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Evaluation Diagnostic steps Decision to Bx Types of bx Pros/cons Bx Tech. F/U common problems Benign Lesions pathophysiology presentations Malignant Lesions W/U and Dx Therapeutic alternatives common pit-falls primary vs. adjuvant Rx pathology prognostication

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surgery breast diseases
Evaluation

Diagnostic steps

Decision to Bx

Types of bx

Pros/cons Bx Tech.

F/U common problems

Benign Lesions

pathophysiology

presentations

Malignant Lesions

W/U and Dx

Therapeutic alternatives

common pit-falls

primary vs. adjuvant Rx

pathology

prognostication

F/U and therapeutic efficacy

Surgery - Breast Diseases
evaluation
Evaluation
  • No hard and fast rules on screening mammo
    • all symptomatic women >30yo
    • within 10 yrs of first degree relative family hx
    • all fatty infiltrated breasts annually >40
  • Other radiographic screening limited to
    • US in palpable abnormalities not clinically distinct in young women
    • W/U palp or mammo soft finding; especially in those with established risk factors
self breast exam
Self Breast Exam

Women are empowered to pay attention to breast health issues by BSE

“Just another way for male physicians to blame women for not finding cancer soon enough.”

No study shows decrease of size at dx greater than 2.5 cm down to 1.8 cm-

need to get size <1.0 cm for survival benefit

evaluation5
Evaluation
  • Clinical history
    • delineate pts risk early - use Gail Model
      • http://bcra.nci.nih.gov/brc/start.htm
      • Menarche, preg hx, breast feeding hx, family hx, hormone use
      • lesion characteristics
        • menstrual changes, dietary influences, wt loss or gain
      • prior breast disease hx
        • pt and relatives - pay close attention to proliferative
    • 69% successful malpractice is in + fam hx
    • 80% pt found lump - Remember Osler!!
evaluation6
Evaluation
  • PE
    • Pennypacker technique of palpation
      • three fingers; vertical strips
      • include axillae and lower 1/2 neck
    • Observation of skin
      • sheer curtain -fluid motion
    • Ck for nipple D/C
      • hemoccult if present; single vs. mult duct
          • Wait any fluid (esp. spontaneous) increases risk
    • mobility
clinical breast exam
Clinical Breast Exam
  • Why do it?
    • Purpose and goals
      • Breast Cancer is a common problem
      • Screening of pre-menopausal women poor and death rate high
      • Post-menopausal still 15% felt before seen on mammo
      • 60% diagnosed breast cancers felt before ever sent for imaging
      • we need to reduce size at dx to increase survival
clinical breast exam8
Clinical Breast Exam
  • How to do it?
    • The mechanics
      • we are feeling to detect cancer - both sensitive and specific
      • dependant on scirrhous nature of most breast cancers
      • optimize conditions to detect differences in density
      • use subtle signs that imply differences in scar activity in the breast
clinical breast exam10
Clinical Breast Exam

Thin out the breast tissue to less than 1” thick

Close attention to mammographic miss locales - UIQ and LOQ

Move the breast and look for differences in texture or mobility of skin relative to gland

Oops decreasing evidence it works to reduce death rates

In the skin, look for peau d’orange

look for nipple excoriation/ Paget’s

lymphatic engorgement or

Cooper’s ligament shortening

evaluation11
Evaluation
  • Every abnormality charted and scaled
    • O’clock and distance to nipple
  • any unclear area submit to alternative exam
  • any suspicious on 1 exam or unclear on 2 different exams (modality or temporal) needs diagnostic evaluation - i.e.. Bx if cannot find a good reason not to.
  • level of suspicion based on fam hx. and other cumulative risk factors
diagnostic evaluation
Diagnostic evaluation
  • when unclear - Bx.
  • never follow more than 12 weeks without a clear commitment
  • Bx method depends on :
    • way in which lesion most crisply seen
    • tolerable sampling bias based on clinical situation
new technologies
New Technologies

Digital Mammo

Ultrasound improvements

MRI

Nuclear medicine

Emerging technologies

digital mammography
Technology

Pixel size not yet equivalent to silver grain size

GE diagnostic unit cautiously approved for screening

Will allow very accurate SCBx

May allow new pattern recognition to standardize reading (CAD)

However post-menopause only 1/2 of unrecognized Ca B/O inaccurate reading; premenopausal Ca not detected 40% of time by mammo alone

Post menopausal

Film=Digital

Film found mor3e solid masses

Digital better with cals

Fewer call backs with digital

Pre-menopausal

Digital is better

NEJM 2005

49528 pts both D+F

0.5% + D &F

Inv CA

25% D&F

10.4% F

11.3%D

21.8% never seen

DCIS

10.7% D&F

5.1% F

7.5% D

7.5% not seen

Digital Mammography
ultrasound mri
Costly technology

New coils allow SCB or localization

True sensitivity and specificity ?

BRCA 1 (&2) have higher incidence of breast cancers not seen on mammo and MRI saves lives here.

Can find 25-28% caners have MF disease – no effect on survival or eventual therapy

Most insurers skeptical

Very good in W/U of cystic lesions

Ability to differentiate solid lesions improving

Left, however, with high false + and false - rates for solid lesions

Ultrasound MRI
nuclear medicine
Nuclear Medicine
  • New isotopes hold promise such as FDG, sestamibi, and C-11 thymidine
  • Imaging with resolution is problematic
    • must detect routinely @ < 10mm
  • More costly than MRI
  • New Contact and PET detectors increasing accuracy dramatically and ? Cheaper than MRI at finding MF disease
experimental emerging techniques
Experimental/ Emerging Techniques
  • Genetic Screening- may assess risk but not direct diagnostic efforts in individuals
  • Electrical Biophysical - uses properties of ionic concentration unique in normal epithelial surfaces
  • Ductal Based Screening and Treatment - ductal lavage and ROBE or breast endoscopy – still limited by pathology accuracy and recent data shows random PAFNA superior at identifying epithelial proliferative disease in chemoprevention (celebrex trial)
    • New scope and hypermethylation mapping
    • Lavage of non-fluid producing ducts in PAFNA +
common problems
Common Problems
  • Mastodynia/Mastalgia
    • cyclical
      • interfere with effects of hormones on breasts or changes menstrual hormonal pattern
    • non-cyclical
      • look for breast “mapped” causes, rx fluid retention
      • rx with non-steroidals
    • R/O non breast causes
      • Tietze’s syndrome, Poland’s syndrome, etc.
    • UCLA Study – (The Breast Journal 2005)
      • 86 pts eval with mammo and US for breast pain
      • 100% negative predictive value
common problems20
Common Problems
  • Fibrocystic disease
    • 40% of all women in 30-50 range carry dx
    • cyclical lumpiness &/or tenderness
    • mega-cystic variant - chronic premenstrual rapidly filling cysts
    • fibrosis variant - multiple FA or pseudo-tumors
    • Beware when ca risks higher and FCD
      • very careful to do detailed screening
common problems21
Common Problems
  • Fibroadenoma family
    • FA
      • low risk except if ductal proliferative changes in young
      • juvenile variant in Orientals & Blacks
      • 10-15% recurrence risk with excision
      • Lactating adenoma issues
    • Benign Phylloides tumors
      • more aggressive in local failure only
common problems22
Common Problems
  • Cystosarcoma phylloides
    • unclear benign/malignant border
    • best considered a special variant of fibrosarcoma
    • risk for local recurrence best predicted by mitotic activity or ? Ki67
      • >10 mitoses/30 HPF =Very malignant behavior
      • like sarcoma spread is to next capillary filter station
    • Rx
      • lumpectomy only for lowest mitotic rates
      • wide excision(TM) for all others & indeterminants
common problems23
Common Problems
  • Nipple D/C
    • single duct, heme+ - 7-9% ca chance
      • Bx - gold standard microductectomy
        • galactogram pre or intra-op
        • nipple to 1 cm beyond obstruction
        • recent data suggests that routine use of breast endoscopy or galactography will double the cancer detection rate in these patients
    • single duct , heme-
      • Bx only if persistent - papilloma likely
    • Multiple duct, heme+
      • culture and rx antibiotics x1-3 mos; bx if not response
    • Multiple duct, heme-
      • w/u prolactin axis
common problems24
Common Problems
  • Infections
    • difficult to cure with antibiotics
    • acne type flora, prolonged rx stills gives failures
      • lactating - nurse or pump through Ab Rx
      • non-lactating - look for ductal blocking lesions
        • both pre and post Rx
      • Post-conservation red breast syndrome
        • radiation mastitis vs. anaerobic step infection
common problems25
Common Problems
  • Abcess
    • any infection that fails to respond clinically in 3 days
      • w/u with US, aspirate or drain all collections
    • Clinical abscesses
      • I&D – or Aspirate, irrigate, antibiotics
      • W/U for ductal lesions within 1 mo of successful Rx
    • Peri-ductal mastitis
      • recurrent infection in large lactiferous ducts
      • may require excision to control
common problems26
Common Problems
  • The funny nipple
    • odd crusting, asymmetric reddening, red area erupting from one of the major duct orifices
      • consider Paget’s until two consecutive negative bx taken of nipple-areolar complex
    • Inversion
      • only important if new and not associated with recent hormone administration
    • Montgomery gland problems
      • common inclusion cysts, hidradenitis like fungal infections
breast masses
Breast Masses
  • OU 4 yr study of 414 pts presenting as breast mass primary c/o – min 6 mo f/u
  • No effect of family hx or risk factors on future ca dx
  • Probability of ca dx
    • 11.3% if pt found
    • 6.9% if physician found
    • 1.9% nurse/phy extender
biopsy decisions
How to find it?

palpation - gold std.

mammo

US

Miralumma

MRI

Thermography

the latest hottest research tool

How big a piece do I need?

surgical excision - gold

surgical incisional

needle incisional

Mammotome, MIBB

ABBI

Cassi - cryocore

Needle core

14G, 16G, 18G

FNA

Biopsy decisions
biopsy decisions30
Biopsy decisions
  • commit yourself to a narrow list of acceptable diagnoses before bx
  • if pre-op dx important, use best single or combo of non-surgical methods first
  • if dx is irrelevant to excision plans, use surgical excision first
  • if Dx not on acceptable list, re-assess your choices - fall back on remaining best list to minimize sampling error
  • Don’t Forget surgical Bx
gynecomastia
Gynecomastia
  • common in young and old
  • risk factors
    • liver disease or decreased steroid clearance
    • Dopamine blockers - Haldol
    • Dopamine del. agents-reserpine & L dopa
    • H2 blockers
    • AIDS drugs
  • unilateral vs bilateral
  • Rx - symptomatic or discreet asymmetry in gland
breast cancer
Breast Cancer
  • 200-230K per year; stable invasive incidence – Oops increasing to 485K/yr 2017
  • 40K deaths per year; 11K preventable with annual >50 screening
  • another 45K DCIS/yr
  • probably 120K - LCIS, ALH, ADH, or other significant proliferative risk lesions
  • probably accounts for >30% of all Ca survivors
breast cancer types of invasive
Ductal-70 %

classic scirrhus

mammo/sono size within 20% of path size

prognosis very grade sensitive

Lobular - 10-12%

may be considerably larger than clinically or radiographically suspected

Minor forms

tubular

very well diff. ductal

medullary

angry histopathologically but benign course if small N0

“bloody cyst” and Rad Rx

adenoid cystic

colloid/mucinous

tumor mass tiny relative to mucus

Breast CancerTypes of invasive
breast cancer34
Other minor forms

all sweat gland derivative types except cystosarcoma family

all treated the same

subtype may only effect interpretation of future systemic or contra-lateral risk

Inflammatory

looks like infection

paucity of systemic symptoms; min Left shift on WBC

High sed rate

underlying breast mass

Bx skin, nipple, cores

may need immunohistochem to correctly differentiate tumor from lymphocytes

Breast Cancer
breast cancer35
Presentations

Lumps

ductal if hard

soft - lobular,colloid,tubular, medullary, DCIS

Firm patches

ductal in tissue

lobular

Stellate mammo

ductal or old lobular

Calcifications

ductal/ DCIS

older with necrosis

Nipple D/C

bloody

single duct

Pagets disease

subareolar DCIS or invasive with centripetal ductal spread

Inflammatory

Breast Cancer
current state of the art in breast cancer screening and rx
1930-1996 no change in age adjusted death rate in US from Breast Cancer

1997-2000 an 18% decrease in death rate accounted for >95% by earlier stage at diagnosis

Rx successes in clinical trials not appreciated as well in nation-wide reviews

Best Rx results seen with rigid evidence based

The Mammo glass ceiling of 1/3 in situ to 2/3 invasive

Still in best situations mammo leaves 2/3 of patients at risk for cancer death

Mammo findings late

calcifications usually represent obstructed ducts with a 600% increase in cross-sectional area

densities depend on immunologic reaction of host to invasion with a scirrhous reaction

Current State of the Art in Breast Cancer Screening and Rx
breast cancer prevention
Breast Cancer Prevention
  • Increased menses = increased breast cancer risk
  • Breast feeding is very important to breast health
    • decreases pre-menopausal breast cancer frequency without affecting lifetime risk
  • Low fat diet, EtOH, and hormone risks??
  • NSABP P-01 SERM as “THE prevention agent”
    • Tamoxifen - proven
    • Evista (raloxifen) - suspected but checkered oncologic history - poor head-to-head against Tam for therapy
    • Peripheral Aromatase Inhibitors - promising data from ATAC trial
slide42
LCIS

Level of evidence - B for excision; A for tam/C for high risk f/u

adh alh
ADH/ALH

Level of evidence - B for excision; B for tam/C for high risk f/u

slide44
DCIS

Level of evidence - A for L+R and TM; B for L alone/C for high risk f/u

clinical stage 1 or 2a
Clinical Stage 1 or 2A

All Patients with tumors >10mm and tumors 5-10mm high grade or pathologic + nodes referred for systemic rx options (I.e. hormonal or chemotherapy)

Level of evidence - A for L+R and MRM; B for MRM + recon; C for no radiation in limited life expectancy; A for adjuvant systemic treatment

slide46

Pathologic Stage 1 or 2A

All Patients referred for BHI f/u as high risk and no routine lab tests; symptomatic screening only for metastasis by ASCO guidelines

All Patients with clinical indications for radiation ( LumpAx) and pathologic indications (+ or close margins; apical nodes +, etc.) referred post chemo. Benefit of Herceptin in node + cases her-2 +. Molecular testing may direct future chemo choices – NSABP retrospective .

Level of evidence - A for adjuvant systemic treatment and radiation treatment; B for F/U

slide47

Clinical Stage 2B or 3A

All Patients referred for systemic rx options (I.e. hormonal or chemotherapy)

Level of evidence - A for L+R and MRM; B for MRM + recon; A for adjuvant systemic treatment; A for radiation post mastectomy for indications listed

slide48

Pathologic Stage 2B or 3A

All Patients referred for BHI f/u as high risk and no routine lab tests; symptomatic screening only for metastasis by ASCO guidelines

All Patients with clinical indications for radiation ( LumpAx) and pathologic indications (+ or close margins; apical nodes +, etc.) referred post chemo.

Level of evidence - A for adjuvant systemic treatment; A for radiation indications listed ; B for f/u recommendations

slide49

Clinical and Pathologic Stage 3B

All Patients referred for systemic rx options (I.e. hormonal or chemotherapy)

Level of evidence - A for MRM, Chemo, and Radiation

slide50

Clinical and Pathologic Stage 4

Level of evidence - D for MRM, Chemo, and Radiation

high risk f u
High Risk F/U

Level of evidence: A for mammo/CBE, C for risk counselling, A for chemoprevention consideration, A-C for additional tests

summary
Summary
  • Benign breast disease is common and its largest impact is confounding Ca dx
  • To make a REAL Difference for patients- we must detect Ca @ <1.0 cm routinely
  • Current Screening of young women poor
  • Genetic screening will assist in risk eval.
  • The Gail model and SERMs to change this disease enormously in the next decade
  • We Need Radically Different Approaches
    • functional screening, new bx techniques, etc.
breast cancer53

BREAST CANCER

“... THE REAL HOPE FOR IMPROVEMENT DOES NOT REST ON AN EXTENSION OF OPERATIVE PROCEDURES, BUT AN EARLY RECOGNITION AND EARLIER EXTIRPATION OF THE FOCUS OF INVASION...”

W.S. HALSTED, 12/1894