1. BREAST CANCER UPDATE DETECTION TO DIAGNOSIS
Vincent M. Scarpinato, M.D., F.A.C.S.
Senior Medical Director
Department of Surgery
Southern Ohio Medical Center
October 2009

2. BREAST CANCER
Most commonly diagnosed cancer in women (excluding skin cancer)
Second most common cause of cancer related deaths (second to lung cancer)
Early Detection = Improved Survival

3. Breast Cancer Statistics
1960: 1/20
2008: 1/8 (12%) Breastcancer.org

4. Breast Cancer Statistics 2006
212,920 cases of Invasive Breast Cancer
61,980 cases of Noninvasive
(“In Situ”) Breast Cancer
40,970 Deaths Breast Cancer Facts & Figures (ACS)

5. Breast Cancer Statistics 2009
192,370 cases of Invasive Breast Cancer (212,920 in 2006)
62,280 cases of In Situ Breast Cancer (61,980 in 2006)
40,170 Deaths (40,970 in 2006) Breast Cancer Facts & Figures (ACS)

6. Breast Cancer Deaths Steady decrease in death-rate since 1990
Earlier detection
Increased awareness
Improved screening/diagnostics
Improved treatment modalities

7. Breast Cancer Therapy Evolution
Halsted: “If some is good, more is better” Radical Mastectomy
Fisher: “Less is more” Lumpectomy/Complete Axillary Node Dissection Plus Whole Breast Irradiation = Mastectomy
Today: “Less and less is more” Lumpectomy/Sentinel Lymph Node Biopsy Plus Partial Breast Irradiation (PBR) = Mastectomy

8. DETECTION SCREENING MAMMOGRAPHY Baseline Study 35-40
Earlier Family History (1st Degree)
Yearly after age ACS/Am Col Surg

9. DETECTION “BI-RADS” Classification
Breast-Imaging Reporting and Data System (BI-RADS)
American College of Radiology (ACR)
Risk Assessment Categories (7)

10. BI-RADS CLASSIFICATION
CATEGORY
DIAGNOSIS
CRITERIA
Incomplete
More imaging required
Rec: Additional Studies 1
Negative
No abnormal findings
Rec: Routine Screening 2
Benign
Clearly Benign findings Rec: Routine Screening 3
Probably
Findings have a High Prob of being Benign (>90)
Rec: 6 month F/U

11. BI-RADS CLASSIFICATION
CATEGORY
DIAGNOSIS
CRITERIA 4
Suspicious Abnormality
Suspicious but not fully characteristic of malignancy
Rec: Consider Biopsy 5
Highly Suspicious Abnormality
High Prob of being malignant (>95%)
Rec: Biopsy 6
Biopsy Proven Malignancy
Known Malignancy being imaged prior to treatment

12. Breast Biopsy Options “Open”/Surgical Biopsy “Closed”/Percutaneous
Incisional
Excisional
“Closed”/Percutaneous
Fine needle aspiration (FNA)
Core Biopsy/”Tru-cut”
Vacuum Assisted/Rotational Biopsy

13. Palpable Breast Biopsy Options

14. Non-Palpable Breast Biopsy Options
Image Guided:
“Radiologically Assisted”
Ultrasound
Mammographic/Stereotactic CT
MRI

15. Fine Needle Aspiration “FNA”

16. Ultrasound Guided FNA
Cyst Aspiration
“FNA”

17. Core Biopsy Devices

18. Ultrasound Guided Breast Biopsy
Solid Lesions

19. Ultrasound Guided Breast Biopsy
Malignant Lesion

20. Ultrasound Guided Breast Biopsy

21. Ultrasound Guided Breast Biopsy
Core Biopsy
of Solid
Lesion

22. Mammographic/Stereotactic Bx
Microcalcifications

23. Mammographic/Stereotactic Bx
Microcalcifications/Magnification View

24. Mammographic/Stereotactic Bx

25. Stereotactic Bx Specimen Xray

26. Mammographic/Stereotactic Bx Clip Application/Postprocedure

27. Post procedure Mammogram

28. Mammographic Wire Localizing Breast Lumpectomy

29. Mammographic Wire Localizing Breast Biopsy

30. Mammographic Wire Localizing Breast Biopsy

31. INTRAOPERATIVE ULTRASOUND Guided Wire Localizing Lumpectomy
For nonpalpable lesion
Seen sonographically
Intraoperative Wire Placement under Ultrasound guidance
Partial Mastectomy/ “Lumpectomy”

36. CT GUIDED LOCALIZATION

37. CT GUIDED LOCALIZATION

38. CT GUIDED LOCALIZATION

39. MRI Breast

40. MRI GUIDED LOCALIZATION or BIOPSY

41. MRI of the Breast CONS PROS More Expensive (much more!)
Claustrophobia
False Positives
Leads to many more biopsies
Leads to more mastectomies J Am Col Surg Oct 2009
PROS
More sensitive than ultrasound
More sensitive than mammogram
More sensitive than physical exam
Better in younger pts (dense tissue)

42. MRI of the Breast May be helpful… Assessing extent of disease
Additional foci
Axillary metastasis
Contralateral disease
Response to chemotx (neoadjuvant)
Residual disease postop
Breast augmentation

43. MRI of the Breast ?Screening
Lifetime Breast Cancer Risk (predictive models) 20 – 25%.
BRCA1 or BRCA2 mutations
Chest Wall Radiation ages 10-30
Congenital Syndromes: Li-Fraumeni, Cowden, etc ACS Guideleines for Breast Cancer Screening CA Cancer J Clin 2007;57:75-89

44. USA 2009 1,000,000 BREAST BIOPSIES ANUALLY 80% BENIGN
35% OF MALIGNANCIES ARE (STILL) DIAGNOSED WITH OPEN BX
30% “unnecessary” mastectomies The Breast Journal, Volume 15 Number 1, –10041% receive “unnecessary” mastecto~41% receive “unnecessary” mastectomy

45. Percutaneous Histology (vs Open/Surgical Biopsy)
Represents “Best Practice” and should be….
“Gold Standard” over open biopsy
Should be <5-10% open biopsies Consensus Conference III Jo Am Co Surg Oct 2009

46. Recommendations after Percutaneous Needle Biopsy
Benign/Concordant
Benign/Discordant
Observation
(Routine Screening)
Surgery
High Risk Histology
(ADH,Radial Scars, Papillary)
Malignant
Surgery
Surgery

47. Clinical Quality Dashboards (Detection to Diagnosis)
Time from reporting abnormal screening to diagnostic mammogram (average: 20 days)
Time from reporting diagnostic mammogram to biopsy (average: 20 days)
Time from reporting of biopsy results to surgery ( days) Oncology Roundtable

48. THANK YOU