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Dr Sandhya PillaiGeneral & Oncoplastic Breast Surgeon
Shorewest Surgical Care
14:00 - 14:55 WS #56: Issues Around Breast Cancer
15:05 - 16:00 WS #68: Issues Around Breast Cancer (Repeated)
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BREAST CANCER ISSUESCURRENT QUESTIONS
Dr Sandhya Pillai
General and Oncoplastic Breast Surgeon
CMDHB
Shorewest Surgical Care
Auckland Breast Centre
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BREAST CANCER MANAGEMENT
1800s
Haldsted
Radical mastectomy
1900s
extended
radical mastectomy
1976
NSABP B-04
Fisher et al
Total mastectomy +
radiation
2007
NSABP 32
SNB alone safe in node
neg2002
AJCC classification of
micromets & ITC
1998
NZ Breast screening
2007
Mainstream
neoadjuvant
therapy
2000
Breast
cancer
subtypes
1962
Eagan
1st mammo Cancer
1985
NSABP B-06
Fisher et al
Partial mastectomy +
rad vs total for <4cm
1986
European Breast screening
1970s
Neoadj
trials
1895
Czerny flank lipoma transfer
1906
Tanzini
Lat dorsi flap
1982
Expanders
2010
Clough quadrant based
oncoplastic atlas
2000
Immediate
reconstruction
1963
Silicon gel implant
Late 1980s
TRAM flap
1990s
DIEP flap
1980s
Extended Lat dorsi for volume
Has changed
markedly over
the last 220 years
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Breast
partial or total mastectomy
BREAST CANCER CHOICES
Axilla
SNB or AND
Adjuvant
chemotherapy
Neoadjuvant
Adjuvant
radiotherapy
Adjuvant
endocrine
therapy
Reconstruction –
immediate/Delayed
Reconstruction –
Autologous/Implant
Therapeutic
mammoplasty
Symmetrisation
Multidisciplinary
team pivotal
role
GP & BCN
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BREAST CANCER ISSUES
CURRENT QUESTIONS
Screening
Diagnosis
Genetics
Treatment
Cosmesis
Contraception/HRT/Fertility
Lymphoedema
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BREAST SCREENING
Breast Screen
Aotearoa
45-69y
2 yearly
mammogramsHOW YOUNG?HOW FREQUENT?
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WHAT AGE TO SCREEN BETWEEN?
US Surveillance, Epidemiology & End Results
US Preventive Task Force Recommendation 2016
Canadian Taskforce Recommendations 2011
Age % of breast cancers that
occur in each age group
<40y 5%
40-49y 16%
50-59y 25%
60-69y 26%
70-74y 9%
75y plus 19%
Reduction in Breast cancer
mortality
Number needed to screen
- -
15% 750-2108
30% 910
32% 432
27% 450
No significant reduction -
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HOW FREQUENTLY TO SCREEN?
Age Number
needed to
screen
RR of cancer
death
<2y
screening
RR of cancer
death
≥2y
screening
Sojourn time Doubling
time
40-49y 750-2108 0.82 1.04 1-25-2.5y 80days
50-69y 432-910 0.86 0.67 3-6.5y 157days
70y plus 450 - 0.68 - -
False Positives
5-15% mammograms result in recalls/further testing and 8/10 of those are benign
Higher false positive rate in younger women
2 yearly screening reduces false positives by 50% in 45-74y
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WHEN & HOW OFTEN TO SCREEN?
Age Recommendation Why
<40y No routine screening Low risk Ca
Risk of false positives
Risk of longer cumulative radiation exposure
40-49y BCFNZ yearly till 50y*
1-2yearly mammogram
Mortality reduction (<2y vs 2 yearly)
Sojourn time shorter
Doubling time shorter
Increased false positive
Increased over diagnosis
Fine line risk-benefit
50-69y 2 yearly No mortality reduction 1 vs 2 yearly
70-74y 2 yearly If well and life expectancy >10y **
Reduction in cancer mortality/ low NNS
75y + or life
expectancy <10y
No benefit to screening
By choice/wellness
*High NNS so not cost effective for public health screening through Breast Screen Programme
*Breast cancer foundation NZ recommendation yearly from 40y
** Lee S et al British Medical Journal 2013
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BREASTCANCER
DIAGNOSISClinical
Radiological
Pathological
TOMOSYNTHESIS VS MAMMOGRAPHY
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“Top health insurer won't give Kiwi women access to breast cancer breakthroughNZ Herald 18 Sep, 2016 5:00am
Digital tomosynthesis creates clearer, more detailed 3D images of breast tissue than a standard 2D mammogram, uncovering cancers at an earlier stage and increasing the odds of survival and recovery.”
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TOMO VERSUS MAMMO
• Machine moves in an arc
• 7 seconds, 11 pictures
• Reconstruct 3D images – 1mm slices
• Less compression needed to dissipate overlap of tissues
• IT issues – needs more storage and better connectivity
• Longer to read
• $100 more than 2D mammograms
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TOMO VERSUS MAMMO
There is evidence:
• 40% increase detection
• 30-40% decrease in recall US
• Useful in further assessment of lesions
• Radiation dose similar now 2.95-3.6Gy
No evidence:
• Decrease in breast cancer mortality
• Reduction in interval cancers
• Reduction in overdiagnosis – more sensitive
• Use as first line population screening tool
Eur Radiol. 2019 Mar;29(3):1175-1186. Aase HS et al.Clin Radiol. 2016 Feb;71(2):141-50.
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TO HAVE OR NOT TO HAVE TOMOSYNTHESIS?
YES if
available/accessible/affordable
Increase detection
Less recall
Radiation same
More comfortable
No survival benefit
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GENETICS
HIGH RISK MANAGEMENT?WHICH MUTATIONS MATTER?WHO TO REFER FOR TESTING?
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HEREDITARY BREAST CANCER
• 5% of breast cancer is hereditary
• 20% of women have a family history
• Most breast cancer due to sporadic somatic mutations
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SURVEILLENCE
HIGH RISK PATIENT MANGEMENT
• Does not reduce risk – picks up cancers early
• Annual tomosynthesis from 30y (mammogram 40y)
• Annual MRI 30y till 50y (10y younger than youngest)
• Reassess at 74y or if life expectancy <10y
• 6monthly Ca125 and USS – no improved survival
CHEMOPROPHYLAXIS• Tamoxifen – risk reduction 40% over 5y• SE poor compliance
• Reversible for fertility – stop for 3 months
RISK REDUCTION
MASTECTOMY
• >90% breast cancer risk reduction
• Psychological/emotional/breastfeeding/sexual/
self esteem implications
RISK REDUCTION
SALPINGO-OOPHRECTOMY
• Breast cancer risk reduction 50%• Ovarian Ca >90%
• Age 35-40y – fertility considerations
• can have HRT post op up to 5y
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WHICH MUTATION MATTERS?I thought
there was
only BRCA
BRCA1PALB
CHEKATM
NBN RAD 50
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HIGH RISK AUTOSOMAL DOMINANT MUTATIONSSYNDROME GENE BREAST CA
LIFETIME RISK
12%
OVARIAN CA
LIFETIME RISK
1.3%
OTHER CANCERS OTHER FINDINGS
Breast ovarian
syndrome
BRCA 1 80%
40% contralat
40% Pancreas, prostate, colon
Breast ovarian
syndrome
BRCA 2 60%
30% contralat
25% Male breast, melanoma,
pancreas, FA
Li Fraumeni P53 40% by age 60y
(early onset)
medullary
breast Ca
n/a Sarcoma, brain, adrenocortical Radiosensitive so MRI
not mammograms
Peutz Jegher STK 11 45% by age 70y 20% Cervical & endometrial 10%
Some form of Ca by age 60y
Pancreas, liver, lung
Pigmentation
Hamartomas
Cowden PTEN 50-85% n/a Follicular thyroid 7%
Skin 4%; colon/endometrial 1%
Hamartomas
Neurodev problems
Trichilemmonas
Hereditary diffuse
gastric cancer
CDH1 Lobular breast ovarian Diffuse gastric Ca
Colorectal
Thyroid
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OTHER SIGNIFICANT MUTATIONS
Moderate risk genes
• PALB2, CHEK, ATM
• Variable penetrance: Significant risk if combined with other genes or
environmental factors
• Risk reduction guidelines not well established – case by case
New discovery genes & Variants of uncertain significance
• BARD1, BRIP1, FANCC, NBN, RAD51C, RAD51D, XRCC2, MRE11A, ,NBN, RAD50
…..and the list continues to grow
• With further research – may become significant or normal variants
• Do not base treatment decisions – consider genetics re-referral 5y
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WHAT TO DO WITH PATIENT WITH MUTATION?
HIGH RISK TREATMENT • Mutation based for the 6 high risk mutations
• Family history based for moderate risk
mutations and variants of uncertain
significance
REFER ALL MUTATIONS TO HIGH RISK CLINICS
- Genetics
- Breast
- Gynaecology
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FAMILY HISTORY – WHO TO REFER?
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GUT INSTINCTWHO TO REFER?
• 45y old with triple negative breast cancer no family
history
• 72y old with prior right breast cancer now thyroid
cancer, colorectal and left breast cancer on patient
initiated PET
• 40y with maternal grandmother breast cancer age
70s and paternal aunt breast cancer age 60s
• 35y old with grandmother 70y and mother 39y with
breast cancer
• 35y old Maori lady with 2 uncles with gastric cancer
and mother with breast cancer, father colon cancer,
sister thyroid cancer
• 65y old with triple negative cancer and no family
history
YES
YES
YES
NO
NO
YES
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Auckland regional health pathwayshttps://aucklandregion.healthpathways.org.nz/index.htm
EVIQ website guidelines https://www.eviq.org.au/cancer-genetics/referral-guidelines/1147-general-
practitioner-referral-guidelines-for
FAMILY HISTORY RISK ASSESSMENT GUIDELINES
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EVIQ GENETICS REFERRAL CRITERIAREFERRAL BASIS Criteria
Family history Known mutation in the family
3 or more 1st/2nd degree relatives with breast or ovarian Ca
2 or more 1st/2nd degree relatives with breast or ovarian Ca AND ≥ 1 of following▪ Ashkenazi Jew▪ One relative breast/ovarian <50y▪ Breast & Ovary in same relative▪ Bilateral breast in same relative▪ Male relative with breast Ca
Personal history of
breast cancer
AND ≥ 1 of
following
• Family or personal hx suggestive of a syndromeBilateral breast and one breast <50y
• Triple negative <50y• Breast cancer <40y• Male with breast cancer• Jewish ancestry• Family history ovarian Ca• Multiple primary cancers• Rare cancers
• https://www.eviq.org.au/cancer-genetics/referral-guidelines/1147-general-practitioner-referral-guidelines-for
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FRA-BOC tool (Cancer Australia)https://canceraustralia.gov.au/clinical-best-practice/gynaecological-
cancers/fra-boc/evaluate
BOADICEA
More involved online tool for larger family histories – for researchhttps://pluto.srl.cam.ac.uk/cgi-bin/bd3/v3/bd.cgi
FAMILY HISTORY RISK ASSESSMENT TOOLS
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GENETICS- WHO TO REFER?
FAMILY HISTORY
BREAST CANCER
• Mutation in family
• ≥3 1st/2nd degree relatives
• ≥ 2 1st/2nd degree relatives + 1 other
high risk factor
PERSONAL HISTORY
BREAST CANCER• Plus 1 other high risk factor
* Private $750, 6 weeks
MUTATION
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TAKE HOME POINTS
(1) Screening 40-49y yearly if affordable
70-74y 2 yearly if affordable
50-74y no benefit to screening <2y
(2) Diagnosis Tomosynthesis if affordable + available
No survival advantage
Less recall/better detection/more comfy
(3) Genetics Refer if mutation/EVIQ family hx criteria
Use FRA-BOC tool
Refer to genetics, gynae, breast
Cost $750, 6 weeks private
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BREAST CANCER TREATMENT
INTRA-OPERATIVE RADIOTHERAPY?
CHEMOTHERAPY/ENDOCRINE/BOTH ?
NEOADJUVANT CHEMOTHERAPY?
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BREAST CANCER TREATMENT
INTRA-OPERATIVE RADIOTHERAPY?
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RADIOTHERAPY OPTIONS
Hypofractionation
• 3 weeks 14-16 fractions 39- 42Gy
non inferior recurrence and less side effects
• T1-3 N0-1 (START A & B trials)
Traditional EBRT
• 6weeks 30 fractions 50Gy
• High grade, high nodal burden
Partial Breast Radiation
• 10 fractions 36-40Gy
• 90% recurrence is in same quadrant
• Less cardiorespiratory SE
• Select group
L
E
S
S
R
A
D
I
A
T
I
O
N
• Elderly• Small cancer• Low grade
• ER +
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SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?
• 90% recurrence is in index quadrant• 20Gy over 20-45min at time of surgery
Who qualifies:
• <3cm
• suitable for BCS
• age >45y
• node negative
• grade1-2
• ER+
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SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?
PROS
• Non inferior recurrence/survival
• Less side effects
• Risk adaptive• Decreased skin SE
• Increased convenience
CONS
• 20% have further EBRT
• 10-15% of breast cancer patients
• New machinery in theatres
• Education
• Cost $8000
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SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?
• If you are eligible
• You can afford IORT
• You want convenience
• You lose nothing by having IORT
• You may still need EBRT 20%
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BREAST CANCER TREATMENT
CHEMOTHERAPY?
ENDOCRINE THERAPY?
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SHOULD I HAVE CHEMOTHERAPY?
Straightforward decision in :
• Majority good features: small, low grade ER+
• Majority bad features: triple neg/HER2+/nodes+++
Difficulty is in:
• Mix of good AND bad prognostic features
Not all patients with positive axillary nodes need chemotherapy
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SHOULD I HAVE CHEMOTHERAPY?
• Predict
http://www.predict.nhs.uk/predict_v2.0.html
• Adjuvant online
http://www.adjuvantonline.com
• life math
http://www.lifemath.net/cancer/breastcancer/therapy/
Genomic
stratification
tests
Not routine
in NZ
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SHOULD I HAVE CHEMOTHERAPY?
Predict http://www.predict.nhs.uk/predict_v2.0.html
Grade 1
1/12
nodes
Grade 3
5/12
nodes
52y old
35mm
ER+, HER2-
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SHOULD I HAVE CHEMOTHERAPY?
USE ONLINE TOOLS TO HELP PATIENT DECIDE
Does survival benefit outweigh side effects in the patient’s eyes
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• ↓ recurrence by 47%
• ↓ mortality by 26%
• ↓ contralateral breast Ca by 47% for ER + tumours
• Aromatase inhibitors slightly more effective in post-menopausal than
tamoxifen
SHOULD I TAKE ENDOCRINE TREATMENT?
Zoladex (GnRH analog) + exemestane (competitive inhibitor)
more effective ovarian suppression than tamoxifen in pre-menopausal
Side effects tamoxifen
Menopausal symptoms
Endometrial cancer 4/1000
DVT/PE 4/1000
Side effects aromatase inhibitors
Menopausal symptoms
Osteoporosis
Myalgia/Arthralgia
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SHOULD I TAKE ENDOCRINE TREATMENT?
IF SIDE EFFECTS TOLERABLE
Reduces recurrence/mortality/contralateral cancer
Use online predict tool to help your patient decide
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BREAST CANCER TREATMENT
NEO-ADJUVANT CHEMOTHERAPY?
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pCR more likely if:
• age <40y
• IDC
• Grade 3
• High Ki67
• ER negative
• HER2+ (upto 60%)
• triple negative (40-50%)
SHOULD I HAVE CHEMOTHERAPY BEFORE SURGERY?
40-60% respond to neoadjuvant chemotherapy
6 months chemotherapy administered prior to surgical intervention
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Down size tumour
• ↑clear margins
• mastectomy → BCS
• immediate reconstruction
• increased nipple preservation
NEOADJUVANT CHEMOTHERAPY
Does NOT change DFS or OS
Down stage positive axilla
• less bulky axillary dissection
• can do SNB post neoadjuvant
• Less arm/breast lymphoedema
Buys time
• genetics testing
• plastics consult
• complete pregnancy
• prognosis determinant
Surgical complications
don’t delay post-op
chemo administration
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SHOULD I HAVE CHEMOTHERAPY BEFORE SURGERY?
• Can’t resect
• Psychologically can cope
• BCS or immediate reconstruction if tumour responds well
• Accept that 40-60% chance tumour may not respond
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TAKE HOME POINTS
(4) IORT Eligible, can afford, convenience
Non inferior; 20% EBRT
(5) Chemo decisions Use predict tool to help your patients decide
(6) Endocrine therapy Decrease mortality/recurrence/contralateral Ca
Use predict tool
(7) Neoadjuvant chemo No survival advantage
More operable, more operative options, buys
time, avoids delays to post-op chemo
40-60% response
Psychologically difficult for patients
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COSMESIS
ANAPLASTIC LARGE CELL LYMPHOMA?
RED BREAST SYNDROME?
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ROLE OF RECONSTRUCTION
• Survivors of breast cancer living longer
• 10% of breast cancer surgeon’s practice requires reconstruction or oncoplastics
• 33% eligible choose to have reconstruction surgery
• 82% psychosocial improvement post reconstruction
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ANAPLASTIC LARGE CELL LYMPHOMA
WHAT IS IT?
• non Hodgkins lymphoma subtype of
implant capsule
• 1/10000-30000 textured implant
• 1/60000 non textured implant
• No difference if fill is saline or silicone
https://associationofbreastsurgery.org.uk/clinical/bia-alcl/
HOW DO I DIAGNOSE IT?
• High index suspicion
• 50% occur 7- 8y post op
• Sudden seroma formation &
normal capsule on imaging
TREATMENT?
• CD30 positive & ALK negative on USS aspirate
• Implant removal + capsule excision
• Rarely chemo/radiation
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• Implant reconstruction with biological mesh
POST RECONSTRUCTION RED BREAST SYNDROME
• Why use mesh – support and shape, one step implant recon,
expander expansion faster
• Types of mesh – biological (Permacol Bovine, Alloderm
human) OR synthetic (TIGR vicryl, Tiloop titanised
polypropylene)
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• Delayed hypersensitivity reaction to a foreign body (mesh)
• Location – lower pole over mesh, min tender
• No fever, elevation of WBC, mild CRP, not unwell
• Antibiotic resistant localized redness of the post recon breast
• Treatment – removal of the ADM
• Prevention – no mesh or synthetic mesh
POST RECONSTRUCTION RED BREAST SYNDROME
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OTHER ISSUES
CONTRACEPTION/HRT?
FERTILITY?
LYMPHOEDEMA?
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CONTRACEPTION/HRTGroup
Normal population risk OCP no significant increased risk
HRT – increased risk after 10y use estrogen only (combined 2-3y)
High risk patient* OCP – controversial use <5y and age >30y no increase risk
Copper IUCD (12y; 99% effective)
Post breast cancer treatment Avoid pregnancy 3years
Behavioural/Barrier 15-33% failure
Chemotherapy – infertility (40% <40y and 80% older)
Copper IUCD
On tamoxifen – can use Levogestrol IUD (Mirena 5-7y)
Surgical sterilization - <30y 18x reversal; 8x IVF requests)
Progestin Pill – can’t have IUCD or pregnancy in 3-5y
Implant – not enough info
Menopausal symptoms post
breast cancer treatment
Non hormonal first
Topical vaginal estrogens are ok
Estrogen patch – not enough information
Oral HRT – not recommended
* Cancer Epidemiol Biomarkers Prev 2006;15(10). October 2006
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• Egg banking important if the patient wants to have
further children
• Not publically funded if the woman already has children
FERTILITY
APPROXIMATE COST
• $11000 to harvest
• $264 per year to store
• $4400 to have IVF
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• <3% sentinel node biopsy
• 20% axillary dissection – worse with radiation as well
• 3% functionally affected
LYMPHOEDEMA
• Pre-clinical detection and treatment results is less
patients developing clinical lymphoedema
• 7% vs 25% *
• * BMJ 2010 RCT
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• Circumference
• Volume - Bioimpedence scan (L-DEX) – electric signal travel time
LYMPHOEDEMA INVESTIGATION & TREATMENT
• Exercise
• Massage
• Compression stockings
• Avoid dependent position
• Avoid weight gain
• Prevent infection and injury
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LYMPHOEDEMA – PRIMARY CARE
HIGH INDEX SUSPICION & EARLY DIAGNOSIS
• Obese/radiation/axillary dissection
• Fullness/heaviness
• Clothing/Jewellery not fitting
• Skin thickening
• Visible swelling – late sign – don’t wait
EARLY REFERRAL TO LYMPHOEDEMA SPECIALIST PHYSIOTHERAPIST
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TAKE HOME POINTS
(8) CosmesisALCL – high index of suspicion seroma 7-8y post implant
(9) HRT post Ca Topical is ok
Patch unsure
HRT not recommended
(10) Contraception post Ca Chemotherapy/Copper IUD/Surgical
(11) Fertility Egg bank free if no kids - expensive
(12) Lymphoedema Early intervention prevents clinical
lymphoedema
Red breast – high index of suspicion mesh implant recon
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LIFESTYLE
• Alcohol reduction
• Smoking cessation
• Healthy eating
• Healthy weight range
• Exercise
• Promote breastfeeding
• HRT
HIGH RISK FAMILY HISTORY RISK REDUCTION GEN MEASURES?
NON MODIFIABLE
• Female
• Age
• Family history
• Personal hx breast cancer
• Breast density
What are our modifiable and non modifiable risk factors ?
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• Surgical management options for breast & axilla
• Adjuvant treatment
• Neoadjuvant treatment
• Reconstruction/Symmetrisation
BREAST CANCER TREATMENT
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First it was the breast
THE DE-ESCALATION OF SURGICAL TREATMENT
Now it is the axilla
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SHOULD I HAVE A PARTIAL MASTECTOMY?
BREAST CONSERVING SURGERY + RADIATION
vs
MASTECTOMY
• Recurrence is the same BCS+radiation vs mastectomy 1-3%
• BCS alone 40% recurrence
YESReasonable chance of clear margins WITH acceptable cosmesis
You can attend radiotherapy
You are comfortable with that decision
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IS A SENTINEL NODE BIOPSY ENOUGH TREATMENT?
SENTINEL NODE BIOPSY
vs
AXILLARY DISSECTION
• Less lymphoedema <3% versus 20%
• Recurrence same <2%
YESNo axillary burden
Low axillary burden in low risk patients WITH adjuvant therapy
• ITC, micromets, 1-2macromets
• No extranodal spread
• Low grade
• Small cancer
• Older patient
• ER+ HER2-
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WHEN TO USE MRI
• Discordance – size discrepancy between mammo and USS
• Lobular Ca – contralateral 10%, multicentric multifocal 10%, 10% mammo-occult
• Mammography occult cancers
• Response to neoadjuvant chemotherapy – if single focus, clipped pre-neoadjuvant and plan for BCS if good response to chem
• Surveillence high risk group age 30-50y
• Surveillence high risk group with dense breasts >50y
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BONE ANTI-RESORPTION THERAPY FOR BREAST CANCER PATIENTS ON AROMATASE INHIBITOR
* Age >65y, ex/smoker, BMI<24, fhx hip fracture, personal hx fragility fracture at age >50y, steroids
BMD (t score) Meaning Risk factors Treatment
T>-1.0 Normal Nil
T>-2.0 Moderate osteopenia No risk factors Exercise
Calcium
Vitamin D
T<1.5 Mild osteopenia 2 risk factors* Exercise
Calcium
Vitamin D
Bisphosphonate
Check BMD 2 yearly
T<-2.0 Severe
osteopenia/osteoprosis
(T<-2.5 osteoporosis)
+/- Risk factors Exercise
Calcium
Vitamin D
Bisphosphonate
Check BMD 2 yearly
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RADIATION REDUCES RECURRENCE
POST-OPERATIVE RADIATION
VS
NO RADIATION
• More than 2 positive nodes (<10% vs 30%)
• Breast conserving surgery (1-3% vs 40%)
• Recurrence is more aggressive (40% mortality)
YESBreast conserving surgery
Cancer with poor prognostic features
• Younger patient
• Higher grade
• Larger
• >2nodes
• Extranodal spread/LVI
• HER2+/triple neg
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CAN I AVOID RADIOTHERAPY AFTER BCS
• Elderly
• <10mm
• Low grade
• ER+
VERY SMALL SELECT GROUP
Awaiting PROSPECT trial
• >50y
• <2cm
• N0/1
• Partial Mastectomy
• margins ≥ 2mm
• preop MRI
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ADJUVANT RADIOTHERAPY
Absolute CI
• pregnancy
• previous radiation (Hodgkin’s)
Relative CI
• Li Fraumeni – radiation induced cancers
• scleroderma & connective tissue disorders
• severe cardiopulmonary disease
• inability to lie supine
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Who might avoid chemotherapy:
• Small tumour
• ER+
• low grade
• low Ki67
• absence of LVI
• <3nodes
• no extranodal spread
ADJUVANT CHEMOTHERAPYNot all patients with positive axillary nodes need chemotherapy
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RECONSTRUCTION OPTIONS – DELAYED VS IMMEDIATE
Who benefits most from immediate reconstruction:
• Patient prefers fewer ops
• No adjuvant treatment
• Neoadjuvant with excellent response
Who should have delayed reconstruction:
• Patient preference cancer out first
• Locally advanced cancer
• Smoking cessation for flap recon
• Weight loss (BMI <30)
• Patient uncertain
No cosmetic
operation is a
one stop shop
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RECONSTRUCTION OPTIONS – AUTOLOGOUS VS IMPLANT
Reconstruction
type
Pros Cons
Autologous Natural texture &
appearance
Blood supply to prior
radiated tissue
Longer operation
longer recovery
more pain
More potential complications
tissue availability
CI if complex prior abdo op
Implant Shorter operation
shorter recovery
shorter hospital stay
difficult to match unilateral
ALCL
Implant related complications
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Down size tumour
• ↑clear margins
• mastectomy → BCS
• immediate reconstruction
• increased nipple preservation
NEOADJUVANT CHEMOTHERAPY
Does NOT change DFS or OS
Down stage positive axilla
• less bulky axillary dissection
• can do SNB post neoadjuvant
• Less arm/breast lymphoedema
• take 3 or more nodes at SNB
• Clip biopsy node pre neoadjuvant and retrieved at SNB
• any residual disease (ITC & micromets inclusive) on SNB gets AND
• Concentric shrinkage
• Single lesion
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RECONSTRUCTION OPTIONS – SINGLE STAGE VS 2 STAGE IMPLANT
Reconstruction
type
Pros Preferred patient Complication
Single stage
(direct to implant
+/- mesh)
One op
Faster recovery
Decrease pain with
ADM, better QOL
Prophylactic surgery
Non ptotic
Cup A- small C
Thick well vascularized
mastectomy flaps
No prior/post op
radiation
30% complication rate implant
loss (15% vs 8%),
flap necrosis (9vs7%)
re-operation (18 vs 14%)
mesh complications
2 stage
(expander then
definitive implant)
Opportunity to correct
Less complications
No prior radiation
Adjuvant treatment
Flap concerns
Ptosis/reduction
<10% complication rate
2nd stage often 6-12mo later
(average 9months)
* smoking, diabetes, prior radiation, steroids, obesity all increase risk of complications
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ONCOPLASTIC FLAPS/MAMMOPLASTY
• Very small breasts – flaps (LICAP/AICAP/LTAP)
• Very large breasts
• No ptosis
• smoker
• diabetic
• Prior radiation
Often need contralateral symmetrisation
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SYMMETRISATION
• No all insurance companies pay for symmetrisation and not all policies cover symmetrisation
• Best not to do at time of cancer operation – radiation will change appearances, complications on unaffected side can delay adjuvant treatment too
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CONTRALATERAL PROPHYLACTIC MASTECOMY
• Insurance cover + genetics tests
• At time of surgery – emotive time
• Delay to adjuvant treatment
• Contralateral increased surveillance post-op
• Psychologist input
Most patients do not need contralateral surgery