Spotlights on the surgery role at San Antoniomedia.aiom.it/userfiles/files/doc/AIOM-Servizi/slide/...San Antonio Breast Cancer Symposium, 12/2017 APPROPRIATE SURGICAL MARGINS APPROPRIATE

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

Spotlights on surgical issues:

• Appropriate surgical margins

• Locoregional recurrence

• Axillary management

• Local therapy in ABC

San Antonio Breast Cancer Symposium, 12/2017

APPROPRIATE SURGICAL MARGINS


Moran et al, 2014

appropriate margin: NO TUMOR ON INK

CURRENT SSO/ASTRO GUIDELINES ON MARGINS:

Is this correct?


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


New meta-analysis

•55.302 patients

(>20.000 additional patients from previous meta-analysis

•7.2 years median follow-up



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)



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


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

Large volume displacement oncoplastic surgery (LVOS)

can secure better clearance of margins

• Positive margin rate • (PMR) comparison

• T-Test evaluation

• Positive margin rate • (PMR) comparison

• T-Test evaluation


Positive margin rate (PMR) comparison

T-Test evaluation

Published PMR between LVOS and TBCS in literature review

LVOS: 12.5% TBCS: 20.4% P-value: <0.001

PMR between Tufts LVOS and TBCS in literature review

Tufts LVOS: 10% TBCS: 20.4% P-value: 0.036

M. Jonczyk et al Tufts Medical Center - Boston Hospital and Academic Medical Center


•Margins

•Locoregional recurrence •Axillary management

•Local therapy in ABC


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


Good results only in low risk patients

(ER+, HER2-, initial negative margins)


• Not the standard of care

• Reported high rates of additional LR





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



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




•Appropriate surgical margins

•Locoregional recurrence

•Axillary management •Local therapy in ABC


SNB IN EARLY BREAST CANCER


MICROMETASTATIC SLN


V. Galimberti IEO, Milan


6681 patients registered

5747 not eligible for randomization

934 patients randomized

467 analyzed 10 withdrew consent

74 lost to follow-up

467 allocated to

no axillary dissection

464 allocated to

axillary dissection

464 analyzed 11 withdrew consent

69 lost to follow-up

2 excluded 1 excluded


MICROMETASTATIC SLN


Arms characteristics well matched V. Galimberti

IEO, Milan


Appropriate balance of adiuvant therapies


10 years results




Low incidence of axillary events disregarding type of surgery


No differences between the AD

and no AD groups for any endpoint

No ALND is acceptable

even in patients scheduled for mastectomy


MICROMETASTATIC SLN


MACROMETASTATIC SLN (Breast conserving surgery)

T. King Dana Farber / Brigham and women’s - Harvard medical school

30-80% of ALND reduction in cN+ (sn) patients worlwide!


(patients undergoing mastectomy)

Dana Farber’s multidisciplinary behavior

No SNB in patients cN0 undergoing mastectomy who will receive PMRT:

• <60 YR

• High risk factors (LVI or HR negative)

1-2 positive SLN

• PMRT + Axillary RT

3 or + positive SLN

• ALND




75 pts patients registered (cT1-2, N0) – no FS

54 (72%) negative SLN 21 (28%) positive SLN

1 ALND

18 pts (24%)

1-2 positive SLN

3 pts (4%)

≥3 positive SLN

3 observation

14 (78%) PMRT + AxRT

17/21 (81%) of positive patients spared ALND


SLNB procedure of choice for axillary stadiation

SNB AFTER NEOADJUVANT TREATMENT




FEASIBILITY OF SLNB AFTER NAD

cN0 – ycN0 PATIENTS

Acceptable SLN identification rate even after NACT

SNB IN NEOADJUVANT TREATMENT


Acceptable identification and false negative rates

(only if ≥3 SLN are removed)



cN+ – ycN0 PATIENTS



INTERPRETATION OF SLNB

AFTER NAD

SLNB in cN+ – ycN0 patients



In ypN0 (sn) pts – ALND can be avoided,

sparing up to 50% of ALND in converted axillas!!

• 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



Significance of micromets and ITCs

Clear indication for ALND



ypN+ PATIENTS

Waiting for more studies

for stronger recomendations


AXILLARY TREATMENT COMPLICATIONS

A. Kuijer

Dana Farber / Brigham and women’s - Harvard medical school


A. Kuijer



A. Kuijer




•Appropriate surgical margins

•Locoregional recurrence

•Axillary management

•Local therapy in ABC


S. Khan

Lynn Sage Breast Center & Dept of Surgery - Northwestern University

OLIGOMETASTATIC BC TREATMENT

S. Khan



S. Khan



S. Khan



S. Khan



S. Khan



S. Khan



S. Khan



S. Khan



THANK YOU !

Documents

Spotlights on the surgery role at San Antoniomedia.aiom.it/userfiles/files/doc/AIOM-Servizi/slide/...San Antonio Breast Cancer Symposium, 12/2017 APPROPRIATE SURGICAL MARGINS APPROPRIATE