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 www.obsp.on.ca Some cancers are not found until they reach this size           A mammogram can find cancer when it is only this size    www.obsp.on.ca

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 Disadvantage 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 1st 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

Breast Imaging Reporting & Data Systems = BIRADS Interpretation Risk Ca Incomplete assessment 1 Negative 0.05% 2 Benign 3 Probably benign 2% 4 Suspicious 15 - 50% 5 Highly suspicious 95 - 99% 6 Known cancer 100%

Imaging BIRADs classification 1 2 3 4 5 No action 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 No lymph node involvement Ductal carcinoma in situ Potential lymph node involvement Invasive ductal carcinoma

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 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 Percent with positive axillary nodes 0.5 - 0.9 cm 21 % 1.0 - 1.9 cm 33 % 2.0 – 2.9 cm 45 % 3.0 – 3.9 cm 55 % 4.0 – 4.9 cm 60 % > 5.0cm 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 radioisotope1 single institution series using blue dye 2 over 60 other observational series reporting similar results one randomized control trial to date with 46 mo f/u demonstrating no difference in adverse events & less morbidity 3 1Krag et al. NEJM 1998; 339(14):941 - 946 2Guiliano et al. Ann Surg 1994; 220:391- 401 3Veronesi 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 Overtreatment Extended Radical Mastectomy Radical Mastectomy Modified Radical Mastectomy BCT + RT Sentinel Node Biopsy BC + RT Ax LND I D E A L T H E R A P Y 1900 1950 2000 Radiation Lumpectomy

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