Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(22): 2014
Can Breast Conserving Surgery be Advocated
for Iraqi Patients with Breast Cancer ?
Ameer Salah Tawfeeq
College of Medicine/ University of Babylon
Apstract
Purpose: Prove the suitability for future implementation of breast conserving surgery for breast
cancer in Iraq.
Patients and Methods: Triple assessment followed by excision biopsy & finally modified radical
mastectomy had been performed for 75 patients with breast cancer between 1/11/2009 & 1/3/2012.
Histopathology had been performed to the removed breasts and a full study had been performed for the
size of the tumor, its pathological type, stage, grade, hormone receptors, resection margin and any
residual cancer.
Results: All patients were females with ages between 26 & 75 (mean age 47 yrs). Mean age at
menarche was 12.5 yrs. 14(18.5%) were nulliparous & 18(24%) were postmenopausal. Right & left
breasts were equally affected. Distribution over the quadrants was: retroaroelar 26 (34.7%), upper outer
quadrant 17(22.7%), upper inner 14(18.7%), lower inner 10(13.3%), lower outer 8 (10.7). 67 (88%)
were ductal & 8(12%) lobular. 15(20%) of the tumors were poorly-differentiated whereas the rest were
moderately-differentiated. 56(75%) were estrogen receptor positive, 49(65%) progesterone receptor
positive & 22/34 patients who had performed HER-2/neu receptors study were positive. Stages were:
stage I 10(13.4%), stage II 39(52%), stage IIIa 20 (26.7%), stage IIIb 4(5.4%) & stage IV 2(2.6%).The
average clear margin in the excised specimens was 15mm. The average tumor size was 4 cm and
30(40%) of tumors were less than 1.5cm in size. Only 10(13.4%) had family history of breast cancer &
15(20%) had past history of oral contraceptive pills. 68 (90.6%) of the breast specimens examined
pathologically after excision biopsy had no residual cancer while 4 (5.3%) had invasive and another 3
(4%) carcinoma in situ. Mammography had been performed in 22 (29.4%) of the patients and was
positive in 19 giving it a PPV of 86.3.
Conclusion: According to the results of the study, all the features of the patients encourage us to move
forward and start performing breast conserving surgery for the suitable patients.
‫الخالصة‬
‫امكانيه تبني عمليات استئصال الورم مع بقاء الثدي في العراق‬
‫ اثبات امكانيه تطبيق المحافظه على الثدي في العراق‬:‫الهدف‬
‫ تللم ا لراء التقيلليم الثجثللي ثللم ا لراء عمليلله رفللع ورم الثللدي ثللم عمليلله استئصللال الثللدي المطللور ل مسلله وسللبعو مر لله لللديها‬: ‫االسلللو‬
‫ وتمللت د ارسله الثللدي المستسصللا نسلي يا مللع د ارسله اللامله لح لم الللورم النللو‬. 2012/3/1 ‫ اللى‬2009/11/1 ‫سلرطا الثللدي للهتلر مل‬
‫النسللي ي مرحللله االنتاللار سللرطانيه الللورم ومسللتلمات الهرمونللات وغيللاص الحافلله ال يللر مصللابه فللي الللورم المرفللو واي ورم متبقللي فللي‬
...‫الثدي‬
‫ معللدل عمللر بدايلله الحللي‬.‫ سللنه‬47 ‫ معللدل العمللر‬.‫ سللنه‬75 ‫ و‬26 ‫ ميللع المر للى ك ل م ل النسللاء واالعمللار تت لراو مللا بللي‬: :‫النتللائ‬
‫) فللي سل اليللاص وغللد تسللاوت االصللابات فللي الثللديي االيمل وااليسللر وكللا‬%24(18 ‫) كل بللدو اطهللال و‬% 18.5( 14 .‫ سللنه‬12.5
‫) فللي الرخللع العلللوي ال للار ي‬%22.7(17 ‫) لللا الحلملله‬%34.7(26 :‫توز للع االصللابه فللي االرخللا الم تلهلله للثللدي بالاللكا التللالي‬
.‫) ف ل للي الرخ ل للع الس ل للهلي ال ل للار ي‬%10.7(8 ‫) ف ل للي الرخ ل للع الس ل للهلي ال ل للدا لي‬%13.3(10 ‫) ف ل للي الرخ ل للع العل ل للوي ال ل للدا لي‬%18.7(14
‫) كانلت‬%75(56 .‫) م االورام كانت غليلله التمايزوالباغيله متوسلطه التملايز‬%20(15 ‫) كانت فصيه‬%12(8 ‫) كانت غناتية‬%88(67
(HER-
‫ مل المر لات الجتلي ا لر فحل‬34/22 ‫ و‬. ‫) فيها م سلات البرو سلترو‬%65(49 ‫فيها م سات هرمو االسترو ي و‬
)%52( 39 II ‫) المرحللله‬%13.4(10 I ‫ المرحللله‬:‫ در لله انتاللار الللورم كانللت بالاللكا التللالي‬.‫لللديه اي للابي‬
‫ كللا الهح ل‬2/neu)
‫) متوسلطه الحافله ريلر مصلابه بالسلرطا كلا غياسلها‬%2.6 ( 2 I V ‫) المرحلا‬%5.4(4 IIIb ‫) المرحلله‬%26.7(20 IIIa ‫المرحلله‬
‫) كل ل ل للديه ت للار ع للائلي‬%13.4(10 ‫ س للم‬1.5 ‫) مل ل االورام كان للت اغ للا مل ل‬%40(30 ‫ س للم و‬4 ‫مل للم مع للدل ح للم ال للورم ك للا‬15
‫) مل عينللات الثللدي المهحوصلله‬%90.6(68 .‫) كللا لللديه تللار دوائللي بتعللاطي الحبللو المانعلله للحمللا‬%20( 15 ‫لسللرطا الثللدي و‬
.‫) ورم مو عي‬%4(3 ‫) كا فيها ورم منتار و‬%5.3(4 ‫نسي يا بعد ا ذ العينه لم يك فيها بقايا للسرطا بينما‬
.86.3 ‫بمقدار‬
‫ مر ه لتعطيها حساسيه للتا ي‬19 ‫) وكانت اي ابيه في‬%29.4( ‫ااعه الثدي ا ر ت الثني وعار مر ه‬
906
‫تا ل عنا ال للذ زمللام المبللادر للبللد بسياسلله رفللع سللرطا الثللدي مللع الحهللا علللى‬
‫ الد ارسلله كللا مواصللهات المللر‬:‫نتللائ‬
‫ حس ل‬: ‫االسللتنتا‬
.‫الثدي بعد انتقاء الحاالت المناسبه لذلك‬
Introduction:
Breast cancer is the commonest female malignancy in the developing Asian
countries (Agawaral et al., 2007).
The previous surgery was the aggressive radical mastectomy which had been
replaced by modified radical mastectomy and simple mastectomy ( Richard, 2004)
and during the 1970s Fisher in New York and Veronesi in Milano revolutionized the
surgical treatment of breast cancer with the shift from the standard modified radical
mastectomy toward breast conserving surgery ( BCS)(Fisher et al., 1989).
BCS combined with postoperative radiotherapy has been shown to be as effective as
mastectomy with no significant difference in disease free and overall survival
(Veronesi et al., 2002).
It had been shown that although the local recurrence rate was higher for patients
who had BCS, the overall survival of the patients who experienced local recurrence
did not differ significantly from the group of patients who never developed local
recurrence (87% Vs 70% after 8 years ) (Mechera and Orteli, 2009).
Lobular carcinoma, high grade tumors, multifocality, absence of estrogen and
progesterone receptors, concomitant DCIS or LCIS were significant predictors of
local recurrence) (Mechera and Orteli, 2009).
In order to reduce the trauma created by conventional axillary LN dissection, it has
been replaced with sentinel lymph node biopsy for clinically node negative breast
cancer which affords improved staging and minimal morbidity (Guiliano et al., 1997).
As there is a trend toward minimally invasive surgery, radiofrequency ablation
(RFA) is gaining acceptance as a treatment modality for several tumor types, but not
yet for primary breast cancer, as there is yet insufficient evidence for its use as a
standard therapy, in particular with regard to complete tumor death within the ablated
whole area (Ohtani et al., 2011).
Other new techniques include cryosurgery, LASER and magnetic resonance guided
high intensity focused ultrasound (Ohtani et al., 2011).
Has the time come in Iraq to take a courageous step to implement BCS surgery to
suitably-selected patients and stop over doing mastectomy as a routine surgery to
every patient who has breast cancer? As it has been shown that of the available
surgical techniques mastectomy is associated with the highest psychosocial morbidity,
and BCS with the least. If BCS is not an option, breast reconstruction may help
restore patients body image, psychology, well-being and expectation after mastectomy
( Krekel et al., 2011).
Patients & Methods:
In the presented prospective study, triple assessment followed by excision biopsy
& finally modified radical mastectomy had been performed for 75 patients with breast
cancer by two specialized surgeons between 1/11/2009 & 1/3/2012. Histopathology
had been performed to the excised masses and breasts and a full study had been
performed for the size of the tumor, its pathological type, stage, grade, hormone
receptors, resection margin and any residual cancer.
Results:
All patients were females with ages between 26 and 75 years (mean age 47). Mean
age at menarche was 12.5 years. 14(18.5%) were nulliparous and 18 (24%) were
postmenopausal. Only 10 (13.4%) had family history of breast cancer and 15 (20%)
907
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(22): 2014
had past history of taking oral contraceptive pills. Mammography had been performed
in 22 (29.4%) of the patients and was positive in 19 giving it a positive predictive
value of 86.3%. Right and left breasts were equally affected. Distribution over the
quadrants was as follows in table no.1:
Retroaroelar
Upper outer quadrant
Upper inner quadrant
Lower inner quadrant
Lower outer quadrant
Total
26 (34.7%)
17 (22.7%)
14 (18.7%)
10 (13.3%)
8 (10.7%)
75 (100%)
Table no. 1
Distribution of breast cancer over the quadrants
67 (88%) were ductal and 8 (12%) were lobular on histopathology. Also 15 (20%)
of the tumors were poorly- differentiated and the rest were moderately-differentiated.
The average clear margin of the excisional biopsy was 15mm.
Tumor size:
0.5- 1.4 cm
1.5- 3 cm
> 3 cm
Total
30 (40%)
30 (40%)
15 (20%)
75 (100%)
Table no. 2
Size of tumors of breast cancer
56 (75%) were estrogen receptor positive, 49 (65%) progesterone receptor positive
and 22/34 patients who had performed HER-2/neu receptors study were positive.
Manchester staging was as follows:
Stage
I
II
IIIa
IIIb
IV
Total
percentage
10 (13.4%)
39 (52%)
20 (26.7%)
4 (5.4%)
2 (2.6%)
75 (100%)
Table no. 3
908
Percentage of stages of breast cancer
68(90.6%) of the breast specimens which had been examined histopathologically
after the excisional biopsy had no residual cancer while 4 (5.3%) had invasive
carcinoma and another 3 (4%) had carcinoma in situ.
Discussion
The aim of the study was to prove the suitability of our patients for implementing
BCS.
We do, in Iraq, a lot of unnecessary second stage mastectomy following the initial
wide local excision which we perform as an excisional biopsy. This wide local
excision may be enough as a curative surgery in most of the cases. The 1 st proof to
this is the residual tumor left in the breast when histopathology had been performed to
the remaining breast after the second stage mastectomy surgery. In our study, residual
tumor had been found in only 10(13.3%) (5 had invasive carcinoma and the other 5
carcinoma in situ). This low number of residual tumor may be attributed to over
excision as we did not bother ourselves with the cosmetic result and we were oriented
to perform mastectomy to all the cases in which cancer had been proven on
histopathology. It had been shown, in a study, that many surgeons tend to over excise
volume of normal tissue in an effort to obtain adequate cancer-free margins and
actually the median excision volume of all palpation-guided tumor excision was over
two times too large ( Krekel et al., 2011).
The second proof was the tumor free resection margin of the removed excisional
biopsies. Positive resection margin leads to an increased rate of local recurrence
(Gage et al., 1996). The average clear margin in our study was 15mm. This number is
even more than what is needed as the practical guideline during surgery is to achieve a
safe and cosmetically acceptable resection margin of 5-10mm ( Krekel et al., 2011).
The golden rule is to adopt BCS but take care of resection margin. Three
prospective trials comparing BCS with mastectomy ( Fitzal et al., 2009) showed that
local recurrence-free survival was significantly worse after BCS. However all three
trials included patients with cancer cells at the resection margin. The other prospective
trials did not find any significant difference in local recurrence-free survival between
BCS and mastectomy and included patients with resection-free margins only ( Fitzal
et al., 2009). Actually in case of positive or close resection margins, systemic
treatment may only delay local recurrence (Freedman et al, 1999) frozen section
biopsy (FSB) is better to be available when the BCS is performed as the usual practice
is to perform total resection of tumor with 1cm of normal tissue. Resection edges
would be subjected to FSB and when the margin was positive wider excision would
be performed (Potter et al, 2007). To obtain clear surgical margin re excision is also
recommended by others (Anscher et al., 1993). In case of narrow or positive margins
the effect of adjuvant radiotherapy may be considered insufficient to achieve local
control and hence a re excision will be required ( Talsma et al., 2011).
We reviewed the size of the excised masses to show whether their sizes were
actually suitable for BCS and we had found that the average lump size in our study
was 4 cm. This is good as lump size exceeding 8.5cm results in a significant cosmetic
failure (
Krekel et al., 2011).
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Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(22): 2014
The current focus is on improving the accuracy of breast conserving surgery (BCS),
which includes a higher rate of margin clearance with smaller excision volume,
thereby improving patient satisfaction and cosmetic outcome (Al-Ghazal et al, 1999).
In our study, 30(40%) of the tumors were less than 1.5 cm in size. Tumors with an
initial size > 2.5 cm were 15 times more likely to have completion mastectomy after
BCS than tumors < 1.5 cm 20 ( Odonell, et al., 2008).
Tolemerase activity levels may be used for evaluating the surgical margins in BCS (
Hara et al., 2001).
It had been found in a study that adopting BCS in properly selected patients
improves the quality of life (QOL) for the patients. Females with BCS reported better
physical and role functioning, were sexually more active and satisfied with their body
image already at one year after diagnosis. Differences in overall QOL & social
functioning were gradually increasing over time and became statstically-significant
only at 5 years (Arndt et al., 2008).
Also females with BCS and females after mastectomy expressed similar levels of
concerns regarding recurrence of breast cancer at the end of 5 years follow up (Arndt
et al., 2008).
Immediate goal nowadays is to perform immediate breast reconstruction whenever
is possible even in BCS cases (Cicero et al., 2011).
In 2008 performance indicator “ percentage of patients in whom cancer tissue has
been left behind after the 1st BCS” was introduced in the Netherlands (Potter et al.,
2007). In the presented study in the vast majority of cases (65/75) no tumor had been
left behind but this may be attributed to the orientation of the surgeon toward future
mastectomy and so the cosmetic result had not been an issue during the 1st surgery.
As it is well known from the literature that radiotherapy is necessary to reduce the
local recurrence in the remaining breast following BCS and it does not affect the
overall survival and adjuvant radiotherapy is a standard procedure for all patients after
BCS ( Fitzal et al., 2009).
Two etiological types of local recurrence exist:
1. True local recurrence from cancer cells that have not been completely removed
during surgery.
2. New primary tumors are defined as new cancers arising from the residual
ipsilateral breast parenchyma (Mechera and Orteli, 2009).
It had been shown in a study comparing the results in patients given or not given
radiotherapy after mastectomy and BCS. In the BCS group the actual rate of local
recurrence was 10% with and 53% without radiotherapy at 15 years (Potter et al.,
2007). In the mastectomy group, the actual rate of chest wall recurrence was 16%
with and 13% without radiotherapy (Potter et al., 2007). Isolated local recurrence did
not but isolated chest wall recurrence did adversely affect survival (Potter et al.,
2007).
910
Radiotherapy should never be an obstacle in the way of starting BCS in our
country attributing it to the lack of the facilities and experience. It had been found that
radiotherapy might not be necessary in some patients. In fact, we are offering the
same treatment to all patients regardless of the age which has been demonstrated to be
a predominant risk factor for local recurrence (Kurtz et al., 1990). Elderly females
were more likely to undergo BCS, less likely to receive adjuvant chemotherapy and
radiotherapy than their younger counterparts ( Chuan-Dong et al., 2009) and the
preliminary evaluation suggests that breast radiotherapy after BCS can be avoided
without exposing these patients to increased risk of distant disease recurrence (Tinterri
et al., 2009). Stratified by age, it could be noticed that in patients over 55 years, the
local relapse rate was markedly lower than in patients with younger age. Also patients
older than 65 years showed a similar incidence of local recurrence independently of
whether they receive radiotherapy or not. Consequently age represents an important
risk factor for local relapse ( Fisher et al., 1995).
It has been found that for positive margins, younger age was an independent risk
factor for finding residual tumor upon re excision (Anscher et al., 1993). Others
indicate that the increased risk of local recurrence is not associated with age but rather
with menopausal status as chemoopherectomy compared with chemotherapy
decreases risk of local recurrence by 50%. Circulating estrogen may be adversely
related to local relapse in young patients supporting the menopause hypothesis
( Jakesz and Hasmaninger, 2002).
In 1990, the National Institute of Health (NHI) released a consensus statement
recommending the use of BCS with adjuvant radiotherapy instead of mastectomy for
the treatment of early stage i.e. (I and II) breast cancer whenever possible ( Cicero,
1990). In our study 49(65.4%) of the patients were stage I & II. The results of 2 large
randomized controlled series have firmly established the principles of BCS being
equally as safe and effective as mastectomy for the majority of patients with stage I
and II disease (Mechera and Orteli, 2009).
In the presented study DCIS constituted only 5% of the patients. This is also good
as a study showed that DCIS leads more often to incomplete resection than invasive
tumors (Margriet et al., 2012).
MRI of the breast had not been performed in any patient in the presented study.
Multiple studies have demonstrated that breast MRI detects foci of cancer not seen
with other imaging modalities in 10% to nearly 30% of patients (Esserman et al.,
1999). MRI improves the selection of patients for BCS & increases likelihood of
obtaining negative margins at the 1st lumpectomy attempt ( Bedrosian et al., 2003) and
conversion from BCS to mastectomy as a result of MRI findings happened in 6.5%25% and performance of wider excision in an additional 3% to 13.5% ( Bedrosian et
al., 2003). The current literature supporting the use of MRI is based on assumption
that changes in management because of true positive MRI findings are beneficial to
patients (Esserman et al., 1999).
Only 10(13.3%) had multifocal disease which is a relative contraindication to BCS
(Anscher et al., 1993).
Also the grade of the tumor was advantageous in our study. A previous study found
tumor grade to be a significant factor in the risk of finding residual cancer (Anscher et
al., 1993).
911
Journal of Babylon University/Pure and Applied Sciences/ No.(2)/ Vol.(22): 2014
56(75%) of patients were ER positive and 49(65%) were PR positive and these
have good prognosis. It is well accepted that estrogen receptor and/or progesteron
receptor positivity is associated with a more advantageous clinical outcome on BCS
than those tumors with negative receptor status (Knight and Osborne, 1980).
The axilla should be managed by a separate incision and the lymph nodes sample
taken can be made more accurate by advocating the sentinel lymph node biopsy
technique and using the gamma camera ( Richard, 2004).
Conclusion:
According to the results of the study, all the features of the patients encourage us to
move forward and start performing breast conserving surgery for the suitable patients
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