from radical mastectomy to partial breast irradiation the evolution of breast cancer care n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care PowerPoint Presentation
Download Presentation
From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care

Loading in 2 Seconds...

play fullscreen
1 / 54

From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care - PowerPoint PPT Presentation


  • 199 Views
  • Uploaded on

From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care. Johnny Ray Bernard, Jr., M.D. October 19, 2012. William Stewart Halsted. 1852: Born in New York City Sept. 23 1870: Graduates from Phillips Academy Andover 1874: Graduates Yale University

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care' - lucas


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
from radical mastectomy to partial breast irradiation the evolution of breast cancer care

From Radical Mastectomy to Partial Breast Irradiation: The Evolution of Breast Cancer Care

Johnny Ray Bernard, Jr., M.D.

October 19, 2012

william stewart halsted
William Stewart Halsted
  • 1852: Born in New York City Sept. 23
  • 1870: Graduates from Phillips Academy Andover
  • 1874: Graduates Yale University
    • Enrolls in Columbia University College of Physician and Surgeons in New York
  • 1881: First emergency blood transfusion, performed on sister
    • Performs one of first operations for gallstones in U.S., performed on mother
  • 1882: Development of Halsted radical mastectomy
  • 1884: Begins cocaine research, developing the nerve block and other local anesthesia techniques.
  • 1889: Invention of surgical gloves
william stewart halsted1
William Stewart Halsted
  • 1889: Publishes inguinal hernia repair method at the same time as EdoardoBassini.
  • 1890: Appointed first Chief of Surgery at Johns Hopkins Hospital
  • 1892: Performs first successful subclavian artery ligation
  • 1893: Started the first formal surgical residency training program in the United States
  • 1898: American Surgical Association establishes Halsted's mastectomy and inguinal hernia repair as gold standards
  • 1922: Dies in Baltimore from post-op complications of bile duct surgery September 7
halsted radical mastectomy
Halsted Radical Mastectomy
  • Developed and first performed by William Stewart Halsted in 1882.
  • En bloc removal of the breast, muscles of the chest wall, and contents of the axilla
halsted radical mastectomy1
Halsted Radical Mastectomy

Osborne, MP. Lancet Oncol. 2007 Mar;8(3):256-65.

halsted radical mastectomy2
Halsted Radical Mastectomy
  • The “established and standardized operation for cancer of the breast in all stages, early or late”
  • From 1895 to the mid-1970s, about 90% of the women being treated for breast cancer in the US underwent the radical mastectomy.

Bloodgood JC. Problems of cancer. J Kansas Med Soc 1930;31:311-6

what changed
What Changed?
  • Patient dissatisfaction with results, anecdotal information regarding other procedures, some surgeons advocating more extensive surgery, some surgeons advocating more limited operations led to controversy regarding the procedure by the mid 1960’s
  • Also new information about tumor spread suggested that less radical surgery might be just as effective as the more extensive operations that were being performed.
national surgical adjuvant breast and bowel project nsabp b 04
National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04
  • To help resolve the controversy, the NSABP initiated the B-04 clinical trial in 1971
  • Aim: To determine whether patients with either clinically negative or clinically positive axillary nodes who received local or regional treatments other than radical mastectomy would have outcomes similar to those achieved with radical mastectomy.

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

slide10

1765 women (1665 in this report) with operable breast cancer were randomized between July 1971 and September 1974. No women received adjuvant chemotherapy. 87% followed for at least 25 years or were known to have died before that time.

radiation
Radiation
  • Supervoltage equipment
  • Tangential fields
  • Node negative: 50 Gy in 25 fractions, 2Gy/fraction
  • Node positive:
    • An additional boost of 10 to 20 Gy
    • 45 Gy in 25 fractions, 1.8 Gy/fraction, was delivered to both the internal mammary nodes and the supraclavicular nodes

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

definitions
Definitions
  • Local recurrence: recurrences in the chest wall, the surgical scar, or both
  • Regional recurrence: recurrences in the supraclavicular, subclavicular, or internal mammary nodes or in the ipsilateral axilla of patients treated with either radical mastectomy or total mastectomy and regional irradiation
    • Women with negative nodes who had total mastectomy alone and who subsequently had ipsilateral positive nodes that required axillary dissection were not considered to have had a recurrence unless the nodes could not be removed

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

end points
End Points
  • Calculated from the date of mastectomy
  • Disease-free survival: The first local, regional, or distant recurrence of tumor; contralateral breast cancer or a second primary tumor other than a tumor in the breast; and death of a woman who had no evidence of cancer
  • Relapse-free survival: The first local, regional, or distant recurrence or an event in the contralateral breast that was judged to be a recurrence
  • Distant-disease-free survival: Distant recurrences that occurred either as the first recurrence or after a local or regional recurrence, contralateral breast cancers, and other second primary cancers
  • Overall Survival: All deaths

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

25yr f u results dfs
25yr F/U: Results-DFS
  • Node Negative: No significant difference (P=0.65)
    • 19% percent vs. 13%, RM vs. TM+XRT (P=0.49)
    • 19% with TM alone (P=0.39, compared to RM)
    • TM+XRT vs. TM alone (P=0.78)
  • Node Positive: No significant difference
    • 11% vs. 10%, RM vs. TM+XRT (P=0.20)
results rfs
Results-RFS
  • Node Negative: No significant difference (P=0.46)
    • 53% percent vs. 52%, RM vs. TM+XRT (P=0.74)
    • 50% with TM alone (P=0.27, compared to RM)
    • TM+XRT vs. TM alone (P=0.15)
  • Node Positive: No significant difference
    • 36% vs. 33%, RM vs. TM+XRT (P=0.40)
results
Results

Regardless of nodal status, most first events were related to distant recurrences of tumor and to deaths that were unrelated to breast cancer.

results1
Results

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

no axillary treatment
No Axillary Treatment
  • 68/365 women with negative nodes who underwent total mastectomy without radiation therapy (18.6%) subsequently had pathological confirmation of positive ipsilateral nodes.
    • Identified within 2 years after surgery in 51/68 (75%) women
    • Between 2-5 years in 10/68 (15%) women
    • Between 5-10 years in 6/68 (9%) women
    • Between 10-25 years in 1/68 (1%) woman
  • Median time from mastectomy to the identification of positive axillary nodes was 14.8 months (range, 3.0 to 134.5).
slide19
Node negative: 68.3% of breast-cancer–related events occurred within the first 5 years of f/u

-65.1% of these were distant recurrences, 10.3% contralateral breast cancer

Node positive: 81.7% of breast-cancer–related events occurred within the first 5 years of f/u

-68.1% of these were distant recurrences

results ddfs os
Results-DDFS & OS

Also, no difference in distant-disease-free survival or overall survival

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

recurrence contralateral cancer
Recurrence & Contralateral Cancer

The cumulative incidence of death after a recurrence or a diagnosis of contralateral breast cancer was 40% in women with negative nodes and 67% in women with positive nodes.

Fisher B, et al. N Engl J Med. 2002 Aug 22;347(8):567-75.

conclusions
Conclusions
  • Similar outcomes for patients with either clinically negative or clinically positive axillary nodes who received local or regional treatments other than the gold standard Halsted radical mastectomy.
  • Thus, less extensive surgery can be safely performed.
  • No benefit for radiation in clinically node negative patients in terms of DFS, RFS, DDFS, OS vs. those with axillary node dissection
    • Benefit in local control vs. those without axillary treatment.
  • Without any axillary treatment, ~20% risk of axillary disease, less with treatment, but still no change in DDFS or OS.
  • Most events occurred within 5 years but long term follow-up of patients is still needed as events still occurred after 5 years.
  • Treatment to improve distant recurrence needed.
slide23

So now we know that we don’t have to perform such extensive surgery, what about not removing the whole breast at all?

surgical pathology
Surgical Pathology
  • Numerous surgical series of mastectomy specimens showed that breast cancer was multifocal and multicentric in nature.
  • Holland, et. al. noted that of 282 mastectomy specimens with invasive cancer, 177 (63%) specimens exhibited additional cancer aside from the index tumor, with 121 (43%) specimens having tumor more than 2cm away from the index tumor.
  • This suggested that women undergoing breast conservation would have a significant rate of local recurrence by removing only the primary tumor.

Holland R, et al. Cancer.

1985 Sep 1;56(5):979-90.

nsabp b 06
NSABP B-06
  • To help resolve the controversy, the NSABP initiated the B-06 clinical trial in 1976.
  • Aim: To determine whether women with stage I or II breast tumors that were 4 cm or less in diameter who received breast-conserving surgery would have outcomes similar to those achieved with total (new standard) mastectomy.

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

slide26

2163 women (1851 in this report) with invasive breast tumors that were <4 cm and with either negative or positive axillary lymph nodes (stage I or II breast cancer) were randomized between August 1976 and January 1984. Axillary nodes were removed regardless of the treatment assignment.

treatment
Treatment
  • Lumpectomy: Removal of sufficient normal breast tissue to ensure both negative margins (no tumor at inked margin) and a satisfactory cosmetic result
    • Only the lower two levels of the axillary nodes were removed
    • +margins underwent total mastectomy but continued to be followed for subsequent events
  • Total Mastectomy:
    • The axillary nodes were removed en bloc with the tumor
  • Radiation:
    • 2Gy/fraction to 50 Gy to the breast, but not the axilla
  • Chemo: Any positive axillary nodes received adjuvant systemic therapy with melphalan and fluorouracil

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

definitions1
Definitions
  • Local recurrence: A first recurrence of a tumor in the chest wall or in the operative scar, but not in the ipsilateral breast, was classified as a local recurrence.
    • Ipsilateral breast recurrence after lumpectomy was considered to be a cosmetic failure since women who underwent total mastectomy were not at risk for such an event.
  • Regional recurrence: Recurrences in the internal mammary, supraclavicular, or ipsilateral axillary nodes were classified as regional occurrences.

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

endpoints
Endpoints
  • Calculated from the date of surgery
  • Disease-free survival: The first recurrence of disease at a local, regional, or distant site; the diagnosis of a second cancer; and death without evidence of cancer
  • Distant-disease–free survival: Distant metastases as first recurrences, distant metastases after a local or regional recurrence, and all second cancers, including tumors in the contralateral breast
  • Overall survival: All deaths

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

20yr f u results ibtr
20yr F/U: Results IBTR
  • 14.3 % L+XRT vs. 39.2% L alone (P<0.001)
  • Benefit of XRT independent of nodal status
    • Node Neg: 17% vs. 32% (P<0.001)
    • Node Pos: 44% vs. 9% (P<0.001)
  • L+XRT Time to Recurrence
    • <5yrs: 40%
    • 5-10yrs: 29%
    • >10yrs: 31%
  • L alone Time to Recurrence
    • <5yrs: 73%
    • 5-10yrs: 18%
    • >10yrs: 9%

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

results2
Results

As in B-04, the most frequent first events were distant recurrences

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

results dfs
Results-DFS

No significant difference (P=0.26)

36% vs. 35% vs. 35%, TM vs. L+XRT vs. L alone

results ddfs os1
Results-DDFS & OS

DDFS: No significant difference (P=0.34)

49% vs. 46% vs. 45%, TM vs. L+XRT vs. L alone

OS: No significant difference (P=0.57)

47% vs. 46% vs. 46%, TM vs. L+XRT vs. L alone

slide34
69% of first recurrences were detected <5yrs of surgery, 20% between 5-10yrs, and 11% after 10 years
  • 9% of local recurrences, 7% of regional recurrences, and 13% of distant recurrences were detected after 10 years
  • Contralateral breast: 38% detected <5yrs of surgery, 30% 5-10yrs, and 32% after 10 years.
recurrence contralateral cancer1
Recurrence & Contralateral Cancer

Fisher B, et al. N Engl J Med.

2002 Oct 17;347(16):1233-41.

recurrence contralateral cancer2
Recurrence & Contralateral Cancer

The cumulative incidence of death after a recurrence or a diagnosis of contralateral breast cancer was 40% in women with negative nodes and 67% in women with positive nodes.

Fisher B, et al. N Engl J Med. 2002 Oct 17;347(16):1233-41.

conclusions1
Conclusions
  • Women with early stage breast cancer who have breast conserving surgery have outcomes similar to those achieved with total mastectomy.
  • Radiation therapy is a critical component of breast conservation.
  • Breast conservation should be offered to women with early stage breast cancer.
  • Most events occurred within 5 years but long term follow-up of patients is still needed as events still occurred after 5 years
  • Treatment to improve distant recurrence needed.
pathologic findings from the nsabp b 06
Pathologic Findings from the NSABP B-06
  • 110 local breast recurrences were observed in 1108 pathologically evaluable patients
  • All 110 recurrences were noted to be in or close to the quadrant of the initial or index cancer.
  • The most common presentation of breast recurrence appeared to be a localized mass within or close to the quadrant of the index cancer (86%).
  • In 14%the recurrence not only involved the same quadrant, but was more diffuse within the breast.

Fisher ER, et al. Cancer. 1986 May 1;57(9):1717-24.

slide39

So now we know that BCT is feasible and most recurrences occur close to the original tumor site, what about not radiating the whole breast?

leading the way to pbi
Leading the Way to PBI
  • Other pathologic studies confirming findings
  • Patients not desiring weeks of radiation treatment
  • Phase I/II studies of accelerated WBI in 4-5 days using multi-catheter interstitial brachy
  • Radiation to just the tumor bed
    • Multi-catheter interstitial brachytherapy
    • Balloon catheters and 3DCRT
    • Strut based catheter (SAVI)
evolution of brachytherapy techniques
Evolution of Brachytherapy Techniques

Interstitial

Balloon

Strut Applicator

Multi-catheter

Single catheter

Multi-catheter

persistent seroma
Persistent Seroma

Balloon applicators

Symptomatic: 3%-46%

Potential causes

Contiguous V200

Tissue compression

Both?

strut based applicator
Strut Based Applicator

Greater flexibility

Treats the widest array of cavity & breast sizes

Enhanced performance

Eliminates skin spacing restrictions

Better outcomes

Lowers toxicity & risk of persistent seroma

Exceptional precision

Sculpt dose with selective radiation

Added convenience

Simple, secure placement and removal

apbi data review
APBI Data Review

* Conclusion - Partial breast irradiation using interstitial HDR implants or EB to deliver radiation to the tumor bed alone for a selected group of early-stage breast cancer patients produces 5-year results similar to those achieved with conventional WBI. Significantly better cosmetic outcome can be achieved with carefully designed HDR multi-catheter implants compared with the outcome after WBI.

There have been no differences in survival with APBI compared to WBI.

thank you
Thank you!

Johnny Ray Bernard, Jr., M.D., DABR

Southern Ohio Medical Center

Senior Medical Director

Radiation Oncology

(O) 740-356-7490

bernardj@somc.org