Breast Diagnosis And Management of of Benign Breast Diseases Resident Basic Science Harry D. Bear, MD, PhD Division of Surgical Oncology Massey Cancer Center

Anatomy of Ductal Systems of the Breast

Lymphatic Drainage of the Breast

Examination of the Axilla

Positioning for Breast Palpation

Breast Palpation Finger “Pads” and Two Hands

Breast Exam - Systematic Coverage of All Breast Tissue

Signs and Symptoms of Breast Cancer  Occult mass or calcifications  Breast mass or “thickening”  Spontaneous nipple discharge  Skin dimpling  Nipple retraction or scaling  Skin erythema or peau d’orange  Focal breast pain – 10%

Signs of Breast Cancer Skin Dimpling

Signs of Breast Cancer Nipple Retraction

Change in Nipple  What do you think this is? A.Eczema of the nipple B.Dried nipple discharge C.Paget’s disease D.Invasive ductal cancer E.Infection after nipple piercing

Change in Nipple

Signs of Breast Cancer Peau D’Orange

Inflammatory Breast Cancer

Breast Disease  Fibrocystic change «“Lumpy breasts” «Most are physiologic - not a disease «Pain - usually cyclical and mild Occasionally severe Reassurance and NSAIDs, local heat or cold

Breast Disease  Fibrocystic change «Common in women «Adenosis «Fibrosis «Cysts «Hyperplasia With or without atypia

Breast Masses  Fibroadenoma «Most common in teens to 20’s «Smooth «Very mobile «Lobulated

Fibroadenoma

Fibroadenoma, Fibrocystic Change

Breast Diseases  Pathologic Nipple Discharge «SPONTANEOUS, not elicited «Grossly bloody - usually papilloma «Unilateral «Only bilateral galactorrhea (milk) needs endocrine evaluation «Mammograms & Galactograms «Cytology - very limited value «Most result from duct ectasia

Breast - Ductal Diseases  Intraductal papilloma «Retroareolar mass «Nipple discharge  Duct ectasia «Palpable dilated ducts «Nipple discharge - many colors

Bloody Nipple Discharge Intraductal Papilloma

Intraductal Papilloma

Nipple Discharge – Duct Ectasia

Breast Masses  Cysts «Round «Smooth «Somewhat mobile «Sometimes painful «Mostly in women > 40

Breast Masses  Management of suspected cysts «Mammogram «Sonogram «Needle aspiration, especially if symptomatic «If cystic by sonogram and no symptoms, follow OR

Aspiration of Breast Cyst

Breast Masses  Abscess «Severe pain «Erythema «Fluctuant mass «Often require surgical drainage  Cystosarcoma phyllodes «Usually large, similar to fibroadenomas «90% are benign, 10% malignant

Screening Mammography  Annually after age 40  Start screening younger for strong family history of pre-menopausal breast cancer (start 5 years younger than youngest age at diagnosis)  NOT just for “high risk” women

Limitations of Mammography  Misses up to 10% of breast cancers  Cannot rule out cancer  Therefore, not a definitive test for palpable masses  Useful to assess other breast tissue  Little if any role in women under 30

Diagnosis of Breast Masses  In women over 30, get mammogram, preferably before biopsy  Shows characteristics of mass, other occult lesions in the same breast and opposite breast  BUT, for a palpable MASS, DO NOT depend on the findings to decide whether nor not to biopsy

Mammograms of a Woman with a 2 cm Breast Cancer

Mammography - Multiple Cancers

Mammographic Signs of Breast Cancer  Mass  Calcifications  Dilated ducts  Architectural distortion  Skin changes  Asymmetry  Enlarged lymph nodes

Mammograms - Spiculated Density

Mammography - Calcifications

Role of Breast Ultrasound  For occult masses – cystic vs. solid  Equivocal findings on mammogram or exam  Guidance for needle biopsy or extent of excision  Cystic vs. solid for palpable mass  NOT yet shown to be effective for screening

Occult Mass on Mammogram

Sonogram of Mass - Simple Cyst

Sonogram of Mass - Complex Cyst

Ultrasound Guided Aspiration of Breast Cyst

Ultrasound - Breast Cancer

Breast Ultrasound - Small Cancer

Breast Biopsy Choices

Fine Needle Aspiration Biopsy

Fine Needle Aspiration Biopsy Smear

Core Needle Biopsy

Needle-core biopsy

Methods of Breast Diagnosis Core Needle Biopsy vs. FNA  Disadvantages «Local anesthetic «Pain «Bleeding «24 – 48 hr. turnaround  Advantages «More material «Invasion vs. DCIS «Marker studies possible

Optimizing Breast Biopsy Methods Compared to Surgical Biopsy  Less traumatic  Minimal scar  Quicker and cheaper than surgery  Definitive diagnosis in most cases

Advantages of Needle Biopsy Core or FNA vs. Surgical Biopsy  Facilitates breast conservation «First excision of known cancer removes less tissue than excision and re-excision «Less disturbance of tissue  One operation, not two  Greater accuracy of sentinel node mapping  Should be used in close to 100%!

And YET…….  More than 1/3 of all breast masses and mammographic abnormalities are still being biopsied by open surgery!* «= almost 600,000 unnecessary operations/year  “Where is the outrage? ” # * Clark-Pearson et al, JACS, 1/2009 # Silverstein, JACS, 1/2009

Diagnosis of Palpable Mass

Cyst Management

Triple Negative Test

 Non-suspicious physical exam (weak link)  Negative mammogram  Benign cytology on FNA or benign Core biopsy Nearly 100% accurate, but must follow-up

Options for Occult Breast Findings  6 Month Follow-up  Image-guided needle biopsy «Stereotactic «Ultrasound  Needle localization and surgical biopsy  BIRADS scoring system (0-6)

Mammography Algorithm

Stereotactic Breast Biopsy

Breast Diagnosis - Mammographic Localization

Breast Diagnosis – Pre-Operative Mammographic Localization MAINLY for borderline lesions after core biopsy or known cancers

Breast Diagnosis - Mammographic Localization

Carcinomas in Situ Ductal and Lobular

Lobular Carcinoma in situ This is NOT cancer!

Duct Carcinoma In Situ

Common Allegations in Missed Breast Cancers  Failure to screen  Failure to know about mammograms  Failure to evaluate/follow-up patient complaint  Failure to follow-up abnormal exam  Failure to refer to specialist  Misinterpretation of abnormal PE with normal mammogram

Missing Breast Cancers  Triad of error «Young age «Self-discovered mass «Negative mammogram

Clues to Effective Chemoprevention  Estrogen has a role in breast cancer etiology  Anti-estrogen therapy can cause regression of breast cancers that express hormone receptors  Tamoxifen, used to decrease recurrence of ER+ breast cancer, also decreased incidence of contralateral breast cancers by almost half

Tamoxifen for Chemoprevention - P1 Women at High Risk for Breast Cancer Women at High Risk for Breast Cancer Tamoxifen for 5 YearsPlacebo for 5 Years Randomize or

Average Annual Rates of Invasive Breast Cancers in P-1 Trial Rate per 1000 Fisher, et al. JNCI, 1998

RALOXIFENE 60 mg/day x 5 years Risk-Eligible Postmenopausal Women STRATIFICATION STRATIFICATION AgeAge Relative RiskRelative Risk RaceRace History of LCISHistory of LCIS TAMOXIFEN 20 mg/day x 5 years NSABP STAR Schema

P-2 STAR Average Annual Rate and Number of Invasive Breast Cancers * # of events 312* RR = 1.02, 95% CI: 0.82 to 1.28