How many women are affected by breast cancer during their lifetime?
1 in 8
Most common factor that increases risk for breast cancer?
1st degree relative.
BRCA 1 cancer associations
Breast and ovarian
Breast cancer screening in average risk women
Regular self-breast exams at age 20. Clinical breast exams every 1-3 years from 20-40. Yearly mammograms starting at age 40.
Breast cancer screening for high risk patients
Monthly self exams at age 20, clinical breast exams 2x/year from age 25, initial mammogram at age 30, mammograms every 1-2 years until 40, yearly mammograms after 40. Start yearly mammograms 10 years before age of 1st degree relative dx'd with breast cancer.
A patient presents to the clinic with a small 1x1cm breast mass that is not concerning on mammogram. What is your next step?
Biopsy, always biopsy clinically suspicous masses regardless of what the mammogram says.
What tool is used to interpret mammograms?
BI-RADS (Breast Imaging Reporting and Database System): 0 = Needs additional evaluation (compare old mammos, u/s, etc), 1 = Normal, 2 = Benign findings, routine screening, 3 = Probably benign findings (<2% are malignant), f/u in 6 months, 4 = suspicious, consider core needle biopsy (15-35% of core needle biopsies are malignant), 5 = highly suggestive of malignancy
When would you use stereotactic-guided core needle biopsy over needle localization and open surgical biopsy?
Stereotactic if the lesion is indeterminate, small and less suspicious. Needle localization and open surgical biopsy if lesion is highly suspicous for malignancy on mammography.
Tx for a patient dx'd with DCIS after core needle biopsy?
Surgical excision. 10-20% of DCIS dx will have additional infiltrative components at excision.
What are the types of DCIS and which types have higher malignant potential?
Comedo, papillary, micropapillary, cribriform and mixed. 30% comedo type have invasive carcinoma and 4% have axillary LN mets, this is why you do sentinel LN w/comedo type.
Tx for diffuse or multicentric DCIS
Simple mastectomy +/- reconstruction. No need for ax dissection or sentinel node of confined to ducts.
What is the difference between atypical ductal hyperplasia and ductal carcinoma in situ?
ADH has secondary bridging and hypertophy of the epithelial and inner layers. DCIS has marked proliferation of carcinoma limited by the basal lamina
Management of a patient who just had LCIS come back on biopsy that was next to a benign breast mass
LCIS is usually an incidental finding on biopsy and not seen on mammography. If found adjacent to benign breast mass, surveillance is okay. If found on core biopsy of calcified mass, excision is appropriate due to 15-20% risk of development into invasive cancer over 20 years, note however that there is almost 0 risk of axillary LN spread. F/u involves mammography every 6 months for the next several years and consideration of bilateral simple mastectomy if high risk.
A patient presents with clustered microcalcifications on mammography. Biopsy shows cells similar to invasive tubular carcinoma, but it's not. What could it be and how do you tx it?
Sclerosing adenitis. Tx w/routine follow-up despite slight increased risk for cancer
Tx for a patient with ADH on core needle biopsy
Needle localization and excision. 15-50% of cases prove to be malignant.
Why do you not usually use FNA for suspicious breast masses?
It cannot distinguish invasive from in situ carcinoma
A 28 year old woman presents with a solid, rubbery and mobile 2cm mass in the outer upper quadrant of her breast that is not fluid filled on u/s. What is your next step?
Surgical excision of fibroadenoma. This can be done without core biopsy due to 98% of solid lesions in this age group (<30) being fibroadenoma.
When is observation of a breast mass okay?
Low risk woman, age < 30 with likely physiologic cystic changes of the breast can be observed for 1-2 menstrual cycles.
Lesions included with fibrocystic changes of the breast
Cysts, fibrosis, sclerosing adenosis, apocrine change and hyperplasia.
Tx of painful fibrocystic changes
Cyst aspiration, elimination of caffeine, vitamin E and f/u in 3 months. If dx is unclear always do a biopsy because fibrocystic change carries a low risk of cancer.
Most common breast tumor in women < 25
Tx of phyllodes tumor
Wide local excistion due to variable malignant potential and larger size when compared to fibroadenoma
Dx for clear discharge from multiple ducts
Fibrocystic change in young people and subareolar duct ectasia in older women
Most common cause of unilateral bloody nipple discharge? How do you work this up? How do you treat it?
Intraductal papilloma. Pt should also have mammogram to check for other abnormalities and ductogram to locate papilloma. Work up with cannulation of the duct in surgery and excision of the duct and ductal system due to small risk of carcinoma.
How is breast cancer staged?
Stage 1 = 93% 5 year survival
Stage 2 = 72% 5 year survival
Stage 3 = 41% 5 year survival
Stage 4 = 18% 5 year survival
Work up for metastatic breast cancer
CXR, LFT, bone scan and CT head/abdomen
Least favorable histologic types of breast cancer
Infiltrating ductal carcinoma (most common), infiltrating lobular carcinoma (multicentric + bilateral), medullary carcinoma (better than invasive ductal, worse than invasive lobular) and inflammatory carcinoma.
Poor prognostic indicators for breast cancer
> 4 + LNs, size > 5cm, + axillary LNs, aneuploidy, high Ki-67 (s-phase fraction) and ER-/Pr-/Her2-Neu +
What is the prognosis for a woman presenting with enlarged supraclavicular LNs due to breast cancer?
This is stage IV disease, 5 year survival is 18%
A woman presents with a crusty nipple lesion and an underlying mass. What is the most likely cause of her condiiton and how do you treat it?
She has Paget's disease of the nipple, which is associated with underlying DCIS or ductal carcinoma 95% of the time. She needs a mammogram, mastectomy and staging due to the underlying mass. If no mass were present and carcinoma were confined to the nipple she could undergo excision of the NAC or radiotherapy.