SURGERY AND BRACHYTHERAPY

PETER SCHWARTZ

St George Hospital Sydney

SURGERY BREAST CANCER

1. Clearance of Recognizable Tumour 2. Nodal assessment ( not DCIS )

St George Experience >500 new patients/anually 65% conservative surgery

SURGERY SELECTION

Adjuvant radiotherapy essential in reducing ipsilateral breast tumour recurrence and traditionally whole breast irradiation (WBI) with breast conserving surgery used

1. Lymphoedema 2. Pain 3. Scar contracture

SURGERY SELECTION Mastectomy • Multifocal • Tumour /Breast ratio unacceptable • Previous radiotherapy • Underlying medical considerations • Genetics • Patient request • Remote locations, logistics, accessibility and

patient concerns regarding WBI effects

Ca Breast

BREAST CANCER

RADIOTHERAPY

Alternatives to Conventional WBI 5-6 weeks • Hypofractionated whole breast (3 weeks) • Brachytherapy (1 week)

SURGERY/BRACHYTHERAPY ASTRO and ESTRO guidelines combined Low risk group • No nodal status • Tumour size to <2-3cm • Favourable prognostic factors • >50-59 age group • Unicentric or focally multifocal • DCIS not allowed

SURGERY/BRACHYTHERAPY

Intermediate Risk – Cautionary Tumour size 2-3cms Age >50-60 Invasive lobular allowed DCIS allowed

• SURGICAL CONSIDERATIONS with BRACHYTHERAPY

1. Margins 2. Reasonable flaps 3. Tumour cavity marking 4. Cosmesis 5. Oncoplastic considerations 6. Keloid formation

MARGINS

POSITIVE MARGIN

Positive margins ie. Ink on invasive / DCIS associated with significant increase in IBTR – not nullified by boost or systemic Rx or favourable pathology

MARGINS

NEGATIVE MARGIN Definiton: No ink on margin – any distance Optimizes IBTR Wider margins do not lower this risk OFTEN NEED CAREFUL PATHOLOGY REVIEW

MARGINS

Reduces IBTR but if not given, wider margins have no benefit

IBTR not influenced by wider margins EXTENSIVE INTRADUCT COMPONENT IBTR not influenced provided clear to ink AGE <40 Higher rate IBTR regardless of surgery. Wider margins

no effect

MARGINS

LOBULAR CANCER 1. Wider than no ink on tumour not indicated 2. Classical LICS at margin not an indication for

re-excision 3. Pleomorphic LCIS uncertain

MARGINS CONCLUSION

EXCISION ALL CLINICALLY EVIDENT TUMOUR

NO INK ON MARGIN SUFFICIENT

Should significantly reduce rate of re-excison which sometimes ends with mastectomy or

poor cosmetic result

(Consensus Statement JCO Feb 10,2014)

CLOSURE TECHNIQUES • Superficial or Layered Closure

No consensus and variable approach • Ann Surg Oncol. 2013 Apr;20(4): Epub 2012

Lumpectomy closure technique does not affect dosimetry in patients undergoing external-beam-based accelerated partial breast irradiation

CLOSURE TECHNIQUES

1.Layered closure

2.Superficial closure

CLOSURE TECHNIQUE EJSO 38(2012) 918-924 Studied association of breast tumour bed

seroma with post-operative complications and late normal tissue toxicity (WBI) 1. Increased post-op infection 2. Reduced cosmesis 3. Increased tissue toxicity (retraction,oedema)

ONCOPLASTIC SURGERY

ONCOPLASTIC SURGERY

SUGGESTED BENEFITS Wider excision margins – reducing reoperation Possibly better cosmesis Combined with other reconstructive procedures Eg.contralateral breast reduction ? Reduction risk of tumour due to reduced

breast volume as secondary benefit

ONCOPLASTIC SURGERY Wider Margins and Cosmesis • Impact of increasing use of neoadjuvant

treament • No evidence of benefit past inked margins

• May reduce need for repetitive surgery • Consider using if cosmesis improved

ONCOPLASTIC SURGERY

ONCOPLASTIC SURGERY

Surgical Options

SURGICAL TECHNIQUE &

BRACHYTHERAPY Aims 1. Patient selection preoperatively 2. Attention to skin flaps 3. Clips to allow future delineation of cavity 4. Maintainance of oncological principles 5. ? Keloid

CONCLUSION

• Useful adjunct in radiotherapy treatment • Possible reduction in recognized side effects

post WBI • Apply appropriate surgical techniques

maintaining oncological principles • Possibly will allow for conservative approach

in IBTR in the future • Awaiting further mature data