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  • Transcript

    • 1. Benign Breast Disease: Surveillance, Diagnosis and Treatment Helen Krontiras, M.D. Assistant Professor of Surgery Co-Director UAB Breast Health Center Co-Director Lynne Cohen Preventive Care Program for Women’s Cancers at UAB
    • 2. Risk factors for breast cancer
      • Major
        • Gender
        • Genetic Predisposition
        • Histologic risk factors
          • Personal history of breast cancer
          • Atypical hyperplasia
          • Lobular carcinoma in situ
        • Age
        • Therapeutic radiation including breast tissue in the field
    • 3. Hereditary Breast Cancer
    • 4. Familial Breast Cancer Syndromes
      • BRCA 1
        • Familial breast and ovarian cancer
      • BRCA 2
        • Familial breast and ovarian cancer, with male breast cancer and pancreatic cancers among others
      • Li-Fraumeni (p53 or CHK2)
        • Sarcomas, brain tumors, adrenal cortical cancers and breast cancer
      • Cowden’s Disease (PTEN)
        • Breast cancer, thyroid cancer and skin lesions
      • Peutz-Jeghers (tumor suppressor LKB1)
        • mucocutaneous melanotic pigmentation, intestinal polyposis and increased risk of breast cancer among others
    • 5. BRCA 1 and 2
      • Autosomal dominant
      • 50% of familial breast cancer syndromes
      • The prevalence of BRCA mutations is 0.1% in the general population
      • BRCA 1
        • chromosome 17q21
        • 50-85% lifetime risk of breast cancer
        • 20-40% lifetime risk of ovarian cancer
      • BRCA 2
        • chromosome 13q12
        • 50-85% lifetime risk of breast cancer
          • Increased risk of male breast cancer as well
        • 10-27% lifetime risk of ovarian cancer
    • 6. Familial Breast Cancer
      • Both maternal and paternal family histories are important
      • Computational tools are available to predict the risk for clinically important BRCA mutations
      • Respect confidentiality
      • DNA testing is available for both genes
      • Genetic counseling for those whom testing is considered
    • 7. General Family History Risk Factors for Carrying a BRCA1 or BCRA2 Mutation
      • Known BRCA1 or BRCA2 mutation
      • Breast and ovarian cancer
      • Early onset breast cancer
      • Multiple breast primaries
      • Male breast cancer
      • Ashkenazi ancestry
    • 8. Probability of developing breast cancer by age
      • From age 30 to age 40 . . . . . . .1 out of 257
      • From age 40 to age 50 . . . . . . .1 out of 67
      • From age 50 to age 60 . . . . . . .1 out of 36
      • From age 60 to age 70 . . . . . . .1 out of 28
      • From age 70 to age 80 . . . . . . .1 out of 24
      • Ever . . . . . . . . . . . . . . . . . . . . . .1 out of 8
      Source: National Cancer Institute Surveillance, Epidemiology, and End Results Program, 1995-1997
    • 9. Continuum of Breast Cancer Development Normal Hyperplasia Atypical hyperplasia Ductal carcinoma in situ Invasive Ductal carcinoma RR 1.5-2.0 RR 4-5 RR 8-10
    • 10. Benign breast disease
      • Proliferative breast disease
      • Relative risk 1.5-2.0
      • Moderate or florid hyperplasia
      • Sclerosing adenosis
      • Intraductal papilloma
      • Apocrine metaplasia
      • Radial scar
      • Proliferative disease with atypia
      • Relative risk 4-5
      • Atypical lobular or ductal hyperplasia
      • LCIS
      • Relative risk 9-11
      • Lobular carcinoma in situ
    • 11. Atypical Hyperplasia Lobular carcinoma in situ
      • Markers for increased risk
      • If found on core biopsy, surgical excision necessary to rule out 30-50% incidence of coexisting cancer
      • If found on excisional biopsy, no further surgical therapy warranted
      • Management of AH and LCIS
        • Surveillance or,
        • Chemoprevention or,
        • Rarely Prophylactic surgery
    • 12. Risk factors for breast cancer
      • Minor
        • Reproductive history
          • Early menarche (<12)
          • Late childbearing (>30)
          • Nulliparity
          • Late Menopause (>55)
        • Alcohol
        • Postmenopausal hormone use
        • Obesity
    • 13. Gail Model
      • Developed at the National Cancer Institute by Dr. Mitchell Gail in 1989
      • Individualized risk prediction
        • Individual’s estimated 5-year and lifetime risk are calculated and compared to women the same age and race who are of average risk
      • Increased risk is defined as a 5-year risk of 1.7% or greater
        • Equates to the risk of an average 60 year old woman
      • Gail Model
      • http://www.cancer.gov/bcrisktool/
    • 14.  
    • 15.  
    • 16. Limitations of Gail Model
      • Not used in those with prior history of breast cancer or LCIS
      • May underestimate risk with family history suggestive of a gene mutation
        • Other models exist for this patient population
      • Validity in women under 35 years of age is unknown
      • Validity in non-Caucasians is unknown
    • 17. Surveillance Average Risk for Breast Cancer
      • Mammography
        • Annual screening beginning at age 40
      • Clinician breast examination
        • Annual evaluation beginning with GYN exams
      • Self breast examination
        • Regular, breast self-awareness
    • 18. Mammography
      • Screening mammogram
        • Asymptomatic patients
        • Two view examination of each breast
          • Craniocaudal
          • Mediolateral oblique
      • Compare with previous mammograms
      RCC LCC RMLO LMLO
    • 19. Mammography
      • Diagnostic mammogram
        • Evaluate physical examination findings
        • Evaluate abnormalities on screening
          • Spot compression
          • Magnification views
          • Additional projections
          • Sonography
    • 20. Benefits of Screening Mammography
      • Randomized trials show reduction in mortality by at least 24%
      • Cancer detected in 2-3 of every 1000 women who undergo regular screening mammography
    • 21. Limitations of Screening Mammography
      • Interval cancer rate 10-20%
      • Biopsy positive predictive value (PPV 2 ) 25%-40%
      • Dense breasts
      • Blind areas of the breast
      • Breast compression
      • “DCIS dilemma”
    • 22. Ultrasound
      • Adjunct to mammography
      • Not a screening tool
      • Used for problem solving
        • Cystic vs solid
        • Evaluate palpable abnormalities
    • 23. Clinical Breast Exam
      • Recommended annually for all women 20 years and older
      • Inspection of nipple and skin
      • Palpation of nodal basins
        • Cervical, supraclicular, infraclavicular, and axilla
      • Systematic examination of the entire breast
        • Include tissue over sternum
        • Inframammary fold
        • Retroareolar area
    • 24. Self Breast Exam
      • Inexpensive, noninvasive
      • 5-7 days after the onset of menses or on the same day of the month for postmenopausal women
      • New changes should be brought to the attention of primary care provider
      • Randomized controlled trials have shown no reduction in mortality from breast cancer among women who performed monthly BSE
    • 25. Options for Management of Women at Moderate Risk for Breast Cancer
      • Surveillance
      • Chemoprevention
        • Tamoxifen
      • Lifestyle modification
    • 26. Chemoprevention Tamoxifen
      • Consider for women at increased risk
      • Currently only FDA approved medication for risk reduction for breast cancer
      • Selective estrogen receptor modulator
      • 50% reduction in breast cancer risk
        • 86% with atypical hyperplasia
        • 56% with lobular carcinoma in situ
      Fisher et al, J Natl Cancer Inst 1998
    • 27. Prevents Breast Cancer & Inhibits Recurrence Increases Thromboembolic Events Increases Incidence of Uterine Cancer Preserves Bone Density Lowers Circulating Cholesterol Tamoxifen Actions Increases incidence of hot flashes Increases incidence vaginal dryness
    • 28. Options for Management of Women at Increased Risk for Inherited Breast Cancer
      • Surveillance
        • Breast self examination
          • Monthly Beginning at age 18
        • Clinical breast examination
          • Semiannually at age 25
        • Mammogram and MRI
          • Annually starting at age 25 or 10 years younger than the youngest affected relative
      • Chemoprevention
        • Tamoxifen
      • Prophylactic surgery
        • Bilateral Total Mastectomy
        • Bilateral Oopherectomy
    • 29. Breast MRI
      • Approved for breast by FDA in 1991
      • Contrast enhanced (Gadolinium)
      • Current data only supports its use for screening in women who are at increased risk for an inherited breast cancer
    • 30. Rationale for MRI Screening of Populations at Increased Risk for Inherited Breast Cancer
      • 80% lifetime risk
      • Develop cancer at an early age when breasts are dense
      • Grow rapidly
        • 50% “interval cancers”
      • Median size 1.7 cm
        • 50% have spread to lymph nodes
    • 31. Palpable Mass
      • Thorough history and physical examination
        • Onset, duration, change over time
        • Breast cancer risk factors
      • Dominant mass
        • Discrete or poorly defined
        • Cystic or solid
      • Persistent through the menstrual cycle
      • Distinct from surrounding tissue
      • Asymmetric with respect to the opposite side
    • 32. Palpable Masses
      • Suspicious masses
        • Hard or firm
        • Indistinct, irregular borders
        • Attached to the skin or deep fascia
      • Benign masses
        • Mobile
        • Well demarcated
        • Soft
      • Accuracy of physical examination alone is limited
        • Correct in 60-85% of cases
        • More difficult in younger women
    • 33.
      • 8 out of 10 lumps are NOT cancer
      • Most are lumps are benign conditions
        • Fibroadenoma
        • Cyst
        • Fibrocystic disease
    • 34. Changing frequencies of discrete breast lumps with age % of total < 20 21-30 31-40 41-50 51-60 >60 10 20 30 50 40 60 70 90 80 0 Cancer Benign breast change Fibroadenoma Cyst Abscess Dixon 1995 Age
    • 35. Algorithm to Evaluate Dominant Mass or Thickening
    • 36. Palpable Mass
      • Any discrete solid mass should prompt a surgical referral for tissue diagnosis
        • Even if mammogram is negative
      • If the clinical examination and mammogram are normal but the patient says she can feel a lump, follow-up clinical examination in 2-3 months
      • Diffuse nodularity without a discrete mass should be followed clinically at a different point in the menstrual cycle
    • 37. Palpable Mass
      • Triple test diagnosis
        • Physical examination
        • Mammography and/or ultrasound
        • Cytology or histology
      • There is 0.5% probability of malignancy when all three are benign
      Donnegan, NEJM 1992
    • 38. Abnormal Mammogram
      • Increased use of screening mammogram
      • has resulted in in the identification of a large
      • number of subclinical abnormalities
        • Mass
        • Calcifications
          • Clustered
          • Pleomorphic
          • Grouped
          • Linear
          • Branching
        • Architectural distortion
    • 39. BIRADS
      • Category 0: Need Additional Imaging Evaluation
      • Category 1: Negative
      • Category 2: Benign Finding
      • Category 3: Probably Benign Finding. Short Interval Follow-Up Suggested
      • Category 4: Suspicious Abnormality. Biopsy Should Be Considered
      • Category 5: Highly Suggestive of Malignancy. Appropriate Action Should Be Taken
      • Category 6: Known Malignancy
      American College of Radiology (ACR) Breast Imaging Reporting and Data System Atlas (BI-RADS® Atlas). Reston, Va: © American College of Radiology; 2003.
    • 40. Abnormal Mammogram
      • Careful physical examination
      • Diagnostic imaging often obviates the need for biopsy in patients with normal physical examination
        • 50% of indeterminate lesions are found to be unequivocally benign or can be followed with interval mammography
      • Patients with new findings that cannot be resolved should be referred to a specialist
    • 41.
      • Core biopsy (preferred) or excisional biopsy for BIRADS 4 or 5
      • Surgical excision indicated after benign core biopsy for atypical hyperplasia, LCIS, radial scar, nondiagnostic specimen, discordant result
    • 42. Nipple Discharge
      • Common symptom but uncommon presentation of breast cancer
      • Likelihood of discharge being associated with carcinoma increases with age
        • 32% of women over 60
        • 7% of women under 60
      • Physical examination
        • Evaluate for palpable masses
      • Cytology not useful in evaluating nipple discharge
      • Imaging
    • 43. Nipple Discharge
      • Physiologic Discharge
        • With compression
        • Bilateral
        • Multiple ducts
      • Pathologic Discharge
        • Spontaneous
        • Unilateral
        • Single duct
        • Bloody
      • DDx
      • Extensive nipple manipulation
      • Vigorous aerobic exercise
      • Stress
      • Pregnancy
      • DDx
      • Intraductal papilomatosis
      • Duct ectasia
      • Intraductal mastitis
      • Cancer
    • 44. Nipple Discharge
      • Physiologic
        • Reassure
        • Follow-up to assure symptoms resolve and no new symptoms
      • Persistent nonlactional galactorrhea
        • Medical evaluation
      • Pathologic
        • Surgical referral
        • Bilateral mammogram
    • 45.
      • The key to any breast complaint is follow-up

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