Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar...
Transcript of Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar...
![Page 1: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/1.jpg)
Primary Surgical Considerations
Terry Mamounas, M.D., M.P.H., F.A.C.S.Professor of Surgery
Northeastern Ohio Universities College of MedicineMedical Director, Aultman Cancer Center
Canton, OHIO
1
![Page 2: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/2.jpg)
• Breast Cancer Diagnosis/Preoperative Local Staging• Primary Surgical Management of Invasive/Non-Invasive BC
– RCT of Lumpectomy vs. Mastectomy– Lumpectomy Utilization/Indications/Contraindications – Technical Considerations/Margin Assessment– Contralateral Prophylactic and Nipple-Sparing Mastectomy
• Special Circumstances in Primary Surgical Management– Family History/BRCA 1 or 2 mutation carriers – Presence of EIC– Lobular Histology/Presence of LCIS– Occult Breast Cancer– Large Tumors/Neoadjuvant Chemotherapy– Management of Patients Presenting with Stage IV Disease
Outline 2
![Page 3: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/3.jpg)
Breast Cancer Diagnosis/
Preoperative Local Staging
3
![Page 4: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/4.jpg)
Breast Cancer Diagnosis
• Currently, minimally invasive proceduresconstitute the standard of care for diagnosis in the majority of patients
• Needle biopsies can be directed by whichever method assures easiest access and best accuracy for obtaining a true positive or true negative result
• Core needle biopsy is the optimal method for BC diagnosis and can be performed by palpation, ultrasound guidance or stereotacticguidance
4
![Page 5: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/5.jpg)
Core Needle Biopsy • Advantages:
• Differentiates between invasive and non-invasive cancer• Leads to one-stage surgical procedures (including SNB
before lumpectomy)• Provides adequate material for biomarkers (ER/PR/HER2) • Neoadjuvant chemo can be given with invasive ca on core
• Limitations:• False negative rate 1-2 %• With non-invasive cancer on core, invasive cancer may
still be present in 10-25% of cases• With atypical hyperplasia on core, invasive or non-
invasive cancer may be present in 15-40 % of cases and open biopsy should follow
Dershaw DD: Breast J 2003, Rao A, et al: Am J Surg 2002, Shin SJ, et al: Arch Pathol Lab Med 2002, Renshaw AA, et al: Am J Clin Pathol 2001, Berg WA, et al: Radiology 2001,Darling ML, et al: AJR 2000, Tocino I, et al: Ann Surg Oncol 1996, Liberman L, et al: AJR 1995, Jackman RJ, et al: Radiology 1994, Adrales G, et al: Am J Surg 2000
5
![Page 6: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/6.jpg)
MRI in Preoperative Local Staging• Because of its high sensitivity in BC diagnosis and
screening, MRI is being increasingly utilized in the preoperative local staging of BC
• Multiple studies (and a meta-analysis) have shown that MRI identifies additional cancer foci, otherwise undetected by clinical assessment and conventional imaging (in both breasts)
• No consensus on whether MRI improves patient outcomes in terms of rates of margin positivity, reoperation, IBTR or DFS and OS
• On the other hand there remains concern that MRI can increase unnecessary mastectomy rates
Houssami N et al: J Clin Oncol 2008; Schnall M et al: Magn Reson imaging Clin N Am, 2006; Liberman L et al: Magn Reson Imaging Clin N Am, 2006; Smith RA et al: N Engl J Med 2007; Morrow M et al: Magn Reson Imaging Clin N Am 2006
6
![Page 7: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/7.jpg)
UK COMICE Randomized Trial: MRI Planning for Breast-Conserving Treatment
• 1623 women with biopsy-proven primary BC• Scheduled for WLE based on triple assessment
• Randomized to receive MRI (n = 816) or no MRI (n = 807)
Turnbull L et al: Lancet 2009
MRI N (%) No MRI N (%)Initial Surgery
Mastectomy 58 (7%) 10 (1%)Pathologically
Avoidable Mastectomy
16 (2%) 2 (0.2%)
PathologyMF/MC disease 101 (14%) 78 (11%)
• Change in management based on MRI = 50/816 (6%)
• Reoperation rates: • MRI: 18.75%• no MRI: 19.33% P = NS
• No significant differences in DFS of QOL (distress/anxiety)
![Page 8: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/8.jpg)
MRI in Preoperative Local StagingPotential Candidates
• Not necessary for all patients who undergo BCS• Can be helpful in:
• Patients with mammographically dense breasts and ill-defined tumors
• Patients with invasive lobular carcinoma• Patients with multi-centric disease• Patients who are candidates for neoadjuvant
chemotherapy• MRI is essential in patients who present with axillary
adenopathy and clinically and radiographically occult breast lesions
8
![Page 9: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/9.jpg)
Primary Surgical Management in Patients
with Invasive and Non-Invasive BC
9
![Page 10: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/10.jpg)
Primary Surgical Management
• Evolution in the paradigm of surgical management over the past 30 years
• Trend towards increasing use of breast conserving procedures without compromising patient outcome
• Breast conserving surgery has become the preferred surgical treatment for the majority of early-stage BC patients
10
![Page 11: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/11.jpg)
Invasive Breast CancerBreast Conserving Surgery vs. Mastectomy
• From 1973-1989, six randomized trials• Two overview analyses• Compared mastectomy to BCS + XRT• Maximum tumor size for entry: 2-5 cm• No differences in overall survival• XRT significantly reduced the rates of IBTR
Fisher B, et al: N Engl J Med 1985, 1989, 1995, 2002, Veronesi U, et al: Eur J Cancer 1990, 1995, World J Surg 1994, N Engl J Med 1981, 2002Van Dongen JA, et al: Eur J Cancer 1992, J Natl Cancer Inst 2000, Lichter AS, et al: J Clin Oncol 1992, Sarrazin D, et al: Radiother Oncol 1989Blichert-Toft M, et al: J Natl Cancer Inst 1992, EBCTCG: N Engl J Med 1995, Morris AD, et al: Cancer J Sci Am 1997
11
![Page 12: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/12.jpg)
Breast Conserving SurgeryUtilization
• 1990: NIH CDC Statement: – 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 because it provides survival equivalent to total mastectomy while preserving the breast.”
• Despite this and the increase in detection of early-stage disease, BCS is underutilized as a surgical option
NIH CDC: JAMA 1991, Newman LA, et al: Surg Clin North Am 2003, Swanson GM, et al: SG&O 1990, Nattinger AB, et al: N Engl J Med 1992Samet JM, et al: Cancer 1994, Johantgen ME, et al: Am J Public Health 1995, Ayanian JZ, et al: BCRT 1996, Morrow M, et al: J Clin Oncol 2001
12
![Page 13: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/13.jpg)
Frequency of Lumpectomy in NSABP Studies
0
10
20
30
40
50
60
70
80
90
B-13 B-15 B-14 B-16 B-19 B-22 B-20 B-25 B-23 B-28 B-29 B-30 B-36 B-32
Node-Positive TrialsNode-Negative Trials
%
NSABP unpublished data 2/17/05
*
*26% node-positive
13
![Page 14: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/14.jpg)
Breast Conserving SurgeryFactors Associated with Increased Rates
• Young age• Treatment in the North-East US• Economic affluence• Treatment in a metro area/cancer center• Treatment in a teaching hospital• White ethnic background• T1 tumors• Absence of EIC
Newman LA, et al: Surg Clin North Am 2003, Swanson GM, et al: SG&O 1990, Nattinger AB, et al: N Engl J Med 1992, Samet JM, et al: Cancer 1994, Johantgen ME, et al: Am J Public Health 1995, Ayanian JZ, et al: BCRT 1996, Morrow M, et al: J Clin Oncol 2001
14
![Page 15: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/15.jpg)
Optimal Lumpectomy Candidates
• Tumors < 5 cm in diameter• Limited to one quadrant• Breast size/tumor size ratio permitting
lumpectomy with acceptable cosmetic result• Patient is desirous of breast preservation• Negative margins following resection• No contraindications to breast XRT
Newman LA, et al: Surg Clin North Am 2003, Winchester JD, et al: CA Cancer J Clin 1998
15
![Page 16: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/16.jpg)
Lumpectomy ContraindicationsAbsolute
• Multi-centric disease in more than one quadrant
• Diffuse suspicious microcalcifications• Inability to obtain clear margins after
multiple resections• First or second trimester of pregnancy• History of therapeutic radiation to the region
Hooning MJ, et al: Neth J Surg 1991, Morrow M, et al: Ann Surg 1998, Jakesz R, et al: Chirurg 1999
16
![Page 17: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/17.jpg)
• Large tumor size/breast size ratio for acceptable cosmesis
• History of collagen vascular disease (relative contraindication to XRT)
• Tumor location beneath nipple
• Unavailability of radiotherapy
Lumpectomy ContraindicationsRelative
Hooning MJ, et al: Neth J Surg 1991, Morrow M, et al: Ann Surg 1998, Jakesz R, et al: Chirurg 1999
17
![Page 18: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/18.jpg)
Lumpectomy TechniqueChoice of Incision
• Incision over mass• Adequate length• Always curvilinear• Keep in mind possible
future mastectomy• Do not combine with
axillary incision
18
![Page 19: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/19.jpg)
• Thick flaps unless mass is superficial
• Keep in mind possible future PBI
• Remove piece of skin if mass is fixed
• Use sharp dissection• Orient specimen and tag
before removing
Lumpectomy TechniqueExcision and Specimen Orientation
Sutures
19
![Page 20: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/20.jpg)
• Inking of specimen by pathologist
• Gross margin inspection
• Resection of additional tissue if necessary
InkNormal BreastTissue
Tumor
Lumpectomy TechniqueIntraoperative Margin Assessment
20
![Page 21: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/21.jpg)
Subcutaneous Stitch
Cavity
• Do not re-approximate breast tissue
• Advancement flaps can be used to minimize defect
• No drains in breast• Subcutaneous and
subcuticular closure
Lumpectomy TechniqueWound Closure
21
![Page 22: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/22.jpg)
• 21 studies reporting LR by quantified final microscopic margin status and the distance for negative margins
• 14,571 pts, 1,026 LRs• Odds of LR were significantly
associated with margin status:– OR = 2.02 for (+)/close vs. (-)
(P < 0.001)– OR = 1.80 for close vs. (-)– OR = 2.42 for (+) vs. (-)
(both P < 0.001)
What Constitutes Adequate Margin for IBC?Meta-Analysis: Effect of Margin Status on LR
Houssami et al: Eur J Cancer 2010
22
![Page 23: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/23.jpg)
• No significant association with margin width: 1 vs. 2 vs. 5 mm , P > 0.10
• Weak evidence that the OR of LR decreased as margin width increased:–OR for 1 mm, 2 mm, 5 mm: 1.0, 0.75, 0.51–P = 0.097 for trend in one model NS in
another model
• Conclusions:–Margin status has a prognostic effect
in women with IBC–Adoption of wider margins, relative
to narrower is unlikely to a have impact on LR
Houssami et al: Eur J Cancer 2010
What Constitutes Adequate Margin for IBC?Meta-Analysis: Effect of Margin Width on LR
23
![Page 24: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/24.jpg)
• 4,660 patients from trials of BCS + XRT for DCIS • Pts with (-) margins significantly less likely to experience
IBTR than pts with (+) margins (OR 0.36)• A (-) margin significantly reduced risk of IBTR compared
with a close (OR 0.59) or unknown margin (OR 0.56)
What Constitutes Adequate Margin for DCIS?Meta-Analysis: Effect of Margin Status on LR
Dunne et al: J Clin Oncol, 2009
24
![Page 25: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/25.jpg)
Dunne et al: J Clin Oncol, 2009
• 2-mm margin was superior to a margin < 2 mm (OR 0.53)• No significant difference in IBTR between 2 mm and more
than 5 mm (OR 1.51; P .05)• A margin of 2 mm seems to be as good as a larger margin
What Constitutes Adequate Margin for DCIS?Meta-Analysis: Effect of Margin Width on LR
25
![Page 26: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/26.jpg)
A Recently Observed Trend:Increase in the Incidence of
Contralateral Prophylactic Mastectomy
Tuttle et al: J Clin Oncol 2007
26
![Page 27: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/27.jpg)
Nipple-Sparing MastectomyBackground
• In most mastectomy techniques the NAC is removed:• Contains terminal ducts• Centripetal lymphatic drainage towards the
subareolar plexus of Sappey• In early mastectomy studies the likelihood of
occult NAC involvement was relatively high (8-50%)• Increased risk with tumor proximity to NAC, poorly
differentiated tumors, lymph node positivity, size >2 cm
Lagios MD, et al: Am J Surg 1979; Fisher ER et al: Cancer 1975; Smith J, et al: Surg Gynecol Obstr 1976; Kissin MW, et al: Br J Surg 1987
27
![Page 28: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/28.jpg)
Nipple-Sparing MastectomyRationale
• In more recent mastectomy series NAC involvement is seen in 6-11%
• In the majority not appreciated preoperatively• Careful intraoperative evaluation of the NAC
by FS or touch prep is necessary for NSM• Several series have demonstrated the
feasibility of NSM but long term FU is needed• Main advantages: cosmesis and preservation
of nipple sensation (variable)• Potential concerns: nipple necrosis, long-term
oncologic safetyLaronga C, et al: Ann Surg Oncol 1999; Simmons RM, et al: Ann Surg Oncol 2002; Klimberg et al: Ann Surg Oncol 1998; Crowe et al:Arch Surg 2004, Pennisi VR, et al: Aesth Plastic Surg 1989
28
![Page 29: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/29.jpg)
Nipple-Sparing MastectomyAppropriate Candidates
• Tumor size 3 cm or less• Tumor location at least 2 cm from the nipple-
areola complex• Absence of multicentricity• Absence of segmental malignant calcifications
extending to the nipple-areola complex• Clinically negative nodes• Negative intraoperative biopsy of nipple-areola
complexSpear SL, et al: Plast Reconstr Surg 2009; Golshan M: Diseases of the Breast, 2009
29
![Page 30: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/30.jpg)
Nipple-Sparing MastectomyTechnical Aspects
• Incisions:• Peri-areolar with lateral extension• Trans-areolar, peri-nipple with lateral
extension• Trans-areolar, trans-nipple with medial and
lateral extensions• Inferior-lateral mammary crease incision• Nipple-sparing omega (mastopexy) incision• Vertical incision
Laronga C, et al: Ann Surg Oncol 1999; Simmons RM, et al: Ann Surg Oncol 2002; Klimberg et al: Ann Surg Oncol 1998; Crowe et al: Arch Surg 2004, Pennisi VR, et al: Aesth Plastic Surg 1989
30
![Page 31: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/31.jpg)
Special Circumstances in Breast Cancer Primary Surgery
31
![Page 32: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/32.jpg)
Family History/BRCA Status and IBTR• Family history is not an independent predictor
of IBTR in case-control studies• Whether BRCA mutations increase IBTR rates
after BCS is controversial:• Pierce et al : No significant increase in 10-year IBTR
rate for BRCA+ pts (12%) vs. BRCA- pts (9%)• Robson et al : Non-significant increase in IBTR
rate for BRCA+ Ashkenazi Jewish pts vs. BRCA- pts (RR=1.79; 95% CI=0.64-5.03)
• Hafty et al : Significant increase in 12-year IBTR rate for BRCA+ pts (49%) vs. BRCA- pts (21%). No oophorectomy or tamoxifen used
Pierce LJ, et al: J Clin Oncol 2006, Robson M, et al: J Natl Cancer Inst 1999, Haffty BG, et al: Lancet 2002
32
![Page 33: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/33.jpg)
Surgical Approach of BRCA+ Patients
• Known Mutation Carriers:- Discuss BCS vs. bilateral mastectomy- XRT is effective without excess toxicity- High rate of IBTR and CBC
• Suspected Mutation Carrier:- Proceed with surgery as planned based on
tumor presentation (consider neoadjuvant Rx)- Proceed with genetic counseling and testing- Revisit the surgical management after
systemic therapy is given and before XRT
33
![Page 34: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/34.jpg)
Extensive Intraductal Component (EIC)DCIS in > 25% of the tumor area
• In early studies, EIC has been found to be associated with increase in IBTR rates after BCS
• Most of these studies included patients with involved margins and margin involvement generally correlates with the presence of EIC
• Subsequent studies that included patients with negative or focally positive margins, showed that presence of EIC does not significantly predict for IBTR
Schnitt SJ, et al: Cancer 1984 Boyages J, et al: Radiother Oncol 1990, Voogd AC, et al: Eur J Cancer 1999, Abner AL, et al: Cancer 2000, Leborgne F, et al: Int J Radiat OncolBiol Phys 1995 Voogd AC, et al: J Clin Oncol 2001, Burke MF, et al: Int J Radiat Oncol Biol Phys 1995, Touboul E, et al: Int J Radiat Oncol Biol Phys 1999,Schnitt SJ, et al: Cancer 74:1746-51, 1994, Anscher MS, et al: Ann Surg 1993, Smitt MC, et al: Cancer 1995, Wazer DE, et al: Int J Radiat Oncol Biol Phys 1999
34
![Page 35: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/35.jpg)
Presence of Lobular Histology
• Invasive lobular carcinoma can present in an insidious fashion making margin assessment often challenging
• Several studies have shown no significant differences in IBTR rates between pts presenting with lobular vs. ductal histology
• In one study, presence of LCIS increased IBTR rates at 10 but not at 5 years and mostly in younger women
Voogd AC, et al: Eur J Cancer 1999, Abner AL, et al: Cancer 2000,Elkhuizen PH, et al: Int J Radiat Oncol Biol Phys 1999, Wazer DE, et al:. Int J Radiat Oncol Biol Phys 1998
35
![Page 36: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/36.jpg)
Occult Breast CancerIncidence and Diagnosis
• 0.3%-1% of breast cancers present with clinical axillary adenopathy with an occult breast primary
• Breast MRI identifies the occult primary in 75-85 % of the cases
• In the majority of cases with negative MRI, no tumor can be identified in the mastectomy specimen
Baron PL, et al: Arch Surg 1990, Merson M, et al: Cancer 1992, Patel J, et al: Cancer 1981, Sakorafas GH, et al: Surg Oncol 1999, Orel SG, et al: Radiology 1999, Henry-Tillman RS, et al: Am J Surg 1999, Morris EA, et al: Radiology 1997, Tilanus-Linthorst MM, et al: BCRT 1997, Baker DR: Clin Breast Cancer 2000
36
![Page 37: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/37.jpg)
Occult Breast CancerLoco-Regional Management
• Traditionally, MRM followed by L-R XRT has been the standard approach
• Acceptable approaches with proven safety (in small series) include:• Axillary node dissection followed by breast
XRT (and regional nodal XRT as appropriate)• Neoadjuvant chemotherapy followed by either
one of the above options• If mastectomy is not performed, omission of
breast XRT increases the rates of IBTR (from about 12-33% to about 14-83%)Baron PL, et al: Arch Surg 1990, Merson M, et al: Cancer 1992, Patel J, et al: Cancer 1981, Sakorafas GH, et al: Surg Oncol 1999, Ellerbroek N, et al: Cancer 1990, Kemeny MM, et al: Am J Surg 1986, Vlastos G, et al: Ann Surg Oncol 2001, Foroudi F, et al: Int J Radiat Oncol Biol Phys 2000
37
![Page 38: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/38.jpg)
Neoadjuvant ChemotherapyLoco-Regional Effects
• NC in operable breast cancer induces clinical response in 80-90% of the pts
• pCR rates range from 15-40%
• NC increases the rates of BCS without significantly increasing IBTR
• Potential to increase cosmetic result by decreasing the amount of breast tissue needed to be removed at lumpectomy
38
![Page 39: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/39.jpg)
• Sometimes difficult to define the extent of residual tumor and as a result the amount of breast tissue to be removed at lumpectomy
• Ideally one would want to remove less than originally required
Challenges in Decreasing the Size of the Lumpectomy Specimen
39
![Page 40: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/40.jpg)
How Do Tumors Shrink in Response to NC?
40
![Page 41: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/41.jpg)
What is Adequate Surgical Resection after NC?
41
![Page 42: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/42.jpg)
1 2 3 4 51: Single predominant mass with identifiable rim, displacing 2: Nodular pattern, irregular borders 3: Diffuse infiltrative pattern 4: Patchy enhancement 5: Septal spread
MRI Phenotypes
Esserman L, et al:. Ann Surg Oncol 2001
42
![Page 43: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/43.jpg)
MRI Can Overestimate the Amount of Residual Disease
Before NC After NC
43
![Page 44: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/44.jpg)
• Identification of the exact tumor location in cases of cCR– Preoperative titanium clip placement
Neoadjuvant ChemotherapySurgical Planning
Kuerer HM, et al: Am J Surg 2001 Kaufmann M, et al: J Clin Oncol 2003, Baron LF, et al: AJR 2000, Edeiken BS, et al: Radiology 1999, Dash N, et al: AJR 1999
44
Before NC After NC
![Page 45: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/45.jpg)
Ensuring Adequate Surgical Resection after NC
• Identify pattern of shrinkage and the extent of residual tumor preoperatively (mammogram, US, MRI)
• Accurately localize tumor bed area in cases of clinical/radiologic CR
• Thoroughly evaluate margins (intraoperatively and postoperatively)
• Perform additional resection if necessary
Delille JP, et al: Radiology 2003, Wasser K, et al: Eur Radiol 2003, Tiling R, et al: Onkologie 2003, Partridge SC, et al: AJR 2002, Esserman L, et al: Ann Surg Oncol 2001
45
![Page 46: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/46.jpg)
Invasive Lobular Carcinoma and NC• Particular attention when planning BCS
in pts with ILC after NC
• ILC often multicentric and can extensively involve the breast without significant clinical or mammographic findings
• MRI is useful in defining the extent in the breast (but not in the axilla)
• Very low pCR rates with ILC (0-3%)
• ILC predicts for ineligibility of BCS
• Unlikely that pts with extensive ILC will be converted to BCS candidates by NC
Lesser, ML, et al: Surgery 1982, Cocquyt VF, et l: Eur J Surg Oncol 2003, Newman LA, et al: Ann Surg Oncol, 2002
46
![Page 47: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/47.jpg)
• Conventional wisdom is that once metastases have occurred, aggressive local therapy provides no survival advantage and should not be pursued except to prevent local complications (bleeding, ulceration, infection)
• Several retrospective studies have shown significantly better outcome for women who had surgical removal of their tumor vs. those who did not (particularly for those who had negative margins)
Primary Surgical Therapy in Patients Presenting with Stage IV BC
Khan SA, et al: Surgery 2002; Rapiti E, et al: J Clin Oncol 2006; Gnerlich J et al: Ann Surg Oncol 2007; Bafford AC et al: Br Ca Res Treat 2009; Babiera GV et al: Ann Surg Oncol 2006; Blanchard DK et al: Br Ca Res Treat 2006; Le Scodan R et al: J Clin Oncol 2009;Ruiterkamp J et al: Eur J Surg Oncol 2009; Shien T et al: Oncol Rep 2009; Cady B et al: Ann Surg Oncol 2008; Fields RC et al: Ann Surg Oncol 2007;
47
![Page 48: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/48.jpg)
• Most studies adjusted for imbalances in known prognostic factors (such as number of mets, location of mets, type of systemic therapy or use of radiotherapy)
• Most studies concluded that unrecognized selection bias may have accounted for the observed benefit of surgery and only a large prospective RCT could reliably answer the question (ECOG 2108)
Primary Surgical Therapy in Patients Presenting with Stage IV BC
Khan SA, et al: Surgery 2002; Rapiti E, et al: J Clin Oncol 2006; Gnerlich J et al: Ann Surg Oncol 2007; Bafford AC et al: Br Ca Res Treat 2009; Babiera GV et al: Ann Surg Oncol 2006; Blanchard DK et al: Br Ca Res Treat 2006; Le Scodan R et al: J Clin Oncol 2009;Ruiterkamp J et al: Eur J Surg Oncol 2009; Shien T et al: Oncol Rep 2009; Cady B et al: Ann Surg Oncol 2008; Fields RC et al: Ann Surg Oncol 2007;
48
![Page 49: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/49.jpg)
• In the absence of RCT data, not removing the primary tumor remains the standard
• Surgery can be entertained in selected cases (before or after systemic therapy) for local control if local manifestations are more likely to contribute to morbidity than distant ones
• In such cases, breast conserving surgery is preferable if it can encompass the scope of the surgical resection
• Axillary node surgery or breast XRT are generally not advisable
Primary Surgical Therapy in Patients Presenting with Stage IV BC
49
![Page 50: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/50.jpg)
• Core needle biopsy is the standard diagnostic procedure for primary BC
• MRI is not indicated for all pts who undergo BCS• Lumpectomy + breast XRT is the preferred
surgical option in the absence of absolute contraindications
• An increase in the use of CPM has been recently reported
• Use of nipple-sparing mastectomy requires careful consideration and patient selection
Summary/Conclusions (1)50
![Page 51: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/51.jpg)
• Family history of breast cancer, presence of EIC (with negative margins), lobular histology and presence of LCIS do not increase the rates of IBTR and are not contraindications to BCS
• In patients presenting with “occult” BC and axillary metastases, MRI plays an important role in identifying the primary in the breast. Breast XRT is an acceptable alternative to mastectomy, if MRI does not identify a distinct lesion.
Summary/Conclusions (2)51
![Page 52: Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO2012_12_Mamounas...subareolar plexus of Sappey • In early mastectomy studies the likelihood of occult NAC involvement](https://reader031.fdocuments.in/reader031/viewer/2022041913/5e686eccd7e819328c2857e4/html5/thumbnails/52.jpg)
• In patients undergoing neoadjuvant chemotherapy, unique primary surgical issues relate to the assessment of the extent of residual disease and the exact location of residual tumor (or tumor bed) in patients with complete clinical and/or radiologic response
• There is currently no definitive evidence that the use of primary breast surgery in patients presenting with stage IV disease improves overall survival
Summary/Conclusions (3)52