How will you approach the 35 year old, with a 2 x 2 x 2cm, firm, mobile, well circumscribed non tender mass on the right breast?

Role of imaging modality Mammography plays a central part in early detection of breast cancers because it can show changes in the breast up to two years before a patient or physician can feel them. Research has shown that annual mammograms lead to early detection of breast cancers, when they are most curable and breast-conservation therapies are available.

Digital and conventional mammography both use x-rays to produce an image of the breast Conventional mammography: image is stored directly on film Digital mammography: images stored as a computer file full-field digital mammography (FFDM); mammography system in which the x-ray film is replaced by solid-state detectors that convert x-rays into electrical signals used to produce images can be enhanced, magnified, or manipulated for further evaluation more easily Digital mammography advantages over conventional mammography: Health care providers can share image files electronically, making long-distance consultations between radiologists and breast surgeons easier. Subtle differences between normal and abnormal tissues may be more easily noted. Fewer follow-up procedures may be needed. Fewer repeat images may be needed, reducing the exposure to radiation. http://www.radiologyinfo.org/en/info.cfm?pg=mammo

Ultrasound to differentiate solid from cystic masses; looks for shape and texture to provide guidance for interventional breast procedures such as cyst aspiration or core biopsy useful when a palpable mass is partially or poorly seen on a mammogram, especially in young women When added to mammography= improved breast cancer detection in high-risk women (Journal of the American Medical Association, 2008)

A mammogram was taken as seen in the picture A mammogram was taken as seen in the picture. Is this benign or malignant? Dx: BENIGN CYST

Differentiate radiologically a benign lesion from a malignant one. Smooth contour Grow significantly Well-circumscribed Stellate or star-bust shaped that extends in all directions Encapsulated Calcifications With “halo sign” Will not change much in shape or size

Difference in ultrasound findings. BENIGN MALIGNANT intense uniform hyperechogenicity Irregular/spiculated borders (“Silhouette sign”) ellipsoid or wider-than-tall (parallel) orientation along with a thin, echogenic capsule taller-than-wide orientation 2 or 3 gentle lobulations and a thin, echogenic capsule angular margins marked hypoechogenicity posterior acoustic shadowing punctuate calcifications duct extension branch pattern microlobulation.

Should the patient have a mother who is a breast cancer survivor, how would that information change your management?

Breast Cancer Screening Tests Mammogram is the best tool available for early breast cancer detection can often identify cancer before symptoms appear and can reveal calcium deposits in the breast, which may be an early sign of cancer HIGH RISK: annual mammogram beginning at an age that is 5 to 10 years younger than the youngest member of the family with breast cancer

Breast Cancer Screening Tests Clinical breast exam thorough physical examination of the breasts done by a physician or nurse practitioner HIGH RISK: recommended every 6 to 12 months Self breast exam identify breast abnormalities and should be performed monthly, about one week after the end of your period Breast MRI For extremely dense breast tissue that make mammograms difficult to interpret

Self breast Exam National Cancer Institute

Estimating Breast Cancer Risk The risk of breast cancer increases as women get older Risk factors include personal history of breast abnormalities, current age, age at first menstrual period, age at first live birth, breast cancer history of close relatives, whether a woman has had a breast biopsy, obesity, physical inactivity, and race The Breast Cancer Risk Assessment Tool (http://www.cancer.gov/bcrisktool) estimates a woman’s risk of developing breast cancer for two time periods: over the next five years and over her lifetime

Risk Calculator 1. Does the woman have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)? 2. What is the woman's age? This tool only calculates risk for women 35 years of age or older.   3. What was the woman's age at the time of her first menstrual period?   4. What was the woman's age at the time of her first live birth of a child?   5. How many of the woman's first-degree relatives - mother, sisters, daughters - have had breast cancer?   6. Has the woman ever had a breast biopsy?     6a. How many breast biopsies (positive or negative) has the woman had?     6b. Has the woman had at least one breast biopsy with atypical hyperplasia?   7. What is the woman's race/ethnicity?   National Cancer Institute

A clinical practice guideline by the US Preventive Services Task Force : "recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2)" The Task Force gave a grade D recommendation. "recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing." The Task Force gave a grade B recommendation. The Task Force noted that about 2% of women have family histories that indicate increased risk as defined by: For non–Ashkenazi Jewish women, any of the following: "2 first-degree relatives with breast cancer, 1 of whom received the diagnosis at age 50 years or younger" "3 or more first- or second-degree relatives with breast cancer regardless of age at diagnosis" "both breast and ovarian cancer among first- and second- degree relatives" "a first-degree relative with bilateral breast cancer" "a combination of 2 or more first- or second-degree relatives with ovarian cancer regardless of age at diagnosis" "a first- or second-degree relative with both breast and ovarian cancer at any age" "a history of breast cancer in a male relative." "For women of Ashkenazi Jewish heritage, an increased-risk family history includes any first-degree relative (or 2 second-degree relatives on the same side of the family) with breast or ovarian cancer."