abnormal mammogram
DESCRIPTION
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? - PowerPoint PPT PresentationTRANSCRIPT
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Abnormal Mammogram
Marion C.W. Henry, MDYale 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 findingsHEENT: 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. Mass2. Microcalcifications3. 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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