Adjuvant therapy in breast cancer Dr Adisai Pattatang
Adjuvant therapy in breast cancer Dr. Adisai Pattatang Chonburi cancer center
Metastesis site
Prognosis factors • • ��������������������� ����� – Clinical factors • Age • Menopausal status
– Pathologic factors • Tumor type • Tumor grade • Tumor size • Lymphovascular invasion • Number of node metastases – Biologic factors • Estrogen receptor • Progesteronr receptor • HER-2(c-erb B 2)
5 yrs. survival
HER-2 IHC normal overexpression
HER-2 FISH Normal Amplified
Predictive factors • ����������� ��� – ER, Pg. R for hormone therapy – HER-2 for Trastrazumab • ����������� – HER-2 for CMF regimen – HER-2 for Tamoxifen
St. Gallen conference 2005 • Increase risk for recurrence or metastasis – Age<35 yrs. – p. T>2 cm. – Histologic grade IDC II or. III – Lymphovascular invasion , LVI – HER-2 positive 3+or amplified in FISH • Number of lymph node metastasis – N 1 1 -3 – N 2 4 -9 – N 3 >9
Assessment of endocrine responsive • Endocrine responsive – ER and Pg. R positive • Endocrine nonresponsive – ER and Pgr negative • Endocrine responsive uncertain – ER or Pg. R positive – Low level ER positive (<10%) – HER-2 positive
• ���� 2 ������������ ��� • Risk category -Low risk �������������� �� 1. p. T </=2 cm 2. Histology grade I tumor 3. No lymphovascular invasion 4. HER 2 negative 5. age<35 yrs.
• -Intermediate risk 1. ������������ �� �������������� 1. p. T > 2 cm 2. Histology grade 2 -3 3. lympovascular invasion 4. HER 2 positive 5. age>35 yrs. 2. ������������ �� 1 -3 ���� HER 2
Adjuvant therapy • Risk category • Low • Intermediate risk ET alone or CT then Etb ET alonec CTd • High risk CT then Etb CT Endocrine responsive ET Nila CT then Etb Endocrine response uncertain ET Nila Endocrine nonresponsive Not applicable
Adjuvant in endocrine responsive • Risk group Endocrine responsive Pre-menopausal Low Intermediate risk High risk Tam or Nila CT then Tam or Tam +/- OFS or OFS 4 CT then Tam Postmenopausal Tam or Nila Tam or AI or Nil CT then Tamc or CT then Aic CT then Tam or CT then AI
Adjuvant in endocrine responseuncertain • Risk group Endocrine response uncertain Pre-menopausal Low Tam or Nila Postmenopausal Tam or AI or Nilb Intermediate risk CTc then Tamd Tam +/- OFS CT then AI or CT then Tam or AI alone High risk CT then AI or CT then Tam CTc then Tamd
Adjuvant in endocrine non-responsive • Risk group Endocrine non-responsive both pre-menopausal and post- menopausal Low risk Not applicable Intermediate risk CT High risk CT
Adjuvant RT • T>5 cm. • T<5 cm. vary in breast size • T 4 • Margin not free or <1 mm. • N>4 nodes • N 1 -3 with unfavorite or ↑risk – extranodalinvasion
Adjuvant biologic therapy • Trastrazumab – In HER-2 positive 3+or – Gene amplified in FISH technique • Lapatinib – In HER-1 positive • Antiangiogenesis – bavasizumap
oncotype
chemotherapy
Tamoxifen mechanism
Breast cancer cell from electronmicroscope
Targeted therapy
Mechanism of tumor growth & metastesis
Angiogenesis
antiangiogenesis
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