Dr Sandhya PillaiGeneral & Oncoplastic Breast Surgeon

Shorewest Surgical Care

14:00 - 14:55 WS #56: Issues Around Breast Cancer

15:05 - 16:00 WS #68: Issues Around Breast Cancer (Repeated)

BREAST CANCER ISSUESCURRENT QUESTIONS

Dr Sandhya Pillai

General and Oncoplastic Breast Surgeon

CMDHB

Shorewest Surgical Care

Auckland Breast Centre

BREAST CANCER MANAGEMENT

1800s

Haldsted

Radical mastectomy

1900s

extended

radical mastectomy

1976

NSABP B-04

Fisher et al

Total mastectomy +

radiation

2007

NSABP 32

SNB alone safe in node

neg2002

AJCC classification of

micromets & ITC

1998

NZ Breast screening

2007

Mainstream

neoadjuvant

therapy

2000

Breast

cancer

subtypes

1962

Eagan

1st mammo Cancer

1985

NSABP B-06

Fisher et al

Partial mastectomy +

rad vs total for <4cm

1986

European Breast screening

1970s

Neoadj

trials

1895

Czerny flank lipoma transfer

1906

Tanzini

Lat dorsi flap

1982

Expanders

2010

Clough quadrant based

oncoplastic atlas

2000

Immediate

reconstruction

1963

Silicon gel implant

Late 1980s

TRAM flap

1990s

DIEP flap

1980s

Extended Lat dorsi for volume

Has changed

markedly over

the last 220 years

Breast

partial or total mastectomy

BREAST CANCER CHOICES

Axilla

SNB or AND

Adjuvant

chemotherapy

Neoadjuvant

Adjuvant

radiotherapy

Adjuvant

endocrine

therapy

Reconstruction –

immediate/Delayed

Reconstruction –

Autologous/Implant

Therapeutic

mammoplasty

Symmetrisation

Multidisciplinary

team pivotal

role

GP & BCN

BREAST CANCER ISSUES

CURRENT QUESTIONS

Screening

Diagnosis

Genetics

Treatment

Cosmesis

Contraception/HRT/Fertility

Lymphoedema

BREAST SCREENING

Breast Screen

Aotearoa

45-69y

2 yearly

mammogramsHOW YOUNG?HOW FREQUENT?

WHAT AGE TO SCREEN BETWEEN?

US Surveillance, Epidemiology & End Results

US Preventive Task Force Recommendation 2016

Canadian Taskforce Recommendations 2011

Age % of breast cancers that

occur in each age group

<40y 5%

40-49y 16%

50-59y 25%

60-69y 26%

70-74y 9%

75y plus 19%

Reduction in Breast cancer

mortality

Number needed to screen

- -

15% 750-2108

30% 910

32% 432

27% 450

No significant reduction -

HOW FREQUENTLY TO SCREEN?

Age Number

needed to

screen

RR of cancer

death

<2y

screening

RR of cancer

death

≥2y

screening

Sojourn time Doubling

time

40-49y 750-2108 0.82 1.04 1-25-2.5y 80days

50-69y 432-910 0.86 0.67 3-6.5y 157days

70y plus 450 - 0.68 - -

False Positives

5-15% mammograms result in recalls/further testing and 8/10 of those are benign

Higher false positive rate in younger women

2 yearly screening reduces false positives by 50% in 45-74y

WHEN & HOW OFTEN TO SCREEN?

Age Recommendation Why

<40y No routine screening Low risk Ca

Risk of false positives

Risk of longer cumulative radiation exposure

40-49y BCFNZ yearly till 50y*

1-2yearly mammogram

Mortality reduction (<2y vs 2 yearly)

Sojourn time shorter

Doubling time shorter

Increased false positive

Increased over diagnosis

Fine line risk-benefit

50-69y 2 yearly No mortality reduction 1 vs 2 yearly

70-74y 2 yearly If well and life expectancy >10y **

Reduction in cancer mortality/ low NNS

75y + or life

expectancy <10y

No benefit to screening

By choice/wellness

*High NNS so not cost effective for public health screening through Breast Screen Programme

*Breast cancer foundation NZ recommendation yearly from 40y

** Lee S et al British Medical Journal 2013

BREASTCANCER

DIAGNOSISClinical

Radiological

Pathological

TOMOSYNTHESIS VS MAMMOGRAPHY

“Top health insurer won't give Kiwi women access to breast cancer breakthroughNZ Herald 18 Sep, 2016 5:00am

Digital tomosynthesis creates clearer, more detailed 3D images of breast tissue than a standard 2D mammogram, uncovering cancers at an earlier stage and increasing the odds of survival and recovery.”

TOMO VERSUS MAMMO

• Machine moves in an arc

• 7 seconds, 11 pictures

• Reconstruct 3D images – 1mm slices

• Less compression needed to dissipate overlap of tissues

• IT issues – needs more storage and better connectivity

• Longer to read

• $100 more than 2D mammograms

TOMO VERSUS MAMMO

There is evidence:

• 40% increase detection

• 30-40% decrease in recall US

• Useful in further assessment of lesions

• Radiation dose similar now 2.95-3.6Gy

No evidence:

• Decrease in breast cancer mortality

• Reduction in interval cancers

• Reduction in overdiagnosis – more sensitive

• Use as first line population screening tool

Eur Radiol. 2019 Mar;29(3):1175-1186. Aase HS et al.Clin Radiol. 2016 Feb;71(2):141-50.

TO HAVE OR NOT TO HAVE TOMOSYNTHESIS?

YES if

available/accessible/affordable

Increase detection

Less recall

Radiation same

More comfortable

No survival benefit

GENETICS

HIGH RISK MANAGEMENT?WHICH MUTATIONS MATTER?WHO TO REFER FOR TESTING?

HEREDITARY BREAST CANCER

• 5% of breast cancer is hereditary

• 20% of women have a family history

• Most breast cancer due to sporadic somatic mutations

SURVEILLENCE

HIGH RISK PATIENT MANGEMENT

• Does not reduce risk – picks up cancers early

• Annual tomosynthesis from 30y (mammogram 40y)

• Annual MRI 30y till 50y (10y younger than youngest)

• Reassess at 74y or if life expectancy <10y

• 6monthly Ca125 and USS – no improved survival

CHEMOPROPHYLAXIS• Tamoxifen – risk reduction 40% over 5y• SE poor compliance

• Reversible for fertility – stop for 3 months

RISK REDUCTION

MASTECTOMY

• >90% breast cancer risk reduction

• Psychological/emotional/breastfeeding/sexual/

self esteem implications

RISK REDUCTION

SALPINGO-OOPHRECTOMY

• Breast cancer risk reduction 50%• Ovarian Ca >90%

• Age 35-40y – fertility considerations

• can have HRT post op up to 5y

WHICH MUTATION MATTERS?I thought

there was

only BRCA

BRCA1PALB

CHEKATM

NBN RAD 50

HIGH RISK AUTOSOMAL DOMINANT MUTATIONSSYNDROME GENE BREAST CA

LIFETIME RISK

12%

OVARIAN CA

LIFETIME RISK

1.3%

OTHER CANCERS OTHER FINDINGS

Breast ovarian

syndrome

BRCA 1 80%

40% contralat

40% Pancreas, prostate, colon

Breast ovarian

syndrome

BRCA 2 60%

30% contralat

25% Male breast, melanoma,

pancreas, FA

Li Fraumeni P53 40% by age 60y

(early onset)

medullary

breast Ca

n/a Sarcoma, brain, adrenocortical Radiosensitive so MRI

not mammograms

Peutz Jegher STK 11 45% by age 70y 20% Cervical & endometrial 10%

Some form of Ca by age 60y

Pancreas, liver, lung

Pigmentation

Hamartomas

Cowden PTEN 50-85% n/a Follicular thyroid 7%

Skin 4%; colon/endometrial 1%

Hamartomas

Neurodev problems

Trichilemmonas

Hereditary diffuse

gastric cancer

CDH1 Lobular breast ovarian Diffuse gastric Ca

Colorectal

Thyroid

OTHER SIGNIFICANT MUTATIONS

Moderate risk genes

• PALB2, CHEK, ATM

• Variable penetrance: Significant risk if combined with other genes or

environmental factors

• Risk reduction guidelines not well established – case by case

New discovery genes & Variants of uncertain significance

• BARD1, BRIP1, FANCC, NBN, RAD51C, RAD51D, XRCC2, MRE11A, ,NBN, RAD50

…..and the list continues to grow

• With further research – may become significant or normal variants

• Do not base treatment decisions – consider genetics re-referral 5y

WHAT TO DO WITH PATIENT WITH MUTATION?

HIGH RISK TREATMENT • Mutation based for the 6 high risk mutations

• Family history based for moderate risk

mutations and variants of uncertain

significance

REFER ALL MUTATIONS TO HIGH RISK CLINICS

- Genetics

- Breast

- Gynaecology

FAMILY HISTORY – WHO TO REFER?

GUT INSTINCTWHO TO REFER?

• 45y old with triple negative breast cancer no family

history

• 72y old with prior right breast cancer now thyroid

cancer, colorectal and left breast cancer on patient

initiated PET

• 40y with maternal grandmother breast cancer age

70s and paternal aunt breast cancer age 60s

• 35y old with grandmother 70y and mother 39y with

breast cancer

• 35y old Maori lady with 2 uncles with gastric cancer

and mother with breast cancer, father colon cancer,

sister thyroid cancer

• 65y old with triple negative cancer and no family

history

YES

YES

YES

NO

NO

YES

Auckland regional health pathwayshttps://aucklandregion.healthpathways.org.nz/index.htm

EVIQ website guidelines https://www.eviq.org.au/cancer-genetics/referral-guidelines/1147-general-

practitioner-referral-guidelines-for

FAMILY HISTORY RISK ASSESSMENT GUIDELINES

EVIQ GENETICS REFERRAL CRITERIAREFERRAL BASIS Criteria

Family history Known mutation in the family

3 or more 1st/2nd degree relatives with breast or ovarian Ca

2 or more 1st/2nd degree relatives with breast or ovarian Ca AND ≥ 1 of following▪ Ashkenazi Jew▪ One relative breast/ovarian <50y▪ Breast & Ovary in same relative▪ Bilateral breast in same relative▪ Male relative with breast Ca

Personal history of

breast cancer

AND ≥ 1 of

following

• Family or personal hx suggestive of a syndromeBilateral breast and one breast <50y

• Triple negative <50y• Breast cancer <40y• Male with breast cancer• Jewish ancestry• Family history ovarian Ca• Multiple primary cancers• Rare cancers

• https://www.eviq.org.au/cancer-genetics/referral-guidelines/1147-general-practitioner-referral-guidelines-for

FRA-BOC tool (Cancer Australia)https://canceraustralia.gov.au/clinical-best-practice/gynaecological-

cancers/fra-boc/evaluate

BOADICEA

More involved online tool for larger family histories – for researchhttps://pluto.srl.cam.ac.uk/cgi-bin/bd3/v3/bd.cgi

FAMILY HISTORY RISK ASSESSMENT TOOLS

GENETICS- WHO TO REFER?

FAMILY HISTORY

BREAST CANCER

• Mutation in family

• ≥3 1st/2nd degree relatives

• ≥ 2 1st/2nd degree relatives + 1 other

high risk factor

PERSONAL HISTORY

BREAST CANCER• Plus 1 other high risk factor

* Private $750, 6 weeks

MUTATION

TAKE HOME POINTS

(1) Screening 40-49y yearly if affordable

70-74y 2 yearly if affordable

50-74y no benefit to screening <2y

(2) Diagnosis Tomosynthesis if affordable + available

No survival advantage

Less recall/better detection/more comfy

(3) Genetics Refer if mutation/EVIQ family hx criteria

Use FRA-BOC tool

Refer to genetics, gynae, breast

Cost $750, 6 weeks private

BREAST CANCER TREATMENT

INTRA-OPERATIVE RADIOTHERAPY?

CHEMOTHERAPY/ENDOCRINE/BOTH ?

NEOADJUVANT CHEMOTHERAPY?

BREAST CANCER TREATMENT

INTRA-OPERATIVE RADIOTHERAPY?

RADIOTHERAPY OPTIONS

Hypofractionation

• 3 weeks 14-16 fractions 39- 42Gy

non inferior recurrence and less side effects

• T1-3 N0-1 (START A & B trials)

Traditional EBRT

• 6weeks 30 fractions 50Gy

• High grade, high nodal burden

Partial Breast Radiation

• 10 fractions 36-40Gy

• 90% recurrence is in same quadrant

• Less cardiorespiratory SE

• Select group

L

E

S

S

R

A

D

I

A

T

I

O

N

• Elderly• Small cancer• Low grade

• ER +

SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?

• 90% recurrence is in index quadrant• 20Gy over 20-45min at time of surgery

Who qualifies:

• <3cm

• suitable for BCS

• age >45y

• node negative

• grade1-2

• ER+

SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?

PROS

• Non inferior recurrence/survival

• Less side effects

• Risk adaptive• Decreased skin SE

• Increased convenience

CONS

• 20% have further EBRT

• 10-15% of breast cancer patients

• New machinery in theatres

• Education

• Cost $8000

SHOULD I HAVE INTRA-OPERATIVE RADIOTHERAPY?

• If you are eligible

• You can afford IORT

• You want convenience

• You lose nothing by having IORT

• You may still need EBRT 20%

BREAST CANCER TREATMENT

CHEMOTHERAPY?

ENDOCRINE THERAPY?

SHOULD I HAVE CHEMOTHERAPY?

Straightforward decision in :

• Majority good features: small, low grade ER+

• Majority bad features: triple neg/HER2+/nodes+++

Difficulty is in:

• Mix of good AND bad prognostic features

Not all patients with positive axillary nodes need chemotherapy

SHOULD I HAVE CHEMOTHERAPY?

• Predict

http://www.predict.nhs.uk/predict_v2.0.html

• Adjuvant online

http://www.adjuvantonline.com

• life math

http://www.lifemath.net/cancer/breastcancer/therapy/

Genomic

stratification

tests

Not routine

in NZ

SHOULD I HAVE CHEMOTHERAPY?

Predict http://www.predict.nhs.uk/predict_v2.0.html

Grade 1

1/12

nodes

Grade 3

5/12

nodes

52y old

35mm

ER+, HER2-

SHOULD I HAVE CHEMOTHERAPY?

USE ONLINE TOOLS TO HELP PATIENT DECIDE

Does survival benefit outweigh side effects in the patient’s eyes

• ↓ recurrence by 47%

• ↓ mortality by 26%

• ↓ contralateral breast Ca by 47% for ER + tumours

• Aromatase inhibitors slightly more effective in post-menopausal than

tamoxifen

SHOULD I TAKE ENDOCRINE TREATMENT?

Zoladex (GnRH analog) + exemestane (competitive inhibitor)

more effective ovarian suppression than tamoxifen in pre-menopausal

Side effects tamoxifen

Menopausal symptoms

Endometrial cancer 4/1000

DVT/PE 4/1000

Side effects aromatase inhibitors

Menopausal symptoms

Osteoporosis

Myalgia/Arthralgia

SHOULD I TAKE ENDOCRINE TREATMENT?

IF SIDE EFFECTS TOLERABLE

Reduces recurrence/mortality/contralateral cancer

Use online predict tool to help your patient decide

BREAST CANCER TREATMENT

NEO-ADJUVANT CHEMOTHERAPY?

pCR more likely if:

• age <40y

• IDC

• Grade 3

• High Ki67

• ER negative

• HER2+ (upto 60%)

• triple negative (40-50%)

SHOULD I HAVE CHEMOTHERAPY BEFORE SURGERY?

40-60% respond to neoadjuvant chemotherapy

6 months chemotherapy administered prior to surgical intervention

Down size tumour

• ↑clear margins

• mastectomy → BCS

• immediate reconstruction

• increased nipple preservation

NEOADJUVANT CHEMOTHERAPY

Does NOT change DFS or OS

Down stage positive axilla

• less bulky axillary dissection

• can do SNB post neoadjuvant

• Less arm/breast lymphoedema

Buys time

• genetics testing

• plastics consult

• complete pregnancy

• prognosis determinant

Surgical complications

don’t delay post-op

chemo administration

SHOULD I HAVE CHEMOTHERAPY BEFORE SURGERY?

• Can’t resect

• Psychologically can cope

• BCS or immediate reconstruction if tumour responds well

• Accept that 40-60% chance tumour may not respond

TAKE HOME POINTS

(4) IORT Eligible, can afford, convenience

Non inferior; 20% EBRT

(5) Chemo decisions Use predict tool to help your patients decide

(6) Endocrine therapy Decrease mortality/recurrence/contralateral Ca

Use predict tool

(7) Neoadjuvant chemo No survival advantage

More operable, more operative options, buys

time, avoids delays to post-op chemo

40-60% response

Psychologically difficult for patients

COSMESIS

ANAPLASTIC LARGE CELL LYMPHOMA?

RED BREAST SYNDROME?

ROLE OF RECONSTRUCTION

• Survivors of breast cancer living longer

• 10% of breast cancer surgeon’s practice requires reconstruction or oncoplastics

• 33% eligible choose to have reconstruction surgery

• 82% psychosocial improvement post reconstruction

ANAPLASTIC LARGE CELL LYMPHOMA

WHAT IS IT?

• non Hodgkins lymphoma subtype of

implant capsule

• 1/10000-30000 textured implant

• 1/60000 non textured implant

• No difference if fill is saline or silicone

https://associationofbreastsurgery.org.uk/clinical/bia-alcl/

HOW DO I DIAGNOSE IT?

• High index suspicion

• 50% occur 7- 8y post op

• Sudden seroma formation &

normal capsule on imaging

TREATMENT?

• CD30 positive & ALK negative on USS aspirate

• Implant removal + capsule excision

• Rarely chemo/radiation

• Implant reconstruction with biological mesh

POST RECONSTRUCTION RED BREAST SYNDROME

• Why use mesh – support and shape, one step implant recon,

expander expansion faster

• Types of mesh – biological (Permacol Bovine, Alloderm

human) OR synthetic (TIGR vicryl, Tiloop titanised

polypropylene)

• Delayed hypersensitivity reaction to a foreign body (mesh)

• Location – lower pole over mesh, min tender

• No fever, elevation of WBC, mild CRP, not unwell

• Antibiotic resistant localized redness of the post recon breast

• Treatment – removal of the ADM

• Prevention – no mesh or synthetic mesh

POST RECONSTRUCTION RED BREAST SYNDROME

OTHER ISSUES

CONTRACEPTION/HRT?

FERTILITY?

LYMPHOEDEMA?

CONTRACEPTION/HRTGroup

Normal population risk OCP no significant increased risk

HRT – increased risk after 10y use estrogen only (combined 2-3y)

High risk patient* OCP – controversial use <5y and age >30y no increase risk

Copper IUCD (12y; 99% effective)

Post breast cancer treatment Avoid pregnancy 3years

Behavioural/Barrier 15-33% failure

Chemotherapy – infertility (40% <40y and 80% older)

Copper IUCD

On tamoxifen – can use Levogestrol IUD (Mirena 5-7y)

Surgical sterilization - <30y 18x reversal; 8x IVF requests)

Progestin Pill – can’t have IUCD or pregnancy in 3-5y

Implant – not enough info

Menopausal symptoms post

breast cancer treatment

Non hormonal first

Topical vaginal estrogens are ok

Estrogen patch – not enough information

Oral HRT – not recommended

* Cancer Epidemiol Biomarkers Prev 2006;15(10). October 2006

• Egg banking important if the patient wants to have

further children

• Not publically funded if the woman already has children

FERTILITY

APPROXIMATE COST

• $11000 to harvest

• $264 per year to store

• $4400 to have IVF

• <3% sentinel node biopsy

• 20% axillary dissection – worse with radiation as well

• 3% functionally affected

LYMPHOEDEMA

• Pre-clinical detection and treatment results is less

patients developing clinical lymphoedema

• 7% vs 25% *

• * BMJ 2010 RCT

• Circumference

• Volume - Bioimpedence scan (L-DEX) – electric signal travel time

LYMPHOEDEMA INVESTIGATION & TREATMENT

• Exercise

• Massage

• Compression stockings

• Avoid dependent position

• Avoid weight gain

• Prevent infection and injury

LYMPHOEDEMA – PRIMARY CARE

HIGH INDEX SUSPICION & EARLY DIAGNOSIS

• Obese/radiation/axillary dissection

• Fullness/heaviness

• Clothing/Jewellery not fitting

• Skin thickening

• Visible swelling – late sign – don’t wait

EARLY REFERRAL TO LYMPHOEDEMA SPECIALIST PHYSIOTHERAPIST

TAKE HOME POINTS

(8) CosmesisALCL – high index of suspicion seroma 7-8y post implant

(9) HRT post Ca Topical is ok

Patch unsure

HRT not recommended

(10) Contraception post Ca Chemotherapy/Copper IUD/Surgical

(11) Fertility Egg bank free if no kids - expensive

(12) Lymphoedema Early intervention prevents clinical

lymphoedema

Red breast – high index of suspicion mesh implant recon

LIFESTYLE

• Alcohol reduction

• Smoking cessation

• Healthy eating

• Healthy weight range

• Exercise

• Promote breastfeeding

• HRT

HIGH RISK FAMILY HISTORY RISK REDUCTION GEN MEASURES?

NON MODIFIABLE

• Female

• Age

• Family history

• Personal hx breast cancer

• Breast density

What are our modifiable and non modifiable risk factors ?

• Surgical management options for breast & axilla

• Adjuvant treatment

• Neoadjuvant treatment

• Reconstruction/Symmetrisation

BREAST CANCER TREATMENT

First it was the breast

THE DE-ESCALATION OF SURGICAL TREATMENT

Now it is the axilla

SHOULD I HAVE A PARTIAL MASTECTOMY?

BREAST CONSERVING SURGERY + RADIATION

vs

MASTECTOMY

• Recurrence is the same BCS+radiation vs mastectomy 1-3%

• BCS alone 40% recurrence

YESReasonable chance of clear margins WITH acceptable cosmesis

You can attend radiotherapy

You are comfortable with that decision

IS A SENTINEL NODE BIOPSY ENOUGH TREATMENT?

SENTINEL NODE BIOPSY

vs

AXILLARY DISSECTION

• Less lymphoedema <3% versus 20%

• Recurrence same <2%

YESNo axillary burden

Low axillary burden in low risk patients WITH adjuvant therapy

• ITC, micromets, 1-2macromets

• No extranodal spread

• Low grade

• Small cancer

• Older patient

• ER+ HER2-

WHEN TO USE MRI

• Discordance – size discrepancy between mammo and USS

• Lobular Ca – contralateral 10%, multicentric multifocal 10%, 10% mammo-occult

• Mammography occult cancers

• Response to neoadjuvant chemotherapy – if single focus, clipped pre-neoadjuvant and plan for BCS if good response to chem

• Surveillence high risk group age 30-50y

• Surveillence high risk group with dense breasts >50y

BONE ANTI-RESORPTION THERAPY FOR BREAST CANCER PATIENTS ON AROMATASE INHIBITOR

* Age >65y, ex/smoker, BMI<24, fhx hip fracture, personal hx fragility fracture at age >50y, steroids

BMD (t score) Meaning Risk factors Treatment

T>-1.0 Normal Nil

T>-2.0 Moderate osteopenia No risk factors Exercise

Calcium

Vitamin D

T<1.5 Mild osteopenia 2 risk factors* Exercise

Calcium

Vitamin D

Bisphosphonate

Check BMD 2 yearly

T<-2.0 Severe

osteopenia/osteoprosis

(T<-2.5 osteoporosis)

+/- Risk factors Exercise

Calcium

Vitamin D

Bisphosphonate

Check BMD 2 yearly

RADIATION REDUCES RECURRENCE

POST-OPERATIVE RADIATION

VS

NO RADIATION

• More than 2 positive nodes (<10% vs 30%)

• Breast conserving surgery (1-3% vs 40%)

• Recurrence is more aggressive (40% mortality)

YESBreast conserving surgery

Cancer with poor prognostic features

• Younger patient

• Higher grade

• Larger

• >2nodes

• Extranodal spread/LVI

• HER2+/triple neg

CAN I AVOID RADIOTHERAPY AFTER BCS

• Elderly

• <10mm

• Low grade

• ER+

VERY SMALL SELECT GROUP

Awaiting PROSPECT trial

• >50y

• <2cm

• N0/1

• Partial Mastectomy

• margins ≥ 2mm

• preop MRI

ADJUVANT RADIOTHERAPY

Absolute CI

• pregnancy

• previous radiation (Hodgkin’s)

Relative CI

• Li Fraumeni – radiation induced cancers

• scleroderma & connective tissue disorders

• severe cardiopulmonary disease

• inability to lie supine

Who might avoid chemotherapy:

• Small tumour

• ER+

• low grade

• low Ki67

• absence of LVI

• <3nodes

• no extranodal spread

ADJUVANT CHEMOTHERAPYNot all patients with positive axillary nodes need chemotherapy

RECONSTRUCTION OPTIONS – DELAYED VS IMMEDIATE

Who benefits most from immediate reconstruction:

• Patient prefers fewer ops

• No adjuvant treatment

• Neoadjuvant with excellent response

Who should have delayed reconstruction:

• Patient preference cancer out first

• Locally advanced cancer

• Smoking cessation for flap recon

• Weight loss (BMI <30)

• Patient uncertain

No cosmetic

operation is a

one stop shop

RECONSTRUCTION OPTIONS – AUTOLOGOUS VS IMPLANT

Reconstruction

type

Pros Cons

Autologous Natural texture &

appearance

Blood supply to prior

radiated tissue

Longer operation

longer recovery

more pain

More potential complications

tissue availability

CI if complex prior abdo op

Implant Shorter operation

shorter recovery

shorter hospital stay

difficult to match unilateral

ALCL

Implant related complications

Down size tumour

• ↑clear margins

• mastectomy → BCS

• immediate reconstruction

• increased nipple preservation

NEOADJUVANT CHEMOTHERAPY

Does NOT change DFS or OS

Down stage positive axilla

• less bulky axillary dissection

• can do SNB post neoadjuvant

• Less arm/breast lymphoedema

• take 3 or more nodes at SNB

• Clip biopsy node pre neoadjuvant and retrieved at SNB

• any residual disease (ITC & micromets inclusive) on SNB gets AND

• Concentric shrinkage

• Single lesion

RECONSTRUCTION OPTIONS – SINGLE STAGE VS 2 STAGE IMPLANT

Reconstruction

type

Pros Preferred patient Complication

Single stage

(direct to implant

+/- mesh)

One op

Faster recovery

Decrease pain with

ADM, better QOL

Prophylactic surgery

Non ptotic

Cup A- small C

Thick well vascularized

mastectomy flaps

No prior/post op

radiation

30% complication rate implant

loss (15% vs 8%),

flap necrosis (9vs7%)

re-operation (18 vs 14%)

mesh complications

2 stage

(expander then

definitive implant)

Opportunity to correct

Less complications

No prior radiation

Adjuvant treatment

Flap concerns

Ptosis/reduction

<10% complication rate

2nd stage often 6-12mo later

(average 9months)

* smoking, diabetes, prior radiation, steroids, obesity all increase risk of complications

ONCOPLASTIC FLAPS/MAMMOPLASTY

• Very small breasts – flaps (LICAP/AICAP/LTAP)

• Very large breasts

• No ptosis

• smoker

• diabetic

• Prior radiation

Often need contralateral symmetrisation

SYMMETRISATION

• No all insurance companies pay for symmetrisation and not all policies cover symmetrisation

• Best not to do at time of cancer operation – radiation will change appearances, complications on unaffected side can delay adjuvant treatment too

CONTRALATERAL PROPHYLACTIC MASTECOMY

• Insurance cover + genetics tests

• At time of surgery – emotive time

• Delay to adjuvant treatment

• Contralateral increased surveillance post-op

• Psychologist input

Most patients do not need contralateral surgery