overview of metastatic breast cancer.pptx

overview of management of metastatic breast cancer

1. Recurrent /Metastatic breast cancer

2. Workup History and physical exam CBC, LFT including ALP Imaging: CT thorax CECT abdomen Bone scan or NaF PET/CT (cat 2B) X-rays of symptomatic bones, and bones abnormal on bone scan

3. Biomarker testing Biopsy of at least first recurrence. Consider rebiopsy if progression ER/PR/Her2 status Germline and somatic profiling to identify candidates for additional targeted therapies Genetic counselling if hereditary

4. Systemic therapy ER/PR+ Her2 neg ER/PR & Her2 + ve ER/PR neg & Her2+ve TNBC Assess GC for fitness for therapy.

5. Visceral crisis  initial systemic therapy to continue until progression or unacceptable toxicity No visceral crisis, h/o prior endocrine therapy within 1 year Premenopausal ovarian ablation/suppression + systemic therapy Postmenopausal  systemic therapy, if progression, switch to different endocrine regimen No visceral crisis and no prior endocrine therapy within 1 year  Add ER modulators in premenopausal

6. Progression: If HR+, alternative endocrine therapy ± targeted therapy if her2+ve No clinical benefit after upto 3 sequential endocrine therapy regimens or symptomatic visceral disease. SYSTEMIC THERAPY If unfit, supportive care

7. ESMO guidelines If visceral crisis, chemo first. Else, All ER+/HER2neg cases Endocrine therapy + CDK 4/6 inhibitor. PIK3CA, BRCA1/2, PALB2(optional) mutation testing if progression All TNBC cases, assess PD-L1, germiline BRCA1/2. PALB2 optional

8. Surgical aspects LRR following surgery, disease in Breast Chest wall post mastectomy Ipsilateral or parastermal or infra/supraclavicular lymph nodes Skin of chest wall Reconstructed breast 2 nd carcinoma

9. LRR can present as isolated local recurrence or with distant metastasis Higher grade of cancer, HER2+ , TNBC, younger patient age, inadequate surgical margins Short disease-free intervals, lymph node recurrence, skin lesions, and lack of tumor ER expression all portend greater risk of disseminated cancer.

10. Isolated local recurrence Recurrence following breast conserving surgery and radiation therapy Recurrence following mastectomy, axillary dissection and radiation therapy Recurrence following mastectomy and axillary dissection without radiation therapy

11. Workup MRI>Mammography. MRI has high NPV. Restaging: Metastatic workup ER/PR/Her2 status: 30% tumors change. [Lowery AJ, Kell MR, Glynn RW, Kerin MJ, Sweeney KJ. Locoregional recurrence after breast cancer surgery: a systematic review by receptor phenotype. Breast Cancer Res Treat. 2012;133(3):831–41] Operability: mastectomy vs rewide excision, reconstruction, axilla

12. Why operate on recurrences? 5-year survival of isolated chest wall recurrence post mastectomy is 68%, and IBTR post BCS is 81% Mastectomy is standard for IBTR, BCS can be considered if negative margin is ensured. Higher incidence of second recurrence in BCS, but impact on overall survival is uncertain. [ Ma J, Jiang R, Fan L, et al. Isolated locoregional recurrence patterns of breast cancer after mastectomy and adjuvant systemic therapies in the contemporary era. Oncotarget . 2015;6:36860–9. ]

13. Ipsilateral LRR vs New primary A long interval since first treatment, Different tumour location in breast and different receptor status or tumour grade indicates a second tumour . Different tumour histology may also help in differentiation between LRR and second independent tumour .

14. IBTR post BCS Panet -Raymond V, Truong PT, McDonald RE, Alexander C, Ross L, Ryhorchuk A, Watson PH. True recurrence versus new primary: an analysis of ipsilateral breast tumor recurrences after breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2011 Oct 1;81(2):409-17. doi : 10.1016/j.ijrobp.2010.05.063. Epub 2011 Feb 1. PMID: 21288654. True recurrence vs new primary 

15. Re-wide excision Salvadori et al, 1999, repeat lumpectomy may be performed in patients having a single lesion, close to the previous scar, away from subareolar tissue and involvement of only breast parenchyma Wide excision with 1-2cm margin including previous scar, right down to pectoralis fascia

16. Salvage mastectomy Multicentric lesion, Lesion away from previous scar, Small breast, Involvement of the skin or fixity to pectoralis muscle

17. Chest wall recurrence Rare after mastectomy Usually presents as skin thickening, skin oedema, subdermal nodules, redness, erythema, ulceration, or satellite nodules. Can also present as a palpable bulge or mass under the skin flap due to recurrence in Intercostal muscles Serratus anterior muscle Ribs 30% have distant metastasis

18. Wide local excision with full thickness of the chest wall in case of isolated chest wall involvement. Patient selection is key Example: long duration between treatment completion and recurrence, favourable histology, and early stage of original disease with a negative axilla.

19. Nodal recurrence ALND  RT  Hormone therapy Internal mammary nodal recurrence  RT f/b systemic therapy (if no RT received previously). Case reports of VATS for internal mammary lymphadenectomy for isolated tumour recurrences

20. Isolated local recurrences- post excision prognosis Retrospective analysis in 2020 by Chi-Chan Yu et al Time to recurrence <29 months, primary size >2cm, grade III tumor poor OS and distant metastasis free survival In patients post mastectomy with resectable local recurrence  surgery +RT+ systemic therapy 69% 5-year DFS and 88% 5-year OS

21. Metastatic breast cancer Role of surgery Survival few months to years. Median 18-24 months. Oligometastatic vs polymetastatic

22. Patient presentation Scenario Presentation Treatment A Obvious fungation , ulceration, bleeding or pain Improved quality of life. No difference in OS or response to systemic therapy. Operability and possibility of complete resection. Reconstruction. B Minor ulceration or impending fungation not affecting quality of life Systemic therapy first, if poor response  operate, provided operable C Good response to systemic treatment at both primary and metastatic sites Benefit from surgery vs no benefit. D Oligometastatic disease with resectable primary site Surgery of the primary tumour may be considered for patients with bone-only metastasis, HR-positive tumours , HER2-negative tumours , patients <55 years, patients with OMD and those with a good response to initial systemic therapy [II, B]. : ESMO

23. Metastatic site local therapy SITE THERAPY Liver Refractory Pain, bleeding. Biliary obstruction. Peripheral lesions  surgery. Central lesions  SBRT Lungs Symptomatic. ICD. Isolated lung mets can be resected Brain Craniotomy & SRS, ESMO , consider systemic therapy first, Sx /SRS for 1-10 BM, WBRT >10 Bone Fracture