Marion C.W. Henry, MD Yale University Abnormal Mammogram Marion C.W. Henry, MD Yale University

Ms. Young Ms. Young is a 43 yr-old woman who presents to your clinic with an abnormal mammogram noted on routine screening examination.

History What other aspects of the history of present illness do you want to know? Make a list of at least three pertinent questions.

History, Ms. Young Characterization of symptoms Consider the Following Characterization of symptoms Temporal sequence Alleviating / Exacerbating factors: Pertinent PMH, ROS, MEDS. Relevant family hx. Associated signs and symptoms

History, Ms. Young Consider the following: Characterization of Symptoms: Does she have any symptoms at all? Temporal sequence: Has she ever had a mammogram before? Alleviating / Exacerbating factors: Are there any? Associated signs/symptoms: Any hx of mass, pain, nipple discharge or skin changes? Pertinent PMH: age at menarche, age at first full-term pregnancy, any previous breast biopsies and results? Hx of hormone therapy? Relevant Family Hx: does cancer run in her family? Any 1st degree relatives with breast cancer? Ovarian cancer?

Physical Examination What specific aspects of the physical exam would you look for?

Physical Examination, Ms. Young Vital Signs: BP=136/80, HR=79, RR=14, T=98.3 Appearance: Slightly overweight, well-appearing Relevant problem-focused exam findings HEENT: anicteric sclera, no lymphadenopathy Genital-rectal: no masses, normal tone Chest: clear bilaterally, good air movement Neuromuscular: grossly normal CV: Rhythm regular, no murmur Skin/Soft Tissue: Breasts: symmetrical ,no masses, no nipple discharge, no skin changes, no axillary adenopathy, Abd: soft, non-tender, no hepatosplenomegaly, Remaining Examination findings non-contributory

Studies Screening Mammogram Diagnostic Mammogram Standard 2 view- CC and MLO Diagnostic Mammogram Spot compression views Oblique or extra views based on location of abnormality

Mammography Can you describe 3 mammographic findings that raise concern?

Mammographic Abnormalities 1. Mass 2. Microcalcifications 3. Asymmetric Density

Breast Mass MLO views

Breast Mass CC views

Asymmetric Density

Microcalcifications Mag View

Spiculated Mass Mag View

Mass with Microcalcifications

Pleomorphic Calcifications

Mammogram Review: BIRAD classification BIRAD 0: cannot be classified at present time without additional views BIRAD I: Absolutely normal BIRAD II: Radiologic abnormality but definitely benign (eg. Vascular calcification, calcified fibroadenoma) BIRAD III: Abnormality with low chance for malignancy (eg. New solid lesion without marked abnormality in margin or small cluster calcification without pleomorphism) BIRAD IV: abnormal mammogram with about 40% malignancy rate (eg. Clustered microcalcifications with pleomorphism or mass with irregular margin) BIRAD V: markedly abnormal mammogram with expected rate of malignancy about 80% (eg. Abnormal lesion with irregular spiculated margin and microcalcifications within lesion)

Studies – Results How will you manage a patient with an abnormal mammogram and a nonpalpable lesion based on each BIRAD Classification ?

Studies – Results BIRAD II: yearly surveillance mammogram BIRAD III: stereotactic biopsy or mammogram at 6 months BIRAD IV: stereotactic or needle-localized biopsy BIRAD V: needle-localized lumpectomy

Ms. Young – BIRAD III abnormality Ms. Young – BIRAD III abnormality. Repeat mammogram in 6 months has minor changes. What now? Stereotactic core needle biopsy with marker clip placement Mammogram specimen to see areas of microcalcification and match to original mammogram

Pathology Your final pathology report shows presence of atypical ductal hyperplasia. What do you tell your patient? Next steps?

Atypical ductal hyperplasia ADH Her relative risk of breast cancer has increased by 3 times If she does not develop breast cancer in the next 8 to 10 years, then her risk returns to normal

Pathology, Scenario 2 Her breast biopsy shows DCIS, Ductal Carcinoma In Situ What next?

Scenario 2, cont Needle – localized excisional biopsy also shows ductal carcinoma in situ with tumor-free margins – now what do you advise your patient?

Ductal Carcinoma In-Situ 2 factors determine your management: size and pathologic type (commedeo or papillary/cribiform type) If papillary/cribiform and less than 1 cm – only excision with free margin is adequate If commedeo type, or greater than 1 cm, or palpable – lumpectomy and radiation or total mastectomy

What is the expected outcome? Following total mastectomy for in situ carcinoma, 99% of patients are cured, less than 1% have axillary node mets Following lumpectomy and radiation, there will be 12% recurrence in the ipsilateral breast. 6% will be in situ recurrence and will be cured with total mastectomy. 6% will be invasive.

Pathology, Scenario 3 The pathology from the biopsy comes back as lobular carcinoma in situ (LCIS) – how do you manage the patient?

Lobular Carcinoma In Situ Lobular carcinoma in situ is not a pre-malignant disease Observe patient closely, ↑↑ risk for invasive CA Anti-estrogen therapy may be beneficial Recommend prophylactic bilateral mastectomy ONLY is patient is carrier for mutated BRCA I or BRCA II gene or has extremely strong family history of breast cancer among multiple first degree relatives

QUESTIONS ??????

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