Ines Buccimazza 16 TH UP CONTROVERSIES AND PROBLEMS IN SURGERY SYMPOSIUM
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1 BILATERAL MASTECTOMY IS NOT ROUTINELY JUSTIFIED IN PATIENTS WITH BILATERAL AXILLARY LYMPHADENOPATHY AND ONLY ONE DETECTABLE PRIMARY BREAST CANCER LESION SURGERY SYMPOSIUM Ines Buccimazza Breast Unit Department of Surgery Nelson R. Mandela School of Medicine University of KwaZulu-Natal Durban
2 To do or not to do Bilateral mastectomy for the treatment of bilateral axillary lymphadenopathy but detectable primary lesion in only one breast that is the question But what is the answer?
3 INTRODUCTION Contralateral axillary involvement Systemic disease (M1) Stage IV Regional metastasis (T0N1) Stage II Uncertain laterality Complicates staging Management dilemma Systematic evaluation
4 BREAST LYMPHATIC DRAINAGE Ipsilateral axilla Extra-axillary areas: 25% Contralateral axilla: 2 routes Alternate routes of drainage Blockage/ damage Physiological alternative CAM: lymphatic spread
5 Occult primary BC INCIDENCE 1% operable breast cancer 75% detected by conventional imaging Contralateral axillary metastasis (CAM) Recent study Excluded other systemic metastasis; used MRI Synchronous and metachronous CAM: 1.9% (Morcos et al, EJSO, 37: 2011)
6 Clinical assessment APPROACH Contralateral breast Other organs Pathological proof Malignant nodal involvement further evaluation Radiological evaluation Occult contralateral 1 breast cancer
7 APPROACH: PATHOLOGY Ultrasound-guided FNAC Atypical or malignant cells Ultrasound-guided CNB Confirm origin of metastasis Breast or other adenocarcinomas Prognostic and predictive markers Difference: occult c/l 1 Concordance: synchronous CAM
8 APPROACH: IMAGING Occult contralateral 1 breast cancer Invasive lobular carcinoma Hereditary breast cancer Different biomarkers Review MMG and US Additional MMG views Repeat US MRI Detect 70% lesions evading conventional imaging
9 TREATMENT Occult breast primary Lesion identified and localised Breast conservation + ALND Mastectomy Adjuvant therapy Not identified: microscopic disease Mastectomy (20% yield) ALND + Radiotherapy (whole breast) Good local control
10 TREATMENT Contralateral axillary metastasis Aggressive 1 tumours; poor pathological features High grade; LVI Hormone receptor negative; Her-2 overexpressing Management complex No clear guidelines Treatment individualized Options: surgery, systemic therapy
11 TREATMENT CAM and other metastatic sites Systemic treatment Axillary dissection selectively Local control Palliation
12 TREATMENT CAM as only site of metastasis Contralateral axillary dissection Who? Early stage tumours No response to systemic therapy (C/L nodes) Why? Excellent axillary control; no axillary recurrences Long-term DFS and cure? Unknown
13 TREATMENT CAM as only site of metastasis Contralateral mastectomy Not routinely indicated Who? Different pathology Hereditary breast cancer
14 TREATMENT CAM as only site of metastasis Systemic therapy Who? Locally advanced/ aggressive tumours Why? High risk distant metastases Response to treatment monitored What? Endocrine therapy: 1 st line hormone receptor positive Chemotherapy: Hormone receptor negative; no response Trastuzumab: HER-2 overexpression
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17 CONCLUSION Contralateral axillary involvement rare Systematic approach Regional metastasis or systemic disease Synchronous occult c/l 1 Treated on own merits BCT option
18 CONCLUSION CAM Management individualized CAM only metastasis Axillary dissection Early stage disease No response to systemic therapy Palliation Mastectomy: specific indications
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