Breast cancer staging update. Ekaterini Tsiapali, MD, FACS MedStar Regional Breast Program Site Director
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1 Breast cancer staging update Ekaterini Tsiapali, MD, FACS MedStar Regional Breast Program Site Director 1 1
2 Review of the AJCC 8 th edition breast cancer staging Review of genomic assays as stage modifiers Case presentation 2 2
3 Breast cancer facts Breast cancer is the most common cancer in women Breast cancer is the second most common cause of cancer death in women 252,000 new cases of invasive breast cancer and 40,000 breast cancer deaths in ,000 new cases of DCIS 1 in 8 women in the US will develop breast cancer 3 3
4 Breast cancer staging system The TNM system has been around since 1959 T = tumor N = nodes M = metastases Clinical and pathologic stage 4 4
5 Breast cancer staging system This is an anatomic stage A patient with a 1.5cm breast cancer and one positive sentinel node, will be staged as T1cN1a, Stage IIA regardless of the biology of the cancer BUT.all breast cancers are not created equal 5 5
6 Breast cancer subtypes Breast cancer is a very heterogeneous disease Subtypes have been identified: - Luminal A (ER/PR +, Her2 neu -, grade I-II) - Luminal B (ER/PR +, but lower, Her2 -, grade III) - Her2 positive - Basal (Triple negative) 6 6
7 Breast cancer staging system What is new in the 8 th edition of the AJCC staging? The tumor biology becomes part of the staging Clinical and pathologic prognostic stage Includes grade and receptor status 7 7
8 Breast cancer staging system 1.5cm breast cancer and one positive sentinel node Per 7 th edition: T1cN1a, Stage IIA Per 8 th edition: T1cN1a - If grade I, triple positive ---- stage IB - If grade II, ER(+), PR(-), Her2 (-) ---- stage IIA - If grade III, triple negative ---- stage IIB 8 8
9 Breast cancer staging system The new staging reflects prognosis better Lower stage does not mean less treatment is needed!! Lower stage means better prognosis with appropriate treatment 9 9
10 Breast cancer staging system T3N1 grade II, triple (+) tumor is stage IIA (formerly IIIA) This reflects better prognosis with - surgery - radiation - endocrine therapy - Her 2 targeted chemotherapy 10 10
11 Breast cancer staging system Incorporation of genomic assays in the staging Several multigene panel were considered: - Oncotype Dx - Mammaprint - Breast cancer index - Endopredict - PAM50 - IHC
12 Breast cancer staging system Oncotype Dx only incorporated so far, due to high quality data (Level I evidence) Oncotype Dx is a 21 gene assay performed on ER/PR (+), Her2 neu (-) tumors The result is the Recurrence Score Based on the RS ( low, intermediate, high) we determine risk of recurrence with endocrine therapy alone and benefit from chemotherapy 12 12
13 Breast cancer staging system Tailor Rx trial Low risk arm: ER/PR(+), Her2 (-) node negative 1.1-5cm or 0.6-1cm for grade II-III Oncotype RS <11 Overall survival 98% at 5 years with endocrine therapy only 13 13
14 Breast cancer staging system Based on the first results from thetailor Rx trial pt1-t2n0 tumors that are - ER/PR(+), Her2 (-) - RS<11 are given a pathologic prognostic stage IA 14 14
15 Case presentation 44yo AA patient presenting with a new left breast mass on mammogram Pat medical history: HIV positive, depression, hypertension, Stevens-Johnson syndrome, stenosis of larynx Past surgical history: tracheostomy 11/2016 Family history: unilateral breast cancer in the paternal grandmother at age 73 GYN history: G3P3, no breastfeeding, no OCP, premenopausal 15 15
16 Case presentation On exam she had a 2cm mass in the left breast 2:00 No adenopathy US-guided biopsy showed invasive ductal carcinoma grade 3, ER/PR/Her2neu negative (triple negative) ct1cn
17 Case presentation She had genetic testing---negative She had a left lumpectomy and SNB The pathology showed an 1.8cm focus of grade 3 IDC 4 sentinel nodes were negative for metastasis. pt1cn
18 18 18
19 Case presentation Adjuvant chemotherapy Adjuvant radiation 19 19
20 Case presentation 69yo AA patient presenting with a right breast mass on mammogram Past medical history: Hypertension, impaired fasting glucose, obesity, osteoarthritis, vitamin D deficiency Past surgical history: Abdominoplasty, left knee replacement 2014, right knee replacement 2015 Family history: no history of breast or ovarian cancer GYN history: G2P2, + breastfeeding, + OCPs, no HRT, postmenopausal 20 20
21 Case presentation On exam she had a 3cm mass in the right lower inner breast No adenopathy US-guided biopsy showed invasive ductal carcinoma, grade 2, ER/PR positive 90%, Her2 neu negative. ct2n
22 Case presentation She had right partial mastectomy and sentinel node biopsy The pathology showed a 2.8 cm focus of grade 2 invasive ductal carcinoma 1 of 3 sentinel nodes was positive pt2n1----stage IIB with AJCC 7 th edition 22 22
23 23 23
24 Case presentation Oncotype RS: 11-low Adjuvant endocrine therapy Adjuvant radiation 24 24
25 Case presentation Oncotype RS: 11-low Adjuvant endocrine therapy Adjuvant radiation 25 25
26 Case presentation 65yo Caucasian patient presenting with a new area of left breast architectural distortion on mammogram Past medical history: Hyperlipidemia, hypertension, Diabetes type II, Cushing s s/p adrenalectomy Past surgical history: Tubal ligation, left adrenalectomy 2010, bilateral breast excisions-benign Family history: negative for breast or ovarian cancer, no Ashkenazi Jewish ancestry GYN history: G0P0, +OCPs, +HRT Premarin for 10 years, post-menopausal 26 26
27 Case presentation On exam there were no palpable masses or adenopathy US guided biopsy showed invasive mammary carcinoma, low grade, ER positive >90%, PR positive >10%, and HER2neu 2+ by IHC, FISH amplified (triple positive tumor) ct1bn
28 Case presentation She had a left breast NL lumpectomy and SNB The pathology showed a 1.5cm focus of grade 2 invasive ductal carcinoma 2 of 4 SN positive pt1cn1a --- stage IIA with the AJCC 7 th edition 28 28
29 29 29
30 Case presentation Adjuvant chemotherapy to include Her2 targeted agent Adjuvant radiation Adjuvant endocrine therapy 30 30
31 Questions? 31 31
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