Update on Breast Care
M. Bernadette Ryan, M.D., FACSHead, Section of Surgical Oncology
May 18, 2009
Outline
ANDI concept in benign breast disease myatalgia
Breast imaging for screening & diagnosis
Breast Cancer 1/2009 update in NCCN guidelines PBI Oncotype Dx
ANDI
Aberrations of normal development and involution
concept of benign disorders based on pathogenesis
First published by Hughes et al. in 1987 in Lancet
Embraced slowly in the USA
ANDI - 2
Bi-directional frameworkHorizontal axis: main clinical
presentation normal - aberration - disease
Vertical axis: stages in development early reproductive (15-25 years) mature reproductive (25-40 years) involution (35-55 years)
ANDI - 3
Normal Process Aberration Disease
EarlyReproductive15-25 years
Lobular developmentStromal developmentNipple eversion
FibroadenomaAdolescent hyperplasiaNipple inversion
Giant FA or multiple FAsGigantomastiaSubareolar abscess/ mammary duct fistula
MatureReproductive25-40 years
Cyclic changes
Epithelia hyperplasia of pregnancy
Cyclic mastalgiaNodularityDuctal papilloma
Bloody nipple discharge
Incapacitating mastalgia
Involution35-55 years
Lobular involution microcystsDuct involution dilation sclerosisEpithelial turnover
Macrocysts, adenosis, sclerosing lesions
Ductal ectasiaNipple inversionHyperplasia
Periductal mastitis/ abscessAtypia
Non - ANDI
Fat necrosisLactational abscessesContributions of smoking and oro-nipple
contact in non-puerperal abscessesTrue neoplasms: phyllodes tumor,
tubular adenoma, lipoma, etc.Mondor’s disease, diabetic mastopathy,
…
Mastalgia
Probably hormonally related usually cyclic and ends with menopause responds to hormone treatment
Many theories: increased estrogen decreased progesterone increased prolactin increased end-organ response low prostaglandin E1 due to EFA deficiency
Mastalgia - 2
Cyclic or non-cyclic breast pain rule out chest wall source in non-cyclic rule out significant lesion with imaging
localized pain may be due to cancer, cyst, sclerosing lesion
Treatment Reassurance if mild Reassurance and primrose oil if moderate Add drugs if severe (interferes with lifestyle)
Mastalgia - 3
Cyclic Pain Non-Cyclic
Primrose oil1000-1500 BID
44-58% 27%
Danazol200-400 mg QD
70-80% 30%
Tamoxifen10 mg QD
80-90% 56%
Bromocriptine2.5 mg BID
47% 20%
Placebo 10-40% 10-40%
Breast Imaging
MammogramsUltrasoundMRIPET scans
Mammograms
Annual screening beginning at age 40 as young as 25 in high risk groups upper limit not established
Digital mammogram may be better especially in young women and older women with dense breasts
Mobile units may increase compliance
Ultrasound
Initial diagnostic tool in women < 30-35 with symptoms or palpable findings
Adjunct to mammography diagnostic w/u biopsy
May be used with mammogram to screen women at high risk or with dense breasts no PRS showing survival benefit
MRI - screening
Screen high risk women BRCA 1 or 2, TB53 or PTEN mutations First degree relative with above & untested Lifetime risk 20-25% by model based on FHx Chest irradiation between ages 10 & 30
Role in women at lesser risk uncertain LCIS, AH, prior breast cancer, 15-20% risk
Not recommended in average risk women
BRCAPRO
Free programs availableNeed extensive family history
age of diagnosis of cancer as well as current age or age of death of relatives
Calculates risk of harboring BrCa gene and risk of developing breast & ovarian cancer
BRCAPRO - 2
BRCAPRO - 3
BRCAPRO - 4
MRI - diagnostic
Define extent of disease before BCS leads to higher mastectomy rate without
clear benefit in local control or survivalDefine extent of disease before & after
neoadjuvant therapy Look for additional primariesLook for occult primary
Paget’s disease & isolated nodal metastases
PET scan
NCCN recommends against use in stage I-III disease “Biopsy of equivocal or suspicious sites is
more likely to provide useful information”Lobular cancer frequently PET negativeNot useful to stage axillaoverall role in breast cancer unclear
NCCN updates: DCIS
Minimum margin is still 1 mm generally decreased failure rates with wider
margins up to 10 mm post-excision mammogram if uncertainty
Recommends against sentinel node biopsy reasonable for mastectomy
Excision alone in “low” risk disease radiation reduces local failure by 50% equivalent survival
NCCN: invasive cancer w/u
Genetic counseling if high riskMRI optionalNo PET or PET/CTER/PR and Her 2: use a reliable labImaging to rule out metastases only if
symptomatic may consider in locally advanced disease
NCCN - local treatment
Negative margin not definedFocally + margin acceptable if no EIC
consider higher XRT boost to tumor bed> 70, T1N0M0, ER/PR +
reasonable to treat with lumpectomy & tamoxifen or an aromatase inhibitor
can be cN0 or pN0
NCCN - neoadjuvant
In Stage II & T3N1: only if pt wants BCSUse in all other Stage IIIConsider AI if post-menopausal & ER/PR
positivecN+: confirm with needle biopsy
Level I & II dissection regardless of responsecN-: SNBx pre- or post-chemo
AxD if +
NCCN - Radiation
Radiation can be with or without a boost boost: < 50, close margins, + nodes or LVI
PBI discouraged outside of a trial Post-mastectomy XRT unchanged:
>/= 4 + nodes, >5 cm, margins < 1mm or + consider in 1-3 nodes
Base XRT on initial clinical stage in neoadjuvant patients
Partial Breast Irradiation
Low risk women age > 45, tumor </= 3 cm, negative
margins & nodes (? DCIS)Potential advantages
shorter treatment course can give prior to chemotherapy may improve access to BCS
? better cosmesis Need PRTs to compare failure rates
PBI - 2
Treat tumor bed with 1 cm marginsIntra-op: single fractionPost-op:
BID x 10 fractions with total dose 34-38.5 GyMammoSite and other balloonsafter loading cathetersexternal beam with 3D conformal/IMRT
NCCN - adjuvant treatment
ER/PR + & Her 2 -: consider OncotypeStill little data on chemo in women > 70
individualize considering co-morbiditiesNo prospective randomized data on use
of Herceptin in tumors < 1 cm & node - but considered reasonable
Baseline & f/u DEXA scans if treat with AI or if menopause induced by treatment
T1/2, ER/PR+, node -, her 2-
adjuvantonline age, health, size, grade, nodes, ER/PR odds of death or recurrence at 10 years odds of benefit from adjuvant treatment
Oncotype Dx 21 gene test on paraffin blocks recurrence score: correlates with 10-year
relapse in tamoxifen-treated patients and with benefit from chemotherapy
Tailor X
PRT to determine value of OncotypeLow RS (1-10): tamoxifen or AIHigh RS (> 26): chemotherapy and
tamoxifen or AIIntermediate RS (11-25): randomize
between 2 treatments above Off study, 18-30 considered intermediate
about $3000 (some insurances cover test)
Future
Greater effort to tailor treatment to individual to avoid toxicity without jeopardizing survival
Pay for performance accredited breast centers adherence to national guidelines volume of breast cases
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