Breast Cancer Tumor Board

1
Breast Cancer Tumor Board

• Chair
• Harold Burstein, MD, PhD
• Faculty
• Jennifer Bellon, MD
• Mehra Golshan, MD

2
Patient Presentation

• 55-year-old woman who works as a medical office
  administrator
• Screening mammogram showed abnormality in breast
  
• Core biopsy revealed invasive cancer with
  associated ductal carcinoma in situ
• Invasive component considered intermediate grade
• She underwent lumpectomy and sentinel lymph node
  mapping
• Lumpectomy revealed a 1.7 cm, grade 2 (moderately
  differentiated) invasive ductal carcinoma

3
Further Tumor Testing

• Sentinel lymph node mapping
• 2 lymph nodes identified
• 1 node contained a 2-mm focus of invasive cancer
  seen on hematoxylin and eosin stain
• Tumor immunophenotyping
• Estrogen receptor positive
• Progesterone receptor low positive
• HER2 1
• HER2 status determination by fluorescence in situ
  hybridization (FISH)
• No evidence for gene amplification, with a ratio
  of 1.2

4
Patient History and Exam

• Patient is otherwise well
• Borderline high cholesterol
• Postmenopausal, grava 3 para 2 with a miscarriage
• No medications
• Medical allergy to sulfa products (rash)
• No family history of breast cancer
• Comprehensive system review notable only for her
  postoperative treatment changes

5
MammogramMagnification View
Graphic courtesy of Dr. Mehra Golshan.
6
Ultrasound View of Lesion
Graphic courtesy of Dr. Mehra Golshan.
7
Specimen Imaging Showing Wire and Calcifications
Graphic courtesy of Dr. Mehra Golshan.
8
ACOSOG Z00115-Year Recurrence Rates
Recurrence
P .11, ALND vs SLND.
Abbreviations ALND, axillary lymph node
dissection SLND, sentinel lymph node
dissection.Giuliano AE, et al. J Clin Oncol.
20102818S.
9
ACOSOG Z0011Predictors of Locoregional
Recurrence in Multivariate Analysis
Factors Associated with Recurrence Factors Not Associated with Recurrence
Age (50 years) Higher modified Bloom-Richardson Estrogen receptor status Progesterone receptor status Tumor size Level 1 lymph nodes Histologic type Sentinel node metastasis size Number positive lymph nodes Adjuvant systemic therapy
Giuliano AE, et al. J Clin Oncol. 20102818S
10
ACOSOG Z0011 Predictors of Disease-Free
Survival in Multivariate Analysis
Factors Associated with Improved Disease-Free Survival Factors Not Associated with Disease-Free Survival
Estrogen receptor status Age Adjuvant systemic therapy Treatment arm Progesterone receptor status Tumor size Level 1 lymph nodes Histologic type Number positive lymph nodes Modified Bloom-Richardson
Giuliano AE, et al. J Clin Oncol. 20102818S
11
Conclusions

• ACOSOG Z0011 was a study of completion dissection
  or not for women with positive sentinel lymph
  nodes
• There was no apparent benefit for completion
  dissection as both groups had very low risk of
  local and regional breast cancer recurrence
• The trial closed having accrued only half its
  patients and remains somewhat underpowered
• Moving forward, it is likely that surgical
  treatment decisions will be individualized
• Role of axillary dissection to be based on tumor
  size, extent of nodal disease, biological
  features of the breast cancer, patient age, and
  other traditional risk factors