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SMALL CANCER AND BRCA MUTATION
Krishna B. CLOUGH
SMALL CANCER AND BRCA MUTATION CLINICAL CASE
Krishna B. CLOUGH
Mrs S.G.
l 34 yrs, journalist , 2 children
l Mother + Aunt + Greataunt Breast Cancer
l BRCA 2 Muta=on
FIRST CONSULTATION : ADVICE
l 1.75m 60 kgs small breasts 85 B Smoker 10 cig/j
l T0N0
l Mammo US: normal
l Seeks your advice
WHAT DO YOU RECOMMEND ?
l ProphylacOc oophorectomy
l ProphylacOc Mastectomy
l TAM
l Other
MRI
l LeR Breast : Nodular image lower pole
l 8 mm round non suspicious ACR 3
l SuggesOons : l MRI guided biopsy
l Control MRI 4/6 months
l Wide local excision
l Other
2nd LOOK ULTRASOUND
l 2nd look US: 8 mm image lower pole ACR 3
l Biopsy : Lobular Neoplasia LIN 2+3
l SuggesOons ? l TAM
l Wide local excison
l WLE + frozen secOon +/-‐ SNB
l Mastectomy uni/bilatéral
WL EXCISION frozen sec=on + SNB
l Invasive Ductal Carcinoma 10mm
l Grade I , low mitoOc index
l ER 100 % RP 100 % HER 2 1+ Ki67 15 %
l Free margins > 10mm
l 3 SN negaOve
1. ADJUVANT TREATMENT ?
l TAM ?
l LH-‐RH Analogs + TAM ?
l LH-‐RH Analogs + TAM ?
l Chemotherapy ?
TAM no other systemic therapy
2. LOCAL TREATMENT ?
l Radiotherapy
l M + IBR (uni/bilateral)
l Nipple sparing M + IBR
l Nipple sparing M + IBR + PBIrradiaOon leR areola
CONSERVATIVE TREATMENT and MUTATION ?
l BRCA+ vs controls : no increase in LR (7yrs) l Contralateral breast : RR 3,5
l 50% risk reducOon (ipsi and controlat) by: l Oophorectomy
l TAM / CT
BILAT. NIPPLE SPARING M + IntraopRT LeU areaola
l Postop unevenful Leaves D3
l Drains removed D10 D14
l D30 : All OK ... but
l Calls for bilat discharge
l Thin skin, « blueish »
D 30: BILATERAL IMPLANT EXPOSURE
SUGGESTIONS ?
l Lavage drainage + implant replacement
l Lavage drainage + Expanders
l Accelular Dermal Matrix
l Bilateral Lat. Dorsi
l Other
BILATERAL IMPLANT REMOVAL 8 MONTHS LATER …
Demands Reconstruction
SUGGESTIONS ?
l Implants
l Expanders
l Bilatéral Lat. Dorsi
l Other flap
l Other
3 LIPOFILLINGS L1 200 cc L2 250cc L3 280 cc
SUGGESTIONS ?
l Implants
l Expanders
l Bilatéral Lat. Dorsi
l Other flap
l Other
IMPLANT 225 CC anat L4 300cc
3. OVARIES : PROPHYLACTIC SURGERY ?
1. Follow up: modali=es ? 1. CA 12.5
2. US
3. MRI
2. Bilateral SO 1. Now
2. 45
3. 50
SEE-FIM
SEE-FIM protocol
