Philippine Society of Oncologists, Inc.

Transcription

1 Philippine Society of Oncologists, Inc. Rm. 803 orth Tower, Cathedral Heights Complex, St. Lukes Medical Center, E. Rodriguez Sr. Ave, Quezon City Tel/Fax o.: loc TeleFax o.: Officers ear 003 President Vice President Secretary Treasurer Members of the Executive Council Elizabeth. Arcellana-uqui, MD Francis O. Javier, MD Rey H. delos Reyes, MD Juanita Lu-Lim, MD Jonathan M. Asprer, MD Rafael S. Claudio, MD Divina B. Esteban, MD Domingo E. Ganzon, MD Luzviminda S. Kwong, MD Gil M. Vicente, MD Immediate Past President Miriam Joy C. Calaguas, MD

2 breast Cancer Algorithm for Suspected Breast Cancer Cpm 6 TH editio Breast CA Suspect History & Physical examination Biopsy: eedle Mammography on-palpable localization/ &/or Positive(+)? mass? specimen ultrasound radiography Palpable mass Biopsy: FAB Core Bx Open Bx Positive for malignancy? Treat 0 egative (-) Continue with recommended screening procedures 3 egative for malignancy 4 Excision biology 5 Positive(+)? 7 6 Treat egative(-) Figure 8 Continue with recommended screening procedures

3 CPM 6 TH EDITIO Algorithm for Histologically Confirmed on-invasive Breast Cancer breast Cancer Histologically Confirmed on-invasive Breast Cancer History Physical examination Mammography Pathology slide reviews 3 DCIS? 4 Margins negative? 5 Excision + RT or Total mastectomy 6 LCIS 7 widespread disease (> quadrants) 8 Total mastectomy (Level I-II evidence) 9 Observation Prophylactic bilateral simple mastectomy +/- breast reconstruction surgery (Level III Evidence) Figure

4 breast Cancer Algorithm for Histologically Confirmed Invasive Breast Cancer Cpm 6 TH editio Histologically Confirmed Invasive Breast Cancer History Physical examination Mammography CBC, platelets liver function tests Chest X-Ray Other symptom-directed tests (e.g. bone scan, ultrasound) Figure 3 3 Stage I? 4 MRM +/- breast reconstruction or BCS* + RT 5 Tumor < cm? 6 o adjuvant therapy 7 Stage II or IIIa? See Figure 3a 8 Tumor > cm 9 Consider adjuvant therapy: ER (-) S-phase >, 7% aneuploidy her -neu positive other negative prognostic indi-cator (Level I & II evidence) 0 Stage IIIB? See Figure 3b Hormone receptor (+)? Hormone Rx Chemotherapy 3 Stage IV 4 Hormone receptor (-) 5 Chemotherapy See Figure 3c * BCS (Breast Conservation Surgery) includes lumpectomy, quadrantectomy, node excision. Segmentectomy and axillary node dissection.

5 CPM 6 TH EDITIO breast Cancer Stage II or IIIA MRM +/- Breast reconstruction BCS* + RT Adjuvant RT for: > 4 nodes (+) T3 or higher odes (+)? Pre-menopausal? Chemotherapy 6 odes (-) Go to Figure 3 Box no Post-menopausal 8 HR (+)? 9 Hormone Rx Chemotherapy Chemotherapy Figure 3a * BCS - (Breast Conservation Surgery) includes lumpectomy, quadrantectomy, node excision. Segmentectomy and axillary node dissection.

6 breast Cancer Cpm 6 TH editio Stage IIIB eoadjuvant Chemotherapy** (Level II evidence) 3 4 Mastectomy &/or RT (Level II & III evidence) Adjuvant chemotherapy Figure 3b **eoadjuvant chemotherapy is Category evidence Stage IV 4 Any life-threatening conditions? HR (+)? 5 3 Chemotherapy +/- RT +/- Surgery (Level II Evidence) Hormonal RX &/or Chemotherapy (Level II Evidence) 6 7 HR (-) Chemotherapy (Level II Evidence) Figure 3c

7 CPM 6 TH EDITIO Breast Cancer Breast Cancer Working Group: breast Cancer Valorie Fullon-Chan, MD; Erlinda C. Gotera, MD; Mark Kho, MD; Rolando A. Lopez, MD; Elizabeth Arcellana- uqui, MD; Gaudencio P. Vega, MD; Teresa Liu-Dumlao, MD; Gregorio L. Galve, MD; Christopher Peña, MD Definition A malignancy of the glandular epithelium of the breast. Epidemiology. Incidence (Philippine Cancer Society - Manila Cancer Registry, 998) Most common cancer among Filipino Women 30./00,000 population (998 Statistics) Second most common cancer in both sexes combined Males: 0.5/00,000 population Male/Female Ratio = :05. Risk Factors Infertility Age-increased risk after 30 Post menopausal hormone replacement therapy Late pregnancy ulliparity Lubular Carcinoma in Situ (LCIS) Family history in first degree relatives Atypical epithelial hyperplasia Early menarche Late Menopause Genetics BRCA genes Prolonged contraceptive use High fat diet -3 alcoholic drinks/day Screening Monthly breast self-examination. Annual breast examination by a trained health worker for all child-bearing women. Annual mammography for women 50 years old and above. For certain high-risk women, baseline mammography at age 35 with repeat upon recommendation of attending physician. Genetic screening and counseling for high-risk patients or if appropriate. Diagnosis Good clinical history and physical examination Biopsy: FAB Core biopsy Open biopsy Recent Developments Chemoprevention - blood tests - liver ultrasound or CT scan - chest x-ray or CT scan - bone scan Antibody-directed treatments Bone marrow transplantation Pathology WHO Classification of Breast Carcinomas: oninvasive carcinoma (not otherwise specified [OS]) Ductal carcinoma in situ Lobular carcinoma in situ Invasive carcinoma Invasive ductal (OS) Invasive ductal carcinoma with extensive intraductal component Invasive lobular Mucinous Medullary Papillary Tubular Adenoid cystic

8 breast Cancer Secretory (juvenile) Apocrine Cribriform Paget disease of the nipple with invasive carcinoma without invasive carcinoma Carcinoma with metaplasia Inflammatory Squamous type Spindle cell type Cartilaginous and osseous type Mixed type Other(s) (specify) Pathology Report Grading ottingham Modification of Scarff-Bloom-Richardson Grading Scheme based on degree of tubule formation, nuclear grade and mitotic rate. Points are assigned to each parameter as follows: (A) Tubules: Tubule formation > 75% = Tubule formation = 0 to 75% = Tubule formation < 0% = 3 (B) uclei small and uniform = moderate variability in size and shape = marked increase in size and marked irregularity = 3 (C) Mitotic rate: scoring of the number of mitoses per 0 fields (at the tumor edge) (40x objective): 0 to 5 = 6 to 0 = greater than = 3 The histological grade is determined by adding the points: Grade I = 3 to 5 points Grade II = 6 to 7 points Grade III = 8 to 9 points Staging Definition of TM Primary Tumor (T) TX T0 Tis T Tmic Ta Tb Tc T T3 T4 Primary tumor cannot be assessed o evidence of primary tumor Cpm 6 TH editio Carcinoma in situ: intraductal carcinoma, lobular carcinoma in situ, or Paget's disease of the nipple with no tumor Tumor cm or less in greatest dimension Microinvasion 0. cm or less in greatest dimension Tumor more than 0. cm but not more than 0.5 cm in greatest dimension More than 0.5 cm but not more than cm in greatest dimension More than cm but not more than cm in greatest dimension Tumor more than cm but not more than 5cm in greatest dimension Tumor more than 5 cm in greatest dimension Tumor of any size with direct extension to chest wall or skin T4a T4b T4c T4c Regional Lymph odes () X 0 3 Distant Metastasis (M) MX Extension to chest wall Edema (including peau d' orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast Both (T4a and T4b) Inflammatory carcinoma Regional lymph nodes cannot be assessed (e.g. previously removed) o regional lymph node metastasis Metastasis to movable ipsilateral axillary lymph node(s) Metastasis to ipsilateral axillary lymph node(s) fixed to one another or to other structures Metastasis to ipsilateral internal mammary lymph node(s) Presence of distant metastasis cannot be assessed

9 CPM 6 TH EDITIO M0 M Stage Grouping o distant metastasis Distant metastasis [includes metastasis to ipsilateral supraclavicular lymph node(s)] Stage 0 Tis 0 M0 Stage I T 0 M0 Stage IIA T0 M0 T M0 T 0 M0 Stage IIB T M0 T3 0 M0 Stage IIIA T0 M0 T M0 T M0 T3 M0 T3 M0 Stage IIIB T4 Any M0 Any T 3 M0 Stage IV Any T Any M Prognostic factors (CAP Consensus Statement, 999) Category I - Factors proven to be of prognostic import and useful in clinical patient management TM Staging histologic grade histologic type mitotic figure counts hormone receptor status (ER, PR) Category II - Factors extensively studied biologically and clinically but prognostic import remains to be valdiated. c-erb- (Her-neu) proliferation markers lymphatic and vascular channel invasion p53 Category III - Factors not sufficiently studied to demonstrate prognostic value DA ploidy analysis microvessel density epidermal growth factor transforming growth factor-α bcl- ps cathepsin D Follow-Up/ Surveillance breast Cancer Periodic history and physical examination Annual mammography Symptom-directed investigations References:. Rosen PP, Oberman HA. Tumors of the Mammary Gland. Washington DC: Armed Forces Institute of Pathology; 993. Atlas of Tumor Pathology; 3rd series, fascicle 7.. Fleming LD, Cooper JS, et al eds. AJCC Manual for Staging of Cancer 5th ed. Philadelphia, Pa: Lippincott Raven; Fitzgibbons PL. Connolly JL, Page DL for the Cancer Committee, College of American Pathologists. Updated Protocol for the Examination of Specimens from Patients with Carcinomas of the Breast. Arch Pathol Lab Med. 000; 4: Connolly JL, et al. Association of Directors of Anatomic and Surgical Pathology Recommendations for the Reporting of Breast Carcinoma. Human Pathology 996;7(3): Sternberg SS. (ed.) Diagnostic Surgical Pathology ew ork: Raven Press, Page, David L. Prognostic Inidicators in Breast Cancer and who needs them. ASCP Reviews in Pathology Anatomic Pathology. 997;:35-5 ( refs.) 7. Rosai, Juan. Ackerman's Surgical Pathology. St. Louis Missourri, Mosby, 996;: College of American Pathologists: Cancer Protocols 000. CAP website. 9. Esteban, DB. Philippine Cancer Society: Manila Cancer Registry ( ) (Personal Com-munication). 0. Adjuvant Therapy for Breast Cancer, IH Consensus Development Conference Statement, ov CC Practice Guidelines: Version, Lecciones JA, Cristal-Luna GR. The Philippine Handbook of Clinical Oncology, st ed The Philippine Society of Oncologists.

10 breast Cancer Drugs Mentioned in the Treatment Guideline Cpm 6 TH editio This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems. Cytotoxic Drugs Alkylating Agents Cyclophosphamide Cyclophar Cytoxan Melphalan Alkeran Antimetabolites 5-Fluorouracil Faulding/DBL Fluorouracil Inj Fluracedyl Fluroblastin Capecitabine Xeloda Methotrexate Emthexate Faulding/DBL Methotrexate Pharmacia Methotrexate Inj Cytotoxic Antibiotics Doxorubicin Adriblastina RD Caelyx Faulding/DBL Doxorubicin HCl Pharmachemie-Doxorubicin Pharmacia Doxorubicin HCl Inj Rubidox Mitotic Inhibitors Docetaxel Taxotere Vinblastine Faulding/DBL Vinblastine Sulfate Inj Vincristine Faulding/DBL Vincristine Sulfate Inj Pharmachemie-Vincristine Pharmacia Vincristine Inj Other Cytotoxics Amifostine Ethyol Carboplatin Bonaplatin Faulding/DBL Carboplatin Paraplatin Gemcitabine Gemzar Paclitaxel Taxol Hormones & Antagonists in Malignant Diseases Anastrozole Arimidex Bicalutamide Casodex Goserelin Zoladex Flutamide Fugerel Prostanon Letrozole Femara Leuprorelin Luprolex Megestrol acetate Megace Pharmachemie-Megestrol Acetate Tamoxifen Cox Tamoxifen Kessar olvadex/olvadex-d Tamoplex Tamoxsta Zitazonium Immunosuppressants Exemestane Aromasin Others Trastuzumab Herceptin