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Diagnostic
Studies
•Diagnostic MGM
•Breast US – cystic or solid ; does not show
microcalcifications!!!
•Breast MRI - younger pts with very dense breasts
•Percutaneous Bx
FNAB - cytology
Needle core bx
Image guided vs non image guided
•Open bx – take to the OR
Diagnostic MGM
•Done when signs or symptoms are present
•Review of previous images when available
•Often includes specialized views such as
• spot compression and magnification
Breast US
•Not used for screening
•Distinguishes a solid from cystic lesion
•Adjunct to MGM
•Used for guiding percutaneous bx of solid
• nodules palpable and nonpalpable
•Not useful for bx of microcalcifications
Breast MRI
•Very limited use—no role for routine screening
•High risk young women with very dense
• breasts with nondiagnostic MGM
•Post neoadjuvant chemotherapy to assess
• for BCT
•Pts with silicon breast implant
•Must be done in a dedicated center with
• experience in interpreting breast MRI and
• capable of MRI directed bx
FNAB
•Image guided—US or stereotactic but not absolutely necessary
•Simple, low morbidity and expeditious- - can have the result at
time of visit if a cytopathologist is available
•Sensitivity 65-98%
•False positives rare, about, 0.2%
•Requires a skilled cytopathologist
•Gives cytology and NOT histology- -cannot distinguish invasive
from noninvasive ca
•Unless it is clearly benign, suspicious, or shows cancer cells, it
is nondiagnostic;
Repeat FNA or use alternative bx technique
High n/c ratio; very rude pile on top of each other,
pleomorphism\
Needle Core Bx
•Image guided—stereotactic or US but not
necessary for an easily palpable mass
•Gives histology, thus, can distinguish in situ
from invasive cancer
•Requires at least 24hrs to have the result
Stereotactic Bx
•Smaller scar than open bx and minimal
anesthesia
•Accuracy=99%, similar to wire localized
excisional bx; however, if malignant, wire
localized excision will be required
•Discordant results require further evaluation
•MGM follow up of benign bx at 6 months
•Contraindicated if pt cannot lie prone, lesion
too faint or superficial for digital imaging
US Guided BX
•More comfortable and quicker than
stereotactic bx
•Not useful for lesions not seen on US such as
microcalcifications
•Discordant results require further evaluation
•US and MGM follow up benign bx at 6 months
Excisional Open Bx
•The highest accuracy for DX but more
• invasive than percutaneous bx
•Combined with wire localization for
• nonpalpable lesions
•Specimen imaging mandatory for wire
• localized excision
Wire localized Specimen MGM
Specific Benign Entities
•Fibrocystic condition – very common
•Mastodynia
•Simple cyst
•Complex cyst
•Fibroadenoma
•Gynecomastia
•Nipple Discharge
•Breast Abscess
Fibrocystic Condition (Changes)
•Clinical manifestations of breast tissue
• response to cyclical hormonal changes
•Often associated with mastodynia or
• mastalgia
Question 9
• A 42-year-old woman with a history of "fibrocystic
condition" undergoes excision of microcalcifications in her
breast which were detected on mammography. The
histologic finding associated with the highest risk of
developing subsequent breast cancer is:
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A. duct ectasia
B. squamous metaplasia
C. sclerosing adenosis
D. florid hyperplasia
E. atypical ductal hyperplasia
Pathological Changes
Sometimes Associated with
Fibrocystic changes
•Non-proliferative changes (RR=1.0)
-cysts, mild hyperplasia of the usual type
•Proliferative lesions without atypia
• (RR=1.5-2.0)-moderate or florid
• hyperplasia, intraductal papilloma,
• sclerosing adenosis
•Atypical hyperplasia(RR=4.0-5.0)
• -ADH, ALH
Question 10
• Which of the following treatments has been shown
to provide relief of symptoms in more than 50% of
patients with cyclical breast pain?
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A. Evening primrose oil
B. Vitamin E
C. Ginger supplements
D. Elimination of caffeine
E. Weight loss
BLOODY NIPPLE DISCHARGE
Question 11
• A 23 y.o lady presents with fever and breast
abscess; she has NKDA. The BEST treatment is:
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A. Empiric cephalexin
B. Empiric trimethoprim/sulfamethoxazole (TMX)
C. Incision and drainage alone
D. Incision and drainage, C & S, empiric cephalexin
E. Incision and drainage, C & S, empiric TMX
Question 12
• The following statements are true regarding ductal
carcinoma in situ EXCEPT :
•A. Precursor of invasive ductal cancer
•B. Usually presents as microcalcifications
on MGM
•C. Never presents as palpable mass
•D. Incidence is rising probably due to
increasing use of MGM
•E. Dx’d by stereotactic core or wire localized
bx
Noninvasive Breast CancerDuctal Carcinoma in Situ (DCIS)
Precursor of invasive ductal cancer
Age of occurrence same as for invasive cancer
Usually presents as microcalcifications
on MGM
Rarely presents as palpable mass
Incidence is rising probably due to
increasing use of MGM
Dx’d by stereotactic core or wire localized
bx
Question 13
• A 39-year-old woman has a 1x1x1-cm focus of
microcalcifications in the lower outer quadrant of her left
breast. No mass is palpable. Stereotactic core biopsy shows
ductal carcinoma in situ, non-comedo type. The next step in
management should be:
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A. total mastectomy
B. a mirror image biopsy of the right breast
C. axillary sentinel node dissection
D. radiation therapy to the left breast
E. wide excision of the microcalcifications with assessment of the margins
Treatment of DCIS
•BCT consisting of breast conserving
• surgery (margin free excision) if pt has
• unicentric disease and RT or
• total mastectomy if BCT is contraindicated
•Axillary staging not needed
•Recurrences after BCT can be invasive
• ca or noninvasive
•Tamoxifen if pt is hormone receptor positive.
Question 14
• Which of the following is least likely to be
diagnosed by mammography?
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A.Comedocarcinoma
B. Lobular carcinoma in situ
C. Radial scar
D. Phyllodes tumor
E. Ductal carcinoma in situ
Lobular Carcinoma In Situ- -LCIS
•Marker of pts at increased risk of having
• invasive breast cancer
•>80% occur in premenopausal women
•Not apparent on CBE or MGM
•Incidental microscopic finding
•Relative risk 6-12 for developing invasive
• breast cancer in either breast
•1% per yr risk of developing invasive ca
•Family hx may further increase the risk
Question 15
• Which of the following statements about LCIS
is NOT true?
• A.Tamoxifen decreases the risk of invasive cancer
• B. Pts. have an increased risk of bilateral breast
cancer
• C. Calcifications or a palpable mass are usually
absent
• D. Resection with negative margins is required
• E. It is most common in premenopausal women
Management of LCIS
•Close observation (CBE Q 6 months,
• annual MGM, monthly BSE)
•Tamoxifen
•Bilateral, prophylactic mastectomy with
• or without reconstruction in select pts
Question 16
• The most common histologic type of invasive
breast cancer is which of the following?
• A. Lobular carcinoma.
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B. Papillary carcinoma.
C. Colloid carcinoma.
D. Medullary carcinoma.
E. Ductal adenocarcinoma
Invasive Breast Cancer (IBC)
•Invasive ductal (70-75%)
•Invasive lobular (5-10%)
•Special types: medullary, tubular, mucinous
• or colloid, papillary (less biologically
• aggressive)
Question 17
• In a 60-year-old woman, US guided core biopsy of a
1-cm in diameter breast mass shows infiltrating
ductal carcinoma. At the minimum, therapy should
include:
• A. excision of the mass with negative margins only
• B. total mastectomy
• C. partial mastectomy, sentinel lymph node biopsy, and
radiation therapy to the breast
• D. chemotherapy with cyclophosphamide and doxorubicin
• E. radiation therapy to the breast only
Neoadjuvant, Induction or Primary
Chemotherapy- -Indications
•Locoregionally advanced breast cancer as
• part of multimodality therapy, then MRM
• followed by RT; enhanced survival
•To downsize a tumor for BCT, particularly
• for tumors large relative to the breast- • no survival advantage
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Question 18
• A 45 yo woman had multicentric breast cancer the
largest focus 1.3 cm infiltrating ductal cancer, ER+,
PR-, HER/2 neu neg; 1/3 SLN was +; the next BEST
operative option is:
• A.Total mastectomy
• B. Modified radical mastectomy
• C. Radical mastectomy
• D. Simple mastectomy
Treatment of Invasive Breast
Cancer (IBC)
•Dependent on TNM stage, hormone
• receptor status, menopausal state,
• overexpression HER2/neu receptor
•Locoregional and Systemic
AJCC Staging (Early Stage, 2010; 7th
edition)
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Stage 0
Stage IA
Stage IB
Stage IIA
Stage IIB
TisN0M0
T1N0M0
T0-T1 N1miM0
T0-1N1M0, T2N0M0
T2N1M0, T3N0M0
AJCC Staging (Advanced)
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Stage IIIA
Stage IIIB
Stage IIIC
Stage IV
T0-3N2M0, T3N1M0
T4 N 0-2M0
Any T N3M0
Any T Any N M1
Locoregional Therapy
•Locoregional: Surgery + Radiation Therapy
• (RT)
•Breast Conserving Therapy (BCT) =
• Breast Conserving Surgery (BCS) + RT
•Total mastectomy (if BCT is
• contraindicated)+reconstruction
• Axillary staging- sentinel lymph node bx
• and/or level 1 and 2 ALND
Contraindications to BCT
•Multicentric cancers
•Diffuse malignant appearing
• microcalcifications
•Previous breast irradiation
•Pregnancy (unless radiation is provided
• after delivery)
•Collagen vascular disease
• (relative contraindication)
Mastectomy for Primary Operable Breast
Cancer
•Patient preference for mastectomy
•Multicentric tumor
•Difficulty with follow-up anticipated
•Inability to achieve negative margin
• with BCS
•Contraindication to radiation therapy
Indications for
Postmastectomy Radiation
• Tumor > 5cm
• T4
• > 4 +LNs
Sentinel Lymph Node
Systemic Therapy
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Chemotherapy- -CMF; AC; AC + Taxol
Hormonal– Tamoxifen(anti-estrogen);
Arimidex (aromatase inhibitor); Femara (AI)
Immunologic—Trastuzumab (Herceptin)—
monoclonal Ab vs HER2/NEU receptors;
Bevacizumab (Avastin)-humanized
monoclonal Ab vs VEGF
Neoadjuvant, Induction or Primary
Chemotherapy- -Indications
•Locoregionally advanced breast cancer as
• part of multimodality therapy, then MRM
• followed by RT; enhanced survival
•To downsize a tumor for BCT, particularly
• for tumors large relative to the breast- • no survival advantage
•
Question 19
• A 55 yo woman had left partial mastectomy for a 2.2
cm ER+, PR+, HER2/neu –ve infiltrating ductal cancer;
0/3 SLN was positive; resection margins were
negative. The BEST postoperative management is:
• A. Adjuvant chemotherapy followed by radiation therapy
• B. Adjuvant chemotherapy followed radiation therapy and then hormonal
Rx
• C. Radiation therapy followed by hormonal therapy
• D. Chemotherapy followed by hormonal therapy
• E. Oncotype Dx detrmination to help in selecting the best treatment
combination
Adjuvant Systemic Therapy
Cytotoxic
Hormonal
Biologic
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Oncotype DX
•A multigene assay to predict recurrence of
tamoxifen-treated, node-negative breast cancer
•3 risk categories
•Low risk—6.8%
•Intermediate risk—14-3%
•High risk—30.5%
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Paik et al: NEJM 2004; 351:2817-26
Breast Cancer in Pregnancy
•Infrequent
 California registry study-1.3 breast ca
Dx’d per 10,000 live births
Delay in Dx results in late stage at Dx
Neither the pt nor physician suspects cancer
Stage for stage, prognosis not different
Most tumors poorly differentiated, ER and
PR neg and approx 30% HER-2/neu pos
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Evaluation for Breast Cancer in
Pregnancy
•CBE
•MGM with shielding-accuracy > 80%
•US to assess the breast and RLN and to
• guide bx
•Core bx preferred to FNA
•Maternal fetal medicine consultation
•Sentinel LNbx with radionuclide safe but
• blue dye
Question 20
• A 30 y.o. woman who is 14 weeks pregnant has a 2.5
cm. dominant slightly tender mass in the left breast.
Biopsy shows grade II infiltrating ductal carcinoma.
She has no palpable adenopathy. The best treatment
now would be:
• A. Partial mastectomy with sentinel lymph node bx followed by
radiotherapy
• B. Partial mastectomy with ALND, followed by adjuvant chemotherapy
• C. Modified radical mastectomy
• D. Modified radical mastectomy followed by adjuvant chemotherapy
• E. Neoadjuvant chemotherapy followed by partial mastectomy
Question 21
• A 34 y.o.woman who is 20 weeks pregnant has a 2.3
cm dominant, slightly tender mass in the LT breast.
Core bx shows infiltrating ductal carcinoma. She
should be advised that:
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A. Preopearative Tamoxifen Rx is safe and effective
B. Chemotherapy is contraindicated
C. Breast conservation is an option
D. Sentinel node biopsy is a significant risk to the fetus
E. She should avoid all future pregnancies
Management of Breast Cancer
in Pregnancy
•RT contraindicated during pregnancy,
• can be delayed until postpartum if ca Dx’d
• 2nd or 3rd trimester as part of BCT
•Indications for chemotherapy the same but
• NOT to be given during the 1st trimester
•Chemotherapy may be given during 2nd
• and 3rd trimesters but not after week 35 to
• avoid the potential for hematologic
• complications at time of delivery
•Taxanes, trastuzumab and hormonal drugs should
• not be used during pregnancy