1. Case 3 Jane McNicholas Consultant Oncoplastic Breast Surgeon
East Lancashire Hospitals

2. Case 3
74 year old woman presents with lump in left breast she noticed 2 weeks ago
In past, was on HRT for 7 years
No FH of breast cancer
Otherwise fit and well

3. Case 3
On examination - 2cm mass in left breast, hard, discrete, feels malignant. No axillary nodes to feel - P5
Mammogram - 2cm mass in left breast - M5
Ultrasound - 22mm lesion in breast - U5
Ultrasound of axilla - normal
FNA - malignant cells - M5
Core Biopsy - Invasive Ductal Cancer, Grade 2 - B5b

4. Case 3
What do you offer the patient?

5. Case 3 WLE + SLNB Mastectomy + SLNB
Axillary node clearance only if SLNB shows metastatic disease
Post-op radiotherapy?
Post-op chemotherapy?
Endocrine therapy?

6. Case 3 Patient chooses WLE and SLNB
Post op histology - 19mm Grade 2 Invasive Ductal Cancer, fully excised. No evidence of lymphovascular invasion. 0/4 lymph nodes
ER - 8/8, PR - 7/8, Her2 - -ve
What is her NPI?

7. Nottingham Prognostic Index
Score 1 2 3
Grade
Lymph nodes
1-3 4+
NPI = Grade + Lymph Nodes + (Size (cm) x0.2)

8. Nottingham Prognostic Index

9. Case 3
NPI = (1.9 x 0.2) = 3.38
Puts patient into a good prognosis group
Post-operative MDT recommended radiotherapy and endocrine therapy (Aromatase inhibitor)

10. Reasons for Mastectomy
Patient choice
Large tumour in relation to breast size
Previous breast conserving surgery with radiotherapy
Multi-focal disease
Unable to have radiotherapy (unable to lie flat, unable to raise arm, pacemaker with left sided tumour
Patients with collagen vascular diseases
Central breast tumour - No longer a valid reason

11. Post-op Radiotherapy
Always given after WLE - local recurrence rate unacceptably high if not given (i.e 25% in 10 years)
Given after mastectomy in patients thought to be at higher risk of local recurrence (i.e. close to chest wall, large tumour, vascular invasion, etc

12. Post-op Chemotherapy
Given to patients at high risk of disease recurrence/progression
Usually node positive, large tumour, adverse histological features, oestrogen receptor negative, herceptin positive
Traditionally given up to 70, but this is changing - over 70 given in many more cases if fit enough

13. Endocrine Therapy
Given to patients who are Oestrogen Receptor positive
First used was Tamoxifen. Side effects include hot flushes (50%), increased thrombo-embolic risk, increased risk of endometrial cancer
Newer agents more widely used now - Anastrozole (Arimidex), Letrozole (Femara) and Exemestane (Aromasin). Side effects are hot flushes (30%) and reduced bone mineral density

14. HRT and Breast Cancer
The Million Women Study is the largest study looking at HRT usage and breast cancer risk
It found that taking HRT for 5 years increased the risk of breast cancer
This increased risk was for Oestrogen only and Combined Preparations but Combined preparations had a greater risk