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Breast Cancer Screening and Diagnosis Guidelines

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Title: Breast Cancer Screening and Diagnosis Guidelines


1
Breast CancerScreening andDiagnosis Guidelines
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Breast cancer screening
  • Lack of knowledge of the pathogenesis of breast
    cancer means that primary prevention is currently
    a distant prospect for the majority of women.
  • Early detection represents an alternative
    approach for reducing mortality from this disease.

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NCCN Clinical Practice Guidelines in
OncologyBreast CancerScreening andDiagnosis
GuidelinesV.1.2007
  • Physical examination
  • Negative physical examination (asymptomatic)
  • Normal risk
  • Increased risk
  • Positive physical examination (symptomatic)
  • Lump/mass
  • age 30 years
  • age lt 30 years
  • Nipple discharge, no palpable mass
  • Asymmetric thickening/nodularity
  • Skin changes
  • Risk factors used in the modified Gail model
  • Mammographic evaluation
  • Mammographic assessment category definitons

9
Physical examination
  • Physical examination
  • Negative physical examination (asymptomatic)
  • Normal risk
  • Increased risk
  • Positive physical examination (symptomatic)
  • Lump/mass
  • age 30 years
  • age lt 30 years
  • Nipple discharge, no palpable mass
  • Asymmetric thickening/nodularity
  • Skin changes
  • Risk factors used in the modified Gail model
  • Mammographic evaluation
  • Mammographic assessment category definitons

10
Negative Physical Examinationnormal risk
11
Negative Physical Examinationincreased risk
12
Negative Physical Examinationincreased risk
13
Negative Physical ExaminationIncreased risk
14
Positive Physical ExaminationLump/Mass, Age 30y
  • Negative physical examination
  • Normal risk
  • Increased risk
  • Positive physical examination
  • Lump/mass
  • Age 30y
  • Age lt 30y
  • Nipple discharge, no palpable mass
  • Asymmetric thickening/nodularity
  • Skin changes
  • Peau dorange
  • Erythema
  • Nipple excoriation
  • Scaling, eczema

15
Positive Physical ExaminationLump/Mass, Age
30yUltrasound, tissue biopsy
  • Ultrasound
  • Solid
  • Intermediate or suspicious
  • Probably benign finding
  • Cyst
  • Symptomatic or non-simple cyst
  • Asymptomatic and simple cyst(s)
  • No abnormality

Lump/mass, age gt 30y, initial evaluation
16
Ultrasound Solid Intermediate or
suspicious Probably benign finding Cyst Symptomati
c or non-simple cyst Asymptomatic and simple
cyst(s) No abnormality
Positive Physical ExaminationLump/Mass, Age
30yUltrasound, observation
17
Ultrasound Solid Intermediate or
suspicious Probably benign finding Cyst Symptomati
c or non-simple cyst Asymptomatic and simple
cyst(s) No abnormality
Positive Physical ExaminationLump/Mass, Age
30yUltrasound
18
Positive Physical ExaminationLump/Mass, Age lt 30y
Negative physical examination Normal
risk Increased risk Positive physical examination
Lump/mass Age 30y Age lt 30y Nipple discharge,
no palpable mass Asymmetric thickening/nodularity
Skin changes Peau dorange Erythema Nipple
excoriation Scaling, eczema
Lump/mass, age gt 30y, initial evaluation
Mammography
Solid Intermediate Or suspicious
Ultrasound
19
Positive Physical ExaminationNipple Discharge
Negative physical examination Normal
risk Increased risk Positive physical examination
Lump/mass Age 30y Age lt 30y Nipple discharge,
no palpable mass Asymmetric thickening/nodularity
Skin changes Peau dorange Erythema Nipple
excoriation Scaling, eczema
20
Positive Physical Examination Asymmetric
thickening/nodularity
Negative physical examination Normal
risk Increased risk Positive physical examination
Lump/mass Age 30y Age lt 30y Nipple discharge,
no palpable mass Asymmetric thickening/nodularity
Skin changes Peau dorange Erythema Nipple
excoriation Scaling, eczema
21
Positive Physical ExaminationSkin Changes
Negative physical examination Normal
risk Increased risk Positive physical examination
Lump/mass Age 30y Age lt 30y Nipple discharge,
no palpable mass Asymmetric thickening/nodularity
Skin changes Peau dorange Erythema Nipple
excoriation Scaling, eczema
22
Risk factors used in the modified Gail model
23
  • Gail model
  • A computer program that uses personal and family
    history to estimate a womans chance of
    developing breast cancer.
  • 1.Does the woman have a medical history of any
    breast cancer or of ductal carcinoma in situ
    (DCIS) or lobular carcinoma in situ (LCIS)? 
  • 2.What is the woman's age?This tool only
    calculates risk for women 35 years of age or
    older. 
  • 3.What was the woman's age at the time of her
    first menstrual period? 
  • 4.What was the woman's age at the time of her
    first live birth of a child? 
  • 5.How many of the woman's first-degree relatives
    - mother, sisters, daughters - have had breast
    cancer? 
  • 6.Has the woman ever had a breast biopsy?   
  • 6a.How many breast biopsies (positive or
    negative) has the woman had?   
  • 6b.Has the woman had at least one breast biopsy
    with atypical hyperplasia? 
  • 7.What is the woman's race/ethnicity? 

24
Risk factors used in the modified Gail model
  • Current age
  • Age at menarche
  • Age at first live birth or nulliparity
  • Number of first-degree relatives with breast
    cancer
  • Number of previous benign breast biopsies
  • Atypical hyperplasia in a previous breast biopsy
  • Race
  • The current Gail model may not accurately assess
    breast cancer risk in non-Caucasian women.

25
Mammographic evaluation
  • Physical examination
  • Negative physical examination
  • Normal risk
  • Increased risk
  • Positive physical examination (symptomatic)
  • Lump/mass
  • age 30 years
  • age lt 30 years
  • Nipple discharge, no palpable mass
  • Asymmetric thickening/nodularity
  • Skin changes
  • Risk factors used in the modified Gail model
  • Mammographic evaluation
  • Mammographic assessment category definitions

26
Mammographic assessment category definitions
27
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Incomplete
  • Category 0- Need Additional Imaging Evaluation
    and/or Prior Mammograms For Comparison
  • Assessment Is Complete - Final Assessment
    Categories
  • Category 1 Negative
  • Category 2 Benign Finding(s)
  • Category 3 Probably Benign Finding - Short
    Interval Follow-Up Suggested
  • Category 4 Suspicious Abnormality - Biopsy
    Should Be Considered
  • Category 5 Highly Suggestive of Malignancy -
    Appropriate Action Should Be Taken
  • Category 6 Known Biopsy - Proven
    Malignancy--Appropriate Action Should Be Taken

28
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Incomplete
  • Category 0- Need Additional Imaging Evaluation
    and/or Prior Mammograms For Comparison
  • Finding for which additional evaluation is
    needed.
  • This is almost always used in a screening
    situation.
  • Under certain circumstances this category may be
    used after a full mammographic workup.
  • A recommendation for additional imaging
    evaluation may include, but is not limited to
    spot compression, magnification, special
    mammographic views and ultrasound.
  • Whenever possible, if the study is not negative
    and does not contain a typically benign finding,
    the current examination should be compared to
    previous studies.
  • The radiologist should use judgment on how
    vigorously to attempt obtaining previous studies.
  • Category 0 should only be used for old film
    comparison whensuch comparison is to make a final
    assessment.

29
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Complete - Final Assessment
    Categories
  • Category 1 Negative
  • There is nothing to comment on.
  • The breasts are symmetric and no masses,
    architectural distortion, or suspicious
    calcifications are present.
  • Category 2 Benign Finding(s)
  • Like Category 1, this is a "normal"assessment,
    but here, the interpreter chooses to describe a
    benign finding in the mammography report.
  • Involuting, calcified fibroadenomas, multiple
    secretory calcifications, fat-containing lesions
    such as oil cysts, lipomas, galactoceles, and
    mixed-density hamartomas all have
    characteristically benign appearances, and may be
    labeled with confidence.
  • The interpreter may also choose to describe
    intramammary lymph nodes, vascular
    calcifications, implants or architectural
    distortion clearly related to prior surgery while
    still concluding that there is no mammographic
    evidence of malignancy.
  • Note that both Category 1 and Category 2
    assessments indicate that there is no
    mammographic evidence of malignancy.
  • The difference is that Category 2 should be used
    when describing one or more specific benign
    mammographic findings in the report, whereas
    Category 1 should be used when no such findings
    are described.

30
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Complete - Final Assessment
    Categories
  • Category 3 Probably Benign Finding - Short
    Interval Follow-Up Suggested
  • A finding placed in this category should have
    less than a 2 risk of malignancy.
  • It is not expected to change over the follow-up
    interval, but the radiologist would prefer to
    establish its stability.
  • There are several prospective clinical studies
    demonstrating the safety and efficacy of initial
    short-term follow-up for specific mammographic
    findings.
  • Three specific findings are described as being
    probably benign (the noncalcified mass, the focal
    asymmetry and the cluster of round punctate
    calcifications the latter is anecdotally
    considered by some radiologists to be an
    absolutely benign feature).
  • All the published studies emphasize the need to
    conduct a complete diagnostic imaging evaluation
    before making a probably benign (Category 3)
    assessment hence it is inadvisable to render
    such an assessment when interpreting a screening
    examination.
  • Also, all the published studies exclude palpable
    lesions, so the use of a probably benign
    assessment for a palpable lesion is not supported
    by scientific data.
  • Finally, evidence from all published studies
    indicate the need for biopsy rather than
    continued follow-up when most probably benign
    findings increase in size orextent.
  • While the vast majority of findings in this
    category will be managed with an initial
    short-term follow-up (6 mo) examination followed
    by additional examinations until longer-term (2 y
    or longer) stability is demonstrated, there may
    be occasions where biopsy is done (patient wishes
    or clinical concerns).

31
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Complete - Final Assessment
    Categories
  • Category 4 Suspicious Abnormality - Biopsy
    Should Be Considered
  • This category is reserved for findings that do
    not have the classic appearance of malignancy but
    have a wide range of probability of malignancy
    that is greater than those in Category 3. Thus,
    most recommendations of breast interventional
    procedures will be placed within this category.
  • It is encouraged that the relevant probabilities
    be indicated so the patient and her physician can
    make an informed decision on the ultimate course
    of action.

32
ACR-BI-RADS - Mammography. 4th Edition.
  • Assessment Is Complete - Final Assessment
    Categories
  • Category 5 Highly Suggestive of Malignancy -
    Appropriate Action Should Be Taken
  • These lesions have a high probability ( 95) of
    being cancer.
  • This category contains lesions for which
    one-stage surgical treatment could be considered
    without preliminary biopsy.
  • However, current oncologic management may require
    percutaneous tissue sampling as, for example,
    when sentinel node imaging is included in
    surgical treatment or when neoadjuvant
    chemotherapy is administered at the outset.
  • Category 6 Known Biopsy - Proven
    Malignancy--Appropriate Action Should Be Taken
  • This category is reserved for lesions identified
    on the imaging study with biopsy proof of
    malignancy prior to definitive therapy.

33
Breast Screening Considerations
  • Consider severe comorbid conditions limiting life
    expectancy and whether therapeutic interventions
    are planned.
  • Upper age limit for screening is not yet
    established.
  • Current evidence does not support the routine use
    of breast scintigraphy (eg, sestamibi scan), or
    ductal lavage as screening procedures.
  • Current evidence does not support the routine use
    of breast MRI as a screening procedure, in
    average risk women.
  • There are limited data supporting the use of MRI
    for breast cancer screening as an adjunct to
    mammography for high risk women.
  • There are limited data supporting the use of
    ultrasound for breast cancer screening as an
    adjunct to mammography for high risk women or
    women with dense breast tissue.
  • A single study (DMIST) suggested benefit of
    digital mammography in young women and women with
    dense breasts1.

34
Mammography Evaluation
35
Mammography Evaluation
36
THANKS for your attention!
  • Dah-Cherng Yeh, M.D.
  • Division of General Surgery
  • Department of Surgery
  • Taichung Veterans General Hospital

37
NCCN Clinical Practice Guidelines in
OncologyBreast Cancer
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38
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www.nccn.org
41
TNM Staging
42
Primary tumor (T)
  • TX Primary tumor cannot be assessed
  • T0 No evidence of primary tumor
  • Tis Carcinoma in situ
  • Tis (DCIS) Ductal carcinoma in situ
  • Tis (LCIS) Lobular carcinoma in situ
  • Tis (Pagets) Pagets disease of the nipple with
    no tumor
  • T1 Tumor 2 cm or less in greatest dimension
  • T1mic Microinvasion 0.1 cm or less in greatest
    dimension
  • T1a Tumor more than 0.1 cm but not more than 0.5
    cm in greatest dimension
  • T1b Tumor more than 0.5 cm but not more than 1 cm
    in greatest dimension
  • T1c Tumor more than 1 cm but not more than 2 cm
    in greatest dimension
  • T2 Tumor more than 2 cm but not more than 5 cm
    in greatest dimension
  • T3 Tumor more than 5 cm in greatest dimension
  • T4 Tumor of any size with direct extension to
    (a) chest wall or (b) skin
  • T4a Extension to chest wall, not including
    pectoralis muscle
  • T4b Edema (including peau dorange) or ulceration
    of the skin of the breast, or satellite skin
    nodules confined to the same breast
  • T4c Both T4a and T4b
  • T4d Inflammatory carcinoma

43
Regional lymph nodes(N)clinical
  • NX Regional lymph nodes cannot be assessed (e.g.,
    previously removed)
  • N0 No regional lymph node metastasis
  • N1 Metastasis to movable ipsilateral axillary
    lymph node(s)
  • N2 Metastasis in ipsilateral axillary lymph nodes
    fixed or matted, or in clinically apparent
    ipsilateral interanl mammary nodes in the absence
    o of clinically evident axillary lymph node
    metastasis
  • N2a Metastasis in ipsilateral axillary lymph
    nodes fixed to one another (matted) or to
    other structures
  • N2b Metastasis only in clinically apparent
    ipsilateral internal mammary nodes and in the
    absence of clinically evident axillary lymph node
    metastasis
  • N3 Metastasis in ipsilateral infraclavicular
    lymph node(s) with or without axillary lymph
    node involvement, or in clinically apparent
    ipsilateral internal mammary lymph node(s) and
    in the presence of clinically evident axillary
    lymph node metastasis or metastasis in
    ipsilateral supraclavicular lymph node(s) with or
    without axillary or internal mammary lymph node
    involvement
  • N3a metastasis in ipsilateral infraclavicular
    lymph node(s)
  • N3b metastasis in ipsilateral internal mammary
    lymph node(s) and axillary lymph node(s)
  • N3c metastasis in ipsilateral supraclavicular
    lymph node(s)

44
Regional lymph nodes(N)pathological
  • pN1 metastasis in 1 to 3 axillary lymph nodes,
    and/or internal mammary nodes with microscopic
    disease detected by sentinel lymph node
    dissection but not clinically apparent
  • pN1mi micrometastasis (greater than 0.2 mm, none
    greater than 2.0 mm)
  • pN1a metastasis 1 to 3 axillary lymph nodes
  • pN1b metastasis in internal mammary nodes with
    microscopic disease detected by sentinel lymph
    node dissection but not clinically apparent
  • pN1c metastasis in 1 to 3 axillary lymph nodes
    and in internal mammary lymph nodes with
    microscopic disease detected by sentinel lymph
    node dissection but not clinically apparent
  • pN2 metastasis in 4 to 9 axillary lymph nodes, or
    in clinically apparent internal mammary lymph
    nodes in the absence of axillary lymph node
    metastasis
  • pN2a metastasis in 4 to 9 axillary lymph nodes
    (at least one tumor deposit greater than 2.0
    mm)
  • pN2b metastasis in clinically apparent internal
    mammary lymph nodes in the absence of axillary
    lymph node metastasis
  • pN3 metastasis in 10 or more axillary lymph
    nodes, or in infraclavicular lymph nodes, or in
    clinically apparent ipsillateral internal
    mammary lymph nodes in the presence of 1 or more
    positive axillary lymph nodes or in more than 3
    axillary lymph nodes with clinically negative
    microscopic metastasis in internal mammary lymph
    nodes or in ipsilateral supraclavicular lymph
    nodes.
  • pN3a metastasis in 10 or more axillary lymph
    nodes (at least one tumor deposit greater than
    2.0 mm), or metastasis to the infraclavicular
    lymph nodes.
  • pN3b metastasis clinically apparent ipsilateral
    internal mammary lymph nodes in the presence of
    1 or more positive axillary lymph nodes or in
    more than 3 axillary lymph nodes and in
    internal mammary lymph nodes with microscopic
    disease detected by sentinel lymph node
    dissection but not clinically apparent
  • pN3c metastasis in ipsilateral supraclavicular
    lymph nodes

45
Regional lymph nodes
  • pNx
  • pN0
  • pN0 (sn)
  • pN0(i-) no regional lymph node metastasis
    histologically, negative IHC.
  • pN0(i) no regional lymph node metastasis
    histologically, positive IHC, no IHC cluster
    greater than 0.2 mm (ITC isolated tumor cell).
  • pN0(mol-) no regional lymph node metastasis
    histologically, negative molecular findings
    (RT-PCR)
  • pN0(mol) no regional lymph node metastasis
    histologically, positive molecular findings
    (RT-PCR)
  • pN1mi micrometastasis (greater than 0.2 mm, none
    greater than 2.0 mm)
  1. Low axillary, Level I
  2. Mid-axillary, Level II
  3. High axillary, apical, infraclavicular, Level III
  4. Supraclavicular
  5. Internal mammary nodes

46
Regional lymph nodes
Axillary Internal mammary Infraclavicular Supraclavicular
pN1mi Micro-metastasis
pN1a 13
pN1b - sn microscopically
pN1c 13 sn microscopically
pN2a 49
pN2b - clinically
pN3a 10
pN3a
pN3b 1 clinically
pN3b gt 3 sn microscopically
pN3c
47
Distant metastasis (M)
  • Mx distant metastasis cannot be assessed
  • M0 no distant metastasis
  • M1 distant metastasis
  • A negative clinical history and examination are
    sufficient to designate a case as M0
  • extensive imaging or other testing is not
    required.
  • Note that positive supraclavicular lymph nodes
    are now classified as N3 rather than M1.
  • M1
  • Pulmonary PUL
  • Osseous OSS
  • Hepatic HEP
  • Brain BRA
  • Lymph nodes LYM
  • Bone marrow MAR
  • Pleura PLE
  • Peritoneum PER
  • Adrenals ADR
  • Skin SKI
  • Other OTH

48
TNM staging
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T0 T1 T2 N1 N1 N0 M0 M0 M0
Stage IIB T2 T3 N1 N0 M0 M0
Stage IIIA T0 T1 T2 T3 T3 N2 N2 N2 N1 N2 M0 M0 M0 M0 M0
Stage IIIB T4 T4 T4 N0 N1 N2 M0 M0 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1
T1 includes T1mic
49
General rules of the TNM system
  • All cases should use the following time
    guidelines for evaluating stage through the
    first course of surgery or 4 months, whichever is
    longer.
  • All cases should be confirmed microscopically for
    TNM classification (including clinical
    classification).
  • Rare cases that do not have biopsy or cytology of
    the tumor can be staged but should be analyzed
    separately and should not be included in survival
    analyses.
  • Four classification are described for each site
  • Clinical classification, cTNM or TNM
  • Surgical classification, sTNM
  • Pathologic classification, pTNM
  • Retreatment classification, rTNM
  • Autopsy classification, aTNM
  • Stage grouping.
  • Carcinoma in situ (CIS), pTis cNo cMo

50
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51
Breast surgery
Breast Nipple Axillary LN Pectoralis major Pectoralis minor
RM Radical Mastectomy
MRM Modified Radical Mastectomy -
SM Simple Mastectomy - - -
QUART Breast preserving surgery ? - -
ScM Subcutaneous Mastectomy - - - -
QUART Quadrectomy, Axillary LN dissection,
Radiotherapy
? quadrectomy, partial mastectomy, wide
excision, lumpectomy
52
Mastectomy
Breast Nipple Axillary LN Pectoralis major Pectoralis minor
RM Radical Mastectomy
MRM Modified Radical Mastectomy -
SM Simple Mastectomy - - -
QUART Breast preserving surgery ? - -
ScM Subcutaneous Mastectomy - - - -
Auchincloss method Pectoralis minor not
resected. Patey method Pectoralis minor
resected.
QUART Quadrectomy, Axillary LN dissection,
Radiotherapy
? quadrectomy, partial mastectomy, wide
excision, lumpectomy
53
Contraindications to breast-conserving therapy
  • Absolute contraindications
  • Prior therapeutic radiation to the involved
    breast
  • When the patient is in the first or second
    trimester of pregnancy
  • The presence of 2 or more distinct tumors
    involving different quadrant of the breast
  • The presence of diffuse, suspicious
    microcalcifications involving more than 1
    quadrant of the breast
  • Tumor margin-to-nipple distance lt 2cm
  • Relative contraindications
  • Large tumor volume-to-breast volume ratio
    precluding an acceptable cosmetic outcome
  • Very large breast which may present unacceptable
    difficulty in delivering a uniform radiation dose
    to the breast
  • History of collagen-vascular disease and primary
    lung disease

54
Axillary Lymph Node Staging
  • In the absence of definitive data demonstrating
    superior survival from the performance of
    axillary lymph node dissection, the performance
    of axillary lymph node dissection may be
    considered optional.
  • patients who have particularly favorable tumors,
  • pure tubular carcinoma lt 1cm
  • pure mucinous carcinoma lt 1cm
  • microinvasive carcinoma
  • patients for whom the selection of adjuvant
    systemic therapy is unlikely to be affected,
  • for the elderly, or those with serious comorbid
    conditions,
  • The axillary dissection should be extended to
    include level III nodes only if there is gross
    disease apparent in the level II nodes.
  • Sentinel lymph node biopsy is the preferred
    method of axillary lymph node staging if there is
    an experienced sentinel node team and the patient
    is an appropriate sentinel lymph node biopsy
    candidate.

55
Sentinel lymph node biopsy
  • Sentinel lymph node biopsy is the preferred
    method of axillary lymph node staging if there is
    an experienced sentinel node team and the patient
    is an appropriate sentinel lymph node biopsy
    candidate.

56
ASCO recommendations for SNB in early-stage
breast cancer
57
Rules for classificationpathologic staging (pN)
  • those lymph nodes located lateral to the lateral
    border of the pectoralis minor muscle, should be
    performed for pathologic (pN) classification.
  • such a resection will ordinarily include six or
    more lymph nodes.
  • alternatively, one or more sentinel lymph nodes
    may be resected and examined for pathologic
    classification.
  • Certain pathologic tumor types, have a very low
    incidence of axillary lymph node metastases and
    do not usually require an axillary lymph node
    dissection
  • Pure tubular carcinoma lt 1cm
  • Pure mucinous carcinoma lt 1cm
  • Microinvasive carcinoma
  • Cancerous nodules in the axillary fat adjacent to
    the breast, without histologic evidence of
    residual lymph node tissue,
  • are classified as regional lymph node metastasis.

58
In Situ Breast Cancer
59
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60
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61
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62
Radiotherapy
  • Breast, Tumor bed partial mastectomy
  • Chest wall T3 or T4
  • Lymph nodes pN
  • Supraclavicular LN
  • Internal mammary LN
  • Lower cervical LN

63
Locoregional Treatment Stage I, II, T3N1
Medial, Central location
64
NCCN Categoties of Consensus
65
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66
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  • ??????? (Neoadjuvant chemotherapy)
  • ????????????????,???????????,????????????????????,
    ???????????????????????
  • ??????? (Adjuvant chemotherapy)
  • ?????????????????,???????????????????(??????????),
    ???????????
  • ??????? (Therapeutic chemotherapy)
  • ?????????????(??????????)???,????????????
  • ????????????????,???????(??)??????????????,???????
    ????????????????,????????????,??????????(?????????
    ?)????????
  • ???????? (Palliative chemotherapy)
  • ????????????????,?????????????????????????????

67
Systemic Adjuvant TreatmentStage I, II
68
Systemic Adjuvant TreatmentStage I, II
69
Mammary carcinomas
  • In situ carcinoma
  • Ductal carcinoma is situ
  • Lobular carcinoma in situ
  • Invasive carcinoma
  • Invasive ductal carcinoma not otherwise specified
  • Invasive lobular carcinoma
  • Classic
  • Solid variant
  • Loose alveolar variant
  • Tubuloalveolar carcinoma
  • Pleomorphic lobular carcinoma
  • Tubular carcinoma
  • Cribriform carcinoma
  • Carcinoma with papillary features
  • Intracystic papillary carcinoma
  • Transitional cell papillary carcinoma
  • Invasive micropapillary carcinoma
  • Secretory carcinoma
  • Cystic hypersecretory carcinoma
  • Carcinomas with lymphoid stroma
  • Medullary carcinoma
  • Atypical medullary carcinoma
  • Lymphoepithelioma-like carcinoma
  • Carcinomas with endocrine differentiation
  • Apocrine carcinoma
  • Acinic cell carcinoma
  • Tumors showing oncocytic features
  • Tumor showing clear cell changes
  • Glycogen-rich carcinoma
  • Lipid-rich carcinoma
  • Carcinomas with myoepithelial cell
    differentiation
  • Adenoid cystic carcinoma
  • Adenomyoepithelioma
  • Low-grade adenosquamous (syringomatous) carcinoma
  • Pure malignant myoepithelioma
  • Poorly differentiated myoepithelial-rich
    carcinoma
  • Sarcomatoid carcinoma
  • Biphasic sarcomatoid carcinoma

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Morphology grade and differentiation
  • For breast cancers, code the tumor grade using
    the following priority order
  • 1) Bloom-Richardson (Nottingham) Scores
  • 2) Bloom-Richardson Grade
  • 3) Nuclear Grade
  • 4) Terminology
  • 5) Histologic Grade.

Gx grade cannot be assessed G1 low combined
histologic grade (favorable) G2 intermediate
combined histologic grade (moderately
favorable) G3 high combined histologic grade
(unfavorable)
Coding Guidelines for Topography and
Morphology (ICD-O-3 pp. 3034).
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Systemic Adjuvant TreatmentStage I, II
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Rules for classificationpathologic staging (pN)
  • those lymph nodes located lateral to the lateral
    border of the pectoralis minor muscle, should be
    performed for pathologic (pN) classification.
  • such a resection will ordinarily include six or
    more lymph nodes.
  • alternatively, one or more sentinel lymph nodes
    may be resected and examined for pathologic
    classification.
  • Certain pathologic tumor types, have a very low
    incidence of axillary lymph node metastases and
    do not usually require an axillary lymph node
    dissection
  • Pure tubular carcinoma lt 1cm
  • Pure mucinous carcinoma lt 1cm
  • Microinvasive carcinoma
  • Cancerous nodules in the axillary fat adjacent to
    the breast, without histologic evidence of
    residual lymph node tissue,
  • are classified as regional lymph node metastasis.

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Neoadjuvant TherapyStage II, T3
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Neoadjuvant TherapyStage II, T3
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LABC(Locally Advanced Breast Cancer)
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Adjuvant Chemotherapy
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Estrogen Receptor Assay
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Progesterone Receptor Assay
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Tamoxifen ????
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Classification of aromatase inhibitors
Type First generation Second generation Third generation
1 Formestane (lentaron) Exemestane (aromasin)
2 Aminoglutethimide Anastrozole (arimidex)
Letrozole (femara )
Vorozole (rivizor)
AI (aromatase inhibitor) Aromasin ???? Arimidex ??
? Femara ???
  • Aromatase inhibitors have been divided into Type
    I (steroidal) and Type 2 (nonsteroidal) and also
    into first-, second- and third-generation agents
    depending on their time of development.
  • All are given orally, with the exception of
    formestane (4-hydroxyandrostenedione) which
    requires intramuscular injection, thereby
    potentially reducing its acceptability.
  • Aminoglutethimide is no longer in use because of
    idiosyncratic side effects. In addition, the
    newer agents are more effective in inhibiting or
    irreversibly inactivating aromatase, thereby
    achieving very low levels of plasma oestrogens.
  • The non-steroidal AIs bind reversibly to the
    aromatase enzyme, whereas exemestane inactivates
    the enzyme by binding irreversibly.

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Adjuvant Hormonal Therapy
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Trastuzumab(Herceptin ???)
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Lapatinib (Tykerb)
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Treatment of Recurrence/Stage IV Disease
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Lobular Carcinoma in Situ
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Ductal Carcinoma in Situ
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Ductal Carcinoma in Situ
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NCCN Clinical Practice Guidelines in
OncologyBreast Cancer V.2 2007
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Pagets Disease
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Pagets Disease
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Invasive Breast CancerStage I, II, T3N1
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Locoregional Treatment Stage I, II, T3N1
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Systemic Adjuvant Treatment Stage I, II, T3N1
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Systemic Adjucant Treatment Stage I, II,
T3N1ER HER2, ER HER2-
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Systemic Adjucant Treatment Stage I, II,
T3N1ER- HER2
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Systemic Adjucant Treatment Stage I, II,
T3N1ER- HER2-
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Systemic Adjucant Treatment Stage I, II,
T3N1Favorable Histologies
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Preoperative Chemotherapy
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Preoperative ChemotherapyStage II, T3N1
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Preoperative ChemotherapyStage II, T3N1
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Locally Advanced Breast Cancer
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Locally Advanced Breast Cancer
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