Benign Breast Disease & Breast Screening. Leah Kelley, MD OPSC Conference Monterey, CA September, 2018

Transcription

1 Benign Breast Disease & Breast Screening Leah Kelley, MD OPSC Conference Monterey, CA September, 2018

2 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

3 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

4 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?

5 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

6 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

7 Breast Mass Common benign masses fibrocystic tissue fibroadenoma

8 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

9 Benign Masses: Cysts Mammography Ultrasound

10 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!

11 Benign Masses: Fibroadenoma Mammography Ultrasound

12 Benign Masses: Other Phyllodes tumor More cellular fibroadenoma May be recurrent with malignant potential Hamartoma Encapsulated benign breast tissue Forms a palpable mass

13 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

14 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

15 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

16 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%

17 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

18 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

19 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

20 Infectious Mastitis Most common organisms: skin flora, MSSA, MRSA Risk factors: Lactation, surgery, injury, obesity, diabetes, prior radiation

21 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

22 Breast Abscess Infectious mastitis can evolve into an abscess

23 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

24 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

25 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

26 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

27 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

28 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:

29 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

30 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

31 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 overdiagnosis

32 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

33 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

34 Breast Density

35 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

36 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

37 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

38 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 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

39 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

40 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

41 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

42 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

43 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

44 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

45 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

46 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