制定阮綜合醫療社團法人阮綜合醫院乳癌 (Breast Cancer) 治療共識

2006.03.09 制定阮綜合醫療社團法人阮綜合醫院乳癌 (Breast Cancer) 治療共識 2007.10.01 修訂 2009.04.22 修訂 2010.04.07 審閱 LCIS (Lobular Carcinoma in Situ) 2011.12.07 修訂 2012.03.07 修訂 Diagnosis Workup Risk Reduction Surveillance Biopsy was core needle biopsy (less than surgical biopsy) Perform surgical excision Ductal carcinoma in situ(dcis) or invasive cancer Manage per appropriate NCCN Guideline Lobular carcinoma in situ (LCIS) identified on breast biopsy.history and physical.diagnostic bilateral mammogram.pathology review.breast sonography Initial biopsy was surgical biopsy LCIS without other cancer. Counseling regarding risk reduction, see NCCN Breast Cancer Risk Reduction Guidelines Surveillance as per.nccn Breast Cancer Risk Reduction Guidelines.NCCN Breast Cancer Screening and Diagnosis Guidelines. LCIS-1

DCIS (Ductal Carcinoma in Situ) Diagnosis Workup Primary Treatment Lumpectomy d,e without lymph node Ductal Carcinoma in Situ (DCIS) Stage 0 Tis, N0, M0.History and physical exam.diagnostic bilateral mammogram.pathology review.determination of tumor estrogen receptor (ER) status.genetic counseling if patient is high risk surgery + whole breast rediation therapy (Category 1) g,h,i,j,k or Total mastectomy with or without sentinel node biopsy f,i ± reconstruction or See Postsurgical Treatment (DCIS 2) for hereditary breast cancer.breast sonography Lumpectomy d,e without lymph node surgery without radiation therapy (category 2B) h,j,k DCIS-1

DCIS (Ductal Carcinoma in Situ) DCIS Postsurgical Treatment Surveillance/Follow-up Risk reduction therapy for ipsilateral breast following breast conserving surgery: Consider Tamoxifen m for 5 years for:.patients treated with breast-conservation therapy( lumpectomy) and radiation therapy (category 1), n especially for those with ER-positive DCIS. The benefit of Tamoxifen for ER-nagative DCIS is uncertain.patients treated with excision alone n Risk reduction therapy for contralateral breast:.counseling regarding consideration of Tamoxifen for risk reduction (category 2B). m.interval history and physical exam every 6~12 mo for 5 years, then annually.mammogram every 12 mo (and 6~12 mo postradiation therapy if breast conserved category 2B ).If treated with Tamoxifen, monitor per NCCN Breast Cancer Risk Reduction Guidelines.Breast sonography every 3 mo for 1 year, then every 6 mo for 5 years. DCIS-2

DCIS (Ductal Carcinoma in Situ) DCIS-A

Invasive Breast Cancer Clinical Stage Locoregional Treatment Systemic Adjuvant Therapy Ductal, Lobular, Mixed, Metaplastic.Stage IA T1N0M0.Stage IB T0N1miM0 T0N1miM0.Stage IIA T0N1M0 T1N1M0 T2N0M0.Stage IIB T2N1M0 T3N0M0.Stage IIIA T0N2M0 T1N2M0 T2N2M0 T3N1M0 T3N2M0.MRM.Total mastectomy (TM) + ALND.TM + SLNB.+ RT (RT indicated: if 4 positiive axillary nodes or tumor > 5cm or margin positive or margin <1mm axillary node 1~3 positive is strongly consider).lumpectomy + ALND + RT.Lumpectomy + SLNB + RT (RT follow C/T when C/T indicated) Hormone receptor (-).T 0.5cm, pn0, no therapy.t 0.5cm, pn1mi, ±C/T.T0.6~1cm pn0 pn1mi, ±C/T.T>1cm N0, or any T node positive, +C/T Hormone receptor (+).T 0.5cm, pn0, ±HT (Hormone Therapy).T 0.5cm, pn1mi, +HT ±C/T.T0.6~1cm pn0 pn1mi, +HT ± C/T.T>1cm N0, or any T node positive, +HT ±C/T (HR+, Her0, N0, T>0.5cm pn0 可進行 RT-PCR assay, 健保不給付, 需病患同意自費 ) HER2(+), 除 T 0.5cm pn0 外需建議 + Trastuzumab( 健保只給付淋巴轉移 ) Tubular, Colloid.MRM.TM + ALND.TM + SLNB.+RT (RT indicated: if 4 positiive axillary nodes or tumor > 5cm or margin positive or margin <1mm axillary node 1~3 positive is strongly consider).lumpecomy + ALND + RT.Lumpecomy + SLNB + RT (RT follow C/T when C/T indicated) Hormone receptor (-).Repeat ER/PR status, if still negative, treat us usual breast histology Hormone receptor (+).Tumor size <1cm, N0, No therapy.tumor size 1~2.9cm, N0, ±HT.Tumor size 3cm, N0, or any T node IBC-1

Invasive Breast Cancer Clinical Stage Primary Treatment Locoregional Treatment Adjuvant Treatment Stage IIA, IIB, IIIA and fulfills criteria for breast conserving.neoadjuvant chemotherapy.ht (if ER positive).mrm.bcs + ALND.+ RT.+ HT (if ER positive).+ C/T LABC.Stage IIIA T0N2M0.Stage IIIB T1N2M0 T2N2M0 T3N1M0 T3N2M0 T4N0M0.Neoadjuvant chemotherapy Response.MRM + RT.BCS + ALND + RT No Response.+ C/T ±RT.+ C/T.+ HT (if hormone receptor positive).individualized Treatment T4N1M0 T4N2M0.Stage IIIC Any T N3M0.Stage IV Any T Any N M1 Hormone receptor (+).+ HT Hormone receptor (-), or HT refractory.+ C/T.+ Trastuzumab (if Her2 positive).+ RT.+ OP If no response.palliative Care IBC-2

Paget s Disease Clinical Presentation Workup Examination or imaging positive for breast lesion Clinical suspicion of Paget s disease a.clinical breast exam.diagnosis bilateral mammogram, ultrasound as necessary See PAGET-2 Examination and imaging negative for breast lesion PAGET-1

Paget s Disease Workup Treatment Breast and NAC biopsy negative Clinical follow-up Re-biopsy if not healing Examination or imaging positive for breast lesion Examination and Core biopsy of breast lesion and full thickness skin biopsy of involved nipple-areola complex (NAC) Full thickness skin Breast DCIS b and NAC Paget s Breast invasive cancer and NAC Paget s b,e Breast negative for cancer and positive NAC Paget s b NAC biopsy positive for Paget s b Mastectomy ± axillary staging c or Excision of breast tumor and excision NAC with whole breast radiation, consider boost to breast and NAC sites d Mastectomy+axillary staging (See BINV-D) or Excision of breast tumor and excision NAC+axillary staging (See BINV-D) with whole breast radiation, consider boost to breast and NAC sites Consider MRI and tissue sampling Mastectomy+axillary staging (See BINV-D) or Excision of NAC with whole breast radiation, consider boost to NAC sites d Appropriate systemic adjuvant therapy imaging negative for breast lesion biopsy of involved NAC NAC biopsy negative for Paget s Clinical follow-up Re-biopsy if not healing PAGET-2

Breast Cancer During Pregnancy Clinical Presentation Primary Treatment a Adjuvant Treatment a 1st trimester Discuss termination: Non-therapeutic Continuing pregnancy Mastectomy + axillary staging a,b,c Begin adjuvant chemotherapy in 2nd trimester a ±Adjuvant radiation therapy ±Adjuvant endocrine therapy Pregnant patient with confirmed breast cancer diagnosis (core biopsy preferred) No distant metastases on staging 2nd trimester/ Early 3rd trimester Mastectomy a or breast-conserving surgery + axillary staging a,b,c or Adjuvant chemotherapy a ± Adjuvant radiation therapy ± Adjuvant endocrine therapy Neoadjuvant chemotherapy a, mastectomy or breast-conserving surgery + axillary staging a,b,c post-partum ±Adjuvant radiation therapy ±Adjuvant endocrine therapy Late 3rd trimester Mastectomy a or breast-conserving surgery + axillary staging a,b,c Adjuvant chemotherapy a ± Adjuvant radiation therapy ± Adjuvant endocrine therapy PREG-1

Phyllodes Tumor Clinical Presentation Work Up Findings Treatment Fibroadenoma Observe Excisional biopsy b Phyllodes tumor includes benign, borderline and malignant Wide excision c without axillary staging Clinical suspicion of phyllodes tumor:.palpable mass.rapid growth.large size (>2cm).Imaging with ultrasound suggestive of fibroadenoma except for size and/or history growth.history and physical exam.ultrasound.mammogram for women 30y Invasive or in situ cancer Fibroadenoma or indeterminate See appropriate guidelines Excisional biopsy b See findings above Core needle biopsy a Phyllodes tumor Wide excixion c without axillary staging Invasive or in situ cancer See appropriate guidelines PHYLL-1

Phyllodes Tumor Recurrence Phyllodes Tumor Clinical Presentation Work Up Findings Treatment No metastatic disease Re-excision with wide margins without axillary staging Consider post-operative radiation d Locally recurrent breast mass following excision of phyllodes tumor.history and physical exam.ultrasound.mammogram.tissue sampling (histology preferred).consider chest imaging Metastatic disease Metastatic disease management following principles of soft tissue sarcoma PHYLL-2

Inflammatory Breast Cancer Clinical Presentation a Work Up Clinical pathologic diagnosis of IBC Staging T4d, N0-N3, M0.History and physical exam.cbc, Platelets.Liver function tests.pathology review b.determination of tumor ER/PR status and Her2 status c.bilateral diagnostic mammogram, ultrasound.breast MRI (optional).bone scan or fluoride PET/CT d.abdomen sonography.chest diagnostic CT.FDG PET/CT scan f (optional) Preoperative chemotherapy, g Anthracycline + Taxane (preferred) g if tumor Her2 positive, trastuzumab containing regimen but not concurrent with Anthracycline Response No response IBC-1

Inflammatory Breast Cancer Treatment Response Total mastectomy + level I/II axillary dissection + radiation therapy to chest wall and supraclavivular nodes (plus internal mammary nodes if involved, consider internal mammary nodes if not clinically involved) ± delayed breast reconstruction i Complete planned chemotherapy j regimen couse if not completed preoperatively plus endocrine treatment if estrogen receptor positive (sequential chemotherapy followed by endocrine therapy). Complete 1 year of trastuzumab if tumor Her2-positive Response See above pathway No response Consider additional systemic chemotherapy j and/or preoperative radiation No response Individualized treatment IBC-2