Spotlights on the surgery role at San Antonio
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1 Spotlights on the surgery role at San Antonio Riccardo Masetti, MD Professor of Surgery Director, Multidisciplinary Breast Center Catholic University Rome, Italy
2 Roma, 21 maggio 2017
3
4 Prof. Masetti has no relevant financial relationships with commercial interests to disclose but. I have to admit that this year, for unexpected familiy reasons, I had to decline at the last minute my participation to SABCS
5 San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
6 APPROPRIATE SURGICAL MARGINS
7 APPROPRIATE SURGICAL MARGINS CURRENT SSO/ASTRO GUIDELINES ON MARGINS: Moran et al, 2014 appropriate margin: NO TUMOR ON INK Is this correct?
8 APPROPRIATE SURGICAL MARGINS New meta-analysis Systematic review of the literature ( ) 38 studies Inclusion criteria: Minimum follow-up: 50 months Explicit pathologic definition of margin status Local recurrence reported in relation to margin status F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
9 APPROPRIATE SURGICAL MARGINS New meta-analysis patients (> additional patients from previous meta-analysis 7.2 years median follow-up F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
10 APPROPRIATE SURGICAL MARGINS Odds Ratio for Local Recurrence by margin Status Positive vs Negative; 2.49 ( ) Close vs Negative: 1.58 ( ) 2 mm vs 1 mm 0.50 ( ) 5 mm vs 1 mm 0.40 ( ) F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
11 APPROPRIATE SURGICAL MARGINS Limitations of metanalysis preclude definitive conclusion regarding appropriate margins However, MVA seems to indicate that having a margin width beyond «no tumor on ink» may further reduce rates of local recurrence (Consistent with DCIS: margins should be >2mm) Further prospective studies are required F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
12 APPROPRIATE SURGICAL MARGINS Does large volume displacement oncoplastic surgery still offer an advantage of a low positive margin rate using the new SSO/ASBrS/ASTRO margin guidelines? LITERATURE REVIEW 45 PAPERS PATIENTS STATISTICS COMPARING LVOS VS TRADITIONAL BCS M. Jonczyk et al Tufts Medical Center - Boston Hospital and Academic Medical Center
13 APPROPRIATE SURGICAL MARGINS Positive margin rate (PMR) comparison T-Test evaluation Published PMR between LVOS and TBCS in literature review PMR between Tufts LVOS and TBCS in literature review LVOS: 12.5% TBCS: 20.4% P-value: <0.001 Tufts LVOS: 10% TBCS: 20.4% P-value: Large volume displacement oncoplastic surgery (LVOS) can secure better clearance of margins M. Jonczyk et al Tufts Medical Center - Boston Hospital and Academic Medical Center
14 San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Margins Locoregional recurrence Axillary management Local therapy in ABC
15 LOCOREGIONAL RECURRENCE
16 LOCOREGIONAL RECURRENCE Challenge of LRR: LRR is increasingly uncommon, so evidence to guide practice is limited Most data come from patients treated with MRM or lumpectomy, ALND and RT Changing treatment landscape has raised new questions: Repeat lumpectomy Axillary management after initial SN bx M. Morrow Memorial Sloan Kettering Cancer Center
17 REPEAT LUMPECTOMY FOR IBTR M. Morrow Memorial Sloan Kettering Cancer Center
18 REPEAT LUMPECTOMY FOR IBTR Good results only in low risk patients (ER+, HER2-, initial negative margins)
19 REPEAT LUMPECTOMY FOR IBTR Not the standard of care Reported high rates of additional LR M. Morrow Memorial Sloan Kettering Cancer Center
20 REPEAT LUMPECTOMY FOR IBTR M. Morrow Memorial Sloan Kettering Cancer Center
21 LOCOREGIONAL RECURRENCE Nothing new as compared to NCCN 2017 guidelines!!
22 REOPERATIVE SENTINEL NODE BIOPSY Success of reoperative SLN is related to number of axillary nodes removed during primary surgery 0-2 nodes removed: 80% SLN identification rate 3-5 nodes removed: 65% SLN identification rate >9 nodes removed : 38% SLN identification rate Extended axillary dissection raises the incidence of aberrant drainage pathways M. Morrow Memorial Sloan Kettering Cancer Center
23 REOPERATIVE SENTINEL NODE BIOPSY M. Morrow Memorial Sloan Kettering Cancer Center
24 REOPERATIVE SENTINEL NODE BIOPSY Conclusions: Technically feasible High rates of aberrant drainage in previously treaten axilla (ALND or SNB) Clinical outcome likely to be determined by recurrence biology, not surgical staging of nodes M. Morrow Memorial Sloan Kettering Cancer Center
25 San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
26 SNB IN EARLY BREAST CANCER
27 SNB IN EARLY BREAST CANCER
28 SNB IN EARLY BREAST CANCER MICROMETASTATIC SLN V. Galimberti IEO, Milan
29 SNB IN EARLY BREAST CANCER 6681 patients registered 5747 not eligible for randomization 934 patients randomized 467 allocated to no axillary dissection 464 allocated to axillary dissection 2 excluded 1 excluded 467 analyzed 10 withdrew consent 74 lost to follow-up 464 analyzed 11 withdrew consent 69 lost to follow-up V. Galimberti IEO, Milan
30 SNB IN EARLY BREAST CANCER MICROMETASTATIC SLN Arms characteristics well matched V. Galimberti IEO, Milan
31 SNB IN EARLY BREAST CANCER Appropriate balance of adiuvant therapies V. Galimberti IEO, Milan
32 SNB IN EARLY BREAST CANCER 10 years results V. Galimberti IEO, Milan
33 SNB IN EARLY BREAST CANCER Low incidence of axillary events disregarding type of surgery V. Galimberti IEO, Milan
34 SNB IN EARLY BREAST CANCER MICROMETASTATIC SLN No differences between the AD and no AD groups for any endpoint No ALND is acceptable even in patients scheduled for mastectomy V. Galimberti IEO, Milan
35 SNB IN EARLY BREAST CANCER MACROMETASTATIC SLN (Breast conserving surgery) 30-80% of ALND reduction in cn+ (sn) patients worlwide! T. King Dana Farber / Brigham and women s - Harvard medical school
36 SNB IN EARLY BREAST CANCER (patients undergoing mastectomy) Dana Farber s multidisciplinary behavior 1-2 positive SLN PMRT + Axillary RT 3 or + positive SLN ALND No SNB in patients cn0 undergoing mastectomy who will receive PMRT: <60 YR High risk factors (LVI or HR negative) T. King Dana Farber / Brigham and women s - Harvard medical school
37 SNB IN EARLY BREAST CANCER 75 pts patients registered (ct1-2, N0) no FS 21 (28%) positive SLN 54 (72%) negative SLN 18 pts (24%) 1-2 positive SLN 3 pts (4%) 3 positive SLN 1 ALND 14 (78%) PMRT + AxRT 3 observation 17/21 (81%) of positive patients spared ALND T. King Dana Farber / Brigham and women s - Harvard medical school
38 SNB AFTER NEOADJUVANT TREATMENT SLNB procedure of choice for axillary stadiation T. King Dana Farber / Brigham and women s - Harvard medical school
39 SNB AFTER NEOADJUVANT TREATMENT FEASIBILITY OF SLNB AFTER NAD T. King Dana Farber / Brigham and women s - Harvard medical school
40 SNB IN NEOADJUVANT TREATMENT cn0 ycn0 PATIENTS Acceptable SLN identification rate even after NACT T. King Dana Farber / Brigham and women s - Harvard medical school
41 SNB AFTER NEOADJUVANT TREATMENT cn+ ycn0 PATIENTS Acceptable identification and false negative rates (only if 3 SLN are removed) T. King Dana Farber / Brigham and women s - Harvard medical school
42 SNB AFTER NEOADJUVANT TREATMENT INTERPRETATION OF SLNB AFTER NAD T. King Dana Farber / Brigham and women s - Harvard medical school
43 SNB AFTER NEOADJUVANT TREATMENT SLNB in cn+ ycn0 patients In ypn0 (sn) pts ALND can be avoided, sparing up to 50% of ALND in converted axillas!! T. King Dana Farber / Brigham and women s - Harvard medical school
44 SNB AFTER NEOADJUVANT TREATMENT Significance of micromets and ITCs No relationship between size of SLN mets and likehood of additional nodal disease 57% of patients with ypn0 (i+) had positive non SLN after NACT Significance of disease <0,2 mm (ypn0i+ / ypn1mic) still unclear More studies are needed to clarify significance of micro mets and ITCs in SLN after NACT T. King Dana Farber / Brigham and women s - Harvard medical school
45 SNB AFTER NEOADJUVANT TREATMENT ypn+ PATIENTS Clear indication for ALND T. King Dana Farber / Brigham and women s - Harvard medical school
46 SNB AFTER NEOADJUVANT TREATMENT Waiting for more studies for stronger recomendations
47 AXILLARY TREATMENT COMPLICATIONS
48 AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
49 AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
50 AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
51 San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
52 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
53 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
54 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
55 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
56 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
57 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
58 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
59 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
60 OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
61 THANK YOU!
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