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Malignant Breast Disease Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery.

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Presentation on theme: "Malignant Breast Disease Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery."— Presentation transcript:

1 Malignant Breast Disease Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery

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

3 Pre-op History History Physical Physical Imaging Imaging Diagnosis Diagnosis Treatment options Treatment options

4 Surgical Options Partial Mastectomy (lumpectomy) Partial Mastectomy (lumpectomy) Total Mastectomy Total Mastectomy –Reconstruction Sentinel lymph node biopsy Sentinel lymph node biopsy Axillary lymph node dissection Axillary lymph node dissection

5 Surgical Treatment Partial Mastectomy 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 no significant difference in survival between MRM, lump w/radiaton, and lump w/o radiation

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8 Partial Mastectomy Contraindications Contraindications –Size relative to breast –Multifocality –Early pregnancy –Inability to receive radiation Connective tissue disease Connective tissue disease Prior radiation Prior radiation

9 Surgical Treatment Radial Mastectomy Radial Mastectomy –Historical – mid 70s –Breast, pectoralis, regional lymph nodes along axillary vein to costoclavicular ligament

10 Surgical Treatment Total Mastectomy axillary dissection Total Mastectomy axillary dissection TM + Skin sparing w/reconstruction TM + Skin sparing w/reconstruction

11 Reconstruction Implants Implants Flaps Flaps –TRAM –Latissimus –DIEP

12 Tissue Expanders

13 TRAM

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15 Oncoplastic Surgery

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19 Preop 4 Days Postop

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

21 Sentinel Lymph Node Contraindications Contraindications –Clinically positive lymph nodes

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

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24 Sentinel Lymph Node Intra-op evaluation Intra-op evaluation –Frozen section –Touch prep –Benefits over axillary node dissection –more accurate pathology –less lymphedema – ( very rare vs 10-50%) –less sensory disturbances –less shoulder dysfunction –less wound infection –less incisional pain

25 Axillary Lymph Node Dissection Indications Indications –Clinically + nodes –+ SLN Level I & II Level I & II

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27 Pathology DCIS DCIS Invasive Ductal Invasive Ductal Invasive Lobular Invasive Lobular

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

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

32 DCIS Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy –Total Mastectomy –Palpable mass –Microinvasion

33 DCIS Radiation Therapy Radiation Therapy –50% decrease in recurrence LE Hormonal Therapy Hormonal Therapy –NSABP B-24 – LE, RT, +TAM vs LE, RT only TAM – 8.2% incidence of IBTR TAM – 8.2% incidence of IBTR Placebo – 13.4% incidence of IBTR Placebo – 13.4% incidence of IBTR

34 Invasive Ductal Ca Most common – % of invasive ca Most common – % of invasive ca

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36 Invasive Lobular Ca 10-15% of breast ca 10-15% of breast ca Fail to form masses Fail to form masses Multifocal and multicentric Multifocal and multicentric Bilateral – 20-29% Bilateral – 20-29%

37 ILC

38 Staging Primary Tumor (T) 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

39 Regional Lymph Nodes (N) NX: unable to assess NX: unable to assess N0: negative N0: negative N1: 1-3 nodes N1: 1-3 nodes N2: 4-9 nodes N2: 4-9 nodes N3: >10 nodes N3: >10 nodes

40 Distant metastatsis: (M) MX: unable to assess MX: unable to assess M0: negative M0: negative M1: distant mets M1: distant mets

41 AJCC Staging Stage 0 Stage 0 –Tis, N0, M0 Stage I Stage I –T1*, N0, M0 Stage IIA Stage IIA –T0, N1, M0 –T1*, N1, M0 –T2, N0, M0 Stage IIB Stage IIB –T2, N1, M0 –T3, N0, M0 Stage IIIA Stage IIIA –T0, N2, M0 –T1*, N2, M0 –T2, N2, M0 –T3, N1, M0 –T3, N2, M0 Stage IIIB Stage IIIB –T4, N0, M0 –T4, N1, M0 –T4, N2, M0 Stage IIIC** Stage IIIC** –Any T, N3, M0 Stage IV Stage IV –Any T, Any N, M1 [Note: T1 includes T1mic]

42 5 year Survival Stage 5-year Relative Survival Rate 0100% I IIA92% IIB81% IIIA67% IIIB54% IV20%

43 Adjuvant Therapy –Assess the risks and benefits of additional therapy after surgery

44 Prognostic Indicators Hormone Receptors – improved prognosis Hormone Receptors – improved prognosis –ER – 70-80% –PR – indicator for a functional ER receptor Epidermal growth factor Epidermal growth factor –HER/erbB2 EGFR EGFR HER2/neu HER2/neu –Cell proliferation & differentiation erbB2 erbB2

45 Prognostic Indicators P53 – tumor suppressor gene P53 – tumor suppressor gene –Overexpression of p53 Poorer prognosis Poorer prognosis Shorter disease-free and survival Shorter disease-free and survival

46 Oncotype Dx ER (+); node (-) ER (+); node (-) Genetic profile – 21 gene assay Genetic profile – 21 gene assay –Recurrence score (3 groups) Low – hormonal therapy Low – hormonal therapy Intermediate – TailorRx trial Intermediate – TailorRx trial –Hormonal vs chemo + hormonal High – chemo + hormonal therapy High – chemo + hormonal therapy

47 Adjuvant Therapy Hormonal therapy Hormonal therapy –Antiestrogen therapy – Tamoxifen Pre & post-menopausal women Pre & post-menopausal women Reduces risk of contralateral disease & mets Reduces risk of contralateral disease & mets Side effects Side effects –Endometrial ca –Thromoembolic events

48 Adjuvant Therapy Hormonal Therapy Hormonal Therapy –Aromastase Inhibitors – blocks the conversion of androstenedione to estrone Post-menopausal women Post-menopausal women –ATAC trial – anastrozole decreased the risk of contralateral cancers compared to TAM Side effects Side effects –Bone loss and joint pain

49 Adjuvant Therapy Chemotherapy Chemotherapy –Size of tumor –Nodal status –ER/PR –HER2/Neu -- Herceptin

50 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

51 LCIS Incidental finding Incidental finding –0.8-8% of breast biopsies Marker for an increased risk Marker for an increased risk –1% per year risk –Bilateral breasts Most common – Ductal carcinoma Most common – Ductal carcinoma

52 LCIS Treatment Treatment –Annual mammograms –6mos CBE –Discuss bilateral prophylactic mastectomies

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

55 Paget’s Disease Treatment Treatment –Surgical treatment TM w/ SLN TM w/ SLN Central segmentectomy w/ SLN  XRT Central segmentectomy w/ SLN  XRT –Adjuvant therapy Chemotherapy Chemotherapy Hormonal therapy Hormonal therapy

56 Locally Advanced Disease Large tumors (>5cm) Large tumors (>5cm) Chest wall involvment Chest wall involvment Ulcerations Ulcerations Fixed axillary lymph nodes Fixed axillary lymph nodes

57 Locally Advanced Disease

58 Treatment Treatment –Neoadjuvant therapy – 80% shrinkage Downstage Downstage BCT vs Mastectomy BCT vs Mastectomy –radiation

59 Post Neoadjuvant therapy

60 Inflammatory Breast Ca Rare & aggressive Rare & aggressive Accounts for 5% of all breast ca Accounts for 5% of all breast ca Younger women higher tendency for distant mets Younger women higher tendency for distant mets AJCC – T4d AJCC – T4d –Stage IIIB –Stage IIIC –Stage IV

61 Inflammatory Breast Ca Presentation Presentation –Rapid onset of erythema, edema (peau d’orange –Often no mass –Axillary node involvement Imaging Imaging –No distinct mass –Skin thickening –Trabecular thickening

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63 Inflammatory Breast Ca Histology Histology –Dermal lymphatic invasion –Not associated with a subtype –High S-phase fraction –Mutation of p53

64 Inflammatory Breast Ca Survival Survival –3yr – 40-70% –5 yr – 50% –10 yr – 26.7%

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

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

67 Breast Ca during Pregnancy Diagnosis Diagnosis –Ultrasound –Mammogram –Core needle biopsy

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

69 Question Following an excisional biopsy for microcalifications, the pathology report states there is LCIS present. You discuss with the patient 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

70 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?

71 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


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