Arrest Report - Shaun Christopher Fenster

Resident
R
id t A
Ambulatory
b l t
Curriculum
PGY 3
Dr Tracie Wilcox
Dr.
Assistant Professor of
M di i
Medicine
Breast Disease
Case 1:
A 41 y o female presents to clinic for
her annual exam. She has no
medical problems and denies a family
history of breast cancer. She has had
routinely normal pap smears
smears. She is
asking you about breast cancer
screening.
screening She performs self breast
exams diligently every month and has
not noticed any changes
changes.
Screening for Breast Cancer
How would you counsel her regarding
screening for breast cancer in a low
risk women of her age group?
Clinical breast exam
Self breast exam
Mammogram
MRI
Self Breast Exams
USPTF: recommends against teaching
breast self – examination – updated 11/09
No change in breast cancer mortality
American cancer society: “ women should
be educated about benefits and limitations
of monthly self breast exams”
ACOG: recommends routine teaching of
SBE
Clinical Breast Exams
American Cancer Society:
Recommends every 3 years between
age of 20
39 then annually
20-39
USPTF does not recommend clinical
breast exam without mammogram
Mammogram
ACS/ACOG/AMA
Recommend starting routine screening
at age 40 with frequency of every 1-2
12
years
ACP/ AFP
Recommend routine screening at age 50
Recommend shared decision making
model and individual risk assessment for
women age 40-49
40 49
Screening Mammography for Women 40 to 49 Years of Age: A Clinical Practice Guideline from the American College of Physicians
Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Katherine Sherif, MD et al., For the Clinical Efficacy Assessment Subcommittee of the
American College of Physicians.3 April 2007 | Volume 146 Issue 7 | Pages 511-515
Mammogram
New USPTF Guidelines – 11/09
Recommends against routine screening
mammogram in women of the general
population age 40-49
Recommends mammography screening every
2 years in women 50-74
50 74
Based on data showing:
increased rate of false-positive mammograms for
women in their 40’s leading to psychological harm
and unnecessary tests/procedures
Higher number needed to screen to save one life
Mammogram
ACS response to new USPTF Guidelines:
“The ACS continues to recommend annual
screening mammography and breast exam for
all women beginning at age 40”.
Recommendations based on data similar to that
reviewed by USPTF + “additional
additional data the
USPTF did not consider”
Based on data showing mortality benefit in
women age 40-49
Mammogram
Age
g
g 40-50 Summaryy
What is the argument
g
against?
g
Breast cancers less common in younger
women
Mortality benefit for screening smaller than
seen for women 50 and over
NNTS 50-59 to save one life: 1339
NNTS 40-49 to save one life: 1904
Abnormal mammogram less likely to be
malignant and leads to unnecessary stress and
biopsies
Increased rates of detection of DCIS
Unclear how often DCIS would progress to further
cancer if left untreated
Mammogram Age 40-50
40 50
What is the argument for?
Screening mammograms for women 40 to 49
years of age decrease the risk for breast cancer
deaths compared with women who do not get
screened
A recent
estimated
ece t meta-analysis
eta a a ys s est
ated tthe
e relative
e at e
reduction in the breast cancer mortality rate to be
15% after 14 years of follow-up
Diagnose breast cancer at earlier stage
Breast cancers in younger patients may be
more aggressive (ER negative)
Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of
the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:34760.
Breast MRI
American Cancer Society
recommends annual MRI in the
following high risk groups:
Known BRCA mutation carriers
First degree relatives of known BRCA
mutation carriers
Women with increased lifetime risk of
over 20-25% based upon prediction
models
Case 2
KP is a 50 y o white female who
presents with concerns about her
personal risk of developing breast
cancer. Her mother was diagnosed
with breast cancer at age 62.
She wants to know if she would be a
p p y
candidate for chemoprophylaxis.
How could you determine this?
Breast Cancer Risk
Assessment Tool (Gail Model)
Calculates a woman’s 5-year
y
and lifetime
risk of developing breast cancer
Includes:
Current age
Number of 1st-degree female relatives with a history of breast
cancer
Age at first live birth, or nulliparity
History and Number of breast biopsies
History of atypical hyperplasia
Age at menarche
Race
The Gail
Model
Based on data from the Breast
Cancer Detection Demonstration
Project
involved white women undergoing
annual screening examinations
Estimates the probability that a woman
will develop invasive or in situ breast
cancer over a defined age interval
Limitations of the Gail
Model
Not to be used in women alreadyy with history
y of
LCIS, DCIS, or invasive breast cancer.
May underestimate the risk in women who have
2nd-degree
degree relatives with breast cancer or who are
known BRCA carriers
May overestimate risk with women who are over
age 50 with history of two or more breast biopsies
or who were under age 20 at first live birth.
Updated model validated in AA women in 2007
Not to be used in women age < 35
Constantino JP, Gail MH, Pee D, et al. J Natl Cancer Inst.
1999;91:1541-1548
.
The CASH (Claus / Yale) Model
Calculates a woman’s
woman s risk of
developing breast cancer over 10year intervals in women with family hx
off breast
b
t cancer
Includes:
Number of 1st- or 2nd-degree relatives
with a history of breast cancer
(maternal and paternal)
Age that 1st- and 2nd-degree relatives
were diagnosed with breast cancer
Limitations of the Claus
M d l
Model
Woman must have at least one 1st- or
2nd-degree
d
relative
l ti with
ith b
breastt cancer
Does not take into account other risk
factors associated with breast cancer
Onlyy included 10% AA women in data
collection studies
Created prior to discovery of BRCA 1 and 2
genes
Case 2 continued
45 yo white female
Menarche at age 11
Nulliparous
N lli
Mother with breast cancer at age
g
62; 2 healthy postmenopausal
sisters
1 previous breast biopsy with
benign pathology
Using the Gail Model
Model, this patient’s
patient s risk
for developing breast cancer is:
5-year risk = 2.8%
Lifetime risk = 23.2%
Chemoprevention
Would you offer this patient
chemoprevention?
If so, what medication would you
ff ?
offer?
Chemoprevention
Average risk for 45 y o caucasian
women is:
5 yr: 1%
Lifetime: 11.9%
Consider chemoprevention in patients
age 35-59 if 5-year GAIL model risk >
1.66%
Chemoprevention Options
SERM:
Tamoxifen
Shown to decrease risk of ER positive invasive breast
cancer and noninvasive breast cancer
Highest benefit in younger women, women without uterus,
and women with highest risk of breast cancer
Taken for 5 years
No study has shown survival benefit
Raloxifen
Reduces incidence of invasive breast cancer in high risk
women
Lower risk of DVT, PE, cataract
Approved in US for prevention of breast cancer in
postmenopausal women with osteoporosis and
postmenopausal women at high risk of developing breast
cancer
A
t
iinhibitors
hibit
tl being
b i studied
t di d
Aromatase
– currently
Case 3
35 y o female with significant family
history for breast cancer tests positive
for the BRCA mutation
mutation. She opts
against surgical prophylaxis.
How would you screen her for breast
cancer?
Increased Surveillance in High Risk
W
ith BRCA mutations
t ti
Women
with
Annual mammogram starting age 25
Annual MRI starting age 25
Clinical
breastt exam 2
2-4x/year
Cli i l b
4 /
starting age 20-25
Annual self breast exam
p
p
Discuss chemoprevention
options
Case 4
A 45 yo AAF presents to your clinic for a
routine physical. Two months prior to
moving to Chicago she detected a lump on
self breast examination. Follow-up
mammogram and biopsy showed
“fib
ti changes”.
h
” Sh
t tto kknow
“fibrocystic
She wants
whether this will increase her chances of
breast cancer and has brought the report
for you to evaluate:
She has no family history of breast cancer
cancer.
Case 9 cont:
Pathology:
“Fibrocystic changes without atypia”
Her breast cancer risk is:
)
1)Average
2)Increased
3)Decreased
“Fibrocystic
Changes”
Fibrocystic Changes
Non proliferative breast lesion
Most common cause of breast nodularity
g 20 to 50
and p
pain in women age
Increase in number of cysts and fibrous
tissue
Exam reveals rubbery non-discrete
glandular tissue. May also appreciate
cysts.
May have associated nipple discharge:
color can be pale green to brown
Fibrocystic Disease
Fibrocystic change of the breast in
conjunction with severe pain (which is
usually cyclical)
cyclical), palpable mass and
occasionally nipple discharge
Fibrocystic Breast and Cancer
Ri k
Risk
Fibrocystic change denotes normal
breast tissue without an appreciable
increase in cancer risk
Proliferative lesions with associated
atypia increase risk
Ex: Atypical hyperplasia – relative risk 36 fold
Case # 5
A 36 y o female presents to your clinic
with complaints of nipple discharge.
What questions do you ask her and
h
d
l t h
?
how
do you evaluate
her?
Historical Questions
Is it unilateral or bilateral?
Is it spontaneous or provoked by manipulation?
What is the color and consistency of the fluid?
How
has it b
been going
H
llong h
i on?
?
Any association with physical events such as
trauma?
Any new medications which might be associated?
Associated amenorrhea or symptoms of
hypogonadism (hot flashes
flashes, vaginal dryness)
Physical Exam
Check for skin changes and asymmetry of breasts
Determine the number of ducts involved
Determine if discharge unilateral or bilateral
Check for associated breast mass and LAD
Check the color and consistency of the fluid?
Straw colored: intraductal papilloma
compressing venous/lymphatic system
Grossly Bloody:
1/3 fibrocystic breast
1/3 intraductal
i t d t l papilloma
ill
Intraductal carcinoma
Test anyy discharge
g for blood with hemoccult test
Intraductal pathology, occasionally breast CA
Case 5 Continued
On further q
questioning
g she reports
p
unilateral discharge that is spontaneous
and is straw colored. She denies any
amenorrhea or hot flashes or vision
changes.
PE reveals no breast asymmetry
asymmetry, no
palpable mass, expressible unilateral
discharge that is straw colored, from a
single
duct,
i l d
t and
d guiac
i negative.
ti
How would you evaluate her further?
Diagnostic Testing
Labs for multiductal discharge: TSH,
prolactin, pregnancy test
g
Mammogram
if >30 ((dedicated
mammogram with magnified views of
retroaerolar area) + peri-areolar u/s +/ductal studies
Cytology – rarely helpful
If negative does not rule out malignancy
Surgical evaluation for breast lump,
imaging abnormality
abnormality, + guaiac test
test,
unilateral spontaneous from one duct
Case 5 Continued
Mammogram shows breast nodule
and breast u/s + ductogram reveal
intraductal papilloma
Referred to surgeon and papilloma
resected
Characterization of Nipple
Di h
Discharge:
Normal Discharge
= Lactation
Physiologic Discharge
= galactorrhea
g
= nonpathologic d/c not related to
pregnancy or nursing
Discharge is usually seen only with
compression of ducts (usually multiple
ducts are involved)
Discharge is usually bilateral
Fluid color may be clear
clear, yellow
yellow, white or
dark green
Guiac negative
g
Causes of Galactorrhea
Idiopathic
Secondary
Hyperprolactinemia – ex: pituitary adenoma
Medications: TCA’s, antipsychotics,narcotics
Menarche or Early Menopause
Nipple Stimulation
Trauma to anterior thoracic nerves
Other: stress, mastitis
Pathologic Causes
= suspicous causes
malignant or nonmalignant
more likely to occur spontaneously
spontaneously, be
unilateral, and confined to one duct
Fluid more often bloody
Associated mass may be present
Pathologic Nipple Discharge
Ddx:
Intraducal papilloma
Most common cause ( 52-57%)
Ductal ectasia
Fibrocystic changes
Malignancy - 5-15%
Increases with increasing age
DCIS most common
False Nipple Discharge
Fluid does NOT originate in breast
secretory unit
Eczema
Cutaneous viral infections
Nipple trauma eg
eg. Joggers nipples
Draining sebacous cyst
Other
off inflammations
Oth skin
ki infections
i f ti
i fl
ti
(e.g. moloscum contagiosum)
Case 6
A 56 y o female presents with left
sided nipple discharge associated
with redness and skin irritation
irritation.
On PE there is no palpable lump in
the breast but + erythema and skin
thickening around the areola
What
kind
Wh t is
i your concern and
d what
h t ki
d
of work up should you order?
Physical Exam
Paget’s
Paget
s Disease
Clinical symptoms:
y p
scaly, raw, vesicular, or ulcerated lesion that
begins on the nipple and then spreads to the
areola
Pain, burning, pruritus
yellow, clear, viscous or bloody discharge
Associated with underlying breast cancer in
97% of cases
Dx: breast exam,mammo,MRI, punch
biopsy
off th
the skin
bi
ki
Trx: mastectomy vs resection of
nipple/areola complex + xrt
`