spotlights on the surgery role at san...
TRANSCRIPT
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
APPROPRIATE SURGICAL MARGINS
Moran et al, 2014
appropriate margin: NO TUMOR ON INK
CURRENT SSO/ASTRO GUIDELINES ON MARGINS:
Is this correct?
APPROPRIATE SURGICAL MARGINS
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
APPROPRIATE SURGICAL MARGINS
New meta-analysis
•55.302 patients
(>20.000 additional patients from previous meta-analysis
•7.2 years median follow-up
F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
APPROPRIATE SURGICAL MARGINS
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)
F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
APPROPRIATE SURGICAL MARGINS
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
F. Vicini et al Beth Israel Deaconess Medical Center - Harvard medical school
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
APPROPRIATE SURGICAL MARGINS
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
APPROPRIATE SURGICAL MARGINS
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
Spotlights on surgical issues:
•Margins
•Locoregional recurrence •Axillary management
•Local therapy in ABC
San Antonio Breast Cancer Symposium, 12/2017
LOCOREGIONAL RECURRENCE
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
M. Morrow Memorial Sloan Kettering Cancer Center
Good results only in low risk patients
(ER+, HER2-, initial negative margins)
REPEAT LUMPECTOMY FOR IBTR
• Not the standard of care
• Reported high rates of additional LR
M. Morrow Memorial Sloan Kettering Cancer Center
REPEAT LUMPECTOMY FOR IBTR
M. Morrow Memorial Sloan Kettering Cancer Center
REPEAT LUMPECTOMY FOR IBTR
Nothing new
as compared to NCCN 2017 guidelines!!
LOCOREGIONAL RECURRENCE
REOPERATIVE SENTINEL NODE BIOPSY
M. Morrow Memorial Sloan Kettering Cancer Center
• 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
REOPERATIVE SENTINEL NODE BIOPSY
M. Morrow Memorial Sloan Kettering Cancer Center
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
REOPERATIVE SENTINEL NODE BIOPSY
M. Morrow Memorial Sloan Kettering Cancer Center
Spotlights on surgical issues:
•Appropriate surgical margins
•Locoregional recurrence
•Axillary management •Local therapy in ABC
San Antonio Breast Cancer Symposium, 12/2017
SNB IN EARLY BREAST CANCER
SNB IN EARLY BREAST CANCER
MICROMETASTATIC SLN
SNB IN EARLY BREAST CANCER
V. Galimberti IEO, Milan
SNB IN EARLY BREAST CANCER
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
V. Galimberti IEO, Milan
MICROMETASTATIC SLN
SNB IN EARLY BREAST CANCER
Arms characteristics well matched V. Galimberti
IEO, Milan
SNB IN EARLY BREAST CANCER
Appropriate balance of adiuvant therapies
V. Galimberti IEO, Milan
10 years results
SNB IN EARLY BREAST CANCER
V. Galimberti IEO, Milan
SNB IN EARLY BREAST CANCER
Low incidence of axillary events disregarding type of surgery
V. Galimberti IEO, Milan
No differences between the AD
and no AD groups for any endpoint
No ALND is acceptable
even in patients scheduled for mastectomy
SNB IN EARLY BREAST CANCER
MICROMETASTATIC SLN
V. Galimberti IEO, Milan
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!
SNB IN EARLY BREAST CANCER
(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
SNB IN EARLY BREAST CANCER
T. King Dana Farber / Brigham and women’s - Harvard medical school
SNB IN EARLY BREAST CANCER
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
T. King Dana Farber / Brigham and women’s - Harvard medical school
SLNB procedure of choice for axillary stadiation
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
FEASIBILITY OF SLNB AFTER NAD
cN0 – ycN0 PATIENTS
Acceptable SLN identification rate even after NACT
SNB IN NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
Acceptable identification and false negative rates
(only if ≥3 SLN are removed)
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
cN+ – ycN0 PATIENTS
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
INTERPRETATION OF SLNB
AFTER NAD
SLNB in cN+ – ycN0 patients
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
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
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
Significance of micromets and ITCs
Clear indication for ALND
SNB AFTER NEOADJUVANT TREATMENT
T. King Dana Farber / Brigham and women’s - Harvard medical school
ypN+ PATIENTS
Waiting for more studies
for stronger recomendations
SNB AFTER NEOADJUVANT TREATMENT
AXILLARY TREATMENT COMPLICATIONS
A. Kuijer
Dana Farber / Brigham and women’s - Harvard medical school
AXILLARY TREATMENT COMPLICATIONS
A. Kuijer
Dana Farber / Brigham and women’s - Harvard medical school
AXILLARY TREATMENT COMPLICATIONS
A. Kuijer
Dana Farber / Brigham and women’s - Harvard medical school
AXILLARY TREATMENT COMPLICATIONS
Spotlights on surgical issues:
•Appropriate surgical margins
•Locoregional recurrence
•Axillary management
•Local therapy in ABC
San Antonio Breast Cancer Symposium, 12/2017
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
S. Khan
Lynn Sage Breast Center & Dept of Surgery - Northwestern University
OLIGOMETASTATIC BC TREATMENT
THANK YOU !