The Diagnosis and Management of Screen Detected Breast Cancer and DCIS by lindayy

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The Diagnosis and Management of Screen Detected Breast Cancer and DCIS

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									  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
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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.
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      Beral, V. and J.M. Dixon, Breast cancer and hormone-replacement therapy in the Million Women
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      breast lesions
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13.                                                                                    carcinoma
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