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Slide 1 - بسم الله الرحمن الرحيم
Slide 3 - incidence In 2006 the estimated age-adjusted annual incidence of breast cancer in the European Union (25 countries) was 110.3/100 000 and the mortality 25.0/100 000. The mortality rate has decreased especially in younger age groups because of earlier detection and improved treatment. However, breast cancer is still the leading cause of cancer-related deaths in European women.
Slide 4 - Diagnosis
Slide 5 - The diagnosis is based on the triad of clinical, radiological and pathological examinations. Clinical examination includes bi-manual palpation of the breasts and local regional lymph nodes.
Slide 6 - Radiological examinations include bilateral mammography of the breasts and ultrasound of the breasts and local regional lymph nodes. MRI of the breasts is not a routine procedure, but may be considered in cases involving diagnostic challenges arising, for example, because of dense breast tissue or positive axillary lymph node status with occult primary tumor in the breast
Slide 7 - Pathological diagnosis should be based on core needle biopsy obtained by manual, or preferably by ultrasound or stereotactic guidance. A core needle biopsy, or if that is not possible, at least a fine needle aspiration indicating carcinoma should be obtained before any surgical operations.
Slide 8 - Final pathological diagnosis should be made according to the World Health Organization classification and the tumor–node–metastasis (TNM) (International Union Against Cancer and American Joint Committee on Cancer, sixth edition 2002) staging system analyzing all tissue removed.
Slide 9 - Staging and risk assessment
Slide 10 - In case of preoperative systemic treatment, a full clinical staging should be carried out at the outset. In case of primary surgery, pathologic TNM staging based on hematoxylin–eosin staining, description of histologic type, standardized grading and evaluation of resection margins should be reported.
Slide 11 - Determination of estrogen receptor (ER) and progesterone receptor (PgR) status is mandatory, preferably by immunohistochemistry [III, B]. Reports of immunohistochemical results for ER and PgR should include the percentage of ER-and PgR-positive cells.
Slide 12 - Hormone receptors are no longer included among the prognostic factors but are the most relevant predictive factor for the choice of treatment.
Slide 13 - Immunohistochemical determination of HER2 receptor expression should be carried out at the same time for treatment planning.
Slide 14 - When semiquantitative results of immunohistochemistry are ambiguous (++), in situ hybridization (FISH or CISH) to determine HER2 gene amplification should be carried out. It is possible to directly carry out a gene amplification study (FISH or CISH) and not carry out the HER2 immunohistochemistry at all.
Slide 15 - staging and risk assessment
Slide 16 - Routine staging examinations include physical examination, full blood counts, routine chemistry including liver enzymes, alkaline phosphatase, calcium and assessment of menopausal status. This staging is needed for all patients and it can be acceptable for patients with small clinical tumors (T1) and without palpable nodes.
Slide 17 - For all other cases and in particular for candidates to preoperative treatment, the conduct of additional investigations should be considered prior rather that after surgery.
Slide 18 - In patients with higher risk (pathological N2 with four or more positive axillary nodes or T4 tumors or with laboratory signs or clinical signs or symptoms suspicious for the presence of metastases) : Chest X-ray, Abdominal ultrasound Isotopic bone scan are appropriate [III, B].
Slide 19 - Postoperatively the pathologist's report should include: 1-number of tumors in the tissue removed, 2-the maximum diameter of the largest tumor (T), 3- histologic type and 4- grade of the tumor, 5- evaluation of the resection margins including the minimum margin in millimetres and its anatomical direction;
Slide 20 - 6-total number of removed lymph nodes, 7- number of positive lymph nodes, 8- extent of metastases in the lymph nodes (ITC, micrometastatic, metastatic), i.e. N-status
Slide 21 - The report should also include: 9- immunohistochemical evaluation of ER and PgR using a standardized assessment methodology, 10- immunohistochemical evaluation of HER2 receptor expression. HER2 gene amplification status may be determined directly from all tumors using in situ hybridization (FISH or CISH) or only from tumors with an ambiguous (2+) immunohistochemistry. Vascular and lymphovascular invasion should also be reported.
Slide 22 - Treatment decisions are based: Primarily on endocrine responsiveness of the tumor. Secondarily on risk of recurrence.
Slide 23 - Definition of risk categories for patients with operated breast cancer
Slide 24 - Risk stratification: has been revised and currently includes three risk groups: Low Intermediate High risk Vascular invasion has been described as an important prognostic factor, particularly in node-negative disease.
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Slide 28 - Treatment Plan
Slide 29 - Treatment planning should be done by a multidisciplinary team including : A surgical, A medical A radiation oncologist. A pathologist in order to integrate local and systemic therapies as well as their sequence [III, B].
Slide 30 - The possibility of hereditary cancer should be explored and counseling of relatives should be considered [IV, D] .
Slide 31 - local therapy :non-invasive carcinoma Intraductal carcinoma (ductal carcinoma in situ, DCIS) may be treated with breast-conserving surgery (BCS) providing healthy tissue margins can be reached. There is no general consensus on what is regarded as a safe (negative) margin. However, margins >10 mm are adequate and margins <1 mm are inadequate.
Slide 32 - Adjuvant breast irradiation after BCS decreases the risk of local recurrence but has no effect on survival However, in some patients with low-risk DCIS (tumor size <10 mm, low/intermediate nuclear grade, adequate surgical margins), the risk of local recurrence following excision only is so low that omitting radiation may be an option.
Slide 33 - Especially in ER-positive DCIS tamoxifen may be considered following BCS (with or without adjuvant radiation)
Slide 34 - Total mastectomy with clear margins in DCIS is curative, and radiation therapy is not recommended. In this group of patients tamoxifen may also be considered as a risk reduction therapy to decrease the risk of contralateral breast cancer
Slide 35 - When ductal carcinoma in situ (DCIS) is treated by breast-conserving surgery, all subgroups of patients benefit from adjuvant radiation (I, A). Adjuvant tamoxifen should be considered in women with ER-positive DCIS (II, B), while its use in patients with ER-negative disease may be detrimental.
Slide 36 - Lobular carcinoma in situ (LCIS) is a risk factor for future development of invasive cancer. It should be completely resected.
Slide 37 - Local Therapy: 2- Invasive Carcinoma
Slide 38 - Operable breast cancer :is initially treated by surgery, using breast-conserving surgery or mastectomy, both in combination with axillary dissection or a sentinel node biopsy.
Slide 39 - Contraindications to BCS include : *Multicentric tumors, *Large tumors (>3–4 cm) in small breasts especially when no neo-adjuvant therapy is planned, * Positive margins after resection, *Inflammatory breast cancer and *Patient's own wish.
Slide 40 - Sentinel node biopsy
Slide 41 - Clinical Recommendations Sentinel node biopsy should not be carried out: In case of palpable axillary nodes, T3 or T4 tumors, Multicentric tumors Prior axillary surgery Large biopsies After breast reconstruction or implantation of a prosthesis During pregnancy or lactation After neo-adjuvant systemic treatment outside of clinical trials.
Slide 42 - -Breast radiotherapy is strongly recommended after breast-conserving surgery [I, A]. -Postmastectomy radiotherapy has been recommended for patients: With four or more positive axillary nodes . Is suggested for all T3 tumors .
Slide 43 - -Post-mastectomy radiotherapy may also be considered in cases of at least T1 tumor with 1–3 positive axillary lymph nodes, particularly if young, -and in cases of T2 or greater medially located tumors which show signs of biological aggressiveness (receptor-negative, grade 3, HER2-positive, high proliferation activity, e.g. Ki-67).
Slide 44 - Postoperative Radiotherapy reduces the risk of local recurrence by two-thirds and has a beneficial effect on survivaL
Slide 45 - In patients >70 years of age who have receptor-positive invasive breast cancer with maximum stage pT1N0 and clear postoperative margins it may be possible to use adjuvant tamoxifen instead of radiation therapy [II, B].
Slide 46 - PRIMARY SYSTEMIC THERAPY: Before primary systemic therapy, a biopsy for histology and analysis of predictive factors should be carried out. In addition, for these higher risk patients, a full clinical staging to rule out metastatic disease is necessary.
Slide 47 - Primary systemic therapy: is indicated for locally advanced breast cancer (stage IIIA, IIIB, IIIC) [III, B].
Slide 48 - It can employ chemotherapy or endocrine therapy on the basis of predictive factors similar to adjuvant treatment.
Slide 49 - Trastuzumab should be considered in the treatment protocol in HER2-positive tumors. It should be followed by both surgery and radiotherapy and postoperative systemic adjuvant treatment
Slide 50 - If possible it should be followed by both surgery and radiotherapy and postoperative systemic treatment .
Slide 51 - Primary systemic therapy is an alternative for large operable breast cancer, to allow breast-conserving surgery [I, A].
Slide 52 - Adjuvant Systemic Therapy
Slide 53 - Treatment is initiated providing that there is a relevant reduction of (calculated) risk of recurrence which can be reached with an acceptable level of treatment-related adverse effects.
Slide 54 - Hormone receptors and HER2 status are the most relevant predictive factors for the choice of treatment modality.
Slide 55 - Tumors with an incomplete (some expression) or high degree of expression of ER and/or PgR are considered endocrine responsive..
Slide 56 - Patients with no detectable expression of ER and PgR in their tumors are considered endocrine non-responsive
Slide 57 - Features indicative of uncertainty of endocrine responsiveness include : -low levels of steroid hormone receptor immunoreactivity, - lack of PgR, G3, high proliferation markers (Ki-67), HER2 overexpression and possibly uPA and PAI1
Slide 58 - Patients with tumors considered endocrine responsive may receive endocrine treatment alone , or a combination of endocrine therapy and chemotherapy
Slide 59 - Choice of treatment modalities according to St Gallen Consensus 2007 (Goldhirsch A et al., 2007)
Slide 60 - Endocrine therapy Patients with tumors considered uncertainly or highly endocrine responsive should be treated with endocrine therapy
Slide 61 - Patients with tumors of uncertain endocrine responsiveness are usually treated with a combination of endocrine therapy and chemotherapy
Slide 62 - Patients with endocrine non-responsive tumors derive greater benefit from chemotherapy and should not receive endocrine therapy.
Slide 63 - In addition to endocrine and chemotherapy, patients with HER2 overexpression or amplification should be considered for adjuvant treatment with trastuzumab .
Slide 65 - For each individual, the choice of adjuvant therapy must take into account the potential benefits, possible side-effects and patient preference. Several decision-making tools have been developed to help doctor–patient communication for adjuvant treatment decisions.
Slide 67 - Endocrine therapy
Slide 68 - Treatment decisions are made on the basis of two main factors: (i) estimated endocrine responsiveness of tumor tissue (ii) risk of relapse
Slide 69 - In premenopausal patients tamoxifen alone (20 mg daily for 5 years) or the combination of ovarian function ablation with tamoxifen are standard therapies. Ovarian function ablation may be achieved by bilateral oophorectomy which leads to irreversible ablation of ovarian function. Gonadotropin-releasing hormone analogues (GnRHAs) generally lead to reversible ovarian suppression sufficient for therapeutic activity. GnRHAs should be given for at least 2 years, although optimal duration for this treatment has not been established
Slide 70 - Combining GnRHAs and aromatase inhibitors (AIs) in premenopausal patients is not indicated, as is the use of AIs alone. In premenopausal patients GnRHAs may be started concurrently with chemotherapy, leading to rapid amenorrhea
Slide 71 - Bilateral ovarectomy or irradiation of the ovaries leads to irreversible ablation of ovarian function. Gonadotropin-releasing hormone analogue (GnRHA) (e.g. goserelin 3.6 mg subcutaneously monthly) generally lead to reversible ovarian suppression. They should be given for at least 2 years, but optimal duration for this treatment has not yet been established.
Slide 72 - In postmenopausal patients :5 years of tamoxifen alone is still a viable option for certain patient categories. For the use of AIs a switch from tamoxifen to an AI after 2–3 years of tamoxifen or initial use of an AI for 5 years are most commonly accepted strategies .
Slide 73 - Initial use of an AI is the preferred option in patients at higher risk of relapse (large tumor size, node positivity, HER2-positive disease).
Slide 74 - For patients who have completed 5 years of tamoxifen the addition of an AI for a further period of 2–3 years may be recommended in cases with node-positive disease .
Slide 75 - The total duration of optimal adjuvant endocrine treatment is between 5 and 10 years, 5 years for tamoxifen alone being standard. Sequential rather than concurrent administration of cytotoxic and endocrine therapies should be used . It is unclear whether AIs should be started concurrently with chemotherapy (CT + ET) or sequentially after chemotherapy (CT/ET
Slide 76 - The long-term skeletal adverse effects associated with AIs are an issue of concern. Women treated with AIs should receive vitamin D and calcium supplements.
Slide 77 - There is no clear evidence for the concomitant use of bisphosphonates with AI in the adjuvant setting. However, several randomized controlled trials are ongoing with pending final results. Before commencing AI treatment, women should have BMD assessed by DEXA with a low threshold, and receive bisphosphonate if T-score is less than –2,5 SD, which equals to osteoporosis
Slide 78 - Patients with tumors of likely or uncertain endocrine responsiveness should be treated with endocrine therapy.
Slide 79 - It is unclear whether aromatase inhibitors should be started concurrently with chemotherapy (CT + ET) or sequentially after chemotherapy (CT/ET).
Slide 80 - In premenopausal patients gonadotropin-releasing hormone analogues can be started concurrently with chemotherapy, leading to rapid amenorrhea.
Slide 81 - Adjuvant aromatase inhibitors increase disease-free survival when compared with tamoxifen. This has been shown for anastrozole (1 mg daily for 5 years) and for letrozole (2.5 mg daily for 5 years) given upfront [I, A].
Slide 82 - Chemotherapy
Slide 83 - Adjuvant chemotherapy for intermediate or high-risk patients should use a combination regimen. *In 2006, the consensus is that such a combination should include an anthracycline and for a duration of at least four cycles of treatment.
Slide 84 - Adjuvant chemotherapy is generally recommended for intermediate- or high-risk patients. A multiplicity of chemotherapy regimens acceptable for adjuvant treatment exist . The use of anthracyclines for all patients and especially for patients with HER2-positive disease may be recommended.
Slide 85 - However, for some patients (elderly, cardiac contraindication, etc.) non-anthracycline-containing regimes (CMF) may still be appropriate [I, A].
Slide 86 - The optimal duration of the treatment is not known. However, at least four cycles (12–16 weeks) should be administered, generally aiming for six to eight cycles (18–24 weeks).
Slide 87 - Taxanes should be used in high-risk patients, especially with ER negative.
Slide 88 - The use of dose-dense schedules with prophylactic G-CSF is controversial, whilst high-dose therapy requiring peripheral blood stem cell support cannot be recommended at all.
Slide 89 - A shorter duration of chemotherapy (12–16 weeks) may be suitable for elderly patients, for whom the role of chemotherapy remains uncertain
Slide 91 - Premenopausal women may benefit from 3- to 6-monthly bisphosphonate infusions during the first year to prevent bone loss associated with temporary or permanent hormonal changes during adjuvant chemotherapy [II, B].
Slide 92 - Trastuzumab
Slide 93 - Patients with HER2 overexpression (3+) or HER2 gene amplification can benefit from adjuvant treatment with trastuzumab.
Slide 94 - There is no evidence for the use of trastuzumab in patients with node-negative, small (<1 cm) tumors, as in this group of patients side-effects may override possible benefits .
Slide 95 - On the basis of pharmacokinetic analyses, a three-weekly schedule (6 mg/kg) is considered equivalent to a weekly schedule (2 mg/ kg).
Slide 96 - The standard duration of adjuvant trastuzumab has not yet been established; for the time being 1 year is recommended. Trastuzumab may be started in parallel with a taxane, but it should not be given concurrently with an anthracycline .
Slide 97 - When given after an anthracycline-containing regimen, trastuzumab has cardiotoxic effects and heart function should be routinely monitored.
Slide 98 - Follow-up
Slide 99 - History taking, eliciting of symptoms and physical examination every 3–6 months for 3 years, every 6–12 months for 3 years, then annually [A].
Slide 100 - With attention paid to long-term side-effects, e.g. osteoporosis. Ipsilateral (after breast-conserving surgery) and contralateral mammography every 1–2 years.
Slide 101 - Not routinely recommended for asymptomatic patients: blood counts, chemistry, chest X-ray, bone scan, liver ultrasound, CT scans of chest and abdomen and any tumor markers such as CA 15-3 or carcinoembryonic antigen.
Slide 102 - Thank You