Early and locally advanced breast cancer
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This document discusses the management of early and locally advanced breast cancer. For early breast cancer, primary surgery involves lumpectomy or mastectomy followed by adjuvant treatment if needed based on tumor characteristics. Breast conserving surgery aims to preserve the breast while achieving comparable survival to mastectomy with low recurrence rates. Neoadjuvant therapy can help reduce tumor size for breast conservation. Locally advanced breast cancer may be treated with neoadjuvant chemotherapy to reduce the risk of recurrence and improve surgical outcomes. Neoadjuvant endocrine therapy is also an option for some postmenopausal women. Adjuvant radiation, chemotherapy, and hormone therapy are used based on tumor markers and response to neoadjuvant treatment. Regular
Early and locally advanced breast cancer
- 1. Management of early and locally advanced breast cancer Abhilash
- 2. Early breast cancer • Stage I • Stage II A • Subset of Stage II B (T2N1) Locally advanced breast cancer • Stage II B • Stage IIIA to IIIC
- 3. Early breast cancer Primary Surgery for breast and regional nodes– Lumpectomy or Mastectomy +/-RT • BCSMastectomy Adjuvant treatment if needed based on tumor characteristics. • Tumor size • Tumor grade • ER/PR/HER2 • LN status
- 4. Breast conserving surgery • To preserve the breast without sacrificing oncological outcome BCS= LUMPECTOMY + adjuvant RT Goals of BCS 1. Cosmetically acceptable 2. Survival comparable to mastectomy 3. Low recurrence rates
- 5. Patient selection for BCS • Comorbid conditions/ Age is not a contraindication. • Nipple, skin retraction is not a contraindication – but resection of NAC should be factored in decision making. • Extensive intraductal component is not a contraindication. • Lymph node positivity is not a contraindication. • Tumor location is not a contraindication. • Not contraindicated in dense breast tissue. • Large tumor in a small breast is a relative contraindication • Collagen vascular disease is a contraindication.
- 6. Absolute contraindication for BCS ●Multicentric disease ●Large tumor size in relation to breast ●Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or MRI) ●Prior history of chest wall RT ●Persistently positive margins despite attempts at re-excision
- 7. Role of neoadjuvant therapy in BCS • Chemotherapy or hormonal therapy to reduce size of the tumor • Clip placement in tumor bed. • Not to be considered if multicentric with extensive skin changes and dermal lymphatic involvement.
- 8. Indications for mastectomy in early breast cancer • Not a candidate for BCS. • Patient choice.
- 11. Adjuvant therapy in early breast cancer
- 17. Locally advanced breast cancer
- 18. Goal of neoadjuvant chemotherapy • Reduce risk of distant recurrence. • Improve surgical outcome in patients – Inoperable disease. – Operable disease desiring breast conservation
- 19. Candidates for neoadjuvant therapy • T4 lesions. • HER2 positive – high pCR to NACT with transtuzumab. • Triple negative disease – High pCR rates compared to HER2 negative ER/PR+ (27-45% vs 10%) • Breast cancer in pregnancy. • Early disease if BCS not possible due to small breast.
- 20. Pretreatment evaluation before NACT • Core biopsy – ER/PR/HER2 • Radio-opaque clips to be placed for subsequent assessment of surgical specimen and for RT planning. • Metastatic workup. • Axillary node evaluation and staging has to be done. SLNB/axillary US with FNA - to be done if no palpable nodes or FNA from palpable node is negative.
- 21. Neoadjuvant treatment options • Triple negative disease – NACT BCS/mastectomy. • Post menopausal women – if not a candidate for chemo/surgery Hormonal therapy. • HER2 positive – NACT + transtuzumab
- 22. Neoadjuvant endocrine therapy • Aromatase inhibitor or tamoxifen • 4-6 months. • May be as effective as NACT in postmenopausal women.
- 23. Adjuvant RT • For all BCS • For post total mastectomy with high risk of recurrence. 1. Positive margins, 2. lymphovascular invasion, 3. >4 axillary nodes with tumour, 4. size > 5 cm 5. high grade tumour.
- 24. Adjuvant chemotherapy • Lymph nodes positive • Tumour > 1 cm • Grade 2 or 3 • ER/PR negative
- 25. Adjuvant therapy • If post NACT Surgery – – ER/PR + , hormonal therapy – ER/PR - ,Chemotherapy – HER2 , transtuzumab • If post neoadjuvant endocrine therapy Surgery endocrine therapy +/- NACT
- 26. Hormone therapy based on menopausal status
- 28. Follow-up