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Breast Surgery Past, Present

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Title: Breast Surgery Past, Present


1
Breast Surgery Past, Present Future
  • Texas Tumor Registrars Association
  • September 29, 2005
  • Walton Taylor, MD
  • Co-Director Presbyterian Allen Breast Center
  • Co-Director Dallas Breast Center at Forest Park

2
Basic Cancer Management
  • Local Therapy
  • Regional Therapy
  • Systemic Therapy

3
Past Interactions
Imager
Surgery
Medical Oncology
Radiation
4
Past Surgical Breast Care
  • Imaging Xeromammograms/Thermography
  • Surgery - Mastectomy
  • Adjuvant Therapy not much
  • Breast surgery was relegated to general surgeons
    who did not like doing it!

5
Current Interactions
Imager
Surgery
Medical Oncology
Radiation
6
Breast Surgery Current Standard of Care
State of the Art
  • Office Care
  • Diagnostic Imaging
  • Biopsy
  • Coordination of BC Treatment
  • Operative Care
  • Lesion Targeting for lumpectomy
  • Whole Breast Surgery
  • Axillary Surgery
  • Post-operative
  • Radiation Therapy
  • Chemotherapy and Hormonal Therapy

7
Breast Surgery Current Standard of Care
  • Office Care
  • Diagnostic Imaging plain films/ultrasound

8
Breast Surgery Current State of the Art
  • Office Care
  • Diagnostic Imaging plain films or digital
  • 13MHz ultrasound

9
Breast Surgery Current State of the Art
  • Office Care
  • Diagnostic Imaging plain films or digital
  • 13MHz ultrasound MRI

10
Breast Surgery Current State of the Art
  • Imaging
  • Office Care
  • Diagnostic Imaging plain films or digital
  • Ultrasound
  • MRI
  • PET
  • PET Mammography

11
Breast Surgery Current Standard of Care
  • Office Care
  • Biopsy - 14g core

12
Stereotactic Biopsy
Breast Surgery Current Standard of Care
13
Breast Surgery Current State of the Art
  • Office Care
  • Ultrasound Biopsy 8 or 11g Core Devices
  • Larger cores, fewer indeterminant dxs
  • EnCor
  • Vacora
  • Cassi
  • Neothermia
  • ATEC
  • Mammotome

14
Breast Surgery Current State of the Art
  • Office Care
  • Ultrasound (or Stereotactic) Biopsy
  • 8 or 11g Core
  • Ultrasound Visible Clip Placement

15
Breast Surgery Current State of the Art
  • US visible marker
  • absorbable echogenic material plus wire marker
  • placed at Stereotactic or Ultrasound Biopsy
  • visible several weeks
  • Allows OR ultrasound localization if needed

16
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17
MRI Guided Biopsy
Breast Surgery Current State of the Art
18
Coordination of Breast Cancer Care
  • Either make the diagnosis or at least discuss the
    entire care plan with patient
  • Surgery
  • /- NeoAdjuvant Chemo or Hormonal therapy
  • /- Adjuvant Chemo or Hormonal therapy
  • /- Radiation Therapy
  • Emotional support of patient and their
    family/friends

19
Breast Surgery Current Standard of Care
State of the Art
  • Office Care
  • Diagnostic Imaging
  • Biopsy
  • Coordination of BC Treatment
  • Operative Care
  • Lesion Targeting for lumpectomy
  • Whole Breast Surgery
  • Axillary Surgery
  • Post-operative
  • Radiation Therapy
  • Chemotherapy and Hormonal Therapy

20
  • Breast Surgery - Lumpectomy
  • Needle Localization
  • Non-Palpable to Palpable Localization
  • Anchor Guide
  • Cryoassisted Lumpectomy
  • Palpable Mass Lumpectomy

21
Breast Surgery Current Standard of Care
Breast Surgery Lumpectomy
22
Breast Surgery Current Standard of Care
Lesion Targeting
  • Preoperative Needle Localization (PNL)
  • Tried and true, reliable
  • Time-consuming
  • Cumbersome Scheduling
  • first case 10 AM
  • limited time slots
  • Little help with margin control
  • Does not make lesion palpable or retractable

23
Breast Surgery Current Standard of Care
Breast Surgery Needle Localization
24
Lesion Targeting US guidance for US visible
lesions
Breast Surgery Current State of the Art
  • Before prep
  • Note depth
  • Proximity to skin
  • Proximity to fascia
  • Mark location
  • /- place wire

25
US guidance for US visible lesions
  • place wire (routine or selective)
  • Small lesion or large breast

26
US guidance for US visible lesions
  • Intraoperative US
  • Examine specimen

27
US guidance for US visible lesions
  • Intraoperative US
  • Margin control
  • Tissue Conservation

28
Make a nonpalpable lesion palpable(and attach a
handle)
  • RF assisted wire anchor
  • Cryo Assisted Lumpectomy (CAL)

29
Make a nonpalpable lesion palpable(and attach a
handle)
  • RF assisted wire anchor
  • RF wire loop at tip

30
Make a nonpalpable lesion palpable(and attach a
handle)
  • RF assisted wire anchor (cont.)
  • Radially-oriented prongs
  • deploy at opposite angles
  • outward from lesion center

31
Make a nonpalpable lesion palpable(and attach a
handle)
  • RF assisted wire anchor (cont.)
  • Deployed device tip and prongs palpable

Preliminary data Improved margin control with
tissue conservation
32
Making a nonpalpable lesion palpable(and attach
a handle)
  • Positive Margins
  • PNL (37) 30
  • AG (30) 10

33
Making a nonpalpable lesion palpable(and attach
a handle)
  • cryoprobe assisted lumpectomy
  • Cryotherapy technology
  • Cryoprobe placed through lesion with US

Image courtesy of Sanarus
34
Make a nonpalpable lesion palpable(and attach a
handle)
  • cryoprobe assisted lumpectomy (cont.)

35
Make a nonpalpable lesion palpable(and attach a
handle)
  • cryoprobe assisted lumpectomy (cont.)
  • Real-time US monitors iceball formation

Images Courtesy of Lorraine Tafra, MD
  • Edges of iceball advance past periphery of
    lesion
  • Iceball maintained as surgeon dissects around
    now- palpable mass
  • Probe acts as a handle

36
Cryo Assisted Lumpectomy Study
  • Prospective, randomized 330 patients
  • Cancers seen on sono and lt1.7 cm
  • Randomized 2/3 CAL 1/3 NWL
  • Endpoints
  • Operative time
  • Volume of tissue removed
  • Pathologic margins
  • Cosmesis

37
Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
38
Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
39
Palpable Mass Lumpectomy
Breast Surgery Current State of the Art
40
Breast Surgery Current Standard of Care
State of the Art
  • Office Care
  • Diagnostic Imaging
  • Biopsy
  • Coordination of BC Treatment
  • Operative Care
  • Lesion Targeting/Lumpectomy
  • Whole Breast Surgery
  • Axillary Surgery
  • Post-operative
  • Radiation Therapy
  • Chemotherapy and Hormonal Therapy

41
Mastectomy
Breast Surgery Current Standard of Care
  • Elliptical Incisions
  • Avoid the Dog Ears - oncoplastic
  • Reconstruction Options
  • TRAM Flap
  • Latissimus Flap
  • Implant/Expander

42
Whole Breast Surgery
Breast Surgery Current State of the Art
  • Skin Sparing Mastectomy with reconstruction
  • ?Nipple Sparing Mastectomy controversial
  • Oncoplastic Techniques
  • Lumpectomy with reduction
  • Local tissue advancement flaps
  • Contralateral reduction/mastopexy to match
    ipsilateral reconstruction

43
Breast Surgery Current Standard of Care
State of the Art
  • Office Care
  • Diagnostic Imaging
  • Biopsy
  • Coordination of BC Treatment
  • Operative Care
  • Lesion Targeting/Lumpectomy
  • Whole Breast Surgery
  • Axillary Surgery
  • Post-operative
  • Radiation Therapy
  • Chemotherapy and Hormonal Therapy

44
Axillary Surgery
  • Past (? Present) Complete Axillary Lymph Node
    Dissection
  • Morbid lymphedema, ROM, neuro deficits
  • Less accurate
  • Techniques varied

45
Axillary Surgery
  • Present Standard of Care Sentinel Lymph Node
    Biopsy

46
Axillary Surgery
  • Present Standard of Care Sentinel Lymph Node
    Biopsy

47
Axillary SLN Surgery
  • NSABP B-32 Randomized study of SLN vs. SLN
    CALND in SLN negative patients (5600 pts)
  • Identification rate 97
  • False negative 9.7
  • 60 only one positive lymph node
  • SLN significantly less morbid than CALND

48
Axillary SLN Surgery
  • ACOSOG Z10 Immunohistochemical analysis of
    negative SLNs and bone marrow (5400 pts)
  • Low morbidity with SLN
  • 12 IHC () unknown clinical significance

49
Axillary SLN Surgery

ACOSOG Z11 Randomized Trial of Observation vs.
CALND for SLN Positive Pts
50
Axillary Surgery
  • Present State of the Art Sentinel Lymph Node
    Biopsy
  • or PET

51
Axillary Surgery
  • Present State of the Art Sentinel Lymph Node
    Biopsy
  • or PET Ultrasound Monitoring

52
Breast Surgery Current Standard of Care
State of the Art
  • Office Care
  • Diagnostic Imaging
  • Biopsy
  • Coordination of BC Treatment
  • Operative Care
  • Lesion Targeting
  • Breast Surgery
  • Axillary Surgery
  • Post-operative
  • Radiation Therapy
  • Chemotherapy and Hormonal Therapy

53
Radiation Oncology
  • Present Standard of Care
  • Whole Breast Radiation with tumor bed boost
  • possible treatment of regional basins

54
Radiation Oncology
  • Partial Breast Radiation

55
Multi-catheter Brachytherapy
Kuske template
56
Mammosite Balloon Catheter
  • MammoSite device (Proxima Therapeutics)
  • Inflatable Balloon Placed In Lumpectomy Cavity
  • Remote Afterloading
  • 3400 cGy (340 cGy X 10) in 5 days
  • FDA approval May 2002

Proxima Therapeutics
57
3D Conformal External Beam RadiotherapyPhase
I/II PBI Trial- William Beaumont Hospital -
Lt ASIO
Rt PSIO
Rt AISO
Lt AISO
58
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59
Systemic Therapy
  • Past Hormonal Tamoxifen
  • Chemotherapy CMF, AC, T, others
  • Present Hormonal AIs
  • Chemotherapy Her/EGFR blockers chemo

60
The Future
61
Future Shock
  • Breast Specialization by 2009 - 75 of breast
    cancer care will be delivered by 250 centers
  • Breast Imager
  • Breast Surgeon
  • Breast Medical Oncologist
  • Breast Radiation Oncologist

62
Future Interactions ?
Imager/Surgeon
Medical Oncology
Radiation
63
High Risk Assessment
  • Gail Risk Assessment
  • Claus Model Assessment
  • Genetic Profiling
  • Brca testing
  • Oncovue

64
Future Breast Cancer Treatment
  • Diagnostic Biopsy tumor/genetic markers
  • Treatment
  • MRI to map complete extent of tumor
  • Neo-ablation therapy to maximally shrink tumor
  • Percutaneous ablation ultrasound, stereo, or
    MRI guided
  • MRI to assess complete destruction
  • Sentinel node irrelevant
  • Radiation therapy focused or whole breast based
    on initial MRI pattern of tumor

65
Future Breast Cancer Treatment
  • Diagnostic Biopsy tumor/genetic markers
  • Oncotech
  • Precision Therapeutics
  • Gene Arrays
  • Oncotype DX
  • Tumor typing

66
Oncotype DX Technology Final Gene Set
PROLIFERATION Ki-67 STK15 Survivin Cyclin B1 MYBL2
ESTROGEN ER PGR Bcl2 SCUBE2
HER2 GRB7 HER2
GSTM1
REFERENCE Beta-actin GAPDH RPLPO GUS TFRC
CD68
INVASION Stromolysin 3 Cathepsin L2
BAG1
67
Oncotype DX Need for Better Markers of
Recurrence
68
Future Breast Cancer Treatment
  • Diagnostic Biopsy tumor/genetic markers
  • Treatment
  • MRI to map complete extent of tumor
  • Neo-ablation therapy (chemo/biologic/hormonal)
    to maximally shrink tumor
  • Percutaneous ablation ultrasound, stereo, or
    MRI guided
  • MRI to assess complete destruction
  • Sentinel node irrelevant
  • Radiation therapy focused or whole breast based
    on initial MRI pattern of tumor

69
Ablative Techniques
  • Technology developed for hepatic tumors now
    applied to treatment of other tumors including
    breast
  • Core biopsy pre-ablation for definitive
    histologic diagnosis and thorough analysis of the
    cancer
  • ER/PR, Her-2/neu, EGFR, Oncotype DX, etc.
  • Current protocols for breast malignancy are
    ablation followed by resection (future MRI
    examination for completeness of ablation plus
    peri-tumoral core biopsies)

70
Ablative Techniques
  • Current ablative techniques under investigation
    include radiofrequency, cryoablation, focused
    ultrasound, microwave and laser
  • Image-guided (ultrasound, stereotactic or MR)
    which allows localization of tumor in
    three-dimensions for percutaneous ablation

71
Ablative Techniques
  • Ablation of breast lesions can be performed in
    the radiology suite, office setting or in
    ambulatory operating room
  • Will offer patients an alternative to surgical
    excision for treatment of benign and malignant
    disease

72
Radiofrequency (RF) Ablation
  • Destruction of solid tumors through heat
  • Generated by high frequency alternating current
  • Probe itself is not the source of heat, but a
    frictional heat from ions within tissue changing
    direction with alternating current

73
RF Breast Cancer Ablation
  • Insulated 15 g probe placed by ultrasound or
    stereotactic guidance
  • Electrode prongs emerge in star-like array
  • Allows larger diameter of tissue destruction
  • Size adjustable
  • Temperature sensing feedback to assess target
    temperature

74
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81
RF Breast Cancer Ablation
  • 5-7 minute to reach target temperature 950C
  • 15 minutes at target
  • 1 minute cool down

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Edge of ablation zone
85
RF Breast Cancer Ablation
  • Pathological Analysis
  • Standard HE
  • NADH tumor viability stain
  • Viable cells stain - blue (cytoplasmic granules
    with NADH oxidation reaction)
  • Non-viable cells stain- grey-washed out

86
RF Breast Cancer Ablation Studies
Jeffrey et al, Arch Surg, 1999Izzo et
al, Cancer, 2001Elliot et al, Amer Surg, 2002
87
RF Ablation and Pre/Post Imaging
  • Burak et al, 10 pts with RF ablation and
    subsequent resection
  • Pre and post ablation MRI
  • 9/10 no enhancement on post ablation MRI
  • Corresponded with residual diseases upon
    resection
  • Burak et al, Cancer, 98, 2003

88
Cryoablative Technique
  • Longstanding successful treatment of metastatic
    hepatic tumors
  • Similar technology now being applied as primary
    treatment for variety of tumors including
    fibroadenomas
  • Investigational studies are underway for breast
    cancer
  • Core biopsy or FNA pre-ablation for definitive
    diagnosis

89
Cryoablative Technique
  • Image-guided via ultrasound which allows 3D
    localization of tumor for percutaneous ablation
  • Local anesthetic to skin freezing acts as
    anesthetic to deep tissue
  • Cryoablation of fibroadema can be performed in
    the office setting or in ambulatory operating
    room

90
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91
Cryoablation of Fibroadenoma
  • Argon gas creates sonographic freezeball
  • Real-time monitoring encompass tumor
  • Multiple freeze-thaw cycles with target temp
    -160 / -196oC

92
Cryoablation of Fibroadenomas
  • Multi-institutional series (50 patients)
  • Core biopsy dx/cryoablation w/o resection
  • Tumor size
  • range 0.7cm-4.2cm
  • median 2.0 cm
  • Tumor volume decrease
  • 65 at 6 months
  • 95 at 12 months
  • Kaufman et al, Amer J Surg, 1842002

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Cryoablation of Fibroadenomas
  • FDA approved treatment of fibroadenomas
  • Currently being used in several institutions off
    protocol for treatment without surgical removal

98
Cryoablation for Breast Cancers
99
Cryoablation Breast Cancer Studies Rand
et al, Cryobiology, 1985Staren et al, Arch Surg,
1997Stocks et al, Abstract, Amer Soc of Breast
Surgeons, 2002
100
Cryoablation of Breast Cancers
  • 27 breast T1 invasive breast cancers
  • Mean tumor size 1.2cm (range 0.6-2.0cm)
  • Ultrasound guided cryoablation
  • Surgical resection by lumpectomy post ablation
  • Average time to resection 14 days (range 6-30
    days)
  • SLNB performed in 25/27 patients
  • M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
    Stocks, R. Simmons, M. Schultz
  • Ann Surg Onc, 2004

101
Cryoablation of Breast Cancers
  • No procedural complications
  • No patient required narcotics for analgesia
  • M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
    Stocks, R. Simmons, M. Schultz
  • Ann Surg Onc, 2004

102
Cryoablation of Breast Cancers
  • 23/27 patients (85) showed no viable invasive
    tumor
  • 4/27 showed DCIS surrounding the cryozone
  • 2 cases adjacent to cryozone
  • 2 cases multifocal disease away from cryozone
  • M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
    Stocks, R. Simmons, M. Schultz
  • Ann Surg Onc, 2004

103
Success of Cryoablation Dependent Upon Size and
Histology
  • All patients 27 21(78)
  • Tumors lt1.0cm 11
    11(100)
  • Tumors gt1.0cm 16
    10 (75)
  • Any size lobular/colloid 5
    2 (40)
  • Any size IFDC with EIC 5
    3(60)
  • Any size IFDC/medullary - EIC 17
    15(88)
  • Tumors lt1.5cm/IFDC/med -EIC 10
    10(100)
  • Tumors gt1.5cm/IFDC/med EIC 7
    5 (71)
  • M. Sable, C. Kaufman, P. Whitworth, H. Change, L.
    Stocks, R. Simmons, M. Schultz
  • Ann Surg Onc, 2004

104
Laser Ablation of Breast Cancers
  • Image-guided by stereotactic mammography or MR
  • Laser generates heat to destroy cancer
  • Can be applied to mammographic microcalcifications
    or lesions seen only on MR

105
Laser Ablation of Breast Cancers
  • Lesion localized by standard stereotactic needle
  • Parallel to needle temperature monitor probe
  • Target temperature 80-100oC 15-20 minutes
  • MR temperature maps to monitor remaining breast
  • Photo courtesy of Dr. Kombiz Dowlatshahi

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Laser Ablation of Breast CancersBloom et
al, Amer J Surg, 2001Photo courtesy of Dr.
Kombiz Dowlatshahi
  • Gross path concentric rings
  • Central cavity-laser tip
  • Peripheral ring-fat necrosis
  • Pseudo-viable zone between
  • recognizable histological tumor
  • Immunostaining shows non-viable tissue

108
HE SectionPhoto courtesy of Dr. Kombiz
Dowlatshahi
109
Cytokeratin SectionPhoto courtesy of Dr.
Kombiz Dowlatshahi
110
Laser Ablation Breast Cancer Studies
Dowlatshahi, et al, Arch Surg,
2000Harms, et al, SPIE, 1999
111
Ablative Techniques
  • The challenge in the success of these techniques
    is the ability to completely map the cancer
    within the breast and then to assure complete
    treatment of the cancer (MR, PEM, thermal
    imaging, ultrasound, core biopsies).

112
Conclusions
  • High Risk Analysis
  • Imaging
  • Local Control
  • Regional Control
  • Systemic Control
  • Long Term Follow-Up
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