abnormal mammogram marion c.w. henry, md yale university
TRANSCRIPT
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Abnormal Mammogram
Marion C.W. Henry, MD
Yale University
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Ms. Young
Ms. Young is a 43 yr-old woman who presents to your clinic with an abnormal mammogram noted on routine screening examination.
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History
What other aspects of the history of present illness do you want to know?
Make a list of at least three pertinent questions.
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History, Ms. Young
Characterization of symptoms
Temporal sequence Alleviating /
Exacerbating factors:
Pertinent PMH, ROS, MEDS.
Relevant family hx. Associated signs and
symptoms
Consider the Following
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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?
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Physical Examination
What specific aspects of the physical exam would you look for?
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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
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Studies
Screening Mammogram• Standard 2 view- CC and MLO
Diagnostic Mammogram• Spot compression views • Oblique or extra views based on location of
abnormality
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Mammography
Can you describe 3 mammographic findings that raise concern?
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Mammographic Abnormalities
1. Mass
2. Microcalcifications
3. Asymmetric Density
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Breast Mass MLO views
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Breast Mass CC views
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Asymmetric Density
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Microcalcifications Mag View
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Spiculated Mass Mag View
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Mass with Microcalcifications
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Pleomorphic Calcifications
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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)
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Studies – Results
How will you manage a patient with an abnormal mammogram and a nonpalpable lesion based on each BIRAD Classification ?
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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
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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
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Pathology
Your final pathology report shows presence of atypical ductal hyperplasia. What do you tell your patient?
Next steps?
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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
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Pathology, Scenario 2
Her breast biopsy shows DCIS, Ductal Carcinoma In Situ
What next?
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Scenario 2, cont
Needle – localized excisional biopsy also shows ductal carcinoma in situ with tumor-free margins – now what do you advise your patient?
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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
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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.
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Pathology, Scenario 3
The pathology from the biopsy comes back as lobular carcinoma in situ (LCIS) – how do you manage the patient?
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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
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QUESTIONS ??????
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