Workup of Breast Masses

Transcription

1 Workup of Breast Masses 06/19/13 1 Primary authors: Ellen Yee, MD, MPH New Mexico VA Health Care System Albuquerque, NM Rachel Bonnema, MD, MS Omaha VA Medical Center Contributors: Linda Baier Manwell University of Wisconsin Madison Center for Women s Health Research Molly Carnes, MD, MS University of Wisconsin Madison Center for Women s Health Research 2 Objectives Review breast cancer screening and diagnostic modalities Discuss causes of breast masses Describe evaluation and diagnostic strategies Identify appropriate indications for a referral to a breast specialist Question #1 A 42 year old female comes to see you for a routine annual examination. Which of the following would you NOT include as part of your exam and discussion with the patient? A. Clinical breast exam B. Teaching about breast self exam C. Discussion about a screening mammogram D. I would include all of the above E. I m not sure, so I will answer after I hear the lecture! 3 4 Evaluation of the Breast Self breast exam Clinical breast exam Mammography Ultrasound MRI Fine needle aspiration Core needle biopsy Breast Self-Exam The USPSTF recommends against teaching breast self examination. Grade D recommendation 5 6 1

2 Breast Self-Exam Breast Self-Awareness Clinical Breast Exam USPSTF Recommendation is against TEACHING women breast self examination Harms include false positive results, which lead to increased anxiety and unnecessary visits, imaging, and biopsies Women should contact their provider if an abnormality is found on breast self exam USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of clinical breast examination beyond screening mammography in women age 40 and older Grade I recommendation 7 8 Clinical Breast Exam Technique: Vertical stripe pattern Duration: 5 10 minutes 63% sensitive when 5+ minutes spent on the exam Best performed after her period USPSTF, 2009; McDonald et al, USPSTF: Breast Cancer Screening The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including specific benefits and harms. (Grade C) Biennial screening mammography for women aged 50 to 74 years (Grade B) Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older (Grade I) 9 10 Question #1 Answer A 42 year old female comes to see you for a routine annual examination. Which of the following would you NOT include as part of your exam and discussion with the patient? A. Clinical breast exam B. Teaching about breast self exam C. Discussion about a screening mammogram D. I would include all of the above E. I m not sure, so I will answer after I hear the lecture! Question #2 All of the following tests are recommended and appropriate for breast cancer screening except: A. Mammography B. MRI C. Ultrasound D. They are all appropriate E. I m not sure, but I might not be teaching BSE to my patients

3 Mammography Screening Asymptomatic women 2 views (4 views if breast implants) Diagnostic Women with breast mass Spot, magnified views Decreased sensitivity in women <40 years Mammography misses 10 20% of clinically palpable breast cancers 13 MRI Pro: Advantageous for Screening patients at high risk Evaluating patients with a new breast cancer diagnosis Monitoring patients undergoing neoadjuvant chemotherapy Evaluating patients with metastatic axillary adenocarcinoma and unknown primary site Evaluation of silicone breast implant patients Con: Imperfect specificity due to overlap in the features of benign and malignant lesions Higher examination cost More limited availability 14 Ultrasound Use for diagnostic purposes: Women under age 30, pregnant or lactating women with focal breast symptoms Differentiate solid vs. cystic mass Evaluate non palpable mass on screening mammogram Masses too small or deep for aspiration Guide core biopsies if stereotactic mammography not available Question #2 Answer All of the following tests are recommended and appropriate for breast cancer screening except: A. Mammography B. MRI C. Ultrasound D. They are all appropriate E. I m not sure, but I might not be teaching BSE to my patients Question #3 Fine needle biopsies, core needle biopsies, and excisional biopsies can all both be used for breast mass diagnosis. A. True B. False Fine Needle Aspiration Uses gauge needle Used to evaluate cysts Non bloody fluid Does not need to be sent for analysis Bloody fluid Send for analysis; refer to breast specialist No fluid Solid mass: aspirate cells for cytology (no malignancy on cytology does NOT mean no cancer refer if residual mass)

4 Core Needle Biopsy Stereotactic mammography or ultrasound guided Uses gauge needle Evaluate non palpable lumps Evaluate palpable lumps Provides histologic tissue Vacuum-Assisted Core Needle Biopsy (VACNB) More tissue removed than without the vacuum 11 gauge VACNB can remove up to 1 cm of mammographic abnormality False Negative Rate 11 g VACNB 3% Non image guided CNB 13% Ultrasound guided CNB 5% 14 g VACNB 22% Triple Diagnosis for Palpable Masses Physical exam, mammography, and fine needle aspiration biopsy If all 3 tests suggest benign disease 0.7% of women had breast cancer Follow with physical exam every 3 6 months for a year If all 3 tests suggest malignancy 99.4% of women had breast cancer Refer for definitive therapy Clinical breast exam + mammogram has PPV of 96% Question #3 Answer Fine needle biopsies, core needle biopsies, and excisional biopsies can all both be used for breast mass diagnosis. A. True B. False Morris et al, 2001 and 2002; Clarke et al, Causes of Breast Masses Normal Structures Ribs, costochondral junction, inframammary fold, fat lobules, fibroglandular tissue Biopsy and scar tissue Cysts Fibroadenomas Fibrocystic changes Carcinomas Breast Mass Characteristics Benign Soft, firm, or cystic Regular Mobile Cancerous Solitary Hard Immobile Irregular 2 cm in size Clinical exam and characteristics are NOT reliable for definitive diagnosis: need further evaluation Barton et al,

5 Case 1 29 year old female, G0P0, presents for an annual exam. LMP was 25 days ago. She thinks she has a right breast mass area of thickening. She has no history of previous masses. Maternal aunt had breast cancer. She reports breast tenderness. There is an 1x1 cm area on right breast, right upper outer quadrant that is slightly tender, mobile, firm. Case 1 Differential: Cyst, fibrocystic changes, thickening, fibroadenoma, carcinoma Cysts Fibrocystic Changes Common in perimenopause May vary with menstrual cycle Round or oval Well circumscribed Smooth, firm, mobile Focal tenderness Normal finding Common in women ages ~60% of premenopausal women Rubbery, painful, diffuse, symmetric thickening Common in upper outer quadrants Spontaneous resolution in up to 20% of cases Treat symptoms: soft supportive bra, NSAIDs, acetaminophen Case 1 Question Case 1: Scenario 1 What would you do next? A. Reassure the patient and see her back in one year B. Biopsy the mass C. Follow up clinical breast exam in 4 6 months D. Refer to a breast specialist E. Order an ultrasound Ultrasound done no abnormalities Likely fibrocystic changes Follow up clinical breast exam in 4 6 weeks If residual mass, refer to breast specialist

6 Case 1: Scenario 2 Ultrasound done cyst Fine needle aspiration if tender or suspect infection Non bloody: do not send for cytology Bloody: send for cytology, refer to breast specialist No fluid: send tissue for cytology (no malignancy does not rule out cancer) Mass remains: refer to breast specialist No mass, no bloody aspirate: repeat CBE in 4 6 weeks, refer if mass recurs or if residual mass Case 2 A 49 year old female presents with a new right breast lump she noticed 1 week prior. No history of trauma to the breast. She had a normal mammogram 6 months prior. Previous breast exams showed no masses. Last breast exam was 9 months prior to presentation. G2 P0, s/p partial abdominal hysterectomy for fibroids. Family hx: +ovarian ca, breast ca, colon ca Case 2: Question 1 All of the following increase the risk of breast cancer in women ages except: A. Extremely dense breasts on mammogram B. First degree relative with breast cancer C. BMI 25 kg/m 2 D. Current use of oral contraceptives E. Prior benign breast biopsy result Answer to Case 2, Question 1 All of the following increase the risk of breast cancer in women ages except: A. Extremely dense breasts on mammogram B. First degree relative with breast cancer C. BMI 25 kg/m 2 D. Current use of oral contraceptives E. Prior benign breast biopsy result Nelson et al, Case 2, continued Case 2: Question 2 Exam shows: mobile, minimally tender, smooth 1 cm mass on right breast No axillary adenopathy bilaterally What would you do next? A. Reassure patient that because she had a normal mammogram 6 months ago there is nothing to worry about B. Repeat mammogram in 6 months C. Have patient return in one month and recheck breast exam D. Repeat mammogram now, with diagnostic views and ultrasound E. Refer to breast surgeon

7 Answer to Case 2, Question 2 What would you do next? A. Reassure patient that because she had a normal mammogram 6 months ago there is nothing to worry about B. Repeat mammogram in 6 months C. Have patient return in one month and recheck breast exam D. Repeat mammogram now, with diagnostic views and ultrasound E. Refer to breast surgeon Case 2 Test Results Mammogram New round 1.1 cm mass BIRADS 4 Ultrasound Irregularly marginated hypoechoic solid mass Case 2 Continued Testing Diagnostic mammogram and US: Birad 4, solid mass Core needle biopsy performed 1. Cancer: refer for definitive therapy 2. Negative for cancer: refer to breast specialist/surgeon 3. For lobular neoplasia, atypical ductal hyperplasia, phylloides tumor, lobular carcinoma insitu, and papillary lesions: refer to breast specialist/surgeon for open biopsy Gail Model: Breast Cancer Risk Assessment Tool Age Age at start of menarche Age at time of first live birth # of first degree relatives (mother, sister, daughter) who have had breast cancer Personal history of breast cancer or DCIS Ever had a breast biopsy Race/ethnicity Rockhill et al, 2001; Pankratz et al, Carcinoma Case 3 Typically singular, unilateral, persistent Typically non tender However, may present in a variable manner No physical exam reliably distinguishes benign vs. malignant masses Most common malpractice claim is failure to diagnose breast cancer If imaging is negative, but mass is present, refer to a breast specialist A 26 year old G1P1 female presents for her annual exam. LMP was 14 days ago. No personal or family history of breast cancer. Left breast has a 2x2 firm, non tender mass that appears mobile

8 Case 3, Question 1 An ultrasound shows a solid lesion, benign features, possible fibroadenoma. What would you do next? A. Follow up in 3 6 months with US and breast examination B. Obtain a mammogram C. Order core needle biopsy of the lesion D. Refer for surgical excision of the lesion E. Reassure the patient that no further follow up is needed Fibroadenomas Most common solid benign tumor Common in young women Median age at diagnosis is 30 years Firm, rubbery Well circumscribed Non tender, very mobile Growth stimulated by: Exogenous estrogen or progestin Lactation Pregnancy Answer to Case 3, Question 1 An ultrasound shows a solid lesion, benign features, possible fibroadenoma. What would you do next? A. Follow up in 3 6 months with US and breast examination B. Obtain a mammogram C. Order core needle biopsy of the lesion D. Refer for surgical excision of the lesion E. Reassure the patient that no further follow up is needed Case 4 31 year old G0P0 female presents for annual exam. LMP 1 month ago. Had been on Implanon, injection, patch, and pill previously for contraception. Two paternal aunts with breast cancer. No family history of ovarian cancer. Physical exam reveals symmetrical breasts with no tenderness, axillary adenopathy, or nipple discharge. Bilaterally very lumpy. Right breast has 1x1 cm area, 1 inch from nipple at 9:00 position, that is firm, non tender, mobile, and rubbery Case 4 Course Case 5 US guided biopsy: Infiltrating ductal carcinoma. Lumpectomy with re excision of lateral margin: Infiltrating ductal carcinoma, focal ductal carcinoma in situ. Adjuvant chemotherapy followed by radiation and adjuvant hormonal therapy. Genetic counseling and testing (BRCA 1 and BRCA 2 negative) 32 year old G1P1, 3 weeks post partum female presents with painful left breast. Is breast feeding. Exam reveals engorged breast, very tender, warm, erythematous. One 4x4 cm area is very hard. Minimal milk discharge from nipple

9 Case 5, Question 1 What is the differential? A. Plugged ducts B. Mastitis C. Abscess D. Cancer E. All of the above Causes of Breast Masses in Pregnant or Lactating Women Lactating adenoma Plugged ducts Milk retention cyst (galactocele) Mastitis Abscess Cancer Invasive Ca seen in 1/3000 1/10,000 pregnant women Other causes noted previously Scott Conner CE, 1999; Sabate et al, Answer to Case 5, Question 1 What is the differential? A. Plugged ducts B. Mastitis C. Abscess D. Cancer E. All of the above Case 5, Question 2 What is your next step? A. Nothing, I would wait as she is breast feeding B. Ultrasound C. Mammogram D. Biopsy E. Antibiotics Pregnant or Lactating Women Breast ultrasound preferred for work up Biopsy: Fine needle aspiration biopsy not as accurate Pregnancy: higher risk of hematoma formation Lactation: higher risk of infection or milk fistula Cessation of lactation may decrease complications Do not postpone workup because of pregnancy Do not withhold mammography in suspicious cases Ionizing radiation to fetus is minimal Answer to Case 5, Question 2 What is your next step? A. Nothing, I would wait as she is breast feeding B. Ultrasound C. Mammogram D. Biopsy E. Antibiotics

10 Case 5, continued Investigate if: Breast mass persists for >2 4 weeks Ultrasound, mammogram, biopsy if needed Mastitis recurs in same area or does not respond to antibiotics Final Thoughts Guideline recommendations vary by organization My approach may differ from yours Work up will depend on Patient s age, preferences Availability of local expertise and procedures No diagnostic test is 100% specific or sensitive Final Thoughts If patient notes a breast lump, pursue evaluation until a determination is made for benign vs. malignant Negative imaging does not necessarily rule out cancer May need further evaluation, referral to a breast specialist 57 References Barton et al. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 1999;282: Breast Lumps in Women. MedicineNet, Inc. ( ) Clarke et al. Replace fine needle aspiration cytology with automated core biopsy in the triple assessment of breast cancer. Ann R Coll Surg Engl 2001;83: Harvey et al. Short term follow up of palpable breast lesions with benign imaging features. AJR Am J Roentgenol 2009;193:1723. Klein S. Evaluation of palpable breast masses. Am Fam Physician 2005;71: McDonald et al. Performance and reporting of clinical breast examination. CA Cancer J Clin 2004;54: Morris et al. A new score for the evaluation of palpable breast masses in women under age 40. Am J Surg 2002;184: Morris et al. Usefulness of the triple test score for palpable breast masses. Arch Surg 2001;136: References National Comprehensive Cancer Network. Breast Cancer Screening and Diagnosis Guidelines. Jenkintown, PA: NCCN, Nelson HD et al. Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta analysis. Ann Intern Med 2012;156: Pankratz et al. Assessment of the accuracy of the Gail model in women with atypical hyperplasia. J Clin Oncol 2008;26: Rockhill et al. Validation of the Gail model of breast cancer risk prediction and implications for chemoprevention. J Natl Cancer Inst 2001; 93: Sabate et al. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics 2007;27:S Saslow et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57: Scott Conner CE. Diagnosing and managing breast disease during pregnancy and lactation. USPSTF. Screening for Breast Cancer. Ann Intern Med 2009;151: