Visión del oncólogo (error en el título, es CES2019-02... Y realmente es distinta de la del 2019-01)

1. CES2019.01 – Cáncer de mama II – Visión del
oncólogo
Mauricio Lema Medina MD
@Onconerd

2. Topics
 Invasive breast carcinoma

3. Objetivo
 Obtener un conocimiento GENERAL del manejo USUAL de pacientes con las patologías a
discutir desde la sospecha diagnóstica, hasta el las pautas de seguimiento post-
tratamiento, pasando por los aspectos más relevantes de tratamientos con intención
curativa.

6. - histology:
- Grade (1-3)

7. - Biology:
- Estrogen receptor
- Progesterone receptor
- Genomics (not in all)

8. - 40/100: ER+/PR+/Her2-/Low ki67
- 20/100: her2+

9. - 40/100: ER+/PR+/Her2-/Low ki67
- 20/100: her2+
- Luminal A
- Luminal B
- HEr2

10. 1. Soft tissue/ Bone
2. Lung
3. LIVER
4. Brain

19. TNM
N1:
movable LN
N2:
Fixed Matted LN
N3:
Infraclavicular LN, or
Supraclavicular LN, or
Axillary + internal mammary LN
T1: up to 2 cm
More than 2,
less than 5 cm
T3: more than
5 cm
M0: No distant
metastasis
M1: Distant
metastasis
T4: Chest wall or
Skin involvement
LN: Lymph nodes
CLINICAL
Enough tnm to guide
therapy for breast cancer

20. TNM
N1:
1-3 axillary ln
N2:
4-9 axillary ln
N3:
More than 10 axillary LN
Infraclavicular LN, or
Supraclavicular LN, or
Axillary + internal mammary LN
T1: up to 2 cm
More than 2,
less than 5 cm
T3: more than
5 cm
M0: No distant
metastasis
M1: Distant
metastasis
T4: Chest wall or
Skin involvement
LN: Lymph nodes
PATHOLOGICAL
Enough tnm to guide
therapy for breast cancer

22. bone
Mammogram /
MR / US / CT
Bone scan /
PET-CT

24. - Ready for action
- t1 n0 m0 – stage 1a
- t1-3 n1-2 m0 – Stage II-IIIa

25. - Ready for action
- t1 n0 m0 – stage 1a
- t1-3 n1-2 m0 – Stage II-IIIa
- Early breast cancer

26. - Ready for action
- t1 n0 m0 – stage 1a
- t1-3 n1-2 m0 – Stage II-IIIa
- Locally advanced breast cancer

27. Pet-ct detects distant
metastasis in up to 4/10

28. - Ready for action
- t1 n0 m0 – stage 1a
- t1-3 n1-2 m0 – Stage II-IIIa

29. - Ready for action
- t1 or T2 n0 m0
- Low-risk by genomic score
- STAGE IA

30. - Ready for action
- T1, T2, T3 n2 m0
-T3 N1
- STAGE IIIA

31. - Ready for action
- Locally-advanced bc (LABC)
- Metastatic breast cancer

33. Breast surgeon

34. surgery
Anti her2

35. 1. surgery

36. 1. surgery
Considerations

37. Radical mastectomy
Modified radical
mastectomy
Simple mastectomy
+ snb
Breast conserving
surgery + snb + rt

38. Mastectomía radical modificada
A.Resección de la mama (en rosado)
B.Disección de ganglios axilares – Nivel I
C.Disección de ganglios axilares – Nivel II
D.Disección de ganglios axilares – Nivel III
Lumpectomía
(cuadrantectomía) – Cirugía
preservadora de mama
QUIRÚRGICO

39. 2. Radiation
indications

40. 2. chemo

41. 4. anti-estrogens

42. 1. chemo

43. Anti-estrogens x5-10 yrs

44. Anti-estrogens x5-10 yrs

45. Anti-estrogens x5-10 yrs

46. Anti-her2 Trastuzumab x3w x 18 (1yr)

47. Anti-her2 Trastuzumab x3w x 18 (1yr)

48. Anti-her2 Trastuzumab x3w x 18 (1 yr)
Anti-estrogens x5-10 yrs

49. Anti-her2 Trastuzumab x3w x 18 (1 yr)
Anti-estrogens x5-10 yrs

50. Anti-her2 Trastuzumab x3w x 18 (1 yr)

52. Anti-estrogens x5-10 yrs

53. Anti-estrogens x5-10 yrs

55. mbc
Visceral crisis or
Triple negative
Chemotherapy
(taxanes)
Bisphosphonates or denosumab
(if + bones involvement)
Luminal
Low-risk
Soft-tissue
+/- bone
Anti-estrogen
(fulvestrant, AI)
Her2+
Trastuzumab +
Pertuzumab +
docetaxel
Metastatic
Breast cancer
-mbc-

56. 85
Stage I
Low-risk
Stage I
high-risk
Or
TNBC
Stage IIB
( n2 )
Stage IIIC ALL
comers
Long-term survival

57. 40
Low-risk
Luminal a
mbc
Her2+
Mbc
(Cleopatra)
Visceral
crisis
TN
MBC
ALL
comers
Median survival

59. Cancer New cases (World) Deaths (World) New cases (Colombia) Deaths (Colombia)
Breast 2’088.849 (2) 626.679 (5) 13.380 (1) 3.702 (4)
Prostate 1’276.106 (4) 358.989 (8) 12.712 (2) 3.166 (5)
Lung 2’093.876 (1) 1’761.007 (1) 5.856 (5) 5.236 (2)
Stomach 1’033.701 (5) 782.685 (3) 7.419 (4) 5.505 (1)
Colon & rectum 1’849.518 (3) 880.792 (2) 9.140 (3) 4.489 (3)
Lymphoma (NH) 509.990 (10) 248.724 (11) 4.170 (6) 1.676 (10)
Uterine cérvix 569.847 (8) 311.365 (9) 3.853 (7) 1.775 (9)
Leukemia 437.003 (12) 309.006 (10) 3.126 (8) 2.192 (7)
Ovarian 295.414 (17) 184.799 (14) 2.414 (9) 1.252 (11)
Pancreas 458.918 (11) 402.232 (7) 2.311 (10) 2.142 (8)
Liver 841.080 (6) 781.636 (4) 2.279 (11) 2.216 (6)
Multiple mieloma 159.885 (21) 106.105 1323 (14) 806 (14)
Esophagus 572.034 (7) 508.585 (6) 922 (15) 710 (15)
Hodgkin 79.999 (25) 26.167 743 (16) 216
Brain 296.851 (16) 241.037 (12) 1884 (12) 1.176 (12)
Gallbladder 219.420 (19) 165.087 (17) 1657 (13) 1.104 (13)
All 18’078.957 9’555.027 101.893 46.057
http://gco.iarc.fr/today/

60. Cancer New cases (World) Deaths (World) New cases (Colombia) Deaths (Colombia)
Breast 2’088.849 (2) 626.679 (5) 13.380 (1) 3.702 (4)
Prostate 1’276.106 (4) 358.989 (8) 12.712 (2) 3.166 (5)
Lung 2’093.876 (1) 1’761.007 (1) 5.856 (5) 5.236 (2)
Stomach 1’033.701 (5) 782.685 (3) 7.419 (4) 5.505 (1)
Colon & rectum 1’849.518 (3) 880.792 (2) 9.140 (3) 4.489 (3)
Lymphoma (NH) 509.990 (10) 248.724 (11) 4.170 (6) 1.676 (10)
Uterine cérvix 569.847 (8) 311.365 (9) 3.853 (7) 1.775 (9)
Leukemia 437.003 (12) 309.006 (10) 3.126 (8) 2.192 (7)
Ovarian 295.414 (17) 184.799 (14) 2.414 (9) 1.252 (11)
Pancreas 458.918 (11) 402.232 (7) 2.311 (10) 2.142 (8)
Liver 841.080 (6) 781.636 (4) 2.279 (11) 2.216 (6)
Multiple mieloma 159.885 (21) 106.105 1323 (14) 806 (14)
Esophagus 572.034 (7) 508.585 (6) 922 (15) 710 (15)
Hodgkin 79.999 (25) 26.167 743 (16) 216
Brain 296.851 (16) 241.037 (12) 1884 (12) 1.176 (12)
Gallbladder 219.420 (19) 165.087 (17) 1657 (13) 1.104 (13)
All 18’078.957 9’555.027 101.893 46.057
http://gco.iarc.fr/today/

61. Workup – Stages I-IIB Comments
H&P
Diagnostic bilateral mammogram
Breast ultrasound
Pathologic review
Determination ER / PR
Determination Her2
Genetic counseling High risk for hereditary cancer
Breast MRI Optional
Counseling for fertility In premenopausal; pregnancy test
Further workup as needed Complete blodd count, liver function tests
Bone scan if symptoms or high alk-phosphatase
Abdomen CT in high alk-phosphatase or symptoms
Chest CT if pulmonary symptoms
Breast cancer
https://www.nccn.org

62. Workup – Stages IIIA T3, N1, MO Comments
H&P
Diagnostic bilateral mammogram
Breast ultrasound
Pathologic review
Determination ER / PR
Determination Her2
Genetic counseling High risk for hereditary cancer
Breast MRI Optional
Counseling for fertility In premenopausal; pregnancy test
Complete blood count
Liver function tests, alk-phosphatase
Chest / abdomen +/- pelvis CT
Bone scan
PET-CT Optional
Breast cancer
https://www.nccn.org

63. Workup – Prior to preoperative
systemic therapy
Comments
H&P
Diagnostic bilateral mammogram
Breast ultrasound
Pathologic review
Axillary assessment Physical exam, ultrasound or other imaging as necessary,
and percutaneous biopsy of suspecious nodes
Determination ER / PR
Determination Her2
Genetic counseling High risk for hereditary cancer
Breast MRI Optional
Counseling for fertility In premenopausal; pregnancy test
Further workup as needed Complete blodd count, liver function tests
Bone scan if symptoms or high alk-phosphatase
Abdomen CT in high alk-phosphatase or symptoms
Chest CT if pulmonary symptoms
Breast cancer
https://www.nccn.org

64. Clinical suspicion
Suspiscious
mammo…
Breast skin changes Nipple abnormalities
Core-needle biopsy
(ie US-guided)
Breast mass
TNM/Stage/Biology
Stage I Stage II
Resectable stage
III
Unresectable
stage III
Metastatic

65. Luminal Her2+ TNBC
Stage I LRT (RT if BCS)
Genomic (Chemo if HR)
Hormonal
LRT (RT if BCS)
Paclitaxel + Trastuzumab
Hormonal if HR+
LRT (RT if BCS)
Adjuvant chemotherapy
Stage II LRT (RT if BCS)
Genomic (Chemo if HR)
Hormonal
LRT (RT if BCS)
AC, followed by Paclitaxel + Trastuzumab
Hormonal if HR+
RT if LN+
LRT (RT if BCS)
Adjuvant chemotherapy
RT if LN+
Stage III Neoadjuvant AC-Paclitaxel
Surgery – RT
Hormonal
Neoadjuvant AC-Paclitaxel + Trastuzumab
Surgery – RT
If not-pCR: T-DM1; else, Trastuzumab
Hormonal if HR+
Neoadjuvant AC-Paclitaxel +/-
Carboplatin
Surgery – RT
If not-pCR: Capecitabine
Low-Risk Metastatic (Bone
and soft tissue metastases,
only)
Ovarian ablation (premenopausal) + AI +
cdk4/6 inhibitor + Denosumab
CLEOPATRA: Docetaxel + Trastuzumab + Pertuzumab +
Denosumab
Single-agent paclitaxel
Visceral crises Single/combined chemo, followed by
hormone
CLEOPATRA Single/combined chemo
Breast cancer pattern of care
LRT: Loco-regional therapy (ie, surgery +/- radiation); RT: radiation therapy; BCS: breast-conserving surgery, HR: Estrogen or progesteron receptor positive, AC: Doxorubicin +
Cyclophosphamide; LN+: positive regional lymph-nodes; pCR: pathologic complete response, T-DM1: Trastuzumab emtansine; AI: Aromatase inhibitor

67. Drug MOA Included in Main toxicities
Doxorubicin Topoisomerase II inhibitor
(anti DNA agent)
A in AC Alopecia
Nausea/Vomiting
Myelosuppression
Mucositis
Cardiac toxicity, 2ry leukemias
Cyclophosph
amide
Alkilating agent (anti DNA
agent)
C in AC Myelossuppression
… See doxorubicin
Paclitaxel Anti microtubule agent
(mitosis poison)
Paclitaxel, alone or in combination Muscle and joint pain
Myelosuppression
Peripheral neuropathy
Capecitabine Antimetabolite (anti
Thymidilate synthase)
Capecitabina, alone or in combination Diarrhea
Hand-foot syndrome
Myelosuppression
Trastuzumab Anti HER-2 monoclonal
antibody
In many Her2+ settings Cardiac toxicity (reversible)
T-DM1 Anti Her2 - Antibody-drug
conjugate
In many Her2+ settings Neuropathy
Thrombocytopenia
Cardiac toxicity

68. Drug MOA Included in Main toxicities
Tamoxifen Selective estrogen
receptor modulator
Anti estrogen for both premenopausal, and post
menopausal women
Hot flashes
Weight gain
Thromboembolic complications
Corpus uteri neoplasms
AI Anti-estrogen through
aromatase inhibition
Alone, or in combination (Anastrozol, Letrozol,
Exemestane)
Hot flashes
Joint pain
Osteoporosis
Dyslipidemia
Fulvestrant ER inactivator Alone, or in combination Hot flashes
Injection-site reaction
Cdk4/6
inhibitor
Cell-cycle inhibitor Alone (abemaciclib) In combination with AI or
Fulvestrant (ribociclib or palbociclib)
Neutropenia
Prolongued QT
Diarrhea, etc.