APPROACH TO A BREAST CANCER CASE IN SURGICAL PRACTICE.pdf

Surgical approach of breast cancer covering classification, anatomy, etiopathogenesis, clinical features, diagnosis, management and prognosis of breast cancer

1. APPROACH TO A BREAST
CASE

2. » ALL WILL GET BREAST AS A SHORT CASE!!

» Commonest cancer in women in India now,
esp urban India

» Urban women- 30% of all cancers

» Incidence in India- 6.2- 39.5 cases per
1,00,000 women

>

3. HISTORY:

» GENEDER:
» Strongest risk factor for breast cancer!!
» Age: West 60-70
> India- 45-55
- Aggrawal et al, Breast cancer in India
» Occupation:
» Address:

4. » Three most common symptoms:
° 80% come with these:
> Pain
Lump
- Nipple discharge

» Main concern- Separate benign and
malignant

>

5. What are the features in
history suggestive of
malignancy?

6. » Age

» Painless lump

» Short duration

» Increasing in size

ONE HISTORY WHICH TELLS YOU THIS IS DEFINIETLY NOT
CA?
HISTORY OF REGRESSION OF LUMP
ANYTHING THAT REGRESSES IS NEVER CANCER

7. » Sanguinous nipple discharge

» Skin changes- Swelling, Redness, Ulceration

» Nipple changes- Ulceration, Destruction,
recent onset retraction

» Associated lump in axilla

» Metastatic sypmtoms- Rare (6-10%
metastatic at presentation, in India about 6-
25%)

- Aggrawal et al, Breast cancer in India

>

8. » How does breast cancer most commonly
present?

» In India-

» Palpable lump-Almost all- 50% LABC in India

- Aggarwal et al. Br Ca in India

9. A. SYMPTOMS OF PATIENTS. B. PRESENTATIONS OF BREAST CANCERS

Figure 23-3 Syrptems of breast dense and presentations of breast cancer. A, Commen syinptcens of breast dissnse. Although pain, "lumpinsas,* and nipple
‘dechargo often causo concam, these symptoms aro associetod with cancer in loss than 10% of afoctod women. B, Presentations of brosst cancer, In the
United States, more than hal! of cancers are asymptomatic and are detected by mammographic scrasring and about ancthar one third present aa palpable
massos—simost al discovered by the pationt.

Western Data

10. » Pain:
° Side
> Duration
- STAR Square
+ CYCLICAL V/S NON-CYCLICAL
° Diffuse V/s Point pain
o MOST COMMON SYMPTOM- 70% of patients
> PAIN MOSTLY INDICATES BENIGN DISEASE
°» BUT ABOUT 10% BREAST CANCERS CAN PRESNT
WITH PAIN

>

11. » CYCLICAL MASTALGIA:
° Physiological: Pre-menstrual edema
» Progestrone- Second half of menstrual cycle-
stroma edematous- percieved as pain
- Robins
+Fibro-adenosis
» Fibro-adenomas

>

12. Table 4.1 Classification of mastalgia
Breast pain
Cylcal pan

| Cause
Hormonal stimulation of normal breast lobules before menses

Norcyclicd pain

Now-beast pain
(Chest wal pin

Notechest wall pain

‚Stretching of Cooper's ligaments
| Prossure from brassiere

Fat necrosis from trauma
Hidradenitis suppurativa

Focal mastitis

Peal mat

Cyst

| Mondors disease (slemsing periphehitis of breast veins)

Tietze's syndrome (costochondritis)
| Localied lateral chest wall pain

| Diffuse lateral chest wall pain

| Radicular pain from cervical arthritis
‚Galler dscase
Ischemic heart disease

‚Source From The New England Journal of Medicine, Santen RJ, Mansel R, Benign breast disorders, Vol, 353, pp. 275-85 [8] © 2005
Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society

13. Management:

This chat once o no you and your deter lo 100
yaoi o, ar ean be an E À ho
ou One eich day by sharing each bon as tarte

Seng

For anal: you got sever bras! pala on the ith day of he
mont hen shade in completly ta square under Pas roto te day
ou pai sat wach moth with th lie P,

a NN O TEENTONEENTEE NTM OIENEIRINTRTATATETA CNT CAT TE)
— + wtf tn SO a YE a FA

Fig A) Caf reat un chart

14. 78 A. Goyal and RE Mansel

|Tarvcadlen 10 mgid.x 3 [Good response | Tamoxiten 10mytd loto the tuner sio

a ii

Danazol 100mg ute
Danazol 20m x 3 [Good response

Vo o mass qe

Goseralin 3 Emg/monn
16 months

Fig. 4.3 Algorithm for the management of mastalgia

15. » Lump:
» Side
» Duration
» Onset:
Reason-
» Progression
» Associated symptoms

D.

16. » Lumps- Reported by patients
» Most commonly
o Cysts
Fibroadenomas
Ca
» Others-
> Fibroadenosis
° Phylloides

>

17. » Chance of malignancy-
» Increases with age

» Age <40- 10% of breast lumps- Malignant
» Age >50- 60% of breast lumps- Malignant

- Robins

18. » Nipple Discharge:

> Type

» Duration

» Side

» Single V/s Multiple ducts
» Spontaneous V/s Induced

>

19. » Presenting complaint - 5%
» Sole presenting complaint of cancer- 1%
» Overall mailign in 3-7% of patients
> Why?
No TDLUs in nipple

- Management of breast diseases. Ismail Jatoi

>

20. What is significant nipple

discharge
Table 3,1 Characteristics of pathologic and physiologic nipple
discharge

‘Charactenstc | Physiologic | Pathol gic
Laterality Bilateral “Unilateral
#Ducts Multiple | One
Spontancity | Expressed | Spontancous
Color |Multicolored, milky, gray, | Bloody,
green. brown, yellow serous, clear
Consistency Sticky, thick | Watery,

- Management of breast diseases. Ismail Jatoi copious

21. » Pathological nipple discharge:

» Most common cause- Benign proliferative
breast disorders

» MC Cause- Pappiloma

» What percentage of sign ND is a/s/w malign?
> 4-21%

» But if other assoc features, percentage will
rise-
> Mass plus nipple discharge- 61%- malignancy!

>

22. Table 3.4 Causes of pathologic nipple discharge
Papilloma

Papiloma

Pally caca

Ductal carcinoma in situ
Invasive ductal carcinoma

ca ei ype

u Cystsibrocyste disease/duct ectasia

23. Table 3.2 Causes of nonpathologic nipple discharge
Hormonal

Bloody ¢ discharge of y pregnancy

Infection (Zuska* $ disease)
Montgomery $ sland discharge |
Fibrocystic change

- Management of breast diseases.
Ismail Jatoi

24. 3 Nipple Discharge 69

History and PE
Multiple ducts, bilateral yr A Single duct, unilateral
expressible, multicolored Spontaneous, serous, bloody
Reassure/ annual mammogram MammogranvUltrasound
Mover 40
ET >
Negative Positive
Schedule Duct Excision Percutaneous BX
Ductoscopy-directed or Ductogram/ Blue dye z Ne
(Benign ProliferativeLesion) (Cancer) (Benign) (Cancer)
de MAI
(to determine extent)
’
Routine follow-up and mammography BCT or mastectomy

Fig. 3.9 Algorithm

25. » Nipple changes:
° Redness
» Destruction
» Inversion/ Retraction
- Nipple retraction of recent onset- S/o Ca

26. » Nipple retraction
» Skin changes

>

27. » Lump- Axilla
» Opposite breast
» Opposite axilla/ Neck

» Bone pains, shortness of breath, cough with
hemoptysis, chest pain, RHC pain , abd
distention, jaundice, abd mass

>

28. » Most common sites of breast cancer
metastasis:

» Bone- 50-60%

» Lung 17-20%

» Brain-16%

» Liver- 6%

» Multiple-10%

» Other LNs- 10%

- Patanaphan V et al. South Med J 1988

D.

29. » Which are most common sites for metastasis
of breast cancer in order of occurrence:

» HR+

» Bone-70-80%

° Lymph nodes

» Visceral- 10-20%
Pleural
* Lung
+ Liver
- Brain

u

30. » HER-2 +;
> Most common visceral- 30-40%

» Brain- 30%
Rem- 70%
» TNBC:

+ Almost same as Her-2 Neu

>

31. » Which bones you will ask for pain?
» MC- Lumbar spine
2 Why?
> Intercostal vein- Batson’s venous plexus vertebra

32. » Past History:
° Co-morbidities
» Prev benign breast diseases/ breast biopsies/breast
surgeries
° Use of OCP/HRT

>

33. Table 23-1 Epithelial Breast Lesions and the Risk of Developing
Invasive Carcinoma

E
Cysts

Apocrine change
Mild hyperplasia

Adenosis
Fibroadenoma without complex features

\[Proliterative Disease Without Atypia [lll] 1-5 to 2 6%-790

Moderate or florid hyperplasia

Sclerosing adenosis

Papilloma

Complex sclerosing lesion (radial scar)

Fibroadenoma with complex features oo o
(Proliferative Disease with A pa 4 10 5 (13%-17%)

Atypical ductal hyperplasia (ADH)

Atypical lobular hyperplasia (ALH) a
[Carcinoma in Sit) 5 10 10 (25%-30%)

Lobular carcinoma in situ (LCIS)

Ductal carcinoma in situ (DCIS)

“Relative risk Is the risk compared to women without any risk factors. Absolute lifetime risk Is
the percentage of patients expected to develop Invasive carcinoma if untreated.

34. » Personal history:
» Menstrual history:

» Age at menarche

» Pre/ Post menopausal
» If pre- Cycles; LMP

» Age at menopause

» Reproductive history:
» Age at first child birth
» No of children

» Breast fed or not

» Duration of breast feeding

35. Magnitude of Risk of Known Breast Cancer Risk Factors

Relative Risk <2 Relative Risk 2-4

Early menarche One first-degree relative with
Late menopause breast cancer

Nuliparity CHEK2 mutation

Estrogen plus progesterone Age >35 y forfirst birth

HRT Proliferative breast disease
Alcohol use Mammographic breast density
Postmenopausal obesity

LCIS, lobular carcinoma in situ; HAT, hormone replacement therapy.

Relative Risk >4

Mutation BRCA1 or BRCA2
LCIS

Atypical hyperplasia
Radiation exposure before 30

36. Graphic

Risk factors

Deleterous Negative Positive =.0 10
MACATIMRCAZ 7.0
genes

Mother or st
with breve)
cancer

Age 3016 24 70 to 74 18.0
Age 14 12
-20 -30

No von 2.0

at menarche
at fret birth

Ace

Age at as ->s

menopnuse

Use or Ne Past/aurent 1.07 to
contraceptive se it |

pi

Hermene Never Current 1.2

replacement
therapy Costrogen
+ progestin?

Alcohol

Breast censity on
meammeography
(Percents)

Bone denmity

Highest
quartile

von

History of a
benign breast

biopsy

History of No
atypical
hyperplom
blopey

37. Graphic

+ pragsatin)
Alcohol 210

S drinkarday
Breast density on =75
mammography
(percents)
Bone density

Mistery of a
bentan breast
biopay
History of
atypical
hyperplasia on
blopeay
Protective factors

Breast feeding
meonthe

Parity

Recreational
exerciae

Postmencpouse

body mana inde:

Chaser =>

Oophorectormy

before age 35

yearn

Aspirin =Once/week | Nonusers
for =6
months

Adapted from: Clemons M. Gous PR Estrogen end the tak of breast
cancer NM ENG! 4 Med 2001: 344:270.

Graphic 64508 Version 4.0

© 2020 UpToDate, Inc. All rights reserved

38. Who are women at high risk?
» Strong family history
» Pre-invasive lesions-
- LCIS
- Atypical Ductal Hyperplasia
- Atypical Lobular Hyperplasia
» Thoracic radiation before age 30

» NCCN 2017- Women >35 years with
any of above- Risk estimation

>

39. Relative Risk

Age at menarche (years)
214 1.00
12-13 1.10
<12 121
Number of blopsies/history of benign breast disease, age <50 y
o 1.00
1 170
32 2.88
Number of biopsies /history of benign breast disease, age 250 y
o 1.02
1 127
22 1.62
‚Age at first five birth (years)
<20y
Number of first-degree relatives with history of breast cancer
124
1 2.68
22 5.78
25-29 y
Number of first-degree relatives with history of breast cancer
o 155
1 2.76
22 a1
230 y
Number of first-degree relatives with history of breast cancer
o 193
1 2.83

417

40. Criteria Used in Calculation of 5-year Risk for Breast Cancer According to
the Modified Gail Model

(Available at www.breastcancerprevention.com)

Question Response
Age _

Age at menarche (first menstrual period)
Age at first live birth or nulliparity

Number of breast biopsies

Atypical hyperplasia Y/N
Number of first-degree relatives with breast
cancer E

Caucasian, African
Race/Ethnicity American, Hispanic,
Other

> EEE = O

41. WHEN TO USE
CHEMOPREVENTION?

» ATYPICAL HYPERPLASIA(Category-1)
» LCIS(Category-1)

» HISTORY OF THORACIC IRRADIATION,
AGE <30 YEARS(Category-2)

» Women age 35 and above, 5-year Gail
risk of breast cancer >1.7%(Category-1)

» NCCN 2017 Guidlines
» ASCO Guidlines 2013

42. » Chemoprevention:
» SERMs
» Post- Menopausal- Als

» Duration- 5 years

O

43. Family History:

» Why?

E

44. Craie NCCN Guidelines Version 1.2020
: Hereditary Cancer Testing Criteria

TESTING CRITERIA FOR HIGH-PENETRANCE BREAST ANDIOR OVARIAN CANCER SUSCEPTIBILITY GENES
[Mi often includes BRCA!, BRCAZ, COHF, PALB2, PTEN, and TPS2 among ofbars. Ste foe a more complete st pe

Testing ls cleicaby indicated In th following ycenarios
{. Indrviduals with any blood relative witha known puthogeniclihely pathogenic varla in a cancer swsceptibity gene
2 Individuals meeting the crtera below but with pervious ted testing (eg single gene andlor absent dein
tupietion analysis) interested in purslng roi gare testing
2. Personal history of cancer
+ Bevast cancer with af east one the following
» Dlagrosed at ape SA y, or
» Dlagrced at age 46-50 y with
Unknow or ited family history, or
A second breast cancer dlagnostd at any age; or
2 close blood relative! wit breast, ovarian, panceati, or high-grade (Gleason scort
prostate cancer at any age
» lagnosad at age $y with biple-negative breast cancer
» Dlagresed a any age wih:
Ashanti Jewish ancestry; or
2 cha thood relativa" with breast casa at ape SEO yor ovarian, pancreatic, or metastatic e intraductal
prostate cancer at any age; e
2A total dagnoses of breast cancer inpatient andlor close blood relatives
+ Dlagnoned at any age with ale breast cancer
+ Epithelial ovarian cancer (including fallogias tube cancer or periloneal cancer} at any age
+ Eneerine parer cancer at any aged )
« Metastatic or intraductal prostate cancer at any age"
+ High-grade [Gleason scare 21) prostate cancer wih
» Ashheeas dnwish ancestry; or
»2 lose relative with breast cancer at age SS y or ovarian, pancreatic, or metastatic or Intraductal prostate
cancer at any age: oF
122 lose relatives with breast or prostate cancer (any grade) at any age.
«A mataton ientiied on tamer gesomic stieg that has clinical implications it also idectiid in the garmin

Jo din systemic therapy dion aig. such a or HERZ-ogatve metaia5c rast cancer
a Fay halo of cance = is

«A ocio ot write india wih a rat or second degree blood Plate meeting any cf the ceils
above (except individuals who meet crtaria only for systemic therapy decision making?

«ha loci ot enacted individual whe otherwise dos nok moet the ctra above but Bas a probably 95% ofa
BRCA 2 pathogenic varía based on prior probably models og, Tyrer-Catick, BRCAPro, Panel]

45. » What is difference between familial and
hereditary breast cancer?
» What percentage each

» Familial- 20-30%
- DeVita

- Hereditary- 5-10%
- DeVita

>

46. BRCA-1 - Located on chromosome 17
BRCA-2- Located on chromosome-13

Different Locus, Different Allele,
Same Phenotype

Chromosome 17 Chromosome 13

Allele
(gene)
Locus
(spot on
rw
Allele elie
(gene)
Locus
(spot on
zn BRCA2

A

47. NATIONAL CANCER INSTITUTE
CHANCES OF DEVELOPING
BREAST CANCER BY AGE 70

Specific mented matations in the BALA! ang BALAZ genes norase the risk of Proust and Anis canoes
Testing far these mutations +5 seually tec armmended in women withost breast cancer pray wher the person's
ineividual er fami history suggests Do possiñe pretence of a hernie matation in BACA) ar ORCAZ. Setting is
oftes recommended in pan
decisions and have inpticathere

m cemty Giagnased wath beeast cancer becouse * can infivesce treatment
their fanıty members

$ i i hi A 4 MUTATED BRCA1
55-65%
45%

i NORMAL BRCA

12%

www.cancer.gov/brca-fact-sheet

48. Nearly 85% lifetime risk of breast cancer
development

Cancer Risk in Carriers of Germ Line
Mutations in BRCA1 & BRCA2

~ = BRCAT
=BRCA2

Female Male Breast Ovary Pancreas Prostate

Prosonted try Judy Garber at 2015 ASCO Annual Meeting.

49. Cancer Type

Male Breast

Prostate

Pancreatic

Risk of Cancer in Individuals
Wth a BRCA1 or BRCA2 Mutation

Individuals With
Mutation

BRCA1 BRCA2
ra um | ma]

2) upto upto

2-7%

General Population
(No Mutation)

50. » When to consider genetic testing

» Management:

» BILATERAL SALPINGO-OOPHORECTOMY

» BILATERAL PROPHYLACTIC MASTECTOMY

» Surveillance- Annual MRI starting at 25
years/ 10 years before first case in family

» Chemoprevention

51. » Treatment History

>

52. Examination:

» Positions
» Inspection
° Puckering/ Dimpling- Cause

What are ligaments of cooper?
Pea u d'orange
- Cause

» Arm and Thorax

» Axilla, SC Fossa

» Opposite

Must not forget

53. » Palpation:
» Position

» Axilla- Both
» Neck

» Percussion
» GE- MUST!!

» DIAGNOSIS:

>

54. STAGING- AJCC-8

» Please read AJCC-8:
>» New- two groups

E

55. » Cancers staged using this system:
- Invasive carcinoma of the breast
- Ductal carcinoma in situ(DCIS) of the breast
» Cancers Not staged using this system:
Breast sarcomas
° Phyllodes tumour
- Breast lymphomas

>

56. » SIGNIFICANT CHANGES:

» Two stage groups:
» Anatomic Stage Group-
- Based on T,N,M categories
> Prognostic Stage Group-
+ Includes T,N,M PLUS
+ TUMOUR GRADE
+ STATUS OF BIOMARKERS- ER,PR, HER 2

D.

57. 41% PATIENTS WILL HAVE
RE-ASSIGNEMENT OF STAGE
WITH NEW STAGING!!!

58. » LCIS removed as pTis category!
- Benign entity, hence removed
» Inclusion of multi-gene panels:
Oncotype Dx
Mammaprint
° EndoPredict
+ PAM50
° Breast Cancer Index

>

59. Anatomy:

» Chest wall:

» Ribs

» Intercostal muscles

» Serratus anterior

NOT PECTORALIS MALOR

>

60. » Regional lymph nodes:

» Intramammary lymph nodes- Axillary Lymph
Nodes for staging purpose

» Supraclavicular Lymph nodes(Ipsilateral)-
Regional lymph nodes for staging purpose

>"

61. » Cervical

» Contralateral Internal mammary
» Contralateral axillary

Classified as MI

D.

62. » Infra-clavicular:
» Apical or Level-ill lymph nodes

» Internal mammary lymph nodes:
Located in the intercostal space
- Along the edge of sternum
- In the endothoracic fascia

65. » Inflammatory Carcinoma:
» Clinico-pathological entity characterized by:
- Diffuse erythema
Edema (Peau d’ orange)
Induration

> Involving approximately one-third or more of
breast skin
» Of recent onset- Duration less than 6 months

>

66. » Primarily a clinical diagnosis
» On imaging-
° mass may be detectable
along with characteristic skin thickening
» Mass may or may not be palpable

>

67. » Cause of skin edema:
° Tumour emboli within dermal lymphatics

» Diagnosis:

» Histopathological diagnosis of tumour
required

» Skin biopsy- Not essential for diagnosis

>

68. » Tumour emboli in dermal lymphatics alone,
no characteristic skin changes?

» Tumour to be staged as per size

>

70. » Internal Mammary Lymph Nodes:
» Detected by:
- Clinical Examination
Imaging studies- CT, MR and ultrasound , not
lymphoscintigraphy
» Supraclavicular:
° Clinical Examination
° Imaging studies- ultrasound ‚CT and PET

>

71. Definition of Distant Metastasis (M)

M Categor;
Mil

CM ie)

MI

M Criteria

No clinical or nulingniphic oedence of dieran
mesrine"

No lim or radiographic evidence uf desant
metastaves im Ihe presence of tumor cells or
depues mo larger han 0.2 mm detected
microscapically ar by molecular technigwes in
circulan bocd. hane mareo, or otter
nonregional nodal tisane le à paper wihout
Speo or Aigues al meta ses

Distum metastuser dececteil by came pi and
fauliographic meune (OM stator hintologically
proven meluntiaueh harper thee 02 mm (pM)

72. Post Neoadjuvant Therapy ycT and
ycN Classification:

» Clinical examination
» And Imaging findings
» IBC- Remains IBC after NACT also

>

73. Pathological Classification:

74. PS
$;

Ph: 4-8 moco fat tent
mor Gepomt 2.0 ment

pros 10 podes (nt lema. <=>
Sn Rama depen 2. me) Lu

76. po

PNOG+)

PNG mo +»

pNi

PNimi
pNia
pNIb
PN tc

pN2

pN2a

PN Criteria

Regional lymph nodes cannot be assessed (e.g...
oot removed for pathological study or
previously removed)

No regional lymph node metastasis identified
or ITC only

ITCs only (mälignam cell clusters no larger
than 0.2 mm) in regional Iymph nodeis)
Posmve molecular findings by reverse
transeriptase polymerase chain reaction
(RT-PCR, no ITCs detected

Micrometastases: or Metastases in 1-3 axillary
Iymph nodes: andlor clinically negative internal
mamımiry nodes with micrometastascs or
mucrometustasecs by sentinel lymph node
biopsy

Micrometastases (approximately 200 cells,
larger than 0.2 men, bet none larger than 2.0
mm)

Metastases in 1-3 axillary Iymph nodes. at
least one metustusis larger than 2.0 mm
Metastases in ıpsilaseral bernal marımary
sentinel nodes, excluding [TCs

PN ta and pNib combined

Mictastuses ın 4—9 uxillary lymph nodes: or
positive ipsilateral internul mammary Iympb
modes by imaging in the absence of axıllary
Iymph node metastases

Metastases in 4-9 axillary lymph nodes (ar
leust one turen deposit larger thin 2.0 mun)

77. pN2b

PN3u

pN ib

pPNAc

Metastases in clinical ly detected internal
mammary mph nodes with or without
microscopic combirmution; with pathologically
negative axillury nodes

Metustases m 10 or more axillary lymph noxics,
ora mfractaviculur (Level IN oxiflary) lymph
nodex;

or positive ipsilateral internal mammary lymph
nodes hy imaging tn the presence of one or
more positive Level 1, IH asillary Iymph nodes;
or in more than three axillary Iymph modes and
nucrometastises or macrometastaseos by
sentinel lymph node biopsy in clinically
negative ipsilateral internal mammary Iymph
wodes:

or in ipsilateral supraclavicular Iymph nudes
Metastuscs in 10 or more axillary Iymph modes
{ot Jeast one numer deposit larger than 24) mm
or metastases to che infracksviculur (Level 111
axillary tyrnph) modes

PN la or pN2a in the presence of CN2b (positive
internal mammary nodes by imaging hk

or PN2a in the presence of pNih

Metastases sn ipsilateral supraclavicular lymph
nodes

78. AJCC Anatomic Stage Group

Then the =tage group

When Fo is... And SN i... And St is... im...
Ten mo M10 o
Lx no mo un
To ™ Eom mo iB
ri N herra mo LEE
To se mo “m
LE ma mo 1A
r= m. ma IA
= Ma mo ne
Ta mo mo zıEs
== mo tin
mz mo CITE
=z mo 1A
ma mao sn
nz mo CITES
FA o mo ts
Ta ma mo ances
Ta mz mo ur
Ace + ma mo LLC

Any T Ans ™ A! 1%

79. TI NO Mo 1 la
Tl No MO 12 lA
TI NO MO Positive Positive Positive lA
Ti NO MO 3 Positive Positive Any lA
Tu Nina MO i} Positive Any Any lA
10-1 Nimi MO 12 Negative Positive Positive lA
Tu. Nimi MO 2 Positive Positive Positive lA
Tl Nim MO 3 Positive Positive Any 1A

MultiGene Panel** - Oncotype Dx” Recurrence Score Less Than 11

Ti-2 NO Mo 13 Negative Positive Any lA
O A E A Sa ee SA
TI NO Mo 1 Negative Positive Negative 1B
{El NO Mo ' Negative Negative Positive 18
TI NO MO 2 Positive Positive Negative 18
Ti No MO 2 Positive Negative Any 18
7 NO Mo 2 Negative Negative Positive 18
n No Mo 3 Positive Negative Any 1
TI NO MO 3 Negative Positive Positive IB
Au] Nimi Mo ' Negative Positive Negative 18
m Nimi Mo 1 Negative Negative Positive 18
TO Nimi Mo 3 Positive Positive Negative IB
Tu Nim MO 2 Positive Negative Any IB
TO-1 Nimi Mo 2 Negative Negative Positive IB
m Nim MO 3 Positive Negative Any 18
Tot Nimi Mo 3 Negative Positive Positive 18

80. » What will you do?
» Mammography- B/L Breast

» Why B/L?
» Synchronous B/L- 1.5-2.5% cases

81. » How to read a MG?
» Type
» Technically adequate
» Type of breast density
» Lesion:
Location
Density
° Borders
Microcalcufications
Surrounding architecural distortion
» Any other lesion
» Skin
» Nipple
» Axilla

82. » Characteristics of a malignant lump?

>

83. BIRADS- Classification:

Fig. 9A Four BI-RADS descriptor for breast density (presented in heterngenecusly dense which may
fight MLO digital mas ums). à Type A—almest entirely fatty, €
b Type B—scattered areas of fibroglantuby density. e Type C-

bacure small lesion. d Type D

nely dense which lowers the sensúviy of memmograpty

84. inal Category |Delintion

0

1
2
3
4

Incomplete—need additional imaging evaluation and/or prior mammograms for comparison
Negative

Benign finding

Probably henign

pican acc

4A: low suspicion for malignancy

4B: Moderate suspicion for malignancy

AC: High suspicion for malignancy

Highly suggestive of malignancy

Known biopsy proven malignancy

85. » BIRADS- 3
° =/<2% Malign chance
» BIRADS-
4-A- 2-10%
4-B-10-50%
» 4-C-50-95%
» BIRADS- 5
» >95%- Chance of malignancy

>

86. » Young women- Ultrasound

» Ultrasound features of malignant mass

——

87. i E
mi eA ]

Figure 23-2 Life cycle changes. A, Mammograms in young women are typically radiodenss or white in appearance, making mass-forming lesions or calcca-
tions (which are also radiodense) difficult to detect, B, The density of a young woman's breast stems from the predominance of fbrous interlobular stroma
and the paucity of adipose tissue. Before pregnancy the lobules are small and are invested by loose cellar intralobular stroma. €, During pregnancy, branch
ing of terminal ducts produces more numerous, larger lobules. Luminal cals within lobules undergo lactational change, a precursor to mik formation. D, With
increasing age the lobules decrease in size and number, and the interlobular stroma is replaced by adipose tissue, E, Mammograms become more radiolucent
with age as a resul of the increase in adipose tissue, which facitates the detection of radiodense mass-forming lesions and calcfications. (A, E, Courtasy of
Dr. Darrel Smith, Brigham and Women's Hospital, Boston, MA)

88. » USG- Guided Core Biopsy-
» Core Biopsy V/s FNAC?

u

89. Staging Investigations:

Cancer Stage

ormmm
History & physical XXXX X
[Complete blood count, platelet count XXX Xx
Liver function tests and alkaline phosphatase level XXX XxX
¡Chest radiograph xxx x
Bilaterat diagnostic mammograms, ultrasound a5 indicated KERR X
[Hormone receptor status XXX Xx
HER-2/neu expression xxx x
Bone scan? xx x
Abdominal (without or without pelvis) computed tomagraphic scan or ultrasound or magnetic resonance LR %
imaging

* Bone scan performed for stage Il only if localized symptoms are present or serum alkaline phosphatase level is elevated.

Abdominal imaging and bone scanning are indicated for evaluation of symptoms or abnormal laboratory test results at any
presenting stage.

Source: Adapted with permission from Carison RW, et al: Breast cancer, in NCCN Practice Guidelines in Oncology. Fort

90. » What percentage come abnormal in each
stage?
» Stage 1-2:
° CXR- Abn- Nil
» Usg- Abn- Nil
Bone Scan- Stage 1-2: 5%
» Stage-Ill:
» Usg Abn- 6%
> CXR- 7%
» Bone Scan- Approx-14%

-—

91. EARLY BREAST CANCER:

» Surgery:

» TMAC V/s BCS

» BCS:

» Indication

» Contra- Indication

» Technique

>

92. » Oncoplasty

» Breast Reconstruction

>

93. » Adjuvant Therapy:

» Indications for chemotherapy
» Indications for RT

» Hormonal Therapy

» Her-2 Neu Therapy

94. BIOMARKERS:

95. » Prognostic
» Predictive
Mrakers

-—

96. Prognostic markers:

» Factors which determine the risk of
recurrence of breast cancer,
regardless of the treatment given

- Hayes D. Predictive and prognostic markers in cancer. Clin Adv Hematol
Oncol, 2011

97. » Traditional factors:

» Lymph node status

» Number of lymph nodes involved
» Tumour size

» Tumour grade

Still most important

=Cianfrocca M, Goldstein Lj. Prognostic and predictive factors in
early-stage breast cancer. Oncologist 2004

-Carter CL, Allen C, Henson DE. Relation of tumour size, lymph
node status, and survival in 24,740 breast cancer cases. Cancer
1989

-Fung F, Vanniyasingam T, et al. Predictors of 5-year local,
regional, and distant recurrent events in a population-based

ort of breast cancer patients. Am | Surg. 2017

98. Predictive Markers:

» Markers which predict response to specific
therapies:

» Most important:
» ER

» PR

» Her-2 Neu

— Hayes D. Predictive and prognostic markers in cancer. Clin Adv Hematol
Oncol, 2071

>

99. » ER Expression:

» Measured by IHC

» Any staining of 1% or more- Positive
» Level-1 Evidence

D.

100. » HER 2:
» 2013 ASCO/CAP Guidelines
» IHC- Protein Expression
» Confirmed by-ISH-Assess gene copy number
» Level-1 Evidence
» IHC:
- Negative:0 or 1+ staining
> Equivocal:2+ staining
> Positive:3+ staining

>

101. » FISH
> If Equivocal by IHC
» Dual Probe FISH:
Negative-HER2/CEP 17 <2.0 AND HER2 copy number <4
+ Equivocal(Perform alternative ISH):
» HER2/CEP 17 <2.0 AND HER2 copy number 4-6
- Positive-HER2/CEP 17 =/>2.0 OR HER2 copy number >6
» Single probe FISH:
Negative <4 HER 2 copies
» Equivocal- 4-6 copies
Positive >6 copies

>

102. Clinically Defned ~ Treatment Oriented Subtypes of Breast Cancer 4
LUMINAL LIKE LUMINAL LIKE

Hormone recepor-postive and HER2-negative luminal Hormone receptor postive and HER2-nepatve luminal disease a a spectrums
disease a a spectrum:

(luminal A-like) Multiparameler molecular marker "favorable prognosis,” available; high ERPR

High receptor, low proliferation and clearly low proliferation rate (low Ki-67, low mitotic count); generally
histological grade | or 2

(Luminal Bike) Muliparameter molecular marker “unfavorable prognosis” if avllable lower ER

Low receptor, high proliferation PR with high proliferation rate (high Ki-67, high mitovic count}; generally
histological grade 3 y

HER2 LIKE HER2-positive and hormone receplor-negative ar HER2-positive and hormone

HER?-postive receplor-positive generally histological grade 3

BASAL LIKE Negative ER, PR, and HER2: generally histological grade 3

Triple-negative

Modified with permission from Konecny eal, 20037 and Eremnann etal, 013")

103. Triple negative
(05% basal like)

—===
Treatment
strategies — ss manipulation a
Novel targeted theraples |

104. » Histological Grade:
» Nottingham Modification- Scraff-Bloom-
Richardson Grading system
» Morphological features:
- Tubule formation
» Nuclear grade
Mittotic count
Assigned value- 1-3

D.

105. 6 Definition

Grade cannot be assessed

Low combined histologic grade (favorable), SBR score of
3-5 points

Intermediate combined histologic grade (moderately
favorable); SBR score of 6-7 points

High combined histologic grade (unfavorable); BSR score of
8-9 points

106. Molecular Biomarkers in

Breast Cancer:

» ER, PR, Her-2 Neu

» IHC-4 Panel- ER,PR, Her-2 Neu, Ki-67

» Oncotype-DX

» Endo-Predict

» PAM-50

» Breast Cancer Index

» Mammaprint

» Urokinase plasminogen activator
Plasminogen activator inhibitor type-1

107. » Oncotype Dx:

» Genomic based test- Assessment of 21 genes

» Result- Outcome of a mathematical formula
of the weighed expression of each gene

» Measured and reported by RT-PCR

» Recurrence Score <11- Cut off

» Required for- T1-T2 NO MO, ER-positive,
HER-2 Negative tumours

» AJCC- Level-1 evidence

>

108. € | breast.pdf

‘SYSTEMIC ADJUVANT TREATMENT - HORMONE RECEPTOR-POSITIVE « HER2-NEGATIVE DISEASE"
PNO —+ Consider adjuvant endocrino therapy" (category 28)

[Tumor $0.5 em)

[including [Adjuvant endocrine therapy? (catogoe 28) or

as! * pNimi —e [Adjuvant cheenotherapy™* followed by endocrine
itherapy"Y (category 28)

‘Adjuvant endocrine therapy or

|pTt, pT2, or pT3;
[End pt opti / +. Not dono— | Adjuvant chemotherapy! followed
($2 mm axillary by endocrina therapy"! (category 1)
node metastasis) Low 1
Ho |mcurrenca |—* Adjuvant endocrine therapy*! >
¡score (<18)
Histology."
«Ductal intermediate ‘Adjuvant endocrine therapy or
sLobular | + |rmcurrence LJ Adjurant chemotherapy?
+ Mixed ‘score (18-30) | followed by endocrine
*Metaplastic therapy!
Ve vale |, Adjuvant endocrino therapy
score 231) + adjuvant chemotherapy

[Node positive [one or mare
‘metastases >2 mm to-one or moro

— Ye 2)
|ipstatralaxiWay tymph nodes)" Adjuvant endocrina therapy + adjuvant chemotherapy" (category 1)

motesapy and endocrino Merapy used a aduvart Peraoy shud be gen
era wh endocree Mercy slow chereferapy Arab dita
tuggest hat sequent er Cancer endocrine therapy wäh radabon thesapy is

be ae ad

"Med buat and dal carcnoma, shuld be graded basad on the ducal

Component ard treated Based on Bis gracing. For metapiasic carcinoma, te These are lites data lo make chemotherapy recommendations for hose >70 y
grognoste vate ol he hola: grace is uncertain. However, when a spectc dee

hstologe subtype of metaplastic carcnoma a present and accounts fer more Pan The 21-gene RT-PCR assay recunence score can be considered in select
10% of ne tumor the suttype i an independent progra variable atients wih 1-3 involved icslaieral auikarı ered nodes to cuite the addilion

109. Additional factors Recommended
for clinical care:

» Ki-67
» Multigene Signature Scores-
» Mammaprint
PAM 50
+ Breast Cancer Index
- Endo predict
Level- II Evidence

110. » Risk Assessment Models:
» Two models:
- Adjuvant! Online
Predict
Can be used to assist regarding decisions about
adjuvant therapy in early breast cancer patients
Both are online tools

>

111. THANK YOU