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  1. 1. Surgical Options for the Treatment of Breast Cancer Helen Krontiras, M.D. Assistant Professor University of Alabama School of Medicine
  2. 2. History Physical Examination <ul><li>Questions regarding presenting symptom </li></ul><ul><li>Questions regarding risk factors </li></ul><ul><li>Past medical history </li></ul><ul><li>Family history </li></ul><ul><li>Review of systems </li></ul><ul><li>Masses </li></ul><ul><li>Skin changes </li></ul><ul><li>Nipple changes </li></ul><ul><li>Nipple discharge </li></ul><ul><li>Lymphadenopathy </li></ul>
  3. 3. Risk factors for breast cancer <ul><li>Gender </li></ul><ul><li>Age </li></ul><ul><li>Personal history of breast cancer </li></ul><ul><li>Reproductive and menstrual history </li></ul><ul><li>Breast density </li></ul><ul><li>Family history of breast cancer </li></ul><ul><li>Genetic factors </li></ul><ul><li>Proliferative breast disease </li></ul><ul><li>Diet and lifestyle factors </li></ul>
  4. 4. Breast Imaging <ul><li>Mammogram </li></ul><ul><li>Ultrasound </li></ul><ul><li>(MRI) </li></ul>
  5. 5. Biopsy <ul><li>Incisional </li></ul><ul><ul><li>Core biopsy </li></ul></ul><ul><ul><ul><li>Palpation </li></ul></ul></ul><ul><ul><ul><li>Image Guided </li></ul></ul></ul><ul><ul><ul><ul><li>Stereotactic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ultrasound guided </li></ul></ul></ul></ul><ul><li>Excisional </li></ul><ul><ul><li>Operative removal of entire lesion </li></ul></ul>
  6. 6. Histology <ul><li>Lobular carcinoma in situ </li></ul><ul><li>Ductal carcinoma in situ </li></ul><ul><li>Invasive ductal carcinoma </li></ul><ul><li>Invasive lobular carcinoma </li></ul>
  7. 7. Lobular Carcinoma in situ <ul><li>Usually diagnosed as an incidental finding </li></ul><ul><li>Marker for increased risk for breast cancer </li></ul><ul><li>If found on core biopsy, excision warranted to rule out coexisting cancer </li></ul><ul><li>Management </li></ul><ul><ul><li>Surveillance </li></ul></ul><ul><ul><li>Chemoprevention </li></ul></ul><ul><ul><li>Bilateral Total Prophylactic Mastectomy </li></ul></ul>
  8. 8. Ductal Carcinoma in situ <ul><li>Stage 0, pre-invasive </li></ul><ul><li>By definition, does not spread to the axillary lymph nodes </li></ul><ul><li>Usually detected mammographically as microcalcifications </li></ul><ul><li>Surgical treatment similar to invasive breast cancer </li></ul>
  9. 9. Invasive ductal carcinoma <ul><li>Most common, 75% of all breast cancers </li></ul><ul><li>AKA IDC, infiltrating ductal </li></ul><ul><li>Increased spread to axillary nodes with increase in size </li></ul>
  10. 10. Invasive lobular carcinoma <ul><li>5-10% of all breast cancers </li></ul><ul><li>Usually presents as an ill defined thickening </li></ul><ul><li>May be mammographically occult </li></ul>
  11. 11. Inflammatory breast cancer <ul><li>Variant with rapid onset </li></ul><ul><li>Poor prognosis </li></ul><ul><li>Erythema, edema of the overlying skin (peau d’orange) secondary to tumor within the dermal lymphatics </li></ul><ul><li>Treatment is chemotherapy followed by surgery and or radiation </li></ul>
  12. 12. Paget’s Disease <ul><li>Benign appearing eczematoid lesion of the nipple </li></ul><ul><li>Caused by large malignant cells (Paget's cells) which arise from the ducts and which invade the surrounding nipple epithelium. </li></ul><ul><li>Usually due to an intraductal carcinoma </li></ul><ul><li>An underlying palpable mass usually indicates invasive ductal carcinoma </li></ul>
  13. 13. Phyllodes Tumor <ul><li>Rare, 0.5%- 1% of breast cancers </li></ul><ul><li>A fibroepithelial tumor of unpredictable behavior </li></ul><ul><li>Treatment is wide local excision with </li></ul><ul><li>2cm margins, no role for chemotherapy or radiation therapy </li></ul><ul><li>Like other stromal tumors, lymph node metastasis is rare </li></ul>
  14. 14. Earlier stage - better survival Stage
  15. 15. Lumpectomy + Mastectomy Neoadjuvant Chemotherapy (SLN BX before,surgery after) Clinical Stage I or II Invasive Breast Cancer SLN BX AND Total + SLN BX Modified Radical
  16. 16. Mastectomy Neoadjuvant Chemotherapy ClinicalStage III Invasive Breast Cancer Radiation Therapy
  17. 17. Breast Cancer Treatment Local Systemic
  18. 18. Local Therapy Breast Axilla
  19. 19. Local Therapy Surgery Radiation Therapy
  20. 20. Breast <ul><li>Mastectomy </li></ul><ul><li>Breast conservation </li></ul><ul><li>Neoadjuvant chemotherapy </li></ul>
  21. 22. Mastectomy <ul><li>Total Mastectomy </li></ul><ul><ul><li>With or without reconstruction </li></ul></ul><ul><ul><li>With or without sentinel lymph node biopsy </li></ul></ul><ul><ul><ul><li>Remove only the breast </li></ul></ul></ul><ul><li>Modified Radical Mastectomy </li></ul><ul><ul><li>With or without reconstruction </li></ul></ul><ul><ul><ul><li>Remove the breast and axillary lymph nodes </li></ul></ul></ul>
  22. 23. Mastectomy with reconstruction <ul><li>Total or MRM plus (immediate or delayed) </li></ul><ul><li>TRAM (Transverse Rectus Abdominis Myocutaneous flap) </li></ul><ul><ul><ul><li>Free – deep inferior epigastric </li></ul></ul></ul><ul><ul><ul><ul><li>Thorocodorsal, subscpular, circumflex scapular </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Internal mammary, thoracoacromial, lateral thoracic </li></ul></ul></ul></ul><ul><ul><ul><li>Pedicled – superior epigastric </li></ul></ul></ul><ul><li>Latissimus dorsi myocutaneous flap </li></ul><ul><li>Expander/Implant </li></ul>
  23. 25. Breast Conservation Therapy <ul><li>Lumpectomy + Radiation Therapy </li></ul><ul><li>Remove the bulk of the tumor surgically and to use moderate doses of radiation therapy to eradicate any residual cancer </li></ul><ul><li>Goal </li></ul><ul><ul><li>Preserve cosmetic outcome </li></ul></ul><ul><ul><li>Provide survival equivalent to mastectomy </li></ul></ul><ul><ul><li>Provide low rate of local recurrence </li></ul></ul>
  24. 26. BCT vs Mastectomy <ul><li>Since 1970, 7 prospective randomized </li></ul><ul><li>studies demonstrate equivalent outcome </li></ul><ul><li>regardless of surgical choice for patients with Stage I or II disease </li></ul>
  25. 27. Radiation Therapy <ul><li>External beam </li></ul><ul><li>Daily therapy for 6 weeks </li></ul><ul><li>Side effects </li></ul><ul><ul><li>Skin changes </li></ul></ul><ul><ul><li>Pulmonary toxicity </li></ul></ul><ul><ul><li>Cardiotoxicity </li></ul></ul>
  26. 28. Contraindications to breast conservation therapy <ul><li>Absolute </li></ul><ul><ul><li>2 or more primary tumors in separate quadrants </li></ul></ul><ul><ul><li>Diffuse malignant appearing calcifications </li></ul></ul><ul><ul><li>History of previous irradiation to the breast region </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Persistent positive margins </li></ul></ul>
  27. 29. Contraindications to breast conservation therapy <ul><li>Relative </li></ul><ul><ul><li>History of collagen vascular disease </li></ul></ul><ul><ul><li>Multiple gross tumors in the same quadrant and indeterminate calcifications </li></ul></ul><ul><ul><li>Large tumor in a small breast </li></ul></ul><ul><ul><li>Breast size </li></ul></ul>Winchester et al, Ca Cancer J Clin, 1998
  28. 30. Contraindications to breast conservation therapy <ul><li>The following should not prevent patients from being candidates for BCT: </li></ul><ul><ul><li>Presence of clinical or pathologic involvement of axillary lymph nodes </li></ul></ul><ul><ul><li>Tumor location </li></ul></ul><ul><ul><li>Family history </li></ul></ul>
  29. 31. Neoadjuvant chemotherapy <ul><li>Chemotherapy given before surgery </li></ul><ul><li>Shrink the tumor </li></ul><ul><li>In Vivo assessment of response to chemo </li></ul><ul><li>No survival advantage or disadvantage </li></ul>
  30. 32. Therapy of Regional Nodes <ul><li>Axillary Node Dissection </li></ul><ul><li>Sentinel Lymph Node Biopsy </li></ul>
  31. 33. Axillary Node Dissection <ul><li>Typically Levels I and II </li></ul><ul><li>10 – 30 lymph nodes removed </li></ul><ul><li>15-20% incidence of lymphedema </li></ul>
  32. 34. Silverstein, The Breast Journal 4:324, 1998 Positive axillary lymph node versus T stage
  33. 35. Sentinel node biopsy <ul><li>The sentinel node is the first node to receive lymphatic drainage from a primary breast cancer and reflects the status of the entire nodal basin </li></ul><ul><ul><li>Identifies the node(s) most likely to contain cancer </li></ul></ul><ul><ul><li>Lessens the morbidity of lymph node staging (3-4% incidence of lymphedema) </li></ul></ul><ul><ul><li>More detailed pathologic analysis with H&E </li></ul></ul><ul><ul><li>Axillary node dissection for those with positive sentinel nodes </li></ul></ul>
  34. 36. Sentinel node biopsy                                                   
  35. 37. Systemic Therapy Cytotoxic Chemotherapy Endocrine Monoclonal antibody
  36. 38. Adjuvant therapy <ul><li>The administration of chemotherapy or radiation therapy after primary surgery of breast cancer to kill or inhibit clinically occult micrometastases or residual disease </li></ul>
  37. 39. Adjuvant therapy recommendation <ul><li>Tumor size ER status Nodal Status Recommendation </li></ul><ul><li>< 1 cm +/- - None required </li></ul><ul><li>>1 cm + - Tam +/- Chemo </li></ul><ul><li>- - Chemo </li></ul><ul><li>Any size + + Tam +/- Chemo </li></ul><ul><li>- + Chemo </li></ul>
  38. 40. Chemotherapy <ul><li>Adriamycin/ Cytoxan (AC) x 4 </li></ul><ul><li>Cyclophosphamide/ Methotrexate/ 5-FU (CMF) x 6 </li></ul>
  39. 41. SERM Selective estrogen receptor modulators <ul><li>Tamoxifen </li></ul><ul><li>For those with ER (estrogen receptor) positive breast cancer </li></ul><ul><li>Prescribed for 5 years </li></ul><ul><li>Antiestrogenic and estrogenic effects </li></ul><ul><li>Side effects </li></ul><ul><ul><ul><li>Hot flashes </li></ul></ul></ul><ul><ul><ul><li>Vaginal dryness, discharge </li></ul></ul></ul><ul><ul><ul><li>Increased risk of endometrial cancer </li></ul></ul></ul><ul><ul><ul><li>Increased risk of thromboembolic events </li></ul></ul></ul><ul><ul><ul><li>Cataracts </li></ul></ul></ul>
  40. 42. Aromatase inhibitors <ul><li>Blocks aromatase enzyme peripherally </li></ul><ul><li>For those with ER positive disease </li></ul><ul><li>Less side effects than tamoxifen </li></ul><ul><li>May be more effective for treatment and prevention </li></ul><ul><ul><li>Arimidex </li></ul></ul><ul><ul><li>Femara </li></ul></ul><ul><ul><li>Exemestane </li></ul></ul>
  41. 43. Herceptin (trastuzumab) <ul><li>Monoclonal antibody that targets the Her2neu gene </li></ul><ul><li>Her2neu is overexpressed in 25% of breast cancers </li></ul><ul><li>Codes for a growth factor </li></ul><ul><li>Clinical trials indicate that Herceptin may increase the effectiveness of chemotherapy without added toxicity </li></ul>