Verzichtauf die Tumoroperationnach neoadjuvanterchemotherapie?

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1 Verzichtauf die Tumoroperationnach neoadjuvanterchemotherapie? Peter Dubsky Brustzentrum St. Anna, Luzern

2 Disclosures None relatedtothesubject Involved in planning of VISION

3 Die folgenden Behandlungstrategien: Sind teilweise experimentell Sie werden im Rahmen von kontrollierten klinischen Studien erforscht Außerhalb von klinischen Studien ist der Verzicht auf eine Tumor OP nach Chemotherapie eine grobe Fahrlässigkeit. Kids, don t try this at home.

4 Hintergrund St. Gallen Consensus 2017 HER2+ TNBC Annals of Oncology 2017, Curigliano et al.

5 Die komplette Remissioneine tägliche Realität In TNBC and in HER2+: (Brightness, Lancet Oncol. 2018) pcr>50% ccrin breast>70% In ER+: RCB0-I still in 25% (ABCSG34, ER+) ccrin breastca. 33% pn+ topn0: 40% (ACOSOG Z1071)

6 St. Gallen Consensus 2017 Annals of Oncology June 2017

7 Die diagnostische Excision (oder Radiologist with a Knife ) OR Images courtesy of Dr. van Duijnhoven, NKI Amsterdam

8 Location, Location, Location : Micromark, Ultracor, UltraClip, Trimark, Biomarc, HydroMark. Titaniumorstainlesssteel: compatible even in 3T MRI Imaging Filler: (pig) Collagen, polylacticacid, polyglycolic acid, suture netting FDA/CE Mark for>6months

9 Diagnosis May SurgeryNovember 2017 TNBC, 2.8cm, craniolateral quadrant right, unifocal tumor No residual tumor but Clip and Filler are visible

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11 ImFall der CR könnenwirnochwenigermachen?

12 OptionennachNACT Resect original tumour bed imaging: no residual disease??? Diagnostic excision 10 gram Biopsies? NurRT? Omit surgery?

13 Nur RT bei Komplettremission? no surgery KeinMRT!-nurPalpation, MG, Sono und: wenig Lokalisationsverfahren, wenig radiologisch gezielte Biopsietechnologien.

14 Surgery following NST Resect original tumour bed imaging: no residual disease??? Diagnostic excision 10 gram Biopsies? Omit surgery? 14

15 MRI/MG/Sono to predict pcr Adjuvant systemic treatments Smart Localization Technique to focus on tumor Adjuvant Radiotherapy 2018: Omit Surgery? (use Biopsy!) Vacuum Assisted Biopsy Techniques Effective neoadjuvant Chemo/Immuno Tx Tumorbiology likely torespondtonact

16 Erste erfolgreiche Daten Machbarkeit J. Heil et al EJC, 2016 n=50; gemischt ER+/ER neg, HER2+/neg. n=38 mit repräsentativen VAB: NPV 94.4%, FNR 4.8% Kuereret al, Ann Surg n=40, TNBC oder HER2+ Accuracy98%, FNR 5%, NPV 95% (47.5% pcr) Tadroset al, JamaSurg n=527, HER2+ oder TNBC pcrder Brust entspricht pcraxillain 95.9%

17 VISION I -Trial Vacuum assisted biopsy Immediately before Surgery as an Intra- or perioperative comparison for patients who underwent Neoadjuvant chemotherapy for breast cancer C. Tausch und M. Knauer

18 Diagnosed Breast Cancer Position Gel-clip Neoadjuvant Chemotherapy rcr (MRI) Ultrasound guided VAB Stereotactic guided VAB Breast Surgery Pathological examination

19 Trial N Biological BC-types RESPONDER (GBG) MD Anderson Cancer Center NOSTRA Feasib. (Birmingham) MICRA/MACRA (Netherlands) Marking Response Kind of biopsy Number of samples 600 all Clip CR, PR VAB? 50 Her2 pos. Triple neg. 150 ER neg. Her2 pos. NRG/BR Inv. ductal carcinoma VISION I SAKK/ABCSG Clip < 2cm VAB 12 Clip No limit US-Core all Seed Partial radiol. (150) Compl. radiol. (375) 352 All without LuminalA Clip HydroMark Clip Complete or near radiol.cr(mri) Complete or near radiol.cr(mri) Core G VAB 6 VAB 8

20 Wie kann es gehen? Exakte bioptische und radiologische Diagnose T<5cm, Fokalität, MK? Clipmarkierung (sonographisch sichtbare) Effiziente NACT Exakte Biopsie Exakte Pathologie Adjuvante RT Adjuvante syst. Therapie Adjuvant systemic treatments Adjuvant Radiotherapy Effective neoadjuvant Chemo/Immun otx MRI/MG/Sono to predict pcr 2018: Omit Surgery? (use Biopsy!) Tumorbiology likely to respond to NACT Smart Localization Technique to focus on tumor Vacuum Assisted Biopsy Techniques

21 #breastdoktor

22 With kind regards from Lucerne!

23 Back upslides

24 IstMRT vielbesser??? Metaanalysis: >900 women, 19 Studies Level of agreement between ptand MRI, US and CBE by error margins 0-3cm MarinovichM et al BJC 2013

25 No association between pcr and MRI response in ER+ n=188, MRI before and during NACT TNBC HER2+ ER+ Change in largest tumor diameter from baseline to surgery Loo C E et al. JCO 2011;29:

26 FNR und NPV der MRT in Hinblick auf pcr Heil et al. 2018

27 MultiparametricMRI-a Hypothesis DCE-MRI Morphology DCE-MRI DCE-MRI Neoangiogenesis DWI DWI 1 H-MRSI 1 H-MRSI Metabolism Pinker et al, Invest. Radiol. 2014; Pinker et al, Radiology 2015; Pinker et al, ClinCancer Res. 2014