Breast Conservative therapy

Breast Conservation Therapy : 

Breast Conservation Therapy Dr Chintamani MS, FRCS(Ed.),FRCS(Glas.),FICS, FIAMS Vardhman Mahavir Medical College Safdarjang hospital New Delhi

Newer trends in BCT : 

Newer trends in BCT BCS for early-stage invasive breast cancer provides survival equivalent to mastectomy Careful patient selection and surgical technique necessary to minimize local recurrence Extensive studies of BCT over last 15 years identified risk factors for local recurrence and previously in-eligible cases are being accepted for lumpectomy (Occult BC,LABC,macromastia,Pregnancy) may be done safely)

Recent trends to facilitate BCT : 

Recent trends to facilitate BCT Use of MRI & USG Touch pre-cytology for intra-operative margin evaluation can improve rates of BCT Brachytherapy may also improve BCT availability & shortening the duration of treatment Local recurrences developing after BCT should be managed aggressively as long term survival can frequently be achieved.

Halsteaden vs Fisher`s view : 

Halsteaden vs Fisher`s view More aggressive surgeries could not halt the progression of metastasis NSABP-B-04 & Milan Cancer Institute trials Abundandance of data regarding the safety of breast preservation for early breast cancer

NCI consensus statement : 

NCI consensus statement “Breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage-I,II breast cancers and is preferable as it provides surgical equivalent to total mastectomy and axillary dissection”

Indian scenario !! : 

Indian scenario !! In theory there is no difference between theory and practice But in practice there is …..Snepschant

Indian scenario !! : 

Indian scenario !! Chintamani, Saxena S,Rekhi B,Bansal A,Bagga A, Murthy NS. Clinico-morphological patterns of breast cancer including family history in a New Delhi hospital, India--a cross-sectional study.World J Surg Oncol. 2005 Oct 13;3:67. Chintamani, Saxena S,Chakroborty A,,Agarwal AK,Sharma VK,Sharma PC,Lenoir G,Goldgar DE,Szabo CI.Contribution of germline BRCA1 and BRCA2 sequence alterations to breast cancer in Northern India.BMC Med Genet. 2006 Oct 4;7:75. Chintamani ,Chakroborty A,Murthy NS,, Bhatnagar D,Mohil RS,Sharma PC,Saxena S.CYP17 gene polymorphism and its association with high-risk north Indian breast cancer patients. J Hum Genet. 2007;52(2):159-65. 2007 Jan 18.

Eligibility & exclusion criteria for BCT [factors] : 

Eligibility & exclusion criteria for BCT [factors] Capability to deliver breast irradiation(patient and center) Likelihood of achieving cosmetically acceptable result Ability to obtain a margin negative lumpectomy Capability to deliver Boost irradiation

Capability to give RT : 

Capability to give RT Access Medical conditions affecting tolerance and toxicity Pregnancy

Aesthetic results!! : 

Aesthetic results!! Can be altered by patient`s body habitus Tumour location Patient should be the one to define cosmetically acceptable result

American College of Radiology & ACS accepted standards : 

American College of Radiology & ACS accepted standards Multicentric disease(tumours in separate quadrants => excessive tumour burden that can not be controlled by RT) Multiple tumours confined to single quadrants of breast can be offered BCT if resection R0 for each, leaving cosmetically acceptable result.

American College of Radiology & ACS accepted standards : 

American College of Radiology & ACS accepted standards Diffuse malignant appearing microcalcifications appearing on the preoperative mammogram is a contra- indication to BCT because the pattern probaboly suggests Extensive Ductal carcinoma in situ & predicts low likelihood of obtaining negative margins

ACR & ACS Guidelines : 

ACR & ACS Guidelines Resecting more limited volume of microcalcification associated with breast cancer, mammography guided wire locallization lumpectomy should be done. These must also have post lumpectomy margin comparing absence of residual calcification before delivering RT even if lumpectomy margin is negative

Guidelines contd. : 

Guidelines contd. Lumpectomy in patients with indeterminate calcification should be considered with caution & whenever possible calcification should be included en bloc with lumpectomy Prior therapeutic irradiations &Pregnancy Positive margins on lumpectomy specimen & re-excision indicate excessive tumour burden. Mutiple unsuccesful excisions indicate excessive tumour burden. Excessive tumor burden delays administration of Post op Chemo and affect cosmesis indicate

Guidelines contd. : 

Guidelines contd. Medical diseases like collagen disease scleroderma, SLE associated with high RT toxicity. Clinical, pre-operative estimaton of tumour size should be <5cm, or unacceptable cosmetic result (Tumour/ breast ratio)

Special instances : 

Special instances Family history [not found a risk factor n=1300..MD Anderson cancer center trial] Primary tumour histology: Invasive lobular cancers: notorious for their ability to present in an insidious manner LCIS in addition to invasive cancer treated with BCT may continue to express a long term increase in risk of new primary in the untreated breast The risk may be suppressed with Tamoxifen therapy

Margin evaluation : 

Margin evaluation Margin [the closest microscopic distance between the inked lumpectomy tissue edge and any cancerous tissue-invasive or DCIS] Obtaining a negative margin in the lumpectomy specimen of breast cancer patient is considered a basic prerequisite for standard of care. Wider margins reduce local recurrence * *Milan Cancer Institute trial 2004

Extensive intra-ductal component : 

Extensive intra-ductal component EIC is known or suspected= >wider margins EIC predictor of likelihood =>additional disease would be found in re-excision specimen EIC positive tumour associated with microcalcifications on mammographic evaluations, aggressive use of image guidance may facilitate the resection attempt Pre-op locallization can bracket the span of suspected disease Intra-operative specimen mammography can direct additional margin resection Essential to follow with postoperative mammogram

Slide 23: 

“We are not retreating We are advancing in another direction” ….Gen.Douglas Mc Arthur