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Published byNorman Lester Modified over 9 years ago
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Hon-chi Yip Department of Surgery North District Hospital
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Definition Multifocal (MF) – multiple tumors in same quadrant (>5cm apart) Multicentric (MC) – multiple tumors in different quadrants Not based on anatomy of breast Increasingly detected due to the widespread use of MRI breast
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1. Monoclonal proliferation of a single mammary carcinoma 2. Multiple independent synchronous tumors in the same breast
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Wide local excision + radiotherapy Established treatment modality for early stage breast cancer No difference in overall, disease-free survival Improved body image and lifestyle score National Institutes of Health (NIH) Consensus Conference statement 1990 BCT as preferred surgical treatment of women with early stage breast cancer NIH Consensus Conference. JAMA 1991;265(3):391-5
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Traditionally contraindicated for BCT Landmark trials for BCT – NSABP B-06, EORTC, Milan etc Exclusion criteria – Multifocal or multicentric disease Increased difficulty to obtain negative margin Potential increase risk of recurrence Fisher B et al. N Engl J Med 2002;347:1233–1241. Veronesi U et al. N Engl J Med 2002;347:1227–1232. van Dongen JA et al. J Natl Cancer Inst 2000;92:1143–1150.
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Allow wide excision for BCT without compromising the natural shape of the breast Integration of plastic surgery techniques for immediate breast reshaping Oncologic efficacy (margin status & recurrence) compare favorably with traditional BCT Results of 298 OPS treated breast cancer ▪ 5 year overall survival 94.6%, DFS 93.7% Recent enthusiasm on BCT in MF / MC disease Staub G et al. Ann Chir Plast Esthet. 2007;53(2):124–34.
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1. Oncological considerations Effect on overall survival Effect on disease recurrence, esp. locoregional 2. Technical considerations Complete excision, negative margin Satisfactory cosmetic result
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Lack of level 1 evidence What are the available evidence in the literature? Medline and PubMed search – keywords: ‘‘Multifocal’’ or ‘‘Multicentric’’ or ‘‘Breast Conservation’’ or ‘‘Mastectomy’’ ‘‘Breast Cancer’’ or ‘‘Ductal Carcinoma In-Situ (DCIS)’’
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Study, yearMF or MCPatients, nLocal recurrence, %Median FU, months Leopold, 1989MF & MC104064 Kurtz, 1990MF & MC612571 Wilson, 1993MF132572 Hartsell, 1994MC273.753 Nos, 1999MF561160 Cho, 2002MF & MC15076 Kaplan, 2003MF & MC36345 Okumura, 2004MF & MC34058 Oh, 2006MF & MC97666 Gentillini, 2008MF & MC476573 Lim, 2009MF147259 Chung, 2012MF1646.1112 Yerushalmi, 2012MF & MC3005.595
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Study, yearMF or MCPatients, nLocal recurrence, %Median FU, months Leopold, 1989MF & MC104064 Kurtz, 1990MF & MC612571 Wilson, 1993MF132572 Resection margins not routinely evaluated Surgery involved gross excision of suspicious masses only No fixed protocol for adjuvant therapy
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Study, yearMF or MCPatients, nLocal recurrence, %Median FU, months Leopold, 1989MF & MC104064 Kurtz, 1990MF & MC612571 Wilson, 1993MF132572 Hartsell, 1994MC273.753 Nos, 1999MF561160 Cho, 2002MF & MC15076 Kaplan, 2003MF & MC36345 Okumura, 2004MF & MC34058 Oh, 2006MF & MC97666 Gentillini, 2008MF & MC476573 Lim, 2009MF147259 Chung, 2012MF1646.1112 Yerushalmi, 2012MF & MC3005.595
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Weissenbacher et al. Breast Cancer Res Treat 2010;122:27-34 Overall survival Chung et al. J Am Coll Surg 2012;215:137-147
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Ustaalioglu BO et al. Am J Clin Oncol 2012;36:580-586
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MF/MC not associated with inferior survival on multivariate analysis Yerushalmi et al. Annals of Oncology 2012;23:876-881
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No comparative survival data on BCT vs mastectomy in MF / MC disease
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Excision of multifocal / multicentric tumors without resulting in significant breast distortion Careful preoperative assessment required
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Routine use of MRI breast in preoperative staging for early CA breast is controversial Meta-analysis showed that MRI could identify additional multifocal / multicentric foci that preclude breast conservation Possibility of false positive finding, unnecessary mastectomy RCT showed no improvement in reoperation rate L Turnbull et al. Lancet 2010;375:563-71 Houssami et al. J Clin Oncol 2008;26:3248-58
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Possible role in confirmed MF / MC disease to rule out additional tumor foci and define extent of disease?
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Size, location and distribution of the lesions Breast volume, ptosis Surgeon preference Single vs multiple wide local excisions Choice of breast restoration Oncoplastic surgical techniques
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When considering BCT, the following factor is contraindication:
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BCT is not absolutely contraindicated in cases of multifocal or multicentric breast cancers Acceptable recurrence rate and survival can be obtained with adequate tumor excision and adjuvant therapy Therapeutic strategy should be individualized based on the feasibility of wide local excision with negative margins and patient’s preference
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1. Monoclonal proliferation of a single mammary carcinoma 2. Multiple independent synchronous tumors in the same breast One small scale series found near identical morphologic and immunohistochemical pattern in 32 multicentric tumor specimens 75% cases had evolutionary related cytogenetically abnormal clone in different tumor lesions from same breast Another study of 24 cases only showed 10 cases of identical histological and immunohistochemical pattern Middleton LP et al.Cancer. 2002 Apr 1;94(7):1910-6. Dawson PJ et al. Hum Pathol. 1995;26:965–969 Texieira MR et al. Br J Cancer 1994;70:922-927
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Excision volume >20% of volume excised – significant risk of deformity OPS allow for significantly greater excision volumes while preserving natural breast shape Tumor location Zones of high risk / low risk of deformity Glandular density Lower risk of necrosis in mobilizing dense glandular breast versus low density breast with major fatty composition
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Level 1 <20% breast volume excised Level 2 20-50% breast volume excised
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Glandular mobilization Intra-mammary flap reconstruction NAC reposition
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Only posterior undermining leaving skin attached Mammoplasty techniques
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St. Gallen International Breast Cancer Conference, Switzerland, Mar 2013 Treatment recommendation after reviewing latest evidence
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