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PRINCIPLES OF BREAST SURGERY
Dr. Mattia Intra
DISCLOSURE OF INTEREST
The author declares no conflict of interest
More surgery
More cure
The maximum tolerable treatment
The most important prognostic factor is the
biology of the tumor.
And the biology is genetically predefined.
What decides the future of the patient
is the intrinsic metastasing property
of the cancer cell
The tumor curability is related to the
risk of distant metastases and the
possibility to eliminate them with
adequate, personalized and targeted
medical therapies.
The anatomical approach
The biological approach
The minimal effective treatment
Foto sarto
This conservative principle inspired the entire history
of the breast cancer treatment over the time: in the breast, axilla, and RT.
In breast cancer, the extension of local treatment doesn't cure
better the disease or increase the prognosis
The very familiar six randomized trials and a subsequent series of consensus conferences and
meta analyses have clearly demonstrated equivalent survival between BCS and mastectomy.
The best performed and the best
reconstructed mastectomy is an
irreversible mutilation, sometimes
unavoidable, often well accepted by the
patients, rarely desired, but it is always a
physical mutilation.
Mastectomy affects and modifies
sensibility, corporeal image,
psychology, sexuality, quality of life of
the patients.
Without considering the possible
problems related to a caducous and
painful foreign body (the prothesis),
or more invasive autologous flaps.
Journal of Clinical Psychology in Medical Settings, 2013
Quality of Life in Women Following Various Surgeries of Body Manipulation: Organ Transplantation, Mastectomy, and
Breast Reconstruction
Women who underwent mastectomy showed the highest anxious-
depressive symptomatology and quality-of-life impairment in
comparison to the remaining groups.
The best performed mastectomy
would never be comparable to an
oncologically and cosmetically
well performed conservative
surgery.
When the correct indications are
followed, BCS achieves better quality
of life than mastectomy
Wrong indication to BCS
Wrong indication to mastectomy
In early breast cancer surgical indications are
clear and precise:
•Radical removal of the tumor with adequate
resection margins.
•Good cosmetic outcome and acceptable symmetry
according to tumor size, breast size and tumor site.
“It is time to declare the case againstbreast-conserving therapy closed and
focus our efforts on new strategiesfor the prevention and cure of breast
cancer.”
Monica Morrow, N Engl J Medicine 2002
Minimizing tumor recurrence in the breast is of major clinical
importance, since local recurrence is associated with a great
emotional distress.
Predictive factors of local recurrence after BCS
- Age - Extensive in situ component- Nodal status - Triple negative subtype- HER2 - Lymphovascular invasion- High Grade - Gene profile- Multifocality - Multicentricity- Margin width - Tumor size
Margin status is surely a prognostic factor. Involved margins are still associated with a
significant increased risk of failure.
This is especially true for patients treated with surgery alone, without adjuvant RT. In
patients undergoing RT, the impact of margin status is less clear.
Impact of margin status
The likelihood of local recurrence is less related to the surgical margin width than
to the underlying tumor biology and to the availability of effective adjuvant therapy.
Systemic treatments that reduce the risk of distant metastases also reduce the risk
of local recurrence.
The impact of the margin width is probably overestimated . A larger margin is associated with decreased failure risk, but the advantage decreases with
increasing width and is small and mostly insignificant
How Important Is Margin Width?
The use of no ink on tumor as the standard for an adequate margin in
invasive cancer in the era
of multidisciplinary therapy is associated with low rates of IBTR,
has the potential to decrease
re-excision rates, improve cosmetic outcomes, and decrease health care
costs
Oncoplastic surgery
Inferior quadrants: unfavourable tumor site
Large tumors
The same conservative concept moved over the time
to cover other fields of investigation (locoregional nodes, radiotherapy), with
similar conclusions
Second stage of Revolution in Breast Cancer Treatment
CONSERVATION OF AXILLARY LYMPH NODES
Sentinel Lymph Node
Is, by definition, the first node or nodes directly draining the lymph from breast carcinoma area.
Sentinel Lymph Node
Is a easily identifiable node that represents the
overwhelmingly most likely site of metastasis.
The widespread adoption of SLNB was supported by the results of at least
90 observational studies, 12 randomized trials, 6 meta-analyses, 2
ASCO guidelines, and an extensive literature covering all aspects of the
procedure.
Follow up 95.6 months
No difference in OS, DFS and LC between conventional axillary-lymph-node dissection
and sentinel lymph node biopsy
Krag DN, Anderson SJ, Julian TB, et al
Sentinel Lymph Node biopsy is the gold standard
procedure to stage the axilla in the operable breast cancer with clinically negative axillary
nodes
Gold Standard
Simple, safe and reliableReproducible High predictive valueLow false negative rate
Sentinel Lymph Node
The acceptance of the SLNB was one of the great success
stories in contemporary surgical oncology
“Is sufficiently robust to withstand variations in
technique, increases staging accuracy by allowing
enhanced pathologic analysis, has less morbidity
than complete axillary lymph node dissection, and
gives local control comparable of that of axillary
dissection”
Sentinel Lymph Node
Sentinel node biopsy for breast cancer: does anybody not need one? Cody HS 3rd, Ann Surg Oncol 2003
Works well in a wide range of
practice settings
Sentinel Lymph Node
SLNB in large tumors (T2-T3)
Cody HS 3rd
SLN biopsy for large and/or multicentric breast cancers: should we worry?
Eur J Surg Oncol 2011; 37(5): 386-7
SLN biopsy in multifocal and multicentric breast tumor
Tousimis E, Van Zee KJ, Fey JV, et al. The accuracy of sentinel lymph node biopsy in multicentric and
multifocal invasive breast cancers. J Am Coll Surg 2003;197:529–35.
Gentilini O, Trifirò G, Intra M, et al.Sentinel limph node biopsy in multicentric breast cancer. The
experience of the European Institute of Oncology.EJSO 2006;32:507-10
SLN biopsy before neoadjuvant chemotherapy
SLN biopsy after neoadjuvant chemotherapy
Reference N°pts. Id. rate NPV Accuracy
Schwartz 2010 79 99% 92% 98%
Gimbergues 2008 129 94% 89% 93%
Lee 2007 219 78% 87% 96%
Shen 2007 69 93% 62% 68%
Kinoshita 2006 77 93% 94% 96%
Mamounas 2005 428 85% 93% 96%
Tanaka 2006 70 90% 97% 98%
Lang 2004 52 88% 96% 98%
Tio 2004 89 87% 96% 98%
With clinically negative axillary nodes at presentation or metastatic nodes but complete response after medical
treatment
SLN biopsy after neoadjuvant chemotherapy
Reference Year N° Pts.Success
rateExtra axillary
drainagePositive
Sec SLN F.up
Intra 2015 212 97.7% 8.0% 16.8% 4.0 y
Cox 2008 56 80% 2.2% 20% 2.2y
Port 2007 54 74% 7.5% 12.5% 2.2y
Taback 2006 6 88% 40% 0% 3.1y
SLN biopsy after negative sentinel node
SLN biopsy after mastectomy
Intra M, Veronesi P, Gentilini OD, et al. Sentinel lymph node biopsy is feasible even after total
mastectomy. J Surg Oncol 2007;95:175–9
Karam A, Stempel M, CodyIII HS, Port ER.Reoperative Sentinel Lymph Node Biopsy after
Previous Mastectomy.J Am Coll Surg 2008;207:543-48
100% SLN identification rate32 % metastatic SLNs
SLNB in patients with previous
aesthetic surgery:The EIOexperience
SLN biopsy in pregnant women
Keleher A, Wendt R 3rd, Delpassand E, et al.The safety of lymphatic mapping in pregnant breast cancer patients using Tc-99m sulfur
colloid.Breast J 2004;10:492-95
Pandit-Taskar N, Dauer LT, Montgomery L, et al.Organ and fetal absorbed dose estimates from 99mTc-sulfur colloid lymphoscintigraphy
and sentinel node localization in breast cancer patients.J Nucl Med 2006;47:1202-08
Gentilini O, Cremonesi M, Veronesi U, et al.Sentinel lymph node biopsy in pregnant patients with breast cancer.
Eur J Nucl Med Mol Imaging 2010;37:78-83
SLN biopsy in male breast cancer
Gennari R, Renne G, Travaini L, Bassi F, Zurrida S. Sentinel Node Biopsy in Male Breast Cancer: Future
Standard Treatment? Eur J Surg 2001;167:461–2
Flynn LW, Park J, Patil SM, et al.Sentinel Lymph Node Biopsy is Successful and accurate in
Male Breast Carcinoma.J Am Coll Surg 2008;206:616-21
An axillary dissection for
uninvolved axillary lymph nodes
must be considered
inappropriate
The SLN biopy era
Unneccessary axillary node dissection in the SLN eraIntra M et al, Eur J Cancer 2007
The removal of non metastatic axillary nodes
Surgical and oncologic failure
The SLN biopy era
Lancet Oncology 2013;14(4): 297-305
April 2001 to February 2010
934 randomized from 27 centers;
Giuliano A, JAMA 2011
EORTC
AMAROS TRIAL
Full dose (21Gy) or BOOST (12Gy) administered in three
minutes
ELIOT(ELectron Intra Operative Therapy
Third stage of Revolution
in Breast Cancer Treatment:
Reduction of Radiotherapy
Partial breast irradiation(PBI)
Conformational 3D
Mammosite
Braquitherapy
Intraoperative radiotherapy with electrons (ELIOT)
ASTRO Consensus Statement 2009
Characteristic A/ Low-risk group - B/ Intermediate-risk group - C/ High-risk group –
Good candidates for APBI Possible candidates for APBI Contraindication for APBI
Patient age >50 years >40-50 years ≤40 yearsHistology IDC, mucinous, tubular, IDC, ILC, mucinous, tubular, -
medullary, and colloid cc. medullary, and colloid cc.ILC Not allowed Allowed -Associated LCIS Allowed Allowed -DCIS Not allowed Allowed -
HG Any Any -Tumour size pT1-2 (≤30 mm) pT1-2 (≤30 mm) pT2 (>30 mm), pT3, pT4Surgical margins Negative (≥2 mm) Negative, but close (<2 mm) PositiveMulticentricity Unicentric Unicentric MulticentricMultifocality Unifocal Multifocal (limited within 2 cm Multifocal (>2 cm from the)
of the index lesion) index lesion)EIC Not allowed Not allowed PresentLVI Not allowed Not allowed PresentER, PR status Any Any -Nodal status pN0 (by SLNB or ALND*) pN1mi, pN1a (by ALND*) pNx; ≥pN2a Neoadj. chemoth. Not allowed Not allowed If used
GEC-ESTRO Recommendations 2009
Practical Radiation Oncology 2016
Conclusions
➢ PBI shouldn’t be considered a totally substitutive technique but a
complementary approach to WBRT.
➢To achieve the higher efficacy of the procedure the most important things are a precise radio-surgical technique and a
careful selection of the patients
Totalmastectomy
ParenchymaNAC
skin
ParenchymaNAC
Nipple sparingMastectomy
Parenchyma
Skin SparingMastectomy
Evolution of mastectomy
Oncological safety
Complete removal of the tumour with the entire breast parenchima
Cosmetic outcome
saving breast appearance,better quality of life
This procedure is usually performed through a radial incision where the skin is carefully dissected off the
breast until all anatomic boundaries of the breast are reached and the
gland in its entirety is excised.
Nipple-sparing mastectomy must be carried out with maximum attention not to leave macroscopic
residues of mammary gland in particular in the axillary extension, peripheral extremities of the
gland and the nipple-areola complex; it is necessary to perform an accurate dissection and a meticulous preparation of the skin flaps and of
the areola-nipple complex which must be reasonably thin without however compromising
its vitality.
Surgical patterns
▪ Radial▪ Periareolar inferior▪ Round Block▪ Vertical pattern▪ Wise pattern▪ Inframammary fold
Radial Incision
PERIAREOLAR INFERIOR
VERTICAL PATTERN
WISE PATTERN
Inframammaryfold
In the absence of contraindications, all patients should be candidates for breast reconstruction
in order to minimize the negative physical and psychological impact of the mastectomy; the breast reconstruction should preferably be
immediate, performed at the same time of the prophylactic mastectomy, by a team of
dedicated plastic surgeons, or with permanent prosthesis or autologous tissues.
Robotic Nipple Sparing Mastectomy and Immediate Robotic Reconstruction
with Implant
Toesca A. ANN SURG 2014
Toesca A et al. 2016
Randomized prospective study comparing "Nipple-sparing"
mastectomy vs robotic nipple-sparing mastectomy for patient satisfaction
THE CENTRALITY OF THE PATIENT
PERSONALIZED
MEDICINE
BREAST CANCER
TREATMENTS
fromMaximun tolerable
treatment
toMinimum effective
treatment
“What our breast cancer patients most need is
better science, not more surgery.”
Hiram S. Cody III.
Ann Surg Oncol 2012
