1. SMALL
CANCER
AND
BRCA
MUTATION
Krishna
B.
CLOUGH

2. SMALL
CANCER
AND
BRCA
MUTATION
CLINICAL
CASE
Krishna
B.
CLOUGH

3. Mrs
S.G.
l 34
yrs,
journalist
,
2
children
l Mother
+
Aunt
+
Greataunt
Breast
Cancer
l BRCA
2
Muta=on

4. FIRST
CONSULTATION
:
ADVICE
l 1.75m
60
kgs
small
breasts
85
B
Smoker
10
cig/j
l T0N0
l Mammo
US:
normal
l Seeks
your
advice

5.
WHAT
DO
YOU
RECOMMEND
?
l ProphylacOc
oophorectomy
l ProphylacOc
Mastectomy
l TAM
l Other

6.
MRI
l LeR
Breast
:
Nodular
image
lower
pole
l 8
mm
round
non
suspicious
ACR
3
l SuggesOons
:
l MRI
guided
biopsy
l Control
MRI
4/6
months
l Wide
local
excision
l Other

7. 2nd
LOOK
ULTRASOUND
l 2nd
look
US:
8
mm
image
lower
pole
ACR
3
l Biopsy
:
Lobular
Neoplasia
LIN
2+3
l SuggesOons
?
l
TAM
l
Wide
local
excison
l
WLE
+
frozen
secOon
+/-­‐
SNB
l
Mastectomy
uni/bilatéral

8. WL
EXCISION
frozen
sec=on
+
SNB
l Invasive
Ductal
Carcinoma
10mm
l Grade
I
,
low
mitoOc
index
l ER
100
%
RP
100
%
HER
2
1+
Ki67
15
%
l Free
margins
>
10mm
l 3
SN
negaOve

9.
1.
ADJUVANT
TREATMENT
?
l TAM
?
l LH-­‐RH
Analogs
+
TAM
?
l LH-­‐RH
Analogs
+
TAM
?
l Chemotherapy
?

10. TAM
no
other
systemic
therapy

11.
2.
LOCAL
TREATMENT
?
l Radiotherapy
l M
+
IBR
(uni/bilateral)
l Nipple
sparing
M
+
IBR
l Nipple
sparing
M
+
IBR
+
PBIrradiaOon
leR
areola

12. CONSERVATIVE
TREATMENT
and
MUTATION
?
l BRCA+
vs
controls
:
no
increase
in
LR
(7yrs)
l Contralateral
breast
:
RR
3,5
l 50%
risk
reducOon
(ipsi
and
controlat)
by:
l Oophorectomy
l TAM
/
CT

13. BILAT.
NIPPLE
SPARING
M
+
IntraopRT
LeU
areaola
l Postop
unevenful
Leaves
D3
l Drains
removed
D10
D14
l D30
:
All
OK
...
but
l Calls
for
bilat
discharge
l Thin
skin,
«
blueish
»

14. D
30:
BILATERAL
IMPLANT
EXPOSURE

15. SUGGESTIONS
?
l Lavage
drainage
+
implant
replacement
l Lavage
drainage
+
Expanders
l Accelular
Dermal
Matrix
l Bilateral
Lat.
Dorsi
l Other

16. BILATERAL
IMPLANT
REMOVAL
8
MONTHS
LATER
…
Demands Reconstruction

17. SUGGESTIONS
?
l Implants
l Expanders
l Bilatéral
Lat.
Dorsi
l Other
flap
l Other

18. 3
LIPOFILLINGS
L1
200
cc
L2
250cc
L3
280
cc

19. SUGGESTIONS
?
l Implants
l Expanders
l Bilatéral
Lat.
Dorsi
l Other
flap
l Other

20.
IMPLANT
225
CC
anat
L4
300cc

21. 3.
OVARIES
:
PROPHYLACTIC
SURGERY
?
1. Follow
up:
modali=es
?
1. CA
12.5
2. US
3. MRI
2. Bilateral
SO
1. Now
2. 45
3. 50

22. SEE-FIM
SEE-FIM protocol