Breast Masses, Screening, High Risk Lesions and Cancer

Deanna J. Attai MD, FACSAssistant Clinical Professor of Surgery

David Geffen School of Medicine at UCLAPresident, American Society of Breast Surgeons

June 2015@DrAttai

Palpable Breast Mass

The breast does NOT normally feel like a fluffy cloud or a pillow!

Palpable Breast Mass

•The breast IS normally lumpy and bumpy

•Breast Self-Awareness: Goal is not to “find something” but to become aware of normal pattern, report changes

The Lumpy Bumpy Breast

Palpable Mass Fibrocystic breast condition

• Younger women • Clinical manifestations of

breast tissue in response to hormonal changes

• Discreet palpable mass or ridge, +/- tender, +/- fluctuates

• Ultrasound “normal fibroglandular tissue”

Palpable MassCyst, Fibroadenoma, Cancer

Cyst Fibroadenoma Cancer

These may all feel similar on palpation!

Simple Cysts• Often fluctuate with cycle• Not common in post-

menopausal women• Classic US appearance

• Simple cysts confirmed by US may be observed

• Aspiration for symptoms

Cyst Aspiration

Cysts – Intervention Required

• Complex cysts – hard to distinguish if cystic vs solid• Partially cystic / solid• Bloody aspirate - core biopsy to rule out malignancy• Multiple recurrence - core biopsy (uncommon)

Fibroadenoma

• 25% of normal breasts at autopsy• Peak age 20-30• More common in African American women• Multiple in ~15-20%• Most growth arrested by 2-3cm; may reach >10cm• Spontaneous infarction – pregnancy/lactation• Reports of regression 20-25%

FibroadenomaANDI – Aberration of Normal Development and Involution

• Benign biphasic lesions – epithelial and stromal component

• Usually well defined border, varying degree of stromal cellularity

• Malignancy uncommon• Observation, core biopsy, excision

Phyllodes Tumors

• 2.5% of fibroepithelial lesions• Hypercellular stroma• Age 40-45, average size ~4cm• Rapidly enlarging mass• Majority are benign• Malignant transformation rare

• Surgical excision with margin• Monitor for recurrence

Galactocele• Benign cyst with inspissated milk and desquamated

epithelial cells• Can lead to duct obstruction and inflammation• Pregnant, lactating women• Painless (often), firm, fluctulent mass• May become infected

• Workup: ultrasound• Treatment: aspiration depending on size, symptoms

Breast Abscess – PeripheralLactational vs Sporadic

• Mass, pain, redness, fever; deeper lesion more subtle presentation

• Almost always follows mastitis• Usually S. aureus• Continue breast feeding• Antibiotics (prolonged) + serial US

aspiration

•Always consider IBC!!

Palpable Breast Masses• Workup depends on age, risk, clinical suspicion

• <30: US, if benign usually clinical follow up +/- imaging • >30: Diagnostic mammogram + US• Minimally invasive core biopsy ALWAYS initial procedure of choice for BIRADS 4, 5 (suspicious) lesions

• “Triple Test” – concordant clinical exam, imaging and pathology

• High risk patient – start workup as above, formal risk assessment, consider genetic evaluation, additional imaging

• Every Woman Counts – Palpable Mass Evaluation• http://qap.sdsu.edu/screening/breastcancer/bda/index3.html

Mammography??Still Necessary… ??Every Year

• ACSwww.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs

• ACRwww.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BreastCancerScreening.pdf

• USPSTFwww.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/breast-cancer-screening1

Breast Cancer Screening Mammography

• Real concern about overdiagnosis / overtreatment• Interval cancers – more aggressive, missed on

screening

• Ideal = Individualized risk-based screening – we are not there yet

Breast Cancer ScreeningMammography

• Full field digital mammography• Same facility / compare

images

• 10-20% cancers not seen on mammogram

• 40-50% with dense breast

Breast Cancer ScreeningUltrasound

• Used to characterize an abnormality seen on mammogram

• May be helpful in women with dense breast tissue

• NOT FDA-approved for cancer screening; automated whole breast US approved as adjunct to mammogram

Breast Cancer ScreeningMRI

• High risk screening• Newly diagnosed, surgical

planning (controversial)

• Evaluates metabolic activity, IV contrast

• Will not show calcifications, low grade DCIS

• Up to 20% false positive

Breast Cancer ScreeningOther Imaging Studies

• Tomosynthesis• Contrast-enhanced mammography• BSGI – Tc-Sestamibi – diagnostic adjunct to mammography• Automated whole-breast ultrasound• PEM scanning – injection of FDG followed by breast imaging

– evaluate diagnosed breast cancer

• Thermography

BI-RADS Breast Imaging-Reporting and Data System

Assessment Categories:•Category 0 – Additional imaging needed•Category 1 – Normal•Category 2 – Benign findings•Category 3 – Probably benign (98%)•Category 4 – Suspicious (a, b, c)•Category 5 – Highly suspicious (>95%)•Category 6 – Known malignancy

BI-RADS Breast Composition Categories

Level 1Fatty Breast

Level 2Average Density

Level 3Heterogeneously

Dense

Level 4Extremely

Dense

Atypia, LCIS, DCIS, Invasive Cancer

26

High Risk Lesions:Atypical Hyperplasia

• Proliferative lesions that possesses some, but not all, of the pathologic features of carcinoma in situ

• Increased subsequent breast cancer risk• Family history may increase risk further

• If found on core biopsy – 10-20% risk of upstaging• Surgical excision recommended• Consider risk reduction with tamoxifen or raloxifene

High Risk Lesions:Lobular Carcinoma In-Situ

• Incidental microscopic finding – high risk marker• 1% risk per year of developing invasive cancer – ductal

or lobular, either breast• Family history may further increase risk

• Variable risk of upstaging• Surgical excision recommended• Consider tamoxifen or raloxifene

High Risk Lesion or Cancer?Ductal Carcinoma In Situ

• Typical presentation – mammographic calcifications

• Occasionally presents as palpable mass

• Incidence is rising due to increased mammographic screening

• Is it cancer???

Treatment of DCIS

• Lumpectomy +/- radiation• Mastectomy if extensive, can’t obtain clear margins• SNB if mastectomy performed• 50% of local recurrences are invasive• Tamoxifen or Anastrozole if ER+

• US trials – tamoxifen or letrozole x 3 months then surgery• UK trials – observation for low grade DCIS

Invasive Breast Cancer

Breast Cancer Statistics

•Most common type of cancer among women•1 in 8 women will develop breast cancer over lifetime

•Second most common cause of cancer deaths among women

•200,000 new cases and 40,000 deaths/year

•Male breast cancer 1 in 1000• ~2360 cases, 440 deaths/year

Breast Cancer Risk Factors

• Female, increasing age• Early menarche, late menopause, nulliparous• Atypical hyperplasia or LCIS • Prior history of breast, ovarian or colon cancer• Family history / Genetic mutation• Breast density• Chest wall irradiation (Hodgkins Lymphoma)• DES exposure in utero

Modifiable Risk Factors

• Breast Feeding• Lifestyle – alcohol intake, obesity, high fat diet, activity• Hormone replacement therapy• ?Chronic stress / inflammation• ?Pesticide / toxin exposure

HBOC Red Flags – BRCA 1/25-10% of all Breast Cancers

• Multiple 1st degree relatives, multiple generations• <Age 50 at diagnosis, <60 for “triple negative”• Bilateral breast cancer• Ovarian cancer – personal or family history• Other cancers in family - colon, prostate, pancreas• Ashkenazi Jewish with breast, ovarian, pancreatic in same

person or in same side of family• Family history of male breast cancer

Risk Assessment Models• Gail Model – not recommended with strong family

history – excludes 2nd degree and paternal relatives as well as other cancers

• Claus – more accurate if + family history; incorporates FH ovarian cancer. Unlike Gail does not include other risk factors

• Tyrer-Cusik (IBIS) – Risk of carrying BRCA 1/2 mutation and individual breast cancer risk – FH, other risk factors

• BRCAPRO – probability of having a BRCA 1/2 mutation with suggestive FH

• BrevaGEN – combines Gail + SNPs

Breast Cancer Risk Factors

75% of women with a newly diagnosed breast cancer have NO identifiable risk factors

All women (and men) are at risk

Pathology of Invasive Breast Cancer

• Infiltrating ductal cancer (70 - 75 %)• Infiltrating lobular cancer (5 - 10%)•Special types

• Medullary, tubular, mucinous or colloid, papillary, other• Inflammatory breast cancer is a subset of infiltrating ductal

Breast Cancer Staging

•Stage 0 – Ductal carcinoma in-situ

•Stage I – Tumor <2cm, negative lymph nodes•Stage II – Tumor 2-5cm OR spread to lymph nodes•Stage III – Tumor >5cm, OR fixed to skin / muscle, OR matted nodes, OR internal mammary nodes

•Stage IV – Metastatic disease (liver, lung, bone, brain most common)

Is It Breast Cancer?

Lump or thickening

Erythema, skin thickening

Nipple retraction or discharge

Breast Cancer Treatment

Local Therapy

42

Systemic Therapy

CANCER

LYMPH NODES

LUNGS

LIVER

HALSTED THEORY

BONE

Halsted Radical Mastectomy

• Aggressive surgery for what was often locally advanced disease

• Did not significantly improve (dismal) survival rate

• High incidence of overall morbidity, lymphedema, arm paralysis

• Described in 1894• Procedure of choice until 1960-70s

• Halsted died in 1922

CANCER

LYMPH NODE

FISHER THEORY

LUNGS

LIVER

BONE

BLOOD STREAM

Preoperative Evaluation

• Complete history and physical exam• Bilateral mammography, other imaging• Chest radiograph• Liver function studies• Further studies only when indicated by symptoms

• NO role for routine tumor markers, bone scan, PET/CT

Local Therapy: Stage I/II• Initial diagnosis by needle core biopsy• Absolute tumor size / location not contraindication to BCT• Sentinel node dissection if 1-2 + sentinel node (BCT)• +SN not a contraindication to breast conservation• Consider molecular profile of tumor, neoadjuvant therapy

• Mastectomy is an option based on patient preference, multicentric disease, contraindication to radiation, tumor size relative to breast size.

• Immediate reconstruction should be considered along with skin-sparing and/or nipple sparing approach

Goals of Breast Conservation

• Minimize local recurrence• Achieve an acceptable

cosmetic result• Minimize risk of complications • Maximize benefit in terms of

quality of life

Sentinel Lymph Node Dissection

• Very high accuracy (97%), Low false negatives• Routinely done for early stage patients

• Lower morbidity, faster recovery

Local Therapy• Stage III or Inflammatory breast cancer• Rule out metastatic disease• Neoadjuvant therapy followed by surgery, radiation

• Stage IV:• Surgery for the primary breast lesion controversial, appropriate

in selected cases

Breast Cancer TreatmentRadiation Therapy

• BCT: local recurrence• Mastectomy: local

recurrence, survival – tumor >5cm, ≥4 nodes (1-3 ongoing study)

• 5 days / week, 3-6 weeks depending on protocol

• APBI – 5 days• IORT

Breast Cancer TreatmentSystemic Chemotherapy

Trend is for more tailored and targeted therapy, and better predictors of who needs chemotherapy

•ER/PR, Her2/neu status, node status•Oncotype Dx, MammaPrint – predict recurrence without treatment, who will benefit from treatment

•Neoadjuvant chemotherapy for large tumors, Her2+, triple negative

Conclusions:

•The goal of breast evaluation is to classify findings as normal physiologic variants, clearly benign or possibly malignant

•Breast cancer risk assessment and screening is becoming more individualized

•Counsel regarding benefits of lifestyle changes•More surgery is not better for breast cancer•A multidisciplinary approach to the breast cancer patient is essential