Transcript Breast Cancer

Breast Cancer
Who Gets What Type of Surgery?
Murray Pfeifer
16th August, 2014
History of Breast Cancer Treatment
 Hipppocrates (460-375BC) spoke of two cases
 Galen (129-200AD)
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Humoral theory
Linked to melancholia
Likened to a ‘crab’
Recognised the merit of local excision were possible
 LeDran 1757 proposed the theory that breast cancer is a local disease
 Spread at first occurs through the lymphatics to lymph nodes before subsequently
entering the general circulation
 This hypothesis suggests that breast cancer can be cured if treated early with
aggressive surgery to the breast.
 This ‘local theory’ prevailed for about two centuries and was the basis on which
radical breast operations were offered to women
The Modern Era (1)
 W Sampson Handley’s ‘Theory of Lymphatic
Permeation’ was mooted around 1860
 Centrifugal lymphatic permeation is the mechanism
for the spread of cancer
 This gave support to the radical operations being
advocated by Halstead, Moore and others
 McWhirter – simple mastectomy supplemented with
XRT resulted in the same survival as patients who had
radical surgery
The Modern Era (2)
Bernard Fisher:
 Lymph nodes not an effective barrier to spread
 Cancer cells pass easily back and forth between lymphatics and blood
vessels
 Spread of cancer therefore not an orderly progression from lymphatics to
blood stream
Gershon-Cohen:
 Breast cancers have a protracted period of occult growth during which time
they have a ample opportunity to metastasize
 This limits the surgical curability of breast cancer
These theories of breast cancer spread were widely adopted and started a
movement to less aggressive surgery
Who gets surgery?
 Almost all women with invasive and in situ breast cancer
will receive surgery as part of their management
 Purpose of surgery:
 To control the locoregional disease by
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Extirpation of the primary tumour
Removal of involved regional lymph nodes
Relative contraindications to surgery:
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Advanced age and frailty
Advanced disease
What are the operations that are
available to us to manage invasive
breast cancer?
 For the primary lesion in the breast:
 Mastectomy
 Wide local excision
 +/- breast reconstruction
 Immediate
 delayed
 For the axilla:
 Sentinel node biopsy
 Axillary clearance
Mastectomy:
 Mastectomy has become increasingly conservative as
a result of our better understanding of tumour
biology
 Simple mastectomy aims to remove almost all breast
tissue including the axillary tail of the breast, the
nipple/ areolar complex, and the underlying pectoral
fascia
 The need for XRT is obviated in most cases
Indications for simple mastectomy:
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Large tumour/ small breast
Centrally located tumour
Multifocal and multicentric cancers
Recurrence of cancer previously managed by breast
conserving treatment
 Patient choice
 Arguably lower local recurrence rates
 Avoidance of XRT
 Social aspects of access to XRT at a remote site
Breast Conserving Treatment:
Wide local excision
And
Radiotherapy
Radiotherapy after BCT is mandatory
 NSABP B-06
 recurrence rate after surgery alone – 35%
 Recurrence rate after surgery and XRT – 10%
Objectives of Breast Conserving
Treatment(BCT):
 Good control of the primary cancer
 Survival equivalence to mastectomy
 Cosmetically acceptable outcome
Good control of the primary tumour:
 Ipsilateral Breast Tumour Recurrence(IBTR)
represents local therapeutic failure and psychological
stress for the patient
 Minimising IBTR depends on adequate resection of
the primary tumour and good radiotherapy to the
breast
 Risk of dissemination of tumour is increased and
survival decreased after local recurrence
 IBTR increases risk of dissemination by 3-4x (Fisher et)
How much is enough?
Criteria for acceptable margins is, with time becoming more
conservative
 Previous standard:
 Ideal >1cm
 Close but acceptable 5mm-1mm
 ASTRO and SSO consensus guideline Feb 2014
 Meta-analysis 33 studies; 28,162 patients
 Positive margins are associated with a >2x risk of IBTR
 Negative margins (no ink on tumour)optimise IBTR. Wider
margins do not lower risk
 Rates of IBTR are reduced with use of systemic therapy
Contraindications to BCT
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More than one tumour
Large tumour, small breast
Diffuse, suspicious microcalcifications
Previous radiotherapy to the breast
Collagen disorders may result in an adverse response to
XRT
 Central tumours where there is a need to excise the
nipple/areolar complex
 Patient choice with respect to XRT
Morbidity of BCT:
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Poor cosmesis
Wound complications
Altered nipple sensation
Initial inflammation in the skin post XRT
Later skin thickening and woody contracture of the breast
Post XRT fatigue
Radiation damage to underlying lung and heart
Radiation induced neoplasms eg angiosarcoma (1 in 476
patients)
 Risk of salvage mastectomy
Is there a survival equivalence
between BCT and Mastectomy in
STI-II cancers:
Yes there is!!
 Numerous controlled trials have consistently
demonstrated this point
 Early Breast Trialist Group meta-analysis of 7 RCTs
showed no difference in 10 year overall survival rates
Surgery of the axilla:
 Decisions about management of the axilla are made
quite independently from decisions about the
management of the primary cancer
Why operate on the axilla?
 To assess prognosis
 To ‘stage’ the disease for purposes of determining
indication for adjuvant systemic therapies and
radiotherapy
 To resect disease that might be present in the axillary
lymph nodes.
Who gets axillary surgery?
 Almost all women with invasive breast cancer
 Selected women with DCIS
 Published data – Upgrade diagnosis of DCIS on core bx in
around 20% (range 13-40%)
 About 10% of patients with high risk DCIS have +ve sentinel
node (high risk=high grade, large size)
 Indications for sentinel node biopsy:
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High grade
Large lesion
Extensive involvement
mastectomy
The Operations
Two Operations:
 Sentinel node biopsy
 Axillary dissection
Sentinel lymph node biopsy
 The sentinel lymph node is the hypothetical first node
or group of nodes draining a cancer
 First mooted by Gould (1960) for parotid cancer
 Popularised by Cabanas for penile cancer
 Used extensively in breast cancer, melanoma, and
head and neck cancer
Who gets Sentinel node biopsy?
 Women who have invasive breast cancer and fulfil the
following criteria:
 Small tumour (T1 or T2)
 No identifiable axillary lymph node involvement
 Exclusions:
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Large tumours (T3 or T4)
Suspicious or proven positive axillary nodes
Prior axillary surgery
Prior cosmetic breast surgery
Following neoadjuvant systemic therapy
Sentinel node biopsy – principles
 Combined technique of vital blue dye and radioisotope.
 Technitium labelled sulphur colloid injected the day prior to
surgery. Usually accompanied by scintngram and CT SPECT
 Blue dye > periareolar injection after induction of
anaesthesia
 Combined technique associated with a higher degree of
identification of the sentinel node than the use of one or
other technique alone.
Sentinel node biopsy principles
Node(s) can either be sent for frozen section whilst the
patient is on the table with a view to completing the
axillary dissection if positive
Or
Node(s) can be sent for paraffin section with a view to
subsequent further treatment if positive
How reliable is sentinel node biopsy?
 Numerous studies including NSABP B-32, ALMANAC,
Milan, and SNAC1 have reported:
 A success rate of 90-98%
 False negative rate 5.5 – 15.7%
 Our own SNAC trial reported a false negative rate - 5.5%
Management of the axilla where
there has been a positive sentinel
node biopsy
 Controversial but usually completion axillary
dissection +/- radiotherapy
 Management is tending to become more
conservative
 Isolated tumour cells and micrometastases are usually
managed with radiotherapy only
 More extensive axillary disease is now being managed
by XRT alone
EORCT AMAROS Study
ASCO 2013 – Emeil Rutgers
 RCT – Surgery v XRT
 Five year follow up
 Results:
 Local recurrence
 Disease free survival
 Overall survival
0.54% v 1.03%
86.7% v 82.7%
93.3% v 92.5%
 Lymphoedema
28% v 14%
Axillary Dissection
Does it still have place?
Yes……. But less so than in years gone by
Axillary dissection – why we do it
 Stage the axilla for prognosis
 Inform the planning of adjuvant therapies
 Locoregional control of disease
 30-40% of patients presenting with breast cancer have disease
in the axillary nodes
 Recurrence rate after axillary dissection <2%
 Therefore an improvement in DFS
 Possible improvement in overall survival (but note NSABP
B-04 – no survival advantage for patients with clinically
negative axilla who had ALND compared to the group in
whom an expectant approach was taken).
Who gets axillary dissection?
 Patients with large tumours – T3 or T4
 Patients with confirmed axillary node metastasis
 Palpable enlarged axillary lymph nodes
 Suspicious axillary nodes seen on ultrasound
examination of the axilla
 Usually confirmed by ultrasound guided FNA cytology
The morbidity of axillary dissection:
 Wound infection
 Seroma
 Pain, parasthesia, and numbness in the distribution of
the intercostobrachial nerve
 Frozen shoulder
 lymphoedema
Is sentinel node biopsy superior to
axillary dissection with respect to
complications?
 ACSOG Z0011, ALMANAC both show that there is
significantly less morbidity after SLNB when
compared to ALND (70% adverse effects v 25% overall)
 Inconsistent application of protocols and incomplete
data capture was a problem in both of these two
studies as it has been in other published studies.
Ductal Carcinoma In Situ
 A condition in which presumably malignant cells
proliferate within lactiferous ducts with no evidence
of invasion through the basement membrane
 Heterogeneous pathology with highly variable
appearance, biology and behaviour
 Represents around 20% of the caseload
 Is largely a disease entity of the mammographic era
 The approach to surgical management is somewhat
different
What surgery is offered?
Mastectomy +/- reconstruction is a commonly utilised option
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Best for large lesions, and multifocal/multicentric lesions
Low local recurrence rate (1%-2%)
In most instances obviates the need for XRT
For many patients it represents too much treatment
Psychosocial issues:
 For some the reassurance of a high probability of cure is
reassuring
 For others there is the psychological morbidity of what might
be perceived as a mutilating operation
What surgery is offered:
Wide local excision
 Wide local excision alone is associated with a high
local recurrence rate (NSABP 20.9% at 5years)
 May be acceptable in selected patients ie small, non
high grade lesions with good margins (>10mm)
 Wide local excision plus XRT lower local recurrence
rates (8%-10% at 5years)
 About half of the local recurrences are invasive
What margins are required in BCT for
DCIS?
 A vexed question in this condition because of the high
incidence of multifocality and multicentricity which
makes pathological assessment of margins difficult
 NZ guideline – margin should be >2mm
 Ideal is 10mm
 Involved margins demands further surgery
Management of the Axilla in DCIS
 Theoretically DCIS should not involve nodes
 In practice microinvasion or even overt invasive disease in
another part of a lesion may result in nodal metastasis in
up to 25% of lesions diagnosed as DCIS on work up
 Risk factors:
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Large tumour
High grade
Palpable tumour
Mammographic density
Should patients with a preoperative
diagnosis of DCIS have sentinel node
biopsy?
Indications for sentinel node biopsy in DCIS:
 Large lesion
 High grade
 Palpable tumour
 Mammographic density
 Patient is having a mastectomy
Who gets what operation?
 40 years ago MASTECTOMY and AXILLARY DISSECTION
 Today –
Multi disiplinary approach with surgery tailored to the needs
of the patient and her condition and integrated with
radiotherpy and systemic therapies
Thankyou