Presentation on theme: "Breast Cancer Who Gets What Type of Surgery? Murray Pfeifer 16 th August, 2014."— Presentation transcript:
Breast Cancer Who Gets What Type of Surgery? Murray Pfeifer 16 th August, 2014
Hipppocrates (460-375BC) spoke of two cases Galen (129-200AD) 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 History of Breast Cancer Treatment
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 (1)
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 The Modern Era (2)
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 1.Extirpation of the primary tumour 2.Removal of involved regional lymph nodes Relative contraindications to surgery: Advanced age and frailty Advanced disease Who gets surgery?
For the primary lesion in the breast: Mastectomy Wide local excision +/- breast reconstruction Immediate delayed For the axilla: Sentinel node biopsy Axillary clearance What are the operations that are available to us to manage invasive breast cancer?
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 Mastectomy:
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 Indications for simple mastectomy:
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% Breast Conserving Treatment:
Good control of the primary cancer Survival equivalence to mastectomy Cosmetically acceptable outcome Objectives of Breast Conserving Treatment(BCT):
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) Good control of the primary tumour:
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 How much is enough?
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 Contraindications to BCT
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 Morbidity of BCT:
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 Is there a survival equivalence between BCT and Mastectomy in STI-II cancers:
Decisions about management of the axilla are made quite independently from decisions about the management of the primary cancer Surgery of 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. Why operate on the axilla?
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: High grade Large lesion Extensive involvement mastectomy Who gets axillary surgery?
Two Operations: Sentinel node biopsy Axillary dissection The Operations
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 Sentinel lymph 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: Large tumours (T3 or T4) Suspicious or proven positive axillary nodes Prior axillary surgery Prior cosmetic breast surgery Following neoadjuvant systemic therapy Who gets Sentinel node biopsy?
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 Sentinel node biopsy principles
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% How reliable is 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 Management of the axilla where there has been a positive sentinel node biopsy
RCT – Surgery v XRT Five year follow up Results: Local recurrence0.54% v 1.03% Disease free survival86.7% v 82.7% Overall survival93.3% v 92.5% Lymphoedema28% v 14% EORCT AMAROS Study ASCO 2013 – Emeil Rutgers
Does it still have place? Yes……. But less so than in years gone by Axillary Dissection
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). Axillary dissection – why we do it
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 Who gets axillary dissection?
Wound infection Seroma Pain, parasthesia, and numbness in the distribution of the intercostobrachial nerve Frozen shoulder lymphoedema The morbidity of axillary dissection:
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. Is sentinel node biopsy superior to axillary dissection with respect to complications?
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 Ductal Carcinoma In Situ
Mastectomy +/- reconstruction is a commonly utilised option 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 surgery is offered:
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 What margins are required in BCT for 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: Large tumour High grade Palpable tumour Mammographic density Management of the Axilla in DCIS
Indications for sentinel node biopsy in DCIS: Large lesion High grade Palpable tumour Mammographic density Patient is having a mastectomy Should patients with a preoperative diagnosis of DCIS have sentinel node biopsy?
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 Who gets what operation?