BREAST CANCER RISK FACTORS/SCREENING
What is the average woman’s lifetime risk of developing breast cancer?
According to the 2014 National Comprehensive Cancer Network (NCCN) guidelines, what groups of women have an increased risk of developing breast cancer?
1. History of breast cancer
2. 5-year risk of invasive breast cancer at least 1.7% in women 35 years old or older using the Gail model
3. Lobular carcinoma in situ (LCIS) or atypical ductal or lobular hyperplasia (ADH/ALH)
4. Lifetime risk over 20% defined by models based on family history
5. History of thoracic radiation therapy when less than 30 years old
6. Family with suggested or known genetic predisposition
What is the modified Gail model?
A model that calculates 5-year and lifetime projected probabilities of developing invasive breast cancer.
What criteria is the modified Gail model based on?
2. Age at menarche
3. Age at first live birth or nulliparity
4. Number of first-degree relatives with breast cancer
5. Number of previous benign breast biopsies
6. Atypical hyperplasia in a previous breast biopsy
If she has any of the following:
1. A family member with a known mutation in a breast cancer susceptibility gene or she is from a population with a known increased risk for genetic predisposition to developing breast cancer.
2. Two or more breast cancer primaries in a single individual or two or more breast cancer primaries diagnosed from the same side of the family (maternal or paternal).
3. A family member with a history of ovarian/fallopian tube/peritoneal cancer.
4. A first- or second-degree relative with early-onset breast cancer, ≤45 years.
5. A family member with a combination of breast cancer and one or more of the following: pancreatic cancer, aggressive prostate cancer, sarcoma, adrenocortical carcinoma, brain tumor, endometrial cancer, leukemia/lymphoma, thyroid cancer, dermatologic manifestations, macrocephaly, hamartomatous GI polyps, or diffuse gastric cancer.
6. A family history of male breast cancer.
7. A personal history of ovarian/fallopian tube/primary peritoneal cancer.
For women at normal risk between the ages of 25 and 39, how often should a clinical breast examination be performed?
Every 1 to 3 years.
For women at normal risk aged 40 years and older, how often should a clinical breast examination be performed?
What are the 2015 American Cancer Society Guidelines for screening mammography?
Optional annual mammograms for women ages 40 to 44, annual mammograms for women ages 45 to 54, and annual or biennial mammograms for women 55 and older.
How often should women who have received prior thoracic irradiation be screened?
1. Age <25, annual clinical breast examination starting 8 to 10 years after radiation.
2. Age ≥25, annual mammogram and MRI, and clinical breast examination every 6 to 12 months.
*Annual mammogram should occur 8 to 10 years after radiation exposure or at age 40, whichever occurs first.
What are the NCCN screening guidelines for women 35 years or older with a 5-year risk of invasive breast cancer ≥1.7%, based on the Gail model?
Annual mammogram and clinical breast examination every 6 to 12 months.
What are the NCCN screening guidelines for women with a lifetime risk of breast cancer over 20%?
Clinical breast examination every 6 to 12 months and annual mammogram starting at age 30. In addition, annual breast MRI is also recommended in women ≥30 years of age.
What are the NCCN screening guidelines for women with a history of LCIS or atypical hyperplasia?
Annual mammogram and clinical breast examination every 6 to 12 months.
What is the risk of developing breast cancer by age 70 in women with a BRCA1 or BRCA2 mutation?
Approximately 65% risk in patients with BRCA1, 45% risk in patients with BRCA2 (U.S. Preventive Services Task Force Recommendation Statement).
What cancers are associated with BRCA1 and BRCA2 mutations?
BRCA1 mutation is associated with increased risk of breast, ovarian, fallopian tube, peritoneal, prostate, and pancreatic cancer.
BRCA2 mutation is associated with increased risk of breast (especially in men), ovarian, prostate, and pancreatic cancer.
What is the overall sensitivity of screening mammography?
Approximately 75% (according to the NCCN guidelines 2015).
For screening mammography, what is the Breast Imaging Reporting and Data System (BI-RADS) categorization?
Category 0: Incomplete assessment. Needs additional imaging evaluation and/or prior mammograms for comparison
Category 1: Negative
Category 2: Benign findings
Category 3: Probably benign findings
Category 4: Suspicious abnormality—biopsy should be considered
Category 5: Highly suggestive of malignancy—appropriate action should be taken
Category 6: Known biopsy-proven malignancy—appropriate action should be taken
For a Category 3 lesion, what is the likelihood of malignancy?
For a Category 5 lesion, what is the likelihood of malignancy?
Is MRI more sensitive than mammogram in the detection of breast cancer?
It is more sensitive, but less specific.
MRI is recommended in women with a BRCA mutation or a first-degree relative of a BRCA carrier (untested), or lifetime risk of at least 20%. It is also recommended in women who received thoracic radiation between the ages of 10 and 30, patients with Li-Fraumeni syndrome and their first-degree relatives, and patients with Cowden and Bannayan–Riley–Ruvalcaba syndromes and their first-degree relatives.
MRI may be considered in patients with a 15% to 20% lifetime risk of developing breast cancer, those with a history of LCIS or ADH/ALH, those with dense or heterogeneous tissue on mammogram, and women with a history of breast cancer.
What is the difference between a screening mammogram and a diagnostic mammogram?
A diagnostic mammogram is performed when there are positive clinical findings or an abnormality seen on screening mammography. The diagnostic mammogram includes spot compression and magnification views.
Does breast ultrasound detect most microcalcifications?
BENIGN BREAST LESIONS
What is fibrocystic disease?
A spectrum of clinical, mammographic, and histological findings, present in 90% of women, representing an abnormal tissue response to circulating hormones.
How does fibrocystic disease typically present?
Premenstrual cyclical mastalgia.
How does fibrocystic disease appear mammographically?
Bilateral symmetrical diffuse or focally dense tissue.
Does presence of fibrocystic disease increase a woman’s risk of developing breast cancer?
What is a galactocele, and how is it treated?
A milk-filled cyst that typically presents during or after cessation of breast-feeding. Treatment involves aspiration or operative excision.
What is the treatment of a palpable cyst?
Aspiration. If it recurs after several aspirations, surgical excision is warranted.
What is Mondor disease?
A benign disorder characterized by thrombophlebitis of the breast.
A benign tumor consisting of stromal and epithelial elements. These tumors are estrogen sensitive.
What is the most common solid tumor found in women younger than 30 years?
How do fibroadenomas present clinically?
A solid, firm, mobile mass.
What is the treatment of a typical fibroadenoma?
Excisional biopsy or observation.
What is a giant fibroadenoma?
A fibroadenoma that attains a size of greater than 5 cm in greatest dimension.
What is the typical history of a giant fibroadenoma?
A rapidly enlarging mass in the breast of a young adult or adolescent.
What is an intraductal papilloma?
A true polyp of epithelium-lined breast ducts.
What is the typical presentation of an intraductal papilloma?
Bloody nipple discharge.
What is the treatment for an intraductal papilloma?
Excisional biopsy. Excision is required because approximately 20% of core needle biopsy diagnosed intraductal papillomas have been shown to be associated with malignancy.
What is the typical history of a patient presenting with a phyllodes tumor?
Rapidly enlarging painless breast mass.
What is the mean age of presentation for a phyllodes tumor?
40 years, older than a patient with a fibroadenoma, but younger than a patient with invasive breast cancer.
Histologically, what is the makeup of a phyllodes tumor?
Composed of both stromal and epithelial elements.
What is the appropriate workup including type of biopsy for a patient with a suspected phyllodes tumor?
Patients should have a complete H&P, ultrasound, and mammogram (if over 30 years old). Excisional biopsy should be performed. Fine needle aspiration does not distinguish a phyllodes tumor from a fibroadenoma, and core needle biopsy may not differentiate them either. Therefore, in patients with an indeterminate core needle biopsy or one that is suggestive of fibroadenoma where there is a high clinical suspicion for a phyllodes tumor, an excisional biopsy must be performed.
What is the appropriate treatment for a phyllodes tumor?
Local surgical excision with margins 1 cm or greater.
When is total mastectomy indicated?
When a negative margin cannot be obtained with lumpectomy or partial mastectomy.
Is axillary lymph node evaluation indicated in the treatment of phyllodes tumor?
No, phyllodes tumors rarely metastasize to the axillary lymph nodes. Therefore, node dissection is not indicated.
In patients who experience a local recurrence of their phyllodes tumor, what is the recommended treatment?
Re-excision with tumor-free margins of 1 cm. Radiation therapy is controversial in the treatment of phyllodes tumors. In certain cases with more aggressive pathology, radiation therapy may be indicated.
Is systemic therapy using endocrine or cytotoxic agents indicated in the treatment of phyllodes tumors?
BREAST CANCER STAGING
According to the 2010 American Joint Committee on Cancer breast cancer guidelines, how is breast cancer staged?
According to TNM staging.
Tx: tumor cannot be assessed
T0: no tumor
Tis: in situ
T1: <20 mm
T2: >20 mm and <50
T3: >50 mm
T4: Extension into chest wall and/or skin
Nx: nodes cannot be assessed
N0: no lymph node metastasis
N1: metastasis to mobile ipsilateral level I and/or II axillary nodes
N2: metastasis to fixed or matted ipsilateral level I and/or II axillary nodes or in clinically detected ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases
N3: metastasis to ipsilateral level III axillary nodes (with or without levels I/II axillary node involvement) or clinically detected ipsilateral internal mammary nodes or ipsilateral supraclavicular nodal involvement (with or without axillary or internal mammary lymph node involvement)
pNx: nodes cannot be assessed
pN0: no lymph node metastasis on histology
pN1: micrometastases or metastases in 1 to 3 axillary nodes or internal mammary nodes on histology, but not clinically detected