BREAST CANCER Whats New In Breast Surgery Rie

BREAST CANCER : What’s New In Breast Surgery Rie Aihara, M. D. FACS Regional Breast Care Division of 21 Century Oncology

Breast Cancer Care �Radical Mastectomy is no longer the standard � Improved adjuvant and neoadjuvant therapy �Chemotherapy �Endocrine therapy �Radiation treatment �Reconstruction �Era of individualized therapy � Receptor status � Molecular subtyping � Genomic assessment � Genetic factors

Breast Cancer Treatment Options Endocrine Therapy Mastectomy SLN Bx → Ax. Diss. Breast Conservation 5 Chemotherapy Radiation

Breast Cancer Surgery: From radical to breast-conserving procedures Removal of whole breast, including pectoral muscles and axillary lymph nodes 1880 1900 No difference in survival with radical mastectomy or lumpectomy Inoperability criteria established for locally advanced breast cancer 1920 Radical mastectomy and supraclavicular dissection Winchester DP, et al. Surg Oncol Clin N Am. 2005; 14: 479. 1940 1960 Modified radical mastectomy 1980 2000 Sentinel lymph node mapping

Other Changes in Surgical Management of the axilla: � ACOSOG Z-0011 data � AMAROS study

ACOSOG Z-0011 � 813 patients with T 1/T 2 clinically node-negative tumors with positive SLNs were randomized to ALND vs no further dissection �showed equivalent results between the 2 arms hm � At 6. 3 years’ follow-up, no differences were found between the 2 groups: �axillary recurrence (0. 5% vs 0. 9%), in-breast recurrence (3. 6% vs 1. 9%), or overall locoregional recurrence (4. 1% vs 2. 8%, P = 0. 53) �Disease-free and overall survival were similar (82. 2% vs 83. 8% and 91. 9% vs 92. 5%) between the groups.

� Applicable to patients with all of the following criteria: • T 1 -2 tumors • One to two positive SLNs without extracapsular extension • Completion of whole-breast radiation therapy • Completion of adjuvant therapy (hormonal, cytotoxic, or both) � Not directly applicable to these patients: • T 3 tumors • more than 2 positive nodes • undergoing mastectomy or partial breast radiation • matted axillary nodes or preoperative palpable nodes • neoadjuvant chemotherapy

AMAROS Trial � Objective: to prove equivalent local/regional control with less morbidity in patients with positive sentinel node biopsy (SLN) if treated with axillary radiation vs axillary node dissection. -744 received ALND and 681 received axillary radiation -82% underwent breast conservation and 18% underwent mastectomy -90% received systemic treatments. -

Results: At 5 years, the axillary recurrence rate was "extremely low" in both groups (0. 54% vs 1. 03%), � There were no significant differences in disease free survival-between the surgery and radiation (86. 9% vs 82. 7%; P =. 1788) or overall survival (93. 3% vs 92. 5%; P =. 3386). � However, the rate of lymphedema in the surgery group was twice that of the radiation group (28% vs 14%). � Either modality provides excellent and comparable axillary control; however, the incidence of lymphedema was lower with axillary radiation than with axillary lymph node dissection � Axillary radiation should be regarded as the recommended treatment for these patients.

Surgical Techniques �Localization technique � Traditionally wire localized � Use of a Infrared technology to localize tumors �Radiation marker � 3 dimentional radiation marker

Traditional Wire Localization Non-palpable lesions: Guidewire placed into lesion or area of abnormality using ultrasound/mammo/ MRI

Savi Scout- Cianna Medical

Savi Scout -No external wires -can be placed up to 7 days prior to surgery Infrared Reflector -incision not limited by wire location

Lumpectomy Specimen

Bio. Zorb by Focal Therapeutics

Slide: Courtesy of Focal Therapeutics

Slide: Courtesy of Focal Therapeutics

Slide: Courtesy of Focal Therapeutics

Path of Surgery Therapy �Less surgery in the breast: � Partial mastectomy � Cryotherapy ? � Percutaneous enucleations �Less Surgery in the axilla � Sentinel node biopsy � Z-11 trial � AMAROS trial � ACOSOG 1071