Breast Update Therese Cusick MS MD FACS

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Bryce Osborne
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1 Breast Update 2017 Therese Cusick MS MD FACS

2 Conflict of Interest Disclosure Nothing to disclose

3 Sources Adapted from SESAP- Surgical Education and Self-Assessment program American College of Surgeons Division of Education

4 0- incomplete 1- normal 2- benign BI-RADS Breast Imaging Reporting and Data System 3- additional imaging needed 4-20% risk of cancer % risk if CA 6- known CA

5 BI-RADS Breast Imaging Reporting and Data System????? BI-RADS 0, 1, 2, 3, 4 A. Repeat mammogram in 1 year B. Repeat mammogram in 6 months C. Additional breast imaging needed D. Biopsy needed D. Excision of mass required even if needle biopsy is negative for malignancy.

6 Breast Abscess A 24 yr old presents with a 5 day hx of breast pain. She has pain, localized erythema and a 3 cm fluctuant mass. U/S reveals an abscess. The patient should be placed on antibiotics and. A. Ultrasound guided core bx B. Incisional bx C. I and D in the OR D. Open and pack at the bedside E. U/S guided aspiration

7 Abscess All of the following are TRUE EXCEPT A. Daily needle aspiration is successful in lactating patients with abscesses <5cm B. U/S guided aspiration can facilitate complete drainage C. Staphylococcus aureus is the most common pathogen D. Abscesses with thick rinds and septa may require surgical incision E. Abscesses are rare in nonlactating women (25%)

8 LCIS A 42 yo, premenopausal woman has microcalcifications seen on screening mammogram. BI-RADS 4. Core bx reveals lobular carcinoma in situ (LCIS). The most appropriate next step is A. 6 month follow up imaging B. Mirror image bx of contralateral breast C. Bilateral prophylactic mastectomy D. Raloxifene for 5 years E. Needle-localized excisional bx

9 LCIS A. Classic LCIS B. Pleomorphic LCIS C. Neither D. Both?Surgical excision is recommended??marker for increased risk of breast CA in EITHER breast??associated with invasive lobular carcinoma? C for all

10 LCIS Increased lifetime risk of breast CA increased 8 fold (either side regardless of LCIS location). No SLN needed. Pleomorphic LCIS is more aggressive and should be treated similar to DCIS and excised for negative margins (unnecessary for tradiational LCIS). No radiation needed for either type.

11 INCREASED RISK A. ADH-atypical ductal hyperplasia B. Intraductal papilloma C. Flat epithelial atypia D. Papilloma with atypia E. Sclerosing adenosis 1. Associated with 4x risk of CA (ADH) 2. Recommend use of chemoprevention (ADH) 3. Highest risk of malignancy at surgical excision (D)

12 Increased risk ADH and ALH are both associated with a 4 fold increased lifetime risk of breast CA. Discussion of chemoprevention is recommended for ADH and ALH. The risk of breast CA increases with multifocality of the atypia. Flat epithelial atypia (on core bx) should be excised but is not an indication for chemoprevention. Papillomas should be excised to R/O concomitant malignancy and are the most common cause of pathologic nipple discharge. Papillomas with atypia have the highest risk of concurrent malignancy at rates greater than 20% at excision.

13 Inflammation Periductal mastitis- Often related to smoking. Can create abscesses and fistulas. Idiopathic Granulomatous Mastitis Noncaseating granulomas centered on lobules. Can create abscesses and fistulas. NOT related to smoking, occurs in younger patients, often associated with a recent pregnancy. Often burns out spontaneously in 6-12 months. Bx and CLOSELY OBSERVE to R/O inflammatory breast CA

14 ALH- Atypical Lobular Hyperplasia All of the following are FALSE about ALH except. A. Breast CA risk is increased 8X (4) B. Annual MRI is recommended (inconclusive) C. Tamoxifen decreases cancer risk by 1/3 (50-86%) D. Lumpectomy and SLN are recommended E. Risk of breast cancer increases with multifocality.

15 Core bx to excision If found on a core bx, all of the following should be excised to R/O upgrade EXCEPT A. Atypical ductal hyperplasia B. Atypical lobular hyperplasia C. Lobular carcinoma in-situ D. Papilloma E. Ductal Ectasia

16 DCIS A 56 yo has 2 cm of intermediate grade ductal carcinoma in situ found on final path report after surgical excision. Which is TRUE? A. SLN bx is recommended at time of lumpectomy. (only if >5cm, palpable, associated with microinvasion, or mastectomy). B. Aromatase inhibitor is drug of choice for adjuvant therapy. (they have not been studied with DCIS). C. Tamoxifen is recommended after bilateral mastectomy. D. If invasive disease is found on final pathology, postmastectomy radiation would be indicated. E. Radiation is recommended after lumpectomy. (decreases local recurrence rate).

17 Mastalgia A B C D E Cyclical mastalgia Noncyclical mastalgia Costochondritis Cervical radiculopathy Breast cancer (incidence 3-7% with pain) 1. Point tenderness with palpation 2. Responsive to caffeine abstinence 3. Shoulder pain 4. Most commonly related to menopause c a d b

18 Mastalgia Cyclical mastalgia- intermittent breast pain, sometimes quite severe, perimenstrual. Wide area of the breast but isolated to the breast tissue. Noncyclical mastalgia- constant. Not associated with cycle. Point or localized tenderness in one breast. Menopause is common inciting event for this mastalgia. Rx- proper bra fitting, caffeine and tobacco abstinence, vitamin E, evening primrose oil, soy. For severe cases, adjusting OCPs and estrogen replacement therapy, danazol, gestrinone, and even tamoxifen.

19 Mastalgia Costochondritis- costochondral or costosternal inflammation of the cartilage at joints from ribs 2-5. Tietze syndrome is costochondritis with associated swelling of the joints. (displace the breast to examine the costochondral junction and differentiate from breast pain) Rx- reassurance and NSAIDS Cervical Radiculopathy with compression of nerve roots C6 and C7 can be associated with pain in the region of the breast. Not true breast pain. Associated with shoulder pain. Rx-eliminate nerve root compression.

20 Mastalgia IF pain is ever associated with breast cancer, it is usually focal, intense, and unilateral. Incidence of breast cancer in cyclical and noncyclical mastalgia is generally low (3-7%). Many people with breast pain worry they have breast cancer. Some patients falsely believe that because they have pain, it can NOT be cancer.

21 MRI Breast MRI is recommended in which of the following patients? A. Hx of breast augmentation. B. Pre-operatively for breast reduction or augmentation. C. Hx of breast CA with lumpectomy and radiation. D. Lifetime risk of breast CA 16% E. Previous therapeutic mantel radiation. (age <=30

23 Mondor Disease A 38 yo presents to your office with (see photo). The next step in management is A. Diagnostic mammogram B. Ultrasound C. Punch biopsy D. Excisional biopsy E. Reassurance

24 Mondor Disease Superficial thrombophlebitis of the subcutaneous veins- most commonly in the anterolateral thoracoabdominal wall (which includes the breast) but also other portions of the body. Cordlike induration. Cause unknown, perhaps associated with trauma. Self-limiting.

25 MRI + mammogram? True or False? If a woman is at high enough risk (20-25% lifetime risk of developing breast CA) to qualify for a breast MRI, then a mammogram is not needed that imaging year.

26 Nipple Discharge Which of the following require duct excision? A. Milky discharge from both breasts? (TSH and prolactin to R/O pituitary tumor) B. Yellow discharge from multiple ducts C. Green discharge from 2 ducts D. Dilated ducts with core showing ductal ectasia E. Bloody discharge from a single duct (consider galactogram to R/O peripheral lesions, ultrasound can show intraluminal lesions).

27 Papillomas Mammography typically negative. U/S may show intraluminal lesion. Galactography may show intraluminal filling defect and could demonstrate a need for needle localization of more peripheral lesions. Could upgrade to DCIS or Invasive Ductal carcinoma (usually papillary type).

28 Mixed epithelial stromal proliferation A 45 yr old presents with an 8 cm mass in her breast with some skin discoloration at the apex of the mass (blue). Core bx reveals mixed epithelial stromal proliferation. The next step should be A. Lumpectomy and SLN B. Modified radical mastectomy C. Punch bx of skin (not inflammatory) D. Chemoradiation E. Simple mastectomy (no nodes)

29 Phyllodes tumors Fibroepithelial tumors of the breast 1% of breast tumors Women Spread hematogenously if malignant so SLN is not needed. CXR appropriate. Enucleation is not appropriate because of high local recurrence rate. Chemoradiation does not play a role in the initial management.

30 Panel Testing Asbs guidelines Nccn guidelines

31 Panel Testing BRCA1 and BRCA2 remain the most likely genes to be found PALB2 CHEK2 ATM CHEK2 and ATMcan have low to moderate penetrance and may not express a malignant phenotype TP53 (Li-Fraumeni) PTEN (Cowdens sydrome)

34 Lymphedema Which of the following is TRUE regarding lymphedema following breast surgery? A. It does not occur with sentinel lymph biopsy. (6.9%, increases with radiation) B. It seldom affects quality of life. C. Weight loss does not reduce upper- extremity lymphedema. D. Laser therapy provides no treatment benefit. E. It is not exacerbated by physical activity.

35 Lymphedema New machine coming to Wesley to help diagnose early lymphedema. 3 stages of lymphedema Swelling Fibrosis Fatty deposition Need to anticipate and catch EARLY! Physical therapy, manual drainage, pneumatic pump, low-level laser,?surgery?

36 New Survivorship Clinic! Wichita finally has a survivorship program open and running! Connie Luty, APRN with decades of experience in women s health will see patient with a breast concern or HX OF BREAST CANCER to guide them through recovering and thriving Brochures available

37 Choosing Wisely Campaign Choosing Wisely is an initiative of the ABIM Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. American Society of Breast Surgeons

38 Choosing Wisely (Breast) Do not routinely. order breast MRI in new breast CA patients excise all axillary nodes in patients having lumpectomy for breast cancer order specialized tumor gene testing in all new breast cancer patients (oncotype) re-operate on patients with invasive cancer close to edge of lumpectomy tissue perform bilateral mastectomy in patients with a single cancer

39 3D mammography DBT-Digital Breast Tomosynthesis Recall reduction Fewer patients made BI-RADS 3 Increased invasive cancer detection No increase in in situ detection

42 Breast Implant-Associated Anaplastic Large Cell Lymphoma Possible association identified in 2011 by the FDA Additional information is being gathered to try to better characterize ALCL in women with implants (FDA and WHO). More likely associated with textured implants (both silicone and saline filled) although smooth implants also have been associated. 359 cases with 9 deaths as of 2/1/ reports of implant type and 203 textured vs 28 smooth

43 Breast Implant-Associated Anaplastic Large Cell Lymphoma Recommendations for health care providers: RARE. Usually associated with persistent seromas. Prophylactic removal of asymptomatic patients is NOT recommended. MRI at 3 years after silicone gel placement and every 2 years thereafter (per FDA).

44 Intra-operative Radiation One time intraoperative radiation therapy coming to Wesley Medical Center. Strict criteria for qualification Still considered experimental/investigational by BCBS of KS but approved by Medicare and other insurance companies

45 New in cancer Node negative and yet still getting chemo Node positive and NOT getting chemo Avoiding radiation over 70 3 weeks of radiation rather than 6 Intraoperative radiation x 1???! Panel testing 3d mammography

Benign Breast Disease. David Anderson, MD Assistant Professor of Clinical Surgery

Benign Breast Disease. David Anderson, MD Assistant Professor of Clinical Surgery Benign Breast Disease David Anderson, MD Assistant Professor of Clinical Surgery Overview Nipple Discharge Breast infection Breast Pain Gynecomastia Fibroepithelial lesions High Risk Lesions-Papilloma,