Surgical Management Surgical Management f B Cf B Cof Breast Cancerof Breast Cancer

Lixana Vega Vega, MDLixana Vega Vega, MDSUNY Downstate Medical CenterSUNY Downstate Medical CenterSUN ow s d c CSUN ow s d c C

Case PresentationCase Presentation

36 y/o female presented with palpable Rt breast mass.36 y/o female presented with palpable Rt breast mass.PMHPMHPMH PMH

20032003-- Lt breast infiltrating ductal carcinoma (T2 N1 M0), Lt breast infiltrating ductal carcinoma (T2 N1 M0), ER/PR neg HER2/neu+1 BRCA negER/PR neg HER2/neu+1 BRCA negER/PR neg, HER2/neu+1, BRCA negER/PR neg, HER2/neu+1, BRCA neg

Neoadjuvant chemotx, lumpectomy and axillary dissection, RT Neoadjuvant chemotx, lumpectomy and axillary dissection, RT and adjuvant chemotx.and adjuvant chemotx.jj

Premenopausal, G2P2, menarche age 13, first birth at age Premenopausal, G2P2, menarche age 13, first birth at age p , , g , gp , , g , g19, +breastfeeding, no OCP/HRT use. 19, +breastfeeding, no OCP/HRT use.

Fam HxFam Hx-- Mother and sister had breast cancer.Mother and sister had breast cancer.

Case PresentationCase Presentation

PEPE-- Rt breastRt breast-- 2cm mass at 9 o’clock. 2cm mass at 9 o’clock. -- Lt breast unremarkable. No lymphadenopathy. Lt breast unremarkable. No lymphadenopathy.

Labs WNLLabs WNLLabs WNLLabs WNLBreast U/SBreast U/S-- Rt breast 1.6cm mass at 9 o’clock and Rt breast 1.6cm mass at 9 o’clock and smaller mass at 11 o’clocksmaller mass at 11 o’clocksmaller mass at 11 o clocksmaller mass at 11 o clockCore needle bxCore needle bx-- infiltrating ductal carcinoma, infiltrating ductal carcinoma, ER/PRER/PRER/PR negER/PR negCT scan of chest, abdomen and pelvisCT scan of chest, abdomen and pelvis-- negativenegativeBone scanBone scan-- negativenegative

Case PresentationCase Presentation

Lumpectomy and Sentinel LN bx was offeredLumpectomy and Sentinel LN bx was offeredLumpectomy and Sentinel LN bx was offered.Lumpectomy and Sentinel LN bx was offered.Pt requested bilateral mastectomies. Pt requested bilateral mastectomies.

L i lL i lLt simple mastectomyLt simple mastectomyRt modified radical mastectomyRt modified radical mastectomyBilateral placement of tissue expanders for delayed Bilateral placement of tissue expanders for delayed reconstruction. reconstruction.

Modified Radical MastectomyModified Radical MastectomyModified Radical MastectomyModified Radical Mastectomy

Supine position, ipsilateral arm Supine position, ipsilateral arm p p pp p pabducted at 90abducted at 90°°Transverse elliptical incision Transverse elliptical incision from lateral edge of sternum tofrom lateral edge of sternum tofrom lateral edge of sternum to from lateral edge of sternum to the midaxillary line.the midaxillary line.Skin flaps limitsSkin flaps limits--

UU Cl i lCl i lUpperUpper-- ClavicleClavicleLowerLower-- Inframammary foldInframammary foldMedialMedial-- Lateral border of sternumLateral border of sternumL lL l L i i d i lL i i d i lLateralLateral-- Latissimus dorsi muscleLatissimus dorsi muscle

Breast tissue dissected off the Breast tissue dissected off the underlying pectoralis major underlying pectoralis major musclemuscleAxillary LN disection.Axillary LN disection.

Modified Radical MastectomyModified Radical MastectomyModified Radical MastectomyModified Radical Mastectomy

Axillary dissectionAxillary dissectionAxillary dissectionAxillary dissection

Axillary dissectionAxillary dissectionAxillary dissectionAxillary dissection

Case PresentationCase Presentation

Pt was discharged home on POD #1 with JP drainsPt was discharged home on POD #1 with JP drainsPt was discharged home on POD #1 with JP drains.Pt was discharged home on POD #1 with JP drains.PathPath

R bR b i fil i d l i hi h di fil i d l i hi h dRt breast massesRt breast masses-- infiltrating ductal carcinoma, high grade, infiltrating ductal carcinoma, high grade, negative marginsnegative marginsRt A ill LNRt A ill LN titiRt Axillary LNRt Axillary LN-- negativenegativeLt breastLt breast-- no tumorno tumorT3 N0 M0T3 N0 M0T3 N0 M0T3 N0 M0

Pt started on adjuvant chemotx, to be followed by RT.Pt started on adjuvant chemotx, to be followed by RT.Tissue expansion uneventful. Tissue expansion uneventful.

Surgical Management Surgical Management f B Cf B Cof Breast Cancerof Breast Cancer

Breast CancerBreast Cancer

Breast cancer Breast cancer Most common cancers in women breast lung and colon caMost common cancers in women breast lung and colon caMost common cancers in women breast, lung and colon ca. Most common cancers in women breast, lung and colon ca. MCC of cancer death among women age 20 to 59 MCC of cancer death among women age 20 to 59 (Jemal et al).(Jemal et al).

B C dB C dBreast Cancer past and present.Breast Cancer past and present.Halstead (1984)Halstead (1984)-- presentation of 50 cases.presentation of 50 cases.

2/3 pt had with locally advanced disease2/3 pt had with locally advanced disease60% pts with axillary lymphadenopathy60% pts with axillary lymphadenopathyR di l t t il d f t 75R di l t t il d f t 75Radical mastectomy prevailed for next 75yrs.Radical mastectomy prevailed for next 75yrs.

1970s 1970s –– average tumor size at presentation average tumor size at presentation –– 2cm2cm19801980 ACSACS 85% t t d ith t I II di85% t t d ith t I II di19801980-- ACSACS-- 85% pt presented with stage I or II disease.85% pt presented with stage I or II disease.

-- 40% pts with axillary lymphadenopathy 40% pts with axillary lymphadenopathy

DefinitionsDefinitionsDefinitionsDefinitions

Radical MastectomyRadical MastectomyyyRemoval of breast tissue, pectoralis Removal of breast tissue, pectoralis major and minor muscles, level I, II and major and minor muscles, level I, II and III axillary LN III axillary LN yy

Modified Radical MastectomyModified Radical MastectomyRemoval of breast tissue, level I and II Removal of breast tissue, level I and II

ill LNill LNaxillary LNaxillary LN

Simple MastectomySimple MastectomyRemoval of breast tissueRemoval of breast tissue

Subcutaneous or SkinSubcutaneous or Skin--sparing sparing MastectomyMastectomy

R l f i lR l f i l l ll lRemoval of nippleRemoval of nipple--areolar complex. areolar complex.

TNM Classification for Breast TNM Classification for Breast Cancer StagingCancer Staging

Primary TumorPrimary TumorPrimary TumorPrimary TumorTxTx-- primary tumor cannot be assessedprimary tumor cannot be assessedT0T0 no evidence of primary tumorno evidence of primary tumorT0T0-- no evidence of primary tumorno evidence of primary tumorTisTis-- carcinoma carcinoma in situin situT1T1 t ≤ 2t ≤ 2T1T1-- tumor ≤ 2cmtumor ≤ 2cmT2T2-- tumor 2 tumor 2 –– 5 cm5 cmT3T3 55T3T3-- tumor > 5 cm tumor > 5 cm T4T4-- any size extending to chest wall, inflammatory any size extending to chest wall, inflammatory

iicarcinoma carcinoma

TNM Classification for Breast TNM Classification for Breast Cancer StagingCancer Staging

R i l L h N dR i l L h N dRegional Lymph Nodes Regional Lymph Nodes NxNx-- Nodes cannot be assessedNodes cannot be assessedN0N0-- No node metastasisNo node metastasisN0N0 No node metastasisNo node metastasisN1N1-- Mets 1Mets 1--3 axillary nodes3 axillary nodes

-- Internal mammary (IM) nodes (+path, not clinically apparent) Internal mammary (IM) nodes (+path, not clinically apparent) N2N2-- Mets 4Mets 4--9 axillary nodes9 axillary nodes

-- Clinically apparent IM nodesClinically apparent IM nodesN3N3 Mets ≥ 10 axillary nodesMets ≥ 10 axillary nodesN3N3-- Mets ≥ 10 axillary nodesMets ≥ 10 axillary nodes

-- Mets IM and axillary nodes Mets IM and axillary nodes -- Mets Supraclavicular or infraclavicular nodesMets Supraclavicular or infraclavicular nodespp

TNM Classification for Breast TNM Classification for Breast Cancer StagingCancer Staging

Distant MetastasesDistant MetastasesDistant MetastasesDistant MetastasesMxMx-- Mets cannot be assessedMets cannot be assessedM0M0 No distant metastasisNo distant metastasisM0M0-- No distant metastasisNo distant metastasisM1M1-- Distant metastasisDistant metastasis

Stage 0Stage 0 TisTis N0 N0 M0M0Stage IStage I T1T1 N0N0 M0M0

Stage II AStage II A T0T0 N1N1 M0M0Stage II AStage II A T0T0T1T1T2T2

N1N1N1N1N0N0

M0M0M0M0M0M0

Stage II BStage II B T2T2T3T3

N1N1N0N0

M0M0M0M0

Stage III AStage III A T0T0 N2N2 M0M0Stage III AStage III A T0T0T1T1T2T2T3T3

N2N2N2N2N2N2N1N1

M0M0M0M0M0M0M0M0T3T3

T3T3N1N1N2N2

M0M0M0M0

Stage III BStage III B T4T4 N0N0 M0M0T4T4T4T4

N1N1N2N2

M0M0M0M0

Stage III CStage III C Any TAny T N3N3 M0M0Stage IVStage IV Any TAny T Any NAny N M1M1

Stage 0 Stage 0 –– TisTisLobular Carcinoma Lobular Carcinoma In Situ In Situ (LCIS)(LCIS)( )( )

Incidental finding in breast biopsies. Incidental finding in breast biopsies. Breast cancer Breast cancer risk factorrisk factor and and notnot a malignancy that a malignancy that

l lll llprogresses locally.progresses locally.Risk of breast cancer development of Risk of breast cancer development of 1 %1 % per year. per year. Risk affectsRisk affects both breastboth breastRisk affects Risk affects both breastboth breast..Pt may develop infiltrating Pt may develop infiltrating lobular or ductallobular or ductal ca.ca.Average time for cancer to develop is Average time for cancer to develop is 1010--15 yrs15 yrs..

TxTxClose follow upClose follow up -- annual mammogramannual mammogramCh iCh iChemopreventionChemoprevention

TamoxifenTamoxifen-- 65%65% risk reduction (Fisher et al). risk reduction (Fisher et al). Prophylactic bilateral mastectomy Prophylactic bilateral mastectomy p y yp y y

Simple or subcutaneous mastectomy. Simple or subcutaneous mastectomy. 90%90% risk reduction (Hartmann et al). risk reduction (Hartmann et al).

Stage 0 Stage 0 –– TisTisDuctal CarcinomaDuctal Carcinoma In SituIn Situ (DCIS)(DCIS)Ductal Carcinoma Ductal Carcinoma In Situ In Situ (DCIS)(DCIS)

PresentationPresentation-- clustered microcalcifications onclustered microcalcifications onPresentationPresentation clustered microcalcifications on clustered microcalcifications on mammogrammammogramManagementManagementManagementManagement

Simple Mastectomy +/Simple Mastectomy +/-- Sentinel LN bxSentinel LN bxE i i d R di i Th (RT)E i i d R di i Th (RT)Excision and Radiation Therapy (RT)Excision and Radiation Therapy (RT)Excision aloneExcision alone

Stage 0 Stage 0 –– TisTisDuctal Carcinoma Ductal Carcinoma In Situ In Situ (DCIS)(DCIS)( )( )

Simple MastectomySimple MastectomyIndicationsIndications

Multicentric diseaseMulticentric disease identified on mammogramidentified on mammogramPositive marginsPositive margins after reexcisionafter reexcisionPositive marginsPositive margins after reexcisionafter reexcisionUnacceptable Unacceptable cosmesiscosmesis to obtain negative marginsto obtain negative marginsPatient’sPatient’s choice.choice.

Cures Cures 98%98% patientspatientsTx failure related to unrecognized invasive carcinoma.Tx failure related to unrecognized invasive carcinoma.

Invasive carcinomaInvasive carcinoma found in found in 26%26% of pts having mastectomy for of pts having mastectomy for DCIS (Morrow, et al)DCIS (Morrow, et al)

Radical tx for a lesion that mayRadical tx for a lesion that may notnot progress to invasiveprogress to invasiveRadical tx for a lesion that may Radical tx for a lesion that may notnot progress to invasive progress to invasive carcinoma. carcinoma.

Stage 0 Stage 0 –– TisTisD l C iD l C i I SiI Si (DCIS)(DCIS)Ductal Carcinoma Ductal Carcinoma In Situ In Situ (DCIS)(DCIS)

Excision and Radiation Therapy (RT) vsExcision and Radiation Therapy (RT) vsExcision and Radiation Therapy (RT) vs Excision and Radiation Therapy (RT) vs Excision aloneExcision alone

Prospective randomized trialsProspective randomized trialsProspective randomized trialsProspective randomized trialsNational Surgical Adjuvant Breast Project National Surgical Adjuvant Breast Project (NSABP) B17(NSABP) B17European Organization for Research and Treatment of Cancer European Organization for Research and Treatment of Cancer (EORTC)(EORTC)United Kingdom TrialUnited Kingdom Trial

RT reduced ipsilateral breast tumor recurrence by 50RT reduced ipsilateral breast tumor recurrence by 50--60%.60%.ddRecurrence with excision 32% vs 16% in excision and RT at 10yrs Recurrence with excision 32% vs 16% in excision and RT at 10yrs

50% of recurrences were invasive ca in both groups. 50% of recurrences were invasive ca in both groups. l b f f Tl b f f TNo survival benefit from RTNo survival benefit from RT. .

Stage I and Stage II Breast CancerStage I and Stage II Breast Cancer

Goal of surgical txGoal of surgical txGoal of surgical txGoal of surgical txRemove all clinically evident tumor in the breast and Remove all clinically evident tumor in the breast and axillary lymph nodesaxillary lymph nodesaxillary lymph nodes.axillary lymph nodes.Modified Radical Mastectomy (MRM) Modified Radical Mastectomy (MRM) BreastBreast conserving Therapy (BCT)conserving Therapy (BCT)BreastBreast--conserving Therapy (BCT)conserving Therapy (BCT)

Excision of primary tumor with negative marginsExcision of primary tumor with negative marginsSentinel LN bx Sentinel LN bx NNRTRT

Stage I and Stage II Breast CancerStage I and Stage II Breast CancerStage I and Stage II Breast CancerStage I and Stage II Breast Cancer

BreastBreast--conserving Therapy (BCT)conserving Therapy (BCT)BreastBreast conserving Therapy (BCT)conserving Therapy (BCT)1.1. Reduce the tumor burden to a microscopic level Reduce the tumor burden to a microscopic level

likely to be controlled by irradiationlikely to be controlled by irradiationlikely to be controlled by irradiation.likely to be controlled by irradiation.2.2. Safely to deliver radiation therapy.Safely to deliver radiation therapy.33 Promptly detect local recurrencesPromptly detect local recurrences3.3. Promptly detect local recurrences.Promptly detect local recurrences.

Stage I and Stage II Breast Cancer Stage I and Stage II Breast Cancer Absolute contraindications to BCTAbsolute contraindications to BCT

Two or more primary tumorsTwo or more primary tumors in different breast quadrants.in different breast quadrants.p yp y qqPersistent Persistent positive marginspositive margins after excision.after excision.DiffuseDiffuse malignantmalignant--appearing microcalcifications.appearing microcalcifications.gg pp gpp gPregnancyPregnancy is a contraidication to RT. is a contraidication to RT.

Third trimesterThird trimester-- tumor excision, then RT after delivery.tumor excision, then RT after delivery.Hx Hx prior RTprior RT to breast. to breast.

Relative contraindications to BCTRelative contraindications to BCTMultifocal or extensive disease in same breast quadrant.Multifocal or extensive disease in same breast quadrant.Unacceptable cosmesis (large tumor in small breast).Unacceptable cosmesis (large tumor in small breast).Hx scleroderma and active SLE.Hx scleroderma and active SLE.

BCT vs MRMBCT vs MRMTTProspective Randomized TrialsProspective Randomized Trials

TrialTrial SurvivalSurvival Local recurrenceLocal recurrenceTrialTrial Survival Survival Local recurrenceLocal recurrenceBCTBCT MRMMRM BCTBCT MRMMRM

Institute Gustave RoussyInstitute Gustave Roussy 7373 6565 99 1414Institute Gustave RoussyInstitute Gustave Roussy 7373 6565 99 1414Milan Cancer InstituteMilan Cancer Institute 4242 4141 77 22

NSABP B06NSABP B06 4646 4747 1414 1010NSABP B06NSABP B06 4646 4747 1414 1010NCINCI 5959 5858 2222 66

EORTCEORTC 6565 6666 2020 1212EORTCEORTC 6565 6666 2020 1212

Axillary NodesAxillary Nodes

Staging proceduresStaging proceduresSentinel lymph node biopsySentinel lymph node biopsySentinel lymph node biopsySentinel lymph node biopsy

Sentinel LNSentinel LN-- 11stst LN that receives drainage from the cancer.LN that receives drainage from the cancer.Uses lymphazurin blue dye, colloids labeled with Uses lymphazurin blue dye, colloids labeled with y p b y , b wy p b y , b wradioactive isotope (technetium), or both.radioactive isotope (technetium), or both.Less morbid than axillary LD dissection.Less morbid than axillary LD dissection.10% false10% false--negative negative (Krag, et al).(Krag, et al).ContraindicationsContraindications

Clinically positive axillary LNClinically positive axillary LNLocally advanced breast cancerLocally advanced breast cancerPatient is pregnant or lactatingPatient is pregnant or lactatingPatient is pregnant or lactatingPatient is pregnant or lactatingPrior axillary surgery.Prior axillary surgery.

Axillary NodesAxillary Nodes

Axillary dissectionAxillary dissectionIndicationsIndicationsIndicationsIndications

Pts with positive Sentinel LN bxPts with positive Sentinel LN bxPts with contraindicatons to Sentinel LN bxPts with contraindicatons to Sentinel LN bxPts with contraindicatons to Sentinel LN bxPts with contraindicatons to Sentinel LN bx

Removal of level I and level II LN identifies Removal of level I and level II LN identifies metastasis in 98% of casesmetastasis in 98% of casesmetastasis in 98% of cases. metastasis in 98% of cases. ComplicationsComplications

LymphedemaLymphedemaIncidence 6 Incidence 6 -- 30%, radiation to axilla increases risk.30%, radiation to axilla increases risk.

I b hi l i jI b hi l i j bbIntercostobrachial nerve injuryIntercostobrachial nerve injury-- numbnessnumbnessLong Thoracic nerve injuryLong Thoracic nerve injury-- Winged scapula defrmity.Winged scapula defrmity.

Stage III and Stage IV Breast Cancer Stage III and Stage IV Breast Cancer ––Locally Advanced Breast CancerLocally Advanced Breast Cancer

Initial surgical treatmentInitial surgical treatmentInitial surgical treatment Initial surgical treatment ↑ rate of recurrence, poor 5↑ rate of recurrence, poor 5--yr survival, tx failure within 2 yrs of dx.yr survival, tx failure within 2 yrs of dx.

Induction chemotherapy to reduce tumor burden.Induction chemotherapy to reduce tumor burden.

Mastectomy or LumpectomyMastectomy or Lumpectomyy p yy p y

Chemotherapy RT and Hormonal TxChemotherapy RT and Hormonal TxChemotherapy, RT and Hormonal Tx Chemotherapy, RT and Hormonal Tx

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