123
What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director, University of Colorado Hospital Breast Center

What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

  • Upload
    others

  • View
    9

  • Download
    0

Embed Size (px)

Citation preview

Page 1: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What Every General Surgeon Should Know About Breast Cancer

Christina A. Finlayson, MDAssociate Professor, Surgery

Director, University of Colorado Hospital Breast Center

Page 2: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Outline

How are we doing in the war against cancer? How do you order a mammogram? How do you stage breast cancer? What does medical oncology have to offer?

Page 3: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Change in the US Death Rates by Cause, 1950 & 2003

21.9

180.7

48.1

586.8

193.9

53.3

190.1231.6

0

100

200

300

400

500

600

HeartDiseases

CerebrovascularDiseases

Pneumonia/Influenza

Cancer

19502003

Rate Per 100,000

Page 4: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Five-year Relative Survival (%) during Three Time Periods By Cancer Site

Site 1974-1976 1983-1985 1995-2001

All sites 50 53 65 Breast (female) 75 78 88 Colon 50 58 64 Lung and bronchus 12 14 15 Melanoma 80 85 92 Pancreas 3 3 5 Prostate 67 75 100

Page 5: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Cancer Survival UCCC vs. Colorado2006

Page 6: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Breast Cancer - 2008

212,920 women diagnosed with invasive breast cancer

40,970 women will die from breast cancer 2 million women living who have been treated

for breast cancer Risk of developing invasive breast cancer is 1

in 8 Risk of dying from breast cancer is 1 in 33

American Cancer Society, 2006

Page 7: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What Every Surgeon Should Know About Breast Cancer

Radiology

Page 8: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society 2003

Patient is asymptomaticInsurance doesn’t require a referralDoesn’t require a physician orderMammographer is not on site

Page 9: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening Guidelines for the Early Detection of Breast Cancer, American Cancer Society 2003

Yearly screening mammograms are recommended starting at age 40 for women of average risk and continuing for as long as a woman is in good health

Page 10: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Mammogram Prevalence 1991-2002, USA

0

10

20

30

40

50

60

7019

91

1992

1993

1994

1995

1996

1997

1998

1999

2000

2002

Year

Prev

alen

ce (%

)

Women with less than a high school education

Women with no health insurance

All women 40 and older

Page 11: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

How Good is Mammography?

8 Randomized Controlled Trials 1960s - 1980 8-30% reduction in breast cancer mortality

Sensitivity Mammography: 85% Physical Exam: 50% But, with the advances in equipment, film, and

training, the sensitivity of mammography has…

Page 12: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

… gone down.

The actual sensitivity of screening mammography in clinical practice today is about 70%

False negative mammogram: biopsy proven cancer within a year of a negative screening mammogram

Page 13: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Why is mammography doing worse?

Prevalence cancers – slow growing, large cancers in the population waiting to be foundIncidence cancers – develop more than

one year after initial screenInterval cancers – become clinically

evident less than one year from last screen

Page 14: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Why is mammography doing worse?

The sensitivity of mammography is determined by competing methods of diagnosisWomen are more sensitive to

detecting lumps and much more likely to bring them to medical attention Providers are also more aware

Page 15: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

If mammography misses so much, is it worth screening?

About 10 years after mammographic screening became widespread in the U.S., mortality from breast cancer started to drop.

Page 16: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

USA - Age-adjusted Breast Cancer Mortality

USA mortality: 1950-1998

Page 17: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

If mammography misses so much, is it worth screening?

We cannot be sure that the change is due to screening, but there is a good correlation:

Page 18: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Sweden has a tremendous yearly screening program: 1951-1996

Sweden - Age-adjusted Breast Cancer Mortality

Page 19: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Great Britain also screens, but only every 3 years: 1950-1999

U.K. - Age-adjusted Breast Cancer Mortality

Page 20: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

while Denmark has no screening program: 1952-1996

Denmark - Age-adjusted Breast Cancer Mortality

Page 21: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Is there a better screening test? No!

Mammography is the best single screening test for women of average risk.Mammo + Physical Examination is a

potent combination for screening

Page 22: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening Guidelines for the Early Detection of Breast Cancer, ACS 2003

Women at increased risk should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (i.e., breast ultrasound and MRI), or having more frequent exams.

Page 23: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Who are women at increased risk?

Family history – first degree relativeExtended family history

Previous biopsyAtypical hyperplasiaLCIS

BRCA1/BRCA2 (Radiation to chest wall)

Page 24: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Imaging options

MammographyUltrasoundMRI, contrast enhanced

Page 25: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Mammography

Gold-standardMultiple studies with mortality as end-pointDecreases mortality from breast cancer by at

least 25-50% Detection rate: 5-7/1000 for first mammogram 2-3/1000 for subsequent mammograms

Page 26: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening Ultrasound

Ultrasound plus mammography finds more cancers than mammography aloneCancers seen by ultrasound are

usually invasiveMany false positives -- many extra

biopsiesU/S adds 1-2 cancer / 1000 screens

Not covered by insurance for screening

Page 27: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening MRI

Warner, E. JAMA, 2004

Page 28: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Screening BRCA1/2:22 Cancers Detected

99%96%97%NPV

42%23%83%PPV

93%95%99.6%Specificity

85%25%38%Sensitivity

236229236Screened

MRIUltrasoundMammogram

Warner, E. JAMA, 2004

Page 29: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

ACS Guidelines for Breast Screening with MRI

Recommend Annual MRI Screening (Based on Evidence) BRCA mutation First-degree relative of BRCA carrier, but

untested Lifetime risk ~20–25% or greater, as defined

by BRCAPRO or other models that are largely dependent on family history

CA Cancer J Clin 2007

Page 30: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

ACS Guidelines for Breast Screening with MRI

Recommend Annual MRI Screening (Based on Expert Consensus Opinion) Radiation to chest between age 10 and 30

years Li-Fraumeni syndrome and first-degree

relatives Cowden and Bannayan-Riley-Ruvalcaba

syndromes and first-degree relatives

CA Cancer J Clin 2007

Page 31: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

ACS Guidelines for Breast Screening with MRI

Insufficient Evidence to Recommend for or against MRI Screening

Lifetime risk 15–20%, as defined by BRCAPRO or other models that are largely dependent on family history

Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)

Atypical ductal hyperplasia (ADH) Heterogeneously or extremely dense breast on

mammography Women with a personal history of breast cancer,

including ductal carcinoma in situ (DCIS)CA Cancer J Clin 2007

Page 32: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

ACS Guidelines for Breast Screening with MRI

Recommend Against MRI Screening (Based on Expert Consensus Opinion )

Women at <15% lifetime risk

CA Cancer J Clin 2007

Page 33: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

High Risk Screening: Cost

Clinical Breast Exam $ 150.00Mammogram 170.00Bilateral MRI 1000.00

Page 34: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Diagnostic Imaging

Page 35: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Diagnostic Imaging

• Workup of an abnormal screening mammogram

• Evaluation of a palpable abnormality or other breast complaint• Evaluates characteristics of palpable mass• Screens remainder of breast

• Imaging of breast cancer after diagnosis• No emergency mammograms

• Radiologist available to interpret at time of imaging

Page 36: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Diagnostic Imaging

• Workup of an abnormal screening mammogram

Page 37: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

BIRADS® Assessments

0 – Additional imaging evaluation needed 1 - Negative (routine screening) 2 - Benign (routine screening) 3 - Probably (6m f/u) 4- Suspicious (biopsy) 5 - Highly suspicious (biopsy) 6 – Known, biopsy proven cancer (**New!!**)

Page 38: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

CC MLO

Page 39: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Spot compressionMagnification

Page 40: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,
Page 41: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,
Page 42: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Spot compressionMagnification

Page 43: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,
Page 44: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Ultrasound evaluates a mammographic mass

Page 45: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Diagnostic Imaging

• Evaluation of a palpable abnormality or other breast complaint• Evaluates characteristics of palpable

mass• Screens remainder of breast

Page 46: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Evaluation of a Palpable Abnormality

• Ultrasound is the mainstay • Identifies over 99% of palpable cancers• 99+% negative predictive value• Not perfect (but close)

• Mammography• Mainly useful for screening the remainder of

the breast• Required by COPIC• A negative mammogram does not exclude

cancer

Page 47: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Ultrasound of palpable mass

Page 48: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Diagnostic Imaging

• Imaging of breast cancer after diagnosis• No emergency mammograms

Page 49: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Imaging after diagnosis

Page 50: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

MRI Ipsilateral Breast

Multifocal/Multicentric

Pre-Contrast Post-Contrast

Page 51: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

MRI Contralateral Breast

“MRI Evaluation of the ContralateralBreast in Womenwith Recently Diagnosed Breast Cancer”Lehman CD, et al

NEJM Mar 29, 2007

Page 52: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

MRI Contralateral Breast

25 institutions Minimum 50 MRIsMinimum 5 MRI biopsies

969 participants30 cancers detected (3.1%)10% false positive biopsiesNPV 99%

Page 53: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

MRI Contralateral Breast

“The current cost of MRI precludes its widespread use in general populations, but this imaging tool appears to improve the detection of cancer in women at increased risk, such as women with a recent diagnosis of breast cancer.”

Lehman et al, 2007

Page 54: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What Every Surgeon Should Know About Breast Cancer

Lymph Node Staging

Page 55: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival

Tumor size Lymph node metastasis

Page 56: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival - Tumor size

Tis noninvasive T1 < 2 cm T2 greater than 2 cm but not greater than 5

cm T3 greater than 5 cm T4 chest wall, skin or inflammatory

involvement

Page 57: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival Lymph node metastases

Clinical staging cN0 no regional lymph node metastases cN1 positive lymph nodes, movable cN2 matted lymph nodes or positive internal

mammary nodes cN3 positive infraclavicular nodes or

internal mammary + axillary nodes orsupraclavicular nodes

Page 58: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival Lymph node metastases

Pathologic staging– pN0 no regional lymph node metastases

Single tumor cells or clusters < 0.2 mm pN0(i-) IHC negative pN0(i+) IHC positive pN0(mol-) RT-PCR negative pN0(mol+) RT-PCR positive

Page 59: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival Lymph node metastases

pN1 positive regional nodespN1a 1-3 positive axillary LNpN1b positive internal mammary

nodes found by SNBx onlypN1c = pN1a+pN1c

Page 60: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival Lymph node metastases

pN2 positive regional nodespN2a 4-9 positive axillary LN (at

least one >2 mm)pN2b positive internal mammary

nodes clinically apparent

Page 61: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Breast Cancer Survival Lymph node metastases

pN3 positive regional nodespN3a >10 positive axillary LN (at

least one >2 mm) or infraclavicularLN positive

pN3b positive internal mammary nodes clinically apparent + pos axillary nodes

pN3c positive supraclavicular nodes

Page 62: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictors of Lymph Node Metastasis

Tumor size Lymphovascular invasionTumor gradePatient age

Page 63: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Axillary Node Dissection

Page 64: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Axillary Node Dissection

Lymphedema Parasthesias Pain Shoulder dysfunction

Page 65: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Definitions –Axillary lymph node dissection

Page 66: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Definitions-Lymphatic Mapping

Page 67: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Definitions-Sentinel lymph node

Lymph nodes identified by lymphatic mapping

Clinically suspicious lymph nodes

Page 68: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Definitions-Sentinel lymph node biopsy

Page 69: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Consensus statements

American Society of Breast Surgeons Institute for Clinical Systemic Improvement Canadian Steering Committee Consensus Conference Committee,

Philadelphia German Society of Senology

Page 70: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Philadelphia Consensus Conference

Sentinel node biopsy can replace routine axillary lymph node dissection for patients with no disease in the sentinel lymph node, with no further axillary treatment necessary.

Schwartz GF, Giuliano AE, Veronesi U, et alCancer, 2002

Page 71: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Specific situations

Positive sentinel node biopsy Large tumors Inflammatory breast cancer Multicentric tumors DCIS Male breast cancer Pregnancy Internal mammary nodes Prior breast or axillary surgery

Page 72: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Positive sentinel lymph nodes

48% of patients with a positive sentinel lymph node will have additional disease found at axillary node dissection

Page 73: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Positive sentinel lymph nodes

Immunohistochemistry upstages H&E negative lymph node status in 10% of patient pN0i+

Node deposits <0.2 mm are also pN0 No recommendation on axillary node

dissection

Page 74: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Positive sentinel lymph nodes

MicrometastasesNode deposits 0.2<2.0 mm20-35% will have additional positive

LNs

Page 75: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Are there alternatives?

Predictive models Axillary Radiation

Page 76: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Predictive models:Van Zee: Ann Surg Oncol, 2003

Page 77: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Axillary Radiation

NSABP B-04 (1985) 818 patients clinically node negative MRM, TM+XRT, or TM alone 10 year axillary recurrence 1.4% (MRM) vs

3.1% (TM+XRT)

Page 78: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Axillary Dissection vsRadiation

Where is the sentinel lymph node?

Page 79: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Surgeons view of the axilla

Page 80: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Radiation Oncologistsview of the axilla

Page 81: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What we did:

2: Interest point viewed on AP DRR; vertebral body level and distance toinferior border of clavicle evaluated

T4

Page 82: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What we did:

3: Interest point evaluated relative to previously designed tangential whole breast fields

Page 83: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Relationship of SLN to Tangent

A: inside treated field - 78%

B: under corner block - 12%

C: outside of field -10%

A+B: if removed corner block -90% A=78%

B=12%C=10%

Rabinovitch et al University of Colorado Cancer Center

Page 84: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

SLN Position and Tangent FieldsKey Findings/Conclusions

Position of SLN relative to vertebral body level Ranges from T2-T7 most often opposite T4 on an AP view

Relationship of SLN to tangents Outside of field 10% Under supero-posterior block 12% Within treated field 78%

Relationship of SLN to clavicle Located inferior to clavicle in 94% Most superior SLN was located 1.5 cm above base of clavicle

Conclusions: Extension of tangents to 1.5 cm above bottom of clavicle would

include SLN in 100% of patients Nearly all SLNs (94%) are located outside of traditional axillary

radiotherapy fields If corner block removed, SLN within treated tangents 90%

90% within treated field if remove corner block

Page 85: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Ongoing studies

NSABP B-32 Randomized SN- patients to ALND vs. no

further surgery EORTC 10981

Randomized SN+ patients to ALND vs. axillary radiation

ACOSOG Z0011 Randomized SN+ patients to ALND vs. no

further therapy (tangential breast radiation only)

Page 86: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Panel recommendations

Macrometastases>2mm

Deposits <0.2 mm

Micrometastases0.2mm<2 mm

IHC+ SNNegative SN

ALNDNo recommendation

No ALND

Page 87: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Multicentric Tumors

10% of presenting breast cancers Tumor in more than one quadrant or

separated by more than 2 cm Peritumoral vs. Subareolar injections SNBx performance similar to patients with

unifocal disease

Page 88: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Ductal Carcinoma in Situ

5-15% are IHC positive SNBx if local treatment is mastectomy

Page 89: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Male Breast Cancer

1700 male breast cancers diagnosed annually

Survival equivalent for women with similar stage

Treatment of male breast cancer parallels treatment for women

Unlikely the SNBx would be less accurate

Page 90: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Pregnancy

Vital dye (lymphazurin) contraindicated Radiolabled colloids probably safe Insufficient data for specific recommendations

Page 91: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Internal mammary lymph nodes

No survival advantage Rarely site of local recurrence Likelihood of SN site 10% Likelihood of metastatic involvement 1% Insufficient data for specific recommendations

Page 92: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Prior breast surgery

Prior diagnostic or excisional breast biopsy not a contraindication

Breast reduction may be contraindication for tumors in the lower or medial aspect of the breast

Breast augmentation with submammary or subpectoral implants probably not a contraindication

Minimal data

Page 93: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Conclusions

Sentinel lymph node biopsy replaces axillary dissection in most situations

An axillary dissection should be performed for most patients with positive sentinel nodes

Morbidity from breast cancer treatment is decreased by limiting axillary dissection to patients with positive lymph nodes.

Page 94: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What Every Surgeon Should Know About Breast Cancer

Medical Oncology

Page 95: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Medical Oncology

Neoadjuvant chemotherapyGenetic profiling - Oncotype

Page 96: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Medical Oncology

Neoadjuvant chemotherapy

Page 97: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Inflammatory breast cancer: T4d N3c M1

Page 98: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Rational of Neoadjuvant Chemotherapy

What we learned from inflammatory breast cancerLocal vs. systemic disease

Page 99: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Effect of Preoperative Chemotherapy on Local-Regional Disease in Women With Operable Breast Cancer: Findings From National Surgical Adjuvant Breast and Bowel Project B-18

Bernard Fisher, et alJ Clin Oncol 1998

Page 100: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Effect of Preoperative Chemotherapy

Disease Free Survival no effect

Distant DFS no effect

Overall Survival no effect

Breast conservation 20% increase

Page 101: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Pre-contrast Post-contrast

Pre-NeoAdjuvant Chemotherapy

Page 102: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Pre-contrast Post-contrast

Post-NeoAdjuvant Chemotherapy

Page 103: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Neoadjuvant Chemotherapy

Who should get it? Inflammatory breast cancerT3/4 tumors not amenable to immediate

surgeryLarge tumor volume to breast volume

ratio desiring breast conservationClinically palpable lymph nodes

Page 104: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Neoadjuvant Chemotherapy

What should they get?Chemotherapy

Adriamycin?Herceptin?

Antiendocrine therapyAromatase Inhibitor

Page 105: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Medical Oncology

Genetic profiling Oncotype

Page 106: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Medical Oncology

55 year old woman treated with lumpectomy/sentinel node biopsy 3 cm High grade ER 60% PR 10% Her-2-neu negative

Page 107: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Oncotype Dx

Produced by Genomic HealthRNA from tumor extracted and purifiedRT-PCR of 21 genesReverse transcription polymerase chain

reactionRecurrence score calculatedBased on “proprietary” Oncotype algorithm

of gene expression

Page 108: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Oncotype Dx21 Gene Assay

Page 109: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

21 Gene PanelAnalyzed by RT-PCR

Page 110: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

What is sent in?

•10 micron section of breast tumor from formalin fixed paraffin embedded tissue submitted x 6

•1 H&E slide from same block

Page 111: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

$3460

Page 112: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

A Multigene Assay to Predict Recurrence of Tamoxifen-Treated, Node-Negative

Breast CancerSoonmyung Paik, M.D., Steven Shak, M.D., Gong Tang, Ph.D., Chungyeul

Kim, M.D., Joffre Baker, Ph.D., Maureen Cronin, Ph.D., Frederick L. Baehner, M.D., Michael G. Walker, Ph.D., Drew Watson, Ph.D., Taesung Park, Ph.D., William Hiller, H.T., Edwin R. Fisher, M.D., D. Lawrence Wickerham, M.D.,

John Bryant, Ph.D., and Norman Wolmark, M.D.

Number 27December 30, 2004Volume 351:2817-2826

Page 113: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Tumors from patients enrolled on 2 NSABP trials analyzed:

NSABP B-14 ER+ LN- breast cancer Tamoxifen (n= 290) vs. Placebo (n=355)

NSABP B-20 ER+ LN- breast cancer Tam (n=227) vs. Tam/CMF (n=434)

Page 114: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Recurrence Score

30%14%7%

10-yr distant

recurrence rate

>3118-300-17Oncotype

Score

HighRisk

IntermedRisk

LowRisk

Page 115: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Treatment benefit

T amoxi f en benef i t by r ecur r ence scor e

0

20

40

60

80

100

120

R e c u r r e n c e s c o r e

Pl acebo

T amoxi f en

Page 116: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Treatment benefit

CMF benefit by recurrence score

0

20

40

60

80

100

Recurrence score

Surv

ival Tamoxifen

CMF

Page 117: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

When to order Oncotype Dx

Newly diagnosed breast cancer Stage I/II, node negativeT1N0 or T2N0

ER+To be treated with Tamoxifen No data on aromatase inhibitors, ER-, or

node + patients

Page 118: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Rate of Distant Recurrence as a Continuous Function of the Recurrence Score

Page 119: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Implications for Therapy

Recurrence score of <18 (Low Risk)No benefit from chemotherapyBenefit from tamoxifen

Recurrence score of > 31(Hi risk)Large absolute benefit from chemotherapyAbsolute increase in DRFS at 10 yrs

27.6%

Page 120: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Medical Oncology

55 year old woman treated with lumpectomy/sentinel node biopsy 3 cm High grade ER 60% PR 10% Her-2-neu negative

Page 121: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Oncotype Score 37

Page 122: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Oncotype Score 37

Average 10 year Risk of Distant Recurrence Tamoxifen only - 25% Tamoxifen + CMF - 9%

Absolute benefit – 16% Relative benefit – 66%

Page 123: What Every General Surgeon Should Know About Breast Cancer · What Every General Surgeon Should Know About Breast Cancer Christina A. Finlayson, MD Associate Professor, Surgery Director,

Conclusion

Breast cancer is not “one” disease Biologic markers are being identified that

predict response to treatment Therapy is being tailored to specific tumor

characteristics, increasing benefit and decreasing risk