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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:

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Breast Conference 9/7/2011


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    1. Breast Conference 9/7/2011

    2. LP • 60 AAF presenting with a left breast mass

    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)

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

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

    6. 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

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

    8. LP

    9. LP

    10. LP

    11. LP Pathology: Breast 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 – • 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

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

    19. 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

    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 – • 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: 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

    30. 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

    31. 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

    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 – • 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: MRM + reconstruction (saline implant) - 1994 right breast reduction – 1997 Colectomy – 1997 Meds: Metformin, Avandia, Prilosec, Ditropan, Naproxen, Percocet, Lisinopril Allergies - Compazine

    43. SS PE: Right 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: 4/2011 – no significant abnormalities US: 4/2011 - no significant abnormalities MRI: Limited exam PET/CT: no evidence of metastasis

    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 – • 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

    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