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

2. 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
In situ cases have stablized since late 1990s due to early detection~40,000 deaths will occur due to breast cancer in 2007

3. Pre-op
History
Physical
Imaging
Diagnosis
Treatment options

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

5. 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

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

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

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

11. Reconstruction
Implants
Flaps
TRAM
Latissimus
DIEP

12. Tissue Expanders

13. TRAM

15. Oncoplastic Surgery

19. Preop Days Postop

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

21. Sentinel Lymph Node
Contraindications
Clinically positive lymph nodes

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

24. Sentinel Lymph Node 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
Clinically + nodes
+ SLN
Level I & II

27. Pathology
DCIS
Invasive Ductal
Invasive Lobular

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

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

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

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

34. Invasive Ductal Ca
Most common – 50-70% of invasive ca

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

37. ILC

38. Staging 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
N0: negative
N1: 1-3 nodes
N2: 4-9 nodes
N3: >10 nodes

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

41. AJCC Staging Stage 0 Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB
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]

42. 5 year Survival Stage 5-year Relative Survival Rate 100% I IIA 92% IIB
100% I
IIA
92%
IIB
81%
IIIA
67%
IIIB
54% IV
20%

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

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

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

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

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

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

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

50. Node (-) & ER/PR (+) & T<1cm & HER2 (-) & no LVI
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)
-- Chemo & hormone

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

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

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

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

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

57. Locally Advanced Disease

58. Locally Advanced Disease
Treatment
Neoadjuvant therapy – 80% shrinkage
Downstage
BCT vs Mastectomy
radiation

59. Post Neoadjuvant therapy

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

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

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

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

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

66. 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

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

68. 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

69. 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

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