breast cancer risk factors non-modifiable age female sex menstrual factors early age at menarche...
TRANSCRIPT
Jose A Torres, MD 1/12/2017
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Background Globally leading cause of cancer related death in
women
~249,000 Americans diagnosed with invasive breast cancer ~40,890 will die of their disease
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Breast cancer risk factors Non-modifiable
Age Female sex Menstrual factors Early age at menarche (onset before age 12 yrs) Older age at menopause (onset beyond age 55 yrs) Nulliparity Family history of breast cancer Genetic predisposition (BRCA1 and BRCA2 mutation carriers) Personal history of breast CA Race, ethnicity (white females) History of radiation exposure
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Breast cancer risk factors Modifiable
Reproductive factors Age at first live birth Parity Lack of breast feeding Obesity EtOH consumption Smoking HRT Decreased physical
activity
Histologic Proliferative breast
disease Atypical ductal
hyperplasia Atypical lobular
hyperplasia LCIS
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Anatomy • Axillary borders
• Superior—axillary vein • Anterior—Pectoralis
minor muscle • Lateral—latissimus dorsi
muscle
• Axillary LN levels • I—lateral to pectoralis
minor • II—posterior to pectoralis
minor • III—medial to pectoralis
minor
• Innervation • Long thoracic nerve—
serratus anterior • Thoracodorsal nerve—
latissimus dorsi • Intercostobrachial nerve—
sensory to upper inner arm
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Case 58 yo F G2P2
PMH: nil PSH: hysterectomy (fibroids) FamHx: Mother—breast cancer
Benign breast exam Undergoing routine surveillance imaging
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Imaging Mammogram (8/2015): BI-RADS 3
No masses or suspicious microcalcifications. Amorphous microcalcifications along superior posterior aspect of L breast—likely vascular calcifications
Mammogram (11/2016): BI-RADS 4 Segmental linear pleomorphic microcalcification in
upper inner L breast
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8/2015 11/2016
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BI-RADS Category Radiologic finding Recommendation
0 Incomplete evaluation Additional imaging
1 Negative Routine screening
2 Benign Routine screening
3 Probably benign (risk 2%)
Short term interval follow up
4 Suspicious (risk 30%)
Biopsy
5 Highly suspicious (risk 95%)
Treat accordingly
6 Known malignancy -
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Pathology 11/17/2016: Excisional biopsy
Invasive ductal carcinoma, poorly differentiated with extensive DCIS ER + PR – HER2 –
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Indications for excisional biopsy after core biopsy Lack concordance (radiology vs pathology) Non-diagnostic study/specimen Atypical ductal hyperplasia Atypical lobular hyperplasia Radial scar LCIS Columnar cell hyperplasia with atypia Papillary lesions
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Pathology 12/13/2016: Simple mastectomy, SLNBx
Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis
T1bN0Mx
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Staging TX Primary tumor cannot
be assessed T0 No evidence of
primary tumor Tis Carcinoma in situ T1 Tumor ≤ 20 mm or
less T1mi ≤ 1 mm T1a > 1 mm but ≤ 5 mm T1b >5 mm but ≤10 mm T1c >10 mm but ≤ 20 mm
T2 >20 mm but ≤ 50 mm T3 >50 mm T4 Tumor of any size
with direct extension to chest wall and/or skin (ulceration or skin nodules) T4a Extends to chest wall T4b Ulceration and/or
ipsilateral satellite nodules and/or edema of skin
T4c Both T4a and T4b T4d Inflammatory
carcinoma
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Staging NX Regional LN cannot be assessed N0 No regional LN metastasis N1 1-3 LN, Metastasis to movable
ipsilateral level I, II axillary LN N2 4-9 LN
N2a Metastasis to ipsilateral level I, II axillary LN fixed to one another (matted) or to other structures
N2b Metastasis only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary LN
N3 ≥10 LN N3a Metastasis in ipsilateral
infraclavicular LN N3b Metastasis in ipsilateral internal
mammary LN and axillary LN N3c Metastasis in ipsilateral
supraclavicular LN
M0 No clinical or radiographic evidence of distant metastasis
M1 Distant detectable metastases as determined by classic clinical and radiographic mean and/or histologically proven larger than 0.2mm
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Anatomic stage T N M
0 Tis N0 M0
IA T1 N0 M0
IB T0 N1mi M0
T1 N1mi M0
IIA T0 N1 M0
T1 N1 M0
T2 N0 M0
IIB T2 N1 M0
T3 N0 M0
IIIA T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
IIIB T4 N0 M0
T4 N1 M0
T4 N2 M0
IIIC Any T N3 M0
IV Any T Any N M1
• Mastectomy + SLNBx
• Mastectomy + SLNBx + reconstruction
• BCT + XRT
• Neoadjuvant chemotherapy+ MRM + XRT + HRT
• ChemoXRT + HRT
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Case 58 yo F s/p L mastectomy and SLNBx
Path: Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis
T1bN0Mx
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Noninvasive carcinoma LCIS
Marker of increased risk 25% harbor invasive ductal
CA Management
Observation Tamoxifen Bilateral mastectomy
DCIS Anatomic precursor to
ipsilateral invasive ductal CA
Excisional biopsy < 1mm margin – need re-
excision Management
BCT + XRT Mastectomy ± SLNB ±
reconstruction BCT + observation
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NSABP B-17 Lumpectomy (LO) vs Lumpectomy + XRT (LRT)
NSABP B-24 LRT + placebo vs LRT + tamoxifen (LRT +TAM)
Endpoints Invasive-IBTR, DCIS-IBTR, contralateral breast cancer Overall survival, breast cancer specific survival, survival
after I-IBTR
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Results LRT reduced I-IBRT by 52% vs LO LRT + TAM reduced I-IBTR by 32% vs LRT + placebo
I-IBTR DCIS-IBTR CBC
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15 yr incidence of I-IBTR 8.5% LRT + TAM
15 yr incidence of CBC 7.3% LRT + TAM
I-IBTR DCIS-IBTR CBC
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Case 58 yo F s/p L mastectomy and SLNBx
Path: Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis
T1bN0Mx
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Invasive ductal carcinoma
RCT of stage I or II breast CA Mastectomy vs lumpectomy (LO) vs lumpectomy + XRT
(LRT) Endpoints
IBTR, Disease-free survival, Distant-disease free survival, Overall survival
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Results 14.3% recurrence of IBTR in LRT
vs 39.2% LO No difference in disease-free
survival, distant disease free survival, overall survival
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Z0011 Trail T1-T2 invasive breast CA, no palpable LAD, 1-2 SLN with
metastasis Randomized after SLNBx
ALND No further axillary treatment
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Results No difference
Overall survival Disease-free survival
ALND worse morbidity
Wound infection Axillary seromas Paresthesias Lymphedema
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Hormone receptor status Identify receptor status of excised mass
Prognosis: ER/PR+ > ER-/PR+ > ER+/PR- > ER-/PR-
Premenopausal ER + Tamoxifen ± ovarian suppression or ablation
Postmenopausal
AI for 5 yrs Tamoxifen for 2-3 yrs -> AI for 5 yrs AI for 2-3 yrs -> Tamoxifen to complete 5yrs of therapy
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HER2 status HER 2 +
AC (doxorubicin/cyclophosphamide) followed by T (docletaxel) + trastuzumab ± pertuzumab
TC +trastuzumab
HER2 – AC followed by paclitaxel every 2 weeks AC followed by paclitaxel every week TC
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Inflammatory breast CA Tumor cells in dermal lymphatics
Stage IIIB—without nodal involvement
Management Neoadjuvant chemotherapy—
anthracycline + taxanes Response—MRM + XRT ± HRT No response—additional
chemotherapy ± HRT
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51 yo F undergoing lumpectomy for 0.9 cm invasive ductal carcinoma. Axillary exam normal. Proper management of axillary LN consist of which of the following? A Observation B SLNB with permanent pathology C SLNB, frozen section, and completion ALND if node are
positive D Partial breast irradiation E Axillary US and no further therapy if no abnormal nodes
seen
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63 yo F with breast mass undergoes lumpectomy and SLNB. Path reports 1.0 cm invasive ductal CA, ER + HER 2+. Which of the following regimens wound be best chemotherapy of choice? A Cyclophosphamide, MTC, 5-FU B Doxorubicin, cyclophosphamide, paclitaxel, trastuzumab C Doxorubicin, cyclophosphamide, paclitaxel D Doxorubicin, cyclophosphamide E Docetaxel, cyclophosphamide
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Case 63 yo M with left breast cancer
ER+ PR + HER2 – Family history
Mother and 2 maternal aunts
Everted left nipple, mobile periareolar mass No axillary lymphadenopathy
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Pathology 11/15/2016: Core needle biopsy
Invasive ductal carcinoma ER+ PR + HER2 –
12/28/2016: Simple mastectomy, SLNBx
Invasive ductal carcinoma SLNBx—0/3 LN negative for metastasis
T2N0Mx
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Imaging Mammogram (10/2016): BI-RADS 0
Breast US (11/2016): BI-RADS 4
Well-circumscribedlobulated heterogenous echoic lesion in retroareolar region. Hypervascular. 1.8 x 1.7 x2.3cm
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Case 63 yo M with left breast cancer
ER+ PR + HER2 – Family history
Mother and 2 maternal aunts
Everted left nipple, mobile periareolar mass No axillary lymphadenopathy
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Pathology 1/5/2017: Core needle biopsy
Adenocarcinoma, moderately differentiated
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Imaging Mammogram (12/2016): BI-RADS 5
Irregular lobulated mass. Slightly spiculated. Focal skin thickening under nipple
Breast US (12/2016): BI-RADS 5 Lobulated hypoechoic mass in retroareolar region. 1.0 x
1.8 x 2.3 cm
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