Pathological assesment of carcinoma breast after neoadjuvant chenotherapy.

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Pathological assesment of carcinoma breast after neoadjuvant chenotherapy.

  1. 1. Dr. Imrana Tanvir Assistant Prof. FMH, Lahore.
  2. 2. Neoadjuvant therapy (NAT) Patients given systemic agents before definitive surgical removal of the tumor.
  3. 3. Origin of Preoperative Therapy Initially neuadjuvant therapy (NAT )was used for locally advanced tumors only. As a result 10 yrs survival improved more than 25% This survival rate varied with different therapies.
  4. 4. Currently, neoadjuvant therapy (NAT) is being used for earlier-stage operable breast carcinoma and likely to become standard of care.
  5. 5. NSABP Protocol B-18 have shown : Neoadjuvant or adjuvant therapy gives identical results for: -loco-regional control -metastasis-free survival.
  6. 6. So why not prefer neoadjuvant over adjuvant?
  7. 7. Major advantages of neoadjuvant therapy.  Increased eligibility for breast conservation.  The efficacy of systemic therapy can be assessed in vivo.  Tumor response provides important clinical information .  Allow more rapid assessment of new treatments.  Research linking tumor response is facilitated.
  8. 8. Pathologic examination of breast tumor specimens after neoadjuvant is challenging.
  9. 9. Recently, a detailed review was conducted at the 2007 National Cancer Institute State of the Science meeting. “Preoperative Therapy in Invasive Breast Cancer: Reviewing state of the science and exploring new research directions.”
  10. 10. Our study followed their recommendations regarding pathological assessment of breast carcinoma after neuadjuvant
  11. 11.  40 patients  Received neoadjuvant therapy. (4 cycles)  Underwent surgery  Pathological assessment was done
  12. 12. The objectives:  To assess pathological changes in the breast tumor by using Miller Payne classification in a group of patients undergoing neoadjuvent chemotherapy.  To highlight the importance of changing trends of pathological reporting in patients receiving neoadjuvent chemotherapy.
  13. 13. CRITERIAS FOR ASSESSMENT Primary Tumor –size –Cellularity –Invasive vs. in situ –Margins Axillary Lymph Nodes –Number of positive nodes –Size of metastases –Extranodal extension
  14. 14. Gross identification of tumor bed
  15. 15. Microscopic identification of tumor bed
  16. 16. MILLER AND PAYNE CLASSIFICATION.  Grade 1:No reduction  Grade 2:Minor loss (≤ 30%)  Grade 3:Some loss (30% -90%)  Grade 4:Marked loss (> 90%)  Grade 5:No residual invasive cancer (pCR)
  17. 17. pCR (yT0;yN0) is a predictor of better long term outcome
  18. 18. 40 patients Tumor size range 19cm to 1cm Rx: 4 cycles  Grade 1: 3 cases 7.5%  Grade 2: 17 cases 42.5%  Grade 3: 8 cases 20%  Grade 4: 5 cases 12.5%  Grade 5: 7 cases 17.5% (pCR) Reduction in cellularity was variable and observe maximally in smaller residual tumors.
  19. 19. Response in Lymph Nodes  The most important prognostic factor in patients who received neoadjuvant therapy.  Response in the breast and in the lymph nodes was generally similar’
  20. 20. MARGINS  In 2 cases tumor was within 1 mm of the closest margin. LYMPHOVASCULAR INVASION  7 cases showed lymphovascular invasion and 2 cases showed DCIS.
  21. 21. Studies have shown that lymphovascular invasion and DCIS is somehow not responsive to the treatment.
  22. 22. RIGHT BREAST, MASTECTOMY / WLE AND AXILLARY DISSECTION:  Residual Invasive ductal carcinoma Grade II  Size 0.8 x 0.6 cm .  Miller and Payne Classification Grade 3.  Intraductal component, 5%
  23. 23.  Margins of resection are free of tumor.  No lymphovascular invasion is seen.  2 out of 12 lymphnodes show metastatic carcinoma with extra nodal extension.
  24. 24. Conclusions  Surgical pathologists must be familiar with the gross examination, sampling, and reporting of breast carcinomas after neoadjuvant therapy.
  25. 25. Conclusions  AJCC, “Miller-Payne” and Residual Cancer Burden assessments improve the classification of residual disease  Accurate and reliable classification of residual disease can assist us with new trials.
  26. 26. Conclusions Consistent recommendations for pathological assessment and reporting of residual disease are needed.

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