Breast CancerWho Gets What Type of Surgery?

Murray Pfeifer16th 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 streamGershon-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 tumour2. 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 excisionAnd

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

OrNode(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 recurrence 0.54% v 1.03% Disease free survival 86.7% v 82.7% Overall survival 93.3% v 92.5%

Lymphoedema 28% v 14%

EORCT AMAROS StudyASCO 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?