Breast

Embryology 5th,6th wk

-2 ventral bands of ectoderm (mammary ridge/milk line) (axilla to inguinal area)

Polymastia

-accessory breast

Polythelia

-accessory nipple -<1% of infant

-asso urinary/CVT abnormality

Inverted nipple

-failure of pit to elevate above skin -4% infant

Witch milk

-maternal H.via placenta

Amastia

-arrest milk line develop

Poland synd

-hypoplasia/absence of breast -rib/costal cartilage defect

-hypoplasia of subcu of chest wall -brachysyndactyly

Symmastia

-rare anomaly

-webbing between breast across midline

Supernumerary breast

-along milkline

-common btw nipple and symphysis -accessory axilla breast

Anatomy -15-20 lobes

-Cooper suspensory ligament

-2nd/3rd rib--6th/7th rib

-lateral sternum--ant axillary line

-retromammary bursa -axillary tail of Spence -upper outer--greater volume -lactiferous sinus--stratified sq.epi major duct--2 cuboidal cell

minor duct--single columnar/cuboid

Nipple-areola complex -pigment

-puberty--darker,elevate configuration -sebaseous gl,sweat gl,accessory gl -smooth m--cir/long--erection Alveolar epithelium -- 2 products

1.prot.component of milk -merocrine secretion -in endoplasmic reticulum 2.lipid component of milk -apocrine secretion -in cytoplasm

colostrum

-first few day

-low lipid--hi Ab(lympho,plasma cell)

Blood supply Artery

-perforating br of int mam.a. -lateral br of post ICS a. -br from axillary a. :highest thoracic :lateral thoracic

:pectoral br of thoraco-acroomial a

Vein

-perforating br of int mam.v. -perforating br of post ICS v. -tributaries of axillary v. °Batson vertebral v.plexus :root of bone metas

Nerve

-3-6 ICS n.

-cervical plexus--ant br of supraclavi n -intercostobrachial n--lat.br of 2 ICS n

Lymph node

Internal mammary node 25% Axillary node 75% Level 1 -axillary v.gr -ext.mammary gr--ant -scapular gr--post Level 2 -central gr -interpectoral gr--rotter Level 3 -subclavicular gr--apical gr Skip metastasis -25-29%--level 2,3 -3%--level 3 **SLNB can miss 3% Node metastasis 1.tumor cluster

-isolated tumor cell <0.2cm 2.micrometas -0.2-2 cm 3.macrometas ->2cm Physiology Estrogen--duct development Progesterone--lobular development Prolactin--lactogenesis Pregnancy

-inc ovarian/placental E&P -duct&lobular epi proliferate -prominent Montgomery gland

Milk production&relaese

-stimulate nerve ending (NAC) -prolactin secretion

-oxytocin--contract myoepithelium

Investigation MMG

-detect early breast ca -true positive 90% -screen at 40 yr Ultrasound

-in equivocal MMG finding ,cystic mass -uls guide bx

Ductogram -nipple discharge

-duct dilator-->small canular -0.1-0.2 ml contrast is injected -filling defect-->intraductal papilloma MRI

-hi-sen,low spec than MRM

1.ALN+ve, unknown 1° 2.promblematic MMG 3.rupture silicone

Nonpalpable lesion Bx -u/s localization--have mass -stereotactic technic --no mass Palpable lesion Bx

-FNA Bx -CNBx

CNBx need further excision 1.ADH, ALH 2.radial scar 3.papilloma lesion 4.vascular proliferation 5.phylloides tumor Indice of Poliferation PCNA Apoptosis Bcl2 protein Bax : Bcl2 ratio (low=poor prog) Angiogenesis VGEF GF EGF, HER2/neu Steroid H.R EP, PR

Gynecomastia

-Male breast enlarge,elongate,inc epi -often unilateral

-12-15 yr

-at least 2 cm in diameter -usually not predispose ca

Physiologic

1.neonate 2.adolescent

3.senescence--dec T,relative inc E

Klinefelter synd (XXY)

-hypoandrogenic state -inc risk of ca breast

Classification

gr1-mild enlarge,wo skin redundancy gr2a-mod enlarge,wo skin redundancy gr2b-mod enlarge,w skin redundancy gr3-mark enlarge,as female breast

Cause

Estrogen excess 1.testicular tumor

-germ cell tumor--seminoma -gonodal tumor--leydig,sertoli cell

2.non testicular tumor

-adrenal cortical tumor -lung ca

-hepatoma

3.non alc/alc cirrhosis Androgen deficiency 1.senescene

2.hypogonadism

1°testicular failure--klinefelter synd 2°testicular failure :trauma,orchitis,cryptorchidism,XRT Tx -add testosterone Drugs reserpine,theophylline verapamil TCA,furosemide Tx -stop drugs Idiopathic -tamoxifen 40 mg/d 1-4 m ANDI

Abberrant of Normal Development

and Involution

Early reproductive yr (15-25yr) Normal 1.lobular development 2.stromal development 3.nipple eversion Disorder 1.fibroadenoma (<3cm) 2.adolescent hypertrophy 3.nipple inversion Disease 1.giant fibroadenoma (>3cm) 2.gigantomastia 3.subareolar absecss

Mammary duct fistula

Later reproductive yr (25-40yr) Normal

1.cyclic change of menstruation 2.epi hyperplasia of preg Disorder

1.cyclic mastalgia and nodularity

2.bloody nipple discharge Disease 1.incapacitating mastalgia 2.- Involution Normal 1.lobular involution 2.duct involution--dilatation/sclerosis 3.epi turnover Disorder 1.macrocyst/sclerosing lesion 2.duct ectasia/nipple retraction 3.epi hyperplasia

Disease 1.-

2.periductal mastitis 3.epi hyperplasia w atypia

Benign breast disease 1.Non-proiferative disorder ¤no inc risk ca

-fibrocystic disease

(cyst & apocrine metaplasia)

-duct ectasia

-mild ductal epi hyperplasia -calcification

-fibroadenoma and related lesion 2.proliferative disorder wo atypia ¤no inc risk ca

-sclerosing adenosis

-radial & complex sclerosing lesion -ductal epi hyperplasia

-intraductal papilloma 3.atypical proliferative lesion ¤inc risk ca 4x

-atypical lobular hyperplasia -atypical ductal hyperplasia

Benign breast Tx Cyst -cyst aspiration Fibrocystic dz -reassure/symp Tx -danazol,nsaid,tamoxifen,bromocrip Fibroadenoma giant fibroadenoma >5cm -should r/o phyllodes tumor

Sx I/C

->40yr

-rapid growth>20% ->5cm

Sclerosing disorder

-excision bx are needed to r/o ca -stereotactic guide bx

Periductal mastitis -ATB--metro+cloxa -abscess--drainage

Recurrent abscess w fistula Fistulectomy Total d excision -small abscess large>50%areolar -same lesion different lesion -no N.inversion mark N.inversion -young pt old pt

-no d/c pus d/c

-no fistulec recur after fistulec Nipple inversion

-shortening subareolar duct -sx correction--cosmetic reason -c/p--nipple sensation/necrosis, fibrosis-->nipple retraction Intraductal papilloma -microdochectomy Cyclic mastalgia

1st_{=Pimrose oil (Gamma Linoleic Acid)} 2nd_=Danazol

3rd_{=Bromocriptine} 4th_=Tamoxifen

Infection 1.bact infection

-Staph--localized,deep abscess Strep--diffuse superficial involve -breast feeding

-subareolar,periduct,retromam space Tx

-local w care--warm comp -iv ATB

-I&D--should Bx abscess cavity Zuska disease

(recurrent periductal mastitis) -recurrent retroarolar infect/abscess

Tx

-ATB+I&D

2.mycotic infection

-blastomycosis or sporotrichosis -intra oral fungi--sucking infant -abscess close to NAC

Tx -antifungal agent -+/-drainage 3.hiradenitis supparativa -axilla--sebaceous gl NAC--Montgoney gl

-mimic chronic inflam,paget,ca

4.mondor s dz

-variant of thrombophlebritis -superficial v of ant chest wall -lateral thoracic v,thoracoepigastric v superficial epigastric v

-tender,cord like structure -benign, self limited dz--4-6 wk

Tx

-anti-inflam

-warm compression

-restrict of motion of ipsilat ext -braissiere support

-not improve-->excision

LCIS & DCIS

LCIS DCIS 1.age 44-47 54-58 yr 2.incidence 2-5 5-10% 3.clinical no mass,pain,dc 4.MMG no microcalci 5.premeno 2/3 1/3 6.synchro 5 2-46% 7.multicentric 60-90 40-80% 8.bilat 50-70 10-20% 9.axilla metas 1 1-2% 10.male - 5% 11.subsequent ca interval to dx 15-20 5-10yr

histo ductal ductal

incidence 25-35% 25-70% laterality bilat ipsilat

LCIS

-only in female breast

-Terminal Duct Lobular Unit--TDLU -distort/distend TDLU

-maintain normal N:C ratio

-calcify in adjacent tissue

-incidental finding DCIS

-can seen in male breast ca -proliferation of epi in duct

-papillary growth -intraductal ca

1.cribiform pattern 2.solid growth pattern 3.comedo growth pattern Classification of DCIS

Histo nu.gr necrosis DCIS grade comedo hi extensive high IM IM focal/no IM noncomedo low absent low ¤IM--intermediate

Ca breast 1.sporadic 65-75% 2.familial 20-30% 3.hereditary 5-10% BRCA1 45% BRCA2 35% p53(Li fraumeni) 1% STK11/LKB1(Peutz Jegh) <1% PTEN(cowden) <1% BRCA1 BRCA2 1.chro 17q21 13q12 2.fxn Tumor suppression

DNA damage repair 3.risk ca 60-80% 4.age young 50 yr 5.fam hx 52% 32% 6.ovary ca 80% 20% 7.male <20% 76% 8.ca prostate,colon,pancreas 9.diff poorly diff well diff 10.HR -ve +ve 11.bilat yes yes

Hereditary risk of ca breast

->=2 fam hx of ca breast/ovary -ca breast < 50yr

-ca breast+ovary in same pt -male breast

Cancer prevention for BRCA mutation

1.prophylactic mastectomy & recons 2.prophylactic oophorectomy & HRT 3.intensive survei for ca breast&ovary 4.chemoprevention

Screening recommendation

-early screen at 25 yr -clinical breast exam q 6 m -MMG q 12 m -TVS, ca-125 q 1yr Invasive breast ca 1.paget dz of nipple -chronic,eczema of nipple -weeping lesion,ulcer -extensive of DCIS -pagetoid feature

-pathognomonic=paget cell in epi -DDx-superficial spreading melanoma :S-100 immunostaining--melanoma :CEA immunostaining--paget dz

2.invasive ductal ca

2.1 adenoca c productive fibrosis (scirrhous,simple,NST)--80% -60% axillary LN metas -perimenopausal,menopause -poor margin

-solitary,firm mass

-cut surface--stellate,chalky white or yellow streak into surrounding tissue 2.2 medullary ca--4%

-special type

-BRCA-1 hereditary breast ca -soft,hemorhage

-often deep in breast -50%asso DCIS

-5yr better than NST,invasive lobular Microscopic

-dense lymphoreticular infiltrate lymp/plasma cell predominate -poorly diff,active mitosis -sheet like growth pattern 2.3 mucinous (colloid)--2% -elderly

-bulky tumor

-extracellular pool of mucin -glistening and gelatinous -firm consistency -5yr--73%, 10yr--59% 2.4 papillary--2% -small -fibrovascular stalk -multilayer epithelium -prognosis as mucinous 2.5 tubular--2% -perimenopausal,menopause -tubular arranged

-long term survival approach 100% 3.invasive lobular ca--10%

-histo--small cell c round nuclei, scant cytoplasm

-special stain--intracytoplasmic mucin, displace nucleus(signet-ring cell) -poorly defined mass

-multifocal,multicentric and bilat -insidious growth--difficult to detect 4.rare ca

-adenoid cystic -squamous cell -apocrine

Ca breast staging

-palpate axillary LN--ccuracy only 33% -axillary LN dissect >=10 node

-tumor size correlate c axillary metas -single most predictor of survival is number of axillary LN involve -supraclavicular LN metas--stage4 T T1-<=2cm T1mi-<=1mm T1a->1, <=5mm T1b->5, <=10mm T1c->10, <=20 T2->2, <=5cm T3->5cm

T4-any size c extend chest wall,skin T4a--chest wall,not pectoralis m. T4b--edema,peau d orange,ulcer T4c--both a+b T4d--inflam ca N N1-1-3, mobile N1mic->0.2-<2mm/>200cell N2-4-9, fix or matted N3->=10 or IMLN/SCLN/IFLN M M0-no M1-distant metas

Early breast ca—stage1, 2a

Locally advance—stage2b,3a,3b,3c (T3/N2) Sentinel LN bx -T1,2,3 , No C/I -palpable lymphadenopathy -prior sx,CMT,XRT -multifocal breast ca Agent 1.radioactive colloid -intraop gamma probe -radioactivity count

2.isosulfan blue dyle (Lymphazurin) -intraop visualization

*combine 1+2=more accurate

Procedure

-4ml of isosulfan blue dye is inject -1ml inject between ca site and skin -nonpalpate--u/s guide,wire localize -3-4 cm incision curved transverse -lower axilla just below hairline -identify lateral of pectoralis m -divided clavipectoral fascia -exposed axilla content

Tx -false+ve--3% (3% skip to level 3) Macrometas(pN1) ->2mm Tx--must ALND Micrometas(pN1mic) -0.2-2mm Tx--should ALND

Isolated tumor cell or tumor cruster (pN0)

-<0.2mm

Ca breast Tx 1.in situ 1.1 LCIS--risk ca 15-20 yr A.close f/u -CBE q 6-12mo -mammogram,US q 1yr B.tamoxifen C.prophylactic bilat.mastectomy -in BRCA1 +ve

-not ALND 1.2 DCIS--premalignant A.local excision -size<0.5 cm -low grade B.local excision + RT ->0.5 cm C/I as BCT -prior RT

-can't free margin

:multicentric/diffuse calcify :persist +ve margin >=2

C.simple mastectomy -can't b

D.chemoprevention -not tamoxifen except

-DCIS in premenopause E.SLNB

-not done--risk +ve <1%

¤Van nuy prognostic index

2.Early breast ca (stage1,2a) -BCT--Tx of choice

-MRM+/-reconstruction--alternative -SLN,RT,systemic tx--if have I/C

3.locally advanced (stage 2b,3a,3b,3c) -metastasis w/u

-neoadjuvant CMTanthracyclin 4 cycle A.65%reduce sizeSx

1.BCT vs MRM 2.ALND vs SLNBx

-FNA -ve before adjuvant CMTcan SLNBx 3.PO RT, CT+/-ET

B.not reduce size

-change anthracyclintaxane -RT

-if HER2+veHerceptin

4.stage 4/recurrent

-local controlSx/RT

-ALNDnot improve overall survival rate -allsystemic tx

Metas breast cainduction CMT 3 mo 1.disease response -pt resectableSx +/- PORT -pt unresectableRT 2.disease progression -2º line CMT +/- targeted Tx Local recurrent A.prior BCT

-total mastectomy +CT+/-ET -not RT

B.prior MRM

-wide local excision +/- RT or -RT alone then CT +/- ET

Tx for metastasis Bone

-bone pain--RT -patho.fx--ORIF

-biphosphonate--all bone metas -ER+ve--ET -ER-ve--CT up 1 grade Brain -localize--sx -multiple,can't sx--steroid+/-RT SC compression -can sx--laminectomy -unresectable--steroid+/-RT Liver -can sx--sx -CT up 1 grade Lungs -isolated should sx > RT

Breast Sx 1.BCT

-wide local excision -margin 1cm

-label margin 3,6,9,12 o clock Absolute C/I

-multicentric, >1quadrant -persistence +ve margin (2 time)

-prior RT

-1st trimester pregnancy Relative C/I

-multifocal but in same quadrant -large and pendulum breast

-large tumor to breast ratio -medial quadrant lesion -CNTexcept RA

-BRCA1,2 mutation

-nipple areola complex excision 2.MRM

-dissect breast, nipple -ALND (at least10) level 1,2 3.SLNB

-if -ve ---not ALND indication

-clinical -ve node -T<5cm

-no prior systemic tx C/I -palpable node -T>5cm---often metas -T1---rare to +ve -inflam ca -metastasis -previous sx -previous neoadjuvant CMT -multifocal Mastectomy Simple mastectomy

-all breast tissue -nipple-areolar complex

-1cm of skin around excised scar

Extend simple mastectomy

-above + level 1 node

Modified radical mastectomy

-above + level 1,2 node -if palpate level 3--remove

The Halstead radical mastectomy

-above + pectoralis major/minor + level 1,2,3 nodes

Nipple sparing mastectomy

->nipple 2cm+frozen

Skin sparing mastectomy -early ca, preserve native skin

Axillary node dissection

-for staging, control regional ds -10-15 node 1,2 level

MRM

-preserve pectoralis m. -removed axillary LN level 1,2 -preserve medial pectoral n. :penetrate pectoralis minor :supply pectoralis major -skin flap 7-8 mm

-fascia of pec.major m.and overlying breast tissue are elevated off -->complete removal of breast

Boundary

lateral--ant margin of latissimus dorsi medial--midline of sternum

seperior--subclavius

inferior--2-3cm inf to inframam.fold

Axillary LN dissection Preserve

-thoracodorsal n

-long thoracic n--wing scapular

If palpate LN at apex of axilla

-divided pectoral minor

:near insertion--coracoid process -dissect axilla v.medial to

costoclavicular (Halsted) ligament

Seroma

-30%of case

-use closed system suction drainage -until <30ml/d

Infection

-2nd to skin flap necrosis -debridement,ATB

Lymphedema

-10%

Predisposing f.

-extensive axillary LN dissection -obesity

-radiation therapy

-presence of pathologic LN

Rx

-fitted compressive sleeves -intermittent compressive device **Patey modification

-remove pectoralis minor -complete dissect level 3 nodes

MRM C/p 1.wound infection -staph 2.flap necrosis -minor <2cm2--conservative -major--graft/flap 3.hematoma 4.pneumothorax -Halsted sx 5.seroma -most common c/p -off when<20 ml ¤2d 6.lymphedema -ALND--25-30% -ALND+RT--50-60% -SLNB--2-4% 7.lymphagiosarcoma -Stewart Treves synd -chronic lymphedema -s/p MRM >10yr -poor prognosis -WLE or RT+CMT 8.nerve inj

-long thorasic n--wing scapula -thoracodorsal n--int rotate,abduct -med pectoral n--m atrophy -intercostobrachial n--sensory

9.chronic pain synd

-s/p intercostobrachial inj -neuroma

10.axillary v/A inj 11.frozen shoulder 12.c/p asso SLNBx

-allergic rxn/shock -not use in pregnancy

Breast reconstruction

-defect can't cover c skin graft -->myocutaneous flap

Immediate after sx

-after mastectomy for early inva ca

Delayed 6mo after complete adju Tx

-for advanced breast ca

-ensure locoregional control of ds

Myocutaneous flap 1.latissimus dorsi flap

-skin paddle--latissimus dorsi m. -thoracodorsal a.--from post ICS a

2.rectus abdominis flap

-Transverse Rectus Abdominis Myocutaneous flap (TRAM) -skin paddle--rectus abdominis m. -inf epigastric a

-free TRAM--microvascu.anastomosis

Chest wall defect

-ca involved chest wall -1,2 rib -- ok

->2 rib--Marlex mesh -then cove by flap

Breast RT I/C -BCT--aftet sx 2-3 wk, not>6 wk -T3,4 -inflam breast -skin,fascia,pectoralis involve -lymphovascular invasion -close margin,free margin <1mm -axilla LN status

:+ve>4node :>2cm

:matted node>3 nodes :gross extracapsular invasion -palliative tx for stage 4/recurrent

Endocrine Tx -all in HR+ve -premense--tamoxifen > AI :20mg/d *5yr :stop if AUB,thromboembolic -postmense--AI > Tamoxifen :upfront--tamoxifen 5yr

:switching--tamoxifen 2yr--AI 3yr :extended AI--tamoxifen 5yr--AI 3yr

Determining menopause

-prior bilat oophorectomy

->=60yr, <=60yr+no mens >=12mo Drugs 1.antiestrogen -tamoxifen,toremifene,fulvestrant Tamoxifen s/e -DVT,pulmo.emboli -endometrial ca

-hot flush--most common -thrombocytopenia,leukopenia 2.AI -anastrozol--arimidex -letrozole--femara AI s/e -osteoporosis 3.LHRH -goserelin,leuprolide,buserelin Chemotherapy I/C -T>1cm

-all in node +ve -ER,PR -ve

-lymphovascular invasion -hi nuclear grade

-HER2/neu overexpression

3 groups

1.non-anthracyclin based regimen--CMF -low risk of recurrent

2.anthracycline based regimen

-FAC*6, CAF*6

-<35yr, node+ve, HER2+ve

3.taxane based regimen

-pacitaxel,docetaxel -failure from 2 -hi risk of recurrent

:<35yr, poorly diff tumor, HR-ve, HER2+ve

3.Target tx

Other Ca

1.axillary LN metas + unknown 1° -1% presentimg sign of ca breast -HR suggest ca breast but not dx -thyroid--breast--pelvis/rectum -breast--MMG/us/MRI

2.ca breast during pregnancy -bigger breast--delay in dx

-MRM>BCT -should not SLNB

-if need RT--after delivery :if must--2nd,3rd trimester -CMT/HT--2nd,3rtrimester -not tamoxifen,metrotrexate -abortion,suppress lactation :not improve prognosis ¤Benign breast in pregnancy :galactocele,lobular hyperplasia lactating adenoma,abscess 3.male breast ca -<1% ca breast -rare in young -peak incidence--60yr -20% is preceded by gynecomastia -asso RTX,estrogen Tx

Klinefelter,testicular feminize synd -same staging

-poor prog than women (advance stage when dx)

Tx

-as female

-advance--orchidectomy 4.phyllodes tumor

-cut surface--classical leaf like appear -stromal cell--always monoclonal -need CNBx (FNA--not adequate) 1.benign

-mitotic <2/10 2.low gr malignant

-mitotic 2-5/10, stromal invade 3.hi gr malignant

-mitotic >5/10, stromal invade

Tx

-wide excision 1cm free margin -not ALND

I/C mastectomy

-large size to breast ratio

5.inflam breast ca

-stage 3b

-<3% of ca breast -75%--LN metas 25%--distant metas -dermal lymph vv invasion -indurate,erythema,raise edge, edema(peau d orange) Tx -neoadjuvant w doxorubicin -MRM remove residual ca 6.Bilateral breast ca -breast ca---risk 5x -metachronous(>3mo) > synchronous Hi-risk -<45yr -familial,hereditary -LCIS,invasive lobular ca Rx Synchronous

-tx higher stage tumor Metachronous

-tx as recurrent ca

7.rare ca

Squamous (epidermoid) cell

-rare, from metaplasia in duct

Adenoid cystic ca

-rare

-indistinguish from adenoid cystic ca arising in salivary gland

-rare node metas

Apocrine ca

-well diff ca

-round vesicular nuclei, prominent nucleoli -low mitotic rate

Sarcoma

-fibrosarcoma,MFH,liposarcoma leiomyosarcoma,rhabdomyosarc chrondosarc,malig schwannoma -large,painless mass,rapid growth

Tx

-wide local excision -may need mastectomy

-ALND not indicate, unless palpable

Angiosarcoma

(lymphangiosarcoma

-post mastec lymphedema /post XRT -p/o 10.5 yr

St gallen Low risk

-node -ve and all of -T<2cm

-gr1

-no perivascular invasion -ER,PR +ve

-HER2 -ve ->35yr

Intermediate risk

Node -ve and at least one of -T>2cm

-gr2,3

-perivascular invasion -ER,PR -ve

-HER2 +ve -<35yr

Node +ve (1-3) and -ER,PR +ve

-HER2 -ve High risk

Node +ve (1-3) and -ER,PR -ve

-HER2 +ve Node +ve (>4)

E.rxn E.uncertain E.nonrxn low ET ET

-Inter ET CT-->ET CT

or (antra) (antra/tax) CT-->ET

(CMF/antra)

high CT-->ET CT-->ET CT (antra) (antra) (tax)

E.responsive--ER/PR+ve

E.uncertain--ER/PR+ve but <10% E.non-responsive--ER/PR-ve

Van Nuy prognostic index (DCIS)

1 2 3

size <=15 16-40 >=41 margin >=10 1-9 <=1 patho

-hi gr no no yes -necrosis no yes y/n -nuclear gr 1,2 1,2 3 age >60 40-60 <40 4-6=excision/lumpectomy only 7-9=add XRT 10-12=mastectomy BIRADs

Breast Imaging Reporting And Data S. 0=incomplete--additional imaging

1=neg--routine screening 2=benign--routine screening 3=probably benign-->98% :microcalcify--f/u 6 mo :mass--f/u 4 mo 4=suspicious abnormality--5-95%--bx 4a=low probability 4b=intermediate probability 4c=intermediate but not typical

5=highly suspicious-->=95%--bx/sx