Treatment of Early Breast Cancer
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Transcript of Treatment of Early Breast Cancer
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Treatment of Early Breast Cancer
Frances Wright MD MEd FRCSC
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Objectives
• imaging & diagnosis
• historical overview of surgical treatment
• current practice– breast surgery– axillary staging
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Radiologic Work-up
• Common– Mammogram– Ultrasound
• Good for young women• Usually targeted
• Uncommon– Galactogram– MRI
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Mammogram
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Some cancers are not found until they reach this size
A mammogram can find cancer when it is only this size
www.obsp.on.ca
Benefits of Mammogram
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Survival and Stage of Breast Cancer
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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
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Mammograms and Cancer
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Ultrasound of Breast Cancer
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Magnetic Resonance Imaging
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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
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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
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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
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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%
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Imaging
• BIRADs classification
1
2
3 5
4
Needs biopsyNo action
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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
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Ductal carcinoma in situ
Invasive ductal carcinoma
Pathology: Ductal Carcinoma in situ and Invasive ductal Carcinoma
No lymph node involvement
Potential lymph node involvement
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• There must be clinical, radiologic and pathologic agreement (concordance) in diagnosis
• If one doesn’t fit – consider surgical excisional biopsy
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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
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The evolution of breast surgery
• Halstedian principles• radical mastectomy
– Breast, pectoralis major and minor and axillary tissue
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The evolution of breast surgery
• Bernard Fisher • breast cancer systemic
at onset• surgery impact is local• lumpectomy + RT =
mastectomy
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The evolution of breast surgery
• “Fisherian” theory• breast conservation
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The evolution of breast surgery
Halstedian principles
radical mastectomy
versus
“Fisherian” theory
breast conservation
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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%
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Mastectomy
• large or multicentric tumours• unacceptable cosmesis, small breast : tumour ratio• persistent positive margins with conserving surgery• contraindication to radiation• patient preference
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Surgical Treatment of Early Breast Cancer
Breast
Breast conservation
or
Mastectomy
Axilla
Sentinel Node Biopsy possible axillary dissection
or
Level I/II axillary dissection
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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
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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
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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
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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
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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
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tumour
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Radioisotope +/-Blue Dye
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radioactivity
blue dye
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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
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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
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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%
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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
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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
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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
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Summary
• Evolution of breast cancer surgery for more to less
• More and more specialized
• Less morbidity for patient