1. Treatment of Early Breast Cancer
Frances Wright MD MEd FRCSC

2. Objectives imaging & diagnosis
historical overview of surgical treatment
current practice
breast surgery
axillary staging

3. Radiologic Work-up Common Mammogram Ultrasound Good for young women
Usually targeted
Uncommon
Galactogram
MRI

4. Mammogram

5. 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   

6. Survival and Stage of Breast Cancer

7. 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

8. Mammograms and Cancer

9. Ultrasound of Breast Cancer

10. Magnetic Resonance Imaging

11. 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

12. 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

13. 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

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

15. Imaging
BIRADs classification 1 2 3 4 5
No action
Needs biopsy

16. 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

17. Pathology: Ductal Carcinoma in situ and Invasive ductal Carcinoma
No lymph node involvement
Ductal carcinoma in situ
Potential lymph node involvement
Invasive ductal carcinoma

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

19. The evolution of breast surgery
Halsted
tumour begins small
systematic progression to surrounding tissues
involvement of lymphatics leads to distant spread
local control = cure

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

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

23. The evolution of breast surgery
“Fisherian” theory
breast conservation

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

25. 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%

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

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

28. 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

29. 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

30. Likelihood of having lymph node involvement
Diameter of primary tumour
Percent with positive axillary nodes cm
21 % 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

31. The sentinel node for breast cancer
Cabanas penile cancer and inguinal nodes
Morton melanoma
Krag isotope in breast cancer
Guiliano - blue dye in breast cancer
Albertini - blue dye and isotope

32. 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

33. tumour

34. Radioisotope +/-Blue Dye

35. radioactivity
blue dye

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

37. 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

38. 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%

39. 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):
2Guiliano et al. Ann Surg 1994; 220:
3Veronesi et al. NEJM 2003; 349(6):

40. 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

41. 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

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