Treatment of Early Breast Cancer
Frances Wright MD MEd FRCSC
Objectives
• imaging & diagnosis
• historical overview of surgical treatment
• current practice
– breast surgery
– axillary staging
Radiologic Work-up
• Common
– Mammogram
– Ultrasound
• Good for young women
• Usually targeted
• Uncommon
– Galactogram
– MRI
Mammogram
Benefits of Mammogram
Some cancers are not found until they reach this size
A mammogram can find cancer when it is only this size
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Survival and Stage of
Breast Cancer
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
Mammograms and Cancer
Ultrasound of Breast Cancer
Magnetic Resonance Imaging
MRI
• Advantage
– Not affected by breast
density
– Can identify occult
disease
• Disadvantage
– Dependent on who does
the imaging
– Sensitive, not very
specific
– Need MRI biopsy
capability
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
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
Breast Imaging Reporting &
Data Systems = BIRADS
Interpretation
Risk Ca
0
Incomplete assessment
1
Negative
0.05%
2
Benign
0.05%
3
Probably benign
2%
4
Suspicious
15 - 50%
5
Highly suspicious
95 - 99%
6
Known cancer
100%
Imaging
•
BIRADs classification
1
2
No action
3
4
5
Needs biopsy
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
Pathology: Ductal Carcinoma in situ and
Invasive ductal Carcinoma
Ductal carcinoma
in situ
Invasive ductal
carcinoma
No lymph node
involvement
Potential lymph node
involvement
• There must be clinical, radiologic
and pathologic agreement
(concordance) in diagnosis
• If one doesn’t fit – consider surgical
excisional biopsy
The evolution of breast surgery
• Halsted 1852 - 1922
• tumour begins small
• systematic progression
to surrounding tissues
• involvement of lymphatics
leads to distant spread
• local control = cure
The evolution of breast surgery
• Halstedian principles
• radical mastectomy
– Breast, pectoralis
major and minor and
axillary tissue
The evolution of breast surgery
• Bernard Fisher
• breast cancer systemic
at onset
• surgery impact is local
• lumpectomy + RT =
mastectomy
The evolution of breast surgery
• “Fisherian” theory
• breast conservation
The evolution of breast surgery
Halstedian principles
radical mastectomy
versus
“Fisherian” theory
breast conservation
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%
Mastectomy
•
•
•
•
•
large or multicentric tumours
unacceptable cosmesis, small breast : tumour ratio
persistent positive margins with conserving surgery
contraindication to radiation
patient preference
Surgical Treatment of Early Breast Cancer
Breast
Axilla
Breast conservation
Sentinel Node Biopsy
possible axillary dissection
or
Level I/II axillary dissection
or
Mastectomy
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
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
Likelihood of having
lymph node involvement
Diameter of
primary tumour
0.5 - 0.9 cm
1.0 - 1.9 cm
2.0 – 2.9 cm
3.0 – 3.9 cm
4.0 – 4.9 cm
> 5.0cm
Percent with positive
axillary nodes
21 %
33 %
45 %
55 %
60 %
70 %
Carter 1989
The sentinel node for breast cancer
• Cabanas 1977 - penile cancer and
inguinal nodes
• Morton 1992 - melanoma
• Krag 1994 - isotope in breast cancer
• Guiliano - blue dye in breast cancer
• Albertini - blue dye and isotope
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
tumour
Radioisotope +/-Blue Dye
radioactivity
blue dye
Pathological evaluation
• usual evaluation is bi-valve of 10 - 20 nodes
• retrieval of fewer nodes (1-3) allows more extensive
evaluation
– H & E multiple sections
– immunohistochemical staining (IHC)
– No accepted standard
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
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%
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):941 - 946
2Guiliano et al. Ann Surg 1994; 220:391- 401
3Veronesi et al. NEJM 2003; 349(6):546 - 53
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
Breast Cancer Treatment in the 20th Century:
Quest for the Ideal Local-regional Therapy
Overtreatment
Extended Radical
Mastectomy
Radical
Mastectomy
Modified Radical
Mastectomy
BC + RT
Ax LND
1900
I D E A L T H E R A P Y
Radiation
1950
Lumpectomy
BCT +
RT
Sentinel
Node
Biopsy
2000
Summary
• Evolution of breast cancer surgery for
more to less
• More and more specialized
• Less morbidity for patient