1. Breast Conference 9/7/2011

2. LP 60 AAF presenting with a left breast mass
The patient noticed a lump in her left breast 10 years ago. She then had a mammography and ultrasound which were interpreted as benign, according to the patient. Three years ago the lesion began to grow gradually. The patient did not have any evaluation of the lesion, and just recently saw her primary care, who referred her for further evaluation of the lesion.

3. LP Menarche: 13y G3P2 (15y), breastfeeding: none OCP: 21y HRT: none
Postmenopausal (55y)
Hx breast bx: none
Hx breast Ca: none
Fhx:
father – multiple myeloma (60y), sister – renal cell carcinoma
Shx:
caffeine (rarely), soy(-), tobacco (past smoker), ETOH (rarely)
Smoked 1 pack/day for 30 years, quit 14 years ago
She had trauma to the left breast many years ago that resolved in swelling that gradually resolved spontaneously

4. LP PMH: s/p MI PSH: Unilateral oophorectomy d/t ectopic pregnancy
Meds: Singulair, Albuterol, Lisinopril
NKDA
Uses singulair and albuterol rarely

5. LP PE: Right breast: Left breast: Left axillary adenopathy
Within normal limits
Left breast:
Nipple areolar complex replaced by tumor
Central 4 cm mass
Left axillary adenopathy

6. LP Radiology: Diagnostic mammogram: US:
Left breast: mass with a spiculated margin central to the nipple in the retroareolar region
Left axilla: multiple enlarged nodes
US:
Left breast: 3.9*3.1*2.4cm irregular mass central to the nipple. Adjacent 2.1*1.3*2cm oval mass
Left axilla: multiple enlarged nodes, hypoechoic with no fatty hilum 6

7. LP
Radiology:
MRI:
Scheduled
PET/CT: 7

8. LP

9. LP

10. LP

11. LP Pathology: Breast lesion: Axillary lesion:
infilrating ductal carcinoma, grade 3
ER, PR, HER2 - pending
Axillary lesion:
Metastatic ductal carcinoma

12. LP
60 F clinical stage IIIB, T4bN1M0

13. LP

14. LP Surgery – Medical oncology – Radiation oncology – Plastic surgery –
Mastectomy + ALND
Medical oncology –
Neoadjuvant chemotherapy
Radiation oncology –
Plastic surgery –
Genetics –
Psychosocial –

15. GM
68 AAF presenting with an abnormal mammogram

16. GM Menarche: 11y G8P5 (19y), breastfeeding: 1 month OCP: none
HRT: none
Postmenopausal
Hx breast Ca: none
Fhx: none
Shx: caffeine(+), soy(-), tobacco(-), ETOH(-)
Bra: 44C

17. GM PMH: HTN, DM, GERD, uterine fibroids PSH: none
Meds: Nexium, Cozaar, NovoLog, Lantus
NKDA
On review of systems she has no other complaints

18. GM PE: Right breast: Left breast: Within normal limits
Palpable mass, 9 o’clock 8cm from nipple
Left breast: Within normal limits
No axillary, supraclavicular or cervical lymphadenopathy

19. GM Radiology: Screening mammogram: US:
Right breast: Cluster of masses at 9 o’clock middle depth
US:
Right breast: irregular hypoechoic mass, 9 o’clock, 13cm from nipple, 1.1*1.4*1cm, with an adjacent 0.5*0.6 cm posterior mass
No axillary adenopathy 19

20. GM

21. GM

22. GM

23. GM

24. GM Pathology: Right breast lesion:
Infiltrating ductal carcinoma, grade 2
ER(+) PR(+), HER2(-)

25. GM
68 F, clinical stage IA/IIA T1c/2N0M0

26. GM Surgery – Medical oncology – Radiation oncology – Plastic surgery –
Partial mastectomy vs. mastectomy + SLNB
Medical oncology –
Radiation oncology –
Plastic surgery –
Genetics –
Psychosocial –

27. DH
77 AAF presenting with an abnormal mammogram

28. DH Menarche: 14y G8P8 (17y) Postmenopausal (early 40’s)
Hx breast bx: none
Hx breast Ca: none
Fhx: son – colon cancer (33y)
Shx: tobacco (+), ETOH(-)
Bra: C

29. DH PMH: HTN, PVD, HLD, DM PSH: Meds: Allergies: Talwin, Aspirin
s/p Whipple procedure 5/2011 – serous cystadenoma
Complicated by anastomotic leak
s/p colon resection d/t cancer – 1982
AAA
Thyroid nodules
s/p hysterectomy
Meds:
Amlodipine, Clonidine, Creon, Colace, Lisinopril, Omeprazole, Pravastatin
Allergies: Talwin, Aspirin
On review of systems she has no other complaints

30. DH PE: Right breast: Left breast:
Nodularity over right thyroid lobe
Right breast:
Palpable mobile mass 5-6 o’clock, nipple inversion
Left breast:
Within normal limits
No axillary, supraclavicular or cervical lymphadenopathy

31. DH Radiology: CT: Diagnostic mammogram: US:
Right breast: 1.5cm nodule, medial aspect
Diagnostic mammogram:
Benign bilateral calcifications
Right breast:
round mass with a spiculated margin 5 o’clock
Density – 10 o’clock
US:
1.7*1.9*1.2cm lesion, 5 o’clock, 4cm from nipple, two 6 and 9mm satellite nodules
Cluster of lymph nodes 10 o’clock
Thyroid: multinodular goiter 31

32. DH

33. DH

34. DH

35. DH

36. DH Pathology: Breast lesion 5 o’clock: Invasive mucinous carcinoma
ER(+) PR(-), HER2(+1)
Grade 2

37. DH
77 F, clinical stage IA, T1cN0M0 mucinous carcinoma

38. DH

39. DH Surgery – Medical oncology – Radiation oncology – Plastic surgery –
Biopsy of 10 o’clock lesion
Partial mastectomy vs. mastectomy + SLNB
Medical oncology –
Radiation oncology –
Plastic surgery –
Genetics –
Psychosocial –

40. SS 52 AAF presenting with a mass on left mastectomy scar 1994 –
T2N0M0 Left breast lobular carcinoma
ER/PR+, HER2 unknown
Modified radical mastectomy, reconstruction
Chemotherapy

41. SS Menarche: 12y G3P3 (14y), breastfeeding: none OCP: none HRT: none
Postmenopausal (51y)
Fhx: none
Shx: caffeine(+), tobacco(+)
Bra: 44D

42. SS PMH: DM, HTN, HLD, CRF, arthritis PSH: Meds: Allergies - Compazine
MRM + reconstruction (saline implant)
right breast reduction – 1997
Colectomy – 1997
Meds:
Metformin, Avandia, Prilosec, Ditropan, Naproxen, Percocet, Lisinopril
Allergies - Compazine
On review of systems she has no other complaints

43. SS PE: Right breast: Left breast:
s/p reduction mammoplasty
Left breast:
s/p mastectomy, reconstruction
s/p excisional biopsy
No axillary, supraclavicular or cervical lymphadenopathy

44. SS Radiology: Diagnostic mammogram: US: MRI:
4/2011 – no significant abnormalities
US:
4/ no significant abnormalities
MRI:
Limited exam
PET/CT: no evidence of metastasis 44

45. SS Pathology: Breast lesion (excisional biopsy):
Infiltrating lobular carcinoma
2.8cm
Involving dermis and subcutaneous tissues
Positive margins
ER(+) PR(+), HER2(+2, -FISH)

46. SS
52 F, recurrent lobular carcinoma, left breast

47. SS Surgery – Medical oncology – Radiation oncology – Plastic surgery –
Resection
Medical oncology –
Radiation oncology –
Plastic surgery –
Implant removal
Genetics –
Psychosocial –

48. Concepts in ALND
Contribution of local therapy to breast cancer survival is controversial
Biological factors may effect selective invasion to lymph nodes rather than visceral organs
Lymph node tumor status influences but not dictates chemotherapy
Earlier detection reduces incidence and number of nodal metastases
Just as certain tumor types metastasize to certain organs and not others.

49. Is axillary lymph node dissection really necessary?
Aim: determine the effects of ALND on overall survival in patients with SLN metastases treated with lumpectomy, adjuvant systemic therapy and radiation
Multicenter randomized phase 3 trial

50. Inclusion: Adult women
Histologically confirmed invasive breast carcinoma
Clinically 5cm or less
No palpable adenopathy
SLN containing metastatic breast cancer (FS, touch or H&E)
Lumpectomy to negative margins
IHC identified only - ineligible

51. Exclusion: 3 or more positive SLN’s Matted nodes
Gross extranodal disease
Neoadjuvant therapy (hormonal or chemotherapy)

52. Disease characteristics were balanced between the groups
Stratification:
Age (50y)
ER status
Tumor size
(≤1cm, >1 and ≤2cm, >2cm)
Disease characteristics were balanced between the groups
Whole breast radiation
Adjuvant systemic therapy determined by physician

53. Endpoints: Primary: Secondary:
Overall survival (time from randomization until death from any cause)
Occurrence of sugical morbidities
Secondary:
Disease free survival (time from randomization to death or first documented recurrence of breast cancer)
Recurrence: locoregional or distant
Non

54. Non inferiority study:
OS not less than 75% of that reported for ALND (80% at 5y, based on literature)
HR for mortality less than 1.3 compared to ALND
Base model:
SLND vs. ALND
Age
Adjuvant treatment
Prognostic variables added individually

55. Median follow up - 6.3 years Extremely low mortality rate (94 deaths)
Decision to terminate the study
Even if all 1900 were accrued, it would take more than 20 years of follow up to reach 500 deaths
None of the planned interim analyses were performed

56. No significant difference in OS between the groups (92.5% vs. 91.8%)
No significant difference in DFS between the groups (83.9% vs. 82.2%)

57. HR (comparing OS between two groups) –
Unadjusted: 0.79
Adjusted for adjuvant therapy and age: 0.87
HR (comparing DFS between two groups) –
Unadjusted: 0.82
Adjusted for adjuvant therapy and age: 0.88

58. Locoregional recurrence – similar between groups
Axillary nodal recurrence rate 0.9% in SLNB only group (total locoregional recurrence – 2.5%)
High rate of locoregional control with multimodality therapy, even without ALND
Higher rate of surgical morbidities in ALND group

59. No benefit from addition of ALND in terms of:
Local control
Disease free survival
Overall survival
Knowing the number of positive nodes is unlikely to change systemic therapy decisions
ALND still standard practice:
Mastectomy
Lumpectomy without radiotherapy
Partial breast irradiation
Neoadjuvant therapy
Prone position radiation