breast conference 9/7/2011
DESCRIPTION
Breast Conference 9/7/2011. LP. 60 AAF presenting with a left breast mass. 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: - PowerPoint PPT PresentationTRANSCRIPT
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)
LP
• PMH: s/p MI • PSH: Unilateral oophorectomy d/t ectopic pregnancy• Meds: Singulair, Albuterol, Lisinopril• NKDA
LP
• PE:– Right breast:
• Within normal limits
– Left breast:• Nipple areolar complex replaced by tumor
• Central 4 cm mass
– Left axillary adenopathy
LP
• Radiology:– Diagnostic mammogram:
• 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
LP
• Pathology:– Breast lesion:
• infilrating ductal carcinoma, grade 3
• ER, PR, HER2 - pending
– Axillary lesion:• Metastatic ductal carcinoma
LP
• Surgery –– Mastectomy + ALND
• Medical oncology – – Neoadjuvant chemotherapy
• Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –
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
GM
• PE:– Right breast:
• Palpable mass, 9 o’clock 8cm from nipple
– Left breast: Within normal limits – No axillary, supraclavicular or cervical
lymphadenopathy
GM
• Radiology:– Screening mammogram:
• 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
GM
• Pathology:– Right breast lesion:
• Infiltrating ductal carcinoma, grade 2
• ER(+) PR(+), HER2(-)
GM
• Surgery – • Partial mastectomy vs. mastectomy + SLNB
• Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –
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
DH• PMH: HTN, PVD, HLD, DM• PSH:
– 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
DH
• PE:– 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
DH
• Radiology:– CT:
• 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:• Right breast:
– 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
DH
• Pathology:– Breast lesion 5 o’clock:
• Invasive mucinous carcinoma
• ER(+) PR(-), HER2(+1)
• Grade 2
DH
• Surgery –– Biopsy of 10 o’clock lesion
– Partial mastectomy vs. mastectomy + SLNB
• Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –
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
SS
• Menarche: 12y• G3P3 (14y), breastfeeding: none• OCP: none• HRT: none• Postmenopausal (51y)
• Fhx: none• Shx: caffeine(+), tobacco(+)• Bra: 44D
SS
• PMH: DM, HTN, HLD, CRF, arthritis• PSH:
– MRM + reconstruction (saline implant) - 1994
– right breast reduction – 1997
– Colectomy – 1997
• Meds: – Metformin, Avandia, Prilosec, Ditropan, Naproxen, Percocet,
Lisinopril
• Allergies - Compazine
SS
• PE:– Right breast:
• s/p reduction mammoplasty
– Left breast:• s/p mastectomy, reconstruction• s/p excisional biopsy
– No axillary, supraclavicular or cervical lymphadenopathy
SS
• Radiology:– Diagnostic mammogram:
• 4/2011 – no significant abnormalities
– US:• 4/2011 - no significant abnormalities
– MRI:• Limited exam
– PET/CT: no evidence of metastasis
SS
• Pathology:– Breast lesion (excisional biopsy):
• Infiltrating lobular carcinoma
• 2.8cm
• Involving dermis and subcutaneous tissues
• Positive margins
• ER(+) PR(+), HER2(+2, -FISH)
SS
• Surgery –– Resection
• Medical oncology – • Radiation oncology – • Plastic surgery –
– Implant removal
• Genetics – • Psychosocial –
• 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
• 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
• 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
• Exclusion:– 3 or more positive SLN’s
– Matted nodes
– Gross extranodal disease
– Neoadjuvant therapy (hormonal or chemotherapy)
• 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
• Endpoints:– Primary:
• 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)
• 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
• 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
• 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%)
• 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
• 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
• 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