Evaluation

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Surgery - Breast Diseases

• Evaluation
• Diagnostic steps
• Decision to Bx
• Types of bx
• Pros/cons Bx Tech.
• F/U common problems
• Benign Lesions
• pathophysiology
• presentations

• Malignant Lesions
• W/U and Dx
• Therapeutic alternatives
• common pit-falls
• primary vs. adjuvant Rx
• pathology
• prognostication
• F/U and therapeutic efficacy

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Evaluation

• No hard and fast rules on screening mammo
• all symptomatic women gt30yo
• within 10 yrs of first degree relative family hx
• all fatty infiltrated breasts annually gt40
• Other radiographic screening limited to
• US in palpable abnormalities not clinically
  distinct in young women
• W/U palp or mammo soft finding especially in
  those with established risk factors

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Self Breast Exam
Women are empowered to pay attention to breast
health issues by BSE Just another way for male
physicians to blame women for not finding cancer
soon enough. No study shows decrease of size at
dx greater than 2.5 cm down to 1.8 cm- need to
get size lt1.0 cm for survival benefit
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Evaluation

• Clinical history
• delineate pts risk early - use Gail Model
• http//bcra.nci.nih.gov/brc/start.htm
• Menarche, preg hx, breast feeding hx, family hx,
  hormone use
• lesion characteristics
• menstrual changes, dietary influences, wt loss or
  gain
• prior breast disease hx
• pt and relatives - pay close attention to
  proliferative
• 69 successful malpractice is in fam hx
• 80 pt found lump - Remember Osler!!

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Evaluation

• PE
• Pennypacker technique of palpation
• three fingers vertical strips
• include axillae and lower 1/2 neck
• Observation of skin
• sheer curtain -fluid motion
• Ck for nipple D/C
• hemoccult if present single vs. mult duct
• Wait any fluid (esp. spontaneous) increases risk
• mobility

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Clinical Breast Exam

• Why do it?
• Purpose and goals
• Breast Cancer is a common problem
• Screening of pre-menopausal women poor and death
  rate high
• Post-menopausal still 15 felt before seen on
  mammo
• 60 diagnosed breast cancers felt before ever
  sent for imaging
• we need to reduce size at dx to increase survival

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Clinical Breast Exam

• How to do it?
• The mechanics
• we are feeling to detect cancer - both sensitive
  and specific
• dependant on scirrhous nature of most breast
  cancers
• optimize conditions to detect differences in
  density
• use subtle signs that imply differences in scar
  activity in the breast

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Clinical Breast Exam
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Clinical Breast Exam
Thin out the breast tissue to less than 1
thick Close attention to mammographic miss
locales - UIQ and LOQ Move the breast and look
for differences in texture or mobility of skin
relative to gland Oops decreasing evidence it
works to reduce death rates
In the skin, look for peau dorange look for
nipple excoriation/ Pagets lymphatic engorgement
or Coopers ligament shortening
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Evaluation

• Every abnormality charted and scaled
• Oclock and distance to nipple
• any unclear area submit to alternative exam
• any suspicious on 1 exam or unclear on 2
  different exams (modality or temporal) needs
  diagnostic evaluation - i.e.. Bx if cannot find a
  good reason not to.
• level of suspicion based on fam hx. and other
  cumulative risk factors

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Diagnostic evaluation

• when unclear - Bx.
• never follow more than 12 weeks without a clear
  commitment
• Bx method depends on
• way in which lesion most crisply seen
• tolerable sampling bias based on clinical
  situation

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New Technologies
Digital Mammo Ultrasound improvements MRI Nuclear
medicine Emerging technologies
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Digital Mammography

• Technology
• Pixel size not yet equivalent to silver grain
  size
• GE diagnostic unit cautiously approved for
  screening
• Will allow very accurate SCBx
• May allow new pattern recognition to standardize
  reading (CAD)
• However post-menopause only 1/2 of unrecognized
  Ca B/O inaccurate reading premenopausal Ca not
  detected 40 of time by mammo alone

• Post menopausal
• FilmDigital
• Film found mor3e solid masses
• Digital better with cals
• Fewer call backs with digital
• Pre-menopausal
• Digital is better
• NEJM 2005
• 49528 pts both DF
• 0.5 D F
• Inv CA
• 25 DF
• 10.4 F
• 11.3D
• 21.8 never seen
• DCIS
• 10.7 DF
• 5.1 F
• 7.5 D

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Ultrasound MRI

• Costly technology
• New coils allow SCB or localization
• True sensitivity and specificity ?
• BRCA 1 (2) have higher incidence of breast
  cancers not seen on mammo and MRI saves lives
  here.
• Can find 25-28 caners have MF disease no
  effect on survival or eventual therapy
• Most insurers skeptical

• Very good in W/U of cystic lesions
• Ability to differentiate solid lesions improving
• Left, however, with high false and false -
  rates for solid lesions

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Nuclear Medicine

• New isotopes hold promise such as FDG, sestamibi,
  and C-11 thymidine
• Imaging with resolution is problematic
• must detect routinely _at_ lt 10mm
• More costly than MRI
• New Contact and PET detectors increasing accuracy
  dramatically and ? Cheaper than MRI at finding MF
  disease

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Experimental/ Emerging Techniques

• Genetic Screening- may assess risk but not direct
  diagnostic efforts in individuals
• Electrical Biophysical - uses properties of ionic
  concentration unique in normal epithelial
  surfaces
• Ductal Based Screening and Treatment - ductal
  lavage and ROBE or breast endoscopy still
  limited by pathology accuracy and recent data
  shows random PAFNA superior at identifying
  epithelial proliferative disease in
  chemoprevention (celebrex trial)
• New scope and hypermethylation mapping
• Lavage of non-fluid producing ducts in PAFNA

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Ductoscopy
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Common Problems

• Mastodynia/Mastalgia
• cyclical
• interfere with effects of hormones on breasts or
  changes menstrual hormonal pattern
• non-cyclical
• look for breast mapped causes, rx fluid
  retention
• rx with non-steroidals
• R/O non breast causes
• Tietzes syndrome, Polands syndrome, etc.
• UCLA Study (The Breast Journal 2005)
• 86 pts eval with mammo and US for breast pain
• 100 negative predictive value

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Common Problems

• Fibrocystic disease
• 40 of all women in 30-50 range carry dx
• cyclical lumpiness /or tenderness
• mega-cystic variant - chronic premenstrual
  rapidly filling cysts
• fibrosis variant - multiple FA or pseudo-tumors
• Beware when ca risks higher and FCD
• very careful to do detailed screening

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Common Problems

• Fibroadenoma family
• FA
• low risk except if ductal proliferative changes
  in young
• juvenile variant in Orientals Blacks
• 10-15 recurrence risk with excision
• Lactating adenoma issues
• Benign Phylloides tumors
• more aggressive in local failure only

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Common Problems

• Cystosarcoma phylloides
• unclear benign/malignant border
• best considered a special variant of fibrosarcoma
• risk for local recurrence best predicted by
  mitotic activity or ? Ki67
• gt10 mitoses/30 HPF Very malignant behavior
• like sarcoma spread is to next capillary filter
  station
• Rx
• lumpectomy only for lowest mitotic rates
• wide excision(TM) for all others indeterminants

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Common Problems

• Nipple D/C
• single duct, heme - 7-9 ca chance
• Bx - gold standard microductectomy
• galactogram pre or intra-op
• nipple to 1 cm beyond obstruction
• recent data suggests that routine use of breast
  endoscopy or galactography will double the cancer
  detection rate in these patients
• single duct , heme-
• Bx only if persistent - papilloma likely
• Multiple duct, heme
• culture and rx antibiotics x1-3 mos bx if not
  response
• Multiple duct, heme-
• w/u prolactin axis

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Common Problems

• Infections
• difficult to cure with antibiotics
• acne type flora, prolonged rx stills gives
  failures
• lactating - nurse or pump through Ab Rx
• non-lactating - look for ductal blocking lesions
• both pre and post Rx
• Post-conservation red breast syndrome
• radiation mastitis vs. anaerobic step infection

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Common Problems

• Abcess
• any infection that fails to respond clinically in
  3 days
• w/u with US, aspirate or drain all collections
• Clinical abscesses
• ID or Aspirate, irrigate, antibiotics
• W/U for ductal lesions within 1 mo of successful
  Rx
• Peri-ductal mastitis
• recurrent infection in large lactiferous ducts
• may require excision to control

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Common Problems

• The funny nipple
• odd crusting, asymmetric reddening, red area
  erupting from one of the major duct orifices
• consider Pagets until two consecutive negative
  bx taken of nipple-areolar complex
• Inversion
• only important if new and not associated with
  recent hormone administration
• Montgomery gland problems
• common inclusion cysts, hidradenitis like fungal
  infections

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Breast Masses

• OU 4 yr study of 414 pts presenting as breast
  mass primary c/o min 6 mo f/u
• No effect of family hx or risk factors on future
  ca dx
• Probability of ca dx
• 11.3 if pt found
• 6.9 if physician found
• 1.9 nurse/phy extender

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Breast Masses
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Biopsy decisions

• How to find it?
• palpation - gold std.
• mammo
• US
• Miralumma
• MRI
• Thermography
• the latest hottest research tool

• How big a piece do I need?
• surgical excision - gold
• surgical incisional
• needle incisional
• Mammotome, MIBB
• ABBI
• Cassi - cryocore
• Needle core
• 14G, 16G, 18G
• FNA

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Biopsy decisions

• commit yourself to a narrow list of acceptable
  diagnoses before bx
• if pre-op dx important, use best single or combo
  of non-surgical methods first
• if dx is irrelevant to excision plans, use
  surgical excision first
• if Dx not on acceptable list, re-assess your
  choices - fall back on remaining best list to
  minimize sampling error
• Dont Forget surgical Bx

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Gynecomastia

• common in young and old
• risk factors
• liver disease or decreased steroid clearance
• Dopamine blockers - Haldol
• Dopamine del. agents-reserpine L dopa
• H2 blockers
• AIDS drugs
• unilateral vs bilateral
• Rx - symptomatic or discreet asymmetry in gland

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Breast Cancer

• 200-230K per year stable invasive incidence
  Oops increasing to 485K/yr 2017
• 40K deaths per year 11K preventable with annual
  gt50 screening
• another 45K DCIS/yr
• probably 120K - LCIS, ALH, ADH, or other
  significant proliferative risk lesions
• probably accounts for gt30 of all Ca survivors

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Breast CancerTypes of invasive

• Minor forms
• tubular
• very well diff. ductal
• medullary
• angry histopathologically but benign course if
  small N0
• bloody cyst and Rad Rx
• adenoid cystic
• colloid/mucinous
• tumor mass tiny relative to mucus

• Ductal-70
• classic scirrhus
• mammo/sono size within 20 of path size
• prognosis very grade sensitive
• Lobular - 10-12
• may be considerably larger than clinically or
  radiographically suspected

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Breast Cancer

• Other minor forms
• all sweat gland derivative types except
  cystosarcoma family
• all treated the same
• subtype may only effect interpretation of future
  systemic or contra-lateral risk

• Inflammatory
• looks like infection
• paucity of systemic symptoms min Left shift on
  WBC
• High sed rate
• underlying breast mass
• Bx skin, nipple, cores
• may need immunohistochem to correctly
  differentiate tumor from lymphocytes

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Breast Cancer

• Presentations
• Lumps
• ductal if hard
• soft - lobular,colloid,tubular, medullary, DCIS
• Firm patches
• ductal in tissue
• lobular
• Stellate mammo
• ductal or old lobular

• Calcifications
• ductal/ DCIS
• older with necrosis
• Nipple D/C
• bloody
• single duct
• Pagets disease
• subareolar DCIS or invasive with centripetal
  ductal spread
• Inflammatory

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Current State of the Art in Breast Cancer
Screening and Rx

• 1930-1996 no change in age adjusted death rate in
  US from Breast Cancer
• 1997-2000 an 18 decrease in death rate accounted
  for gt95 by earlier stage at diagnosis
• Rx successes in clinical trials not appreciated
  as well in nation-wide reviews
• Best Rx results seen with rigid evidence based

• The Mammo glass ceiling of 1/3 in situ to 2/3
  invasive
• Still in best situations mammo leaves 2/3 of
  patients at risk for cancer death
• Mammo findings late
• calcifications usually represent obstructed ducts
  with a 600 increase in cross-sectional area
• densities depend on immunologic reaction of host
  to invasion with a scirrhous reaction

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Breast Cancer Prevention

• Increased menses increased breast cancer risk
• Breast feeding is very important to breast health
• decreases pre-menopausal breast cancer frequency
  without affecting lifetime risk
• Low fat diet, EtOH, and hormone risks??
• NSABP P-01 SERM as THE prevention agent
• Tamoxifen - proven
• Evista (raloxifen) - suspected but checkered
  oncologic history - poor head-to-head against Tam
  for therapy
• Peripheral Aromatase Inhibitors - promising data
  from ATAC trial

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Palpable Mass
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Nipple Discharge
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Mammo abnormality
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Painful breast / FCD
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LCIS
Level of evidence - B for excision A for tam/C
for high risk f/u
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ADH/ALH
Level of evidence - B for excision B for tam/C
for high risk f/u
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DCIS
Level of evidence - A for LR and TM B for L
alone/C for high risk f/u
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Clinical Stage 1 or 2A
All Patients with tumors gt10mm and tumors 5-10mm
high grade or pathologic nodes referred for
systemic rx options (I.e. hormonal or
chemotherapy)
Level of evidence - A for LR and MRM B for MRM
recon C for no radiation in limited life
expectancy A for adjuvant systemic treatment
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Pathologic Stage 1 or 2A
All Patients referred for BHI f/u as high risk
and no routine lab tests symptomatic screening
only for metastasis by ASCO guidelines
All Patients with clinical indications for
radiation ( LumpAx) and pathologic indications (
or close margins apical nodes , etc.) referred
post chemo. Benefit of Herceptin in node cases
her-2 . Molecular testing may direct future
chemo choices NSABP retrospective .
Level of evidence - A for adjuvant systemic
treatment and radiation treatment B for F/U
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Clinical Stage 2B or 3A
All Patients referred for systemic rx options
(I.e. hormonal or chemotherapy)
Level of evidence - A for LR and MRM B for MRM
recon A for adjuvant systemic treatment A for
radiation post mastectomy for indications listed
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Pathologic Stage 2B or 3A
All Patients referred for BHI f/u as high risk
and no routine lab tests symptomatic screening
only for metastasis by ASCO guidelines
All Patients with clinical indications for
radiation ( LumpAx) and pathologic indications (
or close margins apical nodes , etc.) referred
post chemo.
Level of evidence - A for adjuvant systemic
treatment A for radiation indications listed B
for f/u recommendations
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Clinical and Pathologic Stage 3B
All Patients referred for systemic rx options
(I.e. hormonal or chemotherapy)
Level of evidence - A for MRM, Chemo, and
Radiation
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Clinical and Pathologic Stage 4
Level of evidence - D for MRM, Chemo, and
Radiation
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High Risk F/U
Level of evidence A for mammo/CBE, C for risk
counselling, A for chemoprevention consideration,
A-C for additional tests
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Summary

• Benign breast disease is common and its largest
  impact is confounding Ca dx
• To make a REAL Difference for patients- we must
  detect Ca _at_ lt1.0 cm routinely
• Current Screening of young women poor
• Genetic screening will assist in risk eval.
• The Gail model and SERMs to change this disease
  enormously in the next decade
• We Need Radically Different Approaches
• functional screening, new bx techniques, etc.

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BREAST CANCER

• ... THE REAL HOPE FOR IMPROVEMENT DOES NOT REST
  ON AN EXTENSION OF OPERATIVE PROCEDURES, BUT AN
  EARLY RECOGNITION AND EARLIER EXTIRPATION OF THE
  FOCUS OF INVASION...
• W.S. HALSTED, 12/1894