Mary Smania, DNP, FNP-BC Clinical Practice Champion Assistant Professor Michigan State University College of Nursing

Identify evidence based routine screening guidelines for women of all ages Identify the elements of a clinical breast exam Differentiate the breast management options based on the patient complaint Identity breast diagnostic imaging options related to breast complaints

Breast Anatomy Breast Cancer

Most common cancer among women, other than skin cancer. 2 nd leading cause of cancer death in women, after lung cancer Just over 200,000 women in the United States will be found to have invasive breast cancer 40,480 women will die from the disease There are approximately 2 ½ million breast cancer survivors in the US ACS (2008)

Risk factors Female Increases with age + Family history Hormonal influences

Osuch, Sparks, Pathak, Barry, & Haan Hughes, L.E., Mansel, R.E. & Webster, D.T (1989)

Osuch, Sparks, Pathak, Barry, & Haan Hughes, L.E., Mansel, R.E. & Webster, D.T

Ages 20-30 s-clinical breast exam (CBE) as part of their periodic health exam at least every three years Ages 40 and above-clinical breast exam every year And when patient has symptoms or concerns or in follow up of the same

Breast health history should be completed with a women s well exam Include personal and family history of breast or ovarian cancer History of breast cancer Menstrual history-menarche, menopause, age at first live birth History of radiation to the thoracic cavity

Length of the exam varies based on breast size and clinician technique Includes inspection and palpation in different positions

First while patient is in the sitting position Arms at sides, arms above head, hands on hips Looking for symmetry, dimpling, retractions, peau d orange

Patient in lying position with arm over the head Cover the entire area of the breast from the mid-axillary line to the sternum and from the clavicle to just below the bra line Use the pads of the fingers not the tips Use a vertical strip pattern started at axilla

Supraclavicular Infraclavicular Axillary

Mastectomy sites-use the same parameters Vertical strip method is similar to mowing a lawn using overlapping strips Pressure applied at light, medium and deep levels

Mammography started in 1960, but modern mammography has existed only since 1969 when the first x-ray units dedicated to breast imaging were available. By 1976, mammography as a screening device became standard practice

An x-ray of the soft tissue of the breast Screening mammogram-2 views of each breast are taken. CC view or Cranio caudal view and MLO View or mediolateral oblique

Focus on getting more information about a specific area (or areas) of concern usually due to a suspicious screening mammogram or a suspicious lump May include compression or magnification views Can be used to evaluate patients who have signs and/or symptoms of breast disease, imaging findings of concern, or prior imaging findings requiring specific followup. Diagnostic mammography requires direct supervision

Breast Imaging Reporting And Data Systems American College of Radiology guidelines and standards for report mammographic findings Clear-cut recommendations to providers

0-Assessment incomplete-need additional imaging evaluation or films for comparison 1-Negative 2-Benign Findings 3-Probably Benignshort interval follow up needed 4-Suspicious abnormality-biopsy should be considered 5-Highly Suggested of malignancyappropriate action should be taken 6-Known biopsy- Proven malignancy

Microcalcifications Nodule Density

Smooth borders Round Calcifications appear vascular Benign calcifications Irregular borders Spiculated Linear pattern Pleomorphic-different shapes/sizes Clustered Benign Suspicious

Benign calcifications Suspicious calcifications

Ultrasound has been used since the early 1950 s Most helpful and accurate in the evaluation of the dense breast Can differentiate between fluid-filled cysts and solid masses

Ultrasound is not used for routine breast cancer screening because it does not consistently detect certain early signs of cancer such as microcalcifications Operator dependent- not used for routine screening

Can be used for palpable lump or thickening especially for women under 30 or with normal mammogram Can be used to evaluate breast pain in conjunction with mammography

Posterior enhancement Smooth Round Anechoic-without echoes Irregular boarders Shadowing Hypoechoic-giving off few echoes; said of tissues or structures that reflect relatively few of the ultrasound waves directed at them. Lobulated Benign Suspicious

Breast Cancer enhance with gadolinium MRI can detect early breast cancer not detected by mammogram-sensitivity 77-100% Not influenced by breast density, less influenced by silicone No radiation

Recommend breast MRI to all BRCA1/2 mutation carriers Discuss option of breast MRI to all women with greater than 19% lifetime risk of breast cancer And women with 15-19% risk and dense breasts or LCIS

BRCA1/2 mutation carriers First-degree relative with BRCA mutation and are untested Lifetime risk of Breast cancer of 20-25% or more

Received radiation treatment to the chest between the ages of 10-30 Carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li Fraumeni or Cowden s)

Who? How frequently? Is mammogram necessary? How to schedule with other imaging? Mortality benefit Undue anxiety

Cost Low specificity (recall, biopsies) Increased anxiety with recall Low sensitivity for DCIS (ductal carcinoma in situ) Techniques not standardized Requires MRI guided biopsy

Breast lumps Nipple discharge Breast pain

History and CBE Mammogram or ultrasound Referral or follow up

Location Method of discovery Size Duration Hormonal influences Characteristics of tenderness

Normal CBE=Absence of mass thickening or asymmetry Any asymmetrical mass, even if only a 2 dimensional thickening, presentation an abnormal finding on CBE

Pre-Menopausal Dominant mass Questionable mass or thickening Mammogram (over 30) or ultrasound Preceding referral? Reexamine day 3-10 of cycle Mass still present Yes Referral No Routine screening Osuch, et al (2003)

Post-menopausal Dominant mass or thickening Referral followed by or preceding mammogram/ultrasound Osuch, et al (2003)

Humes et al (2000)

Benign-aberrations of normal development and involution Cyst Fibroadenoma Fibrocystic tissue Malignant

Breast cysts Fibrocystic tissue fibroadenoma

Fibroadenomas are common in adolescents and women in their 20-30 s Cysts are most common in women in their 40 s Benign breast nodularity is common in all premenopausal women and uncommon after age 55 In women over 55 the most common etiology of a breast mass is cancer

First goal: Characterization of the CBE finding if visible Second goal: Detection of Occult Abnormalities Ultimate goal: To rule out breast cancer

Used to further characterize a mammographic mass The primary role of ultrasonography is to differentiate a fluid-filled cyst from a solid mass. Ultrasonography also is used for imaging examinations of women with palpable findings even in the absence of mammographic abnormality to differentiate a solid from a cystic mass. This is especially helpful to women with dense breasts.

Eisenberg (2003)

To distinguish a cyst from a solid mass To accomplish an expedient diagnosis To accomplish therapeutic drainage and pain relief To establish the etiology of a cyst as benign To provide optimal CBE free of interfering masses

Eisenberg (2003)

Core biopsy Open biopsy

Core biopsy Fine needle aspiration

Eisenberg (2003)

Refer for biopsy Normal findings of a sonographic evaluation in the presence of a palpable mass does not exclude carcinoma; clinical management is needed

25 year old presents complaining of lump in her left breast that has been present for the past 3 months. She noted the lump when she was showering and states that the lump is tender to touch at times. She has no other health issues. She has no history of breast or ovarian cancer in her family. She is a student at MSU. CBE-2 cm firm nodule at 3 o clock of the left breast. Not affixed to the skin-mobile. No nipple discharge, skin changes.

What is your next step?

Ultrasound shows 2.5 x 1.5 smooth breast nodule with appearance of fibroadenoma What is your next step?

56 yo white female presents for annual examination. She is post-menopausal. She has a family history of mother with breast cancer at age 60 and sister with breast cancer at age 51. She is currently taking prempro for severe hot flashes. She has taken hrt for the past 5 years. She had her yearly mammogram 2 months ago-normal. CBE thickening at 12 o clock of the right breast approximately 3 cm in size, not affixed to skin, firm. Pt. has not noted this thickening herself. It is not tender to palpation. What is your next step?

Ultrasound is normal. What is your next step?

The most common breast complaint

66% of women report breast pain The most common breast complaint Causes anxiety and worry Etiology often unknown Commonly hormonally influenced Self-limiting in 80-85% of patients

Location Duration Unilateral/bilateral Rank on 10 point scale Relation to hormones Lifestyle Worry

Cardiff Mastalgia Clinic:1982 15% of cancer patients presented with breast pain, most of whom had masses on self exam 7% of cancer patients presented with mastalgia alone-unilateral, localized constant and persistent

Diagnostic work up Supportive bra Caffeine, Reassurance No sign of breast cancer Common symptom Self limited

Nipple Discharge Non-Spontaneous Spontaneous Normal Physiology Pathology Osuch, et al (2003)

Spontaneous Color One duct/more than one Unilateral/bilateral Duration Persistent

Nipple Discharge Single duct Multiple Ducts Probable benign Possible cancer Probable benign breast pathology Duct Ectasia Osuch, et al (2003)

Unilateral single duct nipple discharge Bloody, Serous or watery Will not resolve spontaneously Surgical Intervention required

Bloody or Serous intraductal papilloma, duct ectasia and Carcinoma 75-85 represent an intraductal papilloma-benign neoplasm Watery Highest incidence of Carcinoma

50 yo white female presents with left breast pain that has been present for 2 months. States the pain occurs when she bumps her breast or when she lies on her left side. Family hx of mother with breast cancer at age 65. Recent mammogram normal. Previous breast biopsies x 2-benign. Exam shows small nodule approximately 1 cm at 12 o clock left breast that is tender to palpation. What do you do next?

Ultrasound shows small septated cyst appears benign.

Bland K.I. & Copeland, E.M. (1998). The Breast: Comprehensive Management of Benign and Malignant Disease (2 nd Ed.). Philadelphia: W.B. Saunders Co. Eisenberg, R.L.. (2003). Clinical Imaging: An Atlas of Differential Diagnosis, 4 th Edition. [Electronic Version}. Lippincott Williams & Wilkins. Hughes, L.E., Mansel, R.E. & Webster, D.T. (Eds.) (1989). Benign Disorders and Diseases of the Breast-concepts and Clinical Management (pp. 5-13). London: Bailliere Tindall. Humes, HD, DuPont, H.L., Gardner, L.B., Griffin, J.W., Harris, E.D., Hazzard, W.R., King, T.E., Loriaux, D.L, Navbel, E.G., Todd, R.F., Traver, P.G. (Eds.). (2000). Kelley s Textbook of Internal Medicine {Electronic Version]. Philadelphia: Lippincott Williams & Wilkins. Osuch, J.R., Sparks, B.T., Pathak, D.R., Barry, H.C. & Zuber, T.J., (2003). Essentials of Breast Care. Participant Manual at the Breast and Cervical Control Conference, Traverse City, MI.