EASO2011 BRS 5 Daher

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EASO2011 BRS 5 Daher

  1. 1. WHAT IS AN ADEQUATEMARGIN DURING BCS? A surgeon’s view Michel Daher, MD, FACS President, Lebanese Cancer Society Professor of Surgery- University of Balamand Director, Ethics & Bioethics Teaching Program, UOB Saint George Hospital- UMC, Beirut 3rd EASO Breast Reconstructive Workshop Cairo, March 28, 2011
  2. 2. GermanyU.K. Portugal Antalya Jordan Saudi Arabia
  3. 3. Republic of Lebanon Population: 4.225.000 Area: 10.452 Km2 Specificity & Diversity: - Cultural - Spiritual
  4. 4. Breast Cancer Incidence (ASR)
  5. 5. Breast Cancer in ME countries(1) Currently, breast cancer incidence rates in ME are lower than in more developed countries (4-5X lower ASR than the U.S.) Screening is a challenge due to this lower incidence (yield) and more importantly, to inadequate infrastructure for screening and follow-up of what is found in a screening program. A demographic shift toward older populations is occurring that will result in many more breast cancers U.S. ASR = 123.8 in the future.
  6. 6. Breast Cancer in ME countries (2) Late stage at diagnosis is more common resulting in higher mortality to incidence ratios The contribution of biology to poor outcomes warrants more research. Palliative care services are grossly inadequate resulting in unnecessarily painful end-of –life and deaths .
  7. 7. Breast Cancer in ME countries (3) Incidence RatesThere are no accurate data about neighboring countries, but what is available shows that Lebanon has the highest rate in the Middle East. Egypt (El Gharbiah) ASR: 49.6 (2002) Jordan ASR: 21.3 (1997) Algeria ASR: 9.5 (1997) Kuwait ASR: 32.8 (1997) Tunisia ASR: 16.7 (1994) Lebanon ASR: 69.1 (2004)
  8. 8. Cancer in LebanonAnnual New Cases* : 2003- 7780 cases 2004- 7450 cases 2005- 8254 cases 2006- 8230 cases 2007- 8330 cases 2008- 8250 casesDeath rate 6.39 per 1,000Total deaths / year 24.092- Cardio-V diseases 40%- Cancers 13% *Lebanese National Cancer Registry since 2003
  9. 9. Breast Cancer in Lebanon Most Common Cancer in women worldwide InLebanon: More than One-third of all women cancers are breast cancers (Around 1420 cases a year) In most Arab Countries:  More than 1/3 of all women cancers are Breast Cancer  More than ½ of patients are below age 50 years
  10. 10. Evolution In Surgical Techniques Better knowledge of Natural History Integration in Multidisciplinary Strategy Adoption of Screening Campaigns
  11. 11. Objectives of Surgery in Breast Cancer Confirm the Diagnosis ( most often known before surgery) Define Prognostic Factors Achieve Loco-regional Control Preserve or Reconstruct the Breast
  12. 12. Surgical options in Primary BC Modified radical Mastectomy +/- Reconstruction Modifiedradical Mastectomy with contralateral prophylactic Mastectomy Breast Conservative Surgery
  13. 13. Options between Modified Radical and Conservative TT Local Control Survival Quality of Life Cosmetic Results Ppsychological Acceptance Follow up Cost
  14. 14. Factors that may influence surgical option for primary breast cancer Patient preference Pregnancy Multifocality (same quadrant) Response to Neo-Adjuvant Chemotherapy Tumor size in relation to breast size Retroareolar localisation Lobular Invasive Carcinoma Young Patient with Extensive Intraductal Carcinoma
  15. 15. Contra-indications for Conservative Treatment (1) Modified Radical Mastectomy is mandatoryTumor MulticentricityMalignant Diffuse MicrocalcificationsFailure of Neo-Adjuvant ChemotherapyPrevious Thoracic IrradiationResection Margins Positive for Tumor
  16. 16. Contra-indications for Conservative Treatment (2) Modified Radical Mastectomy is MandatoryInflammatory CarcinomaLocally Advanced Carcinoma (skin infiltration)Associated Diseases excluding Radiotherapy(Sclerodermia, Tuberculosis)Non Compliance for Post operative Surveillance
  17. 17. Final Decision for Surgical Option for primary breast cancer Preop and Postop Radiology Study and may include MRI Multidisciplinary concertation Optimal Surgery: Quality of Resection (margin control), Esthetic Result (Oncoplasty) Expertise of the Pathologist (Frozen Section, Margin Control…) Final Pathology
  18. 18. Breast conserving surgery14012010080604020 0 1955 1958 1960 1964 1967 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001-20 18
  19. 19. Conservative treatment of breast cancer 1 + +/-Breast conserving surg Radiotherapy Systemic treatment 2 + + Systemic treatment Breast conserving surg Radiotherapy + Systemic treatment 19
  20. 20. Conservative Treatment of Breast Cancer Excision of the Tumor together with at least 2 cm of tissue around the tumor + HP test of the tumor and of the specimen margins Quadrantectomy In case of intra-ductal (in situ) component Lumpectomy High risk of residual microscopic disease Frequent recurrence 20
  21. 21. The « Must » of a Conservative Treatment Acceptable Local Control (<1% recurrence/year) Acceptable Cosmetic Result (Shape, Volume, Sensibility, Symetry) of Breast Acceptable Morbidity ( due to axillary dissection) Acceptaple Psychological ResultVeronesi U.; Changing concepts in breast cancer management, The European Journal of Cancer, vol. 34, Pergamon, sept. 1998, pg.3;Development Panel Consensus National Institute of Health Consensus Statement; Treatment of early-stage breast cancer. J. Natl. Cancer Just Monogr. 1992; 11: 11 ;
  22. 22. Different Clinical SituationsNon Palpable Lesions- Increase in frequency/ Screening- Preop Diagnosis by Micro or Macro Biopsies- Preoperative Localisation ( # méthods )- Radiology Confirmation of the Oriented SpecimenPalpable Tumors- Preop Diagnosis by FNA or FNB-Allow a one-stage Good and Complete Excision “The first excision is the best excision”
  23. 23. The IncisionsDepends of: the Localisation, Site, Size, Shape andBreast SizeDifferent Types:- Direct Incision:- Peri-Areolar Incision: Petit JY et al. Atlas of Breast Surgery (2008). These Incisions must take into consideration the possibility of a later mastectomy
  24. 24. Breast Excision/ Partial Mastectomy-Quadrandectomy:- Tumorectomy:
  25. 25. WHAT IS AN ADEQUATE MARGIN DURING BCS? Or what is a good surgical resection?
  26. 26. WHAT IS AN ADEQUATE MARGIN DURING BCS? In all studies with careful case definition, the determination of clear margins has been the most important feature predicting the success of excision. However, overall size, some special histologic patterns, and focal density of disease near the margin have an effect in some studies.
  27. 27. WHAT IS AN ADEQUATE MARGIN DURING BCS?• Need for close collaboration between Surgeon, Pathologist, and Radiologist• Specimen oriented, not opened, fresh, and Inked• Distance in mm between Tumor and Margin• Histology: Invasive or In Situ
  28. 28. Specimen Managementfor the Pathologist Orientation Fresh Closed Inked
  29. 29. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definition of a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  30. 30. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definition of a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  31. 31. Definition of a Negative Margin: controversies• Margin microscopically négative( NSABP) • 1mm • 5mm • 1cm • More than 1cm ( Milano) ( Silverstein)
  32. 32. “ What is clear from the preponderance of studies is that it is absolutely unacceptable to have tumor cells directly at the cut edge of the excised specimen”  S. Eva Singletary, MD, The American Journal of Surgery, 2002
  33. 33. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definition of a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  34. 34. Does Clear Margins= Complete Local Control of the Disease?  Review of cases with residual tumor after Tumorectomy with Clear Margins *  *13 - 25 % Residual Tumor  And after systematic wider reexcision**  **Total: 34/177 19,2 %
  35. 35. Does Clear Margins= Complete Local Control of the Disease? Author (Year) Nb with residual T (margin < 0) Smitt (95) 2/8 25 % Beron (96) 5/38 13 % Saarela (97) 4/26 15 % Beck (98) 23/105 22 %
  36. 36. Peritumoralmicroscopic disease 17% 42% 59% 1 1 1 T1 cm cm cm 36
  37. 37. Does Clear Margins= Complete Local Control of the Disease? Clear Margins does not guarantee for a complete excision of the disease This can explain the Recurrence Rate at 10 years after quadrantectomy: Without RadioT 27,1 % With RadioT 6,9 % The risk for residual disease is minimal but not nil for clear margins  What size of Neg Margins we need ?
  38. 38. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definitionof a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  39. 39. Is there a correlation between Local Recurrence and Margins Status? Negative Margins: 2-12% “Close” Margins (less than1mm): 6-13% Focally Positive Margins: ~14% Multiple Focally Pos Margins: 15-27% J Am Coll Surg 2007;205: 362–376.
  40. 40. Is there a correlation betweenLocal Recurrence and Margins Status? Positive Margin does not mean obligatory résidual tumor* Local Recurrence increases if Positive Margins*  8 - 25 % follow up 3,5 à 4,5 y (8-13-13-18-25)  6 - 24 % follow up 5 - 8 y (6-10-10-10-11-15-16-17- 19-20-22- 24)  12 - 31 % follow up 10 y (12-15-16-31) Local Recurrence is earlier in positive margins with Invasive v/s In Situ**  20 % at follow up 5 y  29 % at follow up 10 y *(Horiguchi 99, Gage 96, Dibiase 98, Peterson 99) **(D Cowen, G Houvenaeghel, V Bardou et al IJROBP 2000)
  41. 41. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definition of a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  42. 42. Which type of Positive Margin Predict Residual Tumor?Review of Residual Tumor in Reexcision Specimen Author (year) Nb cases + margin No residual T Haga 1995 7/23 30 % Beron 1996 29/41 71 % Wazer 1997 71/160 44 % Saarela 1997 5/8 62 % Beck 1998 16/39 41 % Papa 1999 67/115 58 % Résidual T.: 29 à 70 % 191 / 386 49,5 %
  43. 43. Which type of Positive Margin Predict Residual Tumor? Author (year) + margin margin < 0 Wazer 1997 89/160 56 % 22/61 36 % Beron 1996 12/41 29 % 13 % Predictive Factors for residual T.:  + margin and Nb of + margins  Présence of extensive intraductal component (Wazer)
  44. 44. Van Nuys Prognostic Index in DCISScore 1 2 3Size =< 15 mm >15-40 mm >40 mmMargins >=10 mm 1-10 mm <1 mmGrade Low Grade Low Grade High Grade No nécrosis Nécrosis Nécrosis
  45. 45. Van Nuys Prognostic Index in DCISFinal Score Recurrence Survival (8y) 3-4 3,8% 93% 5-7 11,1% 84% 8-9 26,5% 61%
  46. 46. WHAT IS AN ADEQUATE MARGIN DURING BCS? Definition of a Negative Margin Does Clear Margins= Complete Local Control of the Disease? Is there a correlation between Local Recurrence and Margins Status? Which type of Positive Margin Predict Residual Tumor? What size of Negative Margins we Need?
  47. 47. What size of Negative Margins we Need? Local Recurrence with > 1 mm free Margin Author Nb marge >1 marge <1 marge + Follow up Recht 134 3 11 22 5y Borger 723 2 6 16 5 Park 486 7 7 19 8 2-7% 6-11%
  48. 48. What size of Negative Margins we Need? Local Recurrence with > 2<2mm free Margin Author Nb margin >2mm margin mm Followup Dewar 663 6 14 10 Kini 400 6 - 10 Smitt 303 2 24 10 Freedman 1262 7 14 10 Wazer 494 4 14 12
  49. 49. What size of Negative Margins we Need? Local Recurrence with > 5 mm free MarginMargins + 0-2 2-5 > 5Local Rec 17% 9% 5% 0% p: 0,009Factors for Local Rec.: age < 45, marge < 2mm Neuschatz et al Cancer 2003 - 509 pts, follow up 10y
  50. 50. Local Recurrence and Adjuvant Chemotherapy margin - margin + <1Follow up 5y 10y 5y 10y% LRChemoT 3 7 1 12No ChemoT 5 7 11 16(p = 0,02)Margin + ou <1: after ChemoT most of Local Recurrencesappears between 5 and 10 y G. Freedman et al IJROBP 1999
  51. 51. Need for Reexcision- When ? Neg Margins : NO “Close” margins= (>= than 2mm): Optional Focally Pos Margins: Yes Pos Margins or Multiple Focally+ :YES Positive Margin
  52. 52. Need for Reexcision- How? Use same incision (rarely have to enlarge) Prior orientation allows select resection Resect 0.5- 1.0 cm tissue for entire new margin Orient new margin with stitch placed at Positive Margin new margin Meticulous hemostasis
  53. 53. Conclusions (1) Conservative treatment of breast cancer involves Team Work. The results depend on the team members expertise and competence. “The first excision is the best excision” Specimen oriented, not opened, fresh, and Inked Definition of a Negative Margin: controversies Clear margins has been the most important feature predicting the success of excision There is a correlation between Local Recurrence, Overall Survival and Margins Status
  54. 54. Conclusions (2) Risk factors associated with higher local recurrences: + margins, < 40y patients, no adjuvant RadioT Recommendation for Reexcision with acceptable cosmetic result or Mastectomy if + Margins or Close Margin (less than 2 mm) Discuss alternatives: Boost RadioT Good Information to the patient: local recurrence, survival, therapeutic alternatives Experience, Volume, and Multidisciplinarity approach
  55. 55. Not to See This..
  56. 56. But This..
  57. 57. Breast Cancer Awareness Campaigns Lebanon
  58. 58. Breast Cancer AwarenessCampaigns Lebanon 2010 2010
  59. 59. UPDATES ON CANCER PAIN & PALLIATIVE CARE Middle East Medical Assembly (MEMA) In Collaboration with Lebanese Cancer Society (LCS) Rafic Hariri School of Nursing HSON)Lebanese Society for the Study of Pain (LSSP) Friday May 6, 2011 Beirut, Lebanon All Are Welcome

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