[The HRT follow-up consultation. What to do in case of breast tumour (clinical or radiological) and microcalcifications. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

OBJECTIVE

The objective was to evaluate the diagnostic value of clinical examination and complementary imaging in the exploration of a breast lump or microcalcifications occurring in a postmenopausal woman taking hormonal replacement therapy (HRT), based on a systematic review of the literature in order to make recommendations for HRT management.

METHODS

A literature review was conducted using Medline, Cochrane Library data and international recommendations in French and English until 2020.

RESULTS

In the presence of a clinical breast mass in postmenopausal women, there is no clinical evidence to rule out cancer. A double evaluation by mammography and ultrasound is recommended and allows the imaging to be classified into 5 BI-RADS categories. The diagnostic management of masses classified BI-RADS 4 and 5 should be based on percutaneous sampling, with microbiopsy being the first step. A total of four situations may arise: 1. Clinical examination has detected a breast mass, but there is no imaging abnormality. In this case, the imaging NPV is high (>96%). If the clinical lesion increases in size, a tissue biopsy should be performed, while continued routine breast screening is recommended if the lesion remains stable and HRT can be continued. 2. Clinical examination, mammography, and ultrasound are in favour of a cyst. Simple cysts can be punctured if painful. There is no contraindication to continuing HRT in the case of simple cysts. Management options for complicated and complex cysts are no different from those offered to women without HRT. Continuation of HRT must consider their histological nature. 3. Clinical examination, mammography, and ultrasonography suggest a benign solid tumour. The management of these benign breast lesions (fibroadenoma…) is not different in women taking an HRT and there is no contraindication to continue the HRT. 4: Clinical examination, imaging and microbiopsy diagnose a malignant tumour. It is imperative that the HRT be stopped, whatever the hormonal dependence of the tumour and whether it is invasive or in situ. The management of the cancerous tumour must consider the updated breast cancer treatment guidelines. In the presence of microcalcifications, the course of action to be taken depends on the BI-RADS classification, established according to the morphology and arrangement of the calcifications. In case of suspicious microcalcifications (BI-RADS 4 or 5), a guided macrobiopsy should be performed. Diagnostic and therapeutic management in these patients is no different from that offered to women without HRT. Discontinuation of HRT is necessary in cases of malignancy (in situ or invasive cancer).

CONCLUSION

A rigorous multidisciplinary approach is necessary for the exploration of a breast mass or microcalcifications in a postmenopausal woman.

[MRI-guided breast microbiospy or macrobiopsy: which is the best option for a small tumor?]

The choice of the optimum therapeutic strategy for breast cancer depends on the histological diagnosis of the sample obtained by biopsy. The microbiopsy is the preferred method as it provides an accurate diagnosis of the histological type as well as the main prognostic factors, whilst being simple, fast and inexepensive. However, some infraclinic breast tumors are not accessible by conventional guidance due to excessive depth inside the breast, their small size or technical inability to image them by mammography or ultrasonography. In those cases, the MRI guidance may help to perform the biopsy. Most MRI biopsies are made by large-core needle that are known to alter the histological structure of the tumor and to disturb the anatomopatholgical analysis (size and surgical margin). Those are very important elements to know before treatment. Our case report details an original technique of MRI microbiopsy of a deep 4mm opacity found on the occasion of a patient's mammography. The operative specimen revealed an invasive ductal carcinoma of 4mm diameter which scored III on the Elston and Ellis scale (oestrogen and progesterone receptors tested negative and HER-2 was over-expressed). It was associated with a high grade in situ ductal carcinoma. No systemic treatment was prescribed due to the small size of the carcinoma. The development of partially or totally amagnetic microbiopsy pistols would help perform microbiopses guided by MRI.