Surgery for Breast Cancer
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1 Surgery for Breast Cancer 1750 Mastectomy - Petit 1894 Radical mastectomy Halsted Extended, Super radical mastectomy 1948 Modified radical mastectomy Patey WLE & RT Baclesse, Mustakallio BCT trials Veronesi, Fischer 1990 s Routine BCT for early Breast Cancer
2 Radical Mastectomy
3 Surgery for Breast Cancer 1750 Mastectomy -Petit 1894 Radical mastectomy Halsted Extended, Super radical mastectomy 1948 Modified radical mastectomy Patey WLE & RT Baclesse, Mustakallio BCT trials Veronesi, Fischer 1990 s Routine BCT for early Breast Cancer
4 Modified Radical Mastectomy
5 Surgery for Breast Cancer 1750 Mastectomy -Petit 1894 Radical mastectomy Halsted Extended, Super radical mastectomy 1948 Modified radical mastectomy Patey WLE & RT Baclesse, Mustakallio BCT trials Veronesi, Fischer 1990 s Routine BCT for early Breast Cancer
6 Breast Cancer Surgery, SGPGI Mastectomy BCS
7 BCT vs. MRM for Early Breast Cancer, SGPGI Mastectomy BCS
8 Breast Conservational Therapy Appropriately selected patients Early stage Low risk for local recurrence No-contra-indications for Radiation 3 components - Mx of breast lump Mx of axilla Mx of residual breast
9
10 Management of Breast Lump Central incision Limited volume of breast tissue removed Minimal skin excised Good hemostasis Cavity walls not re-approximated Avoid drains Separate breast & axillary incisions
11 Incision Planning
12
13
14
15 Management of Axilla Conventional Axillary dissection Recent Sentinel LN biopsy
16 Sentinel Lymph Node First lymph node(s) draining the breast Blue dye and/or radio pharmaceutical injection Exploration, identification of blue tract and/or scan with hand held gamma probe Frozen section evaluation of sentinel node(s) to determine extent of axillary dissection
17 Radio-pharmaceutical SLN study
18 Blue Dye SLN Study
19
20 Our experience Patients: , n=36 Tumors < 5 cm tumor Mobile axillary lymph node Planned treatment: Lumpectomy + axillary dissection External RT Boost to the tumor bed.
21 Investigations Hematology Biochemistry Chest X- ray Bilateral mammograms Liver scan Radio-nuclide bone scan
22 Demography Age (median, range) Parity (median, range) 44, years 3, 0 10 children Menstrual status Premenopausal : 72% Postmenopausal : 28% Histopathology Infiltrating duct Ca. : 94% Colloid Ca. : 3% Squamous Ca. : 3%
23 Tumor and nodal stages Tumor stage Nodal stage Total N0 (none) N1 (mobile) Tx / Tis T1 (<2cm) T2 (2-5cm) Total
24 ER and PR receptor status Estrogen receptor (ER) Progesterone receptor (PR) Positive Negative NA Total Positive Negative NA Total
25 Interventions Surgery Lumpectomy + Axillary Clearance : 34 Revision excision : 2 Radiotherapy External beam : 45 50Gy : 36 Boost: Gy : 33 No boost / yet to commence : 3 Chemotherapy CMF / FAC / FACV : 34 None / did not follow up : 2 Hormonal Tamoxifen / others : 33 None : 1 To commence : 2
26 Treatment portals in teletherapy
27 Skin reactions Grade I ( Erythema ) 0 Grade II ( Dry Desquamation ) 22 (61%) Grade III ( Moist Desquamation ) 14 (39%) Grade IV ( Necrosis) 0
28
29 Boost to Primary site Treatment volume May be per-operative or post-operative Techniques: Interstitial brachytherapy Electron beam Telecobalt Brachytherapy preferred for Large breast and deep tumours Positive margins, pathological risk factors, not undergoing re-excision
30 Boost to Primary site Treatment volume localization Target volume depends on margins Usually entire quadrant, 3cm margin for electrons Localized by Preoperative mammograms Surgical clips Ultrasound of the postoperative breast
31 Preoperative mammogram
32 Per-operative implant Lumpectomy + axillary dissection
33 Perop brachytherapy
34 Post implant imaging
35 Dosimetry
36 Tumor bed localization post op
37 Some issues in tumor bed boost When performing a per-op implant Direct visualization of tumor bed One anaesthetic procedure No information on status of margins of excision When performing a post-op implant Special effort to localize the tumor bed May optimise dose of boost Extra procedure
38 Margins of excision Variable Margins + Margins - P value Age (mean, SD) 42.9, , Menopause Pre 7 (27%) 19 (73%) 0.67 Post 2 (20%) 8 (80%) T stage Tx 1 (20%) 4 (80%) T1 0 5 (100%) 0.33 T2 8 (31%) 18 (69%) N stage N (100%) 0.00 N1 9 (45%) 11 (55%) Breast recurrences None 9 (27%) 24 (73%) 0.56 Present 0 3 (100%)
39 Interstitial Implant (75%) Boost technique and doses Technique No. Dose (Gy) Per operative 11 Post operative External RT (17%) (Co-60 / Electrons ) No Boost (8%) 3 0
40 Author Boost to Primary site Treatment Techniques % Recurrence External RT Ir 192 Electron Clark Veronesi Chauvet Gerard Vicini Triedman Pezner Van Limbergen
41 Cosmesis Influencing Factors Type of breast surgery and extent of resection Scar orientation Radiotherapy treatment volume Radiotherapy dose and fractionation Type of boost (?) Use of adjuvant chemotherapy
42 Local disease free survival Projected 5 year result 81% Local disease free survival
43 Local Failure - reasons Local recurrence at 16 months, dead of distant metastasis at 30 months Local recurrence at 41 months, dead of distant metastasis at 45 months Scar and axillary recurrence in a squamous cell cancer at 37 months, no further treatment due to financial constraints.
44 Distant disease free survival Projected 5 year result 71% Distant disease free survival (months)
45 Distant failure - reasons Local + distant failure (ascitis and liver metastasis) - dead Malignant ascitis at 37 months - dead Distant failure in contra lateral breast, axilla, supra clavicular fossa and liver at about 45 months dead Brain metastasis at 6 months, dead at 30 months Supra clavicular fossa recurrance at 24 months, salvaged with chemotherapy and RT, alive at 36 months
46 Overall survival Projected 5 year result 74% Overall survival (months)
47 Invasive Early Breast Cancers Randomized trials Group Pts. Stage Surgery Adjuv. Local Recurrence Treat CS &RT Mast. EORTC 874 I - II LE, MRM CMF 9% 8% DBCG 904 I - III WE, Q, CMF, 4% 3% MRM T NCI 237 I - II LE, MRM AC 19% 6% NSABP 1219 I - II WE, MRM Melph, 5 FU 10% 8% IGR 179 I - II WE, None 9% 7% MRM Milan 701 I Q, RM CMF 6% 2% SGPGI 36 I - II WE CMF 8% -
48 Invasive Early Breast Cancers Randomized trials Group Regional Failure Distant Failure DFS ( 10yr) CS &RT Mast. CS &RT Mast. CS &RT Mast. EORTC <1% <1% %* 71%* DBCG 2% 2% 13% 14% 70% 66% NCI % 76% NSABP 4% 4% 23% 19% 55% 55% IGR 1% 5% 26% 27% 69% 60% Milan 2% 3% 16% 21% 77% 76% SGPGI 6% 14% 70% (5yr)
49 Invasive Early Breast Cancers Impressions from Randomized trials No sign. difference in all major end points Cosmesis : Good to excellent with breast conservative therapy Milan trial: 10 yr.. DFS better in node +ve with BCT + RT ( 71% Vs 57%, p=0.03) Similar incidence of contralateral breast cancers and 2nd non breast malignancies
50 Breast conservation with limited surgery + Radiotherapy is a viable option for Early Stage Breast cancer
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