Treatment of Early Breast Cancer

Frances Wright MD MEd FRCSC

Objectives

• imaging & diagnosis

• historical overview of surgical treatment

• current practice– breast surgery– axillary staging

Radiologic Work-up

• Common– Mammogram– Ultrasound

• Good for young women• Usually targeted

• Uncommon– Galactogram– MRI

Mammogram

Some cancers are not found until they reach this size

         

A mammogram can find cancer when it is only this size   

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Benefits of Mammogram

Survival and Stage of Breast Cancer

Mammogram X-ray of the Breast

• No screening tool 100% effective

• 85-90% of all breast cancers in women > 50 can be identified on mammogram

Mammograms and Cancer

Ultrasound of Breast Cancer

Magnetic Resonance Imaging

MRI

• Advantage– Not affected by breast

density– Can identify occult

disease

• Disadvantage– Dependent on who does

the imaging– Sensitive, not very

specific– Need MRI biopsy

capability

Breast MRI – Screening…

• Who should get ?– Screening - evidence

• BRCA mutation carriers• Untested 1st degree relatives of carriers• Family history of hereditary cancer syndrome;

risk > 25%

– Screening – no good evidence • Prior chest radiation before age 30 (Hodgkins)• Some women with LCIS/atypia

MRI for Surgeons

• Treatment Planning – 3% of contralateral breast cancers are occult to

physical exam/ mammo (Lehman 2007)– Occult primary with axillary mets– Paget’s disease of the nipple– Invasive lobular carcinoma – Extent of disease work up– Evaluation of residual disease

Breast Imaging Reporting & Data Systems = BIRADSInterpretation Risk Ca

0 Incomplete assessment

1 Negative 0.05%

2 Benign 0.05%

3 Probably benign 2%

4 Suspicious 15 - 50%

5 Highly suspicious 95 - 99%

6 Known cancer 100%

Imaging

• BIRADs classification

1

2

3 5

4

Needs biopsyNo action

The work-up: Pathology

• Core needle biopsy– Gives more information – – type of cells – invasive vs. non-invasive

• Fine needle biopsy – not done as much now– Malignant vs. not malignant– Rule out cyst

• Excisional biopsy - uncommon now

Ductal carcinoma in situ

Invasive ductal carcinoma

Pathology: Ductal Carcinoma in situ and Invasive ductal Carcinoma

No lymph node involvement

Potential lymph node involvement

• There must be clinical, radiologic and pathologic agreement (concordance) in diagnosis

• If one doesn’t fit – consider surgical excisional biopsy

The evolution of breast surgery

• Halsted 1852 - 1922 • tumour begins small• systematic progression

to surrounding tissues

• involvement of lymphatics leads to distant spread

• local control = cure

The evolution of breast surgery

• Halstedian principles• radical mastectomy

– Breast, pectoralis major and minor and axillary tissue

The evolution of breast surgery

• Bernard Fisher • breast cancer systemic

at onset• surgery impact is local• lumpectomy + RT =

mastectomy

The evolution of breast surgery

• “Fisherian” theory• breast conservation

The evolution of breast surgery

Halstedian principles

radical mastectomy

versus

“Fisherian” theory

breast conservation

Breast conservation

• removal of tumour with a margin of normal tissue • post-operative radiation to reduce local recurrence

rates• suitable for clinical stage I-II tumours (< 5cm, mobile)• acceptable cosmetic outcome• equivalent survival to mastectomy

• higher local recurrence rate 7-8% vs. 5%

Mastectomy

• large or multicentric tumours• unacceptable cosmesis, small breast : tumour ratio• persistent positive margins with conserving surgery• contraindication to radiation• patient preference

Surgical Treatment of Early Breast Cancer

Breast

Breast conservation

or

Mastectomy

Axilla

Sentinel Node Biopsy possible axillary dissection

or

Level I/II axillary dissection

Axillary Surgery

• axillary status most significant prognostic indicator• role in determining need for adjuvant therapy• provides local control if nodes involved with tumour• controversial survival benefit

Axillary Lymph Node Dissection

• associated morbidities– decrease range of motion, sensory defects, pain– nerve injury– lymphedema of ipsilateral arm (10-15%)

• majority of women node negative• no benefit from removal of negative nodes

Likelihood of having lymph node involvement

Diameter of primary tumour

Percent with positive axillary nodes

0.5 - 0.9 cm 21 %

1.0 - 1.9 cm 33 %

2.0 – 2.9 cm 45 %

3.0 – 3.9 cm 55 %

4.0 – 4.9 cm 60 %

> 5.0cm 70 %

Carter 1989

The sentinel node for breast cancer

• Cabanas 1977 - penile cancer and inguinal nodes

• Morton 1992 - melanoma

• Krag 1994 - isotope in breast cancer

• Guiliano - blue dye in breast cancer

• Albertini - blue dye and isotope

Sentinel node concept

• first node or nodes in the draining nodal basin most likely to harbour metastases

• status of the sentinel node reflects the status of the entire nodal basin

• if found to be negative, no further axillary nodes removed

• enables staging with less morbidity

tumour

Radioisotope +/-Blue Dye

radioactivity

blue dye

Pathological evaluation

• usual evaluation is bi-valve of 10 - 20 nodes • retrieval of fewer nodes (1-3) allows more extensive

evaluation– H & E multiple sections – immunohistochemical staining (IHC)

– No accepted standard

Sentinel node biopsy for who?

• small invasive T1 - T2 tumours • clinically node negative• contraindicated in

– locally advanced or inflammatory • Not as accurate

– prior lumpectomy– prior ALND

Sentinel node biopsy by whom?

• specialized multidisciplinary technique involving surgeon, nuclear medicine and

pathology• surgeons should be familiar with risks/benefits and

perform breast surgery routinely• recommended surgeons have performed at least 20

cases with “back up” axillary dissection first• should have a localization rate > 90%• should have false negative rate < 5%

Sentinel Node Biopsy - evidence?

• multi-institutional validation study using radioisotope1

• single institution series using blue dye 2

• over 60 other observational series reporting similar results

• one randomized control trial to date with 46 mo f/u demonstrating no difference in adverse events & less morbidity 3

1Krag et al. NEJM 1998; 339(14):941 - 9462Guiliano et al. Ann Surg 1994; 220:391- 4013Veronesi et al. NEJM 2003; 349(6):546 - 53

Sentinel Node Biopsy - evidence?

• two large multicentre trials recently completed accrual– NSABP 32 & ACOSOG Z0010

– ACOSOG Z0011 accruing (SLN node positive)

• objectives:– determine local recurrence and survival in women

undergoing sentinel lymph node biopsy only – determine morbidity associated with sentinel

lymph node biopsy

Breast Cancer Treatment in the 20th Century:Quest for the Ideal Local-regional Therapy

1900 2000

Radical Mastectomy

Extended Radical Mastectomy

Modified Radical Mastectomy

Lumpectomy

BC + RT

Ax LND

BCT + RT

Sentinel Node BiopsyI D E A L T H E R A P Y

1950 Radiation

Overtreatment

Summary

• Evolution of breast cancer surgery for more to less

• More and more specialized

• Less morbidity for patient