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BREAST CANCER UPDATE DETECTION TO DIAGNOSIS

BREAST CANCER UPDATE DETECTION TO DIAGNOSIS. Vincent M. Scarpinato, M.D., F.A.C.S. Senior Medical Director Department of Surgery Southern Ohio Medical Center October 2009. BREAST CANCER. Most commonly diagnosed cancer in women (excluding skin cancer)

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BREAST CANCER UPDATE DETECTION TO DIAGNOSIS

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  1. BREAST CANCER UPDATEDETECTION TO DIAGNOSIS Vincent M. Scarpinato, M.D., F.A.C.S. Senior Medical Director Department of Surgery Southern Ohio Medical Center October 2009

  2. BREAST CANCER • Most commonly diagnosed cancer in women (excluding skin cancer) • Second most common cause of cancer related deaths (second to lung cancer) • Early Detection = Improved Survival

  3. Breast Cancer Statistics • 1960: 1/20 • 2008: 1/8 (12%) Breastcancer.org

  4. Breast Cancer Statistics 2006 • 212,920 cases of Invasive Breast Cancer • 61,980 cases of Noninvasive (“In Situ”) Breast Cancer • 40,970 Deaths Breast Cancer Facts & Figures 2005-2006 (ACS)

  5. Breast Cancer Statistics 2009 • 192,370 cases of Invasive Breast Cancer (212,920 in 2006) • 62,280 cases of In Situ Breast Cancer(61,980 in 2006) • 40,170 Deaths (40,970 in 2006) Breast Cancer Facts & Figures 2008-2009 (ACS)

  6. Breast Cancer Deaths • Steady decrease in death-rate since 1990 • Earlier detection • Increased awareness • Improved screening/diagnostics • Improved treatment modalities

  7. Breast Cancer Therapy Evolution • Halsted: “If some is good, more is better”Radical Mastectomy • Fisher: “Less is more”Lumpectomy/Complete Axillary Node Dissection PlusWhole Breast Irradiation = Mastectomy • Today: “Less and less is more”Lumpectomy/Sentinel Lymph Node Biopsy Plus Partial Breast Irradiation (PBR) = Mastectomy

  8. DETECTION • SCREENING MAMMOGRAPHY • Baseline Study 35-40 • Earlier Family History (1st Degree) • Yearly after age 40 ACS/Am Col Surg

  9. DETECTION • “BI-RADS” Classification • Breast-Imaging Reporting and Data System (BI-RADS) • American College of Radiology (ACR) • Risk Assessment Categories (7)

  10. BI-RADS CLASSIFICATION

  11. BI-RADS CLASSIFICATION

  12. Breast Biopsy Options • “Open”/Surgical Biopsy • Incisional • Excisional • “Closed”/Percutaneous • Fine needle aspiration (FNA) • Core Biopsy/”Tru-cut” • Vacuum Assisted/Rotational Biopsy

  13. Palpable Breast Biopsy Options

  14. Non-PalpableBreast Biopsy Options • Image Guided: “Radiologically Assisted” • Ultrasound • Mammographic/Stereotactic • CT • MRI

  15. Fine Needle Aspiration “FNA”

  16. Ultrasound Guided FNA Cyst Aspiration “FNA”

  17. Core Biopsy Devices

  18. Ultrasound Guided Breast Biopsy Solid Lesions

  19. Ultrasound Guided Breast Biopsy Malignant Lesion

  20. Ultrasound Guided Breast Biopsy

  21. Ultrasound Guided Breast Biopsy Core Biopsy of Solid Lesion

  22. Mammographic/Stereotactic Bx Microcalcifications

  23. Mammographic/Stereotactic Bx Microcalcifications/Magnification View

  24. Mammographic/Stereotactic Bx

  25. Stereotactic BxSpecimen Xray

  26. Mammographic/Stereotactic BxClip Application/Postprocedure

  27. Post procedure Mammogram

  28. Mammographic Wire Localizing Breast Lumpectomy

  29. Mammographic Wire Localizing Breast Biopsy

  30. Mammographic Wire Localizing Breast Biopsy

  31. INTRAOPERATIVE ULTRASOUND Guided Wire Localizing Lumpectomy • For nonpalpable lesion • Seen sonographically • Intraoperative Wire Placement under Ultrasound guidance • Partial Mastectomy/ “Lumpectomy”

  32. CT GUIDED LOCALIZATION

  33. CT GUIDED LOCALIZATION

  34. CT GUIDED LOCALIZATION

  35. MRI Breast

  36. MRI GUIDED LOCALIZATION or BIOPSY

  37. PROS More sensitive than ultrasound More sensitive than mammogram More sensitive than physical exam Better in younger pts (dense tissue) CONS More Expensive (much more!) Claustrophobia False Positives Leads to many more biopsies Leads to more mastectomies J Am Col Surg Oct 2009 MRI of the Breast

  38. MRI of the Breast • May be helpful… • Assessing extent of disease • Additional foci • Axillary metastasis • Contralateral disease • Response to chemotx (neoadjuvant) • Residual disease postop • Breast augmentation

  39. MRI of the Breast?Screening • Lifetime Breast Cancer Risk (predictive models) 20 – 25%. • BRCA1 or BRCA2 mutations • Chest Wall Radiation ages 10-30 • Congenital Syndromes: Li-Fraumeni, Cowden, etc. ACS Guideleines for Breast Cancer Screening CA Cancer J Clin 2007;57:75-89

  40. USA 2009 • 1,000,000 BREAST BIOPSIES ANUALLY • 80% BENIGN • 35% OF MALIGNANCIES ARE (STILL) DIAGNOSED WITH OPEN BX • 30% “unnecessary” mastectomies The Breast Journal, Volume 15 Number 1, 2009 93–10041% receive “unnecessary” mastecto~41% receive “unnecessary” mastectomy

  41. Percutaneous Histology(vs Open/Surgical Biopsy) • Represents “Best Practice” and should be…. • “Gold Standard” over open biopsy • Should be <5-10% open biopsies Consensus Conference III Jo Am Co Surg Oct 2009

  42. Recommendations afterPercutaneous Needle Biopsy Benign/Concordant Benign/Discordant Observation (Routine Screening) Surgery High Risk Histology (ADH,Radial Scars, Papillary) Malignant Surgery Surgery

  43. Clinical Quality Dashboards(Detection to Diagnosis) • Time from reporting abnormal screening to diagnostic mammogram (average: 20 days) • Time from reporting diagnostic mammogram to biopsy (average: 20 days) • Time from reporting of biopsy results to surgery (8.1-16.9 days) Oncology Roundtable

  44. THANK YOU

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