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Evaluation, Surgical Treatment, and Post-Treatment Surveillance of
Early Stage Breast Cancer: National Guidelines
Deanna J. Attai, MD, FACSAssistant Clinical Professor of Surgery
David Geffen School of Medicine at UCLA
No Financial Disclosures
Breast Cancer Statistics
•Most common type of cancer among women (excluding skin cancer)
•Second most common cause of cancer deaths among women
•1 in 8 women, 1 in 1000 men •Women: 200,000 new cases, 40,000 deaths/year•Men: 2360 new cases, 450 deaths/year
• Incidence and survival vary depending on race, ethnicity, socio-economic status
Breast Cancer Staging
•Stage 0 – Ductal carcinoma in-situ / DCIS
•Stage I – Tumor <2cm, negative lymph nodes•Stage II – Tumor 2-5cm OR spread to lymph nodes
•Stage III – Tumor >5cm, OR fixed to skin / muscle, OR matted nodes, OR internal mammary nodes
•Stage IV – Metastatic disease (liver, lung, bone, brain most common)
Preoperative Workup
• History and physical exam• CBC, platelets, LFT, AlkPhos• Diagnostic bilateral mammogram, consider ultrasound• MRI optional• Pathology review, ER/PR and Her2/neu status• Genetic counseling if at risk for hereditary cancer• Fertility counseling if premenopausal• Assess for psychological distress
Preoperative Workup
•For clinical stage I-IIB additional studies ONLY if directed by signs/symptoms:
•Bone scan localized bone pain or AlkPhos•Abdomen/pelvis CT, MRI, PET/CT elevated LFT, abdominal symptoms, abnormal PE
•Chest CT pulmonary symptoms
•Tumor markers NOT recommended
Team Approach
Breast Cancer Surgery
• First described 1500s• General Anesthesia 1840s• Halsted Radical Mastectomy:
1894-1960-70’s
• Halsted died in 1922
CANCER
LYMPH NODE
FISHER THEORY
LUNGS
LIVER
BONE
BLOOD STREAM
Dr. Bernard FisherNSABP B04 Enrollment 1971-1974
www.NSABP.edu
Fisher B et al. N Engl J Med 2002;347:567-575.
NSABP B04 Results
• Preservation of the pectoral muscle new standard of care• 2 step procedure should be performed
NSABP B06 Enrollment 1976-1984
www.NSABP.edu
NSABP B06 Results
Fisher, et al N Engl J Med,Vol. 347, No. 16 · October 17, 2002
NSABP B06 Results
• No difference in survival at 20 years
• Lumpectomy without postoperative irradiation higher local recurrence 39.2% vs. 14.3%
• BCS New standard of care for Stage I/II
Fisher, et al N Engl J MedVol. 347, No. 16 · October 17, 2002
Breast Surgery
• May need re-evaluation due to national increase in mastectomy rates for early stage breast cancer
• NCCN does not indicate preference for surgery
Surgical Technique
“The NCCN panel accepts ‘no ink on tumor’ from the 2014 SSO-ASTRO Consensus Guideline on Margins”
Surgical Margins
Surgical Margins
“The ASCO review panel endorses the SSO/ASTRO recommendations with qualifications… reinforces and amplifies the guideline authors’ call for the monitoring of outcomes at the institutional level”
Importance of Axillary Lymph Node Status
• Node status determines stage, predicts outcome• Node status influences adjuvant therapy decisions:
- Chemotherapy, anti-estrogen therapy- Drug choice, dose, combination- Radiation therapy
• Positive nodes in ~ 5-30% clinical stage I & II patients• High rate of lymphedema, paresthesias, shoulder
dysfunction. No benefit in node-negative patients
History of Axillary Lymphadenectomy
• Petit 1774 • Pancoast 1884 • Halsted 1895 • Patey 1948 • Krag, Morton, Giuliano, Tafra, Ross, Reintgen, 1990s
- Sentinel Node
Development and Validation of Sentinel Node Biopsy Technique• Morton, D, et al. Technical Details of Intraoperative Lymphatic Mapping for Early Stage Melanoma Arch Surg. 1992;127(4):392-399
• Krag DN, et al. Surgical resection and radiolocalization of the sentinel lymph
node in breast cancer using a gamma probe. Surg Oncol 1993;2:335-339
• Giuliano AE, et al.Lymphatic mapping and sentinel lymphadenectomy for breast
cancer. Ann Surg 1994;220:391
Sentinel Lymph Node Dissection
Sentinel Node BiopsyNSABP B32; Enrollment 1999-2004
Mamounas, EP Clin Med Resv.1(4); 2003 Oct
NSABP B32 Results• 5,611 patients, 80 sites, 232 surgeons• SN Identification rate 97%• 26% had positive node• 9.7% false negative rate; less common with >1SN, more
common if excisional biopsy performed first• OS, DFS, Regional Control statistically equivalent
• SNB alone is safe, appropriate, and effective in patients with clinically negative nodes
• Lumpectomy AND mastectomy patients
Positive Sentinel Node (891 patients)Axillary
Dissection (445)
No axillary
Dissection (446)
Positive Sentinel NodeACOSOG Z0011 Trial
• No difference in OS or DFS• 70% vs. 25% wound infections, axillary seromas, paresthesias• Lymphedema 13% vs. 2%; longer term after SNB 5-8%
Giuliano AE, et alJAMA 2011;305:569-75
ACOSOG Z0011 Change in Practice
Breast Conservation Patients•No intraoperative frozen section•No ALND if 1-2 positive nodes
Other Patient Populations?•Mastectomy, APBI, Neoadjuvant Therapy•AMAROS Trial - Radiation shown to be as effective as AXND, lower morbidity
Surgical Axillary Staging
Surgical Axillary Staging
• Women without SLN metastasis should not receive ALND• Women with 1-2 metastatic SLNs planning to undergo breast
conserving surgery with WBR should not undergo ALND
Surgical Axillary Staging
• Sentinel node biopsy for Stage I-II patients• NCCN includes Stage IIIA• Lumpectomy and mastectomy
Immediate Reconstruction•Most patients are a candidate unless locally advanced or inflammatory cancer
• Implant or free flap (fat and skin); less commonly muscle flap used
•Skin-sparing / NAC-sparing mastectomy with reconstruction can result in minimal scarring
•Collaboration with breast surgeon, plastic surgeon, medical oncologist, and radiation oncologist is crucial for optimal results
Federal Legislation
•Women’s Health and Cancer Rights Act of 1998
• Insurers who cover medical / surgical treatment for breast cancer must cover:
• Ipsilateral mastectomy reconstruction•Surgery / reconstruction of other breast for symmetry•Prostheses and lymphedema management
32
Reconstructive Surgery
Reconstructive Surgery
• All women should be educated about reconstructive options • Oncoplastic techniques can increase breast conservation• NAC-sparing may be an option in patients who are carefully
selected by experienced multidisciplinary teams
Reconstructive Surgery Options
• Tissue expander -> Implant• Direct to implant• Latissimus flap• Free flap (DIEP and others)• Oncoplastic reconstruction • Fat grafting after lumpectomy or mastectomy
35
Nipple Sparing Mastectomy
36
Target enrollment: 2000 cases
NSM / Implant
37
NSM / DIEP
38
Lumpectomy / Oncoplastic Reduction
39
Post-treatment Surveillance
Post-treatment Surveillance
• Regular history, PE and mammography recommended• Physical exam
• q 3-6 months x 3 years• q 6-12 months years 4-5• Annual after year 5
• Breast conserving surgery• Post-treatment mammogram no earlier than 6 months after radiation, or at 1 year after initial study
• Resume annual imaging unless otherwise indicated
Post-Treatment Surveillance
•NOT RECOMMENDED for asymptomatic patients:•CBC, chemistry panels, LFTs•Tumor markers CEA, CA 15.3, CA 27.29•Breast MRI•Chest x-ray•Liver ultrasound•Pelvic ultrasound•Chest / Abdomen / Pelvis CT, MRI, PET/CT
References
•National Comprehensive Cancer Network• www.NCCN.org
•National Accreditation Program for Breast Centers• https://www.facs.org/quality%20programs/napbc/standards
•American Society of Clinical Oncology• http://www.instituteforquality.org/practice-guidelines
•The American Society of Breast Surgeons• https://www.breastsurgeons.org/new_layout/about/statements/index.php
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