Breast Cancer Special

Bilateral and Contralateral Breast Cancer

Contralateral Breast Cancer (CBC)

  • Physics
    • Contralateral breast receive between 0.5 to 4 Gy of internal and external scatter radiation
  • Risk ( protective) factors
    • Women with a first primary are at a 2-6-fold increased risk of developing contralateral breast cancer compared with the risk in the general population of women developing a first primary cancer. The incidence rate of contralateral breast cancer varies from four to eight per 1000 person-years.
    • TAM and chemotherapy both reduce the risk of CBC
  • Radiation may or may not increase CBC risk
  • Invasive Ductal Carcinoma primary
    • Contralateral breast cancer risk remains fairly constant at 0.75% per year after treatment.
    • 80% of the CBC will be invasive and 20% will be DCIS
  • DCIS primary
    • 4-yr CBC risk 2% with medial wedge for DCIS (EORTC study)
    • Risk of developing invasive CBC is the same as for patient with primary IDC.

Absolute CBC risk due to Radiation from SEER data

Follow up duration Absolute risk of contralateral breast cancer
10-yrs 0.5%
15-yrs 1.3%
20-yrs 1.6%

Comparing BCT vs Mastectomy alone

  • Synchroncous (< 1 year) or metachronous breast cancer
    • Metachronous breast cancer have similar prognosis compared to unilateral breast cancer when matched for stage of disease
    • Synchronous bilateral breast cancer have worse prognosis compared to metachronous or unilateral breast cancer.

BREAST CANCER IN AUGMENTED BREAST

SCREENING MAMMOGRAPHY

  • subglandular implants
    • 49 % decrese in measureable tissue non-displaced view
    • 39 % decrease with implant-displaced views
  • subpectoral implants
    • 28 % decrease in measurable tissue
    • 9% decrease in nondisplaced and displaced views
  • firm capsule around a prosthesis make an examination of the breast difficult.

DIAGNOSIS

  • In patients with breast augmentation cancer identified by
    • 51 % by mammography
    • 81% by palpation
  • Silversteins' data reveal that augmented have
    • a slightly greater risk of invasive tumors
    • have an increased likelihood of axillary lymph node metastases.
  • clinical detection of breast cancer, as evidenced by pathologic staging, is not delayed.
  • false negative rate of mammography is 40% in implanted patients

TREATMENTS

  • Breast conservation therapy with maintenance of the implant.
  • Breast conservation therapy with explantation of the implant with or without mastopexy.
  • Mastectomy with implant exchange and/or autogenous tissue reconstruction.

RESULTS
Silverstein Review

# patients recurrences death from breast cancer
nonaugmented 3922 19.5% 10.5 %
augmented 129 14.7% 10.1%
p-value 0.49 0.65

[Ref. Handel N, Silverstein MJ. ]

  • augmented patients have similar prognosis compared to nonaugmented patients
  • no difference in recurrence
  • no difference in death from breast cancer

COSMESIS

SURGERY [Ref. Taylor]

  • Satisfactory cosmesis was recorded in 81% of patients
  • Impaired cosmetic results are more likely with improper orientation of tylectomy
  • axillary incisions
  • larger volume of breast resection

RADIATION TECHNIQUE

  • Steep dose-response from 50-60 Gy with poor cosmesis in pts with > 50 Gy RT.
  • Fraction size > 2 Gy also contributes to poor cosmesis
  • Total dose to the tumor site > 65 Gy
  • 4-MV photons had worse cosmesis compared to higher energy photons.

CHEMORADIATION [Ref. Toledano]

  • Patients' overall satisfaction with cosmesis was not statistically different between the two arms, with approximately 92% with at least satisfactory results (p = 0.72)
  • differences between the treated and untreated breasts were greater after the concurrent regimen (29% vs. 14% with more than moderate differences; p = 0.0015).
  • Physician assessment of overall cosmesis was less favorable, with lower rates of at least satisfactory results in the concurrent arm (60% vs. 85%; p = 0.001).

BOOST RADIATION

  • 20 Gy or more negatively impact on cosmesis (JNCI 00;92(14):1143-50)
  • EORTC 22881/10882 showed that 16 Gy boost after 50 Gy in 25 fractions could be given in 3 ways with no differences cosmesis:[2]
    • electron,
    • brachytherapy,
    • and photons
  • EORTC 22881/10882 also showed that 16 Gy boost had negative, but limited impact on cosmetic results after 3 years.[2]
    • Excellent or good Cosmesis by Harvard Criteria
    • 86% (no boost) vs 71% (boost group) (p < 0.01)

Pregnancy and Breast Cancer

Pregnancy and Risk of Developing Breast Cancer

  • Uniparous women were at higher risk of breast cancer than nulliparous women for up to 15 years after childbirth and at lower risk (NEJM 1994;331:5).
  • The excess risk was most pronounced among women who were older at the time of their first delivery (odds ratio 5 years after delivery among women 35 years old at first delivery, 1.26; 95 percent confidence interval, 1.10 to 1.44).

Prognosis of Pregnant Women with Breast Cancer

  • Rate of positive LN for patient who have breast cancer during pregnancy is high (9 papers report median of 65% LN(+) rate)
  • More larger tumors (31% had < 2 cm tumors vs 50% for non-pregnant women)
  • Except for 1 series when the pregnancy-assciated breast cancer patients are evaluated with nonpregnant controls, equivalent survival rates are found at least for early stages.

Chemotherapy during Pregnancy

  • 1st trimester (no chemo)
  • Schapira reviewed 8 reports and found aggregate fetal malformation rate of 12.7%.
  • In Sweet et al. series 40% of infants exposed to chemotherapy in utero were of low birthweight, and the concern is one of future growth and development.
  • 2nd and 3rd trimester
  • Chemotherapy most experience with Cyclophosphomide, doxorubicine, 5-fluorouricil

Radiation during Pregnancy

  • Radiation should be delayed until birth
  • 5 cGy is the upper limit of tolerable radiation for pregnant women
  • Pregnancy is a contra-indication for RT but this is not contra-indication to breast conservation.
  • Lactation – 25% able to breast feed post RT

Prophylactic Mastectomy

Prophylactic mastectomy is one option for intervention considered by some women at defined high breast cancer risk.

  • Possible causes for prophylactic mastectomy
    • inherited breast cancer high risk
    • Rotterdam study showed a high incidence of premalignant lesions such as DCIS, LCIS, atypical lobular hyperplasia, and atypical ductal hyperplasia in prophylatic mastectomy specimens of women at hereditary risk for breast cancer, especially women who had mastectomy after the age of 40 years.
    • breast cancer associated genes (e.g. BRCA-1 and BRCA-2 mutations).
  • risk is quantified by mathematical models incorporating known risk factors (e.g. the models of Gail and Claus).
  • Technique
    • When prophylactic mastectomy is performed, the operation should be total mastectomy with removal of the nipple/areolar complex. As approximately 10-20% of the breast epithelium remains under the areola after subcutaneous mastectomy.
  • Results
    • 0.2% - 1% of women developed invasive breast cancer after prophylactic mastectomy.
    • To date, the decrease in breast cancer risk has not produced an effect on overall survival.

T0 Breast Cancer

Incidence

  • .3% to 1% of breast cancer present with axillary LN but no discernable primary

Differential Diagnosis

  • Breast, uterus, overy, stomach, thyroid, kidney, lymphoma, melanoma, SCC of H&N, SCC of lung, skin, sweat glands, or neurogenic.
  • If diagnostic workup is negative and histology is adeno or undifferentiated or unclassified, the occult primary is most likely to be the ipsilateral breast.

Workup

  • physical examination, and diagnostic mammography.
  • imaging studies to exclude distant metastatic
  • breast MRI examination to identify a primary cancer in the breast. (NCCN)

Treatment Options

  • MRM
  • Breast conservation
    • Excisional biopsy of the axillary nodes
    • - or -
    • Standard (level I&II) dissection
    • +/- Radiation - 4 field breast
  • Chemotherapy
    • Postoperative multi-drug chemothearpy

Rate of breast cancer development after Nodal Excision[1]

  • Observation: 14% to 55%
  • RT or MRM: 12% -33%
Bibliography
1. Georges Vlastos, MD, Marina E. Jean, MD, Attiqa N. Mirza, MD, Nadeem Q. Mirza, MD, MPH, Henry M. Kuerer, MD, PhD, Frederick C. Ames, MD, Kelly K. Hunt, MD, Merrick I. Ross, MD, Thomas A. Buchholz, MD, Aman U. Buzdar, MD, and S. Eva Singletary, MD. Feasibility of Breast Preservation in the Treatment of Occult Primary Carcinoma Presenting With Axillary Metastases. Annals of Surgical Oncology 2001, 8(5):425–431.
2. Vrieling C, Collette L, Fourquet A, Hoogenraad WJ, Horiot JC, Jager JJ, Pierart M, Poortmans PM, Struikmans H, Van der Hulst M, Van der Schueren E, Bartelink H. The influence of the boost in breast-conserving therapy on cosmetic outcome in the EORTC "boost versus no boost" trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. European Organization for Research and Treatment of Cancer. Int J Radiat Oncol Biol Phys. 1999 Oct 1;45(3):677-85.
Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-Share Alike 2.5 License.