SMALL CANCER AND BRCA MUTATION Krishna B. CLOUGH
Oct 29, 2014
SMALL CANCER AND BRCA MUTATION
Krishna B. CLOUGH
SMALL CANCER AND BRCA MUTATION CLINICAL CASE
Krishna B. CLOUGH
Mrs S.G.
l 34 yrs, journalist , 2 children
l Mother + Aunt + Greataunt Breast Cancer
l BRCA 2 Muta=on
FIRST CONSULTATION : ADVICE
l 1.75m 60 kgs small breasts 85 B Smoker 10 cig/j
l T0N0
l Mammo US: normal
l Seeks your advice
WHAT DO YOU RECOMMEND ?
l ProphylacOc oophorectomy
l ProphylacOc Mastectomy
l TAM
l Other
MRI
l LeR Breast : Nodular image lower pole
l 8 mm round non suspicious ACR 3
l SuggesOons : l MRI guided biopsy
l Control MRI 4/6 months
l Wide local excision
l Other
2nd LOOK ULTRASOUND
l 2nd look US: 8 mm image lower pole ACR 3
l Biopsy : Lobular Neoplasia LIN 2+3
l SuggesOons ? l TAM
l Wide local excison
l WLE + frozen secOon +/-‐ SNB
l Mastectomy uni/bilatéral
WL EXCISION frozen sec=on + SNB
l Invasive Ductal Carcinoma 10mm
l Grade I , low mitoOc index
l ER 100 % RP 100 % HER 2 1+ Ki67 15 %
l Free margins > 10mm
l 3 SN negaOve
1. ADJUVANT TREATMENT ?
l TAM ?
l LH-‐RH Analogs + TAM ?
l LH-‐RH Analogs + TAM ?
l Chemotherapy ?
TAM no other systemic therapy
2. LOCAL TREATMENT ?
l Radiotherapy
l M + IBR (uni/bilateral)
l Nipple sparing M + IBR
l Nipple sparing M + IBR + PBIrradiaOon leR areola
CONSERVATIVE TREATMENT and MUTATION ?
l BRCA+ vs controls : no increase in LR (7yrs) l Contralateral breast : RR 3,5
l 50% risk reducOon (ipsi and controlat) by: l Oophorectomy
l TAM / CT
BILAT. NIPPLE SPARING M + IntraopRT LeU areaola
l Postop unevenful Leaves D3
l Drains removed D10 D14
l D30 : All OK ... but
l Calls for bilat discharge
l Thin skin, « blueish »
D 30: BILATERAL IMPLANT EXPOSURE
SUGGESTIONS ?
l Lavage drainage + implant replacement
l Lavage drainage + Expanders
l Accelular Dermal Matrix
l Bilateral Lat. Dorsi
l Other
BILATERAL IMPLANT REMOVAL 8 MONTHS LATER …
Demands Reconstruction
SUGGESTIONS ?
l Implants
l Expanders
l Bilatéral Lat. Dorsi
l Other flap
l Other
3 LIPOFILLINGS L1 200 cc L2 250cc L3 280 cc
SUGGESTIONS ?
l Implants
l Expanders
l Bilatéral Lat. Dorsi
l Other flap
l Other
IMPLANT 225 CC anat L4 300cc
3. OVARIES : PROPHYLACTIC SURGERY ?
1. Follow up: modali=es ? 1. CA 12.5
2. US
3. MRI
2. Bilateral SO 1. Now
2. 45
3. 50
SEE-FIM
SEE-FIM protocol