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Download Update on Breast Care - Mithoefer Center for Rural Surgery
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Update on Breast Care M. Bernadette Ryan, M.D., FACS Head, Section of Surgical Oncology May 18, 2009 Outline ANDI concept in benign breast disease myatalgia Breast imaging for screening & diagnosis Breast Cancer 1/2009 update in NCCN guidelines PBI Oncotype Dx ANDI Aberrations of normal development and involution concept of benign disorders based on pathogenesis First published by Hughes et al. in 1987 in Lancet Embraced slowly in the USA ANDI - 2 Bi-directional framework Horizontal axis: main clinical presentation normal - aberration - disease Vertical axis: stages in development early reproductive (15-25 years) mature reproductive (25-40 years) involution (35-55 years) ANDI - 3 Normal Process Aberration Disease Early Reproductive 15-25 years Lobular development Stromal development Nipple eversion Fibroadenoma Adolescent hyperplasia Nipple inversion Giant FA or multiple FAs Gigantomastia Subareolar abscess/ mammary duct fistula Mature Reproductive 25-40 years Cyclic changes Cyclic mastalgia Nodularity Ductal papilloma Incapacitating mastalgia Involution 35-55 years Epithelia hyperplasia of pregnancy Lobular involution microcysts Duct involution dilation sclerosis Epithelial turnover Bloody nipple discharge Macrocysts, adenosis, sclerosing lesions Ductal ectasia Nipple inversion Hyperplasia Periductal mastitis/ abscess Atypia Non - ANDI Fat necrosis Lactational abscesses Contributions of smoking and oro-nipple contact in non-puerperal abscesses True neoplasms: phyllodes tumor, tubular adenoma, lipoma, etc. Mondor’s disease, diabetic mastopathy, … Mastalgia Probably hormonally related usually cyclic and ends with menopause responds to hormone treatment Many theories: increased estrogen decreased progesterone increased prolactin increased end-organ response low prostaglandin E1 due to EFA deficiency Mastalgia - 2 Cyclic or non-cyclic breast pain rule out chest wall source in non-cyclic rule out significant lesion with imaging localized pain may be due to cancer, cyst, sclerosing lesion Treatment Reassurance if mild Reassurance and primrose oil if moderate Add drugs if severe (interferes with lifestyle) Mastalgia - 3 Cyclic Pain Non-Cyclic Primrose oil 44-58% 27% Danazol 70-80% 30% Tamoxifen 80-90% 56% 1000-1500 BID 200-400 mg QD 10 mg QD Bromocriptine 47% 20% Placebo 10-40% 2.5 mg BID 10-40% Breast Imaging Mammograms Ultrasound MRI PET scans Mammograms Annual screening beginning at age 40 as young as 25 in high risk groups upper limit not established Digital mammogram may be better especially in young women and older women with dense breasts Mobile units may increase compliance Ultrasound Initial diagnostic tool in women < 30-35 with symptoms or palpable findings Adjunct to mammography diagnostic w/u biopsy May be used with mammogram to screen women at high risk or with dense breasts no PRS showing survival benefit MRI - screening Screen high risk women BRCA 1 or 2, TB53 or PTEN mutations First degree relative with above & untested Lifetime risk 20-25% by model based on FHx Chest irradiation between ages 10 & 30 Role in women at lesser risk uncertain LCIS, AH, prior breast cancer, 15-20% risk Not recommended in average risk women BRCAPRO Free programs available Need extensive family history age of diagnosis of cancer as well as current age or age of death of relatives Calculates risk of harboring BrCa gene and risk of developing breast & ovarian cancer BRCAPRO - 2 BRCAPRO - 3 BRCAPRO - 4 MRI - diagnostic Define extent of disease before BCS leads to higher mastectomy rate without clear benefit in local control or survival Define extent of disease before & after neoadjuvant therapy Look for additional primaries Look for occult primary Paget’s disease & isolated nodal metastases PET scan NCCN recommends against use in stage IIII disease “Biopsy of equivocal or suspicious sites is more likely to provide useful information” Lobular cancer frequently PET negative Not useful to stage axilla overall role in breast cancer unclear NCCN updates: DCIS Minimum margin is still 1 mm generally decreased failure rates with wider margins up to 10 mm post-excision mammogram if uncertainty Recommends against sentinel node biopsy reasonable for mastectomy Excision alone in “low” risk disease radiation reduces local failure by 50% equivalent survival NCCN: invasive cancer w/u Genetic counseling if high risk MRI optional No PET or PET/CT ER/PR and Her 2: use a reliable lab Imaging to rule out metastases only if symptomatic may consider in locally advanced disease NCCN - local treatment Negative margin not defined Focally + margin acceptable if no EIC consider higher XRT boost to tumor bed > 70, T1N0M0, ER/PR + reasonable to treat with lumpectomy & tamoxifen or an aromatase inhibitor can be cN0 or pN0 NCCN - neoadjuvant In Stage II & T3N1: only if pt wants BCS Use in all other Stage III Consider AI if post-menopausal & ER/PR positive cN+: confirm with needle biopsy Level I & II dissection regardless of response cN-: SNBx pre- or post-chemo AxD if + NCCN - Radiation Radiation can be with or without a boost boost: < 50, close margins, + nodes or LVI PBI discouraged outside of a trial Post-mastectomy XRT unchanged: >/= 4 + nodes, >5 cm, margins < 1mm or + consider in 1-3 nodes Base XRT on initial clinical stage in neoadjuvant patients Partial Breast Irradiation Low risk women age > 45, tumor </= 3 cm, negative margins & nodes (? DCIS) Potential advantages shorter treatment course can give prior to chemotherapy may improve access to BCS ? better cosmesis Need PRTs to compare failure rates PBI - 2 Treat tumor bed with 1 cm margins Intra-op: single fraction Post-op: BID x 10 fractions with total dose 34-38.5 Gy MammoSite and other balloons after loading catheters external beam with 3D conformal/IMRT NCCN - adjuvant treatment ER/PR + & Her 2 -: consider Oncotype Still little data on chemo in women > 70 individualize considering co-morbidities No prospective randomized data on use of Herceptin in tumors < 1 cm & node but considered reasonable Baseline & f/u DEXA scans if treat with AI or if menopause induced by treatment T1/2, ER/PR+, node -, her 2adjuvantonline age, health, size, grade, nodes, ER/PR odds of death or recurrence at 10 years odds of benefit from adjuvant treatment Oncotype Dx 21 gene test on paraffin blocks recurrence score: correlates with 10-year relapse in tamoxifen-treated patients and with benefit from chemotherapy Tailor X PRT to determine value of Oncotype Low RS (1-10): tamoxifen or AI High RS (> 26): chemotherapy and tamoxifen or AI Intermediate RS (11-25): randomize between 2 treatments above Off study, 18-30 considered intermediate about $3000 (some insurances cover test) Future Greater effort to tailor treatment to individual to avoid toxicity without jeopardizing survival Pay for performance accredited breast centers adherence to national guidelines volume of breast cases Comments or questions?
