Breast

Malignant Breast Disease

Breast Cancer
Over 180,000 new cases ~62,000 are in situ (30%) 2nd leading cause of all cancer deaths 80% of cases occur >50yo

Pre-op

History Physical Imaging Diagnosis Treatment options

Surgical Options

Partial Mastectomy (lumpectomy) Total Mastectomy Reconstruction Sentinel lymph node biopsy Axillary lymph node dissection

Surgical Treatment

Partial Mastectomy Radiation therapy Free margins Aesthetic results NSABP B-06 no significant difference in survival between MRM, lump w/radiaton, and lump w/o radiation

Partial Mastectomy

Contraindications Size relative to breast Multifocality Early pregnancy Inability to receive radiation Connective tissue disease Prior radiation

Surgical Treatment

Radial MastectomyHistorical – mid 70sBreast, pectoralis, regional lymph nodes along axillary vein to costoclavicular ligament

Surgical Treatment

Total Mastectomy axillary dissection TM + Skin sparing w/reconstruction

Reconstruction

Implants Flaps TRAM Latissimus DIEP

Tissue Expanders

TRAM

Oncoplastic Surgery

Preop 4 Days Postop

Surgical Treatment

Sentinel Node Biopsy The 1st node in the ipsilateral axilla to drain the tumor >97% concordance rate

Sentinel Lymph Node

Contraindications Clinically positive lymph nodes

Sentinel Lymph Node

Technetium-99m sulfur colloid Intradermal : peritumoral or periareolar Isosulfan blue dye Intraparenchymal Problems: Anaphylactic reaction (1-3%) Skin discoloration Contraindicated in pregnancy

Sentinel Lymph Node

Intra-op evaluationFrozen sectionTouch prepBenefits over axillary node dissectionmore accurate pathologyless lymphedema – ( very rare vs 10-50%)less sensory disturbancesless shoulder dysfunctionless wound infectionless incisional pain

Axillary Lymph Node Dissection

Indications Clinically + nodes + SLN Level I & II

Pathology

DCIS Invasive Ductal Invasive Lobular

DCIS

200% b/w 1983-1992 15-30% all screen-detected tumors Diagnosis Screening mammogram Microcalcifications Linear, heterogenous Biopsy Stereotactic Open biopsy

DCIS

Treatment Partial Mastectomy Followed by radiation +/- hormonal therapy Total mastectomy Diffuse disease Multifocal Persistent positive margins Inability to give radiation Patient choice

DCIS

Sentinel Lymph Node Biopsy Total Mastectomy Palpable mass Microinvasion

DCIS

Radiation Therapy50% decrease in recurrence LEHormonal TherapyNSABP B-24 – LE, RT, +TAM vs LE, RT onlyTAM – 8.2% incidence of IBTRPlacebo – 13.4% incidence of IBTR

Invasive Ductal Ca

Most common – 50-70% of invasive ca

Invasive Lobular Ca

10-15% of breast caFail to form massesMultifocal and multicentricBilateral – 20-29%


ILC

Staging

Primary Tumor (T)TX: unable to assessT0: no evidence of primary tumorTis: DCIS, LCIS or Paget’s (nipple only)T1: <2cm T2: 2cm-5cm T3: >5cm T4: extension

Regional Lymph Nodes (N)

NX: unable to assess N0: negative N1: 1-3 nodes N2: 4-9 nodes N3: >10 nodes

Distant metastatsis: (M)

MX: unable to assess M0: negative M1: distant mets

AJCC Staging

Stage 0 Tis, N0, M0 Stage I T1*, N0, M0 Stage IIA T0, N1, M0 T1*, N1, M0 T2, N0, M0 Stage IIB T2, N1, M0 T3, N0, M0 Stage IIIA T0, N2, M0 T1*, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0
Stage IIIB T4, N0, M0 T4, N1, M0 T4, N2, M0 Stage IIIC** Any T, N3, M0 Stage IV Any T, Any N, M1

[Note: T1 includes T1mic]

5 year Survival
Stage
5-year Relative Survival Rate
0
100%
I
100%
IIA
92%
IIB
81%
IIIA
67%
IIIB
54%
IV
20%

Adjuvant Therapy

www.adjuvantonline.com Assess the risks and benefits of additional therapy after surgery

Prognostic Indicators

Hormone Receptors – improved prognosisER – 70-80%PR – indicator for a functional ER receptorEpidermal growth factor HER/erbB2EGFRHER2/neuCell proliferation & differentiationerbB2

Prognostic Indicators

P53 – tumor suppressor geneOverexpression of p53Poorer prognosisShorter disease-free and survival

Oncotype Dx

ER (+); node (-) Genetic profile – 21 gene assayRecurrence score (3 groups)Low – hormonal therapyIntermediate – TailorRx trialHormonal vs chemo + hormonalHigh – chemo + hormonal therapy

Adjuvant Therapy

Hormonal therapyAntiestrogen therapy – TamoxifenPre & post-menopausal womenReduces risk of contralateral disease & metsSide effectsEndometrial caThromoembolic events

Adjuvant Therapy

Hormonal TherapyAromastase Inhibitors – blocks the conversion of androstenedione to estronePost-menopausal womenATAC trial – anastrozole decreased the risk of contralateral cancers compared to TAMSide effectsBone loss and joint pain

Adjuvant Therapy

Chemotherapy Size of tumor Nodal status ER/PR HER2/Neu -- Herceptin

Low Risk

Node (-) & ER/PR (+) & T<1cm & HER2 (-) & no LVI
-- Hormonal therapy -- consider Oncotype
Intermediate Risk
Node (-) & at least 1 of the following T>2cm grade II/III LVI <35 yo HER2 (+) Node + (1-3) & HER2 (-)
ER/PR (+) -- OncotypeDX -- hormonal therapy -- Chemo & hormonal therapy ER/PR (-) -- Chemo
High Risk
Node + (1-3) & HER2 + Node +(>4)
ER/PR (+) -- Chemo & hormone ER/PR (-) -- Chemo

LCIS

Incidental finding0.8-8% of breast biopsiesMarker for an increased risk1% per year riskBilateral breastsMost common – Ductal carcinoma

LCIS

Treatment Annual mammograms 6mos CBE Discuss bilateral prophylactic mastectomies


Paget’s Disease Chronic, eczema-like rash of the nipple and areolar skin ~97% underlying Ca Diagnosis Punch biopsy Core needle biopsy



Paget’s Disease TreatmentSurgical treatmentTM w/ SLNCentral segmentectomy w/ SLN  XRTAdjuvant therapyChemotherapyHormonal therapy

Locally Advanced Disease

Large tumors (>5cm) Chest wall involvment Ulcerations Fixed axillary lymph nodes

Locally Advanced Disease

Locally Advanced Disease
TreatmentNeoadjuvant therapy – 80% shrinkageDownstageBCT vs Mastectomyradiation

Post Neoadjuvant therapy

Inflammatory Breast Ca
Rare & aggressiveAccounts for 5% of all breast caYounger women higher tendency for distant metsAJCC – T4dStage IIIBStage IIICStage IV

Inflammatory Breast Ca

PresentationRapid onset of erythema, edema (peau d’orangeOften no massAxillary node involvementImagingNo distinct massSkin thickeningTrabecular thickening

Inflammatory Breast Ca

Histology Dermal lymphatic invasion Not associated with a subtype High S-phase fraction Mutation of p53

Inflammatory Breast Ca

Survival3yr – 40-70%5 yr – 50%10 yr – 26.7%

Male Breast Cancer

1% of all breast ca >90% Ductal Ca ER/PR + 5-10% are hereditary BRCA 2 gene

Breast CA during Pregnancy

1 in 3,000 pregnancies Most common non-GYN cancer Present as a painless mass Worse prognosis Advanced stage Stage II-III 75% rate (median 40mos) Hyperestrogenic state

Breast Ca during Pregnancy

Diagnosis Ultrasound Mammogram Core needle biopsy

Breast Ca during Pregnancy

Treatment 1st trimester TM with SLN bx Chemotherapy Significant risk of spontaneous abortion Fetal malformation 2nd & 3rd trimester TM w/ SLN bx or Lumpectomy with SLN bx radiation Chemotherapy

Question

Following an excisional biopsy for microcalifications, the pathology report states there is LCIS present. You discuss with the patient She needs a lumpectomy then RT She would benefit from a mirror biopsy She has a future cancer risk of 1% per yr No known therapy to help her

Question

55 yo female underwent a Rt lumpectomy with SLN bx. Pathology showed a 3.5 cm well-differentiated infiltrating Ductal ca. The sentinel lymph nodes were negative (0/2). No evidence of any distance mets. What is her stage?


40 yo woman presents with a 2cm mass in her right breast first detected by mammo. A core biopsy reveals infiltrating ductal ca. She has no palpable lymph nodes. Appropriate therapy for the patient would include: -- partial mastectomy -- sentinel lymph node biopsy -- consideration of adjuvant chemo -- radiation therapy -- all of the above