Lumps, Bumps, Leaking and Pain I HAVE NO DISCLOSURES Management of Breast Conditions Rebecca A. Jackson, MD Professor Department of Obstetrics, Gynecology and Reproductive Sciences University of California, San Francisco Likelihood of Cancer in Dominant Plan Breast Mass by Age oPalpable breast mass 60% 50% 37% oNon‐Palpable breast mass 40% oMastalgia 30% 20% Nipple Discharge 9% o 10% 1% 0% <40 yo 41-55 >55 yo Of all discrete breast masses, about 10% are cancerous. (In contrast, 8% of abnormal mammos = cancer) Failure to diagnose breast cancer “Dominant Mass”? in a timely manner is a leading cause of malpractice claims o Discrete or dominant mass= stands out from adjoining breast tissue, definable Common reasons: borders, is measurable, not bilateral. o Unimpressive o Nodularity or thickening = ill‐defined, physical findings often bilateral, fluctuates with menstrual o Failure to f/u with pt cycle o Palpable mass with negative mammo o In women <40 referred for mass, only 1/3 had confirmed dominant mass Breast Mass: Diagnostic Options Question 1 o Physical exam A 42 yr old woman with no family or personal history of breast cancer has o Ultrasound found a breast lump. She doesn’t know o Diagnostic Mammogram how long it has been there. It is not o Digital Breast Tomosynthesis (DBT) painful. o Cyst aspiration On exam, it is a discrete mass, 2 cm, o Fine needle aspiration relatively smooth, mobile and non‐tender. o Core needle biopsy She has no axillary lymphadenopathy. o Excisional biopsy What is your next step? Q1: Palpable mass in 42 yo Q1b: Palpable mass in 42 yo Next step (pick one)? A mammography was chosen and is A. Nothing now. Re‐examine in 1‐2 months negative. Next step (pick one)? B. Ultrasound A. Re‐examine in 1‐2 months C. Digital Mammography B. F/u 1 year for annual exam D. DBT: Digital Breast Tomosythesis C. Ultrasound E. Office aspiration D. Office aspiration F. FNAB (fine needle aspiration biopsy) E. FNAB G. Core biopsy F. Core biopsy Q1c: Palpable mass in 42 yo Step 1: Palpable Breast Mass An ultrasound was chosen as the first step. It shows a cystic mass. Next step? oDetermine if mass is cystic or A. Re‐examine in 1‐2 months solid B. F/u 1 year for annual exam o Simple cysts are benign and don’t C. Standard diagnostic mammogram require further evaluation D. DBT (digital breast tomosynthesis) o 20‐25% of palpable masses are simple E. Office aspiration cysts, most occurring in 40‐49 yo’s F. FNA o Options?: Ultrasound, office aspiration, FNA, core needle biopsy G. Core biopsy Breast Exam Ultrasound o Nether sensitive (50‐60%) nor specific (60‐ o Primary Use: Classify mass as cystic or solid 90%) (even when done by experts) o Also can help to further classify mass via Bi‐ Cannot reliably distinguish cyst from solid (58% o Rads system for sono‐‐ but much less data on accuracy) risk of cancer assoc with each classification o Not reliable for determining if biopsy needed Guidance for cyst aspiration or biopsy o Nonetheless, it is important for determining if o mass is discrete (vs nodularity or thickening) o Adjunct to evaluate symmetric densities and for follow‐up of masses detected by mammography o Perform in 2 positions, methodical, spirals or strips Can be the first test performed & if cyst is o Mark mass prior to biopsy so others can find it o confirmed—the only test required Fibroadenoma Cancer Cyst Cyst Aspiration o Simple office procedure: 20‐23 gauge needle and syringe, ultrasound guidance optional, specialized training not necessary o Primary Use: Confirm mass is cystic o Secondary use: Relieve pain/pressure due to Anechoic, well- symptomatic cyst circumscribed, Well-circumscribed, Irregular, deep superficial o Benefits: If cystic fluid obtained, establishes Ultrasound is 98-100% accurate for diagnosis of simple cysts. immediate diagnosis and provides However, for solid masses, it cannot reliably distinguish benign symptomatic relief from malignant. Cyst Aspiration (cont’d) Adequate/reassuring if: 1. Cyst fully collapses (no residual mass) 2. Fluid is not brown/red (cloudy ok) 3. Does not re‐accumulate (i.e. frequent f/u) o If all are true, no need to send fluid. o F/u in 1‐3 months to ensure no reaccumulation or residual mass o If no fluid or if bloodyfurther workup Fine Needle Aspiration: QUIZ Fine Needle Aspiration Biopsy o Primary Use: Diagnosis of solid masses o FNAB should be done by an experienced o Least invasive biopsy method cytopathologist or breast surgeon? ….TRUE OR o Sensitivity is operator dependent: FALSE? o For experienced personnel, 92‐98% o For untrained personnel, 75% Average (as low as 65%). o A diagnosis of FATTY TISSUE on FNA means o Experienced cytopathologist necessary to interpret what? o Cannot diagnose DCIS, atypical hyperplasia or infiltrating carcinoma. However, >90% there is o When should you FOLLOW‐UP a woman with a sufficient material to perform prognostic studies palpable mass and negative FNA and o A non‐diagnostic result in the setting of a discrete mammogram? mass requires further work‐up (possible sampling error) Palpable mass: Diagnostic Mammography Breast Cyst o Cannot accurately differentiate benign from malignant masses or cystic from solid Can’t distinguish cyst from solid on mammogram o Poor sensitivity in young women due to density o 15‐20% of mammos are normal in women with palpable mass o Primary Use: Screen opposite breast (in women >40 yo) and identify other non‐palpable suspicious areas o Secondary use: Further classification of the palpable mass EVEN IF THE MAMMO IS NORMAL, FURTHER WORK‐UP IS REQUIRED Cyst is anechoic on ultrasound Breast Density Small Cancer Spiculated mass Merriman’s: Waimea What about DBT? Digital Breast Tomosynthesis; “3D Mammography” o 3‐D depiction of breast using series of low‐dose digital mammograms at various angles o Better for delineating true lesions from spurious lesions caused by overlapping structures seen on routine mammography. o Higher radiation dose: sometimes twice as high b/c do both a digital mammogram and DBT are done o Newer techniques have lower radiation dose but upgrading is costly Is Breast tomosynthesis (DBT) better than Pt with mass mammography for palpable mass? marked by BB. Difficult to see Too soon to say: Most studies have o well on mammo. been done in screening setting Distinct edges o But promising —especially in the on DBT. setting of dense breasts. U/S confirmed a o A few small studies show better cyst. characterization of lesions when used in diagnostic setting leading to fewer biopsies Conventional DBT Friedewald 2014 JAMA Radiol Clin North Am. 2010 Sep; 48(5): 917–929. Breast Tomosynthesis: Invasive ductal carcinoma: patient experience Subtle on mammo Spiculated edges well seen on DBT Traditional Mammo DBT Radiol Clin North Am. 2010 Sep; 48(5): 917–929. Core Needle Biopsy o Primary Use: Diagnosis of solid Breast tomosynthesis: Radiology experience masses, f/u of non‐diagnostic FNAB o Can distinguish DCIS from invasive disease and because it is a tissue specimen, interpretation is easier (unlike FNA) o Few direct comparisons to FNAB for palpable lesions: o Preferred for Studies mixed for sensitivity‐ some biopsy non- showing FNA better and some with CNB better. Similar specificity. palpable lesions Question 1 So, what is the best first step? o First step = determine if cystic or solid. A 42 year old woman with no family or personal o How depends on your institution (availability and history of breast cancer has found a breast expertise of various services) and whether patient is lump. She doesn’t know how long it has been symptomatic there. It is not painful. o FNAB: Therapeutic, diagnostic and cost‐efficient On exam, it is a discrete mass, about 2 cm, o U/S: Similar in cost to FNAB, but FNAB more cost relatively smooth, mobile and non‐tender. She effective b/c 80% of masses are NOT cystic on U/S has no axillary lymphadenopathy. and will require FNAB to further evaluate o If FNAB not available: U/S first will eliminate What is your next step? need for core biopsy in 20% that do have cysts Plate lunch, loco moco, and So, what is the best first step? malasadas o Office aspiration: Reasonable 1st step esp if symptomatic. If not cystic, will require biopsy o Mammography: not best 1st step b/c can’t reliably distinguish benign from malignant or cystic from solid (but is usually part of a complete evaluation) o F/U 1‐2 mos: Could be ok in young woman (<40) who will reliably follow‐up. Discuss options, get agreement, document well. If Honokaa, past Waimea on the mass persists, go to U/S or FNA. way to Hilo or Waipio Valley Step 2: for a cystic mass… Step 2: for a solid mass o If symptomatic, aspirate Biopsy (FNA or core needle biopsy) o If diagnosed by ultrasound and no PLUS aspiration is done, f/u 1 year. Mammogram (to further characterize mass o If aspirated and fluid is not bloody, f/u 1‐ and to screen rest of breasts) 3 months to ensure no residual mass or o If both are negative, f/u 3‐6 months re‐accumulation If either is equivocal or results are not o For any patient >40, also get mammo for o screening (>50 recommend, >40 shared concordant, refer to breast surgeon for decision) further evaluation Ultrasound F/u instead of Surveillance instead of biopsy for solid biopsy for solid mass? mass? o 2 small retrospective cohort studies—largest n=312 with palpable mass & U/S= “probably o Retrospective cohort study of 441 benign” patients with benign solid lesions by sono o Mostly young women so low pretest probability of (Birads 3 and 4A) cancer (avg age 34yo) o Excluded those with immediate biopsy o Strict criteria for calling lesion “probably benign” (300) leaving 141 who had surveillance.