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2 years later, she noticed multiple 1.5 -2 cm. nodular masses at the MRM site.
Breast Cancer Recurrence
• anytime, mostly occur in the first 3 – 5 years after initial treatment
• can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body
• most common sites of recurrence include the lymph nodes, the bones, liver, or lungs
Factors for recurrence• Lymph node involvement • Tumor size
– the larger the tumor, the greater the chance of recurrence. • Hormone receptors
– two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+)
– ER-positive tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
• Histologic grade – Grade 4 tumors contain very abnormal and rapidly growing cancer cells– The higher the histologic grade, the greater chance of recurrence.
• Nuclear grade– Refers to the rate at which cancer cells in the tumor divide to form more cells– Cancer cells with a high nuclear grade (also called proliferative capacity) are usually
more aggressive (faster growing). • Oncogene expression
– tumors that contain certain oncogenes may increase a patient's chance of recurrence.
Breast Changes
• An area that is distinctly different from any other area on either breast
• A lump or thickening, in or near the breast or in the underarm, that persists through the menstrual cycle
• A change in the size, shape, or contour of the breast• A mass or lump, which may feel as small as a pea• A marble-like area under the skin• A change in the feel or appearance of the skin on the breast
or nipple [dimpled, puckered, scaly, or inflamed (red, warm, or swollen)]
• Bloody or clear fluid discharge from the nipples• Redness of the skin on the breast or nipple
Impression?
Locoregional recurrence of the breast cancer on the mastectomy site
Treatment
• With previous mastectomy:– Surgical resection of the locoregional recurrence– Appropriate reconstruction– Chemotherapy– Anti-estrogen therapy
Biopsy?
• Yes!– to determine the characteristics of the
lesion/tumor– to determine the staging of the recurrence– to permit doctors discuss the appropriate
management• A current study shows that 10 out of 29 recurrent
tumors changed ~ 35%
Biopsy Of Recurrent Breast Cancer Can Alter Treatment
• Article Date: 20 Mar 2009• A group of doctors from Toronto has recently
completed the world's first study that compared original breast cancer tumors with a biopsy of suspected tumors that recurred elsewhere in the body.
• found that the biopsy resulted in 20% of the women having a significant change in their treatment– change in drug treatment – change in diagnosis to a benign condition.
• "The results show that cancers may change over time and not respond to treatment that was appropriate for the original cancer,“
• principal investigator, Dr. Mark Clemons, a medical oncologist specializing in breast cancer in the Princess Margaret Hospital Cancer Program, University Health Network (UHN).
• leading us in a new direction to understand more about why some women don't respond to treatment
• this will help us to always deliver the right treatment, to the right patient, at the right time
Biopsy Of Recurrent Breast Cancer Can Alter Treatment
• 29 biopsies of accessible, recurrent tumors taken from women whose breast cancer had spread to bone, skin, lymph nodes, lung or liver
• compared the results of the original cancer with the results of the new biopsy by analyzing the predictive markers that influence breast cancer tumor growth - estrogen, progesterone and Her2 status
• the presence, absence and/or combinations of these markers become the map oncologists use to determine the most effective treatment for each patient.
Biopsy Of Recurrent Breast Cancer Can Alter Treatment
• Result:– 15 cases was unchanged– 10 cases the markers in the cancer changed– 3 cases, women originally felt to have metastatic
breast cancer had benign disease– 1 case, the "recurring" cancer was a different type
of cancer, lymphoma which is treated in a very different way to breast cancer.
Biopsy Of Recurrent Breast Cancer Can Alter Treatment
References:
• Brunicardi, F. C., et. al., Schwart's Manual of Surgery, 8th ed., 2006
• www.medicinet.com • Annals of Oncology, Oxford University Press
(Doi:10.1093/annonc/mdp028) • www.cancer.org (American Cancer Society)