Breast Cancer Screening

1. Breast Cancer Screening Margaret Thompson MD Breast Surgeon Cleveland Clinic Florida

2. Screening Recommendations

3. PREVIOUSGuidelines for Early Detection of Breast Cancer in Average-Risk, Asymptomatic Women • Age 20-39 • Clinical breast examination at least every 3 years • Breast self-examination • Age 40 and over • Annual mammogram • Annual clinical breast examination • Monthly Breast self-examination

4. October 20, 2015

6. Breast Self-Examination

9. Evaluating Breast Complaints & Masses

11. Screening Mammogram • Only imaging modality proven to reduce breast cancer mortality • 20-year follow-up before & after introduction of screening • Age 40-69, 44% reduction in breast cancer mortality Tabar, Lancet 2003

12. Diagnostic Studies • Diagnostic Mammogram • Targeted Breast Ultrasound • Breast MRI • Percutaneous CNB • USG CNB • SCNB • MRIG CNB

13. Screening vs Diagnostic Mammogram Screening Mammogram • No breast s/s • Goal is to find breast cancer when it’s too small to be palpated • Usually takes 2 views of each breast. • Some women, such as those with large breasts, may need to have more pictures to see as much breast tissue as possible.

14. Screening vs Diagnostic Mammogram • Diagnostic mammograms • Investigate possible problems • Lump, nipple discharge, pain, skin changes • Abnormal screening mammogram • Images reviewed by radiologist at same time •  Can be spot, rolled, magnification views • Better define calcifications, overlapping glandular tissue vs underlying lesion

19. Tomosynthesis (TOMO)=3D mammogram

20. Tomosynthesis (TOMO) = 3D Mammogram • Uses X-ray like the standard 2-D digital mammography • Tomo camera moves in an arc over the breast • Taking 15 mini-pictures within 4 seconds • These multiple pictures create layer-by-layer look of breast tissue, 1mm at a time • Thus, removing tissue overlap that may hide cancers or mistake dense breast tissue as tumors

21. Tomosynthesis (TOMO)=3D mammogram • Why is TOMO a better? • Less need for recalls • Fewer false-positives • Fewer invasive testing procedures • Earlier detection / treatment • Compression similar to or slightly less pressure than a standard 2-D

22. BIRADS Classification

23. Biopsy • 1 in 6 women Will Need A Breast Biopsy • Millions Performed Each Year • 80% Non Cancerous (5-7% High risk) • ↑ performed for Non-Palpable Lesions

24. Minimally Invasive Biopsy Techniques • Accurately dx malignant or pre-malignant breast lesions • Avoid an open surgical procedure for benign abnormalities • Allows additional breast imaging prior to initial therapy • Maintains patient eligibility for NACT trials • Fertility, plastic surgical, & genetic consultations can be obtained before definitive surgical excision • Optimizes oncologic & cosmetic surgical planning • Goal is to minimize # of surgical interventions • Surgery can more often be performed as a single procedure with clear margins • Resulting in fewer financial & nonfinancial burdens to the patient

25. Fine Needle Aspiration • FNA of Solid Masses • 25 – 28 gauge • Yields Cytological Information, Not Histological • Insufficient Data For Diagnosis In Up 36% Of Cases For Nonpalpable Lesions

26. Core Needle Biopsy

27. Vacuum Assist – CNB • Same General Principle As CNB, 7-11 gauge • Vacuum Used To Pull Tissue Into Sampling Chamber • Removed With High-Speed Internal Rotating Knives • Specimen Suctioned Into Chamber • Multiple Samples Removed Through Single-Insertion

28. Hand Held Vs Vacuum Asst

29. USG, SCNB, MRI Guided? • Depends on the target lesion • mass vsmicrocalcifications • Target location • mid-depth breast vs adjacent to skin or implant vs axilla • Intent to remove the entire lesion • Training & experience of person doing the biopsy

30. Stereotactic Core Needle Biopsy • Microcalcifications – • Indeterminate / Suspicious • Non-palpable Mammographic Solid Lesions • Asymmetric Densities • Lesion Seen In Only One View • Lesions Seen Only On Mammogram

31. Stereotactic Core Needle Biopsy

32. Ultrasound Guided CNB

33. MRI Guided CNB

34. Post Biopsy Mammogram Calcs Post biopsy clip

35. Open Surgical Biopsy • Increases • Repeated Surgery • Costs • Time to complete treatment

36. Wire / Needle Localization Breast Biopsy • Nonpalpable Lesions • Cannot Be Seen By Intraoperative US • Preoperative Wire Placement in Radiology • Painful • Anxiety • Delay to OR

37. I-125 Radioactive Seed Localization (RSL) • SEED vs WIRE localization • Significant benefit of RSL • Involved margin status • Re-operation rates • Reduced operative time • No stat sig diff • Volume of tissue excised

39. I-125 Radioactive Seed Localization (RSL)

40. Punch Biopsy • Inserted into center of skin lesion • Twist / turn with slight pressure, small plug of tissue removed

41. Management of Specific Benign Breast Complaints

42. Mastalgia • Most common breast complaint • Cyclical or noncyclical, idiopathic • Resolves spontaneously 20-30% • Recur 60% • R/t caffeine intake, PMS, hormone levels • Most respond to reassurance

43. Fibrocystic Changes • AKA Fibrocystic disease • Premenopausal, 30-50 yo • Lumpy bumpy on p/e • Treat symptoms / reassurance • FNA • Cytology if bloody aspirate • Clip placement • Not collapse  CNB

44. Management Mastalgia & Fibrocystic Changes • Avoid or ↓ Caffeine • Coffee, Tea, Sodas, Chocolates, Red Bull • Avoid or ↓ Nicotine • ↓ Salt Intake • Support / Sports Bra • Avoid Underwire Bra • Ibuprofen / NSAIDs • Warm Compresses / Heating Pad • Evening of Primrose Oil • Vitamin E

45. Nipple Discharge • Usually due benign condition • Physiologic d/c • Ductalectasia • Intraductalpapilloma • Characteristics • Self induced  counsel to stop • Spontaneous • Uni or bilateral • Uni or multiductal • Color - Milky, bloody, clear, darker green-brown • Posttraumatic, cyclical

46. Ductal Ectasia

47. Bloody Nipple Discharge • IntraductalPapilloma • Most common cause • 17% malignancy • Mammo, US, MRI, ductogram • Excision • Single duct excision • +/- Localization • Major duct excision

49. Fibroepithelial LesionsFibroadenomas • Most common benign breast lesion; 20-30 yo • Usual stable or slow growth • c/o solitary nontender mass • p/e smooth rubbery mobile mass • US, +/-mammogram, +/- CNB • Tx: monitor, close f/u q 6 m, surgical excision, cryoablation

50. Fibroepithelial LesionsPhyllodes Tumor • Similar to FAs • Rapid growth, larger sizes • Need CNB • Difficult to differentiate from FAs • Pathological dx on CNB needs surgical excision to r/o PT • Low, intermediate, high grade • Minimal metastatic potential, proclivity for LR, need 1 cm margin on excision