1. Breast cancer screening recommendations:
-USPSTF: mammograms every 2 years from age 50 to 74, no self exams
-ACS: mammograms every year from age 40 on, no set age to stop (stop when other chronic diseases get bad), self exams should be done starting at age 20. If someone is high-risk, they should get annual to biennal mammograms starting age 30,
2. Mammography has 3 findings: mass, asymmetric density (can result from prev surg, rad, infection, or normal variant), microcalcifications.
For stratifying the risk of a mammographic finding, there is the BI-RADS system:
0: needs additional evaluation (i.e. u/s for masses or densities and spot magnification mammograms for microcalcifications)
1: normal
2: benign findings, normal screening
3: probably benign, short-follow up (6 mos). Risk of malignancy <2%. Biopsy only if the patients have other suspicious lesions, or are wanting to get pregnant or receive a transplant soon (because the immunosuppresive drugs may worsen the cancer prognosis or quicken its spread, also because the presence of cancer may be a contraindication to receiving a transplant)
4: suspicious, core biopsy warranted. Risk of malignancy 15-35%.
5: highly suspicious of malignancy.
3. A solid breast mass in any woman over the age of 35 is cancer until proven otherwise, and requires a mammogram (u/s if it feels cystic) and core biopsy. In a woman less than 30, it is 98% likely to be fibroadenoma; you can do FNA, core needle, or observation, depending on what the patient wants. Mammogram is indicated if there is a clinical or historical reason to suspect cancer.
4. Bloody nipple discharge is never normal and must be surgically investigated-- its likely an intraductal papilloma. Mammography is required to find an underlying mass (4-13% risk in older women of cancer), and then you must cannulate the duct, do a ductogram (inject dye) and excise the duct.
5. Other signs:
-Edema/peau d'orange, overlying ulceration: suggests inflammatory process
-Retraction of skin: suggests mass invading support structures
-Supraclavicular node: suggests stage IV disease, unresectable and uncurable. (the tumor usually drains to Level I nodes which are lateral to pec minor, then Level II which are deep to pec minor, then level III which are medial to pec minor, then it goes to systemic lymphatics and spupraclavicular simultaneously.
-Overlying skin nodules: may be satellite lesions, require biopsy
6. Treatment
-Stage 0 or small stage I (<1 cm): lumpectomy, radiation, hormone therapy is if its ER+, nothing if ER-
-Stage I with 1-2 cm: lumpectomy, radiation, hormone therapy if ER+, adjuvant chemo (esp in premenopasual women)
-Stage II (primary >2cm or +LN): lumpectomy OR modified radical mastectomy if relative or absolute CI to lumpectomy. radiation. hormone therapy if ER+, adjuvant chemo for everyone under 70.
-Stage III (primary >5cm, fixed nodes, or inflammatory lesions): neoadjuvant chemo (i.e before surgery), modified radical mastectomy, postop rad and chemo. 5 year survival 41%
-Stage IV (distant mets): palliative radiation and chemo. No surgery. 5 year survival 18%.
7. Altered mental status, lethargy, or coma in a patient with a history of breast cancer: rule out hypercalcemia due to bony mets or PTHrp secreting mass.
8. Breast masses in pregnancy: should be managed the same way as those in women who are not pregnant. If biopsy reveals cancer stage I or II, treatment is still excision: either lumpectomy + radiation or mastectomy. If its the third trimester, she can get excision and wait until postpartum to get the radiation. But if its the first or second trimester, she must get a mastectomy because she won't be able to get radiation. If it's stage III or IV, she'll have to get the full gamut of chemo, radiation, and mastectomy, which may require an abortion.
9. Breast lump in a...
-adolescent boy: gynecomastia, will self-resolve
-6 y/o girl: breast buds. Do not biopsy or excise, as it will alter future breast development
-50 y/o man: if its just enlargement, its likely hypertrophy due to medications (anti-fungals, anti-testosterones, marijuana or alcohol, digoxin, K-sparing diuretics). Watch, and biopsy only if it doesn't regress. If it's a firm, well-circumscribed mass, mammogram and biopsy are warranted.
10. Paget's disease of the breast is frequently (>95%) associated with underlying carcinoma. It's important to do a mammogram to look for an underlying mass; if its present, biopsy it. If no mass is present, biopsy the skin lesions.