Workup of breast problems

Eliza Pile-Spellman M.D.

212 305-0519

• When is a mammogram appropriate?• When is an ultrasound appropriate?• What is the difference between a targeted and a

screening ultrasound?• When is an MRI appropriate?• What is the standard screening tool for breast

cancer?• At what age should screening start?• What significance does pain have in reference to

breast cancer symptoms?

Breast Cancer

• Most common cancer in women (except skin cancer)

• 2nd leading cause of cancer death in women (lung cancer 1st)

• In 2007, 211,990 women in U.S. were dx with invasive breast cancer

• 40,110 will die from the disease• There are slightly more than 2 million

women in the US living with breast cancer

Estimated Breast cancer 2009

• Female

• 192,370 new cases• 40,179 deaths

• male

• 1910 new cases• 440 deaths

• Incidence of breast cancer increasing 1% per yr since the 1940’s

• Mortality rate has been decreasing probably due to early detection and better Tx

Impact of mammography

• 40% of cancers are detected by mammography alone

• 10 % are detected by palpation alone

• Survival is related to node status • Node status correlates with tumor size• Of Cancers < 1 cm – 15% are node pos• Of cancers > 1 cm - 30 % are node pos• Mammography detects smaller tumors• (average size palp tumors is 2 cm) • (average size mammo detected tumors

1cm)

Stage

DCIS or <5 mm

5 yr Survival %

98

10 yr survival %

95

Node neg 85 75

Node pos

Mets

55

10

2

Risk Factors

• Gender (75% of women who devel breast cancer have no other risk factor)

• Aging- risk increases with age (18% dx in women in their 40s , 77% of women > 50 when dx)

• 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)

Risk factors

• Family history: male relatives with breast cancer count

• Family history of ovarian /breast (2 or more relatives

• Ashkenazi jewish heritage

• Family hx of Cowdens or LI-Fraumeni syndromes

Risk factors

• Personal history breast cancer(3-4 fold increase in devel 2 nd cancer)

• Hx radiation to breast• Previous bx showing atypia• Early menarche, late menopause• DES therapy – slight increased risk• No children or 1st child after 30• Oral contraceptive use –slight increase

Risk factors

• 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)

• Hormone replacement tx

• Alcohol –increased risk

• Obesity –increased

• Physical activity decreases risk

? Risk factors

• Environmental

• antiperspirants

No assoc increased risk

• Underwire bras

• Smoking

• Induced abortion

• Breast implants

• Night work

Protective effect

• 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)

• Finding by questionaire• Aspirin reduces Aromatase production which

suppresses estrogen production• Acetominophen and ibuprophen had no effect• American Medical Association (Vol. 291, No. 20:• 2433-2489)

Workup of breast problems

• Asymptomatic vs symptomatic

Screening

• How often should women be screened

• What to do in high risk patients

• Patients with a hx of breast cancer

Asymptomatic women (screening)

• American cancer society guidelines:

• Yearly mammography starting at age 40 for as long as the woman is in good health

< 40 and no family history

• Screening not recommended

< 40 and mother or sister with premenopausal breast cancer

• Begin screening with mammography and ? Ultrasound/MRI 5 -10 years prior to dx of relative

• In 2003 only 70 % of women in the U.S. reported having had a mammogram in the last 2 years.

Reasons for noncompliance

• Fear of pain

• fear of cancer

• fear of radiation

• primary care provider does not recommend

Screening Mammograms

• Asymptomatic women• lower cost• recall pts if abnormal• recall rate 10%• recall rate lower if old films• 4 standard views• letter to pt in lay language• ? Last reported physical breast exam

Management of abnl mammo

• Recall 10%

• addl views and or us

• 10% of recalls bx rec

• 20-30% of pts rec for bx will have a cancer

• Screen 1000 women

• recall 100

• of these 10 will be rec for bx

• of these 2-3 will be positive for carcinoma

double reading• Increased cancer detection rate 7%

(MGH)

• No significant increase in recall rate.

• Screening costs decreased if batch read

• CAD

mammography report• Breast density

• Birads system –standardized reporting system

• Impression

• Recommendation

• Letter directly to patient reporting findings

Breast density

Birads classification

• 0 incomplete• 1 negative• 2 benign• 3 probably benign (<2% chance

malignancy)• 4 suspicious (? too broad a category)• 5 highly suspicious• 6 known cancer

mammography report• Breast density

• Birads system –standardized reporting system (breast imaging reporting and data system)

• Impression

• Recommendation

• Letter directly to patient reporting findings

Birads Classification

• Must be included in report

• must appear on billing form

• must track suspicious and highly susp lesions(4 & 5)

• attempt to standardize reports

• universal language

Grade 2

• Calcifications– coarse (fat necrosis,

fibroadenoma)– skin calc -rings– vascular

• masses– calcified fibroadenomas– fat containing

lesions:lipoma, oil cyst– hamartoma

Grade 3

• Probably benign finding

• <2% chance of cancer

• after thorough workup

• recommend 6 month followup

• some of these may be bx because of pt anxiety

Management of grade 4 and 5

• NONPALPABLE LESIONS

• Core bx

• FNA

• excisional bx

Core bx indications

• Indeterminate calc to prove benign

• 2nd lesion in pt with cancer (ques need for mastectomy if 2 remote sites )

• sample 2 ends of large area (too large for lumpectomy)

• malignant mass

• malignant calc

Symptomatic

• Palpable mass

• Nipple discharge

• Breast pain diffuse or focal

• Suspected abscess

• Nipple retraction

• Unilateral Axillary adenopathy

Diagnostic Mammogram• Symptomatic women

– lump– pain– discharge– palpable axillary node– personal hx of breast cancer (within 5 yrs)– monitored by radiologist at inc cost

• Recall from screening• tailored exam

Requisitionname and phone #

• Palpable mass• Nodularity• Pain• Thickening• Lumps both breasts

• Palpable mass right breast 10 00 near areolar margin

• Pain right upper outer quadrant

• Bloody nipple discharge rt breast

• Draw a picture

Screening ultrasound

• At this time, screening ultrasound is not recommended

• Ongoing ACR trial – multiinstitutional involving women at high risk for breast cancer (mostly patients with personal history of breast cancer)

ACRIN 6666 ultrasound trial

• 2007 – preliminary results

• Use of us would increase detection yield by 4.2 per 1000 women screened, regardless of breast density

• Downside –increase in number of biopsies performed

Comparison screening

• Mammography• 2.6% referred for bx• 29% positive

• Ultrasound• 7.7% referred fo bx• 15% positive

Screening MRI

• ACS guidelines- in addition to mammography

• BRCA1 or BRCA2

• Lifetime risk of breast cancer 20% or higher

• Hx of exposure to chest radiation between ages 10-30

• Does not include intermediate risk patients

Breast MRI Indications

• Pt with known cancer for extent of disease

• Workup of problem patient – palpable mass with normal mammogram and ultrasound

• R/o rupture in a patient with implants

MRI

• Expensive

• Requires injection

• Insurance companies will pay on limited basis

• Very sensitive but not specific

• Many false positive

Palpable masses

• 9 yo with palpable mass in the 12:00 location of the right breast

Right breast palp area (subareolar

Rt breast palp

Left breast comparison

Breast development

• Begins during adolescence

• surge of estrogen responsible for devel of ducts

• progesterone necessary for devel of lobules

• Palpable breast masses are uncommon is children

• most masses have a benign etiology

• surgery can arrest breast development

Causes of palp masses in children

• Breast bud• cyst• fibroadenoma• phylloides• lymph node• galactocoele• duct ectasia• abscess• gynecomastia

• Primary breast cancer rare(<.2% cancers in pts <20)

• metastatic disease– late finding– rhabdomyosarcoma– leukemia– lymphoma

• Fibroadenomas are most common solid mass in children and adolescents

19 yo with palp mass

• workup

palp

30 yr old with palpable mass

41 yo palp mass

• 4776708

38 yo palp mass

• Work up

palpable mass

PALP SEBACEOUS CYST

Palpable mass Age < 30 years

• Start with targeted ultrasound

• If ultrasound is negative, report should indicate further workup should be based on clinical grounds

• If mass is cancer after workup, do mammogram- screen other breast

Palp mass Age 30 or >

• Mammogram with skin marker placed over palp, and spot tangential view

• Targeted ultrasound with core bx as necessary

PALP MASS

<30 yrs 30 or>

Mammogram + USUS

Cyst stopSolid –core bx

nipple discharge

• Workup

• What type of discharge is important?

• How often assoc with breast cancer?

Nipple Discharge

• Important only when spontaneous• can be clear, or bloody• only 10% due to cancer• elicited discharge (squeezing the nipple) not

important• copious production of breast secretions by

manipulating the nipple is common in parous premenopausal women and smokers

Nipple Discharge

• Multiple duct discharge is often bilateral and virtually never due to an underlying cancer

• usually caused by duct ectasia

• unless copious -leave alone and reassure patient.

Galactorrhoea- if not pregnant or postpartem, prolactin-secreting pituitary tumor

Dark green discharge from multiple ducts

Solitary Papilloma

• All ages

• 70% present with a serous or bloody nipple discharge

• occurs in the major collecting ducts in the subareolar area

• may be palpable and fill a duct

Solitary Papilloma

• Most common cause of spontaneous nipple discharge

• hemorrhagic infarction is often present and is thought to be the cause of bloody nipple discharge

• galactogram or blind terminal duct excision?

65 yr old with bloody nipple discharge

35 yo pre renal transpant

w/u bloody nipple discharge

• >30

• Mammogram• Ultrasound• Ductogram• ? MRI

22 yr old with diffuse breast pain for 3 weeks

• Patient 2

• 25 y o woman with focal breast pain in the right breast 5:00 with no family history of breast cancer.

• Patient 3

• 29 y o woman with a lump in her left breast in the 2:00 position for 3 weeks.

• Patient 4

• 32 y o woman with a lump in her right breast at 12:00.

• Patient 5

• 50 y o woman with a strong family history of breast cancer and normal mammogram who requests an MRI for screening.

• Patient 6

• 45 y o with a mass in her right breast at 4:00.

Multifocal disease not evident on mammogram or ultrasound

Same breast with multicentric disease not evident on mammogram or ultrasound