Breast Conference 9/7/2011

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• 60 AAF presenting with a left breast mass

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• 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)

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

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• PE:– Right breast:

• Within normal limits

– Left breast:• Nipple areolar complex replaced by tumor

• Central 4 cm mass

– Left axillary adenopathy

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• 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

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• Radiology:– MRI:

• Scheduled

– PET/CT:• Scheduled

LPLP

LPLP

LPLP

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• Pathology:– Breast lesion:

• infilrating ductal carcinoma, grade 3

• ER, PR, HER2 - pending

– Axillary lesion:• Metastatic ductal carcinoma

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• 60 F clinical stage IIIB, T4bN1M0

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• Surgery –– Mastectomy + ALND

• Medical oncology – – Neoadjuvant chemotherapy

• Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –

GM

• 68 AAF presenting with an abnormal mammogram

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• 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

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• PMH: HTN, DM, GERD, uterine fibroids • PSH: none• Meds: Nexium, Cozaar, NovoLog, Lantus• NKDA

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• PE:– Right breast:

• Palpable mass, 9 o’clock 8cm from nipple

– Left breast: Within normal limits – No axillary, supraclavicular or cervical

lymphadenopathy

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• 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

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• Pathology:– Right breast lesion:

• Infiltrating ductal carcinoma, grade 2

• ER(+) PR(+), HER2(-)

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• 68 F, clinical stage IA/IIA T1c/2N0M0

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• Surgery – • Partial mastectomy vs. mastectomy + SLNB

• Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –

DH

• 77 AAF presenting with an abnormal mammogram

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

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

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• 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

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• 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

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• Pathology:– Breast lesion 5 o’clock:

• Invasive mucinous carcinoma

• ER(+) PR(-), HER2(+1)

• Grade 2

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• 77 F, clinical stage IA, T1cN0M0 mucinous carcinoma

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• Surgery –– Biopsy of 10 o’clock lesion

– Partial mastectomy vs. mastectomy + SLNB

• Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –

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

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• Menarche: 12y• G3P3 (14y), breastfeeding: none• OCP: none• HRT: none• Postmenopausal (51y)

• Fhx: none• Shx: caffeine(+), tobacco(+)• Bra: 44D

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• 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

SS

• PE:– Right breast:

• s/p reduction mammoplasty

– Left breast:• s/p mastectomy, reconstruction• s/p excisional biopsy

– No axillary, supraclavicular or cervical lymphadenopathy

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• Radiology:– Diagnostic mammogram:

• 4/2011 – no significant abnormalities

– US:• 4/2011 - no significant abnormalities

– MRI:• Limited exam

– PET/CT: no evidence of metastasis

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• Pathology:– Breast lesion (excisional biopsy):

• Infiltrating lobular carcinoma

• 2.8cm

• Involving dermis and subcutaneous tissues

• Positive margins

• ER(+) PR(+), HER2(+2, -FISH)

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• 52 F, recurrent lobular carcinoma, left breast

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• Surgery –– Resection

• Medical oncology – • Radiation oncology – • Plastic surgery –

– Implant removal

• Genetics – • Psychosocial –

• 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

• 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

• 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

• Exclusion:– 3 or more positive SLN’s

– Matted nodes

– Gross extranodal disease

– Neoadjuvant therapy (hormonal or chemotherapy)

• Stratification:– Age (50y)

– ER status

– Tumor size (≤1cm, >1 and ≤2cm, >2cm)

• Disease characteristics were balanced between the groups

• Whole breast radiation• Adjuvant systemic therapy determined by physician

• Endpoints:– Primary:

• Overall survival (time from randomization until death from any cause)

• Occurrence of sugical morbidities

– Secondary:• Disease free survival (time from randomization to death or

first documented recurrence of breast cancer)

• Non inferiority study:– OS not less than 75% of that reported for ALND (80% at 5y,

based on literature)– HR for mortality less than 1.3 compared to ALND

• Base model:– SLND vs. ALND– Age– Adjuvant treatment

• Prognostic variables added individually

• Median follow up - 6.3 years• Extremely low mortality rate (94 deaths)

– Decision to terminate the study

– Even if all 1900 were accrued, it would take more than 20 years of follow up to reach 500 deaths

• None of the planned interim analyses were performed

• No significant difference in OS between the groups (92.5% vs. 91.8%)

• No significant difference in DFS between the groups (83.9% vs. 82.2%)

• HR (comparing OS between two groups) – – Unadjusted: 0.79

– Adjusted for adjuvant therapy and age: 0.87

• HR (comparing DFS between two groups) – – Unadjusted: 0.82

– Adjusted for adjuvant therapy and age: 0.88

• Locoregional recurrence – similar between groups– Axillary nodal recurrence rate 0.9% in SLNB only

group (total locoregional recurrence – 2.5%)• High rate of locoregional control with multimodality

therapy, even without ALND

• Higher rate of surgical morbidities in ALND group

• No benefit from addition of ALND in terms of:– Local control

– Disease free survival

– Overall survival

• Knowing the number of positive nodes is unlikely to change systemic therapy decisions

• ALND still standard practice:

– Mastectomy

– Lumpectomy without radiotherapy

– Partial breast irradiation

– Neoadjuvant therapy

– Prone position radiation