• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
BALKAN MCO 2011 - J. Zgajnar and M. Margaritoni - Surgery (SLNB, management of non palpable lesions, specific problems of the Balkan region, oncoplastic surgery)
 

BALKAN MCO 2011 - J. Zgajnar and M. Margaritoni - Surgery (SLNB, management of non palpable lesions, specific problems of the Balkan region, oncoplastic surgery)

on

  • 530 views

 

Statistics

Views

Total Views
530
Views on SlideShare
529
Embed Views
1

Actions

Likes
0
Downloads
0
Comments
0

1 Embed 1

http://www.eso.net 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    BALKAN MCO 2011 - J. Zgajnar and M. Margaritoni - Surgery (SLNB, management of non palpable lesions, specific problems of the Balkan region, oncoplastic surgery) BALKAN MCO 2011 - J. Zgajnar and M. Margaritoni - Surgery (SLNB, management of non palpable lesions, specific problems of the Balkan region, oncoplastic surgery) Presentation Transcript

      • BREAST
      • CANCER
      • SURGERY
      • AXILLARY SURGERY
      • NONPALPABLE BREAST LESIONS
      • Janez Žgajnar
      • Institute of Oncology Ljubljana
    • In all breast lesions
      • Triple assessment is mandatory
        • Clinical examination
        • Imaging techniques
        • Biopsy
          • Fine Needle Aspiration Biopsy (FNAB)
          • Core biopsy
          • Surgical biopsy (not recommended as a first step)
    • Mammography
      • Indications
        • S creening
        • Confirmed breast cancer (any age)
        • Nonconclusive FNAB/CB in palpable tumour (age>35)
      • Technique
        • Bilateral mammography in two projections (CC and MLO)
    •  
    •  
    •  
    • Ultrasound
      • Indications
        • First imaging technique in younger than 35
        • Additional tool in mammographically dense breasts
        • To detect cysts
        • US guided FNAB or CB
      • Technique
        • Trained operator!!!!
        • High resolution machine
    •  
    •  
    • MRI
      • Indications
        • Additional diagnosis in dense breasts
        • To exclude multicentricity of the disease
        • In follow-up
        • Silicon implants
    •  
    • F INE N EEDLE A SPIRATION B IOPSY
      • Fine needle (19-23G)
      • Cytological specimen
      • Easy, fast,cheap, specific
      • Trained personnel needed
      • Invasiveness of the disease not determined
      • Inadequate in nonpalpable lesions or prior to neoadjuvant chemotherapy
    • Core biopsy
      • Wide needle (14-20 G)
      • Histopathological report
      • Trained personnel needed
      • 5-10 more costly compared to the FNAB
      • Obligatory in nonpalpable lesions or prior to neoadjuvant chemotherapy
    • D ecision on first t reatment based on :
      • Clinical presentation
      • Diagnosis
      • Stage of the disease
    • Aim of the surgery in BC
      • To achieve the local control of the disease
      • To obtain material for the diagnosis and prognosis
      • To cure the patient (in selected cases)
      • ..with minimal side effects !
    • Cancer has to be radically excised
      • The aim is to achieve 1 cm clear surgical margins
      • Technique
        • Mastectomy
        • Breast conserving treatment (BCT)
    •  
    •  
    • EBCTCG meta analysis
    • Tumour size : breast size is crucial
    • What to do?
      • Quadrantectomy
      • Wide local excision
      • Lumpectomy
      • Tumourectomy
      • Segmental excision
      • Partial mastectomy
    •  
    • margins evaluation
    • margins dilemma
      • Aim to achieve 1 cm
      • In most cases 1-2 mm acceptable
      • Local reccurence rate depends on tumor caracteristics ( Nguyen et al., JCO, 2008)
        • luminal A 0,8% (5y)
        • Luminal B 1,5%
        • Basal like 7,1%
    • Internal mammary chain Rotter nodes intramammary Infraclavicular nodes axillary lnn.
    •  
    • Side effects od the ALND
      • Lymphedema
      • Impaired shoulder movements
      • Cutaneous sensitory disturbances in the axillary region
      • More limb infections
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    • SLNB indications
      • The only absolute contraindication
        • metastatic disease in the lymphnodes
      • DCIS
        • if mastectomy
        • if palpable, high grade
      • Profilactic mastectomy
      • Staging information N1  N2 ~ 20%
      • Local control ?
        • local reccurence rate ~ 1%
      • Survival ?
      • Staging information?
        • How often ALND upstages the disease?
          • N0 (i+)  N1
            • 108/836 ( 12,3% ) patients with ITC positive SLN had non-SLN involvement (the majority macro-mets)*
            • 15% **
            • 6/27 (22%) ***
            • our results: 1/15 (7%)
          • N1 (micro+macro)  N2
            • 81/402 ( 20% ) patients with 1-3 positive SLN had ≥4 nodes involved****
            • 23/284 (8%) ***
            • our results: 57/274 (21%)
      *van Deurzen et al, JNCI 2008 **Viale et al, Am Surg 2005 ***Staver et al, Ann Surg Oncol 2010 ****Katz et al, JCO 2008
      • Local control?
        • National cancer data base
          • 1998-2000: 5 years follow up
          • Comparison of SLNB alone vs. cALND for patients with positive SLN
          • macromets in SLN (n=22.075) : non-significant trend toward lower axillary reccurence in cALND group
            • HR 0.58; p=0.076
          • micromets in SLN (n=2.203) : non-significant trend toward lower axillary reccurence in cALND group
            • Rate 0.6% (SLNB alone) vs. 0.2% (cALND); p=0.063
      *Bilimoria et al, JCO 2009
      • Local control?
        • studies demonstrating axillary reccurence in SLN positive patients with no ALND
      Author No. of patients No. of recurrences Median follow-up (months) Guenther (2003) 46 0 32 Fant (2003) 31 0 30 Naik (2004) 210 3 25 Langer (2005) 27 0 42 Jeruss (2005) 73 0 27 Hwang (2007) 196 0 30 Park (2007) 278 6 23 Zakaria (2008) 86 0 30 TOTAL 947 9 (1%) 27
      • Survival?
        • National cancer data base
          • 1998-2000: 5 years follow up
          • Comparison of SLNB alone vs. cALND for patients with positive SLN
          • macromets in SLN (n=22.075) : non-significant trend toward higher overall survival in cALND group
            • HR 0.89; p=0.13
          • micromets in SLN (n=2.203) : non-significant trend toward higher overall survival in cALND group
            • HR 0.84; p=0.33
      *Bilimoria et al, JCO 2009
      • More than 50% of patients have no non-SLN metastases
      • Local control acceptable without ALND
      • Increased morbidity
        • Lymphedema
        • Sensory changes
        • Arm motility
      • Adjuvant systemic and radiotherapy may sterilize residual disease in non-SLNs
        • NSAPB B-18 trial:
          • Patients with neoadjuvant chemotherapy: 42% positive nodes
          • Patients who underwent surgery first: 58% positive nodes
        • neoadjuvant chemotherapy sterilize lymph nodes in 1/3 of patients with pre-chemo proven axillary metastases*
      *Khan et al, Ann Surg Oncol 2005 Newman et al, Ann Surg Oncol 2007
      • ACOSOG Z0011
        • Closed due to slow accrual
      • IBCSG 23-01
        • Closed due to slow accrual
      • AMAROS
        • Data not yet available
      Patients with up to two positive (macromets) SLNs RANDOMIZATION ALND NO ALND Patients with ITC or micromets in SLNs RANDOMIZATION ALND NO ALND Patients with positive SLNs RANDOMIZATION ALND RT of the axilla
      • National Cancer Data Base*
        • 1998 – 2005: 97.314 patients
        • 21% of patients with positive SLN did not undergo ALND
        • In 2005:
          • 45% of those with micromets in SLN did not undergo ALND
          • 17% of those with macromets in SLN did not undergo ALND
      • Most surgeons (77%) and medical oncologists (77%) would not recommend ALND for patients with micromets in SLN**
      *Bilimoria et al, JCO 2009 **Wasif et al, Ann Surg Oncol 2009
    • Acosog Z 11 Giuliano AE et al, JAMA, 2011
    • St. Gallen consensus 2011
      • ITC or micromets in SLN
        • No ALND
      • Macromets in SLN
        • ALND ...... however
      • Macromets in 1-2 SLN in breast conserving surgery (ACOSOG Z11 inclusion criteria)
        • No ALND in some centers
    • Nonpalpable lesions
    •  
    • Surgery of screening detected cancers encompasses..
      • ...ALL BREAST SURGICAL TECHNIQUES!
    • Screen-detected breast cancer surgery
      • Nonpalpable breast lesions
        • Therapeutic
        • Diagnostic
      • Extensive, multicentric, multifocal nonpalpable breast lesions
      • Palpable unifocal breast lesions
    • Surgical techniques to be used
      • Surgery of nonpalpable lesion following a localization
      • Breast conserving surgery
      • Mastectomy
      • Regional lymphnodes surgery
      • Reconstruction techniques
    • Some important facts
      • Most of screening detected breast lesions (>50%) today are nonpalpable
      • Multidisciplinary approach
        • Image diagnostics
        • Pathology
        • Nuclear medicine
        • Surgery
    • Localisation
      • Localisation control
        • Mammographic
        • Ultrasonic
        • MRI
      • Localisation techniques
        • Guidewire
        • ROLL
        • Titanium seed
        • Skin marking
        • Carbon injection
        • Blue dye injection
    • What do we want? correct wrong
    • Rx control
    • ROLL Radioguided Occult Lesion Localization (Luini A et al., BJS, 1999)
      • Into the center of the nonpalpable lesion human serum albumin, labeled with 3,7 MBq 99 Tc in 2ml of saline is injected
      • colloid size 10 – 150  m
      • Followed by injection of 0,1 ml of contrast
    •  
    •  
    •  
    • Titanium seed I 125
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    • Frozen section?
      • Not recommended !!
    • EUSOMA GUIDELINES Perry N.M. on behalf of EUSOMA Eur J Cancer 200 1 ;37: 159 - 172
      • Benign vs. Malig. ratio diagnostic biopsies
        • 0,5 : 1
      • Localisation within 1cm distance
        • >90%
      • Proportion of succesfully excised at first operation
        • >95%
      • Proportion of benign lesions weight <30 g
        • >90%
      • No frozen sections, when T>10mm
        • >90%
    • European guidelines
      • BCS in 70-80% od screen-detected cancers
      • Reexcision in therapeutic excision
        • <10%
    •