Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• Breast awareness:
  • Starting at age 18 years:
    • Women should be familiar with their breasts and promptly report changes to their health care provider:
      • Periodic, consistent breast self-exam (BSE) may facilitate breast self-awareness
        • Premenopausal women may find BSE most informative when performed at the end of menses

• Clinical breast exam, every 6 to 12 months:
  • Starting at age 25 years:
    • Randomized trials comparing clinical breast exam versus no screening have not been performed:
      • Rationale for recommending clinical breast exam every 6 to 12 months is the concern for interval breast cancers
• Breast screening:
  • Age 25 to 29 years:
    • Annual breast MRI screening with contrast:
      • or Mammogram with consideration of tomosynthesis:
        • Only if MRI is unavailable:
          • Breast MRI is preferred due to the theoretical risk of radiation exposure in pathogenic /likely pathogenic variant carriers
    • Individualized based on family history if a breast cancer diagnosis before age 30 is present
  • Age 30 to 75 years:
    • Annual mammogram with consideration of tomosynthesis and breast MRI screening with contrast:
      • The criteria for high-quality breast MRI include:
        • A dedicated breast coil
        • The ability to perform biopsy under MRI guidance
        • Radiologists experienced in breast MRI
        • Regional availability
      • Breast MRI is preferably performed on:
        • Days 7 to 15 of a menstrual cycle for premenopausal women
  • Age greater than 75 years:
    • Management should be considered on an individual basis
  • For women with a BRCA pathogenic / likely pathogenic variant who are treated for breast cancer and have not had a bilateral mastectomy:
    • Screening with annual mammogram with consideration of tomosynthesis and breast MRI should continue as described above
      • The appropriateness of imaging modalities and scheduling is still under study. Lowry KP, Lee JM, Kong CY, et al. Cancer 2012;118:2021-2030.
      • Lehman CD, Lee JM, DeMartini WB, et al. Screening MRI in women with a personal history of breast cancer. J Natl Cancer Inst 2016;108. 
• Discuss option of risk-reducing mastectomy:
  • Counseling should include a discussion regarding:
    • Degree of protection
    • Reconstruction options, and risks
  • In addition, the family history and residual breast cancer risk with age and life expectancy should be considered during counseling 
• Recommend risk-reducing salpingo-oophorectomy (RRSO):
  • Given the high rate of occult neoplasms:
    • Special attention should be given to sampling and pathologic review of the ovaries and fallopian tubes
  • Typically between 35 and 40 years, and upon completion of child bearing
  • Because ovarian cancer onset in patients with BRCA2 pathogenic / likely pathogenic variants is an average of 8 to 10 years later than in patients with BRCA1 pathogenic / likely pathogenic variants:
    • It is reasonable to delay RRSO for management of ovarian cancer risk:
      • Until age 40 to 45 years in patients with BRCA2 pathogenic / likely pathogenic variants unless age at diagnosis in the family warrants earlier age for consideration of prophylactic surgery. 
    • Counseling includes a discussion of:
      • Reproductive desires
      • Extent of cancer risk
      • Degree of protection for breast and ovarian cancer
      • Management of menopausal symptoms
      • Hormone replacement therapy, and related medical issues
    • Salpingectomy alone is not the standard of care for risk reduction, although clinical trials of interval salpingectomy and delayed oophorectomy are ongoing:
      • The concern for risk-reducing salpingectomy alone is that women are still at risk for developing ovarian cancer
      • In addition, in premenopausal women, oophorectomy likely reduces the risk of developing breast cancer but the magnitude is uncertain and may be gene-specific
• Limited data suggest that there may be a slightly increased risk of serous uterine cancer among women with a BRCA1 pathogenic / likely pathogenic variant.
  • The clinical significance of these findings is unclear
  • Further evaluation of the risk of serous uterine cancer in the BRCA population needs to be undertaken
  • The provider and patient should discuss the risks and benefits of concurrent hysterectomy at the time of RRSO for women with a BRCA1 pathogenic / likely pathogenic variant prior to surgery
  • Women who undergo hysterectomy at the time of RRSO are candidates for estrogen alone hormone replacement therapy, which is associated with a decreased risk of breast cancer compared to combined estrogen and progesterone, which is required when the uterus is left in situ (Chlebowski R, et al. JAMA Oncol 2015;1:296-305)

• Address psychosocial and quality-of-life aspects of undergoing risk-reducing mastectomy and /or salpingo-oophorectomy
• For those patients who have not elected RRSO:
  • Transvaginal ultrasound combined with serum CA-125 for ovarian cancer screening:
    • Although of uncertain benefit, may be considered at the clinician’s discretion starting at age 30 to 35 years
• Consider risk reduction agents as options for breast and ovarian cancer, including discussion of risks and benefits 

#Arrangoiz #CancerSurgeon #BreastSurgeon #BreastCancer #BRCA1 #BRCAPositiveBreastCancer #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncology

• Per American Society of Clinical Oncology / College of American Pathologists (ASCO / CAP) guidelines:
  • Tumors with an immunohistochemical result of 2+ (equivocal):
    • HER2 / CEP 17 ratio of > 2.0 and copy number of > 4.0:
      • Are considered positive
• References:
  • Wolff AC, Hammond MEH, Allison KH, Harvey BE, Mangu PB, Bartlett JMS, et al. Human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists Clinical Practice Guideline focused update. J Clin Oncol. 2018;142(11):1364-1382.
  • Lin L, Sirohi D, Coleman JF, Gulbahce HE. American Society of Clinical Oncology/College of American Pathologists 2018 focused update of breast cancer HER2 FISH testing guidelines. results from a National Reference Laboratory. Am J Clin Pathol. 2019;152(4):479-485.

#Arrangoiz #BreastSugeon #CancerSurgeon #SurgicalOncologist #Miami #CASO #CenterforAdvancedSurgicalOncology

If you’re having thyroid surgery, it’s important to know how to best prepare for your procedure and what to expect while you recover. This includes any tests you’ll need before surgery, as well as what to avoid after surgery to help ensure its success.

How should I prepare for thyroid surgery?

After your thyroidectomy or thyroid lobectomy is scheduled, you’ll have a pre-operative evaluation with members of your thyroid surgery care team. That evaluation may include blood tests, an electrocardiogram (EKG), X-rays or other imaging studies.

We’ll give you specific instructions on when to stop eating, drinking and taking medications prior to surgery. It’s very important that you follow these guidelines for your own safety, and you’ll need to have an empty stomach before any surgical procedure that requires anesthesia. If you don’t follow the instructions, your thyroid surgery might be cancelled. Please contact us with any specific questions.

What is recovery like after thyroid surgery?

After your thyroidectomy or thyroid lobectomy, you may have a temporary sore throat, neck pain, difficulty swallowing or a weak voice.

Your diet will be restricted for the evening of your surgery, but in most cases, it can return to normal the next day.

Before you leave the hospital, we’ll schedule a follow-up appointment, give instructions for your at-home recovery and go over any prescribed medications.

Most people are ready to return home within one day of surgery, but take off about two weeks from work to recover. You’ll need to refrain from heavy lifting or other tasks that can strain your neck for up to three weeks after your surgery. Soaking or scrubbing the site of your incision is also discouraged for at least one week to allow it time to properly heal. Showering is generally allowed after about one day.

Pain at the site of your incision will improve after a few days but may continue for a week or so. If you notice sudden swelling in your neck, which could signify an infection, contact our office.

Due to disturbance of the parathyroid glands, which regulate calcium balance, your calcium level may drop after surgery. If it drops, you may notice numbness and tingling of your fingers or around your mouth. We’ll monitor your calcium levels through blood tests, and give you instructions about taking calcium replacements if needed.

What are the side effects of thyroid surgery?

After a total thyroidectomy, you will take lifelong thyroid hormone replacements. Because your entire thyroid gland is removed, it will no longer supply you with the hormone you need to control your body’s metabolic processes. You might also have to take supplements after thyroidectomy to balance your calcium levels.

After a thyroid lobectomy, you’ll need to have your thyroid hormone levels checked and will be prescribed a thyroid hormone replacement, if needed.

In the weeks after your thyroid surgery, you may have neck pain, soreness of your vocal chords or a weak voice. These symptoms are usually temporary.

Will I need to follow a special diet after thyroid surgery?

For most people, a special diet after a thyroidectomy or thyroid lobectomy isn’t necessary. You’ll likely be able to eat and drink normally the morning after your surgery, but you may prefer softer foods at first. We’ll let you know if and for how long you need to restrict your eating and drinking.

#Arrangoiz #ThyroidSurgeon #CenterforAdvancedSurgicalOncology #CASO #CancerSurgeon #HeadandNeckSurgeon

• Trastuzumab and pertuzumab can cause:
  • Decrease in ejection fraction in up to 20% of patients:
    • Although this is often reversible
• Trastuzumab:
  • Can less commonly cause pneumonitis
• Pertuzumab:
  • Can cause rash and diarrhea

• References:
  • Gianni L, Pienkowski T, Im YH, Roman L, Tseng LM, Liu MC, et al. Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial. Lancet Oncol. 2012;13(1):25-32.
  • Schneeweiss A, Chia S, Hickish T, Harvey V, Eniu A, Hegg R, et al. Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol. 2013;24(9):2278-2284.

#Arrangoiz #CancerSurgeon #BreastSurgeon #CASO #CenterforAdvancedSurgicalOncology #BreastCancer

What is the preferred adjuvant regimen for an invasive ductal carcinoma, ER positive, PR positive, HER2 positive by immunohistochemistry for a 0.9 cm grade tumor with 0/2 sentinel lymph nodes involved with tumor?

• The APT trial:
  • Showed a 3-year survival free rate from invasive disease of 98.7% for node negative tumors up to 3 cm in size:
    • With use of weekly paclitaxel / trastuzumab

• References:
  • Tolaney SM, Barry WT, Dang CT, Yardley DA, Moy B, Marcom PK, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer. New Engl J Med. 2015;372(2):134-141.
  • Tolaney SM, Guo H, Pernas S, Barry WT, Dillon DA, Ritterhouse L. Seven-year follow-up analysis of adjuvant paclitaxel and trastuzumab trial for node-negative, human epidermal growth factor receptor 2-positive breast cancer.J Clin Oncol. 2019;37(22):1868-1875.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncology #CASO #CenterforAdvancedSurgicalOncology

• Neutropenia is found in up to 79.5% of patients on palbociclib:
  • Neutropenia and the risk for infections must be discussed with patients prior to initiation of treatment
• Other common adverse effects of this drug include:
  • Fatigue (37.4%)
  • Nausea (35.1%)
  • Alopecia (32.9%)

• References:
  • Finn RS, Martin M, Rugo HS, Jones S, Im SA, Gelmon K, et al. Palbociclib and Letrozole in advanced breast cancer. New Engl J Med. 2016;375(20):1925-1936.
  • Finn RS, Crown JP2, Lang I3, Boer K4, Bondarenko IM5, Kulyk SO, et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-1/TRIO-18): a randomised phase 2 study. Lancet Oncol. 2015;16(1):25-35.

#Arrangoiz #BreastSurgeon #BreastCancer #CancerSurgeon #SurgicalOncology #CASO #CenterforAdvancedSurgicalOncology

• Presence of clinical lymph node metastasis or distant metastasis (rare)
• Clinically apparent invasion of the recurrent laryngeal nerve (RLN) or trachea
• Diagnosis of aggressive sub type of papillary thyroid carcinoma on cytology (rare)
• Tumor adherent to the trachea, possibly invading
• Tumors located along the course of the RLN
• Associated with other thyroid or parathyroid disease requiring surgery
• Age less than 20 (no current evidence)

#Arrangoiz #ThyroidExpert #ThyroidSurgeon #HeadandNeckSurgeon #EndocrineSurgery @CASO #CenterforAdvancedSurgicalOncology

• The use of an aromatase inhibitor (letrozole) with an inhibitor of the cyclin dependent kinases 4 and 6 (ribociclib):
  • Was compared with aromatase inhibitor alone in postmenopausal women with hormone receptor positive, HER2-negative metastatic breast cancer:
    • In the MONALEESA-2 study:
      • Results showed an improvement in:
        • Progression-free survival (PFS):
          • From 42.2% to 63%
        • Overall response rate:
          • From 37.1% to 52.7%
            • With the addition of ribociclib to letrozole alone
• This regimen was also investigated in pre menopausal women with advanced, hormone receptor-positive breast cancer:
  • Improved PFS compared with placebo plus endocrine therapy
• References:
  • Hortobagi GN, Stemmer SM, Burris HA, Yap YS, Sonke GS, Paluch-Shimon S, et al. Ribociclib as first-line therapy for HR-positive, advanced breast cancer. N Engl J Med. 2016;375(18)1738-1748.
  • Tripathy D, Im SA2, Colleoni M3, Franke F4, Bardia A5, Harbeck Nm et al. Ribociclib plus endocrine therapy for premenopausal women with hormone-receptor-positive, advanced breast cancer (MONALEESA-7): a randomised phase 3 trial. Lancet Oncol. 2018;19(7):904-915.

#Arrangoiz #CancerSurgeon #BreastSurgeon #BreastCancer #Monaleesa2 #Ribociclib #CASO #CenterforADvancedSurgicalOncology

Chemotherapy for a Young Patient with Triple Negative Breast Cancer

• The best choice for chemotherapy for a young patient with a node-positive triple negative breast cancer:
  • Would be dose-dense doxorubicin and cyclophosphamide, followed by paclitaxel, each given for 4 cycles 2 weeks apart with growth factor support:
    • This regimen is supported by results of the:
      • CALGB 9741 study
  • For triple negative breast cancer and node positive disease:
    • The use of an anthracycline-containing regimen is favored compared to a non-anthracycline containing regimen
• References:
  • Citron ML, Berry DA, Cirrincione C, Hudis C, Winer EP, Gradishar WJ, et al. Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol. 2003;21(8):1431-1439.
  • Blum JL, Flynn PJ, Yothers G, Asmar L, Geyer CE Jr, Jacobs SA et al. Anthracyclines in early breast cancer: The ABC Trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG Oncology). J Clin Oncol. 2017;35(23):2647-2655.

Suppression of Ovarian Function Trial (SOFT) Trial

• In the Suppression of Ovarian Function Trial (SOFT) trial:
  • Ovarian function suppression given for five years reduced disease-free survival (DFS) events when added to 5 years of adjuvant tamoxifen:
    • 78.9% to 83.2% DFS at 8 years, hazard ratio (HR) of 0.76, P = .009
  • One-third of women entered in the SOFT trial were randomized to receive the aromatase inhibitor exemestane plus ovarian function suppression:
    • They had an even better disease-free survival
• References:
• Francis PA, Pagani O, Fleming GF, Walley BA, Colleoni M, Lang I, et al. Tailoring adjuvant endocrine therapy for premenopausal breast cancer. N Eng J Med. 2018;379(2):122-137.
• Francis PA, Regan MM, Fleming GF, Lang I, Ciruelos E, Bellet M, et al. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med. 2015;372(5):436-446.

#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncologist @CASO @CenterforAdvancedSurgicalOncology #BreastCancer