Breast Cancer in the US Breast Cancer is estimated to affect over 230000 women annually in the US Based on SEER Database rates from 20092011 the cumulative lifetime risk of an average woman in the general US population is 123 ID: 934757
Download Presentation The PPT/PDF document "PGY 101: Chapter 74 Breast" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
PGY 101: Chapter 74
Breast
Slide2Breast Cancer in the US
Breast Cancer is estimated to affect
over 230,000
women
annually in the US
Based on SEER Database rates from 2009-2011, the
cumulative lifetime risk
of an average woman in the general US population is 12.3%
Estimated 15,480 new cases of female breast cancer in Florida
Slide3Breast Cancer in the US
Greatest risk in the 5
th
and 6
th
decade of life
Median Age at Diagnosis
61
Slide4Breast Cancer in the US
Early Detection through screening
Advances in Systemic Therapy
Patient Education
Personalized Care
Percent surviving 5 years
89.2%
Slide5SEER Cancer Statistics 2014
Breast Cancer
Slide6What is Breast Cancer?
Slide7Breast Cancer Risk
Non-Modifiable
Being a Woman
Getting Older
Family History of Cancer
Menstruating Early
Late Menopause
Never Having ChildrenOlder Age at First BirthHistory of RadiationDense BreastsHistory of Breast BiopsyHistory of Abnormal BiopsyModifiable
Hormone TherapyObesityUnhealthy DietSedentary LifestyleDrinking AlcoholLack of Screening
Education, Awareness, Action
Slide8History of Breast Cancer in First degree relatives increase an individuals risk of breast cancer
2-fold increased risk in women whose sisters or mothers have had breast cancer
Hereditary Breast Cancer
Stratton MR. Nat Genet. 2008;40:17
Family History
Slide9Known inherited alterations in genes that lead to an increased risk of developing breast cancer
Genetics
Approximately 5-10% of all breast cancer
Lead to a 10- to 20 – fold increased lifetime risk of developing breast cancer as well as many associated cancers
Ovarian, Pancreas, Prostate, Melanoma, Thyroid, Colon
Cancers occur at younger ages
Slide10Inherited Gene Alterations
BR (Breast) CA (Cancer) Susceptibility genes (BRCA 1 & BRCA 2)
Approximately 80% of all hereditary breast cancers
Cumulative lifetime risk of Breast Cancer:
BRCA 1 – 65-87%
BRCA 2 – 45-55%
Cumulative lifetime risk of Ovarian Cancer:
BRCA 1 – 39-51%
BRCA 2 – 11-35%
Slide11What if a Woman has a strong Family History but Negative for BRCA?
Slide12Risk Calculators
Slide13Mammography remains the only study proven to detect early breast cancer and decrease breast cancer related deaths
Breast cancer mortality reduction up to 40%
Screening detected cancers
S
maller in size
L
ess likely to have lymph nodes involved
Less likely to receive chemotherapyScreening
Slide14American Cancer Society Recommendations
Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good
health
Clinical breast exam (CBE) about every 3 years for women in their 20s and 30s and every year for women 40 and
over
Women should know how their breasts normally look and feel and report any breast change promptly to their health care
provider
Breast self-exam (BSE) is an option for women starting in their 20sRecommendations vary based on risk
Slide15General Population
– Baseline mammogram between 35-40 and annual mammography starting at age 40.
Start 10 years younger then your youngest 1
st
degree relative diagnosed with breast
cancer
High Risk Population
– Annual mammography and MRI starting at the age of 30BRCA 1 or 2 carriers1st degree relative of BRCA carriers but untestedLifetime risk of 20-25% based on family risk assessment modelsHistory of chest wall radiationScreening
Slide16Screening
Slide17Slide18Diagnostic Imaging
Addition of Spot Magnification Mammographic Views, Breast Ultrasound, and or MRI
Mag Views
Ultrasound
MRI
Slide19Slide201
2
3
4
5
Slide21Biopsy for Diagnosis
Stereotactic
Ultrasound
MRI
Slide22Stage
Tumor Size
Lymph Node Involvement
Spread to other Organs
Tumor Proteins
ER
PR
Her2 NeuCancer Staging
Slide23Size
Nodes
Metastasis
Tumor Marker Profile: ER/PR/Her 2 status
Slide24Breast Cancer Treatment
Cure
Breast
Whole Body
Surgical Oncologists
Radiation Oncologists
Plastic/Reconstructive Surgeons
Medical Oncologists
Anti-Estrogen Therapy
Chemotherapy
Targeted Therapy
Slide25Surgical Treatment
Breast Tissue
Lymph Nodes
Breast Saving
Mastectomy
Slide26Dr. William S. Halsted
(1852-1922)
Halstedian Principle:
“Cancer spreads in an orderly, slow, and localized manner, contiguous with its site of origin”
Slide27The Complete Operation
“The result of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital from June 1889 to 1894”
Skin Envelope
NAC
Breast Tissue
Pectoralis
Major and Minor
Axillary Levels I-III
Slide28Radical Mastectomy
Slide29Surgical Evolution
Radical Mastectomy
Modified Radical Mastectomy
Skin Sparing Mastectomy
Nipple Sparing Mastectomy
Partial Mastectomy
No difference in Survival
Slide30Fisher B, Anderson S, Bryant J et al. N Engl J Med. 2002;347:1233-1241.
NASBP B06 Breast Conservation
Slide31Fisher B, Anderson S, Bryant J et al. N Engl J Med. 2002;347:1233-1241.
NSABP B06 Breast Conservation
Slide32Breast Conservation
Candidacy
Focality of Disease
Tumor
Location
PMH/Genetic
Prior Radiation
Cosmetic Outcome
Slide33Slide34Reconstructive Surgery
Slide35Reconstructive Surgery
Women’s Health and Cancer Rights Act of 1998
Mandated that all health plans include breast and nipple reconstruction as well as contralateral breast symmetry procedures to all mastectomy patients
Slide36Surgical Evolution
Levels I, II, III
Levels I, II
Sentinel Lymph Node Biopsy
Slide37Sentinel Lymph Node Biopsy
Giuliano AE. Ann Surg. 1994;220:391-401
Slide38Sentinel Lymph Node Biopsy
1977
1994
1992
Penile Squamous Cell Cancer
Cabanas
Breast Cancer
Giuliano
Melanoma
Morton
Cabanas RM. Cancer. 1977;39:456-466.
Morton DL. Surg Oncol Clin North Am. 1992;1:247-259
Giuliano AE. Ann Surg. 1994;220:391-401
Slide39Study
Year
(
n)
Identification
Accuracy
Negative Predictive Value
Sensitivity
False Negative Rate
Giuliano
1994
174
78.0
95.6
93.5
93.7
4.3
S
entinel
lymph node
biopsy is
an accurate method of
axillary lymph node staging in women with early stage clinically node negative breast cancer
Giuliano AE. Ann Surg. 1994;220:391-401
Slide40Randomized Controlled Trials
Study
Year
(
n)
Identification
Rate (%)
Accuracy
(%)
Negative Predictive Value (%)
Sensitivity
(%)
False Negative Rate (%)
Veronesi
2003
516
99
96.9
95.4
91.2
8.8
Krag
2007
5536
97.2
97.1
96.1
90.2
9.8
Zavagno
2008
749
95
94.4
92.3
83.3
16.7
Veronesi U. N Engl J Med. 2003;349:546-553
Krag DN. Lancet Oncol. 2007;8:881-888
Zavagno G. Ann Surg. 2008;247:207-213
Slide41Randomized Controlled Trials
Study
Year
(
n)
Local
Regional
Overall Survival
Disease
Free Survival
ALND
SLNB
ALND
SLNB
ALND
SLNB
ALND
SLNB
Veronesi
2010
516
1.5
1.5
0
0.7
89.7
93.5
88.8
89.9
Krag
2010
5536
1.9
1.7
0.3
0.5
91.8
90.3
82.4
81.5
Zavagno
2008
749
0.8
3.4
0
1.1
95.5
94.8
89.9
87.6
Veronesi U. Ann Surg. 2010;251:595-600
Krag DN. Lancet Oncol. 2010;11:927-933
Zavagno G. Ann Surg. 2008;247:207-213
Slide42ACOSOG Z0011
Clinical T1-T2, N0, M0 undergoing BCT + XRT
(n=856)
+ ALND
(n=420)
Endpoints:
Locoregional Recurrence
Overall SurvivalNo ALND(n=436)Giuliano AE, McCall L, Beitsch et al. Ann Surg. 2010;252:426-32
Patient with ≤ 2 SLNB
Slide43ACOSOG Z0011
Giuliano AE, Hunt K, Ballman KV et al. JAMA. 2011;305:569-575.
92.5%
91.8%
83.9%
82.2%
Slide44ACOSOG Z0011
Giuliano AE, McCall L, Beitsch et al.
Ann Surg. 2010;252:426-32
SLNB + ALND
SLNB
Local Recurrence
3.6
1.8
Regional
Recurrence
0.5
0.9
Slide45ACOSOG Z0011
At
6.3 year follow-up
, women with clinically node-negative early stage breast cancer with < 3 positive sentinel nodes, who underwent breast conservation surgery demonstrated:
No Benefit in Locoregional control following ALND
No Benefit in Overall or Disease-free survival following ALND
Slide46Breast Cancer Treatment
Cure
Breast
Whole Body
Surgical Oncologists
Radiation Oncologists
Plastic/Reconstructive Surgeons
Medical Oncologists
Anti-Estrogen Therapy
Chemotherapy
Targeted Therapy
Slide47Adjuvant Therapy
Whole Breast Radiation
All Breast Conservation
Locally Advanced Mastectomy
Nodal Disease
Close Margins
Inflammatory
Partial Breast RadiationSelected Early StageRadiation Therapy
Slide48Chemotherapy
Endocrine Therapy
Tamoxifen
Aromatase Inhibitors
Targeted Therapy
Additional Therapy
Systemic Therapy
Clinical StageBiology of the Tumor Tumor Marker Profile Oncotype
Slide49Slide50Endocrine Therapy (Anti Estrogen Therapy)
Any ER or PR + patient > 1%
Premenopausal/DCIS:
Tamoxifen
, Postmenopausal: Aromatase Inhibitors
Chemotherapy
ER/PR/Her2 negative
Any Her2 ++/- ER/PR + Her2 negativeNode + diseaseTargeted Therapy: HerceptinHer 2 +Adjuvant Therapy
Systemic Therapy
Slide51Genomic Profiling of Tumors
Slide52Oncotype DX
Clinical Practice Guidelines
NCCN
Guidelines
Consider
use in >0.5cm, HR+, HER 2 – negative disease, pT1-3 and pN0 or pN1mic
ASCO Guidelines
Newly diagnosed patients with node-negative, ER+ breast cancer who will receive tamoxifen
Slide53Oncotype DX
Proliferation
Ki-67
STK15
Survivin
Cyclin
B1MYBL2InvasionStromelysin 3Cathepsin L2HER 2GRB7HER2
ReferenceKi-67GAPDHRPLPOGUSTFRC
Other
GSTM1
CD68
BAG1
Estrogen
ER
PR
Bcl-2
SCUBE2
16 Cancer Genes
5 Reference Genes
Paik S et al. NEJM. 2004;351:2817
Slide54Paik S et al. NEJM. 2004;351:2817
RS <18
RS18-30
RS>30
NSABP B-14: Recurrence Score as
Predictor of 10 yr Distant Recurrence (
n
=675)
Slide55Oncotype DX
Paik S et al. NEJM. 2004;351:2817
10-yr Rate of Distant Recurrence
6.8%
14.3%
30.5%
95% CI
(4-9.6%)
(8-20.3%)
(23.6-37.4%)
Slide56Women
with Node
-negative,
HR+ Breast Cancer
Oncotype
DX
Low RS
Intermediate RS
High RS
Endocrine
Endocrine
Endocrine
+ chemo
Endocrine
+ chemo
Slide57Treatment Algorithm
Classic Treatment Design:
Surgery
+/- Chemo +/- XRT +/- EndocrineNeoadjuvant therapy:
Chemo
Surgery +/- XRT +/- Endocrine
Inflammatory Breast Cancer:
Chemo +/- Surgery, XRT, Endocrine
Slide58Neoadjuvant Chemotherapy
Surgical:
Treat locally advanced cancers
Convert mastectomy candidates into breast conservation candidates
Improve
cosmesis
in patients undergoing breast conservation
Medical:Use primary tumor and nodal response to tailor locoregional and systemic therapyIdentify better predictors of complete response
Slide59Pre- Neoadjuvant
Post- Neoadjuvant
pCR
Slide60Pre- Neoadjuvant
Post- Neoadjuvant
Slide61Loco-Regional Endpoints
In Breast pCR:
2
5-30% w/ anthracyclines/taxanes40-50% w/ chemo + trastuzamab in HER-2+
50-60% w/ chemo + two anti-HER-2 agents
Axillary pCR:
30% w/ anthracyclines
Up to 40% w/ anthracyclines/taxanes> 50% w/ chemo + anti-HER-2 therapies
Slide62True
or False: 97% of the lymphatic drainage of the breast drains to the internal mammary lymph node basin
.
Slide63True
or False:
Axillary Node Levels are based on the
pectoralis major muscle
Slide64When
performing a modified radical mastectomy, what levels of axillary nodes are removed?
Level I
Level IILevel III
All of the above
Only A &
B
Slide65Which
is the only screening modality that has shown to decrease mortality from breast cancer in woman over the age of 50
?
Breast UltrasoundBreast Mammography
Breast MRI
Breast
Thermography
Slide66A 24 you woman undergoes a breast ultrasound for a self-palpated left breast mass. You order a breast ultrasound which is demonstrated below. What Bi-Rad classification is this lesion?
Bi-
Rads
0Bi-Rads
1
Bi-
Rads
2Bi-Rads 4
Slide67A 63 you woman undergoes a breast ultrasound for a self-palpated left breast mass. Her diagnostic breast ultrasound is demonstrated below. What Bi-Rad classification is this lesion?
Bi-
Rads
0Bi-Rads
1
Bi-
Rads
2Bi-Rads 5
Slide68Which
Bi-
Rads classification recommends 6 month short term follow up imaging?
Bi-Rads 0Bi-
Rads
2
Bi-
Rads 3Bi-Rads 4
Slide69True or False: Breast cancer affects 1 in 8 women in the United States.
Slide70Indications for genetic testing in a patient diagnosed with breast cancer are?
A woman diagnosed prior to the age of 45
A woman diagnosed at any age, who has two family members with breast, ovarian or pancreatic cancer
Any man diagnosed with breast cancer
All of the
above
Slide71True
or False: Survival is improved in patients undergoing mastectomy for a Stage II and Stage III breast cancer as compared to breast conservation surgery
.
Slide7255
yo postmenopausal woman presents to you for a high risk evaluation. You perform quantitative risk assessment on her using the GAIL risk assessment model. Her 5 year risk is 4.2% as compared to 1.8% of the general population, and her lifetime risk is 42% as compared to 16% of the general population. Your talk to her about chemoprevention. Which medications would you use for chemoprevention?
Raloxifene
Tamoxifen
Exemestane
All of the above
1 & 3
Slide73True or False: A 48
yo
woman presents to your office for evaluation of newly diagnosed Triple negative inflammatory breast cancer. You explain that your treatment algorithm includes modified radical mastectomy followed by adjuvant chemotherapy and radiation therapy.
Slide74A 72
yo
old undergoes her screening mammogram. She is called back for compression views of her left breast which is demonstrated below. What is the next step in management?
Ultrasound guided percutaneous biopsyStereotactic percutaneous biopsy
Wire localized excisional biopsy
Short term follow up diagnostic breast imaging in 6
mo
Slide75Your
patient undergoes a stereotactic biopsy. Her pathology demonstrates grade 2 DCIS ER 0%, PR 24%. The area of calcifications spans 2 cm. What is not a treatment option for your patient?
Surgery
Tamoxifen
Radiation Therapy
Chemotherapy
Slide76True or False: Radiation therapy decreases risk of local recurrence by at least 50
%.
Slide77True
or False: Approximately 20% of all breast cancers are associated with genetic mutation
.
Slide78True
or False: Male breast cancer is higher in BRCA 1 gene mutation carriers
.
Slide79A
62
yo woman is diagnosed with a new screen-detected left breast cancer. On clinical exam her tumor measures 3 cm in size. What is her T stage
?Tis
T1
T2
T3
T4
Slide80A 65
yo
woman presents with a 6 week history of eczematoid
changes to her right nipple. She has tried every over the counter moisturizer and lose dose steroid cream without relief. She states that her recent mammogram was just prior to the onset of symptoms which was negative. You punch biopsy the skin and it is diagnostic for paget cells within the dermis. What is the next step in management?
Central lumpectomy with sentinel lymph node biopsy
Simple mastectomy with sentinel lymph node biopsy
Breast MRI
Modified Radical Mastecotmy
Slide81Paget’s Disease
1-3% of all breast cancers
Eczematoid
changes of the nipple: itching, erythema, nipple dischargeDx: Biopsy demonstrates Paget cells in the dermis (in-situ disease)Typically underlying malignancy therefore get diagnostic imaging, if negative include MRI
Tx
: Classically mastectomy, but depending in-breast disease central lumpectomy + XRT
Slide82A
57
yo woman presents to your office with complaints of a 1 month history of breast erythema, induration, and edema. She was prescribed antibiotic therapy by her PCP which did not help with her symptoms. Due to persistence in symptoms, her PCP referred her to you for evaluation. What is pathognomonic for her disease process
?
Dermal lymphatic invasion
Pagetoid
cells within the dermis
Lymphovascular invasionAll of the above
Slide83What
is the mainstay of treatment for the above patient
?
Modified Radical mastectomyChemotherapy
Radiation therapy
Central lumpectomy
Slide84A 62 you woman is recently diagnosed with a screen-detected right breast invasive ductal carcinoma. She undergoes wire localized segmental mastectomy with sentinel lymph node biopsy. Her final pathology demonstrates a 2 cm invasive ductal carcinoma, ER/PR positive, Her 2
neu
negative with clear margins and negative lymph nodes. What adjuvant therapy does she need?
Chemotherapy because her tumor is > 1 cm in size plus radiation therapy and an aromatase inhibitor
No chemotherapy because her lymph nodes were negative, therefore only radiation therapy and an aromatase inhibitor
Send an
Oncotype
score to determine need for chemotherapy, then proceed with radiation therapy followed by an aromatase inhibitorOnly Tamoxifen
Slide85What if the above patient’s
Oncotype
returned as 12?
No chemotherapy, but radiation therapy followed by an aromatase inhibitorChemotherapy followed by radiation therapy and an aromastase inhibitor
Radiation therapy alone
None of the
above
Slide86True or False: All woman undergoing breast conservation therapy who have a positive sentinel lymph node require completion axillary dissection.
Slide87Benign Breast Disease
Slide88Fibrocystic Changes
Generic term used to describe symptoms related to the aberration of normal development and involution of the breast
Encompasses:
Cyclical Change
Cyst formation
Fibroadenoma formation
Duct ectasia
Sclerosing AdenosisBenign Nodular breast tissue
Slide89Cysts
Fluid filled round structures derived from the terminal duct lobular unit
Common in Perimenopausal
women
Fluctuate in relation to the menstrual cycle and hormonal milieu
Slide90Cysts
Exam:
Firm or Rubbery, well defined
Imaging:
US (Anechoic)
Mammography
Treatment:
Asymptomatic:ObservationSymptomatic: AspirationRecurrent or Bloody: Excision
Slide91A 21
yo
old woman presents for evaluation of a self-palpated right breast lump. You order an ultrasound which is demonstrated below. What is the next step in management
?
Reassure her that it is benign and tell her to follow as needed
Reassure her that it is benign and have her follow up in 6 months with repeat ultrasound
Explain that it is likely benign however recommend surgical excisional biopsy
Explain that you are concerned that it is malignant and move forward with an ultrasound guided biopsy
Slide92Fibroadenomas
Fibroepithelial Lesion
Solid round structures arise from the epithelium of the terminal duct lobular unit
Most common breast mass in adolescent women
Occur from teens through 70s
Slide93Fibroadenoma
Exam:
Painless well circumscribed mass
10-20% are multiple or bilateral
Imaging:
US (Isoechoic, wider than tall, gently lobulated/elliptical)
Mammography
Treatment: ObservationSurgicalGiant JuvenileEnlargingSymptomatic: Painful
Slide94Fibroadenoma
Slide95A 34
yo
uninsured woman presents to your office with a neglected left breast mass. She cannot fit in the mammography unit, therefore you order a breast ultrasound, for which a representative image is demonstrated below. You order an ultrasound guided biopsy. Her pathology is also provided. What is her most likely diagnosis
?
Locally advanced Invasive ductal carcinoma
Inflammatory breast cancer
Locally advanced invasive lobular carcinoma
Borderline malignant phyllodes tumor
Slide96Phyllodes Tumor
Fibroepithelial Lesion
<1% of all breast tumors
Occurs in wide range of ages: 10-80
Wide range of biological behavior
Benign
– <2, no atypia, no stromal overgrowth, well-circumscribed
Borderline – 2-10, mild atypia, no stromal overgrowth, infiltrative marginsMalignant – >10, marked atypia, presence of stromal overgrowth, infiltrative margins
Slide97Phyllodes Tumor
Exam:
Painless firm discrete palpable mass
Average size is 4 – 5 cm (1-20 cm reported)
Imaging:
US (Isoechoic, circumscribed, lobulated, Horizontal striations)
Mammography (Sharply defined high density mass)
Treatment: Excision with 1 cm margin
Slide98Phyllodes Tumor
Slide99Phyllodes Tumor
Leaf-like Architecture
Slide100A 50
yo
woman undergoes screening mammogram and is called back for spot compression views which is demonstrated below. She is then referred for stereotactic biopsy which demonstrates a radial scar. What is your next step in management
?Wire localization excisional biopsy
Wire localized segmental mastectomy
Short term 6 month mammographic follow
up
Continued annual surveillance
Slide101Sclerosing Lesions
Sclerosing Adenosis
Benign proliferative disorder
Not a precursor to breast cancer
Safely observed unless presence of atypia
Slide102Sclerosing Lesions
Radial Scar
Rosettes or proliferation centers that might give rise to carcinoma
Often spiculated lesion on mammography
Found in both benign and malignant breast tissue therefore thought to be associated with increase risk of subsequent cancer
Increased cancer with larger lesions and in women with age >50
Treatment: Excisional biopsy
Slide103Mastalgia
Common complaint
Typically no histologic difference in women with or without mastalgia
Treatment is reassurance – rule out malignancy if age appropriate
Evening primrose oil, and vitamin E have been studied in randomized controlled trials
Slide104The most common cause of bloody nipple discharge is?
Duct
ectasia
Intraductal papilloma
DCIS
Invasive ductal carcinoma
Slide105A 45
yo
woman presents for evaluation of bloody nipple discharge. She states that it is unilateral, single duct, and spontaneous. She underwent diagnostic mammogram last week which was normal. What is your next step in management?
Repeat mammogramBreast MRI
Retroareolar
ultrasound
Ductogram
3&4
Slide106Your previous patient undergoes an ultrasound and
ductogram
which is demonstrated below. What is your diagnosis?
Ductal carcinoma in situ
Invasive ductal carcinoma
Duct
ectasia
Intraductal papilloma
Slide107Nipple Discharge
Accounts for 3-8% of all breast clinic referrals
Typically associated with a benign cause
2/3
rd
of non-lactating women have a small amount of fluid on manual expression
Risk of cancer increases with age:
< 40 – 3%40-60 – 1%> 60 – 32%Divided into Surgical and Non surgical nipple dischargeSurgical: Papillomas, DCIS, CancerNonsurgical: Physiologic, endocrine, pharmacologic, idiopathic
Slide108Nipple Discharge
Exam:
Number of ducts
Laterality
Color
Spontaneity
Imaging:
MammoUltrasound (retroareolar)DuctogramTreatment: Duct excision – selected or terminal duct excision
Slide109Ductogram
Slide110Duct Ectasia
Dilation of the subareolar duct in peri and post-menopausal women
Typically asymptomatic
May present with cheesy, viscous, toothpaste like discharge or have nipple retraction
Observation, unless discharge is persistent or repeated bouts of periductal mastitis/abscess
Slide111Papilloma
Typically arise from central/subareolar ducts
Most common in women 30 to 50 years of life
50% are single lesions
30% present with bloody nipple discharge
Treatment is surgical excision because of upgrade rates:
DCIS 10.5%
ADH 14.5%
Slide112Papilloma
Slide113Terminal Duct Excision
Slide114A 34
yo
woman presents for evaluation of a new right breast mass. She states that it is associated with fevers, chills, and has been progressively worsening over the past 24 hours. What is your plan in treatment
?
Systemic chemotherapy followed by surgery if good response
Antibiotic therapy and surveillance
Ultrasound guided biopsy
Incision and drainage with antibiotic therapy
Slide115Breast Infection
Lactational
MCO: Staph Aureus
First 6 wks or during weaning
Either from mouth of baby or skin of nipple
Related to blockage of lactiferous ducts
stagnate milk bacterial overgrowth
Diagnosis: Clinical exam and breast ultrasoundTx: Aspiration/Drainage/AbxNon-lactational (Periductal Infection)MCO: Staph AureusYoung smokersAssociated with duct ectasiaSecretions become stagnate in dilated ducts bacterial overgrowthDiagnosis: Clinical exam and breast ultrasoundTx: Aspiration/Drainage/Abx or Fistulotomy
Slide116Which of the below is not an indication for surgical excision
?
Atypical ductal hyperplasia
Radial scarFlat epithelial
atypia
Discordance between pathology and radiographic imaging
Pseudoangiomatous
Stromal HyperplasiaAll of the above are indications for excision
Slide117Pseudoangiomatous Stromal Hyperplasia (PASH)
Myofibroblasts that proliferate in response to hormonal stimuli
Affects women from teens to 50s
Presents as discrete painless mass
Imaging: focal asymmetry or well circumscribed mass
Treatment: Observation (some studies suggest excision)
Increase risk of recurrence up to 22%
Slide118Fibromatosis
Desmoid tumor of the breast
Affects women from teens to 80s
Typically presents as firm unilateral painless mass
Microscopically the tumor is composed of spindle cells
Margins are infiltrative and typically invade around normal structures
Proper treatment is wide local excision
The role of adjuvant radiation and chemo is investigational
Slide119