1. BRIEF OVERVIEW ON BREAST CANCER AND SURGICAL MANAGEMENT
PETER W. BLUMENCRANZ, M.D., F.A.C.S.
Surgical Oncology
Medical Director, The Comprehensive Breast Care Center of Tampa Bay
November 27, 2018

2. HISTORY OF BREAST CANCER SURGERY
1846 discovery of ether anesthesia
Dr. William Halstead, Johns Hopkins
The radical mastectomy
Father of modern breast surgery
The bigger the operation the better the cure
This concept lasted 70+ years despite earlier dx of breast cancer

4. THE 1980’s BREAST CONSERVATION
Lumpectomy, axillary node dissection, and post-operative radiotherapy
equal survival to mastectomy (NSABP B-06)

5. THE 1990’s PERCUTANEOUS IMAGE-GUIDED BIOPSY
Stereotactic
Ultrasound Guided
Minimally invasive biopsy ideal for subsequent lymphatic mapping

6. 2000 AND BEYOND Sentinel Lymph Node Biopsy
Accelerated Partial Breast Irradiation
Gene Signatures- for prognosis and prediction

7. Breast Anatomy ducts lobules dilated section of duct (to hold milk)
nipple
fat
pectoralis major muscle
chest wall / rib cage
Enlargement:
normal duct cells
basement membrane
lumen (center of duct)
Enlargement

8. SOME BASIC TERMINOLOGY
Non-invasive Carcinoma (DCIS/LCIS)
Infiltrating Ductal Carcinoma
Infiltrating Lobular Carcinoma
Inflammatory Breast Cancer

9. BREAST IMAGING
Mammogram 2D, 3D
Breast Ultrasound
Breast MRI

10. BREAST BIOPSY Stereotactic breast biopsy U/S guided Core needle biopsy
Wire localization biopsy
MRI guided breast biopsy

11. LOCALIZATION OF NON-PALPABLE LESIONS
Ultrasound localization
Wire localization
Specimen ultrasound vs. Mozart (3D tomosynthesis) digital specimen xray
Savi Scout Reflector (micro radar)

12. SCOUT Reflector

13. Savi Scout
SCOUT uses radar waves designed specifically to penetrate breast tissue
Contact handpiece to breast surface to transmit radar signal to the reflector

14. BREAST RESECTION Partial Mastectomy Mastectomy Simple Modified Radical
Skin Sparing/Nipple Sparing

15. INDICATIONS FOR PARITAL MASTECTOMY
Tumor size
Breast size
Multifocal cancer
Review and resolve any imaging questions
Followed by radiation therapy – WBRT or APBI

16. ACCELERATED PARTIAL BREAST IRRADIATION-BRACHYTHERAPY
Kuske Template
Balloon Brachytherapy
Interstitial Multi-Catheter Brachytherapy
So let’s talk about how Interstitial Multi-Catheter Brachytherapy led to the development of MammoSite Balloon Brachytherapy.

17. ACCELERATED PARTIAL BREAST IRRADIATION (APBI)
Began using MammoSite in February 2003
Allows radiation therapy to be completed in 5 days rather than 6 weeks. Used for early stage node negative breast cancers.
Treated over 1200 patients with brachytherapy catheters
Initially under ASBS registry study (IRB Protocol)
Currently not under study
Patient demand for APBI has increased
_ Now using multilumen catheters

18. ADVANTAGE OF LOCAL BREAST RADIATION
Eliminate scheduling problems with systemic chemotherapy.
Intensifying radiotherapy to the tissue at greatest risk for subclinical disease may further reduce local recurrence rates.
Cosmetic outcome may be improved because skin and integral breast parenchymal doses are lower, especially for women with large breasts.
Convenience to patient (eg. less time off from work, reduced need for transportation, etc.)

19. Patient Flow – Example 12-Day Plan
Mon
Tues
Wed
Thur
Fri
Sat
Sun 1
Lumpectomy
w/CED 2 3 4
(POD 3)
Pathology
&
MammoSite Placement 5
Rad Onc
CT Scan
Tx Planning 6 7 8
Treatment
3.4 Gy
BID 9 10 11 12
(POD 11) Treatment
Removal
Here is a calendar that illustrates an example of a 12-day patient flow plan.

20. INDICATIONS FOR MASTECTOMY
Large tumor
Multicentric cancer
Complex imaging
Difficult breast exam
Psychological factors

21. PROPHYLACTIC MASTECTOMY
Psychological factors
Risk of spread from opposite side
BRCA positive

22. BRCA MUTATION In 5-10% of all breast cancer patients
Hereditary breast and ovarian cancer syndrome
Up to 87% chance of breast ca and 44% chance of ovarian ca by age 70
Up to 50% chance of breast ca by age 50
Nextgen sequencing – gene panel testing

23. ONCOPLASTIC SURGERY
Combines sound oncologic surgical principles with plastic surgical techniques.
Combined with neoadjuvant chemotherapy and breast imaging, oncoplastic techniques may further increase breast conservation rates.
This should be a team effort of the surgical oncologist and plastic reconstructive surgeon.

25. Scout reflectors bracket area

30. SKIN SPARING MASTECTOMY
For patients requiring mastectomy, skin-sparing with immediate reconstruction is widely practiced with excellent oncologic control and cosmesis.
SSM removes the nipple and areola but saves most of the skin envelope for reconstruction.
What about nipple-sparing?

31. NIPPLE-SPARING MASTECTOMY
Patient selection is critical.
Generally, for more peripheral tumors 3cm or less.
Exclusions: extensive multicentric disease, tumors within 2cm of the nipple areolar complex (NAC), significant ptosis.

33. NIPPLE-SPARING MASTECTOMY
Around 5-10 % chance of loss of NAC due to positive bx on frozen or permanent section or due to vascular compromise.
Loss of nipple sensation.
What about local recurrence in the breast and NAC?

34. WHAT IS SENTINEL LYMPH NODE BIOPSY
Selective node biopsy of the first draining node(s)
Mapping the lymphatic drainage of a tumor
Reduces the morbidity of axillary node dissection e.g.lymphedema, numbness, risk of lymphangitis, seroma, decreased mobility

36. LYMPHOSINTIGRAPHY

39. BRIEF OVERVIEW ON BREAST CANCER AND SURGICAL MANAGEMENT
PETER W. BLUMENCRANZ, M.D., F.A.C.S.
Surgical Oncology
Medical Director, The Comprehensive Breast Care Center of Tampa Bay
December 12, 2017

40. AXILLARY NODE DISSECTION
Removal of all nodes under the arm
When to do and not to do
Indications have changed in 2011

41. ACOSOG Z0011 TRIAL
Initially published in 2011 and 10 year follow-up published Sept

42. BREAST CANCER TREATMENT OPTIONS
Who needs what?
How do we decide?
Endocrine Therapy
Mastectomy
Chemotherapy
There are a multitude of treatment options for breast cancer, and proper treatment involves a multidisciplinary approach. The surgeon is most often the quarterback, advising and determining which treatments will be needed along with the help of the specialists on that team. As you can see, there are many options for these patients, and they need guidance to navigate appropriately through the choices in order to obtain the best outcomes. Physicians need guidance as well in order to provide the best combination of care for each individual patient.
Breast Conservation
Radiation 5

43. MOLECULAR DIAGNOSTICS
OncotypeDx – 21 gene assay – paraffin embedded tissue
Mammaprint – 70 gene assay- fresh tissue or paraffin embedded
Blueprint – 80 gene molecular subtyping