Diagnostic Studies Diagnostic MGM Breast US – cystic or solid ; does not show microcalcifications!!! Breast MRI - younger pts with very dense breasts Percutaneous Bx FNAB - cytology Needle core bx Image guided vs non image guided Open bx – take to the OR

Diagnostic MGM Done when signs or symptoms are present Review of previous images when available Often includes specialized views such as spot compression and magnification

Breast US Not used for screening Distinguishes a solid from cystic lesion Adjunct to MGM Used for guiding percutaneous bx of solid nodules palpable and nonpalpable Not useful for bx of microcalcifications

Breast MRI Very limited use—no role for routine screening High risk young women with very dense breasts with nondiagnostic MGM Post neoadjuvant chemotherapy to assess for BCT Pts with silicon breast implant Must be done in a dedicated center with experience in interpreting breast MRI and capable of MRI directed bx

FNAB Image guided—US or stereotactic but not absolutely necessary Simple, low morbidity and expeditious- - can have the result at time of visit if a cytopathologist is available Sensitivity 65-98% False positives rare, about, 0.2% Requires a skilled cytopathologist Gives cytology and NOT histology- -cannot distinguish invasive from noninvasive ca Unless it is clearly benign, suspicious, or shows cancer cells, it is nondiagnostic; Repeat FNA or use alternative bx technique High n/c ratio; very rude pile on top of each other, pleomorphism\

Needle Core Bx Image guided—stereotactic or US but not necessary for an easily palpable mass Gives histology, thus, can distinguish in situ from invasive cancer Requires at least 24hrs to have the result

Stereotactic Bx Smaller scar than open bx and minimal anesthesia Accuracy=99%, similar to wire localized excisional bx; however, if malignant, wire localized excision will be required Discordant results require further evaluation MGM follow up of benign bx at 6 months Contraindicated if pt cannot lie prone, lesion too faint or superficial for digital imaging

US Guided BX More comfortable and quicker than stereotactic bx Not useful for lesions not seen on US such as microcalcifications Discordant results require further evaluation US and MGM follow up benign bx at 6 months

Excisional Open Bx The highest accuracy for DX but more invasive than percutaneous bx Combined with wire localization for nonpalpable lesions Specimen imaging mandatory for wire localized excision

Wire localized Specimen MGM

Specific Benign Entities Fibrocystic condition – very common Mastodynia Simple cyst Complex cyst Fibroadenoma Gynecomastia Nipple Discharge Breast Abscess

Fibrocystic Condition (Changes) Clinical manifestations of breast tissue response to cyclical hormonal changes Often associated with mastodynia or mastalgia

Question 9 A 42-year-old woman with a history of "fibrocystic condition" undergoes excision of microcalcifications in her breast which were detected on mammography. The histologic finding associated with the highest risk of developing subsequent breast cancer is: A. duct ectasia B. squamous metaplasia C. sclerosing adenosis D. florid hyperplasia E. atypical ductal hyperplasia

Pathological Changes Sometimes Associated with Fibrocystic changes Non-proliferative changes (RR=1.0) -cysts, mild hyperplasia of the usual type Proliferative lesions without atypia (RR=1.5-2.0)-moderate or florid hyperplasia, intraductal papilloma, sclerosing adenosis Atypical hyperplasia(RR=4.0-5.0) -ADH, ALH

Question 10 Which of the following treatments has been shown to provide relief of symptoms in more than 50% of patients with cyclical breast pain? A. Evening primrose oil B. Vitamin E C. Ginger supplements D. Elimination of caffeine E. Weight loss

BLOODY NIPPLE DISCHARGE

Question 11 A 23 y.o lady presents with fever and breast abscess; she has NKDA. The BEST treatment is: A. Empiric cephalexin B. Empiric trimethoprim/sulfamethoxazole (TMX) C. Incision and drainage alone D. Incision and drainage, C & S, empiric cephalexin E. Incision and drainage, C & S, empiric TMX

Question 12 The following statements are true regarding ductal carcinoma in situ EXCEPT : A. Precursor of invasive ductal cancer B. Usually presents as microcalcifications on MGM C. Never presents as palpable mass D. Incidence is rising probably due to increasing use of MGM E. Dx’d by stereotactic core or wire localized bx

Noninvasive Breast Cancer-Ductal Carcinoma in Situ (DCIS) Precursor of invasive ductal cancer Age of occurrence same as for invasive cancer Usually presents as microcalcifications on MGM Rarely presents as palpable mass Incidence is rising probably due to increasing use of MGM Dx’d by stereotactic core or wire localized bx

Question 13 A 39-year-old woman has a 1x1x1-cm focus of microcalcifications in the lower outer quadrant of her left breast. No mass is palpable. Stereotactic core biopsy shows ductal carcinoma in situ, non-comedo type. The next step in management should be: A. total mastectomy B. a mirror image biopsy of the right breast C. axillary sentinel node dissection D. radiation therapy to the left breast E. wide excision of the microcalcifications with assessment of the margins

Treatment of DCIS BCT consisting of breast conserving surgery (margin free excision) if pt has unicentric disease and RT or total mastectomy if BCT is contraindicated Axillary staging not needed Recurrences after BCT can be invasive ca or noninvasive Tamoxifen if pt is hormone receptor positive.

Question 14 Which of the following is least likely to be diagnosed by mammography? A.Comedocarcinoma B. Lobular carcinoma in situ C. Radial scar D. Phyllodes tumor E. Ductal carcinoma in situ

Lobular Carcinoma In Situ- -LCIS Marker of pts at increased risk of having invasive breast cancer >80% occur in premenopausal women Not apparent on CBE or MGM Incidental microscopic finding Relative risk 6-12 for developing invasive breast cancer in either breast 1% per yr risk of developing invasive ca Family hx may further increase the risk

Question 15 Which of the following statements about LCIS is NOT true? A.Tamoxifen decreases the risk of invasive cancer B. Pts. have an increased risk of bilateral breast cancer C. Calcifications or a palpable mass are usually absent D. Resection with negative margins is required E. It is most common in premenopausal women

Management of LCIS Close observation (CBE Q 6 months, annual MGM, monthly BSE) Tamoxifen Bilateral, prophylactic mastectomy with or without reconstruction in select pts

Question 16 The most common histologic type of invasive breast cancer is which of the following? A. Lobular carcinoma. B. Papillary carcinoma. C. Colloid carcinoma. D. Medullary carcinoma. E. Ductal adenocarcinoma

Invasive Breast Cancer (IBC) Invasive ductal (70-75%) Invasive lobular (5-10%) Special types: medullary, tubular, mucinous or colloid, papillary (less biologically aggressive)

Question 17 In a 60-year-old woman, US guided core biopsy of a 1-cm in diameter breast mass shows infiltrating ductal carcinoma. At the minimum, therapy should include: A. excision of the mass with negative margins only B. total mastectomy C. partial mastectomy, sentinel lymph node biopsy, and radiation therapy to the breast D. chemotherapy with cyclophosphamide and doxorubicin E. radiation therapy to the breast only

Neoadjuvant, Induction or Primary Chemotherapy- -Indications Locoregionally advanced breast cancer as part of multimodality therapy, then MRM followed by RT; enhanced survival To downsize a tumor for BCT, particularly for tumors large relative to the breast- - no survival advantage

Question 18 A 45 yo woman had multicentric breast cancer the largest focus 1.3 cm infiltrating ductal cancer, ER+, PR-, HER/2 neu neg; 1/3 SLN was +; the next BEST operative option is: A.Total mastectomy B. Modified radical mastectomy C. Radical mastectomy D. Simple mastectomy

Treatment of Invasive Breast Cancer (IBC) Dependent on TNM stage, hormone receptor status, menopausal state, overexpression HER2/neu receptor Locoregional and Systemic

AJCC Staging (Early Stage, 2010; 7th edition) Stage 0 TisN0M0 Stage IA T1N0M0 Stage IB T0-T1 N1miM0 Stage IIA T0-1N1M0, T2N0M0 Stage IIB T2N1M0, T3N0M0

AJCC Staging (Advanced) Stage IIIA T0-3N2M0, T3N1M0 Stage IIIB T4 N 0-2M0 Stage IIIC Any T N3M0 Stage IV Any T Any N M1

Locoregional Therapy Locoregional: Surgery + Radiation Therapy (RT) Breast Conserving Therapy (BCT) = Breast Conserving Surgery (BCS) + RT Total mastectomy (if BCT is contraindicated)+reconstruction Axillary staging- sentinel lymph node bx and/or level 1 and 2 ALND

Contraindications to BCT Multicentric cancers Diffuse malignant appearing microcalcifications Previous breast irradiation Pregnancy (unless radiation is provided after delivery) Collagen vascular disease (relative contraindication)

Mastectomy for Primary Operable Breast Cancer Patient preference for mastectomy Multicentric tumor Difficulty with follow-up anticipated Inability to achieve negative margin with BCS Contraindication to radiation therapy

Indications for Postmastectomy Radiation Tumor > 5cm T4 > 4 +LNs

Sentinel Lymph Node

Systemic Therapy Chemotherapy- -CMF; AC; AC + Taxol Hormonal– Tamoxifen(anti-estrogen); Arimidex (aromatase inhibitor); Femara (AI) Immunologic—Trastuzumab (Herceptin)— monoclonal Ab vs HER2/NEU receptors; Bevacizumab (Avastin)-humanized monoclonal Ab vs VEGF

Neoadjuvant, Induction or Primary Chemotherapy- -Indications Locoregionally advanced breast cancer as part of multimodality therapy, then MRM followed by RT; enhanced survival To downsize a tumor for BCT, particularly for tumors large relative to the breast- - no survival advantage

Question 19 A 55 yo woman had left partial mastectomy for a 2.2 cm ER+, PR+, HER2/neu –ve infiltrating ductal cancer; 0/3 SLN was positive; resection margins were negative. The BEST postoperative management is: A. Adjuvant chemotherapy followed by radiation therapy B. Adjuvant chemotherapy followed radiation therapy and then hormonal Rx C. Radiation therapy followed by hormonal therapy D. Chemotherapy followed by hormonal therapy E. Oncotype Dx detrmination to help in selecting the best treatment combination

Adjuvant Systemic Therapy Cytotoxic Hormonal Biologic

Oncotype DX A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer 3 risk categories Low risk—6.8% Intermediate risk—14-3% High risk—30.5% Paik et al: NEJM 2004; 351:2817-26

Breast Cancer in Pregnancy Infrequent California registry study-1.3 breast ca Dx’d per 10,000 live births Delay in Dx results in late stage at Dx Neither the pt nor physician suspects cancer Stage for stage, prognosis not different Most tumors poorly differentiated, ER and PR neg and approx 30% HER-2/neu pos

Evaluation for Breast Cancer in Pregnancy CBE MGM with shielding-accuracy > 80% US to assess the breast and RLN and to guide bx Core bx preferred to FNA Maternal fetal medicine consultation Sentinel LNbx with radionuclide safe but blue dye

Question 20 A 30 y.o. woman who is 14 weeks pregnant has a 2.5 cm. dominant slightly tender mass in the left breast. Biopsy shows grade II infiltrating ductal carcinoma. She has no palpable adenopathy. The best treatment now would be: A. Partial mastectomy with sentinel lymph node bx followed by radiotherapy B. Partial mastectomy with ALND, followed by adjuvant chemotherapy C. Modified radical mastectomy D. Modified radical mastectomy followed by adjuvant chemotherapy E. Neoadjuvant chemotherapy followed by partial mastectomy

Question 21 A 34 y.o.woman who is 20 weeks pregnant has a 2.3 cm dominant, slightly tender mass in the LT breast. Core bx shows infiltrating ductal carcinoma. She should be advised that: A. Preopearative Tamoxifen Rx is safe and effective B. Chemotherapy is contraindicated C. Breast conservation is an option D. Sentinel node biopsy is a significant risk to the fetus E. She should avoid all future pregnancies

Management of Breast Cancer in Pregnancy RT contraindicated during pregnancy, can be delayed until postpartum if ca Dx’d 2nd or 3rd trimester as part of BCT Indications for chemotherapy the same but NOT to be given during the 1st trimester Chemotherapy may be given during 2nd and 3rd trimesters but not after week 35 to avoid the potential for hematologic complications at time of delivery Taxanes, trastuzumab and hormonal drugs should not be used during pregnancy