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Controversies in Surgical Approach to Breast Cancer

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Controversies in Surgical Approach to Breast Cancer. By Suebwong Chutapisith, MD, PhD

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Controversies in Surgical Approach to Breast Cancer

  1. 1. Controversies in Surgical Approach to Breast Cancer Suebwong Chuthapisith MD, PhD Assistant Professor, Department of Surgery Faculty of Medicine Siriraj Hospital , Mahidol University, THAILAND
  2. 2. Controversy 1 : Detecting lesion in dense breast Controversy 2 : How to deal with positive SLNB? Controversy 3 :Use of IORT following BCS Controversies in breast cancer: surgeons’ concern
  3. 3. Controversy 1 : Detecting lesion in dense breast Controversy 2 : How to deal with positive SLNB? Controversy 3 :Use of IORT following BCS Controversies in breast cancer: surgeons’ concern
  4. 4. In screening and detecting of breast cancer, mammography is a standard and is recommended (annually) for women age > 40 yrs Lee et al. J Am Coll Radiol 2010;7:18. However, detecting small cancer with mammography alone may not be adequate in women with dense breast composition.
  5. 5. D1 Fatty D2 Fibroglandular D3 Heteroge- nously D4 Extremely BIRADS ACR; 5th Edition: 2013 In the Western women, 70-75% have D1/D2
  6. 6. Percentage breast density Relative risk 5-24% 1.79 25-49% 2.11 50-74% 2.92 > 75% 4.64 Mc Cormack VA. Cancer Epidemiol Biomarkers Prev 2006:15:1159.
  7. 7. • Density: masking effect – Masking effect of breast density leads to an increased percentage of interval breast cancer – Dense breast may make a woman more likely to be diagnosed with an interval cancer Breast density and breast cancer risk Vacek and Geller. Cancer Epidemiol Biomarkers Prev 2004:13:715. Bae MS. Radiology 2014;356:227.
  8. 8. • Density as an independent risk factor – Density refers to the amount of epithelial and stromal elements of the breast – The greater amount of epithelial tissue, the greater chance of breast cancer – Fourfold increase in the risk of breast cancer in women with dense breast Breast density and breast cancer risk
  9. 9. Microscopic difference between dense and non-dense breast
  10. 10. Breast density in Thai women
  11. 11. Siriraj Experience: Breast densities: 14,770 women Number % Fatty breast 287 2.0 Fibrograndular dense 2,357 16.0 Heterogenously dense 10,537 71.3 Extremely dense 1,589 10.7 Total 14,770 100 Korphrapong P et al. Acta Rad 2014;55:903.
  12. 12. Age (yr) Fatty (%) Fibrograndular dense (%) Heterogenously dense (%) Extremely dense (%) <40 4 (0.2) 90 (6.6) 96 (70.9) 300 (22.1) 40-49 37 (0.6) 681(10.2) 4,998 (75.1) 941(14.1) 50-59 106 (2) 1,067 (20.4) 3,754 (71.7) 309 (5.9) 60-69 95 (7.4) 419 (32.8) 725 (56.8) 38 (2.9) >70 45 (18.4) 100 (40.8) 99 (40.4) 1 (0.4) Total 287 (2.0) 2,357 (15.9) 10,537 (71.3) 1,589 (10.8) Siriraj Experience: 14,770 women by age group Korphrapong P et al. Acta Rad 2014;55:903.
  13. 13. • US State of legislation regarding breast density notification started in Connecticut in 2009 Require notification to patients regarding their breast density and informing them that they may benefit from supplemental screening tests
  14. 14. Notification Law (year) Bill Introduced Insurance: cover additional testing 2009: Connecticut 2011: Texas 2012: California, Virginia 2013: Alabama, Maryland, New York 2014: Arizona, Hawaii, Minnesota, Nevada, New Jersey, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennesse Colorado Delaware Illinois Indiana Iowa Kentucky Michigan Ohio South Carolina Washington Connecticut Indiana Illinois New Jersey
  15. 15. Potential supplemental tests Whole breast ultrasound Automated whole breast ultrasound Digital breast tomosynthesis Contrast- enhanced mammography MRI PEM and BSGI
  16. 16. • Hand-held US (HHUS) and automated US (ABUS) • Improve detection of breast cancer, in particular in non-fatty breast density, range from 0.3 to 6.8 cancers per 1000 exam • However, increase rate of biopsy and detect more non-cancerous lesions Whole breast ultrasound Korphrapong P et al. Acta Rad 2014;55:903.
  17. 17. Findings Screening BC_F/U Diagnose MMG - mass 22% 26% 40% MMG - microcal 37% 23% 10% MMG - mass with microcal 19% 19% 30% Occult lesions (ultrasound detected) 22% 31% 19% Breast cancer screening: Siriraj-Thanyarak experience 2001-2005 69,672 examinations 1,405 breast cancer lesions from 1,268 patients Angsusinha T et al.
  18. 18. 115 cancers from 14,483 women with non-fatty breast CANCER (n=115) Sensitivity (%) MM / MM+US CDR per1,000 MM / MM+US PPV (%) MM / MM+US Age group <40 100 /100 1.4 / 1.4 14.3 / 5.1 40-49 69.6 / 84.8 5.6 / 6.9 29.1 / 14.3 50-59 72.2 / 95.5 6.6 / 8.6 36.4 / 24.6 60-69 88.2 / 94.1 13.5 / 14.4 51.7 / 38.1 >70 83.3 / 100 25 / 30.0 83.3 / 60 Total 74.8 / 91.3 6.5 / 7.9 33.9 / 19.6 Korphrapong P et al. Acta Rad 2014;55:903. Improved 1.4 per 1000 Decreased PPV
  19. 19. Mammography is not enough in detecting small lesions in the women with dense breast, so consider supplemental tests Whole breast ultrasound Automated whole breast ultrasound Digital breast tomosynthesis Contrast- enhanced mammography
  20. 20. Controversy 1 : Detecting lesion in dense breast Controversy 2 : How to deal with positive SLNB? Controversy 3 :Use of IORT following BCS Controversies in breast cancer: surgeon’ s concerns
  21. 21. • Nodal status has been designated as the most important prognostic factors • Nodal status influences adjuvant therapy and treatment outcome • Sentinel lymph node : the first node or group of node draining in cancer • Sentinel lymph node biopsy : is the standard of care in early breast cancer management
  22. 22. ITC : less than 2 mm or < 200 cells Macrometastasis : greater than 2mm.Micrometastasis : 0.2-2 mm
  23. 23. • Isolated tumor cells (ITC) is pathological N0. • Treatment is as node negative.
  24. 24. Micrometastasis : 0.2-2 mm
  25. 25. Boer M et al. N Engl J Med 2009;361:653.
  26. 26. Boer M et al. N Engl J Med 2009;361:653. N=2707 pNmi was inferior to pN0. Therefore, AD should be considered.
  27. 27. Montagna E et al. Breast Cancer Res Treat 2009;118:385. pNmi was comparable to pN0. Therefore, AD might be an overtreatment. Langer I et al.. Ann Surg Oncol 2009;16:3366.
  28. 28. 931 women with clinically node negative Positive SLNB : micrometastasis Both BCS and mastectomy (10%) included Both randomly to AD or no AD 5 yrs OS : 97.9 % for AD and 98% for no AD (p = 0.35) 5 yrs DFS : 87.3 % for AD and 88.4 % for no AD (p = 0.48) Golimberti V et al. Lancet Oncol 2013;:297-305.
  29. 29. Isolated tumor cells, and even metastases up to 2 mm (micrometastases) in a single sentinel node, were not considered to constitute an indication for axillary dissection regardless of the type of breast surgery carried out. Goldhirsch A et al. Ann Oncol 2011;22:1736.
  30. 30. Axillary dissection vs No further surgery Macrometastasis : >2mm
  31. 31. ACOSOG Z0011 Giuliano AE et al. JAMA 2011;305:569. Continue from ACOSOG Z0010 891 sentinel LN positive (only 1-2 nodes) 115 Cancer Center in the US All had T1-T2 Undergoing BCS with post-op RT
  32. 32. Giuliano AE et al. JAMA 2011;305:569.
  33. 33. Giuliano AE et al. JAMA 2011;305:569.
  34. 34. Can axillary RT replace axillary dissection in positive axillary LN following SLNB? Straver M E et al. JCO 2010;28:731-737 AMAROS Trial 2001 to April 2010 4827 patients 35 centers in Europe
  35. 35. Donker et al. Lancet Oncol 2014;1303-10.
  36. 36. Donker et al. Lancet Oncol 2014;1303-10.
  37. 37. Donker et al. Lancet Oncol 2014;1303-10.
  38. 38. Donker et al. Lancet Oncol 2014;1303-10.
  39. 39. Messages from ACOSOG Z0011 and AMAROS trial Some patients with early breast cancer who had positive sentinel lymph node biopsy may be avoided from axillary dissection, in particular patients who undergone breast conserving surgery However, those patients who undergone mastectomy (60% in Siriraj) are still in controversy.
  40. 40. Controversy 1 : Detecting lesion in dense breast Controversy 2 : How to deal with positive SLNB? Controversy 3 : Use of IORT following BCS Controversies in breast cancer: surgeons’ concern
  41. 41. • Breast conserving therapy (BCT) is the standard of treatment for early breast cancer • BCT consists of breast conserving surgery (BCS) and whole breast radiation • Lumpectomy alone without RT showed high recurrent rate
  42. 42. APBI techniques:APBI techniques: Interstitial brachytherapy Balloon catheter brachytherapy Skowronek J Contemp Brachy 2012;4(3):152-164 http://www.mammosite.com
  43. 43. IORT techniques Low energy 50 Kv Intrabeam Electron Mobetron
  44. 44. IORT : local recur = 3.3 %, 95% CI = 2.3-5.11 WBRT : local recur = 1.3%, 95%CI = 0.7-2.5 Difference =2.0%
  45. 45. IORT : local recur = 4.4 %, 95% CI = 2.7-6.1 WBRT : local recur = 0.4 %, 95%CI = 0.0-1.0
  46. 46. No difference in mortality
  47. 47. Subsequent analysis identified factors associated with LR in IORT group Subsequent analysis identified factors associated with LR in IORT group On muliti-variated analysis, factors associated with LR were Factor Hazard ratio 95% CI Size > 2 cm 2.24 1.03-4.87 Node positive > 4 2.61 0.91-7.50 Poorly diff 2.18 1.00-4.79 Triple negative 2.4 0.94-6.1
  48. 48. The logical conclusion is that intraoperative radiation therapy with electrons should be restricted to suitable patients, once characteristics defining suitability have been defined. The logical conclusion is that intraoperative radiation therapy with electrons should be restricted to suitable patients, once characteristics defining suitability have been defined.
  49. 49. Boost (9 Gy) Single dose (21 Gy) Invasive breast cancer and age less than 50 year Invasive ductal carcinoma and favorable histology or Age ≥ 55 year Invasive breast cancer and tumor size > 2 cm from imaging Tumor ≤ 2 cm from imaging or previous surgery or Single malignant lesion Invasive breast cancer and angiolymphatic invasion evidenced in core needle biopsy Estrogen receptor positive No angiolymphatic invasion or extensive intraductal component from previous core biopsy Node negative
  50. 50. 1. Wide excision done.
  51. 51. 2. Mobilize breast tissue at least 2 cm around the cavity and do purse-string suture.
  52. 52. 3. Move Mobetron in and do docking.
  53. 53. Characteristics Boost group (N=23) Single group (N=79) Overall (N=102) Age (yr) : mean 51.2 (33-78) 64.8 (54-90) 61.7 (33-90) Tumor size (cm) : mean 1.6 (0.5-4.0) 1.3 (0.3-3.2) 1.4 (0.3-4.0) Histology - Invasive ductal CA 21 (100%) 72 (91.0%) 93 (91.1%) - Mucinous CA 0 2 (2.5%) 2 (2.0%) - Invasive papillary CA 0 5 (6.5%) 5 (4.9%) ER positive 21 (91.3%) 79 (100%) 100 (98%) Nodal status - N0 15 (65.3%) 76(96.2 %) 91 (89.2%) - N1 7 (30.4%) 3 (3.8 %) 10 (9.8%) - N2 1 (4.3%) 0 1 (1.0%) IORT: Result from Siriraj Hospital
  54. 54. Characteristics Boost group (N=23) Single group (N=79) Overall (N=102) Age (yr) : mean 51.2 (33-78) 64.8 (54-90) 61.7 (33-90) Tumor size (cm) : mean 1.6 (0.5-4.0) 1.3 (0.3-3.2) 1.4 (0.3-4.0) Histology - Invasive ductal CA 21 (100%) 72 (91.0%) 93 (91.1%) - Mucinous CA 0 2 (2.5%) 2 (2.0%) - Invasive papillary CA 0 5 (6.5%) 5 (4.9%) ER positive 21 (91.3%) 79 (100%) 100 (98%) Nodal status - N0 15 (65.3%) 76(96.2 %) 91 (89.2%) - N1 7 (30.4%) 3 (3.8 %) 10 (9.8%) - N2 1 (4.3%) 0 1 (1.0%) IORT: Result from Siriraj Hospital
  55. 55. Characteristics Boost group (N=23) Single group (N=79) Overall (N=102) Median follow up time (days) 1258.5 (401-1523) 634.43 (100-1458) 946.45 (100-1523) AXLD 10 (43.5%) 0 10 (9.8%) Op time (mins) 125.9 (72-235) 126.4 (80-194) 126.3 (80-235) Positive margin 0 2 (4.5%) 2 (3%) Ipsilat recurrence 1 (4.3%) 1 (1.3%)(axillary) 2 (1.9%) Contralat recurrence 1 (4.3%) 2 (2.5%) 3 (2.9%) Systemic recurrence 2 (8.7%) 0 2 (1.9%) BCA related death 2 (8.7%) 0 2 (1.9%) Non-BCA death 0 1 (1.3%) 1 (1.0%) Total save of ERT procedures 115 1975 2090 IORT: Result from Siriraj Hospital
  56. 56. Controversy 3 IORT following breast conserving surgery has shown higher ipsilateral recurrence than conventional whole breast irradiation However, in some selected patients, the non-inferior result might be demonstrated.

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