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

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

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

4. 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

5. 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?

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

7. 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

8. 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

9. Mammography
Can you describe 3 mammographic findings that raise concern?

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

11. Breast Mass MLO views

12. Breast Mass CC views

13. Asymmetric Density

14. Microcalcifications Mag View

15. Spiculated Mass Mag View

16. Mass with Microcalcifications

17. Pleomorphic Calcifications

18. 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)

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

20. 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

21. 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

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

23. 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

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

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

26. 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

27. 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.

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

29. 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

30. QUESTIONS ??????

31. Acknowledgment
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