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Malignant Breast Disease Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery Slide 2 Breast Cancer Over 180,000 new cases Over 180,000 new cases ~62,000 are in situ (30%) ~62,000 are in situ (30%) 2 nd leading cause of all cancer deaths 2 nd leading cause of all cancer deaths 80% of cases occur >50yo 80% of cases occur >50yo Slide 3 Pre-op History History Physical Physical Imaging Imaging Diagnosis Diagnosis Treatment options Treatment options Slide 4 Surgical Options Partial Mastectomy (lumpectomy) Partial Mastectomy (lumpectomy) Total Mastectomy Total Mastectomy Reconstruction Sentinel lymph node biopsy Sentinel lymph node biopsy Axillary lymph node dissection Axillary lymph node dissection Slide 5 Surgical Treatment Partial Mastectomy 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 no significant difference in survival between MRM, lump w/radiaton, and lump w/o radiation Slide 6 Slide 7 Slide 8 Partial Mastectomy Contraindications Contraindications Size relative to breast Multifocality Early pregnancy Inability to receive radiation Connective tissue disease Connective tissue disease Prior radiation Prior radiation Slide 9 Surgical Treatment Radial Mastectomy Radial Mastectomy Historical mid 70s Breast, pectoralis, regional lymph nodes along axillary vein to costoclavicular ligament Slide 10 Surgical Treatment Total Mastectomy axillary dissection Total Mastectomy axillary dissection TM + Skin sparing w/reconstruction TM + Skin sparing w/reconstruction Slide 11 Reconstruction Implants Implants Flaps Flaps TRAM Latissimus DIEP Slide 12 Tissue Expanders Slide 13 TRAM Slide 14 Slide 15 Oncoplastic Surgery Slide 16 Slide 17 Slide 18 Slide 19 Preop 4 Days Postop Slide 20 Surgical Treatment Sentinel Node Biopsy Sentinel Node Biopsy The 1 st node in the ipsilateral axilla to drain the tumor >97% concordance rate Slide 21 Sentinel Lymph Node Contraindications Contraindications Clinically positive lymph nodes Slide 22 Sentinel Lymph Node Technetium-99m sulfur colloid Technetium-99m sulfur colloid Intradermal : peritumoral or periareolar Isosulfan blue dye Isosulfan blue dye Intraparenchymal Problems: Anaphylactic reaction (1-3%) Skin discoloration Contraindicated in pregnancy Slide 23 Slide 24 Sentinel Lymph Node Intra-op evaluation 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 Slide 25 Axillary Lymph Node Dissection Indications Indications Clinically + nodes + SLN Level I & II Level I & II Slide 26 Slide 27 Pathology DCIS DCIS Invasive Ductal Invasive Ductal Invasive Lobular Invasive Lobular Slide 28 DCIS 200% b/w 1983-1992 200% b/w 1983-1992 15-30% all screen-detected tumors 15-30% all screen-detected tumors Diagnosis Diagnosis Screening mammogram Microcalcifications Microcalcifications Linear, heterogenous Biopsy Stereotactic Stereotactic Open biopsy Open biopsy Slide 29 Slide 30 Slide 31 DCIS Treatment Treatment Partial Mastectomy Followed by radiation +/- hormonal therapy Followed by radiation +/- hormonal therapy Total mastectomy Diffuse disease Diffuse disease Multifocal Multifocal Persistent positive margins Persistent positive margins Inability to give radiation Inability to give radiation Patient choice Patient choice Slide 32 DCIS Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy Total Mastectomy Palpable mass Microinvasion Slide 33 DCIS Radiation Therapy Radiation Therapy 50% decrease in recurrence LE Hormonal Therapy Hormonal Therapy NSABP B-24 LE, RT, +TAM vs LE, RT only TAM 8.2% incidence of IBTR TAM 8.2% incidence of IBTR Placebo 13.4% incidence of IBTR Placebo 13.4% incidence of IBTR Slide 34 Invasive Ductal Ca Most common 50- 70% of invasive ca Most common 50- 70% of invasive ca Slide 35 Slide 36 Invasive Lobular Ca 10-15% of breast ca 10-15% of breast ca Fail to form masses Fail to form masses Multifocal and multicentric Multifocal and multicentric Bilateral 20-29% Bilateral 20-29% Slide 37 ILC Slide 38 Staging Primary Tumor (T) Primary Tumor (T) TX: unable to assess T0: no evidence of primary tumor Tis: DCIS, LCIS or Pagets (nipple only) T1: 5cm T4: extension Slide 39 Regional Lymph Nodes (N) NX: unable to assess NX: unable to assess N0: negative N0: negative N1: 1-3 nodes N1: 1-3 nodes N2: 4-9 nodes N2: 4-9 nodes N3: >10 nodes N3: >10 nodes Slide 40 Distant metastatsis: (M) MX: unable to assess MX: unable to assess M0: negative M0: negative M1: distant mets M1: distant mets Slide 41 AJCC Staging Stage 0 Stage 0 Tis, N0, M0 Stage I Stage I T1*, N0, M0 Stage IIA Stage IIA T0, N1, M0 T1*, N1, M0 T2, N0, M0 Stage IIB Stage IIB T2, N1, M0 T3, N0, M0 Stage IIIA Stage IIIA T0, N2, M0 T1*, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 Stage IIIB Stage IIIB T4, N0, M0 T4, N1, M0 T4, N2, M0 Stage IIIC** Stage IIIC** Any T, N3, M0 Stage IV Stage IV Any T, Any N, M1 [Note: T1 includes T1mic] Slide 42 5 year Survival Stage 5-year Relative Survival Rate 0100% I IIA92% IIB81% IIIA67% IIIB54% IV20% Slide 43 Adjuvant Therapy www.adjuvantonline.com www.adjuvantonline.com www.adjuvantonline.com Assess the risks and benefits of additional therapy after surgery Slide 44 Prognostic Indicators Hormone Receptors improved prognosis Hormone Receptors improved prognosis ER 70-80% PR indicator for a functional ER receptor Epidermal growth factor Epidermal growth factor HER/erbB2 EGFR EGFR HER2/neu HER2/neu Cell proliferation & differentiation erbB2 erbB2 Slide 45 Prognostic Indicators P53 tumor suppressor gene P53 tumor suppressor gene Overexpression of p53 Poorer prognosis Poorer prognosis Shorter disease-free and survival Shorter disease-free and survival Slide 46 Oncotype Dx ER (+); node (-) ER (+); node (-) Genetic profile 21 gene assay Genetic profile 21 gene assay Recurrence score (3 groups) Low hormonal therapy Low hormonal therapy Intermediate TailorRx trial Intermediate TailorRx trial Hormonal vs chemo + hormonal High chemo + hormonal therapy High chemo + hormonal therapy Slide 47 Adjuvant Therapy Hormonal therapy Hormonal therapy Antiestrogen therapy Tamoxifen Pre & post-menopausal women Pre & post-menopausal women Reduces risk of contralateral disease & mets Reduces risk of contralateral disease & mets Side effects Side effects Endometrial ca Thromoembolic events Slide 48 Adjuvant Therapy Hormonal Therapy Hormonal Therapy Aromastase Inhibitors blocks the conversion of androstenedione to estrone Post-menopausal women Post-menopausal women ATAC trial anastrozole decreased the risk of contralateral cancers compared to TAM Side effects Side effects Bone loss and joint pain Slide 49 Adjuvant Therapy Chemotherapy Chemotherapy Size of tumor Nodal status ER/PR HER2/Neu -- Herceptin Slide 50 Low Risk Node (-) & ER/PR (+) & T2cm - grade II/III - LVI - 4) ER/PR (+) -- Chemo & hormone ER/PR (-) -- Chemo Slide 51 LCIS Incidental finding Incidental finding 0.8-8% of breast biopsies Marker for an increased risk Marker for an increased risk 1% per year risk Bilateral breasts Most common Ductal carcinoma Most common Ductal carcinoma Slide 52 LCIS Treatment Treatment Annual mammograms 6mos CBE Discuss bilateral prophylactic mastectomies Slide 53 Slide 54 Pagets Disease Chronic, eczema-like rash of the nipple and areolar skin Chronic, eczema-like rash of the nipple and areolar skin ~97% underlying Ca ~97% underlying Ca Diagnosis Diagnosis Punch biopsy Core needle biopsy Slide 55 Pagets Disease Treatment Treatment Surgical treatment TM w/ SLN TM w/ SLN Central segmentectomy w/ SLN XRT Central segmentectomy w/ SLN XRT Adjuvant therapy Chemotherapy Chemotherapy Hormonal therapy Hormonal therapy Slide 56 Locally Advanced Disease Large tumors (>5cm) Large tumors (>5cm) Chest wall involvment Chest wall involvment Ulcerations Ulcerations Fixed axillary lymph nodes Fixed axillary lymph nodes Slide 57 Locally Advanced Disease Slide 58 Treatment Treatment Neoadjuvant therapy 80% shrinkage Downstage Downstage BCT vs Mastectomy BCT vs Mastectomy radiation Slide 59 Post Neoadjuvant therapy Slide 60 Inflammatory Breast Ca Rare & aggressive Rare & aggressive Accounts for 5% of all breast ca Accounts for 5% of all breast ca Younger women higher tendency for distant mets Younger women higher tendency for distant mets AJCC T4d AJCC T4d Stage IIIB Stage IIIC Stage IV Slide 61 Inflammatory Breast Ca Presentation Presentation Rapid onset of erythema, edema (peau dorange Often no mass Axillary node involvement Imaging Imaging No distinct mass Skin thickening Trabecular thickening Slide 62 Slide 63 Inflammatory Breast Ca Histology Histology Dermal lymphatic invasion Not associated with a subtype High S-phase fraction Mutation of p53 Slide 64 Inflammatory Breast Ca Survival Survival 3yr 40-70% 5 yr 50% 10 yr 26.7% Slide 65 Male Breast Cancer 1% of all breast ca 1% of all breast ca >90% Ductal Ca >90% Ductal Ca ER/PR + ER/PR + 5-10% are hereditary 5-10% are hereditary BRCA 2 gene Slide 66 Breast CA during Pregnancy 1 in 3,000 pregnancies 1 in 3,000 pregnancies Most common non-GYN cancer Most common non-GYN cancer Present as a painless mass Present as a painless mass Worse prognosis Worse prognosis Advanced stage Stage II-III 75% rate (median 40mos) Stage II-III 75% rate (median 40mos) Hyperestrogenic state Slide 67 Breast Ca during Pregnancy Diagnosis Diagnosis Ultrasound Mammogram Core needle biopsy Slide 68 Breast Ca during Pregnancy Treatment Treatment 1 st trimester TM with SLN bx TM with SLN bx Chemotherapy Chemotherapy Significant risk of spontaneous abortion Fetal malformation 2 nd & 3 rd trimester TM w/ SLN bx or TM w/ SLN bx or Lumpectomy with SLN bx Lumpectomy with SLN bx radiation Chemotherapy Chemotherapy Slide 69 Question Following an excisional biopsy for microcalifications, the pathology report states there is LCIS present. You discuss with the patient 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 Slide 70 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? Slide 71 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