Breast

Question 1

What types of things need to be done during the initial work-up of breast cancer?

Answer 1

• Make sure the patient has had a bilateral mammogram.
• Make sure the patient has had an ultrasound of the cancer AND the axillary nodes. It is standard practice to ultrasound the nodes.
• If there is an enlarged or atypical axillary node on ultrasound or exam – biopsy it. Core biopsy, not FNA.
• Make sure to mention family history.
• Make sure to mention a review of symptoms.
• Always ask about ER, PR and Her-2 status.

Question 2

In breast cancer, how do I design a treatment plan for the patient?

Answer 2

• This is ALL based on PRELIMINARY CLINCAL STAGING. You must enunciate your clinical stage and say that you will use this to develop the treatment plan.
• You must mention T stage – size of tumor as measured by mammo, US or exam.
• You must mention N stage – clinical exam and US.
• You must mention ER, PR, and Her-2.

Question 3

In breast cancer, why do I need to know family history up front?

Answer 3

Because they may be a candidate for genetic testing and the genetic results might influence which surgery they want. For example, if they are BRCA+, they may want a bilateral mastectomy instead of a lumpectomy. So, I always make sure I offer genetic counseling BEFORE making a surgery decision if they meet criteria.

Question 4

In breast cancer, who MUST get a breast MRI?

Answer 4

Nobody. MRI is not absolutely required in any situation for breast cancer.

Question 5

Who do we like to get MRI on?

Answer 5

• Any lobular cancer. They tend to be larger than predicted by conventional imaging.
• Anybody we are planning neoadjuvant chemo on – because we get a pre- and post- treatment MRI and that helps us decide what to do with the nodes (see later discussion).
• Anybody the radiologist wants to – the radiologist will tell us if they have concerns about extent of disease (ie…chest wall involvement) or otherwise a difficult mammogram – if they want it we get it. So it is important to communicate with them.

Question 6

In breast cancer, who gets a metastatic work-up?

Answer 6

• Anyone with a positive finding on review of systems.
• Anyone who is node positive.
• Anyone who has inflammatory cancer.

Question 7

What is the metastatic work-up for breast cancer?

Answer 7

• CT chest/abd/pelvis and bone scan
• PET is not the first-line metastatic work-up according to NCCN. I don’t know why. Its just not. Don’t say PET.

So, remember – early stage patients go to surgery first, advanced stage patients get chemo first.

Question 8

In breast cancer, who is a candidate for neoadjuvant chemotherapy?

Answer 8

• You MUST mention that you would consider neoadjuvant chemo on any of the following:
  
  • Any node positive patient
  • Any T2 or higher (> 2 cm)
  • Any triple negative cancer > 5mm in size
  • Any Her-2 Positive cancer > 5 mm in size
  • Any inflammatory cancer
• You must consider neoadjuvant in all of these patients.
• Now, you and your oncologist might not do neoadjuvant chemo in all of these patients. For example, an elderly patient with a 3 cm tumor and nodes clinically negative who wants a mastectomy -à well I would just take her to surgery and get it staged out completely and she probably wont need chemo at all anyways.

Question 9

In breast cancer, who gets radiation?

Answer 9

• Any breast conservation patient is a candidate for radiation.
• Any T3 or higher (> 5 cm) will get post-mastectomy radiation.
• Any node-positive patient will get post-mastectomy radiation.

Question 10

In breast cancer, what if a sentinel node is positive?

Answer 10

• If you are doing breast conservation, and if they have a positive sentinel node with no extracapsular extension, they do NOT need a completion axillary dissection because they are getting radiation anyway. According to the Z-11 trial there is no difference in outcomes in these patients if they have axillary dissection or not as long as they get radiation
• For mastectomy patients, it’s tricky
  
  • I do frozen sections. If positive, I do a completion dissection right then.
  • If the frozen section is negative but the final path is positive, you can have a discussion with the radiation oncologist on whether or not you go back to do axillary radiation or a completion dissection or both. There is no defined answer on this.

Question 11

In breast cancer, how do we manage lymph nodes after neoadjuvant chemotherapy?

Answer 11

• If nodes were clinically and radiographically negative before therapy started, then all we need to do is a sentinel node just like usual. We manage these cases the same way as if they didn’t have neoadjuvant.
• If the nodes were positive before neoadjuvant therapy, you have to assess response post-treatment (usually with your post-treatment MRI):
  
  • If the nodes did NOT shrink – just do an axillary dissection.
  • If the nodes did shrink, you can try a sentinel node. Do a frozen. If the frozen is positive, then do a completion dissection.
    
    • There are research protocols ongoing addressing this very topic, but right now do a dissection if the frozen is positive
  • I will usually wire localize the node that was positive up front – because I worry it might not be the sentinel node. This is not mandatory.

Question 12

What is the sequence of events in breast cancer treatment?

Answer 12

• For early stage patient is goes:
  
  • Surgery –> Chemo (if needed) –> XRT (if needed) –> Hormonal therapy (if ER/PR +)
• For advanced stage patients it goes:
  
  • Chemo –> surgery –> XRT –> hormonal therapy

Question 13

Who gets an MRI with DCIS?

Answer 13

• The same basic MRI principles apply as above.
• We tend to get an MRI if the DCIS has a palpable mass.

Question 14

Who do we do sentinel nodes on in DCIS?

Answer 14

• Think of it like this—- what if the pathologist finds a focus of invasive cancer in the DCIS? Can I come back and do nodes later?
• So, consider doing a sentinel node in DCIS if:
  
  • It is located in the upper outer quadrant (because it would be very hard to map a sentinel node later with the tissue disruption.
  • You are doing a mastectomy. Always do a sentinel node for DCIS mastectomy or else you will get burned some day when the pathologist finds invasion.

Question 15

What about radiation therapy in DCIS?

Answer 15

• Never with mastectomy.
• Always considered with breast conservation.
• So, who doesn’t need it?
  
  • There is no difference in outcomes with XRT, hormonal therapy, or both if:
    
    • Postmenopausal
    • Margin on DCIS > 2 mm
    • It is ER+
    • So, these patients can safely be treated with just hormone therapy and skip the XRT

Question 16

Who needs hormonal treatment in DCIS?

Answer 16

• Everyone who gets breast conservation.
• If the patient gets a mastectomy and has another breast, it is given for prophylaxis.
• Bilateral mastectomy patients with DCIS do NOT get hormonal therapy.

Question 17

Why do we give hormonal therapy – ie…Tamoxifen of anastozole – at the end of the treatment cycle?

Answer 17

I don’t know. This has always bothered me. I am not aware of any data that shows that decreased estrogen levels delay wound healing. So, why do we hold anti-estrogen therapy until the end of breast cancer treatment?? I have no idea. Seems to me we should be starting hormonal therapy the minute we get the diagnosis.

Men don’t have much estrogen and we operate on them all the time. We don’t check estrogen levels on patients when we do hernia surgery, or colorectal surgery, or gallbladder surgery, or bariatric surgery. So why would an anti-estrogen drug need to be held until after breast surgery??

Should we give our patients estrogen to help with wound healing? Obviously I think not. So I have no idea why we can’t start tamoxifen the day we get the diagnosis of breast cancer.

It’s a great mystery to me.

Question 18

In breast cancer, how does Her-2 factor in?

Answer 18

If they are Her-2 positive, they will get Herceptin as part of their neoadjuvant regimen, and then they will get it post-op for another year. Herceptin is given during chemo and radiation. It is given on top of all of this.

Question 19

In breast cancer, what about OncoType?

Answer 19

Oncotype is used to calculate a recurrence risk based on genetic analysis of the cancer cells themselves. High Oncotype score means cancer is more likely to recur.

So, we use Oncotype when we are on the fence about whether or not a patient needs chemo or not:

• Patients who are ER/PR positive, Her-2 negative, node negative, T1 or T2.
• Patients with low grade tumors, ER/PR positive, Her-2 negative, T1 or T2 but have 1 or two positive sentinel nodes or a micro-metastasis. You could consider hormonal therapy only in these patients if they are post-menopausal.

Question 20

What are the breast cancer TNM stages?

Answer 20

T

• T1:
  
  • T1a: >1 mm but
  • T1b: >5 mm but
  • T1c: >10 mm but
• T2: > 20 mm but
• T3: > 50 mm
• T4: direct invasion to chest wall or skin (ulcerations or macrocopic nodules)

N

• N0: no nodes
• cN1: moveable ipsilateral zone 1 or 2
• pN1: 1-3 axillary nodes
• cN2: fixed/matted ipsilateral zone 1 or 2
• pN2: 4-9 axillary nodes or intermal mammary node
• cN3: ipsilateral zone 3, internal mammary, or supraclavicular
• pN3: 10+ axillary nodes

M

• M0: no mets
• M1: distant mets

Question 21

Breast Cancer Staging

Answer 21

Very complex. Even Stage I can have micromets to LNs.

Question 22

DCIS Follow-up

Answer 22

• Interval H&P q6-12 months for 5 y, then annually.
• Annual mammograms if breast tissue still present.

Question 23

Breast cancer, invasive Follow-up

Answer 23

• Interval H&P q3-12 months x 5y, then annually.
• Annual mammograms if breast tissue still present.

Question 24

What is Z11 criteria?

Answer 24

In cases with T1-2, ALND can be avoided only if all of the following criteria are met:

• T1 or T2 tumors
• Clinically negative nodes
• 1-2 positive nodes on SLNB (on the basis of H&E staining)
• Planned breast conserving therapy
• Planned whole-breast RT
• No neoadjuvant chemotherapy planned

Question 25

Key Steps to Lumpectomy with SLNB

Answer 25

* Not mentioned in the figure, but be sure to orient specimen for pathology and to place marker clips in the specimen cavity to guide the radiation oncologist.

Question 26

Key Steps to Mastectomy

Answer 26

Question 27

Key Steps to ALND

Answer 27

Question 28

Management of breast cancer in pregnant patient

Answer 28

Key Points:

• No XRT while pregnant
• No BCS in 1st trimester; mastectomy rec’d
• Blue dye mapping with lymphazurin or methylene blue is contraindicated in pregnancy; Tc-99 okay

Question 29

What are acceptable surgical margins in breast cancer?

Answer 29

• DCIS: 2mm margins
• Invasivce cancer: ink negative margins