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BREAST DISEASES
AUGUST 2013
Joel A. Okoli, MD, MPH, FACS
Associate Professor of Surgery
Division of Surgical Oncology
Morehouse School of Medicine
Atlanta, GA
OBJECTIVES
1.
2.
3.
4.
Understand the epidemiology of breast cancer
Know the screening and diagnostic modalities
Discuss the common benign breast diseases
Know the therapeutic approach to non-invasive and
invasive breast cancers
Question 1
• The following statements are true about breast cancer in the
US EXCEPT:
• A. Breast cancer is the leading cause of cancer mortality in women
• B. The mortality rate for breast cancer has been decreasing for the past
several years
• C. Stage for stage the prognosis for male breast cancer is similar to female
breast cancer
• D. Over 70% of women diagnosed with breast cancer have no family
history
• E. Breast cancer is a very heterogeneous disease, hence treatment must
be individualized
Epidemiology of breast cancer
•
•
•
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2012: 229,060 new cases
Females: 226,870 new cases
most common female cancer—30%
F: 39,510 deaths, 2nd only to lung ca
Males: 2,190 new cases; 410 deaths
AGE
•Birth - 39: 1 in 207
•40-59:
1 in 24
•60-79:
1 in 13
•Birth to death: 1 in 7
•
Jemal et al:CA Cancer J Clin 2005 55: 10-30
•2% of breast ca <30; 70% Dx’d > 50
•
•
Kearny& August: ACoS Breast Disease
Curriculum, 2003
•NO AGE GROUP IN WHICH THE PROBABILITY OF HAVING BREST CA IS ZERO
•
Question 2
• The following statements about breast cancer
epidemiology are false EXCEPT:
• A. The most important risk factor for breast cancer is increasing age
• B. From birth to age 39, the probability of getting breast cancer is 1 in
1000
• C. Using risk estimation models, it is possible to determine the risk of
breast cancer and thus determine the use of chemoprevention
• D. The incidence and mortality rates for African-Americans are higher than
for Caucasians
• E. Having the first child before the age of 30 decreases the risk of having
any type of breast cancer
Risk Estimation Models-Gail
•Based on age, menarche, age at 1st life
• birth, previous biopsies, atypical hyperplasia,
• breast ca in 1o relatives
•Provides 5-yr and life time (to age 90) risk
• estimate
•If for example, 5-yr risk > 1.66%, consider
• chemoprevention
•Overestimates risk in women not screened
• regularly
•Not useful in pts with prior breast ca ,DCIS or LCIS
•Not applicable if family history suggests HBC
Kearny & August: ACoS Breast Disease
Curriculum, 2003
Proven Risk Factors
•Gender F:M- -100:1
•Age
•Family history
•High risk lesions(ADH, ALH, LCIS)
•Early menarche, late menopause
•Nulliparity or first birth after age 30
•Radiation exposure
•HRT
•Alcohol consumption
Risk Estimation Models-Claus
•Includes information about :
No. of breast ca.
Age at onset
Paternal and maternal relatives
•Useful for women with a strong family hx of breast ca with unknown
• BRCA1 and BRCA2 status
Kearny & August: ACoS Breast Disease
Curriculum, 2003
Question 3
• The following statements regarding screening for
breast cancer are true EXCEPT:
• A. Mammogram is very sensitive so if it is negative, clinical breast
examination is unnecessary
• B. Ultrasonography is NOT a useful screening modality.
• C. While MRI is more sensitive than MGM, it is only recommended for high
risk populations when MGM is non diagnostic or as an adjunct to MGM in
select cases
• D. A lady whose mother had breast cancer at age 40 should have her
baseline MGM at age 30
• E. BSE while considered optional by American Cancer Society may
sometimes be useful
ACS Breast Ca Screening Guidelines
•Age 20-39
 CBE; monthly BSE (optional); MGM >25 if
risk is increased
•Age > 40
Annual MGM, CBE; monthly BSE
(optional)
•MGM and CBE are complementary as 10-15% of
breast cancers are only detected by CBE
•
CA Cancer J Clin 2009; 59:27-41 (Jan/Feb 2009)
Screening in High Risk Populations
 Annual Screening MGM & MRI beginning
at age 30 for:







Evidence Based-known BRCA carriers
1st degree relative of BRCA carrier (untested)
> 20-25% lifetime risk
Expert Consensus Opinion—
Radiation to chest between age 10 and 30 years
Li-Fraumeni syndrome and first-degree relatives
Cowden and Bannayan-Riley-Ruvalcaba syndromes and
first-degree relatives
Saslow, Boetes, Burke et al: CA Cancer J Clin 2007; 57:75-89
Screening MRI: Insufficient
Evidence for or against
• Lifetime risk 15–20%, as defined by BRCAPRO
• Lobular carcinoma in situ (LCIS),atypical lobular
hyperplasia (ALH), atypical ductal hyperplasia (ADH)
• Heterogeneously or extremely dense breast on
mammography
Saslow, Boetes, Burke et al: CA Cancer J Clin 2007; 57:75-89
Question 4
• The following statements about hereditary breast cancers are
true EXCEPT:
A. constitute 5-10% of all breast ca.
• B. Multiple generations
• C. Multiple 1o relatives
D. Both males and females are equally affected
E. When suspected consultation with a genetic counsellor is
useful
Effect of Screening on Mortality from Breast Ca
•In the US, 1975-2000: total reduction in
• mortality rate using 7 statistical models- • 28 to 65% (median, 46%).
•By 2000, approx. 70% of women >40
• had MGM in the previous 2 yrs.
Berry et al: NEJM 2005;353: 1784-1792
Findings Suggestive of Hereditary Breast Cancer
(HBC)
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•
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•
•
•
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HBCs constitute 5-10% of all breast ca.
Multiple generations
Multiple 1o relatives
Premenopausal breast ca
Bilateral breast ca
Family h/o ovarian ca
Family h/o other cancers
Kearny & August: ACoS Breast Disease
Curriculum, 2003
Question 5
• Genes associated with HBC include the
following EXCEPT:
A. BRCA 1 & 2
B. P53
C. CD 1
D. Possibly ATM
E. MSH2
FIGURE 2 Proportion of Breast Cancer Attributable to Known and Unknown Germline Genetic
Mutations
From Chen, Y.-C. et al.
CA Cancer J Clin 2005;55:45-54.
Copyright ©2005 American Cancer Society
Genes Associated with HBC
•BRCA1
•BRCA2
•P53 (Li-Fraumeni syndrome)
•CD1 (Cowden Syndrome)
•Possibly ATM (Ataxia Telangiectasia Mutated)
BRCA1 & BRCA2 Genes
•BRCA1
Chromosome 17q21
40-50% of HBC
50-85% risk of female breast ca
2nd breast cancer risk up to 65%
Ovarian ca - -20-40%
Male breast cancer-up to approx. 6%
Probable increased risk of prostate ca
Possible increased risk of colon ca
Wonderlick: Lynn Sage
Breast Cancer Program,
Northwestern CCC
Cancer and Genetics
•BRCA2
Chromosome 13q12
33-50%of HBC
50-85% risk of female breast ca
2nd breast cancer risk 50%
Ovarian ca- -10-20%
Male breast ca- - 6%
Increased risk of prostate ca
Possible increased risk of colon ca
Wonderlick: Lynn Sage
Breast Cancer Program,
Northwestern CCC
Cancer and Genetics
HBC Management
•Monthly BSE starting at age 18 y
•CBE, semiannually, starting at age 25
•Annual MGM and breast MRI screening starting at age 25, or individualized
based on earliest age of onset in family
•Discuss option of risk reducing mastectomy on case-by-case
• basis and counsel regarding degree of protection, reconstruction
• options
•Consider chemoprevention, discussing risks and benefits
•Advise about risk to relatives, genetic counseling and possible testing
• for at-risk relatives
•Education regarding signs and sxs of cancer(s) esp. those associated
• with BRCA gene mutations
•
NCCN Practice Guidelines-v.1.2006
Breast Evaluation
•The ultimate goal is to classify findings as:
Normal
Clearly benign
Possibly malignant
 Not always readily apparent hence,
consultation is necessary
Question 6
• During a modified mastectomy and axillary
dissection, which of the following nerves, if divided,
produces the least significant morbidity?
•
•
•
•
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A. Long thoracic nerve (respiratory nerve of Bell).
B. Intercostobrachial nerve.
C. Lateral pectoral nerve.
D. Axillary nerve.
E. Thoracodorsal nerve.
• 4 types of mastectomy
• Modified radical mastectomy – key difference is
pec major or NAH
• Radical mastectomy – entire breast is removed
with pec major, and axillary lymph node
dissection (level 1, 2, sometimes 3)
• Partial mastectomy
• Simple/total mastectomy – superior – clavicle
sternum, intermammary border; lateral border
of pectoralis major
• Pec minor NOTHING to do with it
Breast Evaluation
NON-HEALING NIPPLE ULCER
Question 7
• The following statements about breast cancer evaluation are
true EXCEPT:
A. Mammography can miss up to 10-15% of breast cancers
B. FNAB and needle core biopsy provide identical results
C. US bx is not useful for evaluation of microcalcifications
D. Stereotactic core bx is the modality of choice for evaluation
of suspicious microcalcifications
E. Wire localized excision is reserved for pts that are not
amenable for stereotactic core bx or those for definitive
surgical therapy of nonpalpable cancer
Screening Mammogram
•Asymptomatic pts
•Craniocaudal(CC) and Medial-lateral
• oblique (MLO)
•Previous images essential
•If screening is abnormal or inconclusive
• additional diagnostic imaging (special views
• and US) may be necessary
MICROCALCIFICATIONS
Question 8
A 41yoF had a screening MGM with equivocal finding and
reported as BIRADS 0; her next recommended action includes
any of the following EXCEPT:
A. Do nothing else as BIRADS 0 means she has nothing wrong
with her breast
B. Bring any previous MGMs for comparison with current one
C. Return for additional imaging for better definition of the
equivocal finding
D. Surgical consultation ideally should await complete radiologic
assessment
BIRADS- -Breast Imaging Reporting And Data
System
•0-incomplete study
•1-normal
•2-benign
•3-probably benign
•4-suspicious
•5-highly suspicious
•6-known cancer