Clinical Evaluation of Breast Diseases Joy Dorscher MD Department of Family Medicine and Community...

Clinical Evaluation of Breast Diseases

Joy Dorscher MDDepartment of Family Medicine and Community [email protected]

Learning Objectives

Be able to identify:• Basic breast evaluation

• Basic breast imaging modalities

• Means of obtaining fluid/tissue for testing

• Tanner staging

• Breast disorders by age and gender

Embryologic Breast Development

• 5-7 weeks gestation

• Bilateral thickening of ectoderm

• Involutes except near the pectoral region

• Glandular development is dependant on placental hormones

Breast Self Examination

Clinical Breast Examination

Clinical Breast Examination

Lump or contour change

Skin tethering Nipple inversion Dilated vessels Ulceration Nipple scaling Edema or Peau

d’orange

Nature of Palpable Lesions

Firmness Irregularity of borders Focal Nodularity Fixation to skin or underlying

muscle Location-quadrant, distance from

nipple Size

Mammography Controversy

Annually (?) When to start (?) When to stop (?) False Positives (?)

Bottom lineMammography is not

the complete answer to breast cancer screening.

Mammography

Positioning Experience

Technologist Radiologist

X ray exposure

BI-RADSBreast Imaging Reporting and Data System

Category 0-6 Discuss results Assess risk Establish plan

Additional filmsRoutine intervalShort term F/UBiopsy

BI-RADS

Category 0- Incomplete

Category 1- Negative-Routine follow up, 5/10000

Category 2- Benign finding-Routine follow up,<2%

Category 3-Probably benign-short interval f/u, <2%

Category 4- Suspicious abnormality-Bx, 23-34%

Category 5- Highly Suggestive->Biopsy, 95%

Category 6- Known Malignancy-follow progress

Malignant Breast Disease

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10 7

T ime i n Y ea rs

No .O fC e lls

10 1 0

9

V isib le onM am mog raphy

P a lpab leL es ion

1 mm le si on

1 cm le si on

B a sed on an ave rage doub li ng tim e o f 100 day s

T aken fr o m Ob st e tric s a nd Gyne c ology 4 th Ed iti on 2002 ,L ipp inco tt, W illi am s, W ilk in s

M a mm o g ra p h ic a n d C li n ic al D et e ct io n o f B re a st Ma ss

BI RADS Category 0

Spot Compression Mammography is one of the methods that is used to further identify lesions on mammography

Ultrasound

Ultrasound

Analyzing cystic structures

Diagnosis with dense breasts

Not much value as a screening tool

3D ultrasound

Magnetic Resonance Mammography

Positives Breast implants and ruptures Highly sensitive to small

abnormalities Used effectively in dense

breasts Evaluate the extent of breast

cancer Can help determine type of

surgery needed May detect breast cancer

recurrences and residual tumors

Locate primary tumor in women with axillary lymph nodes

Useful in screening women at high risk for breast cancer

Equivocal mammogram

Negatives Time consuming Expensive Contrast agent (allergy or preg) Tolerate any claustrophobia MRI can be non-specific-2X bx Minimally invasive breast biopsy

techniques need to be further developed

Cannot image calcifications MRI centers cannot always

produce results cited in research studies

Inability to lie prone Extremely large breasts

Scintimammography

Uses Tc99m Sestamibi which concentrates in the mitochondria

Differences in uptake between normal and abnormal cells

Best when used for palpable lesions

May provide more functional information (drug resistance)

Has no value as a screening test

PET Scan

Metabolic activity Vascularization Oxygen

consumption Tumor receptor

sites Most helpful Least available Most expensive

eMed Aug 25,2008

Imaging Modalities

Modality Sensitivity Specificity PPV Indications

Mammography 63-95%

(>90% palp

50% nonpalp

35% dense)

14-90%

(90% palp)

10-50%

(94% palp)

Asymptomatic, >35 screening, micro-calcifications

US 68-97% (palpable)

74-94% (palpable)

92% (palpable) Women < 35yo, cystic structures.

MRI 86-100% 21-97%

(<40% primary cancer)

52% Scar, implants, multiple lesions, borderline

Scintography 76-95% (palp)

52-91% (nonpalp)

62-94%

(94% nonpalpable)

70-83%

(83% palpable, 79% non palp)

>1cm axilla asses., predict drug resis.

PET 96%

(90% axillary metastasis)

100% Axilla assessment, scar, multifocal

Obtaining Tissue/Biopsy

Fine Needle Aspiration Core Needle Biopsy Excisional Biopsy Incisional Biopsy

Fine Needle Aspiration (FNA)

Palpable lesionCystic

structuresSolid masses

Malignant cells are loosely cohesive

Used less often

FNA

Positive Quick Painless Inexpensive No incision Minimal chance of

infection or bruising Immediate results Office procedure

Negative Less accurate Palpable lesion In situ vs. invasiveIn situ vs. invasive Cytotechnologist,

cytospin and slides Can’t use with

implants or lesions near chest wall

Core Needle Biopsy

Positive Quick Painless Inexpensive Small incision Minimal chance of

bruising/infection Can distinguish in situ vs.

invasive May avoid surgery If palpable> office

procedure Histologic assessment

ER, PR, Her2Neu

Negative Slightly less accurate May not provide

complete description of the tumor

If not palpable> hospital and possibly may still need surgery

Can not be used with breast implants or coumadin therapy or near chest wall

Incisional Biopsy

As for excisional biopsy with added complication of possibly needing more surgery.

Excisional Biopsy

Positive Accurate Provide complete

information about tumor

Rare false negative May be treatment

Negative Expensive Invasive/painful Time to heal Greater chance of

infection/bruising Change feel/look of

the breast Hospital procedure

Localization of Nonpalpable Lesions

Needle Localization Stereotactic Biopsy

Needle Localization

A wire is placed by radiologist for the surgeon to know what section of breast is abnormal

Can remove the tissue with the needle tip intact

Stereotactic Biopsy

Tanner staging-Female Breast

Preadolescent nipple is elevated with no underlying glandular tissue or increased pigmentation of the areola

(~11 yo)- glandular tissue in the subareaola is obvious. Nipple and breast are single mound off of the breast wall

(~12 yo) there is increase in the among of palpable glandular tissue with increased diameter and pigmentation of the areola breast and nipple in single plane.

(~13 yo) the areola further enlarges in a single plane, The nipple and areola form a separate mound above the level of the breast

(15 yo) there is a final development of a smooth contour with projection with nipple and areola

Tanner Staging-Female Genitalia

Prepubertal; no pubic hair Straight hair is extending

along and between the labia Pubic hair is increased in

quantity, darker and present in the typical female triangle

Pubic hair is more dense, curled and adult in distribution but less abundant

Abundant, adult type pattern hair may extend onto the medial aspect of the thigh

Tanner Staging -Male Preubertal, no pubic hair, genitalia

unchanged from early childhood Light colored hair develops laterally

and later becomes darker, penis and testes may be slightly larger, scrotal skin becomes more textured

Pubic hair is extended across the top of the penis; testes and scrotum are further enlarged; penis is larger especially in length

More abundant pubic hair with curling, genitalia resemble that of an adult, glans has become larger and broader

Quantity and pattern of pubic hair with hair present along the inner borders of the thighs. Testes and scrotum are adult in size.

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Pediatric Breast Examination

Breast Buds Newborn Gynecomastia Mastitis Neonatorum

Pediatric Breast Congenital Anomalies

Polythelia Polymastia Athelia Amastia Amasia


Polytheliao Nipples

Polymastiao Breast

Athelia Amastia Amasia

Supernummary tissue

Failure of mammary ridge to regress in utero


Polythelia Polymastia Athelia

Absence of nipple/areola complex Amastia Amasia

Pediatric Breast Congenital Anomalies Polythelia Polymastia Athelia Amastia

o Absence of breast and nipple

o Pectoralis Muscle Amasia


Polythelia Polymastia Athelia Amastia Amasia

o Absence of breast tissueo Usually iatrogenic

Adolescent Female Breast Abnormalities Masses

FibroadenomaCystosarcoma phylloidesAbscessCystTrauma

DischargeMammary Duct Ectasia

All ages/both genders

Adolescent Female Breast Masses

FibroadenomaFibroadenoma Characteristics

Benign Proliferating epithelium and supporting fibrous

tissue Smooth, mobile, round (usually 1-3 cm) May be affected by menses

Treatment Monitor for 1-3 months

Considerations Removal may lead to iatrogenic amasia

Adolescent Female Breast MassesCystosarcoma phylloides Charactoristics

Cellular stroma with nuclear atypia and mitotic figures

May:o Have thinning increased vascularity of overlaying skino acutely enlarge

Painless Treatment

Excise with wide margins Considerations

Requires histologic differentiationo up to 25% are malignant


Abscess Characteristics

Behaves as an infection-because it iso Usually Staph or Strep

TreatmentRequires I & D +/- Abx


Cyst Characteristics

Mobile, round, nontender Treatment

Watch for 2-3 months Aspiration

o Diagnostic o May be curative

Adolescent Female Breast MassesTrauma Characteristics

May not recall insighting incidentMay cause a palpable mass

o peripheral calcificationso fibrotic scar o echogenic internal bands on ultrasound,

mammogram or MRM Treatment

Watchful waiting unless infected hematoma

ConsiderationsFuture abnormal imaging studies

Adolescent Female Breast DischargeMammary Duct Ectasia Charactorisitcs

Nipple discharge &/or breast mass in subaereolar region

All ages/both genders Benign lesion Self-limiting Usually unilateral Periductal fibrosis and inflammation with nipple

discharge +/- bloody discharge Treatment

Surgical removal Considerations

Dx on US

Normal Adolescent Breast Development Breast asymmetry at thelarche A homogenous enlargement of one

breast No distinct mass or discharge May or may not be breast tenderness May need ultrasound to make certain

diagnosis Treated with assurance and follow up

•Kleinfelter’s•Testicular feminization•Hormone secreting tumor•Hyper or hypo thryroidism•Cirrhosis•Drug use (cimetidine or marijuana)•Familial predisposition•Obesity

Gynecomastia in boysNormal (70%) to floridly abnormal

Genetic Breast Disorders in Adolescence

BRCA1 and BRCA2 Li-Fraumani Syndrome Cowden Syndrome Ataxia-telangectasia Syndrome Colon Cancer Gene mutations HBOC-Hereditary Breast and Ovarian

Cancer

Adult Benign Breast Disease

Fibrocystic Changes Fibroadenoma Lipoma Fat Necrosis Intraductal Papilloma Mammary Duct Ectasia Galactocele


Fibrocystic Changes Characteristics

Fairly common Mastadynia Usually discrete masses Usually bilateral Increase in size and tenderness

just prior to menses +/- nipple discharge

Treatment controversial

Considerations Really is 32 different processes Nonproliferative changes Proliferative changes without

atypia Proliferative changes with atypia

May be a single cyst


Fibroadenoma Characteristics

Solid round rubbery Freely moving Painless

Treatment 10% disappear

spontaneously Considerations

Hyperplastic process in single duct

Usually 20-30 year olds


Lipoma Characteristics

Harmless fatty tumor Well defined Semi-firm Nontender

Treatment Surgical

Considerations Can occur anywhere on

the body


Fat Necrosis Characteristics

due to trauma, surgery or radiation

Firm fixed hardIrregular borders

TreatmentInfected hematoma

ConsiderationsConsider abuse


Intraductal Papilloma Characteristics

Wart-like growths in the lining of the mammary duct near the nipple

Typically not palpable +/- bloody discharge Usually 45-50 year old

Treatment Surgical removal


Mammary Duct Ectasia Characteristics

Dilation of the mammary ducts Periductal fibrosis and

inflammation Nipple retraction is common

Treatment Surgical removal

Considerations Any age group


Galactocele Warm Tender Associated with post

partum and/or breast feeding

Mastitis Infection

• Endemic• Epidemic

Chiari-Frommel Syndrome

Malignant Diseases of the Breast The average American woman has

a12% lifetime risk of developing cancer With a first degree relative the risk

increase 2-3 fold This increase to 9 fold if the disease was

bilateral in a premenopausal relative But only 5% of the breast cancers are

truly hereditary in nature

Risk Factors-Numerous

3 of 4 who get breast cancer do not have clearly identifiable risk factors

Possibly related to lifetime Estrogen exposure

Risks-vast and varied

Bone Mineral Density Weight gain in post menopausal

women ETOH OCPs (>10 years) EVIDENCE IS NOT STRONG TAKE HOME MESSAGE->STAY

TUNED

Epidemiology of Breast CancerWomen’s Health Initiative

Overall the breast cancer rates have increased 1.7% per year since 1990

Then in 1999 the rates began to decrease by 1% each year

Breast cancer incidence decreased in US women by 7-8% from 2002 to 2003.

The largest decrease was seen in ER positive breast cancers where they saw a decrease of 12% (ER negative decreased by 4%)

Hormone therapy dropped by 68% between 2001 and 2003

RR Factors related to increased risk

>4 Advanced age, No. Am or No. Europ. Descent, high perimenopausal IGF-1 and/or [E], h/o mother & sister with breast cancer

2-4 High SES, >30 yo at first FT preg., h/o cancer in 1 breast, 10 relative with Breast Cancer, h/o benign dysplastic lesion, mammo changes, or high dose ionizing radiation to the chest

1.1-1.9

Nulliparity, early menarche, late menopause, post menopausal obesity, high fat diet/sat fat-rich diet, suburban or no. US, white race >45 yo, black race, h/o endometrial or ovarian cancer

<1 Late menarche, BF > 1 year, monounsat fat-rich diet, phy. act, premenopausal obesity

One Theory of Breast CancerEarly Life Events

Mammary Gland Mass Seen in Caucasian with higher birth weights and

taller stature Growth enhancement

All growth enhancing factors are hormones and are involved in the underlying process that leads to breast cancer

Initiated cells Full term pregnancy after 35 yo has a slight transient

increase in risk (initiated clones are responding to the higher hormonal levels but there is protection later because of terminal differentiation of immature mammary cells)

Modified Gail Risk Factor Assessment Medical History of DCIS or LCIS Current age Age at menarche Age at first live birth Number of 10 relatives with breast

cancer Previous breast biopsy +/- atypia Race/ethnicity

Gail Risk Factor Assessment

Assess risk for five years and life time Under predicts:

Personal h/o lobular neoplasia over 60 multiple more distant relatives FH ovarian cancer or bilateral disease

Over predicts young women with first birth before 20 years of age

Does not take into account relatives unless first degree Does not look at other cancers such as ovarian Does not take into account age of diagnosis (pre vs. post menopause) or bilateral disease Does not take into account ethnicity ie. Ashkenazi Jews Doesn’t take into account bilateral disease or age of diagnosis therefore would underestimate BRCA

Paget’s Disease

Characteristics Long standing eczematous appearing rash of

nipple and areola complex Itching Tenderness Burning Occ. Bloody discharge Skin dimpling Peau d’orange

Treatment As eczema then biopsy

In Situ Cancer

LCIS From a terminal lobular apparatus Diffuse throughout the breast Non palpable 90-100% multicentricity 10-37% develop invasive carcinoma (bilateral)

DCIS Originates in ductal luminal cells Invasive cancer develops in 30-50% over a 10

years-usually in same location as original biopsy

Clinical Evaluation of Breast Diseases Joy Dorscher MD Department of Family Medicine and Community...

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