SURGERY AND BRACHYTHERAPY
PETER SCHWARTZ
St George Hospital Sydney
SURGERY BREAST CANCER
1. Clearance of Recognizable Tumour 2. Nodal assessment ( not DCIS )
St George Experience >500 new patients/anually 65% conservative surgery
SURGERY SELECTION
Adjuvant radiotherapy essential in reducing ipsilateral breast tumour recurrence and traditionally whole breast irradiation (WBI) with breast conserving surgery used
1. Lymphoedema 2. Pain 3. Scar contracture
SURGERY SELECTION Mastectomy • Multifocal • Tumour /Breast ratio unacceptable • Previous radiotherapy • Underlying medical considerations • Genetics • Patient request • Remote locations, logistics, accessibility and
patient concerns regarding WBI effects
Ca Breast
BREAST CANCER
RADIOTHERAPY
Alternatives to Conventional WBI 5-6 weeks • Hypofractionated whole breast (3 weeks) • Brachytherapy (1 week)
SURGERY/BRACHYTHERAPY ASTRO and ESTRO guidelines combined Low risk group • No nodal status • Tumour size to <2-3cm • Favourable prognostic factors • >50-59 age group • Unicentric or focally multifocal • DCIS not allowed
SURGERY/BRACHYTHERAPY
Intermediate Risk – Cautionary Tumour size 2-3cms Age >50-60 Invasive lobular allowed DCIS allowed
• SURGICAL CONSIDERATIONS with BRACHYTHERAPY
1. Margins 2. Reasonable flaps 3. Tumour cavity marking 4. Cosmesis 5. Oncoplastic considerations 6. Keloid formation
MARGINS
POSITIVE MARGIN
Positive margins ie. Ink on invasive / DCIS associated with significant increase in IBTR – not nullified by boost or systemic Rx or favourable pathology
MARGINS
NEGATIVE MARGIN Definiton: No ink on margin – any distance Optimizes IBTR Wider margins do not lower this risk OFTEN NEED CAREFUL PATHOLOGY REVIEW
MARGINS
Reduces IBTR but if not given, wider margins have no benefit
IBTR not influenced by wider margins EXTENSIVE INTRADUCT COMPONENT IBTR not influenced provided clear to ink AGE <40 Higher rate IBTR regardless of surgery. Wider margins
no effect
MARGINS
LOBULAR CANCER 1. Wider than no ink on tumour not indicated 2. Classical LICS at margin not an indication for
re-excision 3. Pleomorphic LCIS uncertain
MARGINS CONCLUSION
EXCISION ALL CLINICALLY EVIDENT TUMOUR
NO INK ON MARGIN SUFFICIENT
Should significantly reduce rate of re-excison which sometimes ends with mastectomy or
poor cosmetic result
(Consensus Statement JCO Feb 10,2014)
CLOSURE TECHNIQUES • Superficial or Layered Closure
No consensus and variable approach • Ann Surg Oncol. 2013 Apr;20(4): Epub 2012
Lumpectomy closure technique does not affect dosimetry in patients undergoing external-beam-based accelerated partial breast irradiation
CLOSURE TECHNIQUES
1.Layered closure
2.Superficial closure
CLOSURE TECHNIQUE EJSO 38(2012) 918-924 Studied association of breast tumour bed
seroma with post-operative complications and late normal tissue toxicity (WBI) 1. Increased post-op infection 2. Reduced cosmesis 3. Increased tissue toxicity (retraction,oedema)
ONCOPLASTIC SURGERY
ONCOPLASTIC SURGERY
SUGGESTED BENEFITS Wider excision margins – reducing reoperation Possibly better cosmesis Combined with other reconstructive procedures Eg.contralateral breast reduction ? Reduction risk of tumour due to reduced
breast volume as secondary benefit
ONCOPLASTIC SURGERY Wider Margins and Cosmesis • Impact of increasing use of neoadjuvant
treament • No evidence of benefit past inked margins
• May reduce need for repetitive surgery • Consider using if cosmesis improved
ONCOPLASTIC SURGERY
ONCOPLASTIC SURGERY
Surgical Options
SURGICAL TECHNIQUE &
BRACHYTHERAPY Aims 1. Patient selection preoperatively 2. Attention to skin flaps 3. Clips to allow future delineation of cavity 4. Maintainance of oncological principles 5. ? Keloid
CONCLUSION
• Useful adjunct in radiotherapy treatment • Possible reduction in recognized side effects
post WBI • Apply appropriate surgical techniques
maintaining oncological principles • Possibly will allow for conservative approach
in IBTR in the future • Awaiting further mature data
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