Spotlights on the surgery role at San Antonio

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Spotlights

on the surgery role at San Antonio

Riccardo Masetti, MD

Professor of Surgery

Director, Multidisciplinary Breast Center Catholic University

Rome, Italy

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Roma, 21 maggio 2017

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Prof. Masetti has no relevant financial relationships with commercial interests to disclose

…but….

I have to admit that this year, for unexpected familiy reasons, I had to decline at the last

minute my participation to SABCS

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Spotlights on surgical issues:

• Appropriate surgical margins

• Locoregional recurrence

• Axillary management

• Local therapy in ABC

San Antonio Breast Cancer Symposium, 12/2017

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APPROPRIATE SURGICAL MARGINS

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APPROPRIATE SURGICAL MARGINS

Moran et al, 2014

appropriate margin:

NO TUMOR ON INK

CURRENT SSO/ASTRO GUIDELINES ON MARGINS:

Is this correct?

(8)

APPROPRIATE SURGICAL MARGINS

New meta-analysis

•Systematic review of the literature (1995-2016)

•38 studies

•Inclusion criteria:

• Minimum follow-up: 50 months

• Explicit pathologic definition of margin status

• Local recurrence reported in relation to margin status

F. Vicini et al

Beth Israel Deaconess Medical Center - Harvard medical school

(9)

APPROPRIATE SURGICAL MARGINS

New meta-analysis

•55.302 patients

( >20.000 additional patients from previous meta-analysis

•7.2 years median follow-up

F. Vicini et al

(10)

APPROPRIATE SURGICAL MARGINS

Odds Ratio for Local Recurrence by margin Status

• Positive vs Negative; 2.49 (2.10-2.96)

• Close vs Negative: 1.58 (1.32-1.89)

• 2 mm vs 1 mm 0.50 (0.42-0.59)

• 5 mm vs 1 mm 0.40 (033-0.48)

F. Vicini et al

(11)

APPROPRIATE SURGICAL MARGINS

Limitations of metanalysis preclude definitive conclusion regarding appropriate margins

However, MVA seems to indicate that having a margin width beyond «no tumor on ink»

may further reduce rates of local recurrence (Consistent with DCIS: margins should be >2mm)

Further prospective studies are required

F. Vicini et al

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Does large volume displacement oncoplastic surgery still offer an advantage of a low positive margin rate using the new SSO/ASBrS/ASTRO margin guidelines?

LITERATURE REVIEW

45 PAPERS 15.102 PATIENTS

STATISTICS COMPARING LVOS VS TRADITIONAL BCS

APPROPRIATE SURGICAL MARGINS

M. Jonczyk et al

Tufts Medical Center - Boston Hospital and Academic Medical Center

(13)

Large volume displacement oncoplastic surgery (LVOS) can secure better clearance of margins

• Positive margin rate

• (PMR) comparison

• T-Test evaluation

• Positive margin rate

• (PMR) comparison

• T-Test evaluation

APPROPRIATE SURGICAL MARGINS

Positive margin rate (PMR) comparison

T-Test evaluation

Published PMR between LVOS and TBCS in literature review

LVOS: 12.5%

TBCS: 20.4%

P-value: <0.001 PMR between Tufts LVOS and

TBCS in literature review

Tufts LVOS: 10%

TBCS: 20.4%

P-value: 0.036

M. Jonczyk et al

Tufts Medical Center - Boston Hospital and Academic Medical Center

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Spotlights on surgical issues:

•Margins

•Locoregional recurrence

•Axillary management

•Local therapy in ABC

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LOCOREGIONAL RECURRENCE

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LOCOREGIONAL RECURRENCE

Challenge of LRR:

• LRR is increasingly uncommon, so evidence to guide practice is limited

• Most data come from patients treated with MRM or lumpectomy, ALND and RT

• Changing treatment landscape has raised new questions:

– Repeat lumpectomy

– Axillary management after initial SN bx

M. Morrow

Memorial Sloan Kettering Cancer Center

(17)

REPEAT LUMPECTOMY FOR IBTR

M. Morrow

(18)

Good results only in low risk patients

(ER+, HER2-, initial negative margins)

REPEAT LUMPECTOMY FOR IBTR

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• Not the standard of care

• Reported high rates of additional LR

M. Morrow

REPEAT LUMPECTOMY FOR IBTR

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M. Morrow

REPEAT LUMPECTOMY FOR IBTR

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Nothing new

as compared to NCCN 2017 guidelines!!

LOCOREGIONAL RECURRENCE

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REOPERATIVE SENTINEL NODE BIOPSY

M. Morrow

• Success of reoperative SLN is related to number of axillary nodes removed during primary surgery

– 0-2 nodes removed: 80% SLN identification rate – 3-5 nodes removed: 65% SLN identification rate – >9 nodes removed : 38% SLN identification rate

• Extended axillary dissection raises the incidence of

aberrant drainage pathways

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REOPERATIVE SENTINEL NODE BIOPSY

M. Morrow

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Conclusions:

• Technically feasible

• High rates of aberrant drainage in previously treaten axilla (ALND or SNB)

• Clinical outcome likely to be determined by

recurrence biology, not surgical staging of nodes REOPERATIVE SENTINEL NODE BIOPSY

M. Morrow

(25)

Spotlights on surgical issues:

•Appropriate surgical margins

•Locoregional recurrence

•Axillary management

•Local therapy in ABC

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SNB IN EARLY BREAST CANCER

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SNB IN EARLY BREAST CANCER

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MICROMETASTATIC SLN

SNB IN EARLY BREAST CANCER

V. Galimberti

IEO, Milan

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SNB IN EARLY BREAST CANCER

6681

patients registered

5747 not eligible for randomization

934

patients randomized

467 analyzed

10 withdrew consent 74 lost to follow-up

467

allocated to

no axillary dissection

464

allocated to

axillary dissection

464 ^analyzed

11 withdrew consent 69 lost to follow-up

2 excluded 1 excluded

V. Galimberti

IEO, Milan

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MICROMETASTATIC SLN

SNB IN EARLY BREAST CANCER

Arms characteristics well matched

V. Galimberti

IEO, Milan

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SNB IN EARLY BREAST CANCER

Appropriate balance of adiuvant therapies

V. Galimberti

IEO, Milan

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10 years results

SNB IN EARLY BREAST CANCER

V. Galimberti

IEO, Milan

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SNB IN EARLY BREAST CANCER

Low incidence of axillary events disregarding type of surgery

V. Galimberti

IEO, Milan

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No differences between the AD and no AD groups for any endpoint

No ALND is acceptable

even in patients scheduled for mastectomy

SNB IN EARLY BREAST CANCER

MICROMETASTATIC SLN

V. Galimberti

IEO, Milan

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MACROMETASTATIC SLN

(Breast conserving surgery)

T. King

Dana Farber / Brigham and women’s - Harvard medical school

30-80% of ALND reduction in cN+ (sn) patients worlwide!

SNB IN EARLY BREAST CANCER

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(patients undergoing mastectomy)

Dana Farber’s multidisciplinary behavior

No SNB in patients cN0 undergoing mastectomy who will receive PMRT:

• <60 YR

• High risk factors (LVI or HR negative) 1-2 positive SLN

• PMRT + Axillary RT

3 or + positive SLN

• ALND

SNB IN EARLY BREAST CANCER

T. King

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SNB IN EARLY BREAST CANCER

75 pts patients registered

(cT1-2, N0) – no FS

54 (72%)

negative SLN

21 (28%)

positive SLN

1 ALND

18 pts (24%)

1-2 positive SLN

3 pts (4%)

≥3 positive SLN

3 observation 14 (78%)

PMRT + AxRT

17/21 (81%) of positive patients spared ALND

T. King

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SLNB procedure of choice for axillary stadiation SNB AFTER NEOADJUVANT TREATMENT

T. King

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SNB AFTER NEOADJUVANT TREATMENT

T. King

FEASIBILITY OF SLNB AFTER NAD

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cN0 – ycN0 PATIENTS

Acceptable SLN identification rate even after NACT

SNB IN NEOADJUVANT TREATMENT

T. King

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Acceptable identification and false negative rates (only if ≥3 SLN are removed)

SNB AFTER NEOADJUVANT TREATMENT

T. King

cN+ – ycN0 PATIENTS

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SNB AFTER NEOADJUVANT TREATMENT

T. King

INTERPRETATION OF SLNB

AFTER NAD

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SLNB in cN+ – ycN0 patients

SNB AFTER NEOADJUVANT TREATMENT

T. King

In ypN0 (sn) pts – ALND can be avoided,

sparing up to 50% of ALND in converted axillas!!

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• No relationship between size of SLN mets and likehood of additional nodal disease

– 57% of patients with ypN0 (i+) had positive non SLN after NACT

• Significance of disease <0,2 mm (ypN0i+ / ypN1mic) still unclear

• More studies are needed to clarify significance of micro mets and ITCs in SLN after NACT

SNB AFTER NEOADJUVANT TREATMENT

T. King

Significance of micromets and ITCs

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Clear indication for ALND

SNB AFTER NEOADJUVANT TREATMENT

T. King

ypN+ PATIENTS

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Waiting for more studies for stronger recomendations

SNB AFTER NEOADJUVANT TREATMENT

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AXILLARY TREATMENT COMPLICATIONS

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A. Kuijer

AXILLARY TREATMENT COMPLICATIONS

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A. Kuijer

AXILLARY TREATMENT COMPLICATIONS

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A. Kuijer

AXILLARY TREATMENT COMPLICATIONS

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Spotlights on surgical issues:

•Appropriate surgical margins

•Locoregional recurrence

•Axillary management

•Local therapy in ABC

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S. Khan

Lynn Sage Breast Center & Dept of Surgery - Northwestern University

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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S. Khan

OLIGOMETASTATIC BC TREATMENT

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