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Current Trends of Breast Cancer Surgery

Jong Han, Yu

Division of Breast

Department of Surgery

Samsung Medical Center

2018. 4. 6.

Current Trends

• Minimizing of Surgical Area

in Breast & Axillary Area

• Risk Reducing Surgery

• Oncoplastic Surgery

Minimizing of Surgical Area

• Breast Cancer Screening Rate (National cancer screening data)

Breast Cancer Stage

Increase of stage 0 & I (early breast cancer)

national cancer screening program

Year

57.1%

KBCS registry dataMin et al., JBC 2016

KBCS registry dataMin et al., JBC 2016

Trends of Breast Cancer opeartion type

Localization for Breast lesion

Localization for Breast lesion

• Operation

- incision

- resection area

F/63

Breast, LEFT 2:00, core biopsy :

INVASIVE DUCTAL CARCINOMA

Breast, left, conserving surgery with sentinel node biopsy:

Invasive ductal carcinoma :1) tumor size: 1.5x1.3x1.2 cm (pT1c)2) nuclear grade: intermediate without necrosis3) Bloom-Richardson grade: II / III4) lymphovascular invasion: absent 5) intraductal component: 5 % / EIC ( - ),

Van Nuys classification group: 1 / 36) microcalcification in stroma, and tumor7) negative resection margins

(superior, 1.0 cm; inferior, 1.7 cm; lateral, 1.0 cm; medial, 0.9 cm; deep, 1.0 cm; superficial, 0.2 cm)

8) no metastasis in 4 regional lymph nodes (pN0(sn))(0/4: Lt.sentinel lymph node for frozen biopsy-5, 0/2;

Lt.non-sentinel lymph node for frozen biopsy-6, 0/2)

Breast, right, 10 o'clock, core biopsy :

DUCTAL CARCINOMA IN SITU, INTERMEDIATE NUCLEAR GRADEMicrocalcification in tumor

Breast, right, conserving surgery with sentinel node biopsy:

Ductal carcinoma in situ, comedo type;1) tumor size: 4.0x2.8x0.8 cm (pTis)2) nuclear grade: high with focal necrosis3) Van Nuys classification group: 3 / 34) lymphovascular invasion: absent 5) microcalcification in stroma, and tumor6) negative resection margins

(deep, 0.8 cm; superior, 0.2 cm; inferior, 3.0 cm; lateral, 2.2 cm; medial, 0.8 cm)

7) no metastasis in 3 regional lymph nodes (pN0(sn))(0/3: Rt.sentinel lymph node for frozen biopsy-5, 0/2;

Rt.non-sentinel lymph node for frozen biopsy-6, 0/1)

KBCS registry dataMin et al., JBC 2016

유방암 수술 방법의 변화

Breast Surgery

Ann Surg 2017;265:581–589

Breast MRI

Risk Reducing Surgery

Educational attainmentHousehold incomeFamily historyDegree of anxiety Fear of recurrence

Expanding reconstructive technique

Avoid the need for long-term active surveillance

,,,,,

In Neoadjuvant Treatment

• Breast-Conserving Surgery

• Axillary Management

Decreasing extent of breast tumor

Minimizing of Surgical Area in Breast Area

항암 전

항암 후

Ex) 수술 전 약물 치료

pCR ↑ BCS rate↑

Tumor downstaging

Breast-conserving surgery

• 14 prospective randomized trials : Neoadjuvant vs Adjuvant chemotherapy

• Total N = 5,500

an absolute decrease in the mastectomy rate of 16.6% (95% CI 15.1–18.1%)

Mieog, J. S et al. Br. J. Surg. (2007)

Downstaged BCS vs preplanned BCS

Mieog, J. S et al. Br. J. Surg. (2007)

Locoregional recurrence

Mieog, J. S et al. Br. J. Surg. (2007)

pCR ↑ BCS rate↑

Rates of pCR to NACT and BCS in randomized trials

pCR ↑ BCS rate↑

• the difficulty in evaluating the extent of residual disease

after NACT, before surgery

• confusion regarding whether resection of the entire volume of

breast tissue originally occupied by the tumour is necessary.

• some definitions of pCR include patients with residual DCIS

• patients who are candidates for primary BCS often

opt for mastectomy, patient preference after NACT might also

contribute to the observed rates of mastectomy in this setting.

King, T. A. & Morrow, M. Nat. Rev. Clin. Oncol. (2015)

• Early randomized trials of NAC more patients underwent BCS (in NAC > in AC)

NSABP B-18, BCS rate : 68% in NAC / 60% in AC

NSABP B-27, BCS rate : 61–63% in NACCALGB 40603 trial, overall BCS rate : 54 ~ 68% in NAC

• Recent studies have shown a shift toward more mastectomies

the National Cancer Database (NCDB) [2006~2011]

mastectomy rates 65% in NAC vs 50% in AC.the secondary analysis

of the Translational Breast Cancer Research Consortium (TBCRC) 017 trial N= 770 [2002 ~ 2011] who underwent NAC and MRI : 55% mastectomy

‘‘peace of mind’’ [avoiding future recurrences and treatments]to be the most important factors in decision-making

“introduction” Olga Kantor et al. Ann Surg Oncol (2018)

Olga Kantor et al. Ann Surg Oncol (2018)

Converting breast conserving surgery

10 studies - 4756 patients

Oncologic Outcomes

Early Breast Cancer Trialists’ Collaborative Group (EBCTCG)* Lancet Oncol 2018

KBCS registry dataMin et al., JBC 2016

유방암 수술 방법의 변화

Breast Surgery

Widening of indication of SLNB

Minimizing of Surgical Area in Axillary Area

Surgery of Axillary nodes

• Axillary node metastasis

- N stage

Prognostic factor

guidance for adjuvant tx.

Primary tumor

Sentinel Lymph Node

Axillary nodes

Sentinel Lymph Node biopsy

Axillary Lymph Node Dissection

• both diagnostic & therapeutic purposes

• Complications

Nerve & Vein injury

Limitation of arm

& shoulder movement

Abnormal sensory

Arm edema

Sentinel Lymph Node biopsy

Tumor

Lymphatic channel

Regional lymphatic system

Sentinel node

Lymphatic Mapping

• Gamma-emitting agent ("hot spot“)• Blue dye (blue colored node)

Blue dye & Radioisotope

• Isosulfan blue

• Methylene blue

• Indigo carmine

• Patent blue

• 99mTc label

• particle size range (50~200 nm)

• removal of all SLN with counts >10% of the most radioactive node. (10% rule)

A Randomized Comparison of Sentinel-NodeBiopsy with Routine Axillary Dissection

Veronesi U, NEJM 2003Overall Survival

Enrollment in March 1998

Number of Patients

: 516 with primary BC

Conclusions: SLN biopsy is a safe

and accurate method of screening

the axillary nodes for metastasis

96.4%

98.4%

• Simple, safe and reliable

• Reproducible

• High predictive value

• Low false negative rate

• No different overall survival

Gold Standard (cN0)

Sentinel Lymph Node Biopsy

Positive sentinel lymph node

ClinicalTrial

No. TumorMedian

F/UResult

AATRM 048/13 /2000

227 T<3.5cm cN0 62 moNo diff. DFSNo death

IBCSG23-01

931 T1 or 2 cN0 60 mo No diff. DFS&OS

N1mic : ALND vs No ALND

Positive sentinel lymph node

ClinicalTrial

No. TumorMedian

F/UResult

ACOSOG Z0011

891 T1 or 2 cN0 6.3 yr No diff. DFS&OS

AMAROS 1425T1/2 (<3cm)

cN0 6.1 yr No diff. DFS&OS

N+ : ALND vs No ALND or ART

Axillary treatment evolves

1990 20102000

ASCO Guideline,2005

Z0011

2012

Giuliano,1991

Krag,1993

Albertini,1996

RCTs, 1999-2001-NSABP B32-ACOSOG Z0010&Z0011 -ALMANAC -AMAROS

B32

(Lancet Oncol 2010)

(JAMA 2011)

ALMANAC(BCRT 2006)

St. Gallen

NCCN

ProceduresAccuracyRCTs QOL,

morbidityOutcomes Guidelines

Changing Practice

AMAROS

2013 2014

IBCSG23-01

(Lancet Oncol2013)

Provided by Pf. Son

AATRM(ASO 2013)

2017

T1 or T2, cN0

* N1mic

* N1(1 or 2) (selected case)

* cN+ ypN+

* N+ (3 ~)

cN+ ypN-

ALND No ALND

Further Axillary Clearance

Radiation therapy, Systemic therapy, [Subtype]

SLN After Neoadjuvant Therapy, cN1 -> cN0

ACOSOG Z1071 SENTINA SN FNAC

N 649 592(cN+)* 153

Mapping Dual tracer recommended(79%)

Technetium required Technetium required, IHC

Pre-op biopsy? Yes Not required (25%) Yes

Nodal pCR 41% 52% ypN0 (?) 35%

ID rate 92.7% 80.1% 87.6%

FNR (Overall) 12.6% 14.2% 8.4%

1 SLN 31.5% 24.3% 18.2%

2 SLN 21.1% 18.5% 4.9%

≥3SLN 9.1% 7.3%

*1737 patients enrolled in 4 arm multicenter trial. 592 ARM C were cN+ to cN0

This presentation is the intellectual property of the presenter. Contact tking7@bwh.harvard.edu for permission to reprint and/or distribute.

Tari A. King MD FACSSan Antonio Breast Cancer Symposium, December 5-9, 2017

Boughey J et al. JAMA 2013; Boileau J et al. JCO 2015; Kuehn T et al. Lancet Oncol 2013

NSABP B-51/RTOG 1304 (NRG 9353) trial schema

the role of XRT in patients with documented positive axillary nodes (T1–T3 N1 M0 breast cancer) who convert to pathologically node-negative disease after NACT

ypN0

N=1636Enroll 5yr

Alliance for Clinical Trials in Oncology A11202 trial schema

the role of ALND in patients with T1–T3 N1 M0 breast cancer who have SLN-positive disease after NACT (ALND vs nodal XRT)

Axillary treatment evolves

1990 20102000

ASCO Guideline,2005

Z0011

2012

Giuliano,1991

Krag,1993

Albertini,1996

RCTs, 1999-2001-NSABP B32-ACOSOG Z0010&Z0011 -ALMANAC -AMAROS

B32

(Lancet Oncol 2010)

(JAMA 2011)

Z0010(JAMA 2011)

ALMANAC(BCRT 2006)

St. Gallen

NCCN

ProceduresAccuracyRCTs QOL,

morbidityOutcomes Guidelines

Changing Practice

AMAROSSENTINA

Z1017

Neoadjuvant setting

Accuracy Outcomes ?

(JAMA 2013)

(Lancet Oncol 2013)

2013 2014

Guidelines ?

IBCSG23-01

(Lancet Oncol2013)

Provided by Pf. Son

AATRM(ASO 2013)

2017

A11202

NSABP B51

T1 or T2, cN0

* N1mic

* N1(1 or 2) (selected case)

* cN+ ypN+ >> clinical trial (RT vs ALND)

* N+ (3 ~)

cN+ ypN-* SLNB

dual tracers≥3SLN )

ALND No ALND

Further Axillary Clearance

Radiation therapy, Systemic therapy, [Subtype]

Risk Reducing Surgery

ovarian cancer at 49

2013. 5. Bilateral risk-reducing mastectomy 2015. 5. Bilateral risk-reducing salphingo-oophorectomy

Lifetime risk of breast and ovarian cancerBRCA carrier

유방 복원술 시행의 변화

KBCS registry dataMin et al., JBC 2016

2015년 5월 급여화 (50%)

Skin Sparing Mastectomy

Removal of the breast and

nipple-areolar complex

Circumareolar incision

Preservation of the native skin

envelop and inframammary

fold

NAC preserving SSM

Nipple-areolar complex(NAC) flap ≤ 3mm thickness

frozen biopsy for nipple margin

NAC sacrifice if cancer involvement in resection margin or unclear.

NAC preserving SSM(유두유륜 및 피부 보존 유방 전절제수술)

Breast reconstruction with implant

Breast reconstruction with tissue

LD flap

TRAM flap(DIEP)

Mastectomy & Immediate Reconstruction

MRM

Implant

LD flap

TRAM flap

(DIEP)

Asan Medical Center

Mastectomy

& Immediate Reconstruction

Total mastectomy Skin sparing mastectomy

Nipple-areolar complex skin-sparing mastectomy

서울아산병원

Trends of Breast Reconstruction

KBCS registry dataMin et al., JBC 2016

Covered by National Health Insurance Since May 2015 (50%)

In SMC

395

Covered by National Health Insurance Since May 2015 (50%)

Risk Reducing Breast Surgery

In Breast Cancer with affected Carrier(BRCA)

• Risk reducing ipsilateral mastectomy

- ipsilateral breast cancer recurrence ↓

• Risk reducing contralateral mastectomy

- contralateral breast cancer development ↓

• Breast Conserving operation ?

Ipsi-lateral Breast cancer recur>7yr IBTR ↑

BRCA1 ≒ BRCA2

Survival No difference : vs mastectomy

Pierce LJ et al., J Clin Oncol (2000)Robson ME et al., Breast Cancer Res (2004)Kirova et al. Breast Cancer Res Treat (2010)

Antonis Valachis et al., Breast Cancer Res Treat(2014)Kirova et al. Breast Cancer Res Treat (2010)

In Breast Cancer with affected Carrier(BRCA)

• Contra-lateral mastectomy ?

Risk of development

contra-lateral breast cancer ↑

BRCA1 > BRCA2

Survival

no additional gain

Antonis Valachis et al., Breast Cancer Res Treat(2014)E. Molina-Montes et al.,The Breast (2014)

Brekelmans CT et al., Eur J Cancer (2007)Rennert G et al., N Engl J Med (2007)

In Breast Cancer with affected Carrier(BRCA)

• Shared Decision Making

students4bestevidence.net

Oncoplastic Surgery

Breast Conserving Surgery

Good (75%) Moderate (20%) Poor (5%)

• Poor results

- Obesity

- Smoking

- Radiation

- improper incision or resection

Oncoplastic Surgery

Breast cancer in upper outer area

Breast cancer in upper outer area

Breast cancer in upper center area

Breast cancerin subareolar area

Breast cancerin lower outer area

Oncoplastic Surgery

NAC-S sparing mastectomy & Reconstruction

+ Good Mastectomy

Summary Current Trends

• Minimizing of Surgical Area in Breast ?in Axillary Area ↑

• Risk Reducing Surgery ↑

• Oncoplastic Surgery ↑(considering cosmesis)