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Transcript of Breast Diagnosis And Management of of Benign Breast Diseases Resident Basic Science - 2014 Harry D....
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