1. Annals of Oncology 24: 2206–2223, 2013 R3 조영학
Personalizing the treatment of women with early breast cancer : highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013
Annals of Oncology 24: 2206–2223, 2013
R3 조영학

2. Introduction
Since the 2011 St Gallen Consensus have seen substantial progress in treatment of early invasive breast cancer
genomic atlas of the disease : use of aromatase inhibitors
Further data became available reducing the necessity for axillary dissection
optimal duration of adjuvant trastuzumab in HER2-positive disease
duration of adjuvant tamoxifen

3. St Gallen 2013: news and progress
Axillary dissection can safely be omitted
micrometastatic disease in sentinel nodes
undergoing breast-conserving surgery and whole breast radiation therapy with up to two macroscopically positive sentinel nodes
Safety and efficacy of shorter courses of whole breast radiation therapy (40 Gy in 15 or 42.5 Gy in 16 fractions)
Over previous standard of 50 Gy in 25 fractions
ATLAS trial reported superiority for 10 years compared with 5 years of adjuvant tamoxifen
Particular benefit of letrozole
premenopausal at diagnosis but became postmenopausal by the time of letrozole administration
Optimal duration of trastuzumab therapy in HER2-positive : 1 year

9. Breast cancer subtypes

11. Breast cancer subtypes
Many different multi-gene assays provide prognostic information
Decisions about inclusion of chemotherapy in the treatment of patients with ER-positive, HER2-negative
21-gene RS (recurrence score) : prognostic information
70-gene signature : Only high RS values (>31)
For many societies, the cost of these multi-gene assays remains prohibitive
Differing implications for the utility or futility of adjuvant cytotoxic therapy
Luminal A-like : more endocrine sensitive, indolent, better prognosis
Luminal B-like : less endocrine sensitive, more aggressive, worse prognosis

12. Panel deliberations (1)
Surgery of the primary
Breast conserving therapy
Absolute contraindications
Margins involved with invasive carcinoma or DCIS after repeated resection
unless postoperative radiation could be delivered
relative contraindications
very young age (<35 years)
extensive or diffuse microcalcifications
Multicentric disease
tumour location near the nipple
mutations of the BRCA1 or BRCA2 genes
Nipple-sparing surgery
margin close to the nipple was not involved
MRI should not be routinely used in the assessment of newly diagnosed breast cancer
패널 토의

13. Panel deliberations (2)
Surgery of the axilla
safely omitted
one or two positive sentinel nodes following BCS when whole breast radiation therapy is planned
required
if no radiotherapy was planned
three or more involved sentinel nodes
nodes were clinically involved before surgery and confirmed by biopsy

14. Panel deliberations (3)
Radiation therapy
short course radiotherapy (40 Gy in 15 or 42.5 Gy in 16 fractions)
not requiring radiotherapy following BCS
elderly and those with substantial comorbidity
Post-mastectomy radiotherapy
four or more positive nodes
presence of adverse tumour pathology
positive deep margins
tumours greater than 5cm regardless of the nodal status

15. Panel deliberations (4)
Pathology
useful surrogate definition of Luminal A-like as distinct from Luminal B-like disease
using a combination of ER, PgR and Ki-67(prognostic marker in early breast cancer)
High Ki-67 status : ≥20%
intrinsic subtypes : whether or not chemotherapy was used, but not the choice of the cytotoxic regimen
multi-gene assay in node-negative, ER-positive and HER2-negative cases
unnecessary
low-risk : tumour size of ≤1 cm in the setting of negative lymph nodes
higher risk : tumour size >5 cm, inflammatory breast cancer, four or more involved nodes, very low ER positivity (e.g. 5%)

16. Panel deliberations (5)
Adjuvant endocrine therapy in premenopausal women
tamoxifen alone was the default adjuvant endocrine therapy
Adjuvant endocrine therapy in postmenopausal women
some postmenopausal women could be treated with tamoxifen alone
treatment should start with the aromatase inhibitor at high risk
initial aromatase inhibitor therapy could be replaced by tamoxifen after 2 years
Extension of aromatase inhibitor therapy beyond the first five years
node-positive
initial treatment was tamoxifen
initial therapy was <5 years of an aromatase inhibitor

17. Panel deliberations (6)
Adjuvant cytotoxic chemotherapy
Indication
histological grade 3, high Ki-67, low hormone receptor status
HER2 positivity or triple-negative status
high 21-gene RS, high-risk 70-gene signature
involvement of more than three lymph nodes
choice of chemotherapy regimen
desire to preserve fertility, avoidance of alopecia, presence of co-morbidities
but not intrinsic subtype or the presence or BRCA1 or BRCA2 mutation

18. Panel deliberations (6)
Anti-HER2 therapies
Trastuzumab therapy : tumours >5 mm or any size
Concurrently with a taxane but not with an anthracycline
duration of trastuzumab should be 1 year
Neoadjuvant cytotoxic chemotherapy
The Panel was split about whether neoadjuvant chemotherapy had benefits beyond local downstaging
Neoadjuvant anti-HER2 therapy
With HER2-positive disease, use of chemotherapy plus trastuzumab alone
Neoadjuvant endocrine therapy
endocrine therapy alone : postmenopausal, strongly positive hormone receptors, low proliferating disease