Breast Diagnosis And Management of of Benign Breast Diseases

Resident Basic Science - 2014Harry D. Bear, MD, PhD

Division of Surgical OncologyMassey Cancer Center

Anatomy of Ductal Systems of the Breast

Lymphatic Drainage of the Breast

Examination of the Axilla

Examination of the Axilla

Positioning for Breast Palpation

Breast PalpationFinger “Pads” and Two Hands

Breast Exam - Systematic Coverage of All Breast Tissue

Signs and Symptoms of Breast Cancer

Occult mass or calcificationsBreast mass or “thickening”Spontaneous nipple dischargeSkin dimplingNipple retraction or scalingSkin erythema or peau d’orangeFocal breast pain – 10%

Signs of Breast Cancer Skin Dimpling

Signs of Breast Cancer Nipple Retraction

Change in Nipple

What do you think this is?A. Eczema of the

nipple

B. Dried nipple discharge

C. Paget’s disease

D. Invasive ductal cancer

E. Infection after nipple piercing

Change in Nipple

Signs of Breast Cancer Peau D’Orange

Inflammatory Breast Cancer

Breast Disease

Fibrocystic change«“Lumpy breasts”«Most are physiologic - not a

disease«Pain - usually cyclical and mild

• Occasionally severe• Reassurance and NSAIDs, local heat

or cold

Breast Disease

Fibrocystic change«Common in women 30 - 50«Adenosis«Fibrosis«Cysts«Hyperplasia

• With or without atypia

Breast Masses

Fibroadenoma«Most common in teens to 20’s«Smooth«Very mobile«Lobulated

Fibroadenoma

Fibroadenoma, Fibrocystic Change

Fibroadenoma, Fibrocystic Change

Breast Diseases

Pathologic Nipple Discharge«SPONTANEOUS, not elicited«Grossly bloody - usually papilloma«Unilateral«Only bilateral galactorrhea (milk)

needs endocrine evaluation«Mammograms & Galactograms«Cytology - very limited value«Most result from duct ectasia

Breast - Ductal Diseases

Intraductal papilloma«Retroareolar mass«Nipple discharge

Duct ectasia«Palpable dilated ducts«Nipple discharge - many colors

Bloody Nipple DischargeIntraductal Papilloma

Intraductal Papilloma

Nipple Discharge – Duct Ectasia

Breast Masses

Cysts «Round«Smooth«Somewhat mobile«Sometimes painful«Mostly in women > 40

Breast Masses

Management of suspected cysts«Mammogram«Sonogram

«Needle aspiration, especially if symptomatic

« If cystic by sonogram and no symptoms, follow

OR

Aspiration of Breast Cyst

Breast Masses

Abscess« Severe pain« Erythema« Fluctuant mass« Often require surgical drainage

Cystosarcoma phyllodes« Usually large, similar to fibroadenomas« 90% are benign, 10% malignant

Screening Mammography

Annually after age 40Start screening younger for strong

family history of pre-menopausal breast cancer (start 5 years younger than youngest age at diagnosis)

NOT just for “high risk” women

Limitations of Mammography

Misses up to 10% of breast cancersCannot rule out cancerTherefore, not a definitive test for

palpable massesUseful to assess other breast tissueLittle if any role in women under 30

Diagnosis of Breast Masses

In women over 30, get mammogram, preferably before biopsy

Shows characteristics of mass, other occult lesions in the same breast and opposite breast

BUT, for a palpable MASS, DO NOT depend on the findings to decide whether nor not to biopsy

Mammograms of a Woman with a 2 cm Breast Cancer

Mammography - Multiple Cancers

Mammographic Signs of Breast Cancer

MassCalcificationsDilated ductsArchitectural distortionSkin changesAsymmetryEnlarged lymph nodes

Mammograms - Spiculated Density

Mammography - Calcifications

Role of Breast Ultrasound

For occult masses – cystic vs. solidEquivocal findings on mammogram

or examGuidance for needle biopsy or extent

of excisionCystic vs. solid for palpable massNOT yet shown to be effective for

screening

Occult Mass on Mammogram

Sonogram of Mass - Simple Cyst

Sonogram of Mass - Complex Cyst

Ultrasound Guided Aspiration of Breast Cyst

Ultrasound - Breast Cancer

Breast Ultrasound - Small Cancer

Breast Biopsy Choices

Fine Needle Aspiration Biopsy

Fine Needle Aspiration Biopsy Smear

Core Needle Biopsy

Needle-core biopsy

Methods of Breast DiagnosisCore Needle Biopsy vs. FNA

Disadvantages« Local anesthetic« Pain« Bleeding« 24 – 48 hr. turnaround

Advantages« More material« Invasion vs. DCIS« Marker studies possible

Optimizing Breast Biopsy MethodsCompared to Surgical Biopsy

Less traumaticMinimal scarQuicker and cheaper than surgeryDefinitive diagnosis in most cases

Advantages of Needle BiopsyCore or FNA vs. Surgical Biopsy

Facilitates breast conservation«First excision of known cancer

removes less tissue than excision and re-excision

«Less disturbance of tissueOne operation, not twoGreater accuracy of sentinel node

mappingShould be used in close to 100%!

And YET…….

More than 1/3 of all breast masses and mammographic abnormalities are still being biopsied by open surgery!*«= almost 600,000 unnecessary

operations/year

“Where is the outrage? ”#

* Clark-Pearson et al, JACS, 1/2009# Silverstein, JACS, 1/2009

Diagnosis of Palpable Mass

Cyst Management

Triple Negative Test

Triple Negative Test

Non-suspicious physical exam (weak link)Negative mammogramBenign cytology on FNA or benign Core

biopsy

Nearly 100% accurate, but must follow-up

Options for Occult Breast Findings

6 Month Follow-upImage-guided needle biopsy

«Stereotactic«Ultrasound

Needle localization and surgical biopsy

BIRADS scoring system (0-6)

Mammography Algorithm

Stereotactic Breast Biopsy

Stereotactic Breast Biopsy

Breast Diagnosis - Mammographic Localization

Breast Diagnosis – Pre-Operative Mammographic Localization

MAINLY for borderline lesions after core biopsy or known cancers

Breast Diagnosis - Mammographic Localization

Carcinomas in SituDuctal and Lobular

Lobular Carcinoma in situ

This is NOT cancer!

Duct Carcinoma In Situ

Common Allegations in Missed Breast Cancers

Failure to screenFailure to know about mammogramsFailure to evaluate/follow-up patient

complaintFailure to follow-up abnormal examFailure to refer to specialistMisinterpretation of abnormal PE

with normal mammogram

Missing Breast Cancers

Triad of error«Young age«Self-discovered mass«Negative mammogram

Clues to Effective Chemoprevention

Estrogen has a role in breast cancer etiology

Anti-estrogen therapy can cause regression of breast cancers that express hormone receptors

Tamoxifen, used to decrease recurrence of ER+ breast cancer, also decreased incidence of contralateral breast cancers by almost half

Tamoxifen for Chemoprevention - P1

Women at High Riskfor Breast Cancer

Women at High Riskfor Breast Cancer

Tamoxifen for 5 Years Placebo for 5 Years

Randomize

or

Average Annual Rates of Invasive Breast Cancers in P-1 Trial

0

2

4

6

8

10

12

14

All Women LCIS Atypical Hyperplasia

Placebo

Tamoxifen

Rat

e p

er 1

000

Fisher, et al. JNCI, 1998

RALOXIFENE60 mg/dayx 5 years

Risk-EligiblePostmenopausal Women

STRATIFICATION• Age• Relative Risk• Race• History of LCIS

TAMOXIFEN20 mg/dayx 5 years

NSABP STAR Schema

P-2 STARAverage Annual Rate and

Number of Invasive Breast Cancers

0

2

4

6

8

10

Gail ModelProjection

TAM Raloxifene

Av

Ann

Rat

e pe

r 10

00

163 168

* # of events

312*

RR = 1.02, 95% CI: 0.82 to 1.28