SPECIAL CIRCUMSTANCES: YOUNG, PREGNANT, MALE CONFLICTS OF INTEREST

• NONE MALE CANCER IMPORTANCE

• STUDIES SUGGEST MEN ARE DIAGNOSED WITH HIGHER STAGE TUMORS AND HAVE A WORSE PROGNOSIS THAN WOMEN. • BUT, WHEN MATCHED STAGE FOR STAGE, MEN APPEAR TO HAVE A COMPARABLE OR BETTER PROGNOSIS THAN WOMEN!!! SUGGESTS DELAY IN DIAGNOSIS ACCOUNTS FOR THE APPARENT WORSE PROGNOSIS EPIDEMIOLOGY OF MALE BREAST CANCER (MBC) • LESS THAN 1% OF ALL MALIGNANCIES IN MEN • LESS THAN 1% OF ALL BREAST CANCERS • IN 2009, 1910 NEW MBC CASES AND 440 DEATHS • MEAN AGE 67 YEARS (5-10 YEARS OLDER THAN IN WOMEN) • INCIDENCE MBC IS INCREASING (x 26% over past 25 years) RISK FACTORS

• MAJORITY OF MEN: NO RISK FACTORS • NIH-AARP DIET AND HEALTH STUDY: – 324,920 MEN, 121 DEVELOPED BREAST CANCER – 1ST DEGREE RELATIVE: RR 1.92 – HX OF BONE FRACTURE AFTER AGE 45: RR 2.2 – OBESITY: RR 1.79

RISK FACTORS FOR MALE BREAST CANCER

C. Gomez-Raposo et al: Cancer Treatment Reviews; 36(2010)451-57 ENDOCRINE RISK FACTORS: IMBALANCE IN ESTROGEN vs ANDROGEN

• LIVER DISEASE • PROLACTINEMIA (ASSOC WITH LOW TESTOSTERONE LEVELS) • EXOGENOUS ESTROGENS (MEN TREATED FOR PROSTATE CANCER, TRANSSEXUALS) • OBESITY RISK FACTORS: TESTICULAR CONDITIONS • UNDESCENDED TESTICLES • CONGENITAL INGUINAL HERNIAS • ORCHIECTOMY • ORCHITIS • INFERTILITY • CONFLICTING EVIDENCE LINKING WITH MBC: LATEST IN 2014 SHOWED 10 FOLD INCREASED RISK

GENETICS

• 15- 20% OF MEN WILL HAVE + FAMILY HX • IN MEN WITH BREAST CANCER: BRCA 2 (5-15%) > BRCA 1 (1-4%) • MEN WITH BRCA 2: 6% LIFETIME RISK (c/w GENERAL POPULATION RISK OF 0.1%) GENETICS

• KLINEFELTER SYNDROME (47 XXY): INCIDENCE OF MBC IS 20-50 X’S HIGHER THAN 46 XY MEN – ATROPHIC TESTES – GYNECOMASTIA – HIGH SERUM GONADOTROPHINS – LOW TESTOSTERONE LEVELS • 3-7.5% OF MEN WITH BREAST CANCER

Harry F. Klinefelter, Jr, M.D. CLINICAL FEATURES OF MBC

• MOST COMMON: SUBAREOLAR MASS • RETRACTION: 9% • DISCHARGE: 6% • ULCERATION: 6% • LEFT>RIGHT • BILATERAL IN 1% DIAGNOSIS AND WORK-UP: MAMMOGRAPHY • FIRST STEP: 92% SENSITIVITY, 90% SPECIFICITY • SHAPE: ROUND, OVAL, IRREGULAR • MARGINS: SPICULATED, ILL-DEFINED, WELL- CIRCUMSCRIBED (INTRACYSTIC PAPILLARY) • CALCIFICATIONS UNCOMMON • ASSOCIATED FINDINGS: AXILLARY ADENOPATHY, SKIN THICKENING, SKIN/NIPPLE RETRACTION

MAMMOGRAPHIC FEATURES OF MBC

Evan GFF, et al. Am J Surg 2001;181:96-100 DIFFERENTIAL DIAGNOSIS: GYNECOMASTIA LOCATION, LOCATION, LOCATION • GYNECOMASTIA IS PROLIFERATION OF SUBAREOLAR DUCTS THEREFORE CENTERED UNDER NIPPLE AND CONTIGUOUS WITH IT • MBC IS DUCTAL IN ORIGIN, SUBAREOLAR, BUT USUALLY ECCENTRIC TO NIPPLE

FORMS OF GYNECOMASTIA

DIFFUSE NODULAR (FLORID) DENDRITIC (FIBROUS) GYNECOMASTIA MALE BREAST CANCER GYNECOMASTIA MALE BREAST CANCER 76 YO MALE WITH 1 MONTH HISTORY OF PALPABLE IDC

Nguyen C, et al. RadioGraphics 2013;33:763-779 88 yo MALE WITH BLOODY IDC

Nguyen C, et al. RadioGraphics 2013;33:763-779 56 YO MALE WITH INTERMITTENT SPONTANEOUS BLOODY NIPPLE DISCHARGE DCIS

Nguyen C, et al. RadioGraphics 2013;33:763-779 83 YO MALE WITH INFILTRATING MAMMARY CARCINOMA

Nguyen C, et al. RadioGraphics 2013;33:763-779 77 YO MALE WITH 3 MONTH HISTORY TENDER MASS: IDC

Chen L, et al. RadioGraphics 2006; 26:993-1006 75 YO WITH DENDRITIC GYNECOMASTIA

Nguyen C, et al. RadioGraphics 2013;33:763-779 MALE BREAST CANCER

Other DCIS 5% 5% Papillary 5% Carcinoma

INVASIVE DUCTAL CARCINOMA 85% INTRACYSTIC PAPILLARY CARCINOMA

ADJUST THE GAIN TO INTERROGATE CYST WALLS: SIMPLE CYSTS IN MALE ARE EXTREMELY RARE Pacelli A, et al. Breast Journal (2002); 8(2);387-390 PAPILLARY DCIS PAPILLARY DCIS

Yang, WT et al. AJR 2001; 176:413-416 CALCIFICATIONS IN MALE BREAST CANCER:

• SEEN IN UP TO 25% OF MBC CASES • CAN LOOK DECEIVINGLY BENIGN!!!

Dershaw DD, et al. AJR 1993;160: 267-270

WHEN IN DOUBT, WORK IT OUT!!!

DIAGNOSIS AND STAGING WORK-UP

• CORE NEEDLE BIOPSY – ESTROGEN RECEPTORS (90% + in MBC) – PROGESTERONE RECEPTORS (81% + in MBC) – Her2-neu (2-15% + in MBC) • Only 48% of men are Stage I/II so men tend to be diagnosed at a later stage. • 50% NODE POSITIVITY

THERAPY: SURGICAL

MODIFIED RADICAL MASTECTOMY WITH AXILLARY LYMPH NODE DISSECTION OR SENTINEL LYMPH NODE BIOPSY THERAPY: RADIATION • RECOMMENDED FOR MEN WITH – POSITIVE LYMPH NODES – TUMORS GREATER THAN 5 CM – POSITIVE MARGINS THERAPY: HORMONAL

• RETROSPECTIVE STUDIES INDICATE REDUCED RISK OF CANCER RECURRENCE/DEATH WITH ADJUVENT TAMOXIFEN • THUS, 5 YEARS OF TAMOXIFEN RECOMMENDED FOR MEN WITH HORMONE RECEPTOR + BREAST CANCER FOLLOWING MASTECTOMY THERAPY: CHEMOTHERAPY

• SIMILAR GUIDELINES FOR ADJUVENT THERAPY IN WOMEN • MANDATORY IN HORMONE RECEPTOR NEGATIVE CASES • ADJUVENT TRASTUZUMAB (HERCEPTIN) SHOULD BE CONSIDERED IN HER 2 + DISEASE PROGNOSIS • TUMOR SIZE AND LN STATUS MOST IMPORTANT PROGNOSTICATORS • MEN WITH 2-5 CM TUMORS HAVE A 40% HIGHER RISK OF DEATH THAN MEN WITH TUMORS <2CM • MEN WITH + LN’S HAVE A 50% HIGHER LIKELIHOOD OF DEATH THAN LN- MEN PREGNANCY-ASSOCIATED BREAST CANCER DEFINITION OF PABC

BREAST CANCER DIAGNOSED DURING PREGNANCY OR WITHIN ONE YEAR AFTER GIVING BIRTH PABC RELEVANT STATISTICS

• EST. 10% OF ALL BREAST CANCER CASES DIAGNOSED IN WOMEN LESS THAN 40. • EST. 3% OF ALL BREAST CANCERS • EST. FREQUENCY: BETWEEN 1 IN 3,000 TO 1 IN 10,000 BIRTHS • MOST COMMON CAUSE OF CANCER-RELATED DEATHS IN PREGNANT AND LACTATING WOMEN

SIGNIFICANCE OF PABC IS CONTROVERSIAL SOME AUTHORS CONCLUDE THAT THIS DIAGNOSIS IS ASSOCIATED WITH A HIGHER RISK OF RECURRENCE AND DEATH

OTHER AUTHORS CONCLUDE THAT THERE IS NO EVIDENCE OF IMPAIRED OUTCOMES WHEN CONTROLLED FOR TUMOR PATHOLOGIC FEATURES 2012

Conclusion: Our results show that PABC is independently associated with poor survival particularly those diagnosed shortly post-partum. This underscores a possible impact of the pregnant breast microenvironment on the biology and consequently the prognosis of these tumors.

Cancer Treatment Reviews 38 (2012) 834–842

SOME REPORTED ADVERSE PROGNOSTIC INDICATORS IN PABC

• LARGER TUMOR SIZE AT DIAGNOSIS • HIGHER GRADE TUMOR AT DIAGNOSIS • MORE ER AND PR NEGATIVITY • MORE HER2/neu POSITIVITY • MORE LYMPH NODE POSITIVITY • MORE LYMPHOVASCULAR INVASION • MORE METASTATIC DISEASE AT PRESENTATION

2012

RESULTS: Of the 99 PABC cases, breast cancer was diagnosed during pregnancy in 36 patients, and after delivery in 63. PABC cases were more likely than controls to be negative for estrogen receptor (59% vs 31%, P < .0001) and negative for progesterone receptor (72% vs 40%, P < .0001). Cases were also more likely to have advanced T class (P = .0271) and N class (P = .0104) and higher grade tumors (P = .0115). With a median follow-up of 6.3 years for cases and 4.7 years for controls, overall survival did not differ between cases and controls (P = .0787). On multivariate analysis, the independent prognostic factors for overall survival were estrogen receptor status (P = .0031) and N class (P = .0003). The diagnosis of PABC was not an independent prognostic factor (P = .1317).

Cancer 2012;118:3254-9 Current or recent pregnancy is associated with adverse pathologic features but not impaired survival in early breast cancer

BUT, IRRESPECTIVE OF CONFLICTING DATA WITH REGARD TO THE INHERENT AGGRESSIVITY OF PABC, EARLY DETECTION/INTERVENTION REMAIN A KEY TO PROLONGING SURVIVAL AND MINIMIZING DEATHS. PABC DELAY IN DIAGNOSIS

• 1991 MSKCC STUDY: – 12 WOMEN DIAGNOSED BEFORE DELIVERY AVG. TUMOR SIZE=2.0 CM – 44 WOMEN DIAGNOSED AFTER DELIVERY AVG TUMOR SIZE= 3.5 CM – AVG. TUMOR SIZE NON PA ASSOC.=2.0 CM • MORE THAN 50% OF PATIENTS DIAGNOSED POSTPARTUM HAD A MASS DOCUMENTED DURING THEIR PREGNANCY THAT WAS BEING FOLLOWED.

Petrek JA, et al. Cancer 1991;67:869-872 DELAY IN DIAGNOSIS

• MEAN BREAST WEIGHT NORMALLY DOUBLES IN PREGNANCY FROM 200 TO 400 GRAMS= INCREASING FIRMNESS AND DENSITY MAKING PHYSICAL EXAM AND MAMMOGRAPHY MORE DIFFICULT

Scott-Conner C, et al. Am J Surg 1995;170:401-405 DELAY IN DIAGNOSIS OF PABC

• MOST RECENTLY MEAN DELAY ESTIMATED AT 1 TO 2 MONTHS • CLINICAL SIGNIFICANCE OF DELAY IN DIAGNOSIS: – ASSUMING 130 DAY TUMOR DOUBLING TIME THE INCREASED RISK OF AXILLARY METASTASIS EQUALS: • 0.9% AT ONE MONTH • 2.6 % AT 3 MONTHS • 5.1% AT 6 MONTHS

Nettleton J, et al. Obstet Gynecol 1996; 87: 414-418 CLINICAL PRESENTATION OF PABC

• PAINLESS MASS/THICKENING • BREAST SWELLING • ERYTHEMA • BLOODY NIPPLE DISCHARGE • MILK REFUSAL = MILK REJECTION SIGN DIFFERENTIAL DIAGNOSIS OF A BREAST MASS IN A PREGNANT/LACTATING WOMAN

• LACTATING ADENOMA • FIBROADENOMA/PHYLLODES • CYST/FIBROCYSTIC CHANGES

• ABSCESS 80% OF PALPABLE MASSES IN PREG/LACT WOMEN • HAMARTOMA

• LIPOMA • GALACTOCELE BENIGN

• 23 WOMEN WITH 24 CANCERS • BREAST DENSITY – BI-RADS TYPE 3 = 14 – BI-RADS TYPE 4 = 4 • MEDIAN AGE = 34 (range 24-45)

Yang WT, et al. Radiology 2006; 239:52-60 ; MD ANDERSON: MAMMOGRAPHY RESULTS

MAMMOGRAPHY POSITIVE IN 18/20 (90%) – MASS = 7 – MASS + Ca = 4 – SUSPICIOUS Ca = 4 – Ca++ AND INCREASED BREAST DENSITY = 2 – FOCAL ASYMMETRIC DENSITY = 1 – ARCHITECTURAL DISTORTION = 1 – DIFFUSELY INCREASED DENSITY =1

EXAMPLE: PALPABLE MASS AT 22 WEEKS GESTATION IN A 36 YO: MD ANDERSON: ULTRASOUND RESULTS

• US POSITIVE IN ALL 21 MALIGNANCIES IN 20 WOMEN – BREAST MASS = 21 – SONOGRAPHIC FEATURES • HYPOECHOGENICITY = 21 • IRREGULAR SHAPE = 12 • INDISTINCT MARGINS = 17 • INCREASED DOPPLER VASCULARITY = 11

US IN PABC

• 1st LINE MODALITY IN W/U OF PALPABLE MASS • ALL PATIENTS WITH A DOMINANT PALPABLE MASS THAT PERSISTS FOR 2 WEEKS OR LONGER SHOULD BE EVALUATED WITH A TARGETED ULTRASOUND • REPORTED AS 100% SENSITIVE AND 100% NEGATIVE PREDICTIVE VALUE FOR PABC

US IN PABC

• ANY SUSPICIOUS MASS CAN BE SAMPLED WITH US-GD’ED CORE BIOPSY • IF POSITIVE, US EVALUATION OF THE AXILLA AND CONSIDER BILATERAL WHOLE BREAST ULTRASOUND • SERIAL US USEFUL IN EVALUATING RESPONSE TO THERAPY IN NEOADJUVANT CHEMORX WHEN TO USE MAMMOGRAPHY • ANY PREGNANT WOMEN WITH NEWLY DIAGNOSED DCIS OR INVASIVE CARCINOMA (MD ANDERSON) • ANY PREGNANT WOMAN WITH DISPARATE ULTRASOUND VS. PHYSICAL EXAM

MAMMOGRAPHY IN PABC

• GENERALLY SAFE IN PABC AND LACTATION • DOSE CONSIDERATIONS: – BILATERAL 2 VIEW SCREENING MAMMOGRAM DOSE IS <3 mGy (= 7 weeks background radiation) – EST. DOSE TO UTERUS IS 0.03 µGy WHICH IS SIGNIFICANTLY LESS THAN THE 50 mGy THRESHOLD BELOW WHICH NO TERATOGENIC EFFECTS ARE KNOWN (ACR GUIDELINES) – LEAD APRON REDUCES DOSE TO UTERUS BY 1/2

Vashi R, et al. AJR 2013;200:321-328 “Furthermore, since the dose to the uterus was found to be extremely low, a mammographic procedure, especially with the use of a lead apron, may be considered by the radiologist faced with a pregnant patient with a possible breast cancer diagnosis.”

Sechopoulos I, et al. Radiology 2008;246:434-443 MAMMOGRAPHY IN PABC

• THERE IS NO PROVEN CARCINOGENIC EFFECT OF RADIATION ON THE ACTIVELY PROLIFERATING BREAST EPITHELIUM IN LACTATING WOMEN MAMMOGRAPHY SCREENING IN PABC

• NOT PERFORMED DURING PREGNANCY • IN WOMEN >40 Y.0., RESUME SCREENING ABOUT 3 MONTHS POST CESSATION OF LACTATION • NO SET GUIDELINES FOR SCREENING HIGH RISK WOMEN MRI IN PABC

• NO REPORTS OF TERATOGENIC EFFECTS OF GADOLINIUM ON HUMANS (BUT NO GOOD STUDIES EITHER) • BUT, Gd DOES CROSS THE PLACENTA TO THE FETUS AND IT IS POSSIBLE THAT Gd IN AMNIOTIC FLUID MAY DISSOCIATE INTO TOXIC FREE Gd IONS • THUS, CONTAST ENHANCED MRI NOT RECOMMENDED DURING PREGNANCY MRI IN PABC

• IN LACTATING WOMEN WITH NEWLY DIAGNOSED CANCER, CE-MRI MAY BE SAFELY PERFORMED. • INTERPRETATION MAY BE DIFFICULT DUE TO INCREASED ENHANCEMENT IN LACTATING BREAST TISSUE • Gd IS EXCRETED INTO BREAST MILK AT A RATE OF 0.0004% OF MATERNAL DOSE • MAY WISH TO PUMP AND DISCARD MILK FOR 24 HOURS IMAGE GUIDED PROCEDURES IN PABC

• US GUIDED BIOPSY IS PROCEDURE OF CHOICE • CAN SAFELY ALSO PERFORM STEREO BIOPSY AND WIRE LOCALIZATIONS • CAN PERFORM MRI BIOPSIES IN LACTATING WOMEN • NO HARMFUL FETAL EFFECTS FROM LIDOCAINE

RISKS OF IMAGED-GUIDED PROCEDURES IN PABC • DUE TO INCREASED VASCULARITY, SLIGHT INCREASE IN RISK OF BLEEDING • MILK FISTULA POSSIBLE BUT RARE – IN WORST CASE MAY NECESSITATE CESSATION OF BREAST FEEDING BREAST CANCER IN YOUNG WOMEN DEFINITION OF YOUNG WOMEN:

WOMEN UNDER 40 YEARS OLD RARE EVENT

• 0.1/100,000 < 20 Y.O. • 1.4/100,000 IN WOMEN 20-24 • 8.1/100,000 IN WOMEN 25-29 • 24.8/100,000 IN WOMEN 30-34 • SEER DATA: <1% OF BREAST CANCERS ARE YOUNGER THAN 30 AND 2.7% ARE YOUNGER THAN 35

SEER DATABASE: 200,000 WOMEN DIAGNOSED WITH BREAST CANCER FROM 1988 -2003 THE HIGHEST MORTALITY DISPARITY BETWEEN < 40 AND >40 WAS PRESENT IN EARLY STAGE, RATHER THAN LATER STAGE, DISEASE! WOMEN<40 WERE 44% MORE LIKELY TO DIE OF STAGE 1 BREAST CANCER

IMPLICATES A UNIQUE BIOLOGY OF BREAST CANCER IN A YOUNGER HOST 20-30 yo = 33% likelihood <35 yo = 9.4% likelihood

HIGHER LIKELIHOOD OF GENETIC PREDISPOSITION (BRCA 1 & 2)

56-88% of BRCA 1 WOMEN <40 28.6% of BRCA 1 carriers associated cancers are WITH under 35 have triple basal phenotype BREAST negative breast cancers CANCER

HIGHER LIKELIHOOD HIGHER LIKELIHOOD OF OF TRIPLE NEGATIVE BASAL SUBTYPE 80-90% CANCER of TN’s exhibit basal Women 20-35 w/ breast ca: 56% black women are TN phenotype 42% white women are TN

HEREDITARY BREAST CANCER

• Women diagnosed with breast cancer at age <35 years are likely to have germ line BRCA 1 and BRCA 2 mutations in up to 15-30% of cases. • BRCA 1-associated cancers are typically high grade and “triple negative”. • 80 -90% of triple negative cancers also exhibit a basal phenotype. INVASIVE DUCTAL CARCINOMA IN YOUNG WOMEN • MORE AGGRESSIVE BIOLOGICAL BEHAVIOR AS COMPARED TO TUMORS IN OLDER WOMEN – LESS WELL DIFFERENTIATED – HIGHER INCIDENCE LYMPHOVASCULAR INVASION – MORE NODE POSITIVITY – LOWER ER/PR POSITIVITY – HIGHER PROLIFERATION RATES

Sidoni A, et al. The Breast (2003);12:247-250 PROGNOSIS

• 1703 PATIENTS, YOUNG AGE PREDICTED FOR A POORER SURVIVAL • 4% DECREASE IN RISK OF RECURRENCE AND A 2% DECREASE IN RISK OF DEATH FOR EVERY YEAR OF AGE (DE LA ROCHEFORDIERE) • <35 YO IS A POWERFUL INDEPENDENT RISK FACTOR OF RECURRENCE-FREE (RR=2.5) AND OVERALL SURVIVAL (RR=2.2)

Shannon C, et al. Eur J Ca (2003); 39: 2632-2642 AS THERE IS NO ROUTINE SCREENING, TWO METHODS OF PRESENTATION:

1. SYMPTOMATIC PATIENT WITH POSITIVE PHYSICAL EXAM

2. PATIENTS IN HIGH-RISK GROUPS WHO ARE FOLLOWING PROTOCOLS FOR EARLY DIAGNOSIS 2 FACTORS AGAINST EARLY DIAGNOSIS

• LOW SUSPICION OF MALIGNANCY IN YOUNG WOMEN DUE TO LOWER PREVALENCE OF BREAST CANCER • LACK OF PATIENT STRATIFICATION ACCORDING TO RISK FACTORS DIAGNOSIS

• PHYSICAL EXAM LESS ACCURATE DUE TO DENSE BREAST TISSUE THAT IS SUBJECT TO CYCLICAL HORMONAL CHANGES • IN ONE STUDY OF WOMEN <30 YO: – CLINICAL EXAM CORRECTLY PREDICTED MALIGNANCY IN ONLY 37% – NEARLY HALF DIAGNOSED AS BENIGN – 30% DIAGNOSED AS FIBROADENOMAS • REINFORCES THE NEED FOR ASTUTE IMAGING WORK-UP AND HISTOLOGIC DIAGNOSIS IN EQUIVOCAL CASES

Ashley S, et al. Br J Surg 1989;76:835-837 MAMMOGRAPHY

• D- MIST TRIAL ESTABLISHED DIGITAL MAMMOGRAPHY AS THE MOST EFFECTIVE MAMMOGRAPHY MODALITY TO DIFFERENTIATE DENSE PARENCHYMA FROM TUMOR. • THE ROLE/EFFECTIVENESS OF TOMOSYNTHESIS HAS YET TO BE FIRMLY ESTABLISHED • ? ROLE OF CONTRAST-ENHANCED DIGITAL SUBTRACTION MAMMOGRAPHY ULTRASOUND

• PROCEDURE OF CHOICE IN IMAGING YOUNG PATIENTS WITH FOCAL BREAST SYMPTOMS AND/OR PALPABLE MASS ULTRASOUND

480 consecutive women (25-55 yo) attending sx’tic breast clinic Houssami N,et al. AJR; 180(4):935-940 MAMMOGRAPHIC FEATURES IN 198 PRE-MENOPAUSAL M.D. ANDERSON PTS. (38 TN’S)

Yang WT, et al. Breast Cancer Res Treat(2008)111:405-410 MAMMOGRAPHIC FEATURES IN 198 PRE-MENOPAUSAL M.D. ANDERSON PTS. (38 TN’S)

Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 315 CONSECUTIVE BREAST CANCERS: 33 TN AND 282 non-TN

Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 MAMMOGRAPHY IN TRIPLE NEGATIVE BREAST CANCER

Dogen BE, et al. Annals Oncol (2012); 23 (supp 6):vi23-29 TN BREAST CANCER WITH GENTLE LOBULATIONS, POSTERIOR ENHANCEMENT, ANECHOIC

Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 TN BREAST CANCER : CIRCUMSCRIBED, PARALLEL, HYPOECHOIC, POSTERIOR ENHANCEMENT

Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 TN BREAST CANCER SHOWING SMOOTH LOBULATED MASS WITH DISPLACEMENT OF COOPERS LIGAMENTS

Wojcinski W et al. J Ultrasound Med 2012;31:1531-1541 MRI TRIPLE NEGATIVE

Dogen BE, et al. Annals Oncol (2012); 23 (supp 6):vi23-29 31 yo WITH TRIPLE NEGATIVE BREAST CANCER

Dogan BE, et al.AJR (2010); 194:1160-1166 YOUNG WOMAN WITH PALPABLE MASS TEACHING POINTS • EXERCISE EXTREME VIGILENCE DURING PERFORMANCE AND INTERPRETATION OF THE DIAGNOSTIC WORK-UP • FAMILY HISTORY IS IMPORTANT!!!! • ERROR ON SIDE OF BIOPSY IF THERE IS ANY DOUBT BASED ON IMAGING FEATURES YOUNG, PREGNANT, MALE: UNIFYING THEME DELAY IN DIAGNOSIS HEIGHTENED AWARENESS

EARLY DETECTION

IMPROVED OUTCOMES THANKTHANK YOU!!!