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Malignant Breast Disease. Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery. Breast Cancer. Over 180,000 new cases ~62,000 are in situ (30%) 2 nd leading cause of all cancer deaths 80% of cases occur >50yo. Pre-op. History Physical Imaging Diagnosis Treatment options.

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Malignant Breast Disease

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Malignant breast disease l.jpg

Malignant Breast Disease

Juhi Asad, DO

Alison Estrabrook, MD

Dept. of Breast Surgery


Breast cancer l.jpg

Breast Cancer

  • Over 180,000 new cases

  • ~62,000 are in situ (30%)

  • 2nd leading cause of all cancer deaths

  • 80% of cases occur >50yo


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Pre-op

  • History

  • Physical

  • Imaging

  • Diagnosis

  • Treatment options


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Surgical Options

  • Partial Mastectomy (lumpectomy)

  • Total Mastectomy

    • Reconstruction

  • Sentinel lymph node biopsy

  • Axillary lymph node dissection


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Surgical Treatment

  • Partial Mastectomy

    • Radiation therapy

    • Free margins

    • Aesthetic results

    • NSABP B-06

      • no significant difference in survival between MRM, lump w/radiaton, and lump w/o radiation


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Partial Mastectomy

  • Contraindications

    • Size relative to breast

    • Multifocality

    • Early pregnancy

    • Inability to receive radiation

      • Connective tissue disease

      • Prior radiation


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Surgical Treatment

  • Radial Mastectomy

    • Historical – mid 70s

    • Breast, pectoralis, regional lymph nodes along axillary vein to costoclavicular ligament


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Surgical Treatment

  • Total Mastectomy axillary dissection

  • TM + Skin sparing w/reconstruction


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Reconstruction

  • Implants

  • Flaps

    • TRAM

    • Latissimus

    • DIEP


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Tissue Expanders


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TRAM


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Oncoplastic Surgery


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Preop 4 Days Postop


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Surgical Treatment

  • Sentinel Node Biopsy

    • The 1st node in the ipsilateral axilla to drain the tumor

    • >97% concordance rate


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Sentinel Lymph Node

  • Contraindications

    • Clinically positive lymph nodes


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Sentinel Lymph Node

  • Technetium-99m sulfur colloid

    • Intradermal : peritumoral or periareolar

  • Isosulfan blue dye

    • Intraparenchymal

      Problems:

    • Anaphylactic reaction (1-3%)

    • Skin discoloration

    • Contraindicated in pregnancy


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Sentinel Lymph Node

  • Intra-op evaluation

    • Frozen section

    • Touch prep

    • Benefits over axillary node dissection

    • more accurate pathology

    • less lymphedema – ( very rare vs 10-50%)

    • less sensory disturbances

    • less shoulder dysfunction

    • less wound infection

    • less incisional pain


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Axillary Lymph Node Dissection

  • Indications

    • Clinically + nodes

    • + SLN

  • Level I & II


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Pathology

  • DCIS

  • Invasive Ductal

  • Invasive Lobular


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DCIS

  • 200% b/w 1983-1992

  • 15-30% all screen-detected tumors

  • Diagnosis

    • Screening mammogram

      • Microcalcifications

        • Linear, heterogenous

    • Biopsy

      • Stereotactic

      • Open biopsy


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DCIS

  • Treatment

    • Partial Mastectomy

      • Followed by radiation +/- hormonal therapy

    • Total mastectomy

      • Diffuse disease

      • Multifocal

      • Persistent positive margins

      • Inability to give radiation

      • Patient choice


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DCIS

  • Sentinel Lymph Node Biopsy

    • Total Mastectomy

    • Palpable mass

    • Microinvasion


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DCIS

  • Radiation Therapy

    • 50% decrease in recurrence LE

  • Hormonal Therapy

    • NSABP B-24 – LE, RT, +TAM vs LE, RT only

      • TAM – 8.2% incidence of IBTR

      • Placebo – 13.4% incidence of IBTR


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Invasive Ductal Ca

  • Most common – 50-70% of invasive ca


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Invasive Lobular Ca

  • 10-15% of breast ca

  • Fail to form masses

  • Multifocal and multicentric

  • Bilateral – 20-29%


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ILC


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T2: 2cm-5cm

T3: >5cm

T4: extension

Staging

  • Primary Tumor (T)

    • TX: unable to assess

    • T0: no evidence of primary tumor

    • Tis: DCIS, LCIS or Paget’s (nipple only)

    • T1: <2cm


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Regional Lymph Nodes (N)

  • NX: unable to assess

  • N0: negative

  • N1: 1-3 nodes

  • N2: 4-9 nodes

  • N3: >10 nodes


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Distant metastatsis: (M)

  • MX: unable to assess

  • M0: negative

  • M1: distant mets


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Stage 0

Tis, N0, M0

Stage I

T1*, N0, M0

Stage IIA

T0, N1, M0

T1*, N1, M0

T2, N0, M0

Stage IIB

T2, N1, M0

T3, N0, M0

Stage IIIA

T0, N2, M0

T1*, N2, M0

T2, N2, M0

T3, N1, M0

T3, N2, M0

Stage IIIB

T4, N0, M0

T4, N1, M0

T4, N2, M0

Stage IIIC**

Any T, N3, M0

Stage IV

Any T, Any N, M1

[Note: T1 includes T1mic]

AJCC Staging


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5 year Survival


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Adjuvant Therapy

  • www.adjuvantonline.com

    • Assess the risks and benefits of additional therapy after surgery


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Prognostic Indicators

  • Hormone Receptors – improved prognosis

    • ER – 70-80%

    • PR – indicator for a functional ER receptor

  • Epidermal growth factor

    • HER/erbB2

      • EGFR

      • HER2/neu

        • Cell proliferation & differentiation

      • erbB2


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Prognostic Indicators

  • P53 – tumor suppressor gene

    • Overexpression of p53

      • Poorer prognosis

      • Shorter disease-free and survival


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Oncotype Dx

  • ER (+); node (-)

  • Genetic profile – 21 gene assay

    • Recurrence score (3 groups)

      • Low – hormonal therapy

      • Intermediate – TailorRx trial

        • Hormonal vs chemo + hormonal

      • High – chemo + hormonal therapy


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Adjuvant Therapy

  • Hormonal therapy

    • Antiestrogen therapy – Tamoxifen

      • Pre & post-menopausal women

      • Reduces risk of contralateral disease & mets

      • Side effects

        • Endometrial ca

        • Thromoembolic events


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Adjuvant Therapy

  • Hormonal Therapy

    • Aromastase Inhibitors – blocks the conversion of androstenedione to estrone

      • Post-menopausal women

        • ATAC trial – anastrozole decreased the risk of contralateral cancers compared to TAM

      • Side effects

        • Bone loss and joint pain


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Adjuvant Therapy

  • Chemotherapy

    • Size of tumor

    • Nodal status

    • ER/PR

    • HER2/Neu -- Herceptin


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LCIS

  • Incidental finding

    • 0.8-8% of breast biopsies

  • Marker for an increased risk

    • 1% per year risk

    • Bilateral breasts

  • Most common – Ductal carcinoma


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LCIS

  • Treatment

    • Annual mammograms

    • 6mos CBE

    • Discuss bilateral prophylactic mastectomies


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Paget’s Disease

  • Chronic, eczema-like rash of the nipple and areolar skin

  • ~97% underlying Ca

  • Diagnosis

    • Punch biopsy

    • Core needle biopsy


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Paget’s Disease

  • Treatment

    • Surgical treatment

      • TM w/ SLN

      • Central segmentectomy w/ SLN  XRT

    • Adjuvant therapy

      • Chemotherapy

      • Hormonal therapy


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Locally Advanced Disease

  • Large tumors (>5cm)

  • Chest wall involvment

  • Ulcerations

  • Fixed axillary lymph nodes


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Locally Advanced Disease


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Locally Advanced Disease

  • Treatment

    • Neoadjuvant therapy – 80% shrinkage

      • Downstage

      • BCT vs Mastectomy

        • radiation


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Post Neoadjuvant therapy


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Inflammatory Breast Ca

  • Rare & aggressive

  • Accounts for 5% of all breast ca

  • Younger women higher tendency for distant mets

  • AJCC – T4d

    • Stage IIIB

    • Stage IIIC

    • Stage IV


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Inflammatory Breast Ca

  • Presentation

    • Rapid onset of erythema, edema (peau d’orange

    • Often no mass

    • Axillary node involvement

  • Imaging

    • No distinct mass

    • Skin thickening

    • Trabecular thickening


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Inflammatory Breast Ca

  • Histology

    • Dermal lymphatic invasion

    • Not associated with a subtype

    • High S-phase fraction

    • Mutation of p53


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Inflammatory Breast Ca

  • Survival

    • 3yr – 40-70%

    • 5 yr – 50%

    • 10 yr – 26.7%


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Male Breast Cancer

  • 1% of all breast ca

  • >90% Ductal Ca

  • ER/PR +

  • 5-10% are hereditary

    • BRCA 2 gene


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Breast CA during Pregnancy

  • 1 in 3,000 pregnancies

  • Most common non-GYN cancer

  • Present as a painless mass

  • Worse prognosis

    • Advanced stage

      • Stage II-III 75% rate (median 40mos)

    • Hyperestrogenic state


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Breast Ca during Pregnancy

  • Diagnosis

    • Ultrasound

    • Mammogram

    • Core needle biopsy


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Breast Ca during Pregnancy

  • Treatment

    • 1st trimester

      • TM with SLN bx

      • Chemotherapy

        • Significant risk of spontaneous abortion

        • Fetal malformation

    • 2nd & 3rd trimester

      • TM w/ SLN bx or

      • Lumpectomy with SLN bx

        • radiation

      • Chemotherapy


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Question

  • Following an excisional biopsy for microcalifications, the pathology report states there is LCIS present. You discuss with the patient

    • She needs a lumpectomy then RT

    • She would benefit from a mirror biopsy

    • She has a future cancer risk of 1% per yr

    • No known therapy to help her


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Question

55 yo female underwent a Rt lumpectomy with SLN bx.

Pathology showed a 3.5 cm well-differentiated infiltrating

Ductal ca. The sentinel lymph nodes were negative (0/2).

No evidence of any distance mets.

What is her stage?


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40 yo woman presents with a 2cm mass in her right breast first detected by mammo. A core biopsy reveals infiltrating ductal ca. She has no palpable lymph nodes. Appropriate therapy for the patient would include:

-- partial mastectomy

-- sentinel lymph node biopsy

-- consideration of adjuvant chemo

-- radiation therapy

-- all of the above


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