In The Name of God

Asieh S. Fattahi M.D.Surgical OncologistAssistant Professor of Surgery Department of Surgery ,Ghaem HospitalMashhad University of Medical SciencesJan 2011

Breast cancer treatment needs multidisciplinary approach and team

Good relation between radiologists ,Pathologists, Surgeons, Medical oncologists and radiotherapist is needed to choose the best treatment options for every patients

Trained nurses needed to help patient and physician in diagnosis and treatment

Supportive group and programs are needed to increase information of patient and her quality of life

With progress in screening modality breast cancer will detected in earlier stage and it can be treated more than before so:

New techniques and modalities are used in diagnosis and treatment of breast cancer

Before 1990Frequency of DCIS :

unusualBiopsy: SurgicalMolecular

biology :minimal understanding

Treatment: Mastectomy

Reconstruction: None/Delayed

After 1990 - Common -needle - Rapid knowledge growth

- Breast conservations

-immediate

Ductography -Nipple Discharge specially bloody N.D. -0.1-0.2 of contrast media is injected and Mamo

are obtained -Irregular mass or filling defects maybe be signs

of cancer -most of the time Intra ductal Papilloma

Ductoscopy for Nipple Discharge -New technical improvement allow intraductal

biopsy -in Bloody Nipple increase risk of cancer

detections -can used specially in high risk patients -helps having better clean margin with

lumpectomy

Sonographic guided biopsy mass is present

Mammography guided biopsy and Streotactic biopsy

micro calcifications are presents

MRI guided biopsy when MRI indicated

wire localized Needle Biopsies Non palpable mass, Micro calcifications

With mass wire insert via ultrasound guidance ,and with calcifications via mammography guidance

With increase of screening mamo ,the number of non palpable lesions increase

Localization of lesion with wire guided surgeon to excise the exact lesion and helps to less aggressive resection with good results

It can be used for helping in lumpectomies for better cosmetic and trapuetic results

If one or two margins will be positive after lumpectomy reexcision will be done

Breast Conservation surgeries (lumpectomy or partial Mastectomy)Mastectomy Radical Modified Radical Mastectomy

(MRM) Extended simple mastectomy Simple mastectomy Skin sparing mastectomy Nipple areola sparing mastectomy

breast conservation surgeries # oncoplastic breast surgeries long term follow up has confirmed that

lumpectomy with radiations provides survival equivalent to mastectomy

Technical improvement in lumpectomy and radiation techniques have reduced local recurrence rate (2-5 % at 10 years)

radiotherapy has no added morbidity for patient

Lumpectomy with assessment of axillary lymph node status and Radiotherapy:

In early breast cancer ,stage I & IIIn selected locally advanced patients can

be used after neoadjuvant chemotherapy and downsize of tumor

¾ of breast cancer patients are eligible for BCT in USA

At least 2mm free margin needed

From 87 articles review:In larger lesions or smaller breast the

removal of adequate volumes of breast tissue to achieve

better tomour free margins and reduce risk of local recurrence may compromise cosmetic outcome .

New surgical techniques so called oncoplastic surgery have been introduced

Neoadjuvant chemo and oncoplastic surgery have reduced the indications of mastectomy

Reconstructions for partial mastectomies ONCOPLASTIC SURGERIES

Different methods of mamoplasty used to fill defects after wide lumpectomies ,and re-excision and makes better cosmetic resuls

they extended indications for more conservstive resection instead of mastectomy

Simple reshapingBreast reduction techniquesLocal tissue arrengementsPedicled flaps ….

Negative margins with frozen sectionMarking the tumor place with clips for

radiotherapy

Patients who desire this kind of surgeryMultifocal lesionsDiffuse ductal carcinoma insituRecurrence after BCTMutations of BRCA1& 2Involved surgical margins after re-excisionSclrederma or other connective tissue

disorderPrior radiation to breast and chest wall

Skin Sparing Mastectomy mastectomy with resection of nipple and

areola and preservation of skin for immediate reconstruction

biopsy site will be excised 1cm around scar

T1-T3 cancersGood cosmetic results,less than 2%

recurrenceNo more increase in recurrence There is no local ,regional,or systemic risk

with this technique

Nipple Areola Sparing Mastectomy subcutaneos mastectomy with preservation

of NAC (nipple areola complex) in selected patients

there are some risks of recurrence in NAC one choice: in prophylactic mastectomyOr in T1 & periferal tumors

_ In some trials they use this technique with intra operative radiotherapy for reduction in risk of recurrence

Meta-analysis:Comparison :1104 skin sparing mastectomy + immediate

reconstruction2653 MRM without reconstructionIn stage I & IINo significant different in local recurrence

with a better cosmetic resultsANN SURG 2010;251:632

Prophylactic mastectomies simple bilateral mastectomy and

immediate reconstruction is used in some patients with strong family history and BRCA1 or BRCA2

mutations if patient selects prophylactic mastectomy because of higher risk of breast cancer in this group

--Prophylactic Oophorectomy and hormone replacement therapy must consider after child bearing ages

Radio Frequency Ablation of a breast lesion

Cry ablationFocused ultrasound

RFA is accomplished by heat generated from high frequency alternating

the friction generated heat from ion movement in the tissue causes increasing levels of cell damage

A single prong or an array prongs deployed from a probe

Small studies Complete ablation 80 –100 %With ultrasound guidance Focus on T1 dis.Ablation fallowed with immediate or

late resectionsImaging expertise requiredDisadvantage:extent and completeness

of ablation can not be evaluated by RFA without resection

RFA with resection improves more negative margins after lumpectomy and decreases need for re-excision

Created an elliptical ice ball as argon gas flows through the needle percutaneousely placed into the lesion

Uses US guidanceFDA approved this for core biopsy-

proven fibroadenomasEffective and safe,can be used

with local anesthesia

Some studies used this for small invasive ductal carsinoma (T=1-1.5)

the presence of DCIS limits the success of US-guided cryoablations

FUS is a thermal ablation technique that uses focused US beams to penetrate through soft tissues to targeted the lesions

Some studies used it in fibroadenoma and invasive breast cancers less than 3.5 cm with 78-96% success rate

Sentinel Lymph node Biopsy (SLNB)

Axillary Lymph Node Dissection (ALND)

Axillary radiation

Axillary dissection - in clinically node + patient and after SLN+ will

be done - the number of involved node is the most

important factor in survival

-There are some morbidity with that Pain,Arm edema, risk of nerve injury ,sarcoma

(rare),…..

SLN Mapping is standard method for staging axilla in patients with clinically node negative breast cancer,T1,T2 early breast cancer.

Mapping has allowed us to be selective about which patients have completion axillary dissection

Time :The day before or in the morning of surgery

place:Intradermal , or sub dermal ,

peritumoral or periareolar injection of radicolloid (Tc –SC 99) 1 ml will be done

In OR injection of blue dye (Lymphazurine,patent blue,Methilene blue) can be used for increase the rate of finding SLN

Mapping lable: Radioisotope or blue dye alone or combonation can be used

Combination improves SLN detection rateBlue dye:disadvantage is 1-3 %allergic

reactionsMethylene Blue has been used similar to

blue dye :lower cost ,lower allergic rate Radioisotope dose 0.1-4 mCi : -Technetium-99m sulfur colloid is used in

US - Tc 99 m-colloidal albumin is used in

Europe

Recently several studies have shown that axillary radiation is an effective treatment in clinically node negative patients with less morbidity

Local recurrence 3-7%(with ALND 2-5%)

Ether Dome in MGH the 3th oldest hospital in USAThe place for first surgery with general anesthesia

in the world