- The document discusses breast cancer histology, biology, staging, and treatment approaches. - It covers breast cancer subtypes like luminal A/B, HER2-positive, and triple negative breast cancer. - Treatment approaches are tailored based on cancer stage, subtype, and risk level, and may involve surgery, radiation, chemotherapy, hormone therapy, targeted therapy, and genomic testing to guide therapy selection. - Early stage disease is typically treated with surgery plus radiation and/or hormone therapy depending on risk factors. Later stages involve neoadjuvant therapy before surgery along with radiation and additional therapies. Metastatic disease utilizes various chemotherapy, hormone therapy or targeted regimens depending on cancer subtype.

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

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

5. - 40/100: ER+/PR+/Her2-/Low ki67
- 20/100: her2+

6. - 40/100: ER+/PR+/Her2-/Low ki67
- 20/100: her2+
- Luminal A
- Luminal B
- HEr2

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

8. TNM & Staging

9. T of the TNM
T Size Descriptor
T1a 0.1-0.5 cm
T1b >0.5-1 cm
T1c >1-2 cm
T2 >2-5 cm
T3 >5 cm
T4 Any size Chest wall – T4a, skin (nodules or
ulceration) - T4b, both – T4c, or
inflammatory – T4d

10. T (Breast Cancer)

11. N of the TNM
N Pathology Clinical
N0 0 None
N1 1-3, axillary Movable axillary
N2 4-9, axillary Fixed axillary
N2 Internal mammary only Internal mammary, only
N3 ≥10, axillary
N3 Axillary + Internal mammary Axillary + Internal mammary
N3 Supraclavicular,
infraclavicular
Supraclavicular, infraclavicular

12. N (Breast Cancer)

13. N0 N1 N2 N3 M1
T0 Tis IIa IIIa IIIc IV
T1 Ia IIa IIIa IIIc IV
T2 IIa IIb IIIa IIIc IV
T3 IIb IIIa IIIa IIIc IV
T4 IIIb IIIb IIIb IIIc IV

14. N0 N1 N2 N3 M1
T0 Tis IIa IIIa IIIc IV
T1 Ia IIa IIIa IIIc IV
T2 IIa IIb IIIa IIIc IV
T3 IIb IIIa IIIa IIIc IV
T4 IIIb IIIb IIIb IIIc IV

15. N0 N1 N2 N3 M1
T0 Tis IIa IIIa IIIc IV
T1 Ia IIa IIIa IIIc IV
T2 IIa IIb IIIa IIIc IV
T3 IIb IIIa IIIa IIIc IV
T4 IIIb IIIb IIIb IIIc IV

16. 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

17. 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

18. For Stage I-IIIa
Plan: initial surgery
bone
ULtraSound
Only if
Clinically
indicated

20. For Stage I-IIIa
Plan: neoadjuvant chemo
bone
Mammogram /
MR / US / CT
Bone scan /
PET-CT

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

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

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

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

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

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

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

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

31. Breast surgeon

32. surgery
Anti her2

33. Modalidades
Cirugía Radioterapia
Quimioterapia
citotóxica
Hormonoterapia
Anti-Her2 Anti cdk4/6
iPARP Inmunoterapia

34. 1. surgery

35. 1. surgery
Considerations

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

37. 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

38. 2. Radiation
indications

39. 2. chemo

40. Genomic testing
in early-breast
cancer
Gene-expression profile is
a powerful prognostic
and predictive tool for
LUMINAL early breast
cancer.
There are several
commercially available
genomic-based assays for
early breast cancer
We will discuss only one

41. N0 N1 N2 N3 M1
T0 Tis IIa IIIa IIIc IV
T1 Ia IIa IIIa IIIc IV
T2 IIa IIb IIIa IIIc IV
T3 IIb IIIa IIIa IIIc IV
T4 IIIb IIIb IIIb IIIc IV

42. ≤50 years-old
21-gene recurrence score assay
(OncoTypeDx)
Luminal A or B (Her2-)
>1-5 cm in size (T1c/2) or >0.5 cm Grade 2 or 3
N0M0
>50 years-old
RSS 0-15 (LR)
Adjuvant hormonal
therapy (no CT)
RSS 16-25
Adjuvant hormonal therapy, CT if
RSS ≥20 or high clinical risk*
RSS >25 (HR)
Adjuvant CT and
hormonal therapy
*High clinical risk is defined as: Tumor >2 cm;
or 1-2 cm, grade 2 or 3; or less ≤1 cm grade 3
RSS: Recurrence score (0-100)
CT: Chemotherapy
EBC: Early-Breast cancer

45. 4. anti-estrogens

46. 1. chemo

47. Anti-estrogens x5-10 yrs

48. Anti-estrogens x5-10 yrs

49. Anti-estrogens x5-10 yrs

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

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

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

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

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

56. Anti-estrogens x5-10 yrs

57. Anti-estrogens x5-10 yrs

59. 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-

60. Modalidades –
intención
curativa
• Cirugía
• Indicada en estadíos I-III (y en algunos IV)
• Mastectomía
• Cirugía preservadora de mama (cuadrantectomía)
• Radioterapia
• Adyuvante indicada en estadíos III, T3, N+, R1
• Quimioterapia citotóxica
• Adyuvante indicada en Triple negativo, Her2+,
Luminales estadío III, N+, genómica alto riesgo
• Hormonoterapia
• Adyuvante indicada en Luminales y Her2+ con
receptores hormonales positivos
• Anti-Her2
• Indicada en Her2+

61. 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

62. 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

63. 85
Stage I
Low-risk
Stage I
high-risk
Or
TNBC
Stage IIB
( n2 )
Stage IIIC ALL
comers
Long-term survival

64. 40
Low-risk
Luminal a
mbc
Her2+
Mbc
(Cleopatra)
Visceral
crisis
TN
MBC
ALL
comers
Median survival