palpable breast mass q...

[RussianJoo]

lymph nodes are not palpable just a mass and the lady is 51 years old, or late 30's and older.. what do you do first? Mammogram or FNA?

FNA right?

---

Members don't see this ad.

 

[lord_jeebus]

This is my weak subject, but ask yourself

If the mammogram was "negative," would you end your work-up there? I doubt it. FNA.

 

[astronomylover]

I think FNA is for a woman who is a young girl since it would be most likely a cyst. Because the woman is over 50, it is always cancer until proven otherwise so mammography would be better to pick up the 'calcifications' that you would see.

 

[RussianJoo]

ok well this is what i found in Katz comprehensive gynocology 5th edition. not sure how great of an OB-GYN book it is...

Mammography is established as part of the diagnostic work-up of women with breast symptoms. Often significant occult disease is identified in another quadrant of the same breast or in the contralateral breast. All patients with breast masses or persistent spontaneous nipple discharge should have mammograms of both breasts before biopsy. Mammography is also indicated in evaluating a breast mass the patient has found but that the physician cannot confirm by palpation. This technique is helpful in difficult clinical situations, such as the evaluation of large breasts or following augmentation mammoplasty. It is important to stress once again that mammography and physical examination are complementary procedures. One procedure does not replace the necessity of carefully performing the other.

 

[beponychick]

I would go with mamo, although in real life you will most likely do an FNA in the office.

 

[Scaredshizzles]

I would go with mamo, although in real life you will most likely do an FNA in the office.

I don't think you would in most cases....Unless you just really enjoyed doing FNAs, most would wait for a mammography---there might be other areas you want to biopsy, or you may note fibrocystic type changes, etc...You may note a mass highly suspicious for cancer and skip the FNA and just do an excisional, etc.

Anyway, Dr. Pestana in the Kaplan surgery videos or lecture notes does a really good review of a workup of breast masses...The protocol isn't always followed, but it answers almost all the test questions/UW questions correctly.

 

[It'sElectric]

x

 

[RussianJoo]

I don't think you would in most cases....Unless you just really enjoyed doing FNAs, most would wait for a mammography---there might be other areas you want to biopsy, or you may note fibrocystic type changes, etc...You may note a mass highly suspicious for cancer and skip the FNA and just do an excisional, etc.

Anyway, Dr. Pestana in the Kaplan surgery videos or lecture notes does a really good review of a workup of breast masses...The protocol isn't always followed, but it answers almost all the test questions/UW questions correctly.

can you share the protocol then?

 

[RussianJoo]

never mind i looked it up.. he says the same thing... mamography first then either FNA or better yet core biopsy if you really suspect it... even if you know it's not cancer cause it comes and goes with menses you still do mamography first then FNA to suck out the fluid.. if it's not bloody then no need to send it to pathology, if it is send it... and then if the mass is still there after aspiration or if it comes back then do excision Bx..

and in young girls with fibroadenomas you can either do an FNA or U/S ...

 

[Scaredshizzles]

never mind i looked it up.. he says the same thing... mamography first then either FNA or better yet core biopsy if you really suspect it... even if you know it's not cancer cause it comes and goes with menses you still do mamography first then FNA to suck out the fluid.. if it's not bloody then no need to send it to pathology, if it is send it... and then if the mass is still there after aspiration or if it comes back then do excision Bx..

and in young girls with fibroadenomas you can either do an FNA or U/S ...

As a general rule, on board exams, FNA is rarely the answer...Only in a very select group of thyroid cases is FNA the usual answer....It is just kind of hard to pinpoint the right situation for FNA, even though it is used fairly commonly in practice. You're not likely to see a case where mammography is already done and they want the next step and the answer is FNA....You'll see a lot more answers with either mammography or excisional +/- sentinel node/axillary node sampling.

 

[RussianJoo]

that's exactly the point of this thread.. cause they will have both FNA and mammography and excisional bx as answer choices.. and they'll describe a women in her 40's who's mother died of breast cancer when she was 51, and who's sister had a modified radical mastectomy at 38, with a mass that's in the upper outer quadrant, that's hard, painless, and not movable with irregular boarders and they'll say what's the next most appropriate step... and most people will say hey it's cancer i'll do excisonal bx.. but no that's wrong the next step is mammogram..

 

[Scaredshizzles]

that's exactly the point of this thread.. cause they will have both FNA and mammography and excisional bx as answer choices.. and they'll describe a women in her 40's who's mother died of breast cancer when she was 51, and who's sister had a modified radical mastectomy at 38, with a mass that's in the upper outer quadrant, that's hard, painless, and not movable with irregular boarders and they'll say what's the next most appropriate step... and most people will say hey it's cancer i'll do excisonal bx.. but no that's wrong the next step is mammogram..

Well that one shouldn't be hard, because no non-emergent surgery is ever done without imaging of some sort. And while onc surgeries are fairly urgent, they are not emergent.

 

[It'sElectric]

I agree with RussianJoo....I just don't get the point of the mammogram at this point???

 

[Scaredshizzles]

I agree with RussianJoo....I just don't get the point of the mammogram at this point???

That's because you're not thinking from a practical standpoint....Patients don't like being operated on, and certainly not multiple times. While the most common breast cancer, even if you are sure that is what is is (i.e. you have a necrotic, fungating mass there), is only going to be one mass, there are some presentations with multiple masses/bilateral, etc. Moreover, you want to know just how large the mass is. You don't want to go in thinking you're going to do a lumpectomy and then realize the mass is just too large and that mastectomy is really your only option...otherwise there wouldn't be enough breast left to reconstruct.

 

[It'sElectric]

That's because you're not thinking from a practical standpoint....Patients don't like being operated on, and certainly not multiple times. While the most common breast cancer, even if you are sure that is what is is (i.e. you have a necrotic, fungating mass there), is only going to be one mass, there are some presentations with multiple masses/bilateral, etc. Moreover, you want to know just how large the mass is. You don't want to go in thinking you're going to do a lumpectomy and then realize the mass is just too large and that mastectomy is really your only option...otherwise there wouldn't be enough breast left to reconstruct.

But shouldn't you biopsy/aspirate it first to know for certain what you're even dealing with before you can even discuss treatment options (i.e. it may be entirely benign). While mammography may tell you a lot, I've never seen a mammography specifically diagnose intraductal carcinoma of the breast. A diagnostic mammogram is going to give you an indicate as to whether a mass is most definitely benign, more likely to be benign, or suspicious for cancer (requiring a biopsy to definitively decide). With that in mind, it was my understanding that any woman over 40 presenting with a palpable mass (already suspicious for cancer - hard, painless, fixed, etc.) most definitely needs to have it biopsied. Similar to the concept that you will biopsy endometrial tissue on any woman over 50 presenting with abnormal vag bleed.

So to me, that seems much more practical. Eh, what do I know. Anyone else care to chime in.

 

[RussianJoo]

I agree with RussianJoo....I just don't get the point of the mammogram at this point???

huh? i never said i didn't agree with doing a mammogram first..the whole thread is supposed to be what the protocol is... because some people have told me to do a mammogram first and others have told me to do an FNA first... i found a source I can trust and I agree with that source and it says to do a mammogram first. That's all.. I agree with that, you need to see if there are other lesions that you might have missed and also the way that mass looks on mammography will give you more support to malignancy or not.. even though you can't diagnose malignancy on mammography you can see what it looks like and it can further support your suspicion.

I wasn't saying that it's stupid to do mammography first i was asking what the protocal was..


and then scared shizzles started talking about how FNA will never be the right answer.. which it doesn't matter cause I didn't ask for right answers I asked for steps in diagnosis... but i pointed out to him that the boards will have it as an answer choice and can make it sound very tempting as an answer choice by describing a women who has all the signs symptoms and risk factors of having a breast cancer and then they'll ask what's the next best step.. and will have

A) FNA
B) Excisional Bx
C) Mammography
D) Radical Mastectomy with Sentinel Node Bx

as answer choices.. and if we don't know the diagnostic protocol then people would be very tempted to pick FNA or excisional Bx cause that's the only way to diagnose cancer or rule out cancer... and that would be the wrong answer.. the answer would be Mammography.

that's all... this isn't difficult or Rocket Science...

 

[It'sElectric]

huh? i never said i didn't agree with doing a mammogram first..the whole thread is supposed to be what the protocol is... because some people have told me to do a mammogram first and others have told me to do an FNA first... i found a source I can trust and I agree with that source and it says to do a mammogram first. That's all.. I agree with that, you need to see if there are other lesions that you might have missed and also the way that mass looks on mammography will give you more support to malignancy or not.. even though you can't diagnose malignancy on mammography you can see what it looks like and it can further support your suspicion.

I wasn't saying that it's stupid to do mammography first i was asking what the protocal was..


and then scared shizzles started talking about how FNA will never be the right answer.. which it doesn't matter cause I didn't ask for right answers I asked for steps in diagnosis... but i pointed out to him that the boards will have it as an answer choice and can make it sound very tempting as an answer choice by describing a women who has all the signs symptoms and risk factors of having a breast cancer and then they'll ask what's the next best step.. and will have

A) FNA
B) Excisional Bx
C) Mammography
D) Radical Mastectomy with Sentinel Node Bx

as answer choices.. and if we don't know the diagnostic protocol then people would be very tempted to pick FNA or excisional Bx cause that's the only way to diagnose cancer or rule out cancer... and that would be the wrong answer.. the answer would be Mammography.

that's all... this isn't difficult or Rocket Science...

I misread your last post. Furthermore, no need to be condescending, especially considering you're the one who started the thread. While it's not rocket science, I'm pretty sure it's not as cut and dry as you think. Looking through my primary Step II book study resources (Boards and Wards/Secrets), they don't give you a clear cut answer. If you look on page 191 of B&W, they have a nice little algorithm for the workup of a breast mass. For a suspicious mass (age>35, family hx, firm, rigid, skin changes, etc.), they have the next step as "core or excisional biopsy, mammography". Now whether the mammogram comes first or not, I have no friggin' clue. Take a look in B&W for yourself.

Furthermore, in Secrets (Page 94): they say, "In a woman 35 years old or over, you will never be faulted for doing a biopsy of any mass. In the absence of a classic benign presentation (e.g. trauma to the breast w/ fat necrosis or bilateral masses w/ premenstrual syndrome mastalgia), always consider biopsy. Also get a baseline mammography."

Again, the next question (45) below on that same page: they essentially say that if a patient is postmenopausal or over age 50 and develops a new breast mass, you should assume cancer until proved otherwise.

Finally, the next question (46): Mammography is best used as a tool to detect nonpalpable breast masses (as a screening tool). A clinically suspicious mass should be biopsied unless imaging demonstrates unequivocally benign findings.

Once again, I have no idea if they're saying to get a mammogram first, or just eventually. My point is that it's NOT as cut and dry as you're implying in regards to the importance of what comes first. And if I had a question as you listed above, the only thing I would no for sure to do is NOT choose "D".

A side note, I realize that Secrets and B&W are not the end all or be all of breast mass work-ups, but they're certainly what I'm using to study for Step 2.

 

[RussianJoo]

that's cause those aren't primary sources.. that's why i was confused too, if you look at my first post i had it all wrong at the begining too. it's really crappy when books just lump stuff together when they know that's not how its going to be asked on the exam and when all those choices will be but then answer choices for the question. i actually had to looked in a text book on OB-GYN and what i found i quoted up top... and it clearly said get mammography first...

you should be thankful i just earned you at least one or two points on the exam.

 

[DrFraud]

I agree with RussianJoo....I just don't get the point of the mammogram at this point???

If you find a suspicious clinical mass, you do b/l mammo first because you want to know 1 - is this is the only mass or are there are others and 2 - to get a radiological eval b-4 doing the FNA to guide the biopsy.






You do NOT do the mammo to rule out doing an FNA if you find a suspicious mass on clinical evaluation. You will almost always do the FNA next reguardless of the mammo. (unless someone is paying for your malpractice and you don't care about your patients)

Just as an example - lets say the pt. in question has two masses, one palpable and one not palpable. The only way to fully evaluate the extent of pathology is to do a b/l mammo first, and then do FNA to the suspicious lesions elicited both by clinical exam and by mammo. In this patients case, the more serious lesion might be the one that isn't palpable.

 

[Scaredshizzles]

If you find a suspicious clinical mass, you do b/l mammo first because you want to know 1 - is this is the only mass or are there are others and 2 - to get a radiological eval b-4 doing the FNA to guide the biopsy.






You do NOT do the mammo to rule out doing an FNA if you find a suspicious mass on clinical evaluation. You will almost always do the FNA next reguardless of the mammo. (unless someone is paying for your malpractice and you don't care about your patients)

Just as an example - lets say the pt. in question has two masses, one palpable and one not palpable. The only way to fully evaluate the extent of pathology is to do a b/l mammo first, and then do FNA to the suspicious lesions elicited both by clinical exam and by mammo. In this patients case, the more serious lesion might be the one that isn't palpable.

Yea, this is pretty much the point. The only thing I would add is that you might skip the FNA altogether and jump to an excisional if the lesion looks serious enough---the reason being that in that scenario an FNA would not chnage your management---If + you would have to excise anyway, and if negative, it wouldn't be enough to rule out cancer in a mass that looks so suspicious on mammo. Once you do the excisional intraoperatively, you'll send that for a frozen, and if you get cancer, you will increase the size of your margins and sample your axillary nodes...(If it is really suspicious, you probably won't wait for frozen and just do the wider margins in the first place because that is thought to be safer in terms of not spreading cancer cells.)

The surgery type questions on step II imo are much more fair than the internal medicine questions. Almost all the surgery questions actually have one clear cut answer that you can arrive at through knowledge and logical reasoning. A fair number of the medicine questions are ambiguous imo, and even if you asked two different attendings in the given subspecialty from which the question was derived, they may give you a difference answer....Both answers of which are reasonable and logically derived.

 

[It'sElectric]

that's cause those aren't primary sources.. that's why i was confused too, if you look at my first post i had it all wrong at the begining too. it's really crappy when books just lump stuff together when they know that's not how its going to be asked on the exam and when all those choices will be but then answer choices for the question. i actually had to looked in a text book on OB-GYN and what i found i quoted up top... and it clearly said get mammography first...

you should be thankful i just earned you at least one or two points on the exam.

Yes, praise be to RussianJoo. I'll send you a thank you card when I see this exact question on Step II. I guess you'll have to do the same for the people who helped you on your other thread regarding endometrial biopsy.

 

[Winged Scapula]

For the most part, you guys and gals are correct. There are a few misunderstandings I'd like to correct, since this is something I do every day.

An imaging study is always the first step. For a woman over 30, a mammogram +/- ultrasound is appropriate, for those under 30, most radiology facilities will not do a mammogram due to the presumed density of the breasts. A sonogram would be appropriate for younger women.

The imaging study comes first because of the opportunity to pick up extent of disease, multifocal or multicentric disease (although MRI is generally better for this) and contralateral lesions. It would be better to biopsy everything seen at once than just the palpable mass.

Imaging studies also allow us to establish modality of biopsy for non-palpable lesions. Lesions only seen on mammogram need a stereotactic biopsy and those seen on mammo and US can be biopsied under either modality, but generally US is more comfortable for the patient (and can be done in my office).

Another reason to do the imaging first is that post-biopsy hematoma can obscure borders and other nearby lesions. If you have done a core bx, the patient may not tolerate sufficient compression to get a good study, so better to do it before any biopsy.

While FNA can be helpful in the case of a patient with known cystic lesion, it is not appropriate for the solid mass - which includes fibroadenomas, BTW (someone above mentioned FNA for these). FNA does not give architecture and therefore, while it can sometimes differentiate between a benign and malignant solid mass in the breast, it cannot differentiate between non-invasive and invasive disease and receptor status (important for adjuvant treatment) cannot be established. Therefore, all solid masses should have core needle biopsies.

The goal is that 80% or more of women have needle biopsies. Unfortunately there are a lot of people out there doing excisional biopsies. These are not incorrect per se, but in terms of preference - you want to reduce the number of times the woman goes to the operating room. By doing a needle biopsy up front, even if benign, you know what operation you're doing when you're in the OR. A cancer operation is totally different than an excisional biopsy. Excisional biopsies are unnecessary in almost all cases (I have done one in the last year and only because the patient was so needle phobic she refused to have anything done except under general anesthesia).

Finally, you can eliminate one of the choices: Radical Mastectomy with SLNB - while a code for Radical (Halstead) Mastectomy exists, they are so rarely done and are never done for women without chest wall invasion (which you have no evidence of in this case). They are testing you to see if you know the difference between Modified Radical Mastectomy (in which case you aren't doing a Sentinel Node but an Axillary Clearance - again, not incorrect in terms of appropriateness, but in most cases without clinically positive nodes, the sentinel node is the right operation first.), a simple/total Mastectomy with Sentinel Node Biopsy and the Radical Mastectomy.

So the protocol is:

- clinically palpable mass
- appropriate imaging (mammo and/or US)
- biopsy (core needle for solid masses; FNA for cystic lesions)
- pathology review (for all core needle biopsies; for FNA from cystic lesions in post-menopausal women [can be a rare cystic malignancy] or bloody fluid)
- post biopsy mammo for core biopsy with clip placement verification (to show that your titanium clip is in the lesion, so if you are biopsying a non-palpable lesion or a lesion which might undergo neoadjuvant chemotherapy, you know where the lesion is if it needs to come out)

The only time I do FNA on a solid mass is in the axilla, neck or groin (where I feel the risk of a large core needle biopsy is too great and I only need to prove mets, don't need architecture) or for patients who would be uncooperative or too anxious for a core needle (this is rare). FNA IS appropriate for thyroid masses as the first step, FYI.

 

[DrFraud]

thank you Winged Scapula

 

[RussianJoo]

thanks, Winged Scapula.

 

[Scaredshizzles]

Thanks winged....three minor questions if you don't mind answering---none of which are step 2 relevant, but I'm interested in oncology..

1. How accurate are core biopsy samples considered? Sensitivity, specificity, that sort of thing? I agree completely that it seems to be site relevant, I've been at places that do more excisional biopsies than core biopsies---although part of that is because I have had a biased sample as a student as we don't rotate through too many private offices/clinics.

2. What makes a core biopsy dangerous in the axilla/groin---just neurovascular structures in the area?

3. What are your thoughts on mammosite balloon catheter types of devices...I've seen a lot of these put in for older women, even when initial surgical impression has been likely benign.

 

[Winged Scapula]

Thanks winged....three minor questions if you don't mind answering---none of which are step 2 relevant, but I'm interested in oncology..

1. How accurate are core biopsy samples considered? Sensitivity, specificity, that sort of thing? I agree completely that it seems to be site relevant, I've been at places that do more excisional biopsies than core biopsies---although part of that is because I have had a biased sample as a student as we don't rotate through too many private offices/clinics.

Most academic and community general surgeons are not trained in core needle biopsy, hence the experience you note. It is a tragedy that many surgeons are still doing excisional biopsy when they should have someone else do the core to make the diagnosis. But its hard to change practice patterns.

The sensitivity and specificity of stereotactic guided core needle biopsy is in the high to mid 90s (93-98%). The numbers for ultrasound guided are slightly lower, ie 91-94%, but still acceptable. US guidance is more operator dependent than stereotaxis. Accuracy is related to site, size of mass, density of breasts and the experience of the person performing the biopsy. In addition, it might be affected by the number of samples taken. I note that many radiologists only take 1-2 tissue samples. Clearly with a large mass, sampling error may be higher in those cases with hetereogeneity of the tissue. If a patient is tolerating it, there is no reason not to take 5 or 6 or more samples, IMHO.

2. What makes a core biopsy dangerous in the axilla/groin---just neurovascular structures in the area?

3 things, IMHO:

1) big things that like to bleed
2) most core needle devices are spring loaded, with a "throw". For a very large mass, over 2 cm, it might be reasonable to place the core device at the lateral edge because the throw would still place the needle inside the lesion. But you must be very careful that you are in the lesion and not anterior/posterior to it.

Some needle devices have no throw but these require you to be in the lesion. For some very firm lesions or dense breasts this can be difficult; I can't always force the needle in and need the device throw to get into it. Rotating core devices are nice in this case but see # 1 above; a rotating 9 gauge core leaves a big hole.

3) some inaccuracy of the ultrasound. If the lesion is sitting right on a vessel or above the heart in a very thin patient, the possibility that the US has a 2 or more mm error in documenting where you are makes me nervous. That said, I HAVE cored lesions in these areas before...its patient and lesion dependent.

On my gen surg oral boards I got some flak for using US to biopsy a palpable mass. I explained that I always want to know exactly where I am in a lesion, to document that the lesion was biopsied (never can be too sure in this day and age) and to document placement of a titanium biopsy marking clip.

But as I noted earlier, if you have a mass in the lymphatic system with a primary source, all you need to do is prove that its metastatic disease. So you don't need a core for that. An FNA will give you that information without causing as much discomfort to the patient (and doesn't require the costly equipment or as much time to do).

3. What are your thoughts on mammosite balloon catheter types of devices...

I place a lot of these (although I use the Contura brand mostly) and think they are an excellent choice, especially for the elderly patient. There is good data that states that patients who live far away from radiation facilities do not get radiation and that the longer courses are often not completed. The early data from the Mammosite registry shows that the efficacy is as good as, if not better, than whole beam external radiation. HOWEVER, we do not have decades of data on recurrence rates and practically no one is putting these in women under 50.

I have several super elderly patients (ie, mid 90s) whom the radiation oncologists would still radiate; they and pretty much any woman having breast conservation over the age of 50 are great candidates for consideration of partial breast radiation with a brachytherapy catheter.

Reimbursement has recently declined dramatically for these however. I have gotten a few checks as of late for $2700 - not bad, until you consider that the catheters cost me $3000. If the insurers continue to drop the reimbursement to the point at which I make more money by seeing a new patient, I will simply have the radiation oncologists place the catheters. Which is too bad, because I enjoy doing it. But as long as they pay me for the catheter and for my time putting them in, I will do them (used to make around $5K for 10 minutes of my time).

...I've seen a lot of these put in for older women, even when initial surgical impression has been likely benign.

Huh? Why would you put one in a patient with benign disease? Are you seeing them put in in the operating room?

I place them in the office under ultrasound guidance after final surgical pathology is back and the Rad Onc has imaged the patient, determined that they are a good candidate and what size balloon device I need. I know some surgeons place them in the OR but my feeling is that:

a) if you don't have final path and have positive margins (or you don't even know if you have a malignancy), you have to remove the balloon

b) you are leaving money on the table - the reimbursement for intraoperative placement is practically nil. I did my first intraoperative one last week for a patient with known negative margins but a serious needle phobia. She wanted me to take her back to the OR to remove the catheter, which I refused to do (no reimbursement at all for that - ie, there's no code, so she would be billed for the OR time - $47/minute, anesthesia, my services, etc.)

 

[Scaredshizzles]

Huh? Why would you put one in a patient with benign disease? Are you seeing them put in in the operating room?

I place them in the office under ultrasound guidance after final surgical pathology is back and the Rad Onc has imaged the patient, determined that they are a good candidate and what size balloon device I need. I know some surgeons place them in the OR but my feeling is that:

a) if you don't have final path and have positive margins (or you don't even know if you have a malignancy), you have to remove the balloon

Yes, I've seen them placed intraoperatively. But as I mentioned, it is likely the result of my having a highly biased sample.

Thanks for taking the time to answer my questions, that was very insightful.