Point of view of the surgeons

Transcription

1 NEOADJUVANT THERAPY: WHEN AND HOW? Point of view of the surgeons Dr. M. Danaei Head of Breast Unit Marienhospital Aachen Germany

2 2

3 3

4 Neoadjuvant therapy and overall survival: 4

5 Neoadjuvant therapy: concept in a specialised breast unit 5

6 6 Outpatient clinic breast unit: Suspicious lump/finding

7 1. Imaging 7

8 8 2. Biopsy sonographically controlled biopsy vacuum assisted biopsy

9 3. Histological verified breast cancer: additional imaging (MRT) 9

10 10 Clarification: BCS or MRM indicated? What about contra lateral? 4. Biopsy confirmation of all ipsi or contra lateral findings prior preoperative tumour board

11 11 Preoperative knowledge: individual risk characteristics: 1. age 2. tumour size 3. nodal status 4. grading 5. hormone receptor state 6. Her2-neu state 7. KI67 8. tumour topic 9. family incidence

12 12 5. Preoperative tumour board Tumour board in our unit

13 13 Preoperative tumour board guidelines & experience radiologist pathologist radiation oncologist surgeon patient oncologist human geneticist resident doctor

14 14 Preoperative tumour board: risk estimation invasive breast cancer low risk medium risk high risk nodal status negative hormone-receptor positive HER2-negative lymph node status positive hormone-receptor negative HER2-positive triple negative age > 50 grade 1 age < 50 age < 30 grade 2 grade 3 tumour size?

15 15 Preoperative tumour board statements on neoadjuvant/(adjuvant) CHT postoperative radiation genetic testing BET / MRM? study participation have to be made here and now!

16 16 Targets: oncological safety prevent relapses increase survival rate quality of living satisfying cosmetic result reduce disease-induced suffering & avoid complications

17 17 recommendation tumour board situation & individual needs of patient treatment concept mandatory requirement: informed consent

18 18 Neoadjuvant chemotherapy and target oriented breast surgery

19 19

20 20

21 21

22 22

23 23

24 24 Concept NACT and surgery SNB or axilla dissection (radiation of lymphatic pathways necessary?) clip marking tumour starting NACT after 3 cycles NACT tumour regress?/re-staging: sonography, MRT, biopsy response?

25 25

26 26 Neoadjuvant CHT: If it works, its amazing...

27 27 ulcerated BC: after the first cycle NACT after the seventh cycle NACT

28 28 Neoadjuvant CHT: But if not works?

29 29 Response assesment: Imaging and histo-pathological expertise (Sinn-score): 1. CR 2. PR 3. No Change partial remission

30 30 No change/progress: stop NACT, immediate surgery CR: further NACT, followed by surgery

31 Breast conserving surgery 31

32 32 Negative examples of breast conserving surgery: better results after NACT?

33 33 Negative examples of breast conserving surgery: better results after NACT?

34 BCS after NCT (3x EC, 4x TAC) 34

35 BCS after NACT 35

36 Mastectomy and Breast Reconstruction 36

37 37 Negative examples MRM better results after NACT?

38 38 Expander and prosthesis technology without radiation: good results expander and prosthesis technology, reconstruction NAC, adapting reduction surgery left expander and prosthesis technology, reconstruction NAC

39 Expander technology with radiation: good result 39

40 Radiation increases risk of capsular fibrosis and inflammation 40

41 41 Prosthesis technology & radiation: negative examples 2 months after expanderimplantation 8 years after prosthesisimplantation (outward performed)

42 42 Alternative after radiation: breast reconstruction with own tissue

43 Alternative after radiation: MRM left side, CHT, radiation, expander-/ prosthesisimplantation (outwards performed) now planning TRAM-Flap 43

44 44 Alternative after radiation: Latissimus plastic surgery

45 45 Alternative after radiation: TRAM-Flap

46 46 Alternative after radiation: TRAM & reconstructed NAC, adapting reduction surgery right side

47 47 Alternative after radiation: TRAM & reconstructed NAC

48 48 What counts in the end? oncological safety and patient satisfaction

49 No single approach is appropriate for all patients decision has to consider the combination of: clinical pathologic features of tumour patient factors such as age, co-morbidities, breast size individual patient needs necessary: patient-based decision making 49

50 Concept + quality + cooperation = good results 50

51 51 NEOADJUVANT THERAPY: WHEN AND HOW? Agree to disagree?

52 52 THANK YOU FOR YOUR ATTENTION!