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The Diagnosis and Management of Screen Detected Breast Cancer and DCIS
The Diagnosis and Management of Screen Detected Breast Cancer and DCIS Chris Allan Epidaemiology Ø Australia- 10 000 new cases breast cancer annually Ø 15% DCIS Ø Commonest cancer (excluding non- melanomatous skin Ca) Ø Leading cause cancer related death Screening Ø Goal – identify asymptomatic Ca’s Ø Allow l Earlier intervention l Breast conserving surgery l Improve prognosis l Population benefit BreastScreen Australia / Qld Ø Since 1991 offered free (no referral) screening MMG to women > 40 Ø Target groups Qld (2001/02) l < 40 ineligible l 40 – 49 eligible 30.8% l 50 – 69 actively recruited 58.7% l > 70 eligible 35.7% Ø Screen 70% for maximal cost-benefit BreastScreen Qld 2002 Ø Outcomes 93% NAD 7% recall Ø Breast Ca detection l 965 cancers • 84% invasive (64% < 15mm T1) • 16% DCIS l 54.5 cancer per 10 000 women screened Ø 68.6% BCS Ø 31.4% mastectomy (more common rural and remote women) Diagnosis 50 – 85% 90% 91% Ø +ve when any test +ve 99.6% sensitivity Ø -ve when all 3 tests -ve History l Age – single greatest risk l FHx • Breast or ovarian Ca – 3 categories of risk • BRCA1 and BRCA2 – 1-2% all breast Ca l Hormonal exposure • Inherent • OCP • HRT l Breast disease l Radiation, alcohol, weight Examination Ø Both breasts, normal side first Ø Inspection Ø Palpation – sitting and supine Ø Nodes Ø General Mammography Ø Invasive disease Ø DCIS l Spiculated mass l Microcalcification l Architectural distortion l Circumscribed mass l Microcalcifications l Ill-defined mass l Circumscribed density l Prominent duct or l Assymetric density nodule l Architectural distortion l Asymmetry l Sub-areolar mass Ultrasound Ø Characterize mammographic abnormality Ø Dense breast Ø No role 10 screening Ø Solid vs cystic Ø Cancer – hypoechoic, height > width, irregular edge, broad acoustic shadow Imaging general Ø Problems l MMG can underestimate extent of DCIS l Lobular Ca easily missed MMG / US (and clinically) Ø Fundamentals l Side of lesion/s l Quadrant l Relationship to nipple (clockface) l Size l Calcifications FNAC Ø Cytological evaluation cellular smear Ø Palpable lesions Ø Experienced cytologist Ø False +ve 1-2% l Malignant diagnosis reliable l Atypical / suspicious ® core Bx ® 95% Ca Ø False – ve 5% l Normal breast tissue / fibrocystic ® core Bx l Benign (eg FA) ® reliable l Non-diagnostic ® repeat FNAC or core Bx v Cannot distinguish DCIS from invasive Ca Core biopsy Ø Histological evaluation tissue core Ø Impalpable lesions Ø Indications l ? DCIS l Inconclusive FNAC l Discrepancy between FNAC and clinical/radiological features Ø Advantages over FNAC l Fewer inadequate specimens l More information – grade, type, DCIS vs invasive, lymphatic invasion, IHC Biopsy of impalpable lesions Ø Majority screen detected lesions ® 15-30% malignant Ø US or stereotactic MMG core Bx l US whenever possible l Stereotactic MMG requires favourably sited lesion l Interpretation • False –ve 1-2% • False +ve rare • DCIS – up to 20% invasive disease • ADH ® hook wire biopsy Ø Mammotome Ø ABBI DCIS Ø Carcinoma confined to basement membrane Ø Microcalcifications MMG hallmark Ø Risk of invasive recurrence depends on disease extent and grade Ø Solid, comedo, papillary/micropapillary DCIS Van Nuys Prognostic Index VNPI (Silverstein et al) Score 1 2 3 Size <15mm 16-40mm >41mm or local recurrence Margin >10mm 1-9mm <1mm Pathology non-high grade non-high grade high grade - necrosis + necrosis ± necrosis Total score Management 3-4 WLE (no benefit from RT) 5-7 WLE + RT (17% reduction in LR with RT) 8–9 mastectomy (60% LR at 8 years despite RT) DCIS Ø Further indications for mastectomy l +ve margins after 2 attempts at WLE l patient choice l poorly localized and absence microCa++ (relative) Ø Meta- analysis LR (Boyages et al.) l WLE 23% l WLE + RT 8% 50% DCIS; 50% invasive l Mastectomy 2% Ø Microinvasion or > 5cm high grade DCIS ® consider level I axillary dissection (? SN) Ø Tamoxifen 5 years ˘ incidence breast Ca events (NSABP B-24) LCIS Ø No clinical or radiological features Ø Chance histological finding Ø Not premalignant either breast Ø Marker for Ca risk in Ø Ca risk 1% per annum Invasive breast cancer Ø Goals of management l Locoregional control l Prevention of recurrence l Improve prognosis l Maximize QOL Management of breast v WLE + RT (breast conservation) vs mastectomy Ø BCS appropriate when • Patient preference • Tumour size (< 4cm) relative to breast • Unifocal tumour or multifocal confined to single quadrant v Subareolar lesions or Paget’s do not preclude BCS Hook wire biopsy / WLE Ø Surgeon-radiologist-pathologist Ø Wire sited morning of OT Ø US or MMG – deploy hook 1cm from lesion Ø Films to confirm position Ø Secure wire externally Hook wire biopsy / WLE Ø Incision l Over lesion l Exclude wire entry point l Circumareolar, curvilinear, radial Ø Locate wire and remove from skin Ø Diathermy dissection Ø Core down to chest wall Ø Orientation sutures Ø X-ray lesion Ø Haemostasis, no drain, subcuticular closure, LA Surgical margins Ø At least 1mm and ideally 5-10mm Ø Deep and superficial margins can be closer – pectoral fascia and skin Ø Involved margins or focally +ve margins with EIC ® further excision Ø FS at original WLE can be helpful Ø Mastectomy indicated after 2 attempts WLE with involved margins Radiotherapy Ø Absolute CI’s l Previous breast RT l Scleroderma l Pregnancy l Unable abduct shoulder Ø Relative CI’s l Unable attend follow-up l Severe CVS or resp illness Ø 45-50 Gy in 25 fractions ± tumour bed boost Ø SE’s – skin irritation, paraesthesiae, pneumonitis, rib osteitis, 2nd malignancy rarely Mastectomy Ø Patient preference Ø BCS contraindicated v BCS and mastectomy LR comparable Ø WLE + RT 1-2% per annum Ø Mastectomy 0.5% per annum Ø Option for immediate or delayed reconstruction myocutaneous flap or prosthesis Management of axilla Ø Goals l Prognosis l Guide for adjuvant therapy l Regional control l ? Survival advantage Ø Indication for axillary dissection – invasive Ca Ø Consider avoiding when l < 5mm favourable tumour, clinically –ve axilla l Elderly or infirm Ø Axillary RT an alternative Ø 15-20% untreated axillae require later Rx Principles of axillary dissection Ø Incision l Anteroposterior l Pec major to lat dorsi Ø Axillary borders define dissection Ø Nodal levels I lateral pec minor II deep pec minor III medial pec minor Ø Preservation n’s to serratus ant, lat dorsi, med pectoral ± intercostobrachial Ø Level I and II dissection (10 LN’s) Ø SE’s – seroma, shoulder stiffness, lymphoedema, paraesthesia Sentinel node biopsy Ø First draining LN Ø Localize with mapping, blue dye and radioactive tracers Ø Detailed pathological assessment Ø Predict axillary status Ø If – ve ® avoid axillary dissection Ø SNAC trial in Australia Pathology essentials Ø Size Ø Tumour type Ø Histological grade – Nottingham score Ø Lymphovascular invasion Ø Margin status Ø Nodal involvement Ø ER / PR expression Ø DCIS – in tumour and adjacent breast Ø Changes in adjacent breast tissue Adjuvant therapy for EBC - Chemotherapy Ø ˘ relapse but no effect locoregional control Ø 10 year survival gains < 50 50- 50-69 favourable 2.6% 1.0% node –ve 7.1% 2.4% +ve node +ve 11.5% 3.2% • Majority offered CT except • > 70 • Medically unfit • Small favourable node –ve cancers • Combined regimens – CMF, AC • Begin 4-6/52 post surgery, RT to follow • SE’s – N/V, mucositis, alopecia, myelosuppression, DVT, myalgia, neuropathy, fatigue • Long term – premature menopause, acute leukaemia, cardiotoxicity, wt ^ Adjuvant therapy for EBC - Tamoxifen Ø NSAID with anti-E activity Ø Significantly l Improves survival l Reduces risk contralateral breast Ca Ø All patients with any level ER or PR expression Ø 20mg daily 5 years (after CT-RT) Ø SE’s – DVT-PE, CVA, endometrial Ca, menopausal symptoms Follow-up First yr 1-5 years > 5 years Hx and Ex 3/12 6/12 annual MMG 6-12/12 annual annual after CT-RT Multidisciplinary approach Ø BreastScreen Ø Surgeon Ø Radiologist Ø Pathologist Ø Breast care nurse Ø Oncologists Ø Allied health Ø GP References 1. cancer. NHMRC Management of early breast cancer. Clinical practice guidelines. 2nd Ed. 2001. 2. NSW Breast Cancer Institute. Breast cancer treatment protocols for clinicians. Version 1. 2001. 3. surgery.2nd Morris PJ and Wood WC. Oxford textbook of surgery.2nd Ed. 2000. 4. BreastScreen Queensland. www.health.qld.gov.au/breastscreen 5. American College of Surgeons. Surgery Principles and Practice. www.acssurgery.com (access via UQ library) 6. Weymouth M. Screen detected breast cancer. www.surgeons.org/about/ast_seminars_2003.html 7. J.M., Oncol, 12(4): 251- Dixon, J.M., Hormone replacement therapy and the breast. Surg Oncol, 2003. 12(4): p. 251-63. 8. Beral, J.M. hormone- Beral, V. and J.M. Dixon, Breast cancer and hormone-replacement therapy in the Million Women Study 9. W.K., vacuum- image- Hung, W.K., et al., Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions 10. F.H., image- Tsang, F.H., et al., Application of image-guided biopsy for impalpable breast lesions in Chinese Surg, 73(1- women. ANZ J Surg, 2003. 73(1-2): p. 23-5. 23- 11. M.J., Silverstein, M.J., et al., A prognostic index for ductal carcinoma in situ of the breast. Cancer, 1996. 77(11): 2267- 77(11): p. 2267-74. 12. Boyages, Boyages, J., G. Delaney, and R. Taylor, Predictors of local recurrence after treatment of ductal meta- 85(3): 616- carcinoma in situ: a meta-analysis. Cancer, 1999. 85(3): p. 616-28. 13. carcinoma Fisher, B., et al., Prevention of invasive breast cancer in women with ductal carcinoma in situ: an project Oncol, update of the national surgical adjuvant breast and bowel project experience. Semin Oncol, 2001. 28(4): p. 400-18. 28(4): 400- 14. Polychemotherapy for early breast cancer: an overview of the randomised trials. Early Breast Trialists' 352(9132): 930- Cancer Trialists' Collaborative Group. Lancet, 1998. 352(9132): p. 930-42.
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