Breast cancer presentation 1 Dr.Ofail Nadeem Feb. 2014

1. Breast cancer
MANAGEMENT
PPTX. BY DR.OFAIL N.K.
FEB.2014

2. • Genetic councelling in breast cancer:
• 1-age<40 with personal Hx of BC
• 2- strong FAMILY Hx of BC at early age
• 3- women<50 with ashknasi-Jewish ancestry or polish
ancestry.
• 4- Relatives with known Hx of BRCA1,BRCA2 gene mut.
• 5- Hx of male BC
• 6- Pt. with 2 primary cancers.
• 7- Pt. with fallopian tube cancer.
• Staging:
• Stage I-------T1N0, T1Nmic
• Stage II------T1N1, T2N0, T2N1, T3N0
• Stage III------ All (N2,N3)M0, T3N1, All T4 M0
• Stage IV------ M1
N1mic=>0.2mm<2mm
pN1=1-3 LN
pN2=4-9 LN
pN3=>=10 LN

3. • Px:
• Axillary LN status, tumor size, grade , age, biological subtype as defined by
mol. Markers.
• ER,PR are growth regulating nuclear transcriptase factors
• Biological subtypes= Luminal = ER+Pr+
• 1- Luminal A=Er+Pr+Her2 –
• 2- Luminal B= ER+PR+Her2+
• 3- HER2= ER-PR-Her2+
• 4- Triple –ve(basal subtype) ER-PR-HER2-

4. • Early stage BC Treatment :
• For BCT combination of Sx, Rt, Ct.
• Sx:
• Lumpectomy is appropriate for DCIS and stage I , II invasive ductal or lobular ca.
• Mastectomy is indicated in all pt. who r not suitable for BCT.
• For invasive cancers SNB +- axillary dissection for the +ve node is routinely accomplished.
• Loco-regional recurrence after lumpectomy alone without adjuvant Rx is 40% for invasive dis.
• Role of additional axillary dissection for +ve SNB by IHC is controversial.
• RT:
• 1- as adj. after lumpectomy for DCIS & early stage invasive dis.
• 2- as adj. after mastectomy for high risk locally advanced dis. Including inflamm. BC.
• 3- as palliative tool for metastatic dis.
•

5. • Technique:
• WBI: EBRT delivered via 3DCRT or IMRT for DCIS and early stage invasive dis.
• Selected nodal irradiation to SC, axilla, IMN done wn there is pathologically documented
dis.
• PBI– using Brachy. Or EBRT is done in selected cases.
• For locally advanced dis. Irradiation to chest wall + sc+ axilla+ breast bed+- IMN is
planned.
• CT/Hormonal:
• 1- Adj. hormonal as chemo prevention in DCIS
• 2- Adj. hormonal used for low and intermediate RISK early dis.
• 3- Adj. CT for intermediate and high RISK early dis. And advanced dis.
• 4- Neo-adj. For locally advanced (for downstaging to allow BCT) and Inflamm. BC.
• First line active hormonal= Tam, arimidex, raloxifen
• First line chemo= anthracycline and taxane based multi-agent CT.
• First line Biologic Rx = Herceptin combined with multi-agent CT.
• Adj. CT is given prior to RT.

6. • 20% of all BC diagnosed as insitu. And generally made via mammography.
• LCIS is managed by active survillence but the option for bilateral mastectomy is based
upon individualized risk assessment under special circumstances e.g: BRCA1,2 mut. Or
strong family Hx.
• Local Rx for LCIS at Dx is not indicated only risk reduction strategies with chemoprevention
(Tam or Ral).
• Adj. RT is indicated in all subgroups of DCIS after lumpectomy.
• A recent single arm observational trial has indicated observation after lumpectomy , this
option is used only in a very selected group of elderly pt with DCIS.
• In DCIS Van-Nuys prognostic index ( I ,II ,III ) is used based on :
• size (<1.5mm, 1.6mm-4mm,>4mm)
• Grade( No necrosis, necrosis, grade III)
• Margin( >10mm, 1-9 mm, <1mm)
• Age( >60y, 40y-60y, <40y)
• If total score 4-6  may consider lumpectomy followed by active survillence.

7. • Adj. hormones in DCIS  Tam reduce recurrence of DCIS but it cannot replace RT in risk
reduction for local recurrence since recurrence rate was 6% after RT as compared with 14%
without.
• Summary:
• LCIS--Routine risk background observation +- Tam. active follow up
•
• - BRCA1,2 background bilateral mastectomies +- reconstruction +- Tam.-active
follow up.
• DCIS - Localised lumpectomy  Margin >2mm observe +- Tam. For low G. Small lesion
premenopausal.
•  Margin <2mm RT +- Tam.
• - diffused(microcalcif.) mastectomy with reconstruction active FU.
• For insitu dis with lumpectomy or mastectomy SNB is generally not indicated. Only in case of

8. Rx of early stage invasive BC: (I-IIa)
BCT( lumpectomy+RT).
Standard is WBI+- regional L.N. as defined by the extent of the disease.
Relative C/I for BCT:
1- Gross multicentric
2-Pg.
3- prior irradiation.
4- scleroderma
If mastectomy done in early disease RT usually is not indicated .
PBI: both WBI & PBI have equivalent local control and survival amomg appropriately selected Pt.

9. Summary for early BC radiation treatment:
Completed lumpectomy risk stratification
(histology(DCIS),invasive, N0-N1, menopausal status<50, Hormonal status, intent to receive CT.
 EarlyBC ( low risk, moderate risk, high risk)
 WBI 50-50.4 Gy In 25-28 f to entire breast followed by boost to lumpectomy site to total 60-66.4 Gy.
 PBI  1- accelerated 34Gy in 3.4 Gy/f Twice a day over 5 days using interstitial BT.
 2- 38.5 Gy in 3.85 Gy/f Twice for 5 days using 3DCRT
Use of risk stratification significantly reduce RR ; however in selected pt ( elderly, early stage, severe
morbidities, limited life span who have low risk of failure may attempt lumpectomy alone.

10. Early stage invasive ca.
localizedlumpectomy (-ve margin >2mm)+SNBWBI/PBIobserve+- TAM
**If recommended CT it is always delivered before RT
diffusedmastectomy+SNBCTRT for intermediate & high risk observe+-
TAM
To be continued next presentation……………………..