Benign Breast Disease · Benign Breast Disease & Breast Screening Leah Kelley, MD OPSC Conference ....
Transcript of Benign Breast Disease · Benign Breast Disease & Breast Screening Leah Kelley, MD OPSC Conference ....
Benign Breast Disease & Breast Screening
Leah Kelley, MD OPSC Conference
Monterey, CA September, 2018
Why this matters to YOU
• Breast symptoms constitute 3% of all visits by female patients (29.7 per 1,000)
• Breast pain and breast mass are the most common complaints
• Breast complaints are highest among women aged 25 to 44 years (48 of 1,000) and among women aged 65 years and older (33 per 1,000)
• The vast majority of presentations are not breast cancer
• Mammographic screening is a matter of medical and public controversy that generates patient questions
Common Benign Breast Conditions
• Cysts/Fibrocystic change
• Fibroadenoma
• Nipple discharge/Galactorrhea
• Infectious mastitis
• Non-infectious inflammatory conditions
• How to NOT miss a Breast Cancer • Imaging • Clinical findings
To Mammo, or Not to Mammo?
• Mammography screening is the subject of two major data-driven controversies
• Ideal onset and interval of screening • 40? 45? 50?
• Annually or biennially?
• Actual efficacy of mammography in decreasing breast cancer-specific mortality • Why has more stage 0-1 diagnoses not decreased the number of stage 4 diagnoses?
• What is the role of mammography versus improved treatment?
Breast Pain/Mastalgia • Many reproductive age women experience cyclic breast
pain, especially in the week before menses
• Noncyclic breast pain is common around menarche, menopause and pregnancy
• Virtually all non-focal breast pain is hormonal in nature and harmless, however it can be very bothersome
• It is generally (but not absolutely) true that breast cancers are painless
Breast Pain
• Examine the breast for underlying physical findings, taking note of focal symptoms
• Evaluate medications, activity, support
• If no findings, re-evaluate after two menstrual cycles with supportive treatment
• Symptomatic treatment with good support, ice, NSAIDs, decreased stimulation, exclude caffeine • Diclofenac gel 2g tid massage into breast tissue • Vitamin E 400IU qd and EPO (evening primrose oil) 1g tid
• Severe/refractory cases: Tamoxifen 10mg qd
Breast Mass • Common benign masses
• fibrocystic tissue
• fibroadenoma
What is Fibrocystic Change?
• NOT fibrocystic “disease”
• Subset of women with dense breasts who also have a propensity for breast cyst formation
• Breast cysts are non-encapsulated lacunae of fluid within the breast tissue
• Frequently wax and wane
• Not a specific risk factor for breast cancer above increased risk associated with breast density, but can contribute to false-positive imaging
• Variable symptoms
Benign Masses: Cysts
• Mammography • Ultrasound
Managing Breast Cysts
• Observe if not painful
• Cut out caffeine—this works for some women but not others
• Drain if palpable and symptomatic
• Do not send fluid for cytology
• If: • Fluid is bloody • There is still a mass after drainage • Mass does not drain
DIAGNOSTIC IMAGING!
Benign Masses: Fibroadenoma
• Mammography • Ultrasound
Benign Masses: Other
• Phyllodes tumor • More cellular fibroadenoma
• May be recurrent with malignant potential
• Hamartoma • Encapsulated benign breast tissue
• Forms a palpable mass
Evaluation of a Breast Mass
• Careful history and clinical examination
• Age-appropriate imaging • Women > 35: diagnostic MMG and US
• Women 25-35: US +/- MMG, radiologist’s discretion
• Women <25, US only
• Clinical follow up per imaging
• Referral to breast surgeon if needed
Evaluation of a Breast Mass
• REMEMBER: a persistent Palpable mass which is does not appear on imaging Requires a tissue diagnosis
• Why? 10-15% of breast cancers are occult
• How? Palpation-guided fine needle aspiration
• When? Right away
What does this Pathology Report Mean?
• Your patient has an abnormal mammogram, and gets called back for a biopsy…
• Completely benign: • Usual ductal hyperplasia
• Fibrocystic breast tissue
• Psuedoangiomatous stromal hyperplasia (PASH)
• Calcifications associated with benign ducts
• Not completely benign: • Atypical ductal/lobular hyperplasia
• Intraductal papilloma
• Radial scar
• Flat epithelial atypia
• Lobular carcinoma in situ/lobular neoplasia
• Malignant: • DCIS
• Invasive ductal/lobular carcinoma
Atypical pathology
• Excisional biopsy is still the standard of care
• 5-15% will be upstaged to DCIS or invasive disease
• Pathologic distinctions can hinge on quantity/extent as much as quality
• Inter-observer variability is significant
• Women with atypical biopsies have 4-8 times increased risk of invasive disease in both breasts
• Increased screening • Annual mammogram
• Consider annual MRI
• Risk reduction • Lifestyle modifications
• Tamoxifen or Raloxifene for 5 years reduces risk by 30-50%
Nipple Discharge
• Galactorrhea implies bilateral milky discharge, and should only be used to describe that
• Nipple discharge is anything else
• Key historical features: – Unilateral or bilateral?
– Clear/serous, yellow/green or bloody?
– Spontaneous or expressed?
– Associated mass, pain, events
– Medications
Galactorrhea
• Multiple etiologies
• Bilateral, milky discharge, spontaneous or expressed
• Virtually always benign
• Often related to medications, esp anti-psychotics
• Check: TSH and Prolactin
• Conservative management and correction of any underlying metabolic or hormonal issues
• If a medication side effect, evaluate in light of risks/benefits
Nipple discharge
• Serous or bloody discharge requires evaluation
• Start with diagnostic mmg and ultrasound
• If negative, consider breast MRI
• If persistent with negative imaging, refer to breast surgery for consideration of central duct excision
• Most common cause is intraductal papilloma
• Can be associated with DCIS or invasive carcinoma
Infectious Mastitis
• Most common organisms: skin flora, MSSA, MRSA
• Risk factors: Lactation, surgery, injury, obesity, diabetes, prior radiation
Infectious Mastitis
• Textbook treatment is dicloxacillin 500 qid
• Significant antibiotic resistance now present the community
• For higher risk patients, consider starting with Keflex 500 qid and Bactrim DS 2 tablets bid • Safe for breast-feeding patients with term infants (avoid in preterm infants or family
history of G6PD) • Alternative: Doxycycline 100 bid (not compatible with breast-feeding) or
Clindamycin 300mg tid
• Monitor closely for clinical response • Poor response should trigger ultrasound for abscess and consideration of biopsy to
rule out carcinoma
Breast Abscess
• Infectious mastitis can evolve into an abscess
Breast Abscess
• Superficial abscess may be treated with small I&D and ½” wicking
• Deep abscess should be treated with image-guided IR drainage and indwelling drain placement
• Drainage and adequate antibiotic coverage will clear the vast majority of breast abscesses
• Surgical intervention is rarely warranted
• In lactating breast, prompt removal of the drain (3-5 days) is important to avoid milk fistula formation
The pregnant and lactating breast
• Extensive hyperplasia, increased metabolic activity, thickened texture create a difficult exam
• Do not ignore masses in the pregnant or lactating woman!
• Evaluation by ultrasound is always safe
• Pregnancy-associated breast cancer: – 1 in 3000 pregnancies
– Breast cancer during pregnancy or first postpartum year
– Most common pregnancy-associated malignancy
Non-Infectious Mastitis
• AKA idiopathic granulomatous mastitis (IGM)
• Inflammatory autoimmune condition of the breast tissue
• Etiology poorly understood • May be be linked to Corynebacterium infection • Trauma to the tissue may precede presentation
• Presents with multiple, waxing/waning, sterile abscesses
• Typical patient is premenopausal and otherwise healthy; affects Latinas disproportionately
Non-Infectious Mastitis
• Management is conservative
• Core biopsy to establish diagnosis and rule out malignancy
• Wound care and pain control, allow spontaneous drainage
• AVOID SURGERY
• DID I MENTION AVOID SURGERY?
• High dose prednisone taper for severe cases
• Most cases are self-limited
Don’t Miss a Clinical Breast Cancer
• Hard, fixed, enlarging mass
• Skin or nipple puckering/retraction
• Enlarged axillary lymph node
• Rash on nipple/areolar complex
• Bloody nipple discharge
• Atypical breast infection
Don’t Miss a Clinical Breast Cancer
• When in doubt, IMAGE • Diagnostic mammogram and ultrasound
• Carefully describe focal findings on imaging order
• When in doubt, REFER • Negative imaging with persistent mass
• Worrisome examination
• Worried patient
• High risk family history
American Society of Breast Surgeons: www.breastsurgeons.org
Screening Mammography
• Two view x-ray examination of an asymptomatic person
• “Digital” refers to the image quality • Most mammos are now digital
• “3D” (aka “tomosynthesis”) refers to new technology allowing multiple views of the breast • Decreases false negative and false
positives, esp in women with dense breasts
Mammo: Who? How Often?
• USPSTF, ACS, and ACR all DISAGREE
• Average risk women may start at 40 and should start by 50
• Repeat every 1-2 years • Annual examinations save more life/years and also increase the number of false positives
• Stop at 75 or life expectancy < 10 yrs
• Women at increased risk should start at 40 and have annual studies • Family history • Personal risk factors: nulliparous, overweight, sedentary, dense breasts with prior biopsies,
postmenopausal hormone replacement therapy • Tyrer-Cuzick modeling
How to Talk to Patients about Mammographic Screening
• FIRST: know her risk • Tyrer-Cuzick can be run in about 90 seconds with patient participation and
produces a printable risk assessment
• SECOND: assess her risk tolerance • Increased screening decreases false negatives and increases false positives • Which “false” seems worse to her?
• THIRD: present options in terms of balance of risks and benefits • The decision is a choice to tolerate one of those risks over the other • Cost of false negatives/no screening: increased stage at diagnosis • Cost of false positives: anxiety, intervention, procedural risks, possible over-
diagnosis
What about Radiation exposure? • Minimal exposure from screening and
diagnostic studies
• Annual mammo x 40yrs = one PET/CT scan
• Significantly greater exposure from daily activities and background
• Risk of cancer from mammographic radiation exposure 1:125000
What about “DENSE” breasts?
• Breast density is the ratio of fibroglandular to fatty tissue in the breast
• It is a fixed characteristic, independent of body weight and breast size
• Breast density will decrease slightly with age in the absence of HRT
• Important for two reasons: • Increased density = decreased mammographic sensitivity (more false negatives)
• Dense breasts are an independent risk factor for breast cancer
• Women with dense breasts should still have mammograms • Improved detection with 3D mammo
Breast Density
What does this mammogram report mean?
• Type of mammogram
• Breast density
• Location and size of any findings
• Interval change from priors, if available
• BIRADS score • Recommendation for additional
management
Ultrasound for breast imaging
• Ultrasound is a powerful diagnostic tool
• Ideally used in the setting of a palpable finding or a known imaging target (abnormal screening study)
• As a screening tool, it has significant disadvantages • High false positive rate • Very operator dependent • Some false negatives (esp calcifications)
• Safe and reasonable for diagnosis in virtually every circumstance: children/adolescents, pregnancy/lactation, very elderly/disabled
Screening MRI
• Breast MRI is a powerful tool due to contrast enhancement and high level of resolution
• Screening MRI: lowest false negatives, highest false positives of any screening approach • Therefore reserved for high risk
women
• Adjunct to mammography, not replacement, in this population
Does Breast Screening Save Lives?
YES
• Population based studies of mammography demonstrate ~30% decreased disease-specific mortality in randomly selected screened populations
• Breast cancer specific mortality has declined by 39% from 1989 to 2015
• Women aged 40-74 who have mammograms are less likely to die of breast cancer than those who do not screen
NO
• Localized breast cancers have increased in incidence without a commensurate decline in advanced cancers, suggesting over-diagnosis
• 10 year survival is 23% better in regional (stage 2B-3C) cancers but only 10% better in local (stage 1A-2A) cancers, suggesting better treatment is mostly responsible
Does Breast Screening Save Lives?
• There is likely more overall benefit in screening women at increased risk of breast cancer
• Younger women have higher risks from screening but more life-years saved
• Annual mammography uptake may be a proxy for better overall health participation, including better breast cancer treatment for women who are diagnosed
• Early detection can reduce the burden of treatment even if overall mortality is unchanged
• Over-diagnosis is real, but identifying women who can forgo or have minimal treatment is a work in progress
Take Home Messages
• Most breast symptoms are not breast cancer, AND not missing a breast cancer is critically important
• Stepwise, clinically-driven evaluation of all symptoms
• Annual screening mammogram is still the standard of care • Individualized discussion based on risk and risk tolerance
• Know your friendly neighborhood breast surgeon and local multidisciplinary breast cancer program
Case #1: 43yo with family history
• 43yo G3P2, otherwise healthy, comes in with pneumonia. She describes prolonged stress due to caring for her mother who is undergoing chemotherapy for breast cancer
• She reveals a family history of breast cancer in her mother at 68, maternal aunt at 61 and a maternal first cousin at 48
• Normal screening breast examination today
• She has never had a mammogram
Case #2: 62yo with palpable mass
• 62 yo G0, postmenopausal on HRT since age 51, presents with a palpable right breast mass. She is not sure how long it has been there and reports it is painless
• Mass is 2cm, indistinct, no adenopathy. Exam complicated by extensive bilateral nodularity consistent with her known history of fibrocystic change
• Last mammo 3 years prior was normal
Case #3: 22yo with a palpable mass
• 22yo G0, college student, on OCPs, presents with a left breast mass
• First noted 3 months prior, painful at times
• On exam: 2cm firm, smooth, round, mobile mass in left outer central breast. Otherwise normal examination bilaterally
Case #4: 35yo with breast pain
• 35yo G3P3 with bothersome bilateral breast pain for 6-12 months, right greater than left
• Not sure if her pain is cyclic since she has a Mirena IUD for contraception. Bothers her while exercising. Does not want her kids to hug her due to pain. Interfering with her sex life
• Examination normal, bilateral tenderness to palpation
Case #5: 55yo with abnormal mammogram
• 55yo G2P2 postmenopausal not on HRT
• Normal screening breast examination at last clinic visit
• Abnormal mammogram showing 1.5cm of microcalcifications
• Biopsy shows atypical lobular hyperplasia
Case #6: 47yo with bloody nipple discharge
• 47yo G1P1 noticed dark staining inside her right bra a few times over last 1-2 months, now with one episode of frank bloody nipple discharge in the shower
• No history of breast trauma or surgery. No family history
• Normal examination except expressible, dark, hemoccult-positive, uniductal right nipple discharge
• Last mammogram normal 18 months ago