Breast Conservative Surgery: An Update How far should we go?

1. Breast Conservative Surgery: An UpdateHow far should we go? • Dr Christina TY Chan • PYNEH

2. Modified radical mastectomy Halstedian radical mastectomy Extended radical mastectomy NSABP B-04 study: Radical mastectomy vs Total mastectomy+ axillary irradiation+/- axillary dissection ??

3. Breast Conservative Therapy • In 1970s • Involvement of “part of the breast” only • Quadrantectomy 2Ablation of tumor with an ample portion of healthy parenchyma 2-3cm margin( Holland principle) • Proposed as far back as the 1930s 1 1 Keynes G. Conservative treatment of cancer of the breast. BMJ 1937;2:643–7 2 Holland R, Veling SHJ, Mravunac M, et al.: Histologic multifocality of Tis, T1-2 breast carcinomas: implications for clinical trials of breast-conserving surgery. Cancer 1985, 56:979–990.

4. Breast Conservative Therapy • In 1969 • Randomized study at Milan Cancer Institute approved by WHO Committee 1Radical mastectomyvsQuadrantectomy • Recruitment in 1973 • Preliminary data in 1977 2 and 1981 3: equal survival rates 1 Meeting of Investigators for Evaluation of Methods and Diagnosis and Treatment of Breast Cancer: Final Report. Geneva: World Health Organization; 1969. 2 Veronesi U, Banfi A, Saccozzi R, et al.: Conservative treatment of breast cancer: a trial in progress at the Cancer Institute in Milan. Cancer 1977, 39:2822–2826. 3 Veronesi U, Saccozzi R, Del Vecchio M, et al.: Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981, 305:6–11.

5. Breast Conservative Therapy • In 1976 • Ramdomized study by the National Surgical Adjuvant Breast and Bowel Project [NSABP B-06] study group Lumpectomy +/- radiation vs Total mastectomy • Lumpectomy + breast irradiation is appropriate Fisher B, Anderson S, Bryant J, et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002, 347:1233–1241.

6. Breast Conservative Therapy • Phase III clinical trials in US and Europe

7. Breast Conservative Therapy • National Cancer Institute (NCI) consensus statement 1991: “…..Breast conservation treatment is an appropriate method of primary therapy for the majority of women with Stage I and II breast cancer and is preferable as it provides survival equivalent to total mastectomy and axillary dissection…..” NIH Consensus Conference. Treatmen to early-stage breast cancer. JAMA 1991;265:391–5

8. In 2002, Milan and NSABP1,2 • Similar 20-year disease-free and overall survival 1Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER et al (2002) Twenty year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233–12412 Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A et al (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mas- tectomy for early breast cancer. N Engl J Med 347:1227–1232,

9. 23 - 50% dissatisfaction 1,2 • 1 A body image scale for us with cancer patient Hopwood P Eur J Cancer 2001:37:189 -97 • 2 Cosmetic evaluation of breast conserving treatment for mammary cancer Van limbergen E Radiother Oncol 1989;16:159-67

10. Breast Conservative Therapy Body Image Psychosocial Sexual Function • Cosmesis Irwig L, Bennets A. Quality of life after breast conservation or mastectomy: a systematic review. ANZ J Surg 1997; 67(11):750–4. Moyer et al 1997

11. Photo x Good BCT Medially located tumours Tumor to breast ratio Weight of the specimen Longer scars Re-excision Sound cosmesis Oncological control

12. Photo x bad BCT Sound cosmesis Oncological control Munshi A. Kakkar S et al. Factors influencing cosmetic outcome in breast conservation. Clinical Oncology (Royal College of Radiologists). 21(4):285-93, 2009 May.

13. Korean paper Woo Chul Noh et al. Ipsilateral Breast Tumor Recurrence after Breast-conserving Therapy: A Comparison of Quadrantectomy versus Lumpectomy at a Single Institution. World J. Surg. 29, 1001–1006 (2005)

14. sphere volume = 4/3πr3 Specific gravity: Water= 1·00 Fat = 0·92 Breast tissue= fibrous and glandular structure= mixture of the two close correlation with estimated volume. 3.4 x 2.4 x 10 % volume: cut-off for predicting cosmesis >12 % volume: poor cosmesis 2 1 R. A. Cochrane et al. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. British Journal of Surgery 2003; 90: 1505–1509 2 Stevenson J, Macmillan RD, Downey S, Renshaw L, Dixon JM. Factors affecting cosmesis after breast conserving surgery. Eur J Cancer 2001; 37(Suppl 5): S31

15. Quadrandectomy photo Lumpectomy photo

16. Local recurrence Oncological control Sound cosmesis

17. 10mm Any negative 5mm 1mm 2mm Consensus ?? • Wide variety of practice patterns 1 • Survey to more than 1,000 surgeons 2 • 351 responses • 67% Community Surgeons 33% University surgeons • Standard: At least 1 mm distance • Annual local recurrence: 0.2-0.4% 3 1 Taghian A, Mohiuddin M, Jagsi R, Goldberg S, Ceilley E, Powell S (2005) Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg 241:629–639 2Sarah L Blair et al. Attaining Negative Margins in Breast-Conservation Operations: Is There a Consensus among Breast Surgeons? J Am Coll Surg 2009;209:608–613 2 Park CC, Mitsumori M, Nixon A, Recht A, Connolly J, Gelman R et al (2000) Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. J Clin Oncol 18:1668–1675

18. Negative margin + + + + + + + x 1mm 2mm + + + + + + + + + + + + + + + + + Positive margin Close at x mm margin

19. 0-7%(median 3%) 3-10%(median 6%) 2-4%(median 2%) Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002; 184:383–93.

20. Retrospective review of pathology report invasive ductal CA up to 39mm (n=582) [Exclude DCIS/ ILC] • 1st OT: Excisional biopsy or lumpectomy • 2nd OT: Lumpectomy or mastectomy Breast Conservative Therapy Kotwall et al. Relationship between initial margin status for invasive breast cancer and residual carcinoma after re-excision. The American Surgeon; Apr 2007; 73, 4; ProQuest Medical Library. 337-343

21. Remaining cancers: small, scattered foci, in situ (60%) • >90% eradicated by standard RT (4,500–5,000 cGy) 1 • Not mandatory for reexcision2,3 • Multifocally/ focally positive or Unknown: re-excision 1 Fletcher GH, Shukovsky LJ. The interplay of radiocurability and tolerance in the irradiation of human cancers. J Radiol Electrol Med Nucl 1975;56:383–400. 2 Deutsch M. The segmental mastectomy margin: do millimeters matter? Int J Radiat Oncol Biol Phys 1991; 21:521–2. 3 Harris JR, Gelman R. What have we learned about risk factors for local recurrence after breast-conserving surgery and irradiation? J Clin Oncol 1994;12:647–9.

22. Conclusion More than enough = better 1 m m Oncological control Sound cosmesis is what really matters