- Genetic counseling is recommended for those with a personal or strong family history of breast cancer, especially at a young age or with known BRCA gene mutations. - Staging involves assessing tumor size, lymph node involvement and metastasis. Treatment for early-stage breast cancer involves lumpectomy or mastectomy with radiation and/or hormone therapy or chemotherapy depending on risk factors like tumor biology. - For ductal carcinoma in situ (DCIS), lumpectomy with clear margins followed by radiation is standard, while mastectomy may be recommended for more extensive DCIS based on individual risk. Active surveillance without radiation may be considered for select low-grade DCIS cases.

1. Breast cancer
MANAGEMENT
PPTX. BY DR.OFAIL N.K.
FEB.2014

2. • 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

3. • 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-

4. • 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.
•

5. • 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.

6. • 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.

7. • 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

8. 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.

9. 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.

10. Early stage invasive ca.
localizedlumpectomy (-ve margin >2mm)+SNBWBI/PBIobserve+- TAM
**If recommended CT it is always delivered before RT
diffusedmastectomy+SNBCTRT for intermediate & high risk observe+-
TAM
To be continued next presentation……………………..