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Malignant Breast Disease

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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  1. Malignant Breast Disease Juhi Asad, DO Alison Estrabrook, MD Dept. of Breast Surgery

  2. 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

  3. Pre-op • History • Physical • Imaging • Diagnosis • Treatment options

  4. Surgical Options • Partial Mastectomy (lumpectomy) • Total Mastectomy • Reconstruction • Sentinel lymph node biopsy • Axillary lymph node dissection

  5. 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

  6. Partial Mastectomy • Contraindications • Size relative to breast • Multifocality • Early pregnancy • Inability to receive radiation • Connective tissue disease • Prior radiation

  7. Surgical Treatment • Radial Mastectomy • Historical – mid 70s • Breast, pectoralis, regional lymph nodes along axillary vein to costoclavicular ligament

  8. Surgical Treatment • Total Mastectomy axillary dissection • TM + Skin sparing w/reconstruction

  9. Reconstruction • Implants • Flaps • TRAM • Latissimus • DIEP

  10. Tissue Expanders

  11. TRAM

  12. Oncoplastic Surgery

  13. Preop 4 Days Postop

  14. Surgical Treatment • Sentinel Node Biopsy • The 1st node in the ipsilateral axilla to drain the tumor • >97% concordance rate

  15. Sentinel Lymph Node • Contraindications • Clinically positive lymph nodes

  16. 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

  17. 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

  18. Axillary Lymph Node Dissection • Indications • Clinically + nodes • + SLN • Level I & II

  19. Pathology • DCIS • Invasive Ductal • Invasive Lobular

  20. DCIS • 200% b/w 1983-1992 • 15-30% all screen-detected tumors • Diagnosis • Screening mammogram • Microcalcifications • Linear, heterogenous • Biopsy • Stereotactic • Open biopsy

  21. DCIS • Treatment • Partial Mastectomy • Followed by radiation +/- hormonal therapy • Total mastectomy • Diffuse disease • Multifocal • Persistent positive margins • Inability to give radiation • Patient choice

  22. DCIS • Sentinel Lymph Node Biopsy • Total Mastectomy • Palpable mass • Microinvasion

  23. 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

  24. Invasive Ductal Ca • Most common – 50-70% of invasive ca

  25. Invasive Lobular Ca • 10-15% of breast ca • Fail to form masses • Multifocal and multicentric • Bilateral – 20-29%

  26. ILC

  27. 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

  28. Regional Lymph Nodes (N) • NX: unable to assess • N0: negative • N1: 1-3 nodes • N2: 4-9 nodes • N3: >10 nodes

  29. Distant metastatsis: (M) • MX: unable to assess • M0: negative • M1: distant mets

  30. 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

  31. 5 year Survival

  32. Adjuvant Therapy • www.adjuvantonline.com • Assess the risks and benefits of additional therapy after surgery

  33. 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

  34. Prognostic Indicators • P53 – tumor suppressor gene • Overexpression of p53 • Poorer prognosis • Shorter disease-free and survival

  35. 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

  36. Adjuvant Therapy • Hormonal therapy • Antiestrogen therapy – Tamoxifen • Pre & post-menopausal women • Reduces risk of contralateral disease & mets • Side effects • Endometrial ca • Thromoembolic events

  37. 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

  38. Adjuvant Therapy • Chemotherapy • Size of tumor • Nodal status • ER/PR • HER2/Neu -- Herceptin

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