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Update on Breast Care
M. Bernadette Ryan, M.D., FACS
Head, Section of Surgical OncologyMay 18, 2009
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Outline
ANDI concept in benign breast disease
myatalgia
Breast imaging for screening & diagnosis
Breast Cancer
1/2009 update in NCCN guidelines
PBI
Oncotype Dx
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ANDI
Aberrations of normal development andinvolution
concept of benign disorders based onpathogenesis
First published by Hughes et al. in 1987 in
LancetEmbraced slowly in the USA
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ANDI - 2
Bi-directional framework
Horizontal 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)
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ANDI - 3
Normal Process Aberration Disease
Early
Reproductive
15-25 years
Lobular development
Stromal development
Nipple eversion
Fibroadenoma
Adolescent hyperplasia
Nipple inversion
Giant FA or multiple FAs
Gigantomastia
Subareolar abscess/
mammary duct fistula
Mature
Reproductive
25-40 years
Cyclic changes
Epithelia hyperplasia
of pregnancy
Cyclic mastalgia
Nodularity
Ductal papilloma
Bloody nipple discharge
Incapacitating mastalgia
Involution
35-55 years
Lobular involution
microcysts
Duct involution
dilation
sclerosis
Epithelial turnover
Macrocysts, adenosis,
sclerosing lesions
Ductal ectasia
Nipple inversion
Hyperplasia
Periductal mastitis/
abscess
Atypia
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Non - ANDI
Fat necrosis
Lactational abscesses
Contributions of smoking and oro-nipplecontact in non-puerperal abscesses
True neoplasms: phyllodes tumor, tubular
adenoma, lipoma, etc.
Mondors disease, diabetic mastopathy,
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Mastalgia
Probably hormonally related
usually cyclic and ends with menopause
responds to hormone treatment
Many theories:
increased estrogen
decreased progesteroneincreased prolactin
increased end-organ response
low prostaglandin E1 due to EFA deficiency
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Mastalgia - 2
Cyclic or non-cyclic breast pain
rule out chest wall source in non-cyclic
rule out significant lesion with imaginglocalized pain may be due to cancer, cyst,
sclerosing lesion
TreatmentReassurance if mild
Reassurance and primrose oil if moderate
Add drugs if severe (interferes with lifestyle)
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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%
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Breast Imaging
Mammograms
Ultrasound
MRI
PET scans
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Mammograms
Annual screening beginning at age 40
as young as 25 in high risk groups
upper limit not established
Digital mammogram may be betterespecially in young women and older
women with dense breastsMobile units may increase compliance
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Ultrasound
Initial diagnostic tool in women < 30-35with symptoms or palpable findings
Adjunct to mammographydiagnostic w/u
biopsy
May be used with mammogram to screenwomen at high risk or with dense breasts
no PRS showing survival benefit
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MRI - screening
Screen high risk women
BRCA 1 or 2, TB53 or PTEN mutations
First degree relative with above & untestedLifetime risk 20-25% by model based on FHx
Chest irradiation between ages 10 & 30
Role in women at lesser risk uncertainLCIS, AH, prior breast cancer, 15-20% risk
Not recommended in average risk women
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BRCAPRO
Free programs available
Need extensive family history
age of diagnosis of cancer as well as currentage or age of death of relatives
Calculates risk of harboring BrCa gene
and risk of developing breast & ovariancancer
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BRCAPRO - 2
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BRCAPRO - 3
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BRCAPRO - 4
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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
Pagets disease & isolated nodal metastases
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PET scan
NCCN recommends against use in stage I-III disease
Biopsy of equivocal or suspicious sites ismore likely to provide useful information
Lobular cancer frequently PET negative
Not useful to stage axillaoverall role in breast cancer unclear
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NCCN updates: DCIS
Minimum margin is still 1 mm
generally decreased failure rates with wider
margins up to 10 mmpost-excision mammogram if uncertainty
Recommends against sentinel node biopsy
reasonable for mastectomyExcision alone in low risk disease
radiation reduces local failure by 50%
equivalent survival
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NCCN: invasive cancer w/u
Genetic counseling if high risk
MRI optional
No PET or PET/CT
ER/PR and Her 2: use a reliable lab
Imaging to rule out metastases only ifsymptomatic
may consider in locally advanced disease
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NCCN - local treatment
Negative margin not defined
Focally + 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 inhibitorcan be cN0 or pN0
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NCCN - neoadjuvant
In Stage II & T3N1: only if pt wants BCS
Use in all other Stage III
Consider AI if post-menopausal & ER/PRpositive
cN+: confirm with needle biopsy
Level I & II dissection regardless of response
cN-: SNBx pre- or post-chemo
AxD if +
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NCCN - Radiation
Radiation can be with or without a boost
boost: < 50, close margins, + nodes or LVI
PBI discouraged outside of a trialPost-mastectomy XRT unchanged:
>/= 4 + nodes, >5 cm, margins < 1mm or
+consider in 1-3 nodes
Base XRT on initial clinical stage in
neoadjuvant patients
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Partial Breast Irradiation
Low risk women
age > 45, tumor
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PBI - 2
Treat tumor bed with 1 cm margins
Intra-op: single fraction
Post-op:BID x 10 fractions with total dose 34-38.5 Gy
MammoSite and other balloons
after loading cathetersexternal beam with 3D conformal/IMRT
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NCCN - adjuvant treatment
ER/PR + & Her 2 -: consider Oncotype
Still little data on chemo in women > 70
individualize considering co-morbidities
No prospective randomized data on use ofHerceptin in tumors < 1 cm & node -
but considered reasonable
Baseline & f/u DEXA scans if treat with AIor if menopause induced by treatment
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T1/2, ER/PR+, node -, her 2-
adjuvantonline
age, health, size, grade, nodes, ER/PR
odds of death or recurrence at 10 yearsodds of benefit from adjuvant treatment
Oncotype Dx
21 gene test on paraffin blocksrecurrence score: correlates with 10-year
relapse in tamoxifen-treated patients andwith benefit from chemotherapy
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Tailor X
PRT to determine value of Oncotype
Low RS (1-10): tamoxifen or AI
High RS (> 26): chemotherapy andtamoxifen or AI
Intermediate RS (11-25): randomize
between 2 treatments aboveOff study, 18-30 considered intermediate
about $3000 (some insurances cover test)
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Future
Greater effort to tailor treatment toindividual to avoid toxicity without
jeopardizing survivalPay for performance
accredited breast centers
adherence to national guidelinesvolume of breast cases
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