Transcript Malignant Breast Disease - Mount Sinai St. Luke's

Malignant Breast
Disease
Juhi Asad, DO
Alison Estrabrook, MD
Dept. of Breast Surgery
Breast Cancer
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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
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History
Physical
Imaging
Diagnosis
Treatment options
Surgical Options
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Partial Mastectomy (lumpectomy)
Total Mastectomy
– Reconstruction
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Sentinel lymph node biopsy
Axillary lymph node dissection
Surgical Treatment
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Partial Mastectomy
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Radiation therapy
Free margins
Aesthetic results
NSABP B-06
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no significant
difference in survival
between MRM, lump
w/radiaton, and
lump w/o radiation
Partial Mastectomy
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Contraindications
– Size relative to breast
– Multifocality
– Early pregnancy
– Inability to receive radiation
Connective tissue disease
 Prior radiation
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Surgical Treatment
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Radial Mastectomy
– Historical – mid 70s
– Breast, pectoralis,
regional lymph
nodes along axillary
vein to
costoclavicular
ligament
Surgical Treatment
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Total Mastectomy
axillary dissection
TM + Skin sparing
w/reconstruction
Reconstruction
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Implants
Flaps
– TRAM
– Latissimus
– DIEP
Tissue Expanders
TRAM
Oncoplastic Surgery
Preop
4 Days Postop
Surgical Treatment
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Sentinel Node
Biopsy
– The 1st node in the
ipsilateral axilla to
drain the tumor
– >97% concordance
rate
Sentinel Lymph Node
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Contraindications
– Clinically positive lymph nodes
Sentinel Lymph Node
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Technetium-99m sulfur colloid
– Intradermal : peritumoral or periareolar
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Isosulfan blue dye
– Intraparenchymal
Problems:
– Anaphylactic reaction (1-3%)
– Skin discoloration
– Contraindicated in pregnancy
Sentinel Lymph Node
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Intra-op evaluation
– Frozen section
– Touch prep
– Benefits over axillary node dissection
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more accurate pathology
less lymphedema – ( very rare vs 10-50%)
less sensory disturbances
less shoulder dysfunction
less wound infection
less incisional pain
Axillary Lymph Node
Dissection
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Indications
– Clinically + nodes
– + SLN
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Level I & II
Pathology
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DCIS
Invasive Ductal
Invasive Lobular
DCIS
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200% b/w 1983-1992
15-30% all screen-detected tumors
Diagnosis
– Screening mammogram
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Microcalcifications
– Linear, heterogenous
– Biopsy
Stereotactic
 Open biopsy
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DCIS
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Treatment
– Partial Mastectomy
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Followed by radiation +/- hormonal therapy
– Total mastectomy
Diffuse disease
 Multifocal
 Persistent positive margins
 Inability to give radiation
 Patient choice
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DCIS
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Sentinel Lymph Node Biopsy
– Total Mastectomy
– Palpable mass
– Microinvasion
DCIS
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Radiation Therapy
– 50% decrease in recurrence LE
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Hormonal Therapy
– NSABP B-24 – LE, RT, +TAM vs LE, RT
only
TAM – 8.2% incidence of IBTR
 Placebo – 13.4% incidence of IBTR
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Invasive Ductal Ca
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Most common – 5070% of invasive ca
Invasive Lobular Ca
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10-15% of breast ca
Fail to form masses
Multifocal and multicentric
Bilateral – 20-29%
ILC
Staging
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Primary Tumor (T)
– TX: unable to assess
– T0: no evidence of primary tumor
– Tis: DCIS, LCIS or Paget’s (nipple only)
– T1: <2cm
– T2: 2cm-5cm
– T3: >5cm
– T4: extension
Regional Lymph Nodes
(N)
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NX: unable to assess
N0: negative
N1: 1-3 nodes
N2: 4-9 nodes
N3: >10 nodes
Distant metastatsis: (M)
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MX: unable to assess
M0: negative
M1: distant mets
AJCC Staging
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Stage 0
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– Tis, N0, M0
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– T4, N0, M0
– T4, N1, M0
– T4, N2, M0
Stage I
– T1*, N0, M0
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Stage IIA
– T0, N1, M0
– T1*, N1, M0
– T2, N0, M0
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Stage IIB
Stage IIIB
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Stage IIIC**
– Any T, N3, M0
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Stage IV
– Any T, Any N, M1
– T2, N1, M0
– T3, N0, M0
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Stage IIIA
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T0, N2, M0
T1*, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
[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
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www.adjuvantonline.com
– Assess the risks and benefits of additional
therapy after surgery
Prognostic Indicators
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Hormone Receptors – improved prognosis
– ER – 70-80%
– PR – indicator for a functional ER receptor
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Epidermal growth factor
– HER/erbB2
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EGFR
HER2/neu
– Cell proliferation & differentiation
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erbB2
Prognostic Indicators
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P53 – tumor suppressor gene
– Overexpression of p53
Poorer prognosis
 Shorter disease-free and survival
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Oncotype Dx
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ER (+); node (-)
Genetic profile – 21 gene assay
– Recurrence score (3 groups)
Low – hormonal therapy
 Intermediate – TailorRx trial
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– Hormonal vs chemo + hormonal
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High – chemo + hormonal therapy
Adjuvant Therapy
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Hormonal therapy
– Antiestrogen therapy – Tamoxifen
Pre & post-menopausal women
 Reduces risk of contralateral disease & mets
 Side effects
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– Endometrial ca
– Thromoembolic events
Adjuvant Therapy
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Hormonal Therapy
– Aromastase Inhibitors – blocks the
conversion of androstenedione to estrone
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Post-menopausal women
– ATAC trial – anastrozole decreased the risk of
contralateral cancers compared to TAM
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Side effects
– Bone loss and joint pain
Adjuvant Therapy
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Chemotherapy
– Size of tumor
– Nodal status
– ER/PR
– HER2/Neu -- Herceptin
Low Risk
Intermediate
Risk
High Risk
-- Hormonal
Node (-) & ER/PR (+) therapy
& T<1cm & HER2 (-) &
-- consider
no LVI
Oncotype
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
Node + (1-3) & HER2
+
Node +(>4)
ER/PR (+)
-- Chemo & hormone
ER/PR (-)
-- Chemo
ER/PR (-)
-- Chemo
LCIS
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Incidental finding
– 0.8-8% of breast biopsies
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Marker for an increased risk
– 1% per year risk
– Bilateral breasts
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Most common – Ductal carcinoma
LCIS
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Treatment
– Annual mammograms
– 6mos CBE
– Discuss bilateral prophylactic
mastectomies
Paget’s Disease
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Chronic, eczema-like rash of the nipple
and areolar skin
~97% underlying Ca
Diagnosis
– Punch biopsy
– Core needle biopsy
Paget’s Disease
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Treatment
– Surgical treatment
TM w/ SLN
 Central segmentectomy w/ SLN  XRT
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– Adjuvant therapy
Chemotherapy
 Hormonal therapy
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Locally Advanced Disease
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Large tumors (>5cm)
Chest wall involvment
Ulcerations
Fixed axillary lymph nodes
Locally Advanced Disease
Locally Advanced Disease
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Treatment
– Neoadjuvant therapy – 80% shrinkage
Downstage
 BCT vs Mastectomy
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– radiation
Post Neoadjuvant therapy
Inflammatory Breast Ca
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Rare & aggressive
Accounts for 5% of all breast ca
Younger women higher tendency for
distant mets
AJCC – T4d
– Stage IIIB
– Stage IIIC
– Stage IV
Inflammatory Breast Ca
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Presentation
– Rapid onset of erythema, edema (peau
d’orange
– Often no mass
– Axillary node involvement
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Imaging
– No distinct mass
– Skin thickening
– Trabecular thickening
Inflammatory Breast Ca
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Histology
– Dermal lymphatic invasion
– Not associated with a subtype
– High S-phase fraction
– Mutation of p53
Inflammatory Breast Ca
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Survival
– 3yr – 40-70%
– 5 yr – 50%
– 10 yr – 26.7%
Male Breast Cancer
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1% of all breast ca
>90% Ductal Ca
ER/PR +
5-10% are hereditary
– BRCA 2 gene
Breast CA during
Pregnancy
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1 in 3,000 pregnancies
Most common non-GYN cancer
Present as a painless mass
Worse prognosis
– Advanced stage
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Stage II-III 75% rate (median 40mos)
– Hyperestrogenic state
Breast Ca during
Pregnancy
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Diagnosis
– Ultrasound
– Mammogram
– Core needle biopsy
Breast Ca during
Pregnancy
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Treatment
– 1st trimester
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TM with SLN bx
Chemotherapy
– Significant risk of spontaneous abortion
– Fetal malformation
– 2nd & 3rd trimester
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TM w/ SLN bx or
Lumpectomy with SLN bx
– radiation
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Chemotherapy
Question
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Following an excisional biopsy for
microcalifications, the pathology report
states there is LCIS present. You
discuss with the patient
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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