Radical Mastectomy is no longer the standard Improved adjuvant and neoadjuvant therapy Chemotherapy Endocrine therapy Radiation treatment Reconstruction Era of individualized therapy Receptor status Molecular subtyping Genomic assessment Genetic factors

5 Breast Conservation Mastectomy Radiation Chemotherapy Endocrine Therapy SLN Bx → Ax. Diss.

Winchester DP, et al. Surg Oncol Clin N Am. 2005;14: Sentinel lymph node mapping No difference in survival with radical mastectomy or lumpectomy Modified radical mastectomy Inoperability criteria established for locally advanced breast cancer Radical mastectomy and supraclavicular dissection Removal of whole breast, including pectoral muscles and axillary lymph nodes

Management of the axilla: ACOSOG Z-0011 data AMAROS study

813 patients with T1/T2 clinically node-negative tumors with positive SLNs were randomized to ALND vs no further dissection showed equivalent results between the 2 arms hm At 6.3 years’ follow-up, no differences were found between the 2 groups: axillary recurrence (0.5% vs 0.9%), in-breast recurrence (3.6% vs 1.9%), or overall locoregional recurrence (4.1% vs 2.8%, P = 0.53) Disease-free and overall survival were similar (82.2% vs 83.8% and 91.9% vs 92.5%) between the groups.

Applicable to patients with all of the following criteria: T1-2 tumors One to two positive SLNs without extracapsular extension Completion of whole-breast radiation therapy Completion of adjuvant therapy (hormonal, cytotoxic, or both) Not directly applicable to these patients: T3 tumors more than 2 positive nodes undergoing mastectomy or partial breast radiation matted axillary nodes or preoperative palpable nodes neoadjuvant chemotherapy

Objective: to prove equivalent local/regional control with less morbidity in patients with positive sentinel node biopsy (SLN) if treated with axillary radiation vs axillary node dissection received ALND and 681 received axillary radiation -82% underwent breast conservation and 18% underwent mastectomy -90% received systemic treatments. -

Results: At 5 years, the axillary recurrence rate was "extremely low" in both groups (0.54% vs 1.03%), There were no significant differences in disease free survival-between the surgery and radiation (86.9% vs 82.7%; P =.1788) or overall survival (93.3% vs 92.5%; P =.3386). However, the rate of lymphedema in the surgery group was twice that of the radiation group (28% vs 14%). Either modality provides excellent and comparable axillary control; however, the incidence of lymphedema was lower with axillary radiation than with axillary lymph node dissection Axillary radiation should be regarded as the recommended treatment for these patients.

Localization technique Traditionally wire localized Use of a Infrared technology to localize tumors Radiation marker 3 dimentional radiation marker

Non-palpable lesions: Guidewire placed into lesion or area of abnormality using ultrasound/mammo/ MRI

Savi Scout- Cianna Medical

- No external wires -can be placed up to 7 days prior to surgery -incision not limited by wire location Infrared Reflector

Slide: Courtesy of Focal Therapeutics

Less surgery in the breast: Partial mastectomy Cryotherapy ? Percutaneous enucleations Less Surgery in the axilla Sentinel node biopsy Z-11 trial AMAROS trial ACOSOG 1071