A 30-year-old woman has a breast mass on ultrasound during a physical exam, but she does not feel a significant lump in her breast. She has a 3-year history of breast enlargement and no family members have had breast or ovarian cancer. Does this situation need to be addressed?
Diagnosis of small masses, imaging is not far away
A 1 cm mass in the upper outer part of the right breast was detected on ultrasound of the breast during a physical examination, but the doctor did not feel any obvious mass on examination, no enlarged lymph nodes were felt in the bilateral axillae or clavicles, and the breast did not have an abnormal shape.
Because imaging is essential to screen for and diagnose breast tumors. Therefore, the physician recommended further breast ultrasound, and the ultrasound report suspected that the nodule in the upper outer right breast was probably malignant, with a Breast Imaging Reporting and Data System (BI-RADS) grade 4B and a recommendation for surgery. Breast magnetic resonance imaging (MRI) is also suspicious for breast cancer.
The doctors concluded that all of these reports suggest the possibility of breast cancer in the breast, and that the numbers in the BI-RADS grading are suggestive, with higher numbers indicating a higher probability of a malignant mass and a grade of 4B indicating a moderate likelihood of malignancy and the need for improved testing.
Small tumors: breast-conserving surgery and pathology to confirm the diagnosis
Imaging suggests a moderate likelihood of malignancy, and although pathologic biopsy is the gold standard for tumor diagnosis, this woman’s tumor is too small for a preoperative puncture biopsy to make a definitive diagnosis and can only be further diagnosed by surgical removal of the mass.
So, what type of surgery is used? The current view is that for early-stage breast cancer, breast-conserving surgery is appropriate if the tumor diameter is small, the ratio of lesion to breast volume is appropriate, good breast shape is predicted to be maintained after breast-conserving surgery, and the patient is willing and not contraindicated to undergo breast-conserving surgery. This woman has a small mass found on imaging and the lesion is solitary, which is consistent with the indication for breast-conserving surgery, and is younger. Breast-conserving surgery has less impact on breast shape, quality of life, and psychological status compared with total breast excision, and she can return to her family and social life sooner after receiving breast-conserving surgery.
Therefore, after completing the relevant examinations, the surgeon, in full communication with the patient and her family, formulated the following surgical plan: first the right breast mass was excised and biopsied to determine the benignity and malignancy of the tumor, and if it was malignant, breast-conserving surgery of the right breast cancer was performed, along with biopsy of the anterior sentinel lymph nodes; if the intraoperative frozen pathology indicated that breast-conserving surgery was not appropriate or metastasis was found in the anterior sentinel lymph nodes, then total mastectomy or If intraoperative cryopathology suggests that breast conservation is not appropriate or if metastasis is found in the anterior lymph nodes, total mastectomy or axillary lymph node dissection is performed.
After surgical excision of the right breast mass, intraoperative cryopathology confirmed cancer, so breast-conserving surgery + sentinel lymph node biopsy of the right breast cancer was performed, and the breast-conserving surgery was successful with no metastasis in the sentinel lymph nodes.
After breast-conserving surgery, adjuvant therapy “keeps up”
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Post-operative pathology: mid- to high-grade ductal carcinoma in situ in the breast, tumor size 0.9 cm x 0.8 cm, no metastatic carcinoma in the sentinel lymph nodes, no carcinoma in any of the margins, pTNM staging pTisN0(sn). Immunohistochemical results showed estrogen receptor (ER) (++), progesterone receptor (PR) (++++), human epidermal growth factor receptor-2 (HER-2) (+), and cell proliferation index Ki-67 (~10%).
A growing number of studies have shown [1][2] that for ductal carcinoma in situ, breast-conserving surgery plus radiotherapy has excellent local control rates, with survival rates similar to those of mastectomy. Based on the surgical situation and postoperative pathological findings, this patient could achieve clearance of the lesion by breast-conserving surgery, and postoperative adjuvant radiotherapy could reduce the local recurrence rate of the breast.
Postoperative pathology confirmed ductal carcinoma in situ in this patient, and adjuvant chemotherapy is not required for this type of breast cancer. Immunohistochemically positive tumor hormone receptors, i.e., ER (++) and PR (++++), make this patient an appropriate candidate for endocrine therapy, and the classic endocrine therapy drug, tamoxifen, has been shown to be effective in reducing the risk of ipsilateral breast cancer recurrence and new contralateral breast cancer in patients with ductal carcinoma in situ.
A growing number of studies have shown that for ductal carcinoma in situ, breast-conserving surgery plus radiation therapy has excellent local control rates, with survival rates similar to those of mastectomy. Based on the surgery and postoperative pathology results, this woman was able to achieve clearance of the lesion with breast-conserving surgery, and postoperative adjuvant radiotherapy reduced the local recurrence rate in the breast. Postoperative pathology confirmed ductal carcinoma in situ, and adjuvant chemotherapy was not required for this type of breast cancer. Immunohistochemistry suggests positive tumor hormone receptors, i.e., ER (++), PR (++++), and these patients are appropriate candidates for endocrine therapy, and the classic drug for endocrine therapy, tamoxifen, has been shown to be effective in reducing the risk of ipsilateral breast cancer recurrence and new breast cancer on the opposite side in patients with ductal carcinoma in situ.
Based on these considerations, this woman received postoperative adjuvant radiotherapy and oral tamoxifen adjuvant endocrine therapy for 5 years.
Summary: For small early-stage breast cancers such as ductal carcinoma in situ, where preoperative biopsy is difficult, pathologic diagnosis of the excised lesion can be performed at the same time as breast-conserving surgery. Adjuvant radiotherapy after breast-conserving surgery can reduce the rate of local recurrence in the breast, and adjuvant endocrine therapy for hormone receptor-positive patients can reduce the risk of ipsilateral recurrence and new breast cancer on the opposite side.