Published on March 12, 2014
Breast cancer MANAGEMENT PPTX. BY DR.OFAIL N.K. FEB.2014
• 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
• 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-
• 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. •
• 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.
• 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.
• 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
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.
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.
Early stage invasive ca. localizedlumpectomy (-ve margin >2mm)+SNBWBI/PBIobserve+- TAM **If recommended CT it is always delivered before RT diffusedmastectomy+SNBCTRT for intermediate & high risk observe+- TAM To be continued next presentation……………………..
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