Que faire avec les maladies des seins en maladie grave

1. Que faire avec les maladies des seins en maladie grave? Anastasia Ammon FLMI, ACS, AALU AVP Tarification & Tarificatrice en chef maladie grave Pr�sent� pour l�Association Qu�b�coise des tarificateurs-vie Le 17 mai 2007

2. Remerciements Merci � nos tarificateurs et notre d�partement de recherche et d�velopement!! Jean-Marc Fix FSA, MAAA Vice-Pr�sident , R & D Dr. Abdelnour Khoury MD, Directeur Recherche m�dicale Guy Royer Assistant vice-pr�sident gestion de risque

3. Maladies b�nignes des seins Nous allons �valuer plusieurs conditions Caract�ristiques Changement prolif�ratif et non prolif�ratif Risque relatif Facteurs de risques Interpr�tation des mammographies et �chographies Implants mammaires Tarification

4. Questions/r�ponses�.. Qu�est-ce qui devrait nous inqui�ter ? Histoire familiale Comment l�histoire familiale a un effet sur l�incidence? Quelle information additionnelle sera requise et est-ce que �a fait du sens ? Quelles sont les exigences requises pour reconsid�ration? Quand le risque devient-il trop grand pour consid�rer?

5. Anatomie du sein The breast is composed mainly of epithelium, fibrous tissue and fat interacting in a constantly changing hormonal environment. There is an important amount of glandular tissue in the upper outer portion of the breast. This is responsible for the tenderness in this region that many women experience prior to their menstrual cycle. It is also the site of half of the breast cancers and benign breast conditions such as fibroadenoma�s, cysts, and hyperplasia. There is also duct ectasia and intraductal papilloma�s originating in the ducts. The breast of younger women are primarily composed of glandular tissue. Which make it more difficult interpreting mammograms. The breast is composed mainly of epithelium, fibrous tissue and fat interacting in a constantly changing hormonal environment. There is an important amount of glandular tissue in the upper outer portion of the breast. This is responsible for the tenderness in this region that many women experience prior to their menstrual cycle. It is also the site of half of the breast cancers and benign breast conditions such as fibroadenoma�s, cysts, and hyperplasia. There is also duct ectasia and intraductal papilloma�s originating in the ducts. The breast of younger women are primarily composed of glandular tissue. Which make it more difficult interpreting mammograms.

6. Maladies des seins Fibroad�nome Papillome intracanalaire Ectasie mammaire intracanalaire Maladies fibrokystiques des seins Dysplasie mammaire Tumeurs phyllodes Microcalcifications Kyste (disparait sur aspiration) N�crose adipeuse Benign changes in breast tissue maybe associated with invasive breast cancer in the future. 'Fibrocystic disease' is the general term applied to the majority of benign changes. The changes may be precursor lesions that may, and may not necessarily progress through increasing malignant phases. The above changes in the breast are often difficult to distinguish from malignant tumors and must be watched for a change in size, lymphatic involvement, in which case the growth should be cut out and examined. Mammograms, ultrasound, FNA of cystic forms can aid in the diagnosis. Benign changes in breast tissue maybe associated with invasive breast cancer in the future. 'Fibrocystic disease' is the general term applied to the majority of benign changes. The changes may be precursor lesions that may, and may not necessarily progress through increasing malignant phases. The above changes in the breast are often difficult to distinguish from malignant tumors and must be watched for a change in size, lymphatic involvement, in which case the growth should be cut out and examined. Mammograms, ultrasound, FNA of cystic forms can aid in the diagnosis.

7. Fibroad�nomes Tumeurs b�nignes solides, les plus communes. Affectent habituellement les femmes ag�es de 20-30 ans. R�pondent aux hormones. Ils sont mobiles et de formes rondes. Diagnostiqu�s par cytoponction � l�aiguille fine � l��chographie: rebords ac�r�s, �choes internes uniformes et sont plus larges que hautes. According to the American Cancer Society, African-American women are affected with fibroadenomas more than any other racial or ethics groups. There are 2 types of fibroadenoma complex and non-complex types. They are hormonally responsive and may increase in size toward the end of each menstrual cycle. If they have a very characteristic appearance they can be followed with regular reexamination. Some women have only one fibroadenoma while others may have multiple. They can also stop growing or even shrink on their own without any treatment. In these cases doctors may recommend not having the tumors removed. According to the American Cancer Society, African-American women are affected with fibroadenomas more than any other racial or ethics groups. There are 2 types of fibroadenoma complex and non-complex types. They are hormonally responsive and may increase in size toward the end of each menstrual cycle. If they have a very characteristic appearance they can be followed with regular reexamination. Some women have only one fibroadenoma while others may have multiple. They can also stop growing or even shrink on their own without any treatment. In these cases doctors may recommend not having the tumors removed.

8. Papillomes intracanalaires Tumeurs des canaux galactophores Affectent habituellement les femmes ag�es entre 30-40 ans. �coulement mamelonnaire (s�reux ou h�morragique). L�sions multiples semblent plus susceptibles au d�veloppement d�un carcinome. The most frequently observed symptom is nipple discharge which may be bloody or serous. Bloody discharge is present in approximately 50% of cases. Multiple intraductal papillomas tend to occur in younger women and are less often associated with nipple discharge. Tend to be less than 1.0 cm in diameter usually 3-4 mm. Some can be as large as 4 cm. Current evidence suggests that these rarely undergo malignant transformation ( 1 lesion). Usually diagnosed by imaging the breast duct with a galactogram (ductogram) or removing a portion of the affected duct (duct excision). The most frequently observed symptom is nipple discharge which may be bloody or serous. Bloody discharge is present in approximately 50% of cases. Multiple intraductal papillomas tend to occur in younger women and are less often associated with nipple discharge. Tend to be less than 1.0 cm in diameter usually 3-4 mm. Some can be as large as 4 cm. Current evidence suggests that these rarely undergo malignant transformation ( 1 lesion). Usually diagnosed by imaging the breast duct with a galactogram (ductogram) or removing a portion of the affected duct (duct excision).

9. Ectasie mammaire canalaire �largissement et durcissement du canal Affecte typiquement les femmes dans leur quarantaine et cinquantaine �coulement mamelonnaire (s�reux, p�teux ou h�morragique). Inversion mamelonnaire. Masse avec r�traction mamelonnaire peut �tre confondue pour un carcinome The nipple and surrounding tissue may be red and tender. Most often unilateral but bilateral involvement may be seen. It can be characterized by a thick green or black nipple discharge (20% of cases). Clear nipple discharge can also be often due to duct ectasia or cyst. Nipple inversion have undergone fibrosis and shortening is seen in about 30% to 40% of cases. Most case improve with application of heat or antibiotic drugs. Occasionally the affected duct is surgically removed. The nipple and surrounding tissue may be red and tender. Most often unilateral but bilateral involvement may be seen. It can be characterized by a thick green or black nipple discharge (20% of cases). Clear nipple discharge can also be often due to duct ectasia or cyst. Nipple inversion have undergone fibrosis and shortening is seen in about 30% to 40% of cases. Most case improve with application of heat or antibiotic drugs. Occasionally the affected duct is surgically removed.

10. Sein fibrokystique / Dysplasie mammaire Condition/maladie du sein la plus commune. Occurence clinique chez 50% des femmes Pr�sence plus fr�quente chez les femmes ag�es entre 35 et 50 ans. Habituellement secondaire � la r�ponse du niveau hormonal. Sympt�mes varient de: kystes, fibrose, aspect noduleux, r�gions d��paississement et sensibilit�es. Fibrocystic breast disease can also be referred as Mammary dysplasia. The condition is characterized by round lumps that move freely within the breast tissue. These lumps are usually tender to the touch, in contrast to a cancerous growth which is often neither nor tender or freely movable when touched. The texture of the lumps can vary from soft to firm. Often the cysts fills with fluid and can enlarge premenstrually in response to the increase in hormonal levels during this time. With these repeated hormonal cycles the breast cysts may become chronically inflamed and surrounded by fibrous tissue which can harden and thicken the cysts. Fibrocystic breast disease can also be referred as Mammary dysplasia. The condition is characterized by round lumps that move freely within the breast tissue. These lumps are usually tender to the touch, in contrast to a cancerous growth which is often neither nor tender or freely movable when touched. The texture of the lumps can vary from soft to firm. Often the cysts fills with fluid and can enlarge premenstrually in response to the increase in hormonal levels during this time. With these repeated hormonal cycles the breast cysts may become chronically inflamed and surrounded by fibrous tissue which can harden and thicken the cysts.

11. Sein fibrokystique suite� Menace typiquement les deux seins dans le QSE (Quadrant sup�rieur externe) et la surface inf�rieure du sein. Cancer difficile � d�tecter lors de la mammographie. �chographie et aspiration � l�aiguille fine sont requises pour un diagnostique pr�cis. Typically in both breasts in the upper outer quadrant and the underside where a ridge may sometimes be felt. For an accurate diagnosis a surgical biopsy may be performed. The needle aspiration helps relieve the pressure from the cyst on the surrounding tissue if it is causing pain as well as ruling out breast cancer. Symptoms of fibrocystic change usually stop after menopause but may be prolonged if a woman is on HRT. Typically in both breasts in the upper outer quadrant and the underside where a ridge may sometimes be felt. For an accurate diagnosis a surgical biopsy may be performed. The needle aspiration helps relieve the pressure from the cyst on the surrounding tissue if it is causing pain as well as ruling out breast cancer. Symptoms of fibrocystic change usually stop after menopause but may be prolonged if a woman is on HRT.

12. Kystes mammaires Kyste simple vs. Kyste complexe. Occurence aussi jeune que 25 ans, plus commun entre les �ges de 35 � 50. Varient en nombre et taille. Aspiration � la fois diagnostique et th�rapeutique. Silencieux ou douleureux. Consistance d�pend de la quantit� de fluide. They appear to originate from the terminal duct lobular unit primarily through hormonally regulated widening and failure to shrink after menstruation or may arise from an obstructed duct. They are often solitary but may be multiple, they may develop suddenly or more gradually and may resolve rapidly. They are usually confirmed with a mammography and ultrasound. The ultrasound can differentiate whether it is in fact a cyst or solid mass. Most simple cysts are well defined, have distinct borders, and ultrasound signals are able to easily pass through them. However some cysts are difficult to interpret as simple cyst on ultrasound, these are called complex cysts as they appear similar to solid masses. If the cyst is causing discomfort, draining the cyst by FNA collapses them and eliminates the pressure pain. Some radiologist inject air into the area after drainage to help minimize the chances of recurrence. When cysts are drained , the fluid is usually discarded unless it is bloody or looks suspicious. They appear to originate from the terminal duct lobular unit primarily through hormonally regulated widening and failure to shrink after menstruation or may arise from an obstructed duct. They are often solitary but may be multiple, they may develop suddenly or more gradually and may resolve rapidly. They are usually confirmed with a mammography and ultrasound. The ultrasound can differentiate whether it is in fact a cyst or solid mass. Most simple cysts are well defined, have distinct borders, and ultrasound signals are able to easily pass through them. However some cysts are difficult to interpret as simple cyst on ultrasound, these are called complex cysts as they appear similar to solid masses. If the cyst is causing discomfort, draining the cyst by FNA collapses them and eliminates the pressure pain. Some radiologist inject air into the area after drainage to help minimize the chances of recurrence. When cysts are drained , the fluid is usually discarded unless it is bloody or looks suspicious.

13. Tumeurs phyllodes Tumeurs localis�es dans les tissus mammaires glandulaires et le stroma mammaire. Moins communes que les fibroad�nomes. Habituellement b�nignes. Elles peuvent �tre malignes et pourraient m�tastaser Traitement : tumorectomie. The difference between phyllodes tumors and fibroadenomas is that there is an overgrowth of the fibro-connective tissue in the phyllodes tumors. Treatment involves removing the mass and a one inch margin of surrounding breast tissue. The difference between phyllodes tumors and fibroadenomas is that there is an overgrowth of the fibro-connective tissue in the phyllodes tumors. Treatment involves removing the mass and a one inch margin of surrounding breast tissue.

14. N�crose adipeuse �paississement et cicatrisation dans le tissu adipeux. Habituellement le r�sultat d�une blessure au sein Occurence � n�importe quel �ge Peut �tre confondue � un cancer lors d�une mammographie. Tumeur irr�guli�re non mobile It can occur spontaneously or as a result of an injury to the breast. When the body attempts to repair damaged breast tissue, the affected area may sometimes be replaced with firm scar tissue. Symptoms of fat necrosis usually subside within a month, biopsy can confirm fat necrosis. According to the American Cancer Society, some areas of fat necrosis can have different responses to injury. Instead of forming scar tissue, the fat cells die and release their contents forming a sac-like collection of greasy fluid called an oil cyst. These can be diagnosed by FNA which also serves as a treatment. Another differentiation include the absence of axillary�s node enlargement and a previous history of sever injury at the site of the mass. It can occur spontaneously or as a result of an injury to the breast. When the body attempts to repair damaged breast tissue, the affected area may sometimes be replaced with firm scar tissue. Symptoms of fat necrosis usually subside within a month, biopsy can confirm fat necrosis. According to the American Cancer Society, some areas of fat necrosis can have different responses to injury. Instead of forming scar tissue, the fat cells die and release their contents forming a sac-like collection of greasy fluid called an oil cyst. These can be diagnosed by FNA which also serves as a treatment. Another differentiation include the absence of axillary�s node enlargement and a previous history of sever injury at the site of the mass.

15.  A= Carcinoma, usually a solitary lesion that is hard, irregular, non mobile, poorly delineated and not tender. B= Fibroadenoma, are usually firm, well delineated and painless. They are distinguished from carcinomas by their mobility and apparent lack of attachment to skin or fascia. C= Intraductal Papilloma, small round tumor located near the nipple. When pressure is applied over the tumor it can frequently cause a serous or bloody discharge from the nipple. The mass cannot be clinically distinguished from early carcinoma, excision is advisable. D= Fibrocystic disease; is the most common lesion of the breast. It consists of a diffuse and nodular fibrosis with cysts of various sizes. Fibrocystic disease can simulate carcinoma of the breast. It usually can be distinguished from it by the cyclic pain and recurrent increase and decrease in size of the mass during each menstrual cycle. E= Fat necrosis; Trauma to the breast may cause local fat necrosis, which presents as a hard, irregular non mobile tumor that is almost indistinguishable from carcinoma. Points of differentiation include absence of axillary's node enlargement and a previous history of severe injury at the site of the mass. A= Carcinoma, usually a solitary lesion that is hard, irregular, non mobile, poorly delineated and not tender. B= Fibroadenoma, are usually firm, well delineated and painless. They are distinguished from carcinomas by their mobility and apparent lack of attachment to skin or fascia. C= Intraductal Papilloma, small round tumor located near the nipple. When pressure is applied over the tumor it can frequently cause a serous or bloody discharge from the nipple. The mass cannot be clinically distinguished from early carcinoma, excision is advisable. D= Fibrocystic disease; is the most common lesion of the breast. It consists of a diffuse and nodular fibrosis with cysts of various sizes. Fibrocystic disease can simulate carcinoma of the breast. It usually can be distinguished from it by the cyclic pain and recurrent increase and decrease in size of the mass during each menstrual cycle. E= Fat necrosis; Trauma to the breast may cause local fat necrosis, which presents as a hard, irregular non mobile tumor that is almost indistinguishable from carcinoma. Points of differentiation include absence of axillary's node enlargement and a previous history of severe injury at the site of the mass.

16. Microcalcifications D�pots de calcium Seules ou en agr�gats� Signifient un changement dans le sein Cette condition pourrait indiquer une condition b�nigne ou un cancer du sein calcifications � calcium deposits, singular or in clusters, that are usually found by mammography.� Also referred to as macrocalcifications and microcalcifications.� It can signify a change within the breast which could result in close monitoring, more frequent mammograms and/or biopsy depending on its presentation. This condition could indicate non-cancerous (benign) breast conditions or breast cancer.calcifications � calcium deposits, singular or in clusters, that are usually found by mammography.� Also referred to as macrocalcifications and microcalcifications.� It can signify a change within the breast which could result in close monitoring, more frequent mammograms and/or biopsy depending on its presentation. This condition could indicate non-cancerous (benign) breast conditions or breast cancer.

17. Microcalcifications suite� caract�ristiques & probabilit� de malignit�; B�nignes: demie-lune, ovales, uniformes, dissemin�es et �largissement sur compression. Suspectes: ronde, variables en taille et forme, lin�arit� pr�cise, qui s��tendent, distribution en agr�gats sans �largissement sur compression. Clusters of numerous microcalcifications in one area can be a sign of ductal carcinoma in-situ or even invasive carcinoma. About half of the cancers found by mammography are detected as clusters of microcalcifications . Disseminated ; widely dispersed in a tissue, organ. Tiny calcium deposits are often the first indication of breast cancer. Clusters of numerous microcalcifications in one area can be a sign of ductal carcinoma in-situ or even invasive carcinoma. About half of the cancers found by mammography are detected as clusters of microcalcifications . Disseminated ; widely dispersed in a tissue, organ. Tiny calcium deposits are often the first indication of breast cancer.

18. Images mammographiques This mammogram demonstrates a lesion consistent with a neoplasm in the upper portion above and just to the left of the white dot marking the point the patient felt some pain on palpation. On biopsy, this was an infiltrating ductal carcinoma. A higher magnification of this lesion, demonstrating tiny peripheral calcifications, is seen on the right. Radiologists categorize the calcifications as malignant or benign based on (1) the location of calcifications, (2) the arrangement (linear or scattered or clusters) (3) the total number of micro calcifications (4) the changes with respect to the previous mammograms. This mammogram demonstrates a lesion consistent with a neoplasm in the upper portion above and just to the left of the white dot marking the point the patient felt some pain on palpation. On biopsy, this was an infiltrating ductal carcinoma. A higher magnification of this lesion, demonstrating tiny peripheral calcifications, is seen on the right. Radiologists categorize the calcifications as malignant or benign based on (1) the location of calcifications, (2) the arrangement (linear or scattered or clusters) (3) the total number of micro calcifications (4) the changes with respect to the previous mammograms.

19. Changements non-prolif�ratifs Ectasie canalaire Fibroad�nome Ad�nose Fibrose Kystes Hyperplasie �pith�liale l�g�re Mastite N�crose adipeuse Changement apocrine There are 2 types of changes seen on biopsies, proliferative changes which will see on the next slide and non-proliferative changes. Non-proliferative changes usually represent no increased risk. However �.There are 2 types of changes seen on biopsies, proliferative changes which will see on the next slide and non-proliferative changes. Non-proliferative changes usually represent no increased risk. However �.

20. Une femme qui a subit une biopsie mammaire b�nigne est 2 fois plus � risque que la population g�n�rale d�avoir un carcinome subs�quent. Why is that ? Well possible explanations are; surgery stimulates neoplastic change. Original biopsy overlooked in situ carcinomas, and the patient selection generally warrants closer surveillance. Why is that ? Well possible explanations are; surgery stimulates neoplastic change. Original biopsy overlooked in situ carcinomas, and the patient selection generally warrants closer surveillance.

21. Definitions Hyperplasie: une augmentation de nombre de cellules dans un organe ou dans un tissu. Hyperplasie atypique: une augmentation anormale de nombre de cellules dans un organe ou dans un tissu. Ad�nose: prolif�ration de tissue glandulaire sans augmentation de nombre de cellules dans un organe ou tissu.

22. Changements prolif�ratifs Hyperplasie canalaire Hyperplasie lobulaire Papillome Hyperplasie floride mod�r�e Ad�nose scl�rosante Hyperplasie canalaire atypique Hyperplasie lobulaire atypique Sclerosing adenosis, is a cellular proliferation which at lower-power magnification is limited to discrete areas and is lobular in configuration. It�s prime significance is its ability to mimic carcinoma. Adenosis very commonly contains microcalcifications which on mammography may raise the suspicion of carcinoma. Since it may occur as a palpable mass and because its pseudoinfiltrative appearance, it may create difficulties in differential diagnosis. All proliferative changes have an increase risk of invasive breast cancer. Sclerosing adenosis, is a cellular proliferation which at lower-power magnification is limited to discrete areas and is lobular in configuration. It�s prime significance is its ability to mimic carcinoma. Adenosis very commonly contains microcalcifications which on mammography may raise the suspicion of carcinoma. Since it may occur as a palpable mass and because its pseudoinfiltrative appearance, it may create difficulties in differential diagnosis. All proliferative changes have an increase risk of invasive breast cancer.

23. Risques relatifs Risque augment� (1.5-2 fois)-changement prolif�ratif Hyperplasie floride mod�r�e Ad�nose scl�rosante Papillome Risque augment� (4-5 fois)-Changement prolif�ratif Hyperplasie canalaire atypique Hyperplasie lobulaire atypique An increase risk of 4-5 times is not acceptable for CI coverage. An increase risk of 4-5 times is not acceptable for CI coverage.

24. Risques relatifs changements prolif�ratifs suite�

25. Risques relatifs changements prolif�ratifs, avec et sans histoire familiale Nearly 40% of women with a family history of breast cancer and atypical hyperplasia subsequently develop breast cancer. Tamoxifen reduces the risk of subsequent invasive breast cancer within 5 years by >80% in women with atypical hyperplasia. Tamoxifen also reduces the incidence of biopsies for BBD among women at risk for breast cancer. Estrogen replacement therapy lowers the risk of breast cancer in women with proliferative benign breast disease with or without atypia. Nearly 40% of women with a family history of breast cancer and atypical hyperplasia subsequently develop breast cancer. Tamoxifen reduces the risk of subsequent invasive breast cancer within 5 years by >80% in women with atypical hyperplasia. Tamoxifen also reduces the incidence of biopsies for BBD among women at risk for breast cancer. Estrogen replacement therapy lowers the risk of breast cancer in women with proliferative benign breast disease with or without atypia.

26. RR conditions b�nignes mammaires

27. RR conditions b�nignes mammaires suite�

28. Facteurs de risques 60-80% de tout les cancers du sein surviennent chez les femmes avec aucun facteur de risque. Simplement �tre une femme et vieillir nous mets � risque de d�velopper un cancer du sein.

29. Facteurs de risques suite� Histoire familiale Ant�c�dents personnels de maladie du sein Race/ethnicit� Susceptibilit� g�n�tique Women (and men) with first degree (i.e. mother, sister, daughter) relatives with breast, or related cancer have an individual risk of developing the disease that is two or three times greater than the general population. New evidence also suggests that if the relative�s cancer was diagnosed in the premenopausal period, an individual�s risk may be increased up to nine times that of an average woman. The overall incidence of breast cancer is higher in Caucasian women, compared with African-American, Hispanic, or Asian women; however, African-American women are more likely to develop breast cancer among all women less than 45 years of age and present with a more advanced stage. The importance of proper examination and mammography cannot be overemphasized for ALL women of color. Scientists estimate that mutations in the BRCA1 and BRCA2 genes may be responsible for about five to ten percent of all the cases of breast cancer and for about 25 percent of the cases in women under the age of 30. BRCA mutation testing is primarily done in certain families whose members are inclined to develop breast cancer at an early age. However, not all women with a family history of cancer have an identifiable genetic mutation when tested. Early menarche/late menopause Other contributing risk factors can include; Women ages 45 or older that have at least 75 percent dense tissue on a mammogram may be at increased risk for breast cancer. Women (and men) with first degree (i.e. mother, sister, daughter) relatives with breast, or related cancer have an individual risk of developing the disease that is two or three times greater than the general population. New evidence also suggests that if the relative�s cancer was diagnosed in the premenopausal period, an individual�s risk may be increased up to nine times that of an average woman. The overall incidence of breast cancer is higher in Caucasian women, compared with African-American, Hispanic, or Asian women; however, African-American women are more likely to develop breast cancer among all women less than 45 years of age and present with a more advanced stage. The importance of proper examination and mammography cannot be overemphasized for ALL women of color. Scientists estimate that mutations in the BRCA1 and BRCA2 genes may be responsible for about five to ten percent of all the cases of breast cancer and for about 25 percent of the cases in women under the age of 30. BRCA mutation testing is primarily done in certain families whose members are inclined to develop breast cancer at an early age. However, not all women with a family history of cancer have an identifiable genetic mutation when tested. Early menarche/late menopause Other contributing risk factors can include; Women ages 45 or older that have at least 75 percent dense tissue on a mammogram may be at increased risk for breast cancer.

30. Tests g�n�tiques Toujours un sujet de controverse. Il y a plus de 2000 mutations associ�es aux g�nes BRCA 1 et BRCA 2. Pas toutes les mutations BRCA portent le m�me risque de cancer. Les femmes qui sont test�s positivement aux mutations du g�ne BRCA sont 20-60% plus � risque de d�velopper un cancer ovarien en plus d��tre plus � risque de d�velopper le cancer du sein.

31. Qui devrait consid�rer tests g�n�tiques ? Les familles qui transf�rent typiquement les mutations du g�ne BRCA poss�dent les caract�ristiques suivantes: Cancer du sein chez 2 membres et plus de la famille du 1er degr� Cancer du sein chez des membres de la famille avant l��ge de 50 ans. Histoire de cancer du sein dans plus d�une g�n�ration. Cancer au niveau des deux seins chez un membre et plus de la famille. Occurence accrue de cancer ovarien. Both men and women may inherit and pass on BRCA1 or BRCA2 mutations. According to the Mayo Clinic, families that typically pass on BRCA defects have : see above. Plus Eastern and Central European (Ashkenazi) Jewish ancestry, with a family history of breast and or ovarian cancer ( researchers have identified 2 types of BRCA 1 mutations and one BRCA 2 mutation that are especially prominent in this group).Both men and women may inherit and pass on BRCA1 or BRCA2 mutations. According to the Mayo Clinic, families that typically pass on BRCA defects have : see above. Plus Eastern and Central European (Ashkenazi) Jewish ancestry, with a family history of breast and or ovarian cancer ( researchers have identified 2 types of BRCA 1 mutations and one BRCA 2 mutation that are especially prominent in this group).

32. D�couverte g�n�tique la plus courante: Le MammaPrint: Approuv� FDA (seulement aux E-U) Profile de 70 g�nes Risque de m�tastases Risque de r�cidive Non disponible � l��chelle mondiale

33. 1999 Femmes Ag�es 25-29

34. 1999 Femmes ag�es 45-49

35. Interpr�tations mammographiques et �chographiques: Trouvailles diff�rentes et elles signifient quoi? Les trouvailles sont-elles vraiment b�nignes ?? Protocoles cliniques Protocoles d�assurance maladie grave

36. BIRADS de l�ACR (American college of radiology) BI-RADS=Breast Imaging Reporting and Data System http://www.mammobase.com/BI-RADS.htm Des tonnes d�interprations utiles &d�finitions!!

37. BIRADS Cat�gories d��valuation Categorie 0: Imagerie additionnelle requise. Categorie 1: N�gatif; aucun commentaire. Categorie 2: Trouvaille b�nigne Finding for which additional imaging evaluation is needed. This is almost always used in a screening situation and should rarely be used after a full imaging work up. A recommendation for additional imaging evaluation includes the use of spot compression, magnification, special mammographic views, ultrasound, etc. There is nothing to comment on. The breasts are symmetrical and no masses, architectural disturbances or suspicious calcifications are present. Category 2; This is also a negative mammogram, but the interpreter may wish to describe a finding. Involuting, calcified fibroadenomas, multiple secretory calcifications, fat containing lesions such as oil cysts, lipomas, galactoceles, and mixed density hamartomas all have characteristic appearances, and may be labeled with confidence. The interpreter might wish to describe intramammary lymph nodes, implants, etc. while still concluding that there is no mammographic evidence of malignancy.Finding for which additional imaging evaluation is needed. This is almost always used in a screening situation and should rarely be used after a full imaging work up. A recommendation for additional imaging evaluation includes the use of spot compression, magnification, special mammographic views, ultrasound, etc. There is nothing to comment on. The breasts are symmetrical and no masses, architectural disturbances or suspicious calcifications are present. Category 2; This is also a negative mammogram, but the interpreter may wish to describe a finding. Involuting, calcified fibroadenomas, multiple secretory calcifications, fat containing lesions such as oil cysts, lipomas, galactoceles, and mixed density hamartomas all have characteristic appearances, and may be labeled with confidence. The interpreter might wish to describe intramammary lymph nodes, implants, etc. while still concluding that there is no mammographic evidence of malignancy.

38. BIRADS Cat�gories d��valuation Cat�gorie 3: L�sion probablement b�nigne � une surveillance � court terme est sugg�r�e. Cat�gorie 4: Anomalies suspectes � une biopsie devrait �tre envisag�e. Cat�gorie 5: L�sions fort suspectes de malignit� � une prise en charge ad�quate est recommand�e. Category 3: A finding placed in this category should have a very high probability of being benign. It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability. Data are becoming available that shed light on the efficacy of short interval follow-up. At the present time, most approaches are intuitive. These will likely undergo future modification as more data accrue as to the validity of an approach, the interval required, and the type of findings that should be followed. Category 4; These are lesions that do not have the characteristic morphologies of breast cancer but have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy. If possible, the relevant probabilities should be cited so that the patient and her physician can make the decision on the ultimate course of action. Category 5; These lesions have a high probability of being cancer. Category 3: A finding placed in this category should have a very high probability of being benign. It is not expected to change over the follow-up interval, but the radiologist would prefer to establish its stability. Data are becoming available that shed light on the efficacy of short interval follow-up. At the present time, most approaches are intuitive. These will likely undergo future modification as more data accrue as to the validity of an approach, the interval required, and the type of findings that should be followed. Category 4; These are lesions that do not have the characteristic morphologies of breast cancer but have a definite probability of being malignant. The radiologist has sufficient concern to urge a biopsy. If possible, the relevant probabilities should be cited so that the patient and her physician can make the decision on the ultimate course of action. Category 5; These lesions have a high probability of being cancer.

39. Image mammographique Generally, A younger woman has denser or fibro-glandular breasts. Her mammogram will look very white or "cloudy" Middle-aged women have a mixture of fibrous and glandular tissues (Figure 8-50-50 breast). Their mammograms look black and white. In a mature breast, most of the fibrous tissue is replaced with fatty tissue. The mammograms tend to look black or gray. Article volume 347:866 dated September 19,2002 in the NEJM; � there is great variation among women in the density of breast parenchyma as seen on mammograms. Mammographic density also varies inversely with age. Thus, younger women tend to have denser breasts than older women, but many older women also have dense breasts.� � The mammographic density of breast parenchyma depends on the amount of connective tissue and glandular tissue in the breast. Breasts dominated by adipose tissue, which appear less dense, are easy to assess with mammography. Thus, the most important clinical implication of denser breasts is that they are more difficult to evaluate with mammography. Generally, A younger woman has denser or fibro-glandular breasts. Her mammogram will look very white or "cloudy" Middle-aged women have a mixture of fibrous and glandular tissues (Figure 8-50-50 breast). Their mammograms look black and white. In a mature breast, most of the fibrous tissue is replaced with fatty tissue. The mammograms tend to look black or gray. Article volume 347:866 dated September 19,2002 in the NEJM; � there is great variation among women in the density of breast parenchyma as seen on mammograms. Mammographic density also varies inversely with age. Thus, younger women tend to have denser breasts than older women, but many older women also have dense breasts.� � The mammographic density of breast parenchyma depends on the amount of connective tissue and glandular tissue in the breast. Breasts dominated by adipose tissue, which appear less dense, are easy to assess with mammography. Thus, the most important clinical implication of denser breasts is that they are more difficult to evaluate with mammography.

40. Mammographie l�sions suspectes Solide, masse non palpable avec: Forme irr�guli�re, spicul�e ou marges mal d�finies, �paississement cutan� focal Agr�gats de microcalcifications de taille vari�e. R�gions de distorsions architecturales. (distorsion parenchymale) Masse solide dominante ou qui d�montre une croissance.

41. Masses et densit�s: Masses diff�rent des densit�s car elles sont vues sur deux plans alors que les densit�s sont vues sur un plan seulement. Masses with smooth rounded edge are generally a fluid-filled cyst that can be confirmed by an ultrasound and aspirated to relieve pain for the woman. Hard lesions with uneven edges might be reason for follow-up procedures. A fat containing mass looks radiolucent on the mammogram. Sometimes, it is very difficult for radiologists to differentiate between a benign and a malignant mass off mammograms, so additional imaging modalities and/or biopsy may be required. Masses with smooth rounded edge are generally a fluid-filled cyst that can be confirmed by an ultrasound and aspirated to relieve pain for the woman. Hard lesions with uneven edges might be reason for follow-up procedures. A fat containing mass looks radiolucent on the mammogram. Sometimes, it is very difficult for radiologists to differentiate between a benign and a malignant mass off mammograms, so additional imaging modalities and/or biopsy may be required.

42. L�sions spicul�es La fa�on la plus d�finitive de d�tecter le cancer Avec les cellules canc�reuses en prolif�ration,celles-ci sont vues en forme �toil�e ou l�sion st�llaire, avec des lignes radiaires irradiant dans toutes les directions � partir d�une r�gion centrale. A white star shape is characteristic of a malignant stellate lesion whereas the black star indicates a radial scar and post-traumatic fat necrosis. In advanced cases, spicules that approach the skin or muscle, cause retraction and localized breast distortion. A white star shape is characteristic of a malignant stellate lesion whereas the black star indicates a radial scar and post-traumatic fat necrosis. In advanced cases, spicules that approach the skin or muscle, cause retraction and localized breast distortion.

43. Mammographie Un examen de d�pistage est celui qui est effectu� sur une femme asymptomatique afin de d�tecter un cancer du sein qui est cliniquement non suspect�. The protocol depends on the specific facility. In America, four films are required of the breasts: two views for each breast. The protocol depends on the specific facility. In America, four films are required of the breasts: two views for each breast.

44. Image mammographique

45. Mammographie Une mammographie diagnostique est effectu�e chez une femme avec des signes cliniques ou sympt�mes sugg�rant un cancer du sein. �galement effectu�e lorsque qu�une �valuation mammographique suppl�mentaire a �t� demand� en raison d�un ant�c�dent de d�pistage mammographique anormal. Effectu�e chez une femme avec un ant�c�dent personnel de cancer du sein trait� par conservation du sein. Effectu�e chez une femme avec un ant�c�dent d�augmentation mammaire. A diagnostic mammogram takes longer than a screening mammogram because it involves more x-rays to obtain views of the breast from several angles. The technician may magnify a suspicious area to produce a detailed picture that can help the doctor make an accurate diagnosis. A diagnostic mammogram takes longer than a screening mammogram because it involves more x-rays to obtain views of the breast from several angles. The technician may magnify a suspicious area to produce a detailed picture that can help the doctor make an accurate diagnosis.

46. Abbr�viations M=Magnification XCCL= Cranio Caudal view eXaggerated to axilLa XCCM= Cranio Caudal view eXaggerated Medially CV= CleaVage AT= Axillary Tail RM= Rolled Medially RL= Rolled Laterally ID= Implant Displaced

47. �chographie mammaire Une �chographie peut faire la distinction entre des masses qui sont solides et des kystes liquides. Permet l��valuation de nodules palpables mais qui sont difficile � �valuer sur une mammographie sp�cialement dans les seins denses de jeunes femmes. Contrairement � la mammographie, une �chographie seule n�est pas utilis�e comme examen de d�pistage car elle ne peut d�tecter facilement les microcalcifications ou petites masses qui sont repr�sentatives de cancer. Ultrasound is unable to image microcalcifications, it may be able to detect macrocalcifications in some cases. Some breast lumps may go undetected on both imaging tests ( mammo and U/S), a lump may be felt, in these cases a FNA biopsy is often performed . Ultrasound is unable to image microcalcifications, it may be able to detect macrocalcifications in some cases. Some breast lumps may go undetected on both imaging tests ( mammo and U/S), a lump may be felt, in these cases a FNA biopsy is often performed .

48. Image �chographique

49. �chographie d�une masse solide maligne Mass is taller than wide, has irregular shape with irregular margins and posterior shadowing. Bx revealed carcinoma. Mass is taller than wide, has irregular shape with irregular margins and posterior shadowing. Bx revealed carcinoma.

50. Implants mammaires Aucune �tude significative concluant la relation entre le cancer du sein et les implants mammaires. Une mammographie diagnostique est habituellement effectu�e au lieu d�une mammographie de d�pistage (vues multiples). Interf�rence avec la mammographie. Interference with mammography due to breast implants may delay or hinder the early detection of breast cancer either by hiding suspicious lesions (wounds or injuries or tumors) or by making it more difficult to include them in the image. Implants increase the difficulty of both taking and reading mammograms. Mammography requires breast compression (hard pressure) that could contribute to implant rupture. In addition to special care taken by the technologist to reduce the risk of implant rupture during this compression, other techniques are used to maximize what is seen of the breast tissue during mammography. These techniques are called breast implant displacement views, Eklund displacement views, or Eklund views, after the radiologist who developed them. These special implant displacement views are done in addition to those views done during routine mammograms. Deposits of calcium can be seen on mammograms and can be mistaken for possible cancer, resulting in additional surgery to biopsy and/or remove the implant to distinguish these deposits from cancer. Calcium deposits may be felt as nodules (hard knots) under the skin around the implant. The displacement procedure involves pushing the implant back and gently pulling the breast tissue into view. Several factors affect the success of this special technique in imaging the breast tissue in women with breast implants. The location of the implant, the hardness of the capsular contracture, the size of the breast tissue compared to the implant, and other factors may affect how well the breast tissue can be imaged. Also, a radiologist may find it difficult to distinguish calcium deposits in the scar tissue around the implant from a breast tumor when he or she is interpreting the mammogram. Occasionally, it is necessary to remove and examine a small amount of tissue (biopsy) to see whether or not it is cancerous. This can frequently be done without removing the implant. At this time, there is no scientific evidence that silicone gel-filled breast implants can increase the risk of other cancers in women, but this possibility cannot be completely ruled out because the studies to evaluate the risk of other cancers have not been done. Interference with mammography due to breast implants may delay or hinder the early detection of breast cancer either by hiding suspicious lesions (wounds or injuries or tumors) or by making it more difficult to include them in the image. Implants increase the difficulty of both taking and reading mammograms. Mammography requires breast compression (hard pressure) that could contribute to implant rupture. In addition to special care taken by the technologist to reduce the risk of implant rupture during this compression, other techniques are used to maximize what is seen of the breast tissue during mammography. These techniques are called breast implant displacement views, Eklund displacement views, or Eklund views, after the radiologist who developed them. These special implant displacement views are done in addition to those views done during routine mammograms. Deposits of calcium can be seen on mammograms and can be mistaken for possible cancer, resulting in additional surgery to biopsy and/or remove the implant to distinguish these deposits from cancer. Calcium deposits may be felt as nodules (hard knots) under the skin around the implant. The displacement procedure involves pushing the implant back and gently pulling the breast tissue into view. Several factors affect the success of this special technique in imaging the breast tissue in women with breast implants. The location of the implant, the hardness of the capsular contracture, the size of the breast tissue compared to the implant, and other factors may affect how well the breast tissue can be imaged. Also, a radiologist may find it difficult to distinguish calcium deposits in the scar tissue around the implant from a breast tumor when he or she is interpreting the mammogram. Occasionally, it is necessary to remove and examine a small amount of tissue (biopsy) to see whether or not it is cancerous. This can frequently be done without removing the implant. At this time, there is no scientific evidence that silicone gel-filled breast implants can increase the risk of other cancers in women, but this possibility cannot be completely ruled out because the studies to evaluate the risk of other cancers have not been done.

51. Implants mammaires suite� Risque de rupture. Risque questionable d�association de rupture des implants de silicone et les maladies du tissu conjonctif. Ils ne sont pas garantie � vie. FDA web site; Rupture of silicone gel-filled implants may allow silicone to migrate through the tissues. The relationship of free silicone to development or progression of disease is unknown. Breast implants are not lifetime devices and cannot be expected to last forever. Some implants deflate or rupture in the first few months after being implanted and some deflate after several years; others are intact 10 or more years after the surgery. For silicone gel and saline-filled implants, some causes of rupture or deflation include damage by surgical instruments during surgery overfilling or underfilling of the implant with saline solution (specific only to saline-filled breast implants) stresses such as trauma or intense physical manipulation excessive compression during mammographic imaging injury to the breast normal aging of the implant unknown/unexplained reasons FDA web site; Rupture of silicone gel-filled implants may allow silicone to migrate through the tissues. The relationship of free silicone to development or progression of disease is unknown. Breast implants are not lifetime devices and cannot be expected to last forever. Some implants deflate or rupture in the first few months after being implanted and some deflate after several years; others are intact 10 or more years after the surgery. For silicone gel and saline-filled implants, some causes of rupture or deflation include damage by surgical instruments during surgery overfilling or underfilling of the implant with saline solution (specific only to saline-filled breast implants) stresses such as trauma or intense physical manipulation excessive compression during mammographic imaging injury to the breast normal aging of the implant unknown/unexplained reasons

52. BMJ 2003 march; 316 (7388): 527-528. The final study cohort comprised 3521 women, with a mean age of 31.6 (SD 8.6) years. The cohort members were followed for an average of 11.3 years. Although 58.7 deaths were expected, 85 women died (standardised mortality ratio 1.5, 1.2 to 1.8; table). Fifteen women committed suicide, compared with 5.2 expected deaths (2.9, 1.6 to 4.8). Excess deaths were also due to malignant disease (1.4, 1.0 to 1.9), mainly lung cancer. The number of deaths for all other causes was close to expected. Deaths due to malignancy were mainly linked to smoking, previously shown as common in our cohort.5 Given the well documented link between psychiatric disorders and a desire for cosmetic surgery, the increased risk for death from suicide may reflect a greater prevalence of psychopathology rather than a causal association between implant surgery and suicide.  BMJ 2003 march; 316 (7388): 527-528. The final study cohort comprised 3521 women, with a mean age of 31.6 (SD 8.6) years. The cohort members were followed for an average of 11.3 years. Although 58.7 deaths were expected, 85 women died (standardised mortality ratio 1.5, 1.2 to 1.8; table). Fifteen women committed suicide, compared with 5.2 expected deaths (2.9, 1.6 to 4.8). Excess deaths were also due to malignant disease (1.4, 1.0 to 1.9), mainly lung cancer. The number of deaths for all other causes was close to expected. Deaths due to malignancy were mainly linked to smoking, previously shown as common in our cohort.5 Given the well documented link between psychiatric disorders and a desire for cosmetic surgery, the increased risk for death from suicide may reflect a greater prevalence of psychopathology rather than a causal association between implant surgery and suicide.

53. Protocole clinique pour d�pistage du cancer du sein

54. Normes d�A/F en maladie grave Histoire familiale de cancer du sein ؠ���� Proposante �ge 50 < �ge 50 > Un membre du 1er degr� diagnostiqu� cancer du sein �ge 35 � 49 +50 +25 �ge 50 et plus +0 +0 Deux membres et plus du 1er degr� dx cancer du sein �ge 50 � 64 +50 +25 to +50 �ge 65 et plus +0 +0 Est-ce que ca va chang�? Based on the studies performed yes these ratings will in fact be changed. Some will become more conservative. Based on the studies performed yes these ratings will in fact be changed. Some will become more conservative.

55. Tarification courante en MG pour les maladies des seins La s�lection des risques devra inclure un RMT et copies des mammographies, �chographies et/ou copies des consultations en sp�cialit�. �ؠNouvelle microcalcification Diff�rer un (1) an ensuite r�f�rer au r�assureur � D�couverte d�une masse/nodule lors d�un examen ou une investigation mammographique en attente Diff�rer un (1) ans ensuite r�f�rer au r�assureur

56. Tarification courante en MG pour les maladies du seins. Maladie fibrokystique SANS BIOPSIE Stable, suivi r�gulier� �chographie requis si �g� de moins de 40 ans. Consid�ration individuelle si �g� de plus de 40 ans. Moins de un (1) an = DIFF�RER Moins de deux (2) ans = +50 Apr�s = +25 Autres = REFUS �

57. Tarification courante en MG sur les maladies des seins Maladie fibrokystique (Suite) AVEC BIOPSIE pathologie b�nigne Sans hyperplasie �pith�liale atypique = +50 Avec hyperplasie �pith�liale atypique = REFUS �

58. Rappelez-vous� Cancer repr�sente 76% des cas de r�clamations en maladie grave chez la femme. 1 femme sur 9 va �tre diagnostiqu�e avec le cancer du sein Soyez prudents lorsque vous tarifez les maladie des seins en maladie grave. Utilisez l�expertise de votre r�assureur et consultants m�dicaux.

59. MERCI! QUESTIONS?