Holcombe C Mansel R E. Axillary surgery in the management of breast cancer. Curr Pract Surg 1996; 8: 17 - 21.
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