Breast Problems08


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  • Cancer mf3719328
  • Re 5544703
  • Re 5544703
  • Breast Problems08

    1. 2. Workup of breast problems Eliza Pile-Spellman M.D. 212 305-0519
    2. 3. <ul><li>When is a mammogram appropriate? </li></ul><ul><li>When is an ultrasound appropriate? </li></ul><ul><li>What is the difference between a targeted and a screening ultrasound? </li></ul><ul><li>When is an MRI appropriate? </li></ul><ul><li>What is the standard screening tool for breast cancer? </li></ul><ul><li>At what age should screening start? </li></ul><ul><li>What significance does pain have in reference to breast cancer symptoms? </li></ul>
    3. 4. Breast Cancer <ul><li>Most common cancer in women (except skin cancer) </li></ul><ul><li>2 nd leading cause of cancer death in women (lung cancer 1 st ) </li></ul><ul><li>In 2007, 211,990 women in U.S. were dx with invasive breast cancer </li></ul><ul><li>40,110 will die from the disease </li></ul><ul><li>There are slightly more than 2 million women in the US living with breast cancer </li></ul>
    4. 5. Estimated Breast cancer 2009 <ul><li>Female </li></ul><ul><li>192,370 new cases </li></ul><ul><li>40,179 deaths </li></ul><ul><li>male </li></ul><ul><li>1910 new cases </li></ul><ul><li>440 deaths </li></ul>
    5. 6. <ul><li>Incidence of breast cancer increasing 1% per yr since the 1940’s </li></ul><ul><li>Mortality rate has been decreasing probably due to early detection and better Tx </li></ul>
    6. 7. Impact of mammography <ul><li>40% of cancers are detected by mammography alone </li></ul><ul><li>10 % are detected by palpation alone </li></ul>
    7. 12. <ul><li>Survival is related to node status </li></ul><ul><li>Node status correlates with tumor size </li></ul><ul><li>Of Cancers < 1 cm – 15% are node pos </li></ul><ul><li>Of cancers > 1 cm - 30 % are node pos </li></ul><ul><li>Mammography detects smaller tumors </li></ul><ul><li>(average size palp tumors is 2 cm) </li></ul><ul><li>(average size mammo detected tumors 1cm) </li></ul>
    8. 13. Stage DCIS or <5 mm 5 yr Survival % 98 10 yr survival % 95 Node neg 85 75 Node pos Mets 55 10 2
    9. 14. Risk Factors <ul><li>Gender (75% of women who devel breast cancer have no other risk factor) </li></ul><ul><li>Aging- risk increases with age (18% dx in women in their 40s , 77% of women > 50 when dx) </li></ul><ul><li>Genetic factors –only 5-10% true hereditary breast cancer with BRCA, BRCA 2 or other mutation.(if pos, 35-85% chance of devel breast cancer in lifetime) </li></ul>
    10. 15. Risk factors <ul><li>Family history: male relatives with breast cancer count </li></ul><ul><li>Family history of ovarian /breast (2 or more relatives </li></ul><ul><li>Ashkenazi jewish heritage </li></ul><ul><li>Family hx of Cowdens or LI-Fraumeni syndromes </li></ul>
    11. 16. Risk factors <ul><li>Personal history breast cancer(3-4 fold increase in devel 2 nd cancer) </li></ul><ul><li>Hx radiation to breast </li></ul><ul><li>Previous bx showing atypia </li></ul><ul><li>Early menarche, late menopause </li></ul><ul><li>DES therapy – slight increased risk </li></ul><ul><li>No children or 1 st child after 30 </li></ul><ul><li>Oral contraceptive use –slight increase </li></ul>
    12. 17. Risk factors <ul><li>Race –white slightly more likely to devel cancer than black, but black more likely to die from cancer (more likely to be dx at later stage) </li></ul><ul><li>Hormone replacement tx </li></ul><ul><li>Alcohol –increased risk </li></ul><ul><li>Obesity –increased </li></ul><ul><li>Physical activity decreases risk </li></ul>
    13. 18. ? Risk factors <ul><li>Environmental </li></ul><ul><li>antiperspirants </li></ul>
    14. 19. No assoc increased risk <ul><li>Underwire bras </li></ul><ul><li>Smoking </li></ul><ul><li>Induced abortion </li></ul><ul><li>Breast implants </li></ul><ul><li>Night work </li></ul>
    15. 20. Protective effect <ul><li>Long island breast cancer study- women who take aspirin daily have a 30% reduction in breast cancer risk for hormone receptor positive tumors only (these have a better prognosis) </li></ul><ul><li>Finding by questionaire </li></ul><ul><li>Aspirin reduces Aromatase production which suppresses estrogen production </li></ul><ul><li>Acetominophen and ibuprophen had no effect </li></ul><ul><li>American Medical Association (Vol. 291, No. 20: </li></ul><ul><li>2433-2489) </li></ul>
    16. 21. Workup of breast problems <ul><li>Asymptomatic vs symptomatic </li></ul>
    17. 22. Screening <ul><li>How often should women be screened </li></ul><ul><li>What to do in high risk patients </li></ul><ul><li>Patients with a hx of breast cancer </li></ul>
    18. 23. Asymptomatic women (screening) <ul><li>American cancer society guidelines: </li></ul><ul><li>Yearly mammography starting at age 40 for as long as the woman is in good health </li></ul>
    19. 24. < 40 and no family history <ul><li>Screening not recommended </li></ul>
    20. 25. < 40 and mother or sister with premenopausal breast cancer <ul><li>Begin screening with mammography and ? Ultrasound/MRI 5 -10 years prior to dx of relative </li></ul>
    21. 26. <ul><li>In 2003 only 70 % of women in the U.S. reported having had a mammogram in the last 2 years. </li></ul>
    22. 27. Reasons for noncompliance <ul><li>Fear of pain </li></ul><ul><li>fear of cancer </li></ul><ul><li>fear of radiation </li></ul><ul><li>primary care provider does not recommend </li></ul>
    23. 28. Screening Mammograms <ul><li>Asymptomatic women </li></ul><ul><li>lower cost </li></ul><ul><li>recall pts if abnormal </li></ul><ul><li>recall rate 10% </li></ul><ul><li>recall rate lower if old films </li></ul><ul><li>4 standard views </li></ul><ul><li>letter to pt in lay language </li></ul><ul><li>? Last reported physical breast exam </li></ul>
    24. 29. Management of abnl mammo <ul><li>Recall 10% </li></ul><ul><li>addl views and or us </li></ul><ul><li>10% of recalls bx rec </li></ul><ul><li>20-30% of pts rec for bx will have a cancer </li></ul>
    25. 30. <ul><li>Screen 1000 women </li></ul><ul><li>recall 100 </li></ul><ul><li>of these 10 will be rec for bx </li></ul><ul><li>of these 2-3 will be positive for carcinoma </li></ul>
    26. 31. double reading <ul><li>Increased cancer detection rate 7% (MGH) </li></ul><ul><li>No significant increase in recall rate. </li></ul><ul><li>Screening costs decreased if batch read </li></ul><ul><li>CAD </li></ul>
    27. 32. mammography report <ul><li>Breast density </li></ul><ul><li>Birads system –standardized reporting system </li></ul><ul><li>Impression </li></ul><ul><li>Recommendation </li></ul><ul><li>Letter directly to patient reporting findings </li></ul>
    28. 33. Breast density
    29. 34. Birads classification <ul><li>0 incomplete </li></ul><ul><li>1 negative </li></ul><ul><li>2 benign </li></ul><ul><li>3 probably benign (<2% chance malignancy) </li></ul><ul><li>4 suspicious (? too broad a category) </li></ul><ul><li>5 highly suspicious </li></ul><ul><li>6 known cancer </li></ul>
    30. 35. mammography report <ul><li>Breast density </li></ul><ul><li>Birads system –standardized reporting system (breast imaging reporting and data system) </li></ul><ul><li>Impression </li></ul><ul><li>Recommendation </li></ul><ul><li>Letter directly to patient reporting findings </li></ul>
    31. 36. Birads Classification <ul><li>Must be included in report </li></ul><ul><li>must appear on billing form </li></ul><ul><li>must track suspicious and highly susp lesions(4 & 5) </li></ul><ul><li>attempt to standardize reports </li></ul><ul><li>universal language </li></ul>
    32. 37. Grade 2 <ul><li>Calcifications </li></ul><ul><ul><li>coarse (fat necrosis, fibroadenoma) </li></ul></ul><ul><ul><li>skin calc -rings </li></ul></ul><ul><ul><li>vascular </li></ul></ul><ul><li>masses </li></ul><ul><ul><li>calcified fibroadenomas </li></ul></ul><ul><ul><li>fat containing lesions:lipoma, oil cyst </li></ul></ul><ul><ul><li>hamartoma </li></ul></ul>
    33. 38. Grade 3 <ul><li>Probably benign finding </li></ul><ul><li><2% chance of cancer </li></ul><ul><li>after thorough workup </li></ul><ul><li>recommend 6 month followup </li></ul><ul><li>some of these may be bx because of pt anxiety </li></ul>
    34. 39. Management of grade 4 and 5 <ul><li>NONPALPABLE LESIONS </li></ul><ul><li>Core bx </li></ul><ul><li>FNA </li></ul><ul><li>excisional bx </li></ul>
    35. 40. Core bx indications <ul><li>Indeterminate calc to prove benign </li></ul><ul><li>2nd lesion in pt with cancer (ques need for mastectomy if 2 remote sites ) </li></ul><ul><li>sample 2 ends of large area (too large for lumpectomy) </li></ul><ul><li>malignant mass </li></ul><ul><li>malignant calc </li></ul>
    36. 45. Symptomatic <ul><li>Palpable mass </li></ul><ul><li>Nipple discharge </li></ul><ul><li>Breast pain diffuse or focal </li></ul><ul><li>Suspected abscess </li></ul><ul><li>Nipple retraction </li></ul><ul><li>Unilateral Axillary adenopathy </li></ul>
    37. 51. Diagnostic Mammogram <ul><li>Symptomatic women </li></ul><ul><ul><li>lump </li></ul></ul><ul><ul><li>pain </li></ul></ul><ul><ul><li>discharge </li></ul></ul><ul><ul><li>palpable axillary node </li></ul></ul><ul><ul><li>personal hx of breast cancer (within 5 yrs) </li></ul></ul><ul><ul><li>monitored by radiologist at inc cost </li></ul></ul><ul><li>Recall from screening </li></ul><ul><li>tailored exam </li></ul>
    38. 52. Requisition name and phone # <ul><li>Palpable mass </li></ul><ul><li>Nodularity </li></ul><ul><li>Pain </li></ul><ul><li>Thickening </li></ul><ul><li>Lumps both breasts </li></ul><ul><li>Palpable mass right breast 10 00 near areolar margin </li></ul><ul><li>Pain right upper outer quadrant </li></ul><ul><li>Bloody nipple discharge rt breast </li></ul><ul><li>Draw a picture </li></ul>
    39. 53. Screening ultrasound <ul><li>At this time, screening ultrasound is not recommended </li></ul><ul><li>Ongoing ACR trial – multiinstitutional involving women at high risk for breast cancer (mostly patients with personal history of breast cancer) </li></ul>
    40. 54. ACRIN 6666 ultrasound trial <ul><li>2007 – preliminary results </li></ul><ul><li>Use of us would increase detection yield by 4.2 per 1000 women screened, regardless of breast density </li></ul><ul><li>Downside –increase in number of biopsies performed </li></ul>
    41. 55. Comparison screening <ul><li>Mammography </li></ul><ul><li>2.6% referred for bx </li></ul><ul><li>29% positive </li></ul><ul><li>Ultrasound </li></ul><ul><li>7.7% referred fo bx </li></ul><ul><li>15% positive </li></ul>
    42. 56. Screening MRI <ul><li>ACS guidelines- in addition to mammography </li></ul><ul><li>BRCA1 or BRCA2 </li></ul><ul><li>Lifetime risk of breast cancer 20% or higher </li></ul><ul><li>Hx of exposure to chest radiation between ages 10-30 </li></ul><ul><li>Does not include intermediate risk patients </li></ul>
    43. 57. Breast MRI Indications <ul><li>Pt with known cancer for extent of disease </li></ul><ul><li>Workup of problem patient – palpable mass with normal mammogram and ultrasound </li></ul><ul><li>R/o rupture in a patient with implants </li></ul>
    44. 58. MRI <ul><li>Expensive </li></ul><ul><li>Requires injection </li></ul><ul><li>Insurance companies will pay on limited basis </li></ul><ul><li>Very sensitive but not specific </li></ul><ul><li>Many false positive </li></ul>
    45. 59. Palpable masses <ul><li>9 yo with palpable mass in the 12:00 location of the right breast </li></ul>
    46. 60. Right breast palp area (subareolar
    47. 61. Rt breast palp
    48. 62. Left breast comparison
    49. 63. Breast development <ul><li>Begins during adolescence </li></ul><ul><li>surge of estrogen responsible for devel of ducts </li></ul><ul><li>progesterone necessary for devel of lobules </li></ul>
    50. 64. <ul><li>Palpable breast masses are uncommon is children </li></ul><ul><li>most masses have a benign etiology </li></ul><ul><li>surgery can arrest breast development </li></ul>
    51. 65. Causes of palp masses in children <ul><li>Breast bud </li></ul><ul><li>cyst </li></ul><ul><li>fibroadenoma </li></ul><ul><li>phylloides </li></ul><ul><li>lymph node </li></ul><ul><li>galactocoele </li></ul><ul><li>duct ectasia </li></ul><ul><li>abscess </li></ul><ul><li>gynecomastia </li></ul><ul><li>Primary breast cancer rare(<.2% cancers in pts <20) </li></ul><ul><li>metastatic disease </li></ul><ul><ul><li>late finding </li></ul></ul><ul><ul><li>rhabdomyosarcoma </li></ul></ul><ul><ul><li>leukemia </li></ul></ul><ul><ul><li>lymphoma </li></ul></ul>
    52. 66. <ul><li>Fibroadenomas are most common solid mass in children and adolescents </li></ul>
    53. 67. 19 yo with palp mass <ul><li>workup </li></ul>
    54. 68. palp
    55. 69. 30 yr old with palpable mass
    56. 73. 41 yo palp mass <ul><li>4776708 </li></ul>
    57. 78. 38 yo palp mass <ul><li>Work up </li></ul>
    58. 84. palpable mass
    60. 90. Palpable mass Age < 30 years <ul><li>Start with targeted ultrasound </li></ul><ul><li>If ultrasound is negative, report should indicate further workup should be based on clinical grounds </li></ul><ul><li>If mass is cancer after workup, do mammogram- screen other breast </li></ul>
    61. 91. Palp mass Age 30 or > <ul><li>Mammogram with skin marker placed over palp, and spot tangential view </li></ul><ul><li>Targeted ultrasound with core bx as necessary </li></ul>
    62. 92. PALP MASS <30 yrs 30 or> Mammogram + US US Cyst stop Solid –core bx
    63. 93. nipple discharge <ul><li>Workup </li></ul><ul><li>What type of discharge is important? </li></ul><ul><li>How often assoc with breast cancer? </li></ul>
    64. 94. Nipple Discharge <ul><li>Important only when spontaneous </li></ul><ul><li>can be clear, or bloody </li></ul><ul><li>only 10% due to cancer </li></ul><ul><li>elicited discharge (squeezing the nipple) not important </li></ul><ul><li>copious production of breast secretions by manipulating the nipple is common in parous premenopausal women and smokers </li></ul>
    65. 95. Nipple Discharge <ul><li>Multiple duct discharge is often bilateral and virtually never due to an underlying cancer </li></ul><ul><li>usually caused by duct ectasia </li></ul><ul><li>unless copious -leave alone and reassure patient. </li></ul>
    66. 96. Galactorrhoea- if not pregnant or postpartem, prolactin-secreting pituitary tumor
    67. 97. Dark green discharge from multiple ducts
    68. 98. Solitary Papilloma <ul><li>All ages </li></ul><ul><li>70% present with a serous or bloody nipple discharge </li></ul><ul><li>occurs in the major collecting ducts in the subareolar area </li></ul><ul><li>may be palpable and fill a duct </li></ul>
    69. 101. Solitary Papilloma <ul><li>Most common cause of spontaneous nipple discharge </li></ul><ul><li>hemorrhagic infarction is often present and is thought to be the cause of bloody nipple discharge </li></ul><ul><li>galactogram or blind terminal duct excision? </li></ul>
    70. 102. 65 yr old with bloody nipple discharge
    71. 108. 35 yo pre renal transpant
    72. 113. w/u bloody nipple discharge <ul><li>>30 </li></ul><ul><li>Mammogram </li></ul><ul><li>Ultrasound </li></ul><ul><li>Ductogram </li></ul><ul><li>? MRI </li></ul>
    73. 114. 22 yr old with diffuse breast pain for 3 weeks
    74. 115. <ul><li>Patient 2 </li></ul><ul><li>25 y o woman with focal breast pain in the right breast 5:00 with no family history of breast cancer. </li></ul>
    75. 116. <ul><li>Patient 3 </li></ul><ul><li>29 y o woman with a lump in her left breast in the 2:00 position for 3 weeks. </li></ul>
    76. 117. <ul><li>Patient 4 </li></ul><ul><li>32 y o woman with a lump in her right breast at 12:00. </li></ul>
    77. 118. <ul><li>Patient 5 </li></ul><ul><li>50 y o woman with a strong family history of breast cancer and normal mammogram who requests an MRI for screening. </li></ul>
    78. 119. <ul><li>Patient 6 </li></ul><ul><li>45 y o with a mass in her right breast at 4:00. </li></ul>
    79. 122. Multifocal disease not evident on mammogram or ultrasound
    80. 123. Same breast with multicentric disease not evident on mammogram or ultrasound