Download Patient Presentation - Projects In Knowledge

Breast Cancer Tumor Board
Chair
Harold Burstein, MD, PhD
Faculty
Jennifer Bellon, MD
Mehra Golshan, MD
Patient Presentation
• 55-year-old woman who works as a medical
office administrator
• Screening mammogram showed abnormality
in breast
• Core biopsy revealed invasive cancer with
associated ductal carcinoma in situ
– Invasive component considered intermediate grade
• She underwent lumpectomy and sentinel lymph
node mapping
• Lumpectomy revealed a 1.7 cm, grade 2
(moderately differentiated) invasive ductal
carcinoma
Further Tumor Testing
• Sentinel lymph node mapping
– 2 lymph nodes identified
– 1 node contained a 2-mm focus of invasive cancer
seen on hematoxylin and eosin stain
• Tumor immunophenotyping
– Estrogen receptor positive
– Progesterone receptor low positive
– HER2 1+
• HER2 status determination by fluorescence in
situ hybridization (FISH)
– No evidence for gene amplification, with a ratio
of 1.2
Patient History and Exam
• Patient is otherwise well
• Borderline high cholesterol
• Postmenopausal, grava 3 para 2 with a
miscarriage
• No medications
• Medical allergy to sulfa products (rash)
• No family history of breast cancer
• Comprehensive system review notable only
for her postoperative treatment changes
Mammogram—Magnification View
Graphic courtesy of Dr. Mehra Golshan.
Ultrasound View of Lesion
Graphic courtesy of Dr. Mehra Golshan.
Specimen Imaging Showing Wire
and Calcifications
Graphic courtesy of Dr. Mehra Golshan.
ACOSOG Z0011—5-Year
Recurrence Rates
6%
Recurrence
ALND (n = 420)
SLND (n = 436)
4.1%
4%
3.6%
2.8%
2%
1.8%
0.9%
0.5%
0%
Local
Regional
Total Locoregional
P = .11, ALND vs SLND.
Abbreviations: ALND, axillary lymph node dissection; SLND, sentinel lymph node dissection.
Giuliano AE, et al. J Clin Oncol. 2010;28:18S.
ACOSOG Z0011—Predictors of
Locoregional Recurrence in
Multivariate Analysis
Factors Associated
with Recurrence
Age (≤50 years)
Higher modified BloomRichardson
Giuliano AE, et al. J Clin Oncol. 2010;28:18S
Factors Not Associated
with Recurrence
Estrogen receptor status
Progesterone receptor status
Tumor size
Level 1 lymph nodes
Histologic type
Sentinel node metastasis size
Number positive lymph nodes
Adjuvant systemic therapy
ACOSOG Z0011: Predictors of
Disease-Free Survival in
Multivariate Analysis
Factors Associated
with Improved DiseaseFree Survival
Estrogen receptor status
Age
Adjuvant systemic therapy
Giuliano AE, et al. J Clin Oncol. 2010;28:18S
Factors Not Associated
with Disease-Free
Survival
Treatment arm
Progesterone receptor status
Tumor size
Level 1 lymph nodes
Histologic type
Number positive lymph nodes
Modified Bloom-Richardson
Conclusions
• ACOSOG Z0011 was a study of completion dissection
or not for women with positive sentinel lymph nodes
• There was no apparent benefit for completion
dissection as both groups had very low risk of local and
regional breast cancer recurrence
• The trial closed having accrued only half its patients
and remains somewhat underpowered
• Moving forward, it is likely that surgical treatment
decisions will be individualized
– Role of axillary dissection to be based on tumor size, extent of
nodal disease, biological features of the breast cancer, patient
age, and other traditional risk factors