Spotlights on the surgery role at San Antonio Riccardo Masetti, MD Professor of Surgery Director, Multidisciplinary Breast Center Catholic University Rome, Italy
Roma, 21 maggio 2017
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
San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
APPROPRIATE SURGICAL MARGINS
APPROPRIATE SURGICAL MARGINS CURRENT SSO/ASTRO GUIDELINES ON MARGINS: Moran et al, 2014 appropriate margin: NO TUMOR ON INK Is this correct?
APPROPRIATE SURGICAL MARGINS New meta-analysis Systematic review of the literature (1995-2016) 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
APPROPRIATE SURGICAL MARGINS New meta-analysis 55.302 patients (>20.000 additional patients from previous meta-analysis 7.2 years median follow-up F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
APPROPRIATE SURGICAL MARGINS Odds Ratio for Local Recurrence by margin Status Positive vs Negative; 2.49 (2.10-2.96) Close vs Negative: 1.58 (1.32-1.89) 2 mm vs 1 mm 0.50 (0.42-0.59) 5 mm vs 1 mm 0.40 (033-0.48) F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
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
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 15.102 PATIENTS STATISTICS COMPARING LVOS VS TRADITIONAL BCS M. Jonczyk et al Tufts Medical Center - Boston Hospital and Academic Medical Center
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: 0.036 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
San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Margins Locoregional recurrence Axillary management Local therapy in ABC
LOCOREGIONAL RECURRENCE
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
REPEAT LUMPECTOMY FOR IBTR M. Morrow Memorial Sloan Kettering Cancer Center
REPEAT LUMPECTOMY FOR IBTR Good results only in low risk patients (ER+, HER2-, initial negative margins)
REPEAT LUMPECTOMY FOR IBTR Not the standard of care Reported high rates of additional LR M. Morrow Memorial Sloan Kettering Cancer Center
REPEAT LUMPECTOMY FOR IBTR M. Morrow Memorial Sloan Kettering Cancer Center
LOCOREGIONAL RECURRENCE Nothing new as compared to NCCN 2017 guidelines!!
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
REOPERATIVE SENTINEL NODE BIOPSY M. Morrow Memorial Sloan Kettering Cancer Center
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
San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
SNB IN EARLY BREAST CANCER
SNB IN EARLY BREAST CANCER
SNB IN EARLY BREAST CANCER MICROMETASTATIC SLN V. Galimberti IEO, Milan
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
SNB IN EARLY BREAST CANCER MICROMETASTATIC SLN Arms characteristics well matched V. Galimberti IEO, Milan
SNB IN EARLY BREAST CANCER Appropriate balance of adiuvant therapies V. Galimberti IEO, Milan
SNB IN EARLY BREAST CANCER 10 years results V. Galimberti IEO, Milan
SNB IN EARLY BREAST CANCER Low incidence of axillary events disregarding type of surgery V. Galimberti IEO, Milan
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
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
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
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
SNB AFTER NEOADJUVANT TREATMENT SLNB procedure of choice for axillary stadiation T. King Dana Farber / Brigham and women s - Harvard medical school
SNB AFTER NEOADJUVANT TREATMENT FEASIBILITY OF SLNB AFTER NAD T. King Dana Farber / Brigham and women s - Harvard medical school
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
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
SNB AFTER NEOADJUVANT TREATMENT INTERPRETATION OF SLNB AFTER NAD T. King Dana Farber / Brigham and women s - Harvard medical school
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
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
SNB AFTER NEOADJUVANT TREATMENT ypn+ PATIENTS Clear indication for ALND T. King Dana Farber / Brigham and women s - Harvard medical school
SNB AFTER NEOADJUVANT TREATMENT Waiting for more studies for stronger recomendations
AXILLARY TREATMENT COMPLICATIONS
AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
AXILLARY TREATMENT COMPLICATIONS A. Kuijer Dana Farber / Brigham and women s - Harvard medical school
San Antonio Breast Cancer Symposium, 12/2017 Spotlights on surgical issues: Appropriate surgical margins Locoregional recurrence Axillary management Local therapy in ABC
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT S. Khan Lynn Sage Breast Center & Dept of Surgery - Northwestern University
THANK YOU!