1. Breast Conservative Surgery: An Update How far should we go?
Good morning chairman, colleagues, ladies and gentlemen, I’m Dr Christina Chan from Pamela Youde Nethersole Eastern Hospital
I’d like to update you on the topic of BCT, a widely practiced surgery for breast cancer nowadays
Dr Christina TY Chan
PYNEH

2. Modified radical mastectomy
Halstedian radical mastectomy
Extended radical mastectomy
Modified radical mastectomy
Centuries ago, we know little about breast cancer, we tend to cut everything out, in hope of a complete clearance of the disease, it ends up something like this [click]
Beside an unsightly result, it is also associated with a lot of morbidity [click]
Until the publication of the LANDMARK paper, the NSABP B-04 study, which showed that less extensive chest-wall surgery did not compromise breast cancer outcome. We started to modify our treatment.
This had greatly improved the cosmesis, and the patients WERE satisfied with this for a period of time. [click]
But, what if, the patient is younger, with a smaller tumor or EVEN non-palpable tumor, or a bilateral disease
with our increasing knowledge of the disease, and the advancements in oncological treatments.
Can we do better? [click]
Now, look at this, thanks to BCT, we can now treat our patient without greatly affecting the natural beauty of the breast.
**B-04 study:
-prospective, randomized clinical trial
-Over 1600 women randomized
-radical mastectomy or total mastectomy + axillary irradiation +/- axillary dissection when regional recurrence occurs
-equivalent survival at 10- and 15-years FU
NSABP B-04 study:
Radical mastectomy vs Total mastectomy + axillary irradiation +/- axillary dissection ??

3. Breast Conservative Therapy
In 1970s
Involvement of “part of the breast” only
Quadrantectomy 2 Ablation of tumor with an ample portion of healthy parenchyma 2-3cm margin( Holland principle)
Proposed as far back as the 1930s 1
Date back to 80 years ago, people had been thinking about this already
But not until decades later, the idea of quadrantectomy was described by Veronesi (??) to remove the tumor with a rim of normal tissue for the local treatment of breast cancer
1 Keynes G. Conservative treatment of cancer of the breast. BMJ 1937;2:643–7
2 Holland R, Veling SHJ, Mravunac M, et al.: Histologic multifocality of Tis, T1-2 breast carcinomas: implications for clinical trials of breast-conserving surgery. Cancer 1985, 56:979–990.

4. Breast Conservative Therapy
In 1969
Randomized study at Milan Cancer Institute approved by WHO Committee 1 Radical mastectomy vs Quadrantectomy
Recruitment in 1973
Preliminary data in and : equal survival rates
AUTHORITIES in Milan, Italy has initiated studies comparing radical mastectomy and quadrantectomy
It showed a promising outcome in years later
1 Meeting of Investigators for Evaluation of Methods and Diagnosis and Treatment of Breast Cancer: Final Report. Geneva: World Health Organization; 1969.
2 Veronesi U, Banfi A, Saccozzi R, et al.: Conservative treatment of breast cancer: a trial in progress at the Cancer Institute in Milan. Cancer 1977, 39:2822–2826.
3 Veronesi U, Saccozzi R, Del Vecchio M, et al.: Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981, 305:6–11.

5. Breast Conservative Therapy
In 1976
Ramdomized study by the National Surgical Adjuvant Breast and Bowel Project [NSABP B-06] study group Lumpectomy +/- radiation vs Total mastectomy
Lumpectomy + breast irradiation is appropriate
Another LANDMARK paper, the NSABP study group showed that when radiation is added, lumpectomy is an appropriate treatment of choice
Fisher B, Anderson S, Bryant J, et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002, 347:1233–1241.

6. Breast Conservative Therapy
Phase III clinical trials in US and Europe
Breast Conservative Therapy
There were a number of Phase III clinical trials going on around the globe [click]
And all showed promising results

7. Breast Conservative Therapy
National Cancer Institute (NCI) consensus statement 1991:
“…..Breast conservation treatment is an appropriate method of primary therapy for the majority of women with Stage I and II breast cancer and is preferable as it provides survival equivalent to total mastectomy and axillary dissection…..”
Around 20 years ago, the National Cancer Institute has published a consensus statement that BCT is equivalent to mastectomy in reaching the primary goal for any cancer surgery,
and that is survival
NIH Consensus Conference. Treatmen to early-stage breast cancer. JAMA 1991;265:391–5

8. Similar 20-year disease-free and overall survival
In 2002, Milan and NSABP1,2
Similar 20-year disease-free and overall survival
This is further supported by the 20-year results from the two LANDMARK paper from the Milan and NSABP group
1Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER et al (2002) Twenty year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233– Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mas- tectomy for early breast cancer. N Engl J Med 347:1227–1232,

9. % dissatisfaction 1,2
After knowing about this, many surgeons are eager to start this overwhelming new treatment
But look at ALL these [click]
Is it really better than mastectomy?
As high as 50% of the patient were not contented about their surgeries
Mind you, these patient need to under go radiotherapies and bear with all the risks and pain; and are subjected to a higher risk of local recurrence
Now THINK, why are we so desperate in preserving the breast tissue ? [click]
1 A body image scale for us with cancer patient Hopwood P Eur J Cancer 2001:37:
2 Cosmetic evaluation of breast conserving treatment for mammary cancer Van limbergen E Radiother Oncol 1989;16:159-67

10. Breast Conservative Therapy
Body Image
Sexual Function
Psychosocial
It’s cosmesis [click]
And ALL [click] the benefits of BCT are derived from a sound cosmesis
If it’s compromised, the patients will not be satisfied [click]
Their family won’t be pleased[click]
And they won’t be happy [click]
Cosmesis
Irwig L, Bennets A. Quality of life after breast conservation or mastectomy: a systematic review. ANZ J Surg 1997; 67(11):750–4.
Moyer et al 1997

11. Photo x Good BCT Sound cosmesis Oncological control
Medially located tumours
Tumor to breast ratio
Weight of the specimen
Longer scars
Re-excision
Sound cosmesis
Oncological control
There’s always a balance, which breast surgeons should strive for
We must have a careful patient selection and tailor-made the management accordingly in order to achieve a safe and sound outcome

12. Photo x bad BCT Sound cosmesis Oncological control
There’re a lot of factors hindering the final outcome
For these, we probably cant do much to help
The only thing that we can do is this [click], in the time of surgery
**Factors adversely affecting cosmesis after ‘wide’ local excision include
-Tumor location: central, medial, inferior
-Tumor to breast ratio
-Weight of the specimen [Volume loss >20%]
-Nipple areola displacement/ distortion
-Inappropriate incision [longer scar]/poor surgical technique
-Re-excision procedures
-Radiotherapy
Oncological control
Munshi A. Kakkar S et al. Factors influencing cosmetic outcome in breast conservation. Clinical Oncology (Royal College of Radiologists). 21(4):285-93, 2009 May.

13. Korean paper
This is a Korean study comparing patients undergoing quadrantectomy and lumpectomy
There’s no statistical difference between these 2 groups.
But what we have resected is significantly more in case of quadrantectomy
Woo Chul Noh et al. Ipsilateral Breast Tumor Recurrence after Breast-conserving Therapy: A Comparison of Quadrantectomy versus Lumpectomy at a Single Institution. World J. Surg. 29, 1001–1006 (2005)

14. 10 % volume: cut-off for predicting cosmesis
sphere volume = 4/3πr3
Tumor
Margin
Volume 1
2 cm
1 cm
34 cc
113 cc
4 cm
270 cc
Specific gravity:
Water= 1·00
Fat = 0·92
Breast tissue= fibrous and glandular structure= mixture of the two
close correlation with estimated volume.
3.4 x
We can see from here, even for a T1 tumor, if we take a 1cm margin, we have already taken 30cc of breast out
If we double the margin [click], the volume taken will actually be tripled
The smaller the lesion, the greater the effect in extending the margin
And we will easily breach the 10% cut off in Orientals as they got smaller breast volume
2.4 x
10 % volume: cut-off for predicting cosmesis
>12 % volume: poor cosmesis 2
1 R. A. Cochrane et al. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. British Journal of Surgery 2003; 90: 1505–1509
2 Stevenson J, Macmillan RD, Downey S, Renshaw L, Dixon JM. Factors affecting cosmesis after breast conserving surgery. Eur J Cancer 2001; 37(Suppl 5): S31

15. photo photo Quadrandectomy Lumpectomy
If more we take doesn’t necessarily converts to better local control and survival, it’s pretty obvious that which procedure is the more preferable one
Patients who are likely to have a poor cosmetic result may be better served by mastectomy and reconstruction, volume replacement or breast-reshaping procedures
photo

16. Local recurrence Oncological control Sound cosmesis
All in all, what we do should not sacrifice the oncological control, which depends on the margin
But how far should we go?
**The national standard for adequacy of conservative breast surgery is achieving a local recurrence rate of 5% or less.
Sound cosmesis

17. Consensus ?? Wide variety of practice patterns 1
Survey to more than 1,000 surgeons 2
351 responses
67% Community Surgeons 33% University surgeons
Standard: At least 1 mm distance
Annual local recurrence: % 3
1mm
2mm
5mm
10mm
Any negative
This topic remains debatable. Right now there is no universally accepted definition for the optimal tumor-free margin.
While European surgeon opt for a wider margin. Americans are satisfied with a tighter one
But we can see from here, there’s a wide range adopted, almost 3/4 of them are confident with a 1-2mm margin
So in practice, a commonly accepted surgical approach is to resect with a 1 cm-thick rim of surrounding breast tissue macroscopically with the expectation that this will yield a microscopic margin of at least 1-2 mm on pathologic analysis
**Most authors define a positive margin as less than 1 mm and a close margin as less than 2 mm of normal breast tissue between the resection margin and the next cancer cell
1 Taghian A, Mohiuddin M, Jagsi R, Goldberg S, Ceilley E, Powell S (2005) Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg 241:629–639
2 Sarah L Blair et al. Attaining Negative Margins in Breast-Conservation Operations: Is There a Consensus among Breast Surgeons? J Am Coll Surg 2009;209:608–613 2 Park CC, Mitsumori M, Nixon A, Recht A, Connolly J, Gelman R et al (2000) Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol 18:1668–1675

18. + + x + 1mm 2mm Close at x mm margin Positive margin Negative margin
Before we go on to look at the results, let’s clarify with some terminologies
Positive margin
Negative margin

19. 0-7% (median 3%) 3-10% (median 6%) 2-4% (median 2%)
I know this is a busy slide, but let’s focus here [click]
What is clear from the various studies is that it is absolutely unacceptable to have tumor cells directly at the cut edge, be it a microscopic/1/2/3/5 mm margin
But is the rate of local recurrence affected by how wide the negative margin is?
Is it really better if we excise more?
It DOES make sense, but this may not be true.
There does not seem to be a direct relationship between width of the negative margin and rate of LR.
The local recurrence rate has a wide range among the different studies.
This may due to the effects of other confounding factors
**Patients in whom a 1 mm negative margin was achieved show LR rates ranging from 0% to 7% (median 3%), while patients with a 2 mm negative margin shown LR rates ranging from 3% to 10% (median 6%) and patients with microscopic negative margins (usually defined as no tumor cells within one microscopic field of the cut edge) show LR rates between 2% and 4% (median 2%).
** Other significant independent predictors of locoregional recurrence: young age (50 years), large tumor size, positive lymph nodes, no chemotherapy, no hormonal therapy
3-10% (median 6%)
2-4% (median 2%)
Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002; 184:383–93.

20. Breast Conservative Therapy
Retrospective review of pathology report invasive ductal CA up to 39mm (n=582) [Exclude DCIS/ ILC]
1st OT: Excisional biopsy or lumpectomy
2nd OT: Lumpectomy or mastectomy
Breast Conservative Therapy
In a retrospective review of the pathology report of 582 patient with open biopsy of the breast followed by a second procedure.
For those with a negative margin of at least 1 mm [click], there’s no macroscopically residual tumor
**excisional bx (no Hx of CA) or lumpectomy (dx CA by FNA/ core) subsequently had 2nd procedure done: lumpectomy or mastectomy
Kotwall et al. Relationship between initial margin status for invasive breast cancer and residual carcinoma after re-excision. The American Surgeon; Apr 2007; 73, 4; ProQuest Medical Library

21. Remaining cancers: small, scattered foci, in situ (60%)
>90% eradicated by standard RT (4,500–5,000 cGy) 1
Not mandatory for reexcision2,3
Multifocally/ focally positive or Unknown: re-excision
These are usually small foci of scattered, in situ cancers in the remainder of the breast
For most of the time the standard doses of radiation should be able to eradicate all these
There is an increasing trend not to mandate a reexcision in this group of patients, as re-excision is detrimental to cosmesis
For those who are margin positive or uncertain margin, we should offer re-excision as the residual breast may harbour an invasive cancer.
1 Fletcher GH, Shukovsky LJ. The interplay of radiocurability and tolerance in the irradiation of human cancers. J Radiol Electrol Med Nucl 1975;56:383–400.
2 Deutsch M. The segmental mastectomy margin: do millimeters matter? Int J Radiat Oncol Biol Phys 1991; 21:521–2.
3 Harris JR, Gelman R. What have we learned about risk factors for local recurrence after breast-conserving surgery and irradiation? J Clin Oncol 1994;12:647–9.

22. More than enough = better
Conclusion
More than enough = better
Dear chairman, ladies and gentlemen, it’s time for a final comment
Resecting more than enough is not better. Margin negativity is what we want
In order to observe the beauty of breast conservative surgery
We must strike a balance between oncological safety and a sound cosmesis
Remember, one millimeter is what really matters
1 m m
Oncological control
Sound cosmesis
is what really matters