Breast cancer update march 2015

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Breast Cancer Update Click to edit Master subtitle style

Wayne Jones

3/17/2015

FRACS

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Topics

•Click Breast to Imaging edit Master title style Click to edit Master title style • Breast Surgery • Adjuvant Treatment Click to edit Master subtitle style

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Breast Imaging • Digital mammography Click to edit Master title • Tomosynthesis mammography Click to edit Master title • Office ultrasound • Image guided biopsies • MRI

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Click to edit Master subtitle style − High risk screening & specific questions − ? Lobular Ca & DCIS − Cost, claustrophobia, over-calls cancer

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Digital Mammography

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Digital Mammography

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Tomosynthesis Mammography

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Office Ultrasound

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U/S Guided Core Biopsy

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Breast MRI

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Breast Surgery Click to edit Master subtitle style

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Mastectomy

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Breast Conservation Surgery

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Breast Conservation Surgery

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Sentinel Node Biopsy • 40% lymph node involvement Tumour Click to edit Master title style • U/S and FNA biopsy • Pre-op ID of sentinel node 95%+ • Smaller operation, less morbidity eg shoulder pain, lymphoedema Click to edit Master subtitle style • No difference in DFS or OS v AND Nodal Basin

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Lymphoscintogram

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Patent Blue V Dye

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Hand-held Gamma Probe

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Hand-held Gamma Probe

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Is Axillary Dissection Needed?

• Currently if

Click to− SNBedit title style positiveMaster have ALND Click to− SNBedit title style negativeMaster avoid ALND • Isolated tumour cells <0.2mm – not significant • Micrometastases <2mm – increased LR, ? ALND

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• Micrometastases >2mm – Do ALND

• If 3 or more nodes involved omit ALND if getting systemic tx and DXR (Z-0011 trial, IBCSG 23-01) 3/17/2015

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Breast Reconstruction • Offered to all ‘Mastectomy Patients’

Click to edit Master title style • Psycho-social & sexuality reasons Click to edit Master title style • Immediate or Delayed

• Implants – one or two stage

Click edit Master subtitle style • TRAM flapsto - muscle, fat & skin • DIEP flaps – fat & skin, microvascular

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Permanent Implants

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How strong are they?

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One Stage Implant

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Two Stage Implant â&#x20AC;&#x201C; Pre-op

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Two Stage Implants

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Two Stage Implant - Expansion

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Two Stage Implant â&#x20AC;&#x201C; Post-op

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TRAM Flap

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Delayed TRAM flap

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Nipple Click to edit Master title style Reconstruction Click to edit Master subtitle style

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Nipple Reconstruction Click to edit Master title style

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Nipple Sparing Mastectomy •Click No increased riskMaster breast cancer if preserve to edit title stylenipple − If >2cm fromMaster nipple, not multifocal Click to edit title style − Frozen Section at surgery

• Routine for prophylatic mastectomies • Selected cancer mastectomies

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− Not contra-indicated as above − Can preserve blood supply

• Inferolateral approach or peri-areola

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Nipple Sparing Mastectomy

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Adjuvant Treatment Click to edit Master subtitle style

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Radiotherapy •Click All cases PartialMaster Mastectomy for DXR toofedit title style •Click Nodal status important to edit Master title style − Was >3 nodes, now 1 node treated (EBCTG 2014)

• Intra-operative DXR − Controversial − Some patients don’t need DXR at all − Editorial Int J Rad Onc 2015 91(2), p255-7

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• Partial breast irradiation

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Endocrine Therapy • Aromatase Inhibitors more effective than Tamoxifen

Click− to edit Master titlecancer style 17% less recurrence, 53% less contralateral

− Less DVT, Hot flushes, uterine Ca, more joint pain, lose bone density

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Can switch to AI after 2y Duration – 10y better than 5y to edit Master subtitle style PrimaryClick endocrine therapy if unfit for surgery Pre-menopausal women − Use Exemestane & Zoladex (GnRH inhibitor) − More effective than Tamoxifen (SOFT trial)

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Chemotherapy rd generation chemo •Click More effective 3 to edit Master title style • Use of multi-agents eg AC & Taxol, FEC & Taxol • Tailor treatment eg basal type, gene array analysis Click to Master • Neo-adjuvant tx edit for Her2 +ve subtitle & “triple style negative” • Management of Her2 +ve Ca <1cm controversial • Consider fertility treatment

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Herceptin (Trastuzumab) • 20% women HER2 +ve Click to edit Master title style • HERA Study – recurrence ↓46% • 12m course $80,000 • Give with chemo • 3m versus 12m?

Click to edit Master subtitle style • Combination with Pertuzumab?

• Need Portacath

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Click to edit Master title style Questions?

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