AMSER Case of the Month: September 2018
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1 AMSER Case of the Month: September year-old woman with a left breast mass noted on screening mammography. Catherine McNulty, MS4 Tulane University School of Medicine Dr. Robin Sobolewski Breast Division Director; AHN Health System Dr. Matthew Hartman Medical Student Coordinator; AHN Health System
2 Patient Presentation CC/HPI: 60-year-old asymptomatic female with a left breast mass noted on screening mammography. Denies any palpable lumps, nipple discharge, pain, skin changes, and unintended weight loss. Targeted physical exam: no dominant mass palpable in either breast; no skin changes or nipple discharge; no palpable axillary, cervical, or supraclavicular lymphadenopathy. Medical Hx: obesity, asthma, anxiety Surgical Hx: cholecystectomy, knee surgery (left), shoulder surgery (right) Medications: albuterol, alprazolam, buproprion, fluoxetine Family Hx: + breast cancer & cervical cancer (sister)
3 ACR Appropriateness Criteria for Yearly Screening Mammogram
4 Screening Mammography
5 Screening Mammography Indeterminate focal asymmetry of the left breast at the 1 o clock position with questionable associated architectural distortion. Diagnosed as BIRADS 0, recommended additional imaging.
6 What additional imaging, if any, should we order?
7
8 Ultrasound of Left Breast
9 Ultrasound of Left Breast Deeply situated oval hypoechoic mass with irregular margins at the 1 o clock position 3 cm from the nipple, measuring 1 x 0.9 x 0.9 cm. There is mild surrounding architectural distortion and mild posterior shadowing. Diagnosis: BIRADS-4 - Suspicious, recommend ultrasound guided core biopsy. Sonography of the left axilla demonstrates multiple normal-appearing lymph nodes.
10 Ultrasound Guided Biopsy Invasive ductal carcinoma, Nottingham Score 3 (tubules 1, nuclear grade 1, mitotic activity 1). Estrogen Receptor: positive Progesterone Receptor: positive HER2/neu: negative
11 Final Dx: Invasive Ductal Carcinoma
12 Invasive Ductal Carcinoma Breast cancer is the most common cancer in women (besides skin cancer) and the second most common cause of cancer mortality in women (lung cancer is #1). Risk factors related to estrogen exposure: Female sex, age (postmenopausal), early menarche/late menopause, obesity, atypical hyperplasia, first-degree relative with breast cancer Invasive (infiltrating) ductal carcinoma is the most common type of breast cancer (70-75% of all breast cancers). May present as a mass on physical exam or on mammography. Clinically detected masses are usually >2 cm while mammography can detect smaller masses. Advanced tumors may have skin changes such as nipple retraction
13 Invasive Ductal Carcinoma Ductal Carcinoma In Situ (DCIS) is a malignant proliferation of cells in ducts with no invasion of the basement membrane. It is stage 0 breast cancer ( pre-invasive ). DCIS becomes invasive ductal carcinoma in ~ 30% of patients if left untreated. Radiographic features of invasive ductal carcinoma: Spiculated, calcified, high density mass on mammography Angular, hypoechogenic mass with posterior acoustic shadowing on U/S Breast cancer most commonly metastasizes to ipsilateral lymph nodes, bone (mixed osteolytic and osteoblastic lesions), and lung.
14 Breast Imaging Reporting and Data System (BI-RADS) Standard way of reporting breast imaging. Every report has a BI-RADS category: 0 need additional imaging and/or prior mammograms for comparison 1 - negative 2 - benign 3 probably benign 4 - suspicious 5 highly suggestive of malignancy 6 known biopsy proven malignancy
15 References: ACR Appropriateness Criteria Breast Cancer Screening. asearch.acr.org. Published Accessed August 17, Barke LD, D'Orsi CJ, Paltiel HJ. ACR Practice Parameter for the Performance of a Breast Ultrasound Examination. American College of Radiology Practice Parameters. Published Accessed August 17, Gay SB, Woodcock RJ. Radiology Recall. Baltimore, MD: Lippincott Williams & Wilkins; Sattar HA. Fundamentals of Pathology: Medical Course and Step 1 Review. Vol 1. Chicago, IL: Pathoma.com; Weerakkody Y. Breast imaging-reporting and data system (BI-RADS) Radiology Reference Article. Radiopaedia.org. Published July Accessed August 17, 2018.
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