1. Breast Cancer Tumor Board Chair Harold Burstein, MD, PhD Faculty Jennifer Bellon, MD Mehra Golshan, MD

2. Patient Presentation 55-year-old woman who works as a medical office administrator Screening mammogram showed abnormality in breast Core biopsy revealed invasive cancer with associated ductal carcinoma in situ –Invasive component considered intermediate grade She underwent lumpectomy and sentinel lymph node mapping Lumpectomy revealed a 1.7 cm, grade 2 (moderately differentiated) invasive ductal carcinoma

3. Further Tumor Testing Sentinel lymph node mapping –2 lymph nodes identified –1 node contained a 2-mm focus of invasive cancer seen on hematoxylin and eosin stain Tumor immunophenotyping –Estrogen receptor positive –Progesterone receptor low positive –HER2 1+ HER2 status determination by fluorescence in situ hybridization (FISH) –No evidence for gene amplification, with a ratio of 1.2

4. Patient History and Exam Patient is otherwise well Borderline high cholesterol Postmenopausal, grava 3 para 2 with a miscarriage No medications Medical allergy to sulfa products (rash) No family history of breast cancer Comprehensive system review notable only for her postoperative treatment changes

5. Mammogram—Magnification View Graphic courtesy of Dr. Mehra Golshan.

6. Ultrasound View of Lesion Graphic courtesy of Dr. Mehra Golshan.

7. Specimen Imaging Showing Wire and Calcifications Graphic courtesy of Dr. Mehra Golshan.

8. ACOSOG Z0011—5-Year Recurrence Rates Recurrence P =.11, ALND vs SLND. Abbreviations: ALND, axillary lymph node dissection; SLND, sentinel lymph node dissection. Giuliano AE, et al. J Clin Oncol. 2010;28:18S. ALND (n = 420) SLND (n = 436)

9. Factors Associated with Recurrence Factors Not Associated with Recurrence Age (≤50 years) Higher modified Bloom- Richardson Estrogen receptor status Progesterone receptor status Tumor size Level 1 lymph nodes Histologic type Sentinel node metastasis size Number positive lymph nodes Adjuvant systemic therapy ACOSOG Z0011—Predictors of Locoregional Recurrence in Multivariate Analysis Giuliano AE, et al. J Clin Oncol. 2010;28:18S

10. Factors Associated with Improved Disease- Free Survival Factors Not Associated with Disease-Free Survival Estrogen receptor status Age Adjuvant systemic therapy Treatment arm Progesterone receptor status Tumor size Level 1 lymph nodes Histologic type Number positive lymph nodes Modified Bloom-Richardson ACOSOG Z0011: Predictors of Disease-Free Survival in Multivariate Analysis Giuliano AE, et al. J Clin Oncol. 2010;28:18S

11. Conclusions ACOSOG Z0011 was a study of completion dissection or not for women with positive sentinel lymph nodes There was no apparent benefit for completion dissection as both groups had very low risk of local and regional breast cancer recurrence The trial closed having accrued only half its patients and remains somewhat underpowered Moving forward, it is likely that surgical treatment decisions will be individualized –Role of axillary dissection to be based on tumor size, extent of nodal disease, biological features of the breast cancer, patient age, and other traditional risk factors