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BCT for multifocal multicentric breast cancer - Is it contraindicated?

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Hon-chi Yip Department of Surgery North District Hospital Anatomy of the breast Lobular units drained by mammary ducts Not organized as quadrants Intraductal spread ... – PowerPoint PPT presentation

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Title: BCT for multifocal multicentric breast cancer - Is it contraindicated?


1
BCT for multifocal multicentric breast cancer
-Is it contraindicated?
  • Hon-chi Yip
  • Department of Surgery
  • North District Hospital

2
Multifocal / multicentric breast cancer
  • Definition
  • Multifocal (MF) multiple tumors in same
    quadrant (gt5cm apart)
  • Multicentric (MC) multiple tumors in different
    quadrants
  • Not based on anatomy of breast
  • Increasingly detected due to the widespread use
    of MRI breast

3
Pathophysiology of multifocality and
multicentricity
  • Monoclonal proliferation of a single mammary
    carcinoma
  • Multiple independent synchronous tumors in the
    same breast

4
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 1991265(3)391-5
5
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 200234712331241.
Veronesi U et al. N Engl J Med 200234712271232.
van Dongen JA et al. J Natl Cancer Inst
20009211431150.
6
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 ef?cacy (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.
200753(2)12434.
7
Important issues
  • Oncological considerations
  • Effect on overall survival
  • Effect on disease recurrence, esp. locoregional
  • Technical considerations
  • Complete excision, negative margin
  • Satisfactory cosmetic result

8
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)

9
Local recurrence
10
Studies on LR in BCT for MF / MC disease
Study, year MF or MC Patients, n Local recurrence, Median FU, months
Leopold, 1989 MF MC 10 40 64
Kurtz, 1990 MF MC 61 25 71
Wilson, 1993 MF 13 25 72
Hartsell, 1994 MC 27 3.7 53
Nos, 1999 MF 56 11 60
Cho, 2002 MF MC 15 0 76
Kaplan, 2003 MF MC 36 3 45
Okumura, 2004 MF MC 34 0 58
Oh, 2006 MF MC 97 6 66
Gentillini, 2008 MF MC 476 5 73
Lim, 2009 MF 147 2 59
Chung, 2012 MF 164 6.1 112
Yerushalmi, 2012 MF MC 300 5.5 95
11
Early studies
Study, year MF or MC Patients, n Local recurrence, Median FU, months
Leopold, 1989 MF MC 10 40 64
Kurtz, 1990 MF MC 61 25 71
Wilson, 1993 MF 13 25 72
  • Resection margins not routinely evaluated
  • Surgery involved gross excision of suspicious
    masses only
  • No fixed protocol for adjuvant therapy

12
Studies on LR in BCT for MF / MC disease
Study, year MF or MC Patients, n Local recurrence, Median FU, months
Leopold, 1989 MF MC 10 40 64
Kurtz, 1990 MF MC 61 25 71
Wilson, 1993 MF 13 25 72
Hartsell, 1994 MC 27 3.7 53
Nos, 1999 MF 56 11 60
Cho, 2002 MF MC 15 0 76
Kaplan, 2003 MF MC 36 3 45
Okumura, 2004 MF MC 34 0 58
Oh, 2006 MF MC 97 6 66
Gentillini, 2008 MF MC 476 5 73
Lim, 2009 MF 147 2 59
Chung, 2012 MF 164 6.1 112
Yerushalmi, 2012 MF MC 300 5.5 95
13
Unifocal vs multifocal CA breastPrognostic
implication
14
Unifocal vs MF/MC recurrence and survival
Overall survival
Weissenbacher et al. Breast Cancer Res Treat
201012227-34
Chung et al. J Am Coll Surg 2012215137-147
15
DFS unifocal vs multicentric disease
Ustaalioglu BO et al. Am J Clin Oncol
201236580-586
16
Unifocal vs MF / MC population based study
  • MF/MC not associated with inferior survival on
    multivariate analysis

Yerushalmi et al. Annals of Oncology
201223876-881
17
MF / MC breast cancer survival
  • No comparative survival data on BCT vs mastectomy
    in MF / MC disease

18
Technical considerations
  • Excision of multifocal / multicentric tumors
    without resulting in significant breast
    distortion
  • Careful preoperative assessment required

19
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 2008263248-58
L Turnbull et al. Lancet 2010375563-71
20
Role of MRI
  • Possible role in confirmed MF / MC disease to
    rule out additional tumor foci and define extent
    of disease?

21
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

22
St Gallen Consensus 2013
  • When considering BCT, the following factor is
    contraindication

23
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 patients preference

24
The end
25
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
194(7)1910-6.
Texieira MR et al. Br J Cancer 199470922-927
Dawson PJ et al. Hum Pathol. 199526965969
26
Selection criteria
  • Excision volume
  • gt20 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

27
Bilevel classification of OPS
  • Level 1
  • lt20 breast volume excised
  • Level 2
  • 20-50 breast volume excised

28
Level 1 OPS
  • Glandular mobilization
  • Intra-mammary flap reconstruction
  • NAC reposition

29
Level 2 OPS
  • Only posterior undermining leaving skin attached
  • Mammoplasty techniques

30
Expert opinion - St. Gallen Consensus 2013
  • St. Gallen International Breast Cancer
    Conference, Switzerland, Mar 2013
  • Treatment recommendation after reviewing latest
    evidence
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