Breast cancer incidence. Multidisciplinary Management in Breast Cancer. Outline. The Breast 11/10/2014. Incidence of breast cancer in Thailand

Transcription

1 Multidisciplinary Management in Breast Cancer October 8 th,2014 Ongart Somintara,M.D. Surgical Oncologist Department of Surgery, Khon Kaen University Breast cancer incidence USA : 2014 Estimate new case 232,670 (14% of all cancer) Estimate death 40,000 Incidence : per 100,000 women per year Lifetime risk of developing cancer: 12.3 % National Cancer Institute. SEER Stat Fact Sheets: Breast Cancer Outline Incidence of breast cancer in Thailand Introduction & Incidence Case demonstration & Discussion Breast imaging Surgical treatment of breast cancer Pathological report in breast cancer Systemic treatment in breast cancer Radiation treatment in breast cancer Pattarawin Attasara TK. Cancer incidence in Thailand. Cancer in Thailand Volume VII, ;VII. The Breast Srinagarind Hospital, 2012 Surapon Weingnon et al. Hospital base tumor registry Srinagarind Hospital report

2 Cancer in female, Srinagarind A woman of 47-year Single Premenopause, From Roiet CC: Abnormal mammogram 2 mo. PTA PI: 2 mo PTA found abnormal mammogram from check up, Impalpable mass over both breast, Not tender, No discharge per nipple Surapon Weingnon et al. Hospital base tumor registry Srinagarind Hospital report Age-specific incidence rate of breast cancer in Thailand Relevant history Menarche 15 yr G0P0 No previous illness No history of pills or radiation exposure No familial history of breast cancer or ovarian cancer Pattarawin Attasara TK. Cancer incidence in Thailand. Cancer in Thailand Volume VII, ;VII. Physical examination - Impalpable mass - Impalpable axillary lymph node 2

3 Pathological report MMG/US Screening in breast cancer Breast, left, needle biopsy : Intraductal carcinoma MMG/US report A cluster of pleomorphic calcifications at the outer lower part of left breast, BIRADS 4b Surgical treatment in breast cancer Stereotactic biopsy (26/9/56) Breast Cancer Treatment Aims Curative Treatment Improve or maintain quality of life Minimize side effects and complications of treatment 3

4 Treatment Modalities Locoregional treatment Surgery Radiation Systemic treatment Chemotherapy Hormonal treatment Targeted therapy Breast Conserving Surgery (BCS) Lumpectomy Wide excision Quadrantectomy Surgery of Breast Cancer s- Radical mastectomy 1970s-MRM 1990s-BCS 2010s-NAC c Reconstructi on Surgical treatment in breast cancer Surgery Breast Mastectomy ( skin sparing, nipple sparing mastectomy) Breast conserving surgery (lumpectomy, wide excision, quadrantectomy) Mastectomy with reconstruction Autologous tissue reconstruction (TRAM,LD flap) Implant base reconstruction (Silicone,Saline) Axillary LN Sentinel lymph node biopsy Axillary lymph node dissection B.Fisher, et al. N Engl Med,2002;347: ) 4

5 Absolute Contraindications for BCS Breast conserving surgery Margins involved with invasive carcinoma or DCIS after repeated resection The minimal acceptable surgical margin no ink on invasive tumour Minimum clearance of 1 mm St.Gallen guideline 2013 BCS contraindication Rt BCS with contralateral mastopexy NCCN 2014 Breast Conserving Surgery (BCS) Mastectomy Total Mastectomy 5

6 Mastectomy Indication Contraindication for BCS Patient s desire Total Mastectomy Principle of breast reconstruction Oncologic safety is the first..... The last is cosmetic outcome Mastectomy with reconstruction Skin sparing mastectomy Transverse Rectus Abdominis Myocutaneous Flap (TRAM flap) after Mastectomy Nipple sparing mastectomy 6

7 Transverse Rectus Abdominis Myocutaneous Flap (TRAM flap) Nipple sparing mastectomy with TRAM flap - Proper in all breast size - Breast ptosis patient Contraindications TRAM flap Previous abdominoplasty,liposucton Obesity (BMI 30) Previous abdominal surgery e.g. Kocher incision Prior radiation therapy at chest wall or mediastinum Smoking (must stop 6 mo before surgery) Skin sparing mastectomy with TRAM flap Bilateral TRAM 7

8 TRAM flap (Scarless over breast) Contraindications Previous lateral thoracotomy History of radiation therapy to the axilla Significant breast ptosis (Relative contraindications) Very large breast in patient who dose not desire reduction Case ผศ.นพ.ดำเน น วช โรดม เป นผ ผ ำต ด Latissimus Dorsi (LD) flap Latissimus Dorsi (LD) flap LD flap Small to medium size of breast Moderate degree of breast ptosis Abdominal donor site unavailable Salvage of previous breast reconstruction 8

9 LD flap Axillary Lymph Node Dissection % have at least one complication after surgery lymphedema numbness a persistent burning sensation infection, and limited movement of the shoulder Sentinel lymph nodes in breast cancer after 10 years. Lancet Oncol Aug;7(8): Surgery at Axilla Axillary Lymph Node Dissection Sentinel Lymph Node Biopsy Axillary Lymph Node Dissection In early stage breast cancer Only % have lymph node metastasis But almost 40-80% have complication from axillary lymph node dissection Sentinel lymph nodes in breast cancer after 10 years. Lancet Oncol Aug;7(8): Axillary Lymph Node Dissection Sentinel lymph node 9

10 Sentinel Lymph Node Biopsy As sentinel lymph node biopsy (SLN) has become a widely accepted alternative to axillary lymph node dissection (ALND) Lymphoscintigraphy NCCN 2014 SLNBx is prefer method for axillary lymph node staging Sentinel lymph node(s) in breast cancer Sentinel lymph nodes in breast cancer after 10 years. Lancet Oncol Aug;7(8): Sentinel Lymph Node Biopsy Sentinel lymph node biopsy (SLNB) NCCN Isosulfan Blue Dye Op : Nipple sparing mastectomy with SLNB with TRAM flap reconstruction 10

11 Pathological finding 2 weeks after operation Pathology Breast tissue, sentinel nodes and subareolar tissue, left, mastectomy: Ductal carcinoma in situ. Tumor size less than 1 cm located in lower inner quadrant. No tumor cell is seen in 2 sentinel nodes and subareolar tissue. 2 mo after operation Tumor biology Hormone receptor - ER : Staining 70% - PR : Staining 50% - Ki 67 : Staining 20% - Her 2 : negative 11

12 Conclusion Female 47 yrs., premenopausal DCIS pt 1 cm = ptis pn negative = N0/2 Free margin ER =positive 70 % PR = positive 50 % Her 2= negative Ki-67 = Positive 20% ptis N0 M0 = Stage 0 A woman of 27 Single From Kalasin CC: Palpable Rt breast mass 2 week PI: 2 week PTA Rt breast mass detected, Not tender, movable Excisional biopsy at provincial hospital was done and refered to Srinagarind Hospital Pathological report Invasive ductal carcinoma Further management? Modified Bloom Richardson grade III Tumor size 2.2 cm Margins are involved Adjuvant treatment Locoregional treatment - Systemic treatment Chemotherapy: - Hormonal therapy: Tamoxifen (chemoprevention) Targeted therapy: - Menarche 14 yr No previous illness Relevant history No history of pills or radiation exposure No familial history of breast cancer or ovarian cancer 12

13 Physical examination Plan of treatment - Surgical scar 2 cm in length at UIQ - Impalpable axillary and cervical node both side BCS (Reexcision with SLNBx) Mastectomy, SLNBx Mastectomy, SLNBx with immediate breast reconstruction Review slide Diagnostic imaging MMG/US? Breast MRI? Pathological report MRI breast Poorly differentiated infiltrating ductal carcinoma Modified Bloom Richardson grade II Tumor size 2.2 cm No intraductal component No angiolymphatic invasion Margins are involved ER 60%, PR 70%, Ki67= 25%, HER2 negative Residual mutifocal cancer at 2 and 3 O clock of Rt breast Focal overlying skin involvement Inframammary lymph nodes at UOQ of Rt breast and bilateral axillary LNs with preserved hilar fat Ductal ectasia at bilateral subareolar regions and multiple cysts in Rt breast, fibrocystic change 13

14 Operation : Reexcision with SLNB (BCS) 40x Pathological finding ER 100x PR 100x Her-2 400x Ki x SLNBx Negative for malignancy (0/4) Pathological report Invasive ductal carcinoma, grade2 Present of multiple nodules 1.5 cm and 0.5 cm in diameter Inferior margin 4 mm Other margin free ER 80% PR 80% HER2 negative Ki 67=30% SLNB negative 0/4 14

15 Pathology report Last follow up pt2nomo Stage IIA Luminal B Echocardiography EF= 62% Post operative A woman of 53-year Married From Nakornpranom CC: Palpable Rt breast mass 4 week PI: 4 week PTA Rt breast mass detected, Not tender, movable Excisional biopsy at provincial hospital was done and refered to Srinagarind Hospital Pathological report Further management Adjuvant systemic treatment? Adjuvant radiation? Invasive ductal carcinoma with DCIS Modified Bloom Richardson grade III Tumor size 2.3 cm Margins are involved 15

16 Relevant history Menarche 17 yr G2P2 First child 20-year No history of OC No previous illness No history of pills or radiation exposure No familial history of breast cancer or ovarian cancer A spiculated mass at upper outer of the right breast associated with multiple intralesional pleomorphic calcifications causing architectural distortion and thickening of overlying skin of the right breast BI-RADS CATEGORY 6 : Known Biopsy-Proven Malignancy Physical examination Palpable mass beneath sx scar, 2.5 cm in size, with palpable right axillary LN, 1.5 cm in size,movable Review slide + Hormonal receptor Breast, right, paraffin tissue block :- Invasive ductal carcinoma, grade III. The immunohistochemical staining result ER negative (0%) PR negative (0%) HER-2 score 0 Ki-67 positive 50% Metastasis work up US abdomen : negative CXR : negative An ill defined mass with pleomorphric calcification 93 16

17 Operation Right MRM (3/1/2556) Conclusion Female 53 yrs. perimenopausal IDC grade 3 pt cm = pt2 pn positive 2/14 = N1 Free margin ER = negative PR = negative Her 2= negative Ki-67 = Positive 80 % pt2 N1M0 = Stage 2 Pathological result Breast mass, right with axillary lymph node, MRM: - Invasive ductal carcinoma grade III with comedocarcinoma. - Tumor size 2.5 cms, located at upper outer quadrant. - Lymphatic channel and surrounding adipose tissue show tumor invasion. - No Paget's disease. - Deep resected surgical margin show no malignant cell involvement. - Axillary lymph nodes (2/14) show tumor metastasis Further management Systemic treatment? Locoregional treatment? Immunohistrochemistry staining Additional report; Hormone receptor of block E: - ER : Staining 0% - PR : Staining 0% - Ki 67 : Staining 80% - Her 2 : Svore 1+ (negative) Adjuvant treatment Systemic treatment Chemotherapy: 4AC 4T ( 23/01/ /06/2556) Hormonal therapy:- Targeted therapy: - Locoregional treatment RT 5,000 Gy ( 4/08/2556 9/09/2556) 17

18 1/04/ wk PTA Headache, no vomiting Pupill 3 mm, RTL BE Left side motor grade 4+ Brain tumor at right posterior parietal lobe 106 PE CT Brain finding There is a large peripheral enhancing rim and enhancing nodule at right corticomedullary junction of right parietal lobe about 4x4.5 cm in and enhancing nodule about 1.3 cm in size. Marked perilesional white mater edema is observed. Shifting of midline structure to left side is noted. Effacement of right lateral ventricle is seen. IMPRESSION: Brain metastasis at right parietal lobe is likely. MRI finding CT & MRI Brain -Enhancing mass at right parieto-occipital region with perilesional edema at right parieto-occipital region and splenium of corpus callosum with shift of midline structure to the left and effacement of occipital horn of right lateral ventricle, necrotic brain metastasis should be considered. 18

19 CT finding Metastatic work up Consistent with local tumor recurrent and metastasis to right chest wall, right axillar and right internal mammary node. Pneumonitis at right middle lobe or chronic bronchitis. CXR (1/04/57) 113 Tc 99m uptake at craniotomy site of right parietal bone Rt. axillary node metastasis Rt. Internal mammary node metastasis Bone scan finding 1. No definite evidence of distant bone metastasis. 2. A new bone lesion at right parietal bone corresponds to history of post-craniotomy which bone invasion in this area cannot be evaluated

20 Operation Craniotomy with tumor removal (7/05/57) Further management? Pathological report Brain tissue, right parietal, tumor removal Consistent with invasive ductal carcinoma, metastasis. Consult RT WBRT Management Systemic treatment Xeloda Hormone receptor ( ) Hormone receptor of S A: -ER : Staining 0% (negative) -PR : Staining 0% (negative) -Ki 67 : Staining 20% -Her 2 : Score 2+ (equivocally staining). Conclusion Locoregional treatment Surgery Breast Breast conserving surgery (lumpectomy, wide excision, quadrantectomy) Mastectomy Mastectomy with reconstruction Autologous tissue reconstruction (TRAM,LD flap) Implant base reconstruction (Silicone,Saline) Axillary LN Sentinel lymph node biopsy Axillary lymph node dissection Radiation Breast conservative surgery Post mastectomy (T 5 cm,ln 4 nodes) 20

21 Conclusion Systemic treatment Chemotherapy Neoadjuvant CMT Adjuvant CMT Palliative CMT Hormonal treatment Tamoxifen premenopause, postmenopausal Aromatase inhibitor (anastrozole,letrozole,exemestane) postmenopause Targeted therapy Trastuzumab, Pertuzumab, Lapatinib (Targeted to Her2) Everolimus (mtor inhibitor) Thank you Thank you 21

22 Systemic Treatment Recommendations for Subtypes Subtype Type of therapy Notes on therapy MMG Luminal A Endocrine therapy alone Few require cytotoxics (e.g. high nodal status or other indicators of risks) Luminal B (HER2 negative) Luminal B (HER2 positive) HER2 positive (non luminal) Triple Negative (ductal) Endocrine ± cytotoxics Cytotoxics+anti- HER2+endocrine therapy Cytotoxics + anti-her2 Cytotoxics Inclusion and type of cytotoxics may depend on level of endocrine receptor expression, perceived risk and patient preference No data are available to support omission of cytotoxics in this group Patients at very low risk (e.g. pt1a and node negative) may be observed without systemic adjuvant therapy St Gallen International. Expert Consensus Ann Onc 2011 MMG US MMG CT brain (1/4/57) 22

23 MRI Brain (10/4/57) Bone scan (22/7/57) CT Chest with upper abdomen CT Chest with upper abdomen 23