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Abnormal Mammogram

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?

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Abnormal Mammogram

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

  5. 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? History, Ms. YoungConsider the following:

  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 Remaining Examination findings non-contributory

  8. Studies • Screening 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. 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 The preceding educational materials were made available through theASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials wewelcome your comments/ suggestions at: feedbackPPTM@surgicaleducation.com

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