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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 [email protected] 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)