The New trends in the Management of Breast Cancer 謝渙發 桃園縣醫師公會監事 怡仁綜合醫院副院長 教育部部定助理教授 國防醫學院外科學系臨床教授

Factors that modify breast cancer risk in women

Diagnostic evaluation of women with suspected breast cancer

Prognostic and predictive factors in early, non-metastatic breast cancer Age and race 35 years-old Pathologic factors, including tumor stage TNM staging, Tumor morphology (IDC 55%, ILC 5%, DCIS13%), Histologic grading (Low-graded/well-, intermediate-graded/ moderately-, and high-graded/poorly- differentiated),, PLVI (peritumoral lymphovascular invasion) Scarff-Bloom-Richardson, Nottingham, SBR Grading ( Tissue markers ER, PR, Her-2-Neu, gemomic profiles Gene expression profiles Oncotype DX, Amsterdam 70-gene profile, PAM50 assay

Bloom-Richardson Grade for Breast Cancer (since 1996)

Genomic profiles of breast cancer ERBB2 oncogene and other coexpressed genes luminal subtype B basal subtype normal breast-like group luminal subtype A

Genomic profiles of breast cancer

microarray-derived 70-gene multigene signature

Triple-negative breast cancer (TNBC) ER(-), PR(-), Her-2-NeU(-) younger and premenopausal African American women Poor prognosis BRCA1-associated Basal-like molecular subtype Paclitaxel-based systemic neoadjuvant/adjuvant chemotherapy

Management of the regional lymph nodes in breast cancer The most prognostic factor for breast cancer ( LN status) Lymphatic drainage: axillary 85%, internal mammary/supraclavicular/infraclavicular 15% likelihood of ALN involvement ( impact to tumor size): Tis – 0.8 percent T1a – 5 percent T1b – 16 percent T1c – 28 percent T2 – 47 percent T3 – 68 percent T4 – 86 percent

1.Invasive/microinvasive breast cancer with clinically node negative 2.Omitted if the nodal information will not affect adjuvant treatment decisions 3.SLND should be performed in women with extensive ductal carcinoma in situ (DCIS), who are undergoing mastectomy 4.A SLND will not be possible after mastectomy if invasive disease is found on final pathology, necessitating an axillary dissection for staging purposes Sentinel lymph node dissection for breast cancer: Indications and outcomes

Breast conserving therapy (BCT) Breast conserving surgery (BCS) + Primary radiotherapy (RT) Goal: survival equivalent of mastectomy + cosmetically acceptable breast +a low rate of recurrence BCS: Lumpectomy, partial mastectomy, quadrantectomy

Selection criteria for BCT (considerations) Age in not a contraindication: Physiological age, Presence of comorbid condition Locally-advanced cancer, involvement of nipple-areola complex presence of an extensive intraductal component (EIC) Lymph node positivity is a marker of worse prognosis A family history of breast cancer A high risk of systemic relapse

Selection criteria for BCT (Contraindications) Multicentric disease (Sono, mmx) Diffuse malignant microcalcifications(mmx) A history of prior therapeutic RT( total irradiation dosage to chest wall) Pregnancy is an absolute contraindication (exempting: BCS at 3rd trimester) Persistently positive resection margins (after multiple attempts of reexcision)

Selection criteria for BCT (Techniques) Evaluation of the axilla ( sentinel LNs ) Margins of resection ( gross 5-10mm, Microscopic 1 mm at least) Wire localization &Specimen radiography (nonpalpable lesion) Specimen orientation ( by surgeon) Intraoperative margin assessment (frozen section, Sono…)

Commonly Used Chemotherapy Regimens

Hormonal Therapy for Advanced Breast Cancer

乳管原位癌 (DCIS) 的 治療方式（ Impact of surgery, radiation, and systemic Rx. On outcomes?) Surgery Mastectomy (1% local failure) Vs Local excision + radiation (12% local failure) Local excision + Radiation Vs local excision alone Hormonal Rx Tamoxifen ---- the only systemic agent for preventing local recurrence or invasive progression Chemotherapy---- No role in patients with pure DCIS

乳管原位癌 (DCIS)---- 結語 1. Dx/Rx---still highly complex with many unanswered questions 2. Noninvasive nature, favorable prognosis --- Not a “cancer” 3. Accurate identification of patient subsets with lower risk factors --- less therapeutic intervention without sacrificing the excellent outcomes 4. Needs more efforts on the development and validation of accurate risk stratification methods (comprehensive understanding of clinical, radiological, pathological, and biological factors)

乳管原位癌 (DCIS) 的 Natural life