Breast Cancer: Specific Situations

Diagnosis And Treatment Of Patients
With Primary And Metastatic Breast Cancer
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Guidelines Breast
Version 2010.1.1
Breast Cancer:
Specific Situations
Breast Cancer:
Specific Situations
© AGO
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Guidelines Breast
Version 2010.1.1

Version 2005:
Göhring / Scharl

Version 2006–2008:
Dall / Gerber / Harbeck / Loibl / Maass /
Oberhoff

Version 2010:
Mundhenke / Rody
Breast Cancer:
Specific Situations
© AGO
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Guidelines Breast
Version 2010.1.1

Young patients

Pregnancy-associated BC

Elderly patients

Male patients

Inflammatory BC

Carcinoma of unknown primary (CUP)

Paget´s disease

Malignant Phyllodes Tumor

Sarcomas
Breast Cancer in
Very Young Women ≤ 35 Years
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Guidelines Breast
Version 2010.1.1

Aggressive biological behavior
2a
B

Benefit from chemotherapy
1b
A
++

Benefit from endocrine therapy
1b
A
++

Benefit from trastuzumab
2b
B
++

Benefit from temporary amenorrhoea
after adjuvant chemotherapy (chemotherapy
induced or GnRHa-related)
2b
B
+/-*

Surgery like ≥ 35y (in particular BCT)
2b
B
+

Stage II–III benefit from PMRT
2b
B
+

Genetic and fertility counseling
2b
B
++
*Study participation recommended
Breast Cancer During Pregnancy*
or Breast Feeding
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Guidelines Breast
Version 2010.1.1
Breast imaging & biopsy like in non-pregnant
(MRI not indicated)
4
C
++

Staging: ultrasound, chest X-ray if indicated
5
D
+/-

Surgery like in non-pregnant patients
4
C
++

Sentinel node excision (technetium only)
4
C
+

SNE during 1st trimester
5
D
+/-
sensitivity and specificity not established
(during lactation); breast feeding should
be avoided for 24 hrs
4
C
++
blue dye (has not been tested in
pregnant animals or humans)
4
C
--



* Participation in register study recommended
Breast Cancer During Pregnancy*
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Guidelines Breast
Version 2010.1.1


Radiation therapy during pregnancy
(Neo-)adjuvant chemotherapy only
after first trimester (indication as in non-pregnant)
 AC, FAC (FEC)
 MTX (e.g. CMF)
 Taxanes
4
3b
4
4
C
D
C
Endocrine treatment
Trastuzumab
4
4
D
D


C
-
++
++
-+/---
* Participation in register study recommended
Breast Cancer During Pregnancy*
© AGO
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Guidelines Breast
Version 2010.1.1

Delivery should be postponed until sufficient
fetal maturation since termination of
pregnancy does not improve maternal
outcome (avoid iatrogenic prematurity)
4

Delivery mode like in non-pregnant women,
avoid delivery 3 weeks from prior
chemotherapy

If further systemic therapy is needed after
delivery, breast feeding may be contraindicated depending on drug toxicities
4
C
++
C
++
++
* Participation in register study recommended
Pregnancy Associated
Breast Cancer*: Outcome
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Oxford
Guidelines Breast
Version 2010.1.1
LoE
BC during pregnancy / lactation
Outcome not compromized,
if treated adaequately

3b
Pregnancy and lactation after BC

Outcome not compromized
3b
* Participation in register study recommended
Treatment for Fit Elderly Patients
(life expectancy > 5yrs and acceptable comorbidities)
© AGO
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Guidelines Breast
Version 2010.1.1

Geriatric assessment
2b
B
++

Treatment according to standard
2a
C
++

Surgery similar to „younger“ age
2b
B
++

Endocrine treatment (endocrine resp.)
1a
A
++

Chemotherapy

< 70 years
1a
A
+

> 70 years (especially N+, ER/PR-)
2a
C
+*

Radiotherapy
2b
C
+

Trastuzumab
2b
C
+
*Study participation recommended
Treatment for Frail Patients
(life expectancy <5yrs, substantial comorbidities)
© AGO
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Guidelines Breast
Version 2010.1.1

Reduced standard treatment

Options extrapolated from trials in elderly:
2b
C
++
No breast surgery
(consider endocrine options)
2b
C
+

No axillary clearing (≥ 60 y, cN0, Rec pos)
2b
C
+

No radiotherapy ( ≥ 70 y, pT1, pN0, Rec pos)
2b
C
+

Hypofractionated radiotherapy
2b
C
+

No chemotherapy >70 years and negative
risk-benefit analysis
2b
C
+

Geriatric Assessment
© AGO
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Guidelines Breast
Version 2010.1.1
•
•
•
No specific algorithm is available
Ability to tolerate treatment varies greatly („functional
reserve“)
Comprehensive geriatric assessment (CGA) describes a
multidisciplinary evaluation of independent predictors of
morbidity and mortality for older individuals
•
•
•
•
Physical, mental, and psycho-social health
Basic activities of daily living (dressing, bathing, meal preparation,
medication management, etc.)
Living arrangements, social network, access to support services
Assessment tools:
•
•
•
•
Charlson Comorbidity Index (widely used; good predictor over a 10year period)1
12 prognostic indicators to estimate 4-year mortality risk
Short screening tests (more qualitative evaluation)
IADL, G8 – genauer ausführen
Radiotherapy in BCT
Which Patients do not Benefit from RT?
© AGO
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Guidelines Breast
Version 2010.1.1
Author
Winzer KJ
Eur J Ca 40;2004:998
Holli KH
Br J Cancer 84:2001:164
Ford HAT
pts.
n
F/U
(m)
LR
DFS/
OAS
pT1N0, G1-2, 45-75
J.
361
59
3x 
=
pT1N0, G1-2, HR+,
1 cm R0, >40 J.
152
67
2x 
=
pT1-2 N0,1cm R0
400
72
2x 
=
pT1N0, G1-2, 1cm R0
Post-MP
163
80
=
=
pT1N0, HR+, >70 J.
Tam+ vs. Tam
636
60
14%
=
pT1-2N0, HR+, >50 J.
Tam+ vs. Tam
760
60
18%
DFS 84 vs 91 %
OAS/DMFS =
pT0-2 N0, >65 J.
255
60
=
=
Ann Oncol 17;2006:401
Lee S
Ann Surg Oncol 11:2004:316
Hughes KS
NEJM 351;2004;971
SABCS 2006
Fyles AW
NEJM 351;2004;1021
Prescott R
Health Tech Assess
11;2007:1
Male Breast Cancer: Diagnostic
Work-Up and Loco-Regional Therapy
© AGO
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LoE / GR
e. V.
in der DGGG e.V.
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in der DKG e.V.
Guidelines Breast
Version 2010.1.1


Diagnostic work up as in women

Mammography

Ultrasound
Standard-surgery: Mastectomy


Sentinel-node excision (SNE)

C
C
B
C
B
+
+/++
++*
+
4
C
+
Radiotherapy as in women
(consider tumor breast relation!)

4
3b
2b
4
2b
Genetic counselling if one additional
relative affected (breast/ovarian cancer)
Screening for 2nd malignancies
according to guidelines
2b B
++
GCP
++
*Participation in register study recommended
Male Breast Cancer:
Systemic Therapy
© AGO
Oxford / AGO
LoE / GR
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Guidelines Breast
Version 2010.1.1

Adjuvant chemotherapy as in women
2a
B
++

Trastuzumab
5
D
+*

Endocrine therapy
4
D
++
- Tamoxifen
4
C
++
- Aromatase inhibitors (adjuvant)
4
D
-
- Aromatase inhibitors (metastatic BC)
4
C
+/-
- GnRHa and AI (metastatic BC)
4
C
+/-
- Fulvestrant (metastatic BC)
4
C
+/-
4
C
++

Palliative chemotherapy as in women
Inflammatory Breast Cancer (IBC, cT4d)
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Guidelines Breast
Version 2010.1.1

In case of invasive BC and clinical signs of
inflammation (>2/3 of the breast affected)
determine stage cT4d
++

Staging
2c
B
++

Preoperative chemotherapy
2c
B
++
2c
B
++


Regimens as in non-inflammatory BC
Mastectomy after chemotherapy

Breast conserving therapy
2b B
--

Sentinel excision only
3b C
--

Radiotherapy
2c
B
++

Postoperative systemic therapy as in
non-inflammatory BC
4
C
++
Axillary Metastasis in Carcinoma
of Unknown Primary (CUP)
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Guidelines Breast
Version 2010.1.1

Mammography / Breast ultrasound
3
B
++

Breast MRI
3
B
++

Staging (CT thorax / abdomen, thyroid
sonography, ENT investigation)
4
A
++

PET / PET-CT
4
B
+/-

Gene expression profiling (e.g. CupPrint™)
2c B
+/-

ER, PR, HER2
5
D
++

Axillary dissection
4
C
++

Systemic treatment according N+ tumor
4
C
++

Mastectomy without (in-)breast tumor
4
C
--

Breast irradiation if breast MRI is negative
4
C
-
Paget´s Disease of the Breast
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Guidelines Breast
Version 2010.1.1
Histological verification
 Mammography, sonography
4
5
1c
2b
2b
D
D
B
B
B
++
++
+
++
+
+/-
5
D
++
Surgical resection only, no adjuvant radiotherapy 4
D
++




Surgery must include NAC (R0)

Wide excision (like DCIS) + radiotherapy

Sentinel-node excision (SNE)
Paget´s disease with underlying disease (e.g.
Invasive breast cancer, DCIS)


MR of the breast if other imaging negative
Therapy according to standard of the underlying
disease
Isolated Paget´s disease of the NAC (<5%):

Malignant Phyllodes Tumor
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Guidelines Breast
Version 2010.1.1





Complete (wide) local excision or MRM
SNE / Axillary dissection in cN0
Staging
Systemic adjuvant therapy (chemo, endocrine)
Adjuvant radiotherapy



if T ≥2 cm (BCT) or T ≥10 cm (mastectomy)
2b
4
5
4
4
2b
B
C
D
C
C
C
++
-++
--+/-
4
4
C
C
++
+/-
4
C
++
Treatment of local recurrence

R0 Resection

Radiotherapy, chemotherapy after R1 resection
Distant metastases (very rare)

Treatment like soft tissue sarcomas
Sarcoma / Angiosarcoma of the Breast
(Note: very aggressive!)
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Guidelines Breast
Version 2010.1.1
Treatment of Primary Disease:
 MG / MS to determine extent of disease
 Preoperative MRI to determine extent of disease
 Staging
 Simple mastectomy (R0!)
 Axillary dissection if cN0
 Adjuvant chemotherapy, radiotherapy
4
4
4
4
4
4
D
D
D
D
D
D
-++
++
++
+/-
Treatment of Local Recurrence:
 R0 Resection
 Radiotherapy, chemotherapy after R1 resection
4
4
C
C
++
+/-
Distant Metastases / Unresectable Tumors:
 Treatment like soft tissue sarcomas
 Paclitaxel weekly
4 C
2b B
++
+