1. Breast Diagnosis And Management of of Benign Breast Diseases Resident Basic Science - 2014 Harry D. Bear, MD, PhD Division of Surgical Oncology Massey Cancer Center

2. Anatomy of Ductal Systems of the Breast

3. Lymphatic Drainage of the Breast

4. Examination of the Axilla

6. Positioning for Breast Palpation

7. Breast Palpation Finger “Pads” and Two Hands

8. Breast Exam - Systematic Coverage of All Breast Tissue

10. 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%

11. Signs of Breast Cancer Skin Dimpling

12. Signs of Breast Cancer Nipple Retraction

13. 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

14. Change in Nipple

15. Signs of Breast Cancer Peau D’Orange

16. Inflammatory Breast Cancer

17. 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

18. Breast Disease  Fibrocystic change «Common in women 30 - 50 «Adenosis «Fibrosis «Cysts «Hyperplasia With or without atypia

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

20. Fibroadenoma

21. Fibroadenoma, Fibrocystic Change

22. 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

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

24. Bloody Nipple Discharge Intraductal Papilloma

25. Intraductal Papilloma

26. Nipple Discharge – Duct Ectasia

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

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

29. Aspiration of Breast Cyst

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

31. 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

32. 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

33. 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

34. Mammograms of a Woman with a 2 cm Breast Cancer

35. Mammography - Multiple Cancers

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

37. Mammograms - Spiculated Density

38. Mammography - Calcifications

39. 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

40. Occult Mass on Mammogram

41. Sonogram of Mass - Simple Cyst

42. Sonogram of Mass - Complex Cyst

43. Ultrasound Guided Aspiration of Breast Cyst

44. Ultrasound - Breast Cancer

45. Breast Ultrasound - Small Cancer

46. Breast Biopsy Choices

47. Fine Needle Aspiration Biopsy

48. Fine Needle Aspiration Biopsy Smear

49. Core Needle Biopsy

50. Needle-core biopsy

51. 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

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

53. 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%!

54. 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

55. Diagnosis of Palpable Mass

56. Cyst Management

57. Triple Negative Test

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

59. 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)

60. Mammography Algorithm

61. Stereotactic Breast Biopsy

63. Breast Diagnosis - Mammographic Localization

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

65. Breast Diagnosis - Mammographic Localization

66. Carcinomas in Situ Ductal and Lobular

67. Lobular Carcinoma in situ This is NOT cancer!

68. Duct Carcinoma In Situ

69. 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

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

71. 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

72. 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

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

74. 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

75. P-2 STAR Average Annual Rate and Number of Invasive Breast Cancers 163168 * # of events 312* RR = 1.02, 95% CI: 0.82 to 1.28