Breast Conservation Treatment

Breast Conservation Treatment

• 1.
  Breast Conservation Surgery DrSushanth Nayak
• 2.
  History • In 70sFischer’s hypothesis- Breast cancer is a systemic disease- thus treatment of carcinoma breast depends on the systemic dissemination before detection. This led to change in treatment of Ca breast- Less radical surgery equivalent to Radical mastectomy with less physical and psychological morbidity. • In 1972 MRM (Madden-Auchincloss) was published
• 3.
  •Next step -Conservative surgery for breast cancer (lumpectomy with axillary lymph node dissection followed by radiation therapy to the breast). •Pioneers of this technique Fisher in America and Veronesi in Italy. •Conservative treatment of the breast appropriate for breast cancer patients with stage I and II :- National Institutes of Health Consensus Conference in 1991
• 4.
  •In 1992, Morton-another step to a less radical approach •Implementation of axillary sentinel node biopsy •The aim of local treatment of breast cancer is to achieve long-term local disease control with the minimum of local morbidity.
• 5.
  Breast Conservation Surgeryis defined as the complete removal of the tumour with a concentric margin of surrounding healthy tissue with maintenance of acceptable cosmesis, and should be followed by radiation therapy to achieve an acceptably low rate of local recurrence.
• 6.
  Major advantages ofBCS- •Produces an acceptable cosmetic appearance in the majority of women. •Lower levels of psychological morbidity with less anxiety, depression, •Improved body image, sexuality, and self-esteem than mastectomy. •Equivalence in terms of disease outcome for BCT and mastectomy
• 7.
  • INDICATIONS ANDCONTRAINDICATIONS TO BREAST CONSERVING SURGERY
• 8.
  • Oncoplastic techniquesto be considered if 1. Significant area of skin to be resected with tumor 2. Large volume resection is expected 3. Tumor is in the area with poor cosmetic outcomes(e.g-lower hemisphere below nipple) OR 4. Resection may lead to nipple malposition
• 9.
  Extent of breastresection- • it is the ratio of anticipated defect to the volume of remaining breast parenchyma • Oncoplastic surgery to be considered if defect likely to be greater than20to 30% of breast volume and for any tumor resection in lower breast Breast size and body habitus- • Patients with larger breasts- good candidates for reduction mammoplasty • Obese patients are considered for this approach • Breast reduction surgery – good option- relieves symptoms of macromastia and give improved outcome after breast irradiation.
• 10.
  Tumor location- Tumorslying directly under NAC or located between NAC and infra-mammary fold require special attention Skin and well vascularised tissue must be approximated properly in this area as deformities in contour will be exacerbated by radiation Timing of Oncoplastic surgery-reconstruction of irradiated breast not recommended after 1-2 yrs of RT In irradiated tissue- higher rates of seroma ,infection ,necrosis Surgical procedures on irradiated breasts should be minimized as healing and recovery are impaired.
• 11.
  • Patient selection-Previously influenced by clinical and pathological factors including- 1. Younger age <35 to 39 2. Extensive in situ component with invasive tumor 3. Grade III on histology 4. Wide spread lymphatic or vascular invasion 5. Young women with strong family history or carriers of BRCA1 and BRCA2 6. Pregnancy – 1 in 3000
• 12.
  •Breast cancers diagnosedamong BRCA1 mutation were significantly more likely to be larger have higher histological grade have negative ER,PR status than in BRCA2 mutations
• 13.
  PREOPERATIVE PLANNING •Decisions BestBased On Imaging •Careful Clinical Examination •Mass Should Be Measured Accurately And Recorded •Ultrasound Of The Whole Breast Is Recommended •Ultrasound-guided Fine-needle Aspiration Biopsy Or Core Biopsy •Patient’s Imaging Should Be Inspected Before Operation
• 14.
  Patient is informedabout 1. 35 % chance of not clearing the disease after BCS 2. May require re-excision or mastectomy to obtain clear margins and excise all disease 3. Common complications such as bleeding, infections , scar, healing issues , frequently seromas
• 15.
  Two breast-conservation surgicalprocedures have been studied extensively 1. Quadrantectomy 2. Wide local excision
• 16.
  Quadrantectomy- • Breast isorganized into segments and each segment drains into major duct and invasive cancer spreads along duct system towards nipple. • According to studies both invasive and non invasive cancers spread towards nipple than any direction • Quadrantectomy is no longer advocated • The majority of patients having BCT can be adequately treated by wide local excision under GA or LA with or without sedation.
• 17.
  • Incisions – Importantto place the incision in a proper position Scar placed along kraissl lines– best cosmetic results, Circumareolar incisions heal well Radial incisions in the upper outer quadrant-worst cosmetic results Radiation reduces the rate of hypertrophic scars-More satisfactory results Submammary, circumareolar, and axillary incisions, are used as they produce the best cosmetic outcomes
• 18.
  • Excision oftumour- Tumour to be excised with 1 cm safety margin Small defects (<5% breast volume) can be left open- Good cosmetic result Larger defects require mobilization of surrounding breast tissue from overlying skin and subcutaneous tissue Fatty breasts produce poor final result as cannot be sutured properly whereas dense fibrous tissue can do so Also fibrous tissues heal well Drains not to be used frequently- not effective and increase infection rate Breast skin wound to be closed in layers with final layer of sub-cuticular sutures ,no interrupted sutures or staples used
• 19.
  • Techniques ofexcising central tumor Nipple to be removed if lesion is closed to nipple and or if there is tethering/inversion/invasion of nipple Pro –op biopsy from duct required to preserve nipple Women with large breasts – NAC can be incorporated in wedge mammoplasty incision and lesion excised in continuity with nipple/areolar skin –acceptable results Alternatively removal of lesion with removal of NAC with underlying breast tissue with defect reconstruction with skin and rotation flap.
• 21.
  TECHNIQUE OF EXCISINGIMPALPABLE CANCERS • Localization of impalpable lesions- with skin marking, injection of blue dye, carbon, or radioisotope, radioactive seed, or insertion of a hook wire with post localization mammograms or use of intraoperative ultrasound.
• 26.
  BREAST-CONSERVING SURGERY AFTERNEOADJUVANT THERAPY • Large and locally advanced breast cancers are treated with neoadjuvant chemotherapy and then become suitable for BCS The aim of BCS after NAC- • Excise any palpable disease or disease marked by calcifications or visible on imaging • surgery should focus on what is left, not what was present at diagnosis • Limit the surgery to the disease visible on imaging or palpable at surgery.
• 27.
  POSTOPERATIVE COMPLICATIONS • Complicationsof wide excision- bleeding , hematoma formation, infection, incomplete excision, and poor cosmetic results. • Common problem following BCS is a poor cosmetic result • the volume of resected breast tissue -important factor affecting cosmesis • inferior cosmetic results obtained with quadrantectomy
• 28.
  • Factors Resultingin Poor Cosmetic Outcome After Breast- Conserving Surgery-
• 29.
  •Excisions less than10% of breast volume-good cosmetic result •>10% resection – poor cosmetic result
• 30.
  INDICATIONS FOR REEXCISION •Patientswith a positive radial (medial, lateral, superior, or inferior) margin for DCIS •Pleomorphic LCIS •Patients with a positive anterior or posterior margin do not require reexcision if full thickness of breast tissue has been taken and a radiotherapy is given
• 31.
  RECURRENCE AFTER BREAST-CONSERVINGSURGERY • Rates vary widely between different centers but nowadays should be less than 0.5% per annum • Factors that affect local recurrence rates after BCT can be divided into 1. Patient, 2. Tumor, 3. Treatment-related factors.
• 32.
  1.Patient-Related Factors- • Inbreast tumor recurrence (IBTR) after BCT can be either true recurrence or second primary(elsewhere in breast) • Common in younger patients and less common in old >65 years age • Reson for local recurrence may be due to Family history of breast cancer carriage of one of known breast cancer predisposing gene associated with increased rate.
• 33.
  2.Tumor-Related Factors Tumor Grade-Grade 1 tumors have the lowest rates • higher recurrence rate in grade 3 compared with grade 2 cancers • Relative risk between grade 1 and grade 2 and 3 is 1.5 Histologic Type- invasive lobular cancer- low rates • invasive ductal carcinoma- higher rates Lymphatic/Vascular Invasion- LVI is a marker for recurrence after mastectomy • Extensive In Situ Component- If clear margins are obtained, there appears to be no increased rate of local recurrence
• 34.
  • Multiple Tumors-Multisitedisease may be associated with a small increase in the risk of local recurrence, but is no longer a contraindication to breast conservation • Tumor Size - not considered important in relation to local recurrences • Other Factors-Tumor location, the presence of skin or nipple retraction, the presence or absence of axillary node involvement, and hormone receptor status of the cancer have not been consistently shown to exert any influence on breast recurrence after BCT.
• 35.
  3.Treatment-Related Factors • Completenessof excision and the use of systemic therapy and appropriate doses of radiotherapy- most important • Margin index to determine whether reexcision is required • Margin index is defined as the margin in millimetres multiplied by 100, divided by the tumor size in millimeters. • When the index is ≥5, residual disease is present in less than 3% of Reexcisions • bigger the tumor the bigger the margin needed • Adjuvant tamoxifen, chemotherapy, and trastuzumab all reduce local recurrence after BCT. • rates of local recurrence are increased if radiotherapy or systemic therapy is delayed for many months.
• 36.
  Components of BCT 1.Lumpectomy ( wide local excision or Quadrantectomy) 2. Axillary Dissection 3. Radiotherapy
• 37.
  Axillary Dissection • Aimof axillary surgery 1. To stage the axilla by SLNB 2. To treat any axillary disease by axillary clearance / axillary dissection. • Indications for axillary dissection: 1. Histologically proven involved axillary lymph nodes after ultrasound-guided fine-needle aspiration biopsy/core biopsy 2. After sentinel node biopsy.
• 38.
  MANAGEMENT OF THEINVOLVED AXILLA 1. Axillary dissection 2. Axillary radiotherapy • A randomized trial AMAROS (After Mapping of the Axilla: Radiotherapy Or Surgery) showed after an average of 6.1 years an axillary recurrence rate of 0.43% after axillary lymph node dissection versus 1.19% after axillary radiotherapy (n = 681). • There was no difference in disease-free or overall survival but an approximate doubling of the lymphoedema rates for lymph node dissection compared with axillary radiotherapy.
• 39.
  Sentinel lymph nodebiopsy (SLNB): • The first axillary node draining the breast (by direct drainage) is designated as the sentinel node (SLN). • SLN is first node involved by tumour cells. • its histological involvement, will give a predictive idea about the further spread of tumour to other nodes. • The incidence of involvement of other nodes without SLN is less than 3% and so if SLNB is negative nodal dissection can be avoided but regular follow-up is needed. • SLNB is done in all cases of early breast cancers, T1 and T2 without clinically palpable node.
• 40.
  • C/I: 1. Clinicallypalpable axillary 2. Multifocal and multicentric tumours 3. Allergic to vital blue dye or radio-colloid 4. In pregnancy 5. In inflammatory carcinoma of breast. • Tracer to identify sentinel nodes can be injected into 1. The subareolar region, 2. Intradermally 3. Peri-tumoral • Injection into skin can allow visualization of lymphatic channels, which may aid sentinel lymph node identification. • Subareolar injection of tracer has advantages over peritumoral injection in patients with multisite or nonpalpable cancers.
• 42.
  •Localisation of Sentinelnode is by 1. Preoperative (Within 12 hours Prior) Or Peri Operative Injection Of Patent Blue (Isosulfan Vital Blue Dye 2.5-7.5 Ml) 2. 99m Tc Radioisotope Labelled Albumin (One Mci On Previous Day) 3. Sulphur Colloid (6 Hours Before) Near The Tumour (Peritumour Area) Or Into Subdermal Plexus Around The Nipple. • Marker will pass through the sentinel node which can be visually detected as blue staining or with a hand held gamma camera • Further, biopsied with a small incision made directly over it. Frozen section biopsy or touch imprint cytology is done for presence of malignant cells.
• 43.
  • If thereis no involvement of sentinel node by tumour then further axillary dissection is not required. • Detection rate of sentinel node for blue dye and radioisotope is 90% and 98%, respectively. • Subdermal/subareolar injection of radioisotope has got better sentinel node localisation than peritumour injection. • But better imaging is obtained by peritumour injection and so Peritumour injection is usually practiced. • Radioisotope tracer injection done in the early morning of the day of surgery into peritumour area and perioperative injection of patent blue dye in subareolar region—as a combined method is often used in many centers.
• 44.
  • After injectionof patent blue, breast is massaged continuously to enhance the uptake. • Incision is made after 5-7 minutes between pectoralis major and latissimus dorsi to identify blue stained lymphatics . • The blue stained lymphatics are traced to 2-3 blue lymph nodes. • Hand-held radioprobe is used to identify the sentinel node which is later excised. • Often 2-3 nodes are removed. • Paraffin section histology is better than frozen section to identify positive sentinel lymph node. • If report comes negative immunohistochemistry test is done to confirm that lymph node is negative for tumour
• 45.
  • Sentinel lymphnode biopsy should be done before wide local excision of the primary tumour. • Wide local excision of the primary tumour is done after SLNB in the same sitting. • SLNB is less invasive than axillary dissection. • It is ideal in early invasive carcinoma. • Positive SLNB is again classified as MACROMETASTASIS (> 2 mm) or MICROMETASTASIS (< 2 mm). • Complications: 1. Blue tattooing of skin which gradually fades; 2. Blue—green urine and stool for short period; 3. Allergic reactions; 4. Anaphylaxis (0.1%); 5. Seroma formation
• 46.
  AXILLARY LYMPH NODEDISSECTION (ALND) • Indications: 1. The clinically node-positive axilla, confirmed by fine needle aspiration or core biopsy, in a patient for whom neoadjuvant chemotherapy is not planned. 2. Occult breast cancer presenting as axillary node metastasis. 3. SLN positive 4. Inflammatory breast cancer. 5. Failed SLN mapping. 6. Inadequate prior ALND with residual clinically suspicious nodes 7. Sentinel or axillary nodes which remain positive after neoadjuvant chemotherapy. 8. Axillary recurrence following previous breast cancer treatment
• 47.
  • The surgicalprocedure includes : clearance of node-bearing tissue between the pectoralis major and latissimus dorsi muscles from the edge of the breast tissue in the low axillary region to the axillary vein and removal of the nodes posterior to the pectoralis minor muscle. • Axillary dissection is the main source of morbidity in patients with early-stage breast cancer. • The immediate Complications: 1. Include acute pain and paresthesias, 2. Need for hospitalization, 3. Reduced range of motion at the shoulder joint, 4. Need for a drain in the surgical bed for 2 weeks or more. • Long-term Complications: 1. Axillary dissection include lymphedema of the ipsilateral arm 2. Numbness 3. Chronic pain 4. Reduced range of motion at the shoulder joint.
• 48.
  SLND vs ALND •Morbidity rates SLND < ALND. • SLND can be performed as an outpatient procedure and does not require a drain. • Patients have more rapid return to full mobility and are able to return to work and other activities weeks sooner than after axillary dissection. • Long-term morbidity, including lymphedema, numbness, and chronic pain, is greatly reduced. • SLND has been shown to provide reliable pathologic staging of the axilla, with false-negative rates generally less than 5% in experienced hands. • Axillary recurrence rates have been shown to be extremely low after a negative sentinel node biopsy without axillary dissection. • A negative sentinel node is now widely accepted as sufficient to establish node-negative disease in a patient, with no further axillary treatment required.
• 49.
  • Although ALND(achieved with a completion level I and II axillary dissection) has been standard practice for patients with positive sentinel nodes, the need for ALND in all patients with a positive sentinel node has been called into question because many patients have small-volume metastases, and the sentinel node is often the only positive node. • A metaanalysis of studies evaluating patients with positive sentinel nodes showed that 53% of patients have additional positive nodes at ALND. • In the case of micrometastatic disease in the sentinel nodes, the rate of nonsentinel node involvement is 20%, and isolated tumor cells, it is less than 12%. These findings led of omitting ALND in selected patients with positive sentinel nodes.
• 50.
  • The resultsof the ACOSOG Z0011 study have changed treatment practices. • It is now widely believed that ALND may be safely omitted in selected patients • with clinically node-negative disease who have a positive sentinel node and are similar to the participants in the Z0011 a (i.e. >2 SLN positive, matted nodes, mastectomy, or breast conservation without whole-breast RT) • However , ALND remains the standard of care for patients 1. With Locally Advanced Breast Cancer 2. Inflammatory Breast Cancer, 3. Patients With A Positive sentinel node who are scheduled for mastectomy, 4. Patients With A positive sentinel node who are scheduled for accelerated partial breast irradiation 5. Patients With A positive sentinel node after neoadjuvant chemotherapy.
• 51.
  RT is amust after conservation of breast. • Local as well as to axilla. • Tangential fields 50 Gy/25 fractions/5 weeks. • Another 10 Gy to tumour bed. • Internal mammary and supraclavicular area may be included in radiation field. Radiation Therapy
• 52.
  Radiation Therapy AfterBreast-Conserving Surgery • For patients with invasive breast cancer treated with breast conserving surgery, adjuvant irradiation of the breast has been conclusively demonstrated to reduce the probability of a breast recurrence and improve outcome. • A meta-analysis of data from 7300 women who participated in a randomized trials of breast-conserving surgery with or without radiation therapy. In this analysis, radiation was found to reduce the 10-year rate of in-breast recurrence from 29% to 10% for patients with negative lymph nodes and from 47% to 13% for patients with positive lymph nodes. • This improvement in local control led to a reduction in the 15-year breast cancer mortality rate and overall death rate • The only group identified that might be able • to avoid irradiation safely is patients older than 70 years who • undergo lumpectomy and adjuvant hormonal therapy for a stage I ER-positive breast cancer.
• 53.
  • Radiation therapyafter lumpectomy has consisted of a 6- to 8-week treatment course, which can be a hardship for patients. • An important Canadian trial ,On the basis of long-term outcome results ,it is reasonable to treat a postmenopausal patient with a non–high-grade, ER-positive, stage I breast cancer with a 16-fraction course of treatment, which shortens the overall treatment time to approximately 3 weeks. • There has also been significant interest in shortening the treatment course to 1 week or less through an approach that focuses the radiation exclusively on the area around the tumor bed, called partial breast irradiation may be performed with brachytherapy catheters, balloon catheters, or external-beam radiation.
• 54.
  FOLLOW-UP • Regular clinicalexamination after BCS or mastectomy has not been shown to be of value. • Patients should be seen for 1 to 2 years to check the wound has healed and the cosmetic result is acceptable. • Defects at the site of wide excision can be improved with lipofilling or lipomodelling. • There is evidence that annual mammography is cost-effective and worthwhile. • Regular MRI screening in younger women and women whose cancer was not visible on mammography also appears cost- effective.
• 55.
  THANK YOU