Breast cancer risk factors Non-modifiable Age Female sex Menstrual factors Early age at menarche...

Jose A Torres, MD 1/12/2017

www.downstatesurgery.org

Background Globally leading cause of cancer related death in

women

~249,000 Americans diagnosed with invasive breast cancer ~40,890 will die of their disease


Breast cancer risk factors Non-modifiable

Age Female sex Menstrual factors Early age at menarche (onset before age 12 yrs) Older age at menopause (onset beyond age 55 yrs) Nulliparity Family history of breast cancer Genetic predisposition (BRCA1 and BRCA2 mutation carriers) Personal history of breast CA Race, ethnicity (white females) History of radiation exposure


Breast cancer risk factors Modifiable

Reproductive factors Age at first live birth Parity Lack of breast feeding Obesity EtOH consumption Smoking HRT Decreased physical

activity

Histologic Proliferative breast

disease Atypical ductal

hyperplasia Atypical lobular

hyperplasia LCIS


Anatomy • Axillary borders

• Superior—axillary vein • Anterior—Pectoralis

minor muscle • Lateral—latissimus dorsi

muscle

• Axillary LN levels • I—lateral to pectoralis

minor • II—posterior to pectoralis

minor • III—medial to pectoralis

minor

• Innervation • Long thoracic nerve—

serratus anterior • Thoracodorsal nerve—

latissimus dorsi • Intercostobrachial nerve—

sensory to upper inner arm


Case 58 yo F G2P2

PMH: nil PSH: hysterectomy (fibroids) FamHx: Mother—breast cancer

Benign breast exam Undergoing routine surveillance imaging


Imaging Mammogram (8/2015): BI-RADS 3

No masses or suspicious microcalcifications. Amorphous microcalcifications along superior posterior aspect of L breast—likely vascular calcifications

Mammogram (11/2016): BI-RADS 4 Segmental linear pleomorphic microcalcification in

upper inner L breast


8/2015 11/2016


BI-RADS Category Radiologic finding Recommendation

0 Incomplete evaluation Additional imaging

1 Negative Routine screening

2 Benign Routine screening

3 Probably benign (risk 2%)

Short term interval follow up

4 Suspicious (risk 30%)

Biopsy

5 Highly suspicious (risk 95%)

Treat accordingly

6 Known malignancy -


Pathology 11/17/2016: Excisional biopsy

Invasive ductal carcinoma, poorly differentiated with extensive DCIS ER + PR – HER2 –


Indications for excisional biopsy after core biopsy Lack concordance (radiology vs pathology) Non-diagnostic study/specimen Atypical ductal hyperplasia Atypical lobular hyperplasia Radial scar LCIS Columnar cell hyperplasia with atypia Papillary lesions


Pathology 12/13/2016: Simple mastectomy, SLNBx

Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis

T1bN0Mx


Staging TX Primary tumor cannot

be assessed T0 No evidence of

primary tumor Tis Carcinoma in situ T1 Tumor ≤ 20 mm or

less T1mi ≤ 1 mm T1a > 1 mm but ≤ 5 mm T1b >5 mm but ≤10 mm T1c >10 mm but ≤ 20 mm

T2 >20 mm but ≤ 50 mm T3 >50 mm T4 Tumor of any size

with direct extension to chest wall and/or skin (ulceration or skin nodules) T4a Extends to chest wall T4b Ulceration and/or

ipsilateral satellite nodules and/or edema of skin

T4c Both T4a and T4b T4d Inflammatory

carcinoma


Staging NX Regional LN cannot be assessed N0 No regional LN metastasis N1 1-3 LN, Metastasis to movable

ipsilateral level I, II axillary LN N2 4-9 LN

N2a Metastasis to ipsilateral level I, II axillary LN fixed to one another (matted) or to other structures

N2b Metastasis only in clinically detected ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary LN

N3 ≥10 LN N3a Metastasis in ipsilateral

infraclavicular LN N3b Metastasis in ipsilateral internal

mammary LN and axillary LN N3c Metastasis in ipsilateral

supraclavicular LN

M0 No clinical or radiographic evidence of distant metastasis

M1 Distant detectable metastases as determined by classic clinical and radiographic mean and/or histologically proven larger than 0.2mm


Anatomic stage T N M

0 Tis N0 M0

IA T1 N0 M0

IB T0 N1mi M0

T1 N1mi M0

IIA T0 N1 M0

T1 N1 M0

T2 N0 M0

IIB T2 N1 M0

T3 N0 M0

IIIA T0 N2 M0

T1 N2 M0

T2 N2 M0

T3 N1 M0

T3 N2 M0

IIIB T4 N0 M0

T4 N1 M0

T4 N2 M0

IIIC Any T N3 M0

IV Any T Any N M1

• Mastectomy + SLNBx

• Mastectomy + SLNBx + reconstruction

• BCT + XRT

• Neoadjuvant chemotherapy+ MRM + XRT + HRT

• ChemoXRT + HRT


Case 58 yo F s/p L mastectomy and SLNBx

Path: Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis

T1bN0Mx


Noninvasive carcinoma LCIS

Marker of increased risk 25% harbor invasive ductal

CA Management

Observation Tamoxifen Bilateral mastectomy

DCIS Anatomic precursor to

ipsilateral invasive ductal CA

Excisional biopsy < 1mm margin – need re-

excision Management

BCT + XRT Mastectomy ± SLNB ±

reconstruction BCT + observation


NSABP B-17 Lumpectomy (LO) vs Lumpectomy + XRT (LRT)

NSABP B-24 LRT + placebo vs LRT + tamoxifen (LRT +TAM)

Endpoints Invasive-IBTR, DCIS-IBTR, contralateral breast cancer Overall survival, breast cancer specific survival, survival

after I-IBTR


Results LRT reduced I-IBRT by 52% vs LO LRT + TAM reduced I-IBTR by 32% vs LRT + placebo

I-IBTR DCIS-IBTR CBC


15 yr incidence of I-IBTR 8.5% LRT + TAM

15 yr incidence of CBC 7.3% LRT + TAM

I-IBTR DCIS-IBTR CBC


Case 58 yo F s/p L mastectomy and SLNBx

Path: Invasive ductal carcinoma, DCIS SLNBx—0/3 LN negative for metastasis

T1bN0Mx


Invasive ductal carcinoma

RCT of stage I or II breast CA Mastectomy vs lumpectomy (LO) vs lumpectomy + XRT

(LRT) Endpoints

IBTR, Disease-free survival, Distant-disease free survival, Overall survival


Results 14.3% recurrence of IBTR in LRT

vs 39.2% LO No difference in disease-free

survival, distant disease free survival, overall survival


Z0011 Trail T1-T2 invasive breast CA, no palpable LAD, 1-2 SLN with

metastasis Randomized after SLNBx

ALND No further axillary treatment


Results No difference

Overall survival Disease-free survival

ALND worse morbidity

Wound infection Axillary seromas Paresthesias Lymphedema


Hormone receptor status Identify receptor status of excised mass

Prognosis: ER/PR+ > ER-/PR+ > ER+/PR- > ER-/PR-

Premenopausal ER + Tamoxifen ± ovarian suppression or ablation

Postmenopausal

AI for 5 yrs Tamoxifen for 2-3 yrs -> AI for 5 yrs AI for 2-3 yrs -> Tamoxifen to complete 5yrs of therapy


HER2 status HER 2 +

AC (doxorubicin/cyclophosphamide) followed by T (docletaxel) + trastuzumab ± pertuzumab

TC +trastuzumab

HER2 – AC followed by paclitaxel every 2 weeks AC followed by paclitaxel every week TC


Inflammatory breast CA Tumor cells in dermal lymphatics

Stage IIIB—without nodal involvement

Management Neoadjuvant chemotherapy—

anthracycline + taxanes Response—MRM + XRT ± HRT No response—additional

chemotherapy ± HRT


51 yo F undergoing lumpectomy for 0.9 cm invasive ductal carcinoma. Axillary exam normal. Proper management of axillary LN consist of which of the following? A Observation B SLNB with permanent pathology C SLNB, frozen section, and completion ALND if node are

positive D Partial breast irradiation E Axillary US and no further therapy if no abnormal nodes

seen


63 yo F with breast mass undergoes lumpectomy and SLNB. Path reports 1.0 cm invasive ductal CA, ER + HER 2+. Which of the following regimens wound be best chemotherapy of choice? A Cyclophosphamide, MTC, 5-FU B Doxorubicin, cyclophosphamide, paclitaxel, trastuzumab C Doxorubicin, cyclophosphamide, paclitaxel D Doxorubicin, cyclophosphamide E Docetaxel, cyclophosphamide


Case 63 yo M with left breast cancer

ER+ PR + HER2 – Family history

Mother and 2 maternal aunts

Everted left nipple, mobile periareolar mass No axillary lymphadenopathy


Pathology 11/15/2016: Core needle biopsy

Invasive ductal carcinoma ER+ PR + HER2 –

12/28/2016: Simple mastectomy, SLNBx

Invasive ductal carcinoma SLNBx—0/3 LN negative for metastasis

T2N0Mx



Breast US (11/2016): BI-RADS 4

Well-circumscribedlobulated heterogenous echoic lesion in retroareolar region. Hypervascular. 1.8 x 1.7 x2.3cm


Case 63 yo M with left breast cancer

ER+ PR + HER2 – Family history

Mother and 2 maternal aunts

Everted left nipple, mobile periareolar mass No axillary lymphadenopathy


Pathology 1/5/2017: Core needle biopsy

Adenocarcinoma, moderately differentiated



Irregular lobulated mass. Slightly spiculated. Focal skin thickening under nipple

Breast US (12/2016): BI-RADS 5 Lobulated hypoechoic mass in retroareolar region. 1.0 x

1.8 x 2.3 cm


Breast cancer risk factors Non-modifiable Age Female sex Menstrual factors Early age at menarche...

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Transcript of Breast cancer risk factors Non-modifiable Age Female sex Menstrual factors Early age at menarche...