Treatment of Early Breast Cancer

Frances Wright MD MEd FRCSC

Objectives

• imaging & diagnosis • historical overview of surgical treatment • current practice – breast surgery – axillary staging

Radiologic Work-up

• Common – Mammogram – Ultrasound • Good for young women • Usually targeted • Uncommon – Galactogram – MRI

Mammogram

Benefits of Mammogram

Some cancers are not found until they reach this size A mammogram can find cancer when it is only this size

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Survival and Stage of Breast Cancer

Mammogram

X-ray of the Breast • No screening tool 100% effective • 85-90% of all breast cancers in women > 50 can be identified on mammogram

Mammograms and Cancer

Ultrasound of Breast Cancer

Magnetic Resonance Imaging

MRI

• Advantage – Not affected by breast density – Can identify occult disease • Disadvantage – Dependent on who does the imaging – Sensitive, not very specific – Need MRI biopsy capability

Breast MRI – Screening…

• Who should get ?

– Screening - evidence • BRCA mutation carriers • Untested 1 st degree relatives of carriers • Family history of hereditary cancer syndrome; risk > 25% – Screening – no good evidence • Prior chest radiation before age 30 (Hodgkins) • Some women with LCIS/atypia

MRI for Surgeons

• Treatment Planning – 3% of contralateral breast cancers are occult to physical exam/ mammo (Lehman 2007) – Occult primary with axillary mets – Paget’s disease of the nipple – Invasive lobular carcinoma – Extent of disease work up – Evaluation of residual disease

3 4 5 6 0 1 2

Breast Imaging Reporting & Data Systems = BIRADS

Interpretation Risk Ca Incomplete assessment Negative Benign 0.05% 0.05% Probably benign Suspicious Highly suspicious Known cancer 2% 15 - 50% 95 - 99% 100%

Imaging

• BIRADs classification

1 2 3

No action

4 5

Needs biopsy

The work-up: Pathology

• Core needle biopsy – Gives more information – – type of cells – invasive vs. non-invasive • Fine needle biopsy – not done as much now – Malignant vs. not malignant – Rule out cyst • Excisional biopsy - uncommon now

Pathology: Ductal Carcinoma

in situ

and Invasive ductal Carcinoma Ductal carcinoma

in situ

No lymph node involvement Invasive ductal carcinoma Potential lymph node involvement

• There must be clinical, radiologic and pathologic agreement (concordance) in diagnosis • If one doesn’t fit – consider surgical excisional biopsy

The evolution of breast surgery • Halsted 1852 - 1922 • tumour begins small • systematic progression to surrounding tissues • involvement of lymphatics leads to distant spread • local control = cure

The evolution of breast surgery • Halstedian principles • radical mastectomy – Breast, pectoralis major and minor and axillary tissue

The evolution of breast surgery • Bernard Fisher • breast cancer systemic at onset • surgery impact is local • lumpectomy + RT = mastectomy

The evolution of breast surgery • “Fisherian” theory • breast conservation

The evolution of breast surgery Halstedian principles radical mastectomy versus “Fisherian” theory breast conservation

Breast conservation

• removal of tumour with a margin of normal tissue • post-operative radiation to reduce local recurrence rates • suitable for clinical stage I-II tumours (< 5cm, mobile) • acceptable cosmetic outcome • equivalent survival to mastectomy • higher local recurrence rate 7-8% vs. 5%

Mastectomy

• large or multicentric tumours • unacceptable cosmesis, small breast : tumour ratio • persistent positive margins with conserving surgery • contraindication to radiation • patient preference

Surgical Treatment of Early Breast Cancer Breast Breast conservation or Mastectomy Axilla Sentinel Node Biopsy possible axillary dissection or Level I/II axillary dissection

Axillary Surgery

• axillary status most significant prognostic indicator • role in determining need for adjuvant therapy • provides local control if nodes involved with tumour • controversial survival benefit

Axillary Lymph Node Dissection • associated morbidities – decrease range of motion, sensory defects, pain – nerve injury – lymphedema of ipsilateral arm (10-15%) • majority of women node negative • no benefit from removal of negative nodes

Likelihood of having lymph node involvement

Diameter of primary tumour

0.5 - 0.9 cm 1.0 - 1.9 cm 2.0 – 2.9 cm 3.0 – 3.9 cm 4.0 – 4.9 cm > 5.0cm

Percent with positive axillary nodes

21 % 33 % 45 % 55 % 60 % 70 % Carter 1989

The sentinel node for breast cancer • Cabanas 1977 - penile cancer and inguinal nodes • Morton 1992 - melanoma • Krag 1994 - isotope in breast cancer • Guiliano - blue dye in breast cancer • Albertini - blue dye and isotope

Sentinel node concept

• first node or nodes in the draining nodal basin most likely to harbour metastases • status of the sentinel node reflects the status of the entire nodal basin • if found to be negative, no further axillary nodes removed • enables staging with less morbidity

tumour

Radioisotope +/-Blue Dye

radioactivity blue dye

Pathological evaluation

• usual evaluation is bi-valve of 10 - 20 nodes • retrieval of fewer nodes (1-3) allows more extensive evaluation – H & E multiple sections – immunohistochemical staining (IHC) – No accepted standard

Sentinel node biopsy for who?

• • • small invasive T1 - T2 tumours clinically node negative contraindicated in – locally advanced or inflammatory • Not as accurate – prior lumpectomy – prior ALND

Sentinel node biopsy by whom?

• • • • • specialized multidisciplinary technique involving surgeon, nuclear medicine and pathology surgeons should be familiar with risks/benefits and perform breast surgery routinely recommended surgeons have performed at least 20 cases with “back up” axillary dissection first should have a localization rate > 90% should have false negative rate < 5%

Sentinel Node Biopsy - evidence?

• multi-institutional validation study using radioisotope 1 • single institution series using blue dye results morbidity 3 2 • over 60 other observational series reporting similar • one randomized control trial to date with 46 mo f/u demonstrating no difference in adverse events & less 1 Krag et al. NEJM 1998; 339(14):941 - 946 2 Guiliano et al. Ann Surg 1994; 220:391- 401 3 Veronesi et al. NEJM 2003; 349(6):546 - 53

Sentinel Node Biopsy - evidence?

• • two large multicentre trials recently completed accrual – NSABP 32 & ACOSOG Z0010 – ACOSOG Z0011 accruing (SLN node positive) objectives: – determine local recurrence and survival in women undergoing sentinel lymph node biopsy only – determine morbidity associated with sentinel lymph node biopsy

Breast Cancer Treatment in the 20th Century: Quest for the Ideal Local-regional Therapy

Radical Mastectomy Extended Radical Mastectomy Modified Radical Mastectomy 1900

Overtreatment

BC + RT Ax LND

I D E A L T H E R A P Y

1950 Radiation Lumpectomy BCT + RT Sentinel Node Biopsy 2000

Summary

• Evolution of breast cancer surgery for more to less • More and more specialized • Less morbidity for patient