hon chi yip department of surgery north district hospital n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
BCT for multifocal multicentric breast cancer - Is it contraindicated? PowerPoint Presentation
Download Presentation
BCT for multifocal multicentric breast cancer - Is it contraindicated?

Loading in 2 Seconds...

play fullscreen
1 / 30

BCT for multifocal multicentric breast cancer - Is it contraindicated? - PowerPoint PPT Presentation


  • 412 Views
  • Uploaded on

Hon-chi Yip Department of Surgery North District Hospital. BCT for multifocal multicentric breast cancer - Is it contraindicated?. Multifocal / multicentric breast cancer. Definition Multifocal (MF) – multiple tumors in same quadrant (>5cm apart)

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 'BCT for multifocal multicentric breast cancer - Is it contraindicated?' - yoshi-fuller


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
hon chi yip department of surgery north district hospital
Hon-chi Yip

Department of Surgery

North District Hospital

BCT for multifocal multicentric breast cancer -Is it contraindicated?

multifocal multicentric breast cancer
Multifocal / multicentric breast cancer
  • Definition
    • Multifocal (MF) – multiple tumors in same quadrant (>5cm apart)
    • Multicentric (MC) – multiple tumors in different quadrants
    • Not based on anatomy of breast
  • Increasingly detected due to the widespread use of MRI breast
pathophysiology of multifocality and multicentricity
Pathophysiology of multifocality and multicentricity
  • Monoclonal proliferation of a single mammary carcinoma
  • Multiple independent synchronous tumors in the same breast
breast conservation therapy
Breast conservation therapy
  • Wide local excision + radiotherapy
  • Established treatment modality for early stage breast cancer
    • No difference in overall, disease-free survival
    • Improved body image and lifestyle score
  • National Institutes of Health (NIH) Consensus Conference statement 1990
    • BCT as preferred surgical treatment of women with early stage breast cancer
  • NIH Consensus Conference. JAMA 1991;265(3):391-5
m ultifocal multicentric breast cancer
Multifocal / multicentric breast cancer
  • Traditionally contraindicated for BCT
  • Landmark trials for BCT – NSABP B-06, EORTC, Milan etc
    • Exclusion criteria – Multifocal or multicentric disease
    • Increased difficulty to obtain negative margin
    • Potential increase risk of recurrence

Fisher B et al. N Engl J Med 2002;347:1233–1241.

Veronesi U et al. N Engl J Med 2002;347:1227–1232.

van Dongen JA et al. J Natl Cancer Inst 2000;92:1143–1150.

development of oncoplastic surgery ops
Development of oncoplastic surgery (OPS)
  • Allow wide excision for BCT without compromising the natural shape of the breast
  • Integration of plastic surgery techniques for immediate breast reshaping
  • Oncologic efficacy (margin status & recurrence) compare favorably with traditional BCT
    • Results of 298 OPS treated breast cancer
      • 5 year overall survival 94.6%, DFS 93.7%
  • Recent enthusiasm on BCT in MF / MC disease

Staub G et al. Ann Chir Plast Esthet. 2007;53(2):124–34.

important issues
Important issues
  • Oncological considerations
    • Effect on overall survival
    • Effect on disease recurrence, esp. locoregional
  • Technical considerations
    • Complete excision, negative margin
    • Satisfactory cosmetic result
oncological considerations
Oncological considerations
  • Lack of level 1 evidence
  • What are the available evidence in the literature?
  • Medline and PubMed search – keywords:
    • ‘‘Multifocal’’ or ‘‘Multicentric’’ or ‘‘Breast Conservation’’ or ‘‘Mastectomy’’
    • ‘‘Breast Cancer’’ or ‘‘Ductal Carcinoma In-Situ (DCIS)’’
early studies
Early studies
  • Resection margins not routinely evaluated
  • Surgery involved gross excision of suspicious masses only
  • No fixed protocol for adjuvant therapy
unifocal vs mf mc recurrence and survival
Unifocalvs MF/MC – recurrence and survival

Overall survival

Weissenbacher et al. Breast Cancer Res Treat 2010;122:27-34

Chung et al. J Am Coll Surg 2012;215:137-147

dfs unifocal vs multicentric disease
DFS – unifocalvsmulticentric disease

Ustaalioglu BO et al. Am J Clin Oncol 2012;36:580-586

unifocal vs mf mc population based study
Unifocalvs MF / MC – population based study
  • MF/MC not associated with inferior survival on multivariate analysis

Yerushalmi et al. Annals of Oncology 2012;23:876-881

mf mc breast cancer survival
MF / MC breast cancer – survival
  • No comparative survival data on BCT vs mastectomy in MF / MC disease
technical considerations
Technical considerations
  • Excision of multifocal / multicentric tumors without resulting in significant breast distortion
  • Careful preoperative assessment required
role of mri breast in preoperative assessment
Role of MRI breast in preoperative assessment
  • Routine use of MRI breast in preoperative staging for early CA breast is controversial
  • Meta-analysis showed that MRI could identify additional multifocal / multicentric foci that preclude breast conservation
  • Possibility of false positive finding, unnecessary mastectomy
  • RCT showed no improvement in reoperation rate

Houssami et al. J Clin Oncol 2008;26:3248-58

L Turnbull et al. Lancet 2010;375:563-71

role of mri
Role of MRI
  • Possible role in confirmed MF / MC disease to rule out additional tumor foci and define extent of disease?
choice of approach
Choice of approach
  • Size, location and distribution of the lesions
  • Breast volume, ptosis
  • Surgeon preference
  • Single vs multiple wide local excisions
  • Choice of breast restoration
    • Oncoplastic surgical techniques
st gallen consensus 2013
St GallenConsensus 2013
  • When considering BCT, the following factor is contraindication:
conclusion
Conclusion
  • BCT is not absolutely contraindicated in cases of multifocal or multicentric breast cancers
  • Acceptable recurrence rate and survival can be obtained with adequate tumor excision and adjuvant therapy
  • Therapeutic strategy should be individualized based on the feasibility of wide local excision with negative margins and patient’s preference
pathophysiology of multifocality and multicentricity1
Pathophysiology of multifocality and multicentricity
  • Monoclonal proliferation of a single mammary carcinoma
  • Multiple independent synchronous tumors in the same breast
  • One small scale series found near identical morphologic and immunohistochemical pattern in 32 multicentric tumor specimens
  • 75% cases had evolutionary related cytogenetically abnormal clone in different tumor lesions from same breast
  • Another study of 24 cases only showed 10 cases of identical histological and immunohistochemical pattern

Middleton LP et al.Cancer. 2002 Apr 1;94(7):1910-6.

Texieira MR et al. Br J Cancer 1994;70:922-927

Dawson PJ et al. Hum Pathol. 1995;26:965–969

selection criteria
Selection criteria
  • Excision volume
    • >20% of volume excised – significant risk of deformity
    • OPS allow for significantly greater excision volumes while preserving natural breast shape
  • Tumor location
    • Zones of high risk / low risk of deformity
  • Glandular density
    • Lower risk of necrosis in mobilizing dense glandular breast versus low density breast with major fatty composition
bilevel classification of ops
Bilevel classification of OPS
  • Level 1
    • <20% breast volume excised
  • Level 2
    • 20-50% breast volume excised
level 1 ops
Level 1 OPS
  • Glandular mobilization
  • Intra-mammary flap reconstruction
  • NAC reposition
level 2 ops
Level 2 OPS
  • Only posterior undermining leaving skin attached
  • Mammoplasty techniques
expert opinion st gallen consensus 2013
Expert opinion - St. Gallen Consensus 2013
  • St. Gallen International Breast Cancer Conference, Switzerland, Mar 2013
  • Treatment recommendation after reviewing latest evidence