Challenges in breast conserving surgery


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Challenges in breast conserving surgery

  1. 1. By Ihab S. Fayek MD. Surgical Oncology National Cancer Institute Cairo University - Egypt
  2. 2. From the Halstedian radical mastectomy to the more aesthetic breast conserving surgery (BCS), the last 40 years have witnessed a fascinating evolution in the role of surgery in the treatment of breast cancer.
  3. 3. Multiple prospective, randomized trials with more than 20 years follow-up have since documented that breast conserving surgery operations followed by whole breast irradiation offers survival outcomes equivalent to mastectomy in appropriately selected patients.
  4. 4.  Recently, Hwang ES et al;2012 stated that Women who underwent lumpectomy plus radiation experienced improved OS and DSS compared with women who underwent mastectomy for early stage breast cancer  Data were obtained from the California Cancer Registry between 1990 and 2004. They analyzed 112,154 women diagnosed with stage I or II breast cancer who underwent lumpectomy plus radiation (55%) or mastectomy alone (45%)  Median follow-up was 110.6 months Cancer 2012
  5. 5. Breast conserving surgery is defined as the complete removal of the tumor with a concentric margin of surrounding healthy tissue with maintenance of acceptable cosmesis, and should be followed by radiation therapy to achieve an acceptably low rate of local recurrence.
  6. 6. For BCT to successful, 3 conditions must be met : (1) Achieve negative surgical margins while maintaining cosmesis of the breast (2) Safely deliver radiation therapy (3) Promptly detect local recurrence
  7. 7. A breast surgeon may be confronted by many Challenges before proceeding to , during and after BCS for female patients with Breast Cancer.
  8. 8. 1) Age 2) Family History 3) BRCA gene mutations 4) Preexisting collagen vascular disease 5) Pregnancy
  9. 9.  Although young age, have been associated with an increased risk for local failure after BCT or after mastectomy; young age alone should not preclude breast conservation  Considering a more aggressive systemic treatment in addition to local treatment appears appropriate.  Jung et al;2012 concluded that under 35-year old patients had significantly higher re-excision rates than the other age groups of 36 to 50 and over 50 J Breast Cancer. 2012 December; 15(4): 412–419.
  10. 10.  Whenever possible, older women should be offered breast conserving therapy rather than mastectomy since this not only improves their quality of life but also reduces risk of subsequent mental health problems.  Controversy exists as to whether or not XRT can be safely omitted after breast conservation in elderly patients.  the National Comprehensive Cancer Network guidelines in 2005 :“Breast irradiation may be omitted in those 70 years of age or older with estrogen receptor positive, clinically node- negative, T1 tumors who receive adjuvant hormonal therapy”.
  11. 11. Giordano SH ,2012 commented that older women with low-risk breast cancer treated with adjuvant radiotherapy are at risk for unnecessary adverse effects, inconvenience of treatment, and possibly increased personal costs for a treatment unlikely to offer them any benefit. However, Institutional variations between the concept of “Better safe than sorry” and the new one “Sometimes, less is more”. J Clin Oncol 30:1577–1578.
  12. 12.  A family history of breast cancer is not a contraindication to breast conservation.  Several studies have shown that the rate of breast recurrence in patients with first-degree or second-degree relatives with breast cancer is not different than that seen in patients without a family history of breast cancer.
  13. 13.  Young women with breast cancer who have a family history of breast cancer and who test negative for mutations in BRCA1 and BRCA2 are at significantly greater risk of contralateral breast cancer than other breast cancer survivors.  Women with a first-degree family history of bilateral disease have risks of contralateral breast cancer similar to mutation carriers (Reiner AS et al,2013) Journal of Clinical Oncology February 1, 2013 vol. 31 no. 4 433-439
  14. 14.  Patients with an inherited germ-line mutation in BRCA 1 or 2, the risk of ipsilateral breast tumor recurrence following BCS and RT is not increased (at least over 10 to 15 years)  However, those patients appear to be at a substantially increased risk of contralateral breast cancer, and this should be considered during the treatment counseling process (Nestle- Krämling C,2012) Breast Care 2012;7:378–382
  15. 15. Breast cancers diagnosed among BRCA1 mutation carriers were significantly more likely to be larger, have higher histologic grade and have negative estrogen and progesterone receptor status than in BRCA 2 mutations.
  16. 16.  Patient with a history of autoimmune diseases such as scleroderma, systemic or discoid lupus, and dermatomyositis may have increased sensitivity to radiation resulting in abnormal fibrosis which may compromise the cosmetic outcome  the consensus of reports indicates that such women are at high risk for unusually severe skin, soft tissue, bone, and pulmonary complications
  17. 17.  Breast cancer is diagnosed in about 1 pregnant woman out of 3,000  Radiation therapy during pregnancy is known to increase the risk of birth defects, so it is not recommended for pregnant women with breast cancer  BCS is only an option if radiation can be delayed until after delivery (3rd trimester?)  Delayed breast reconstruction is a valid option for those patients
  18. 18. 1) Tumor Size 2) Tumor Location 3) Tumor Histology 4) Tumor Grade 5) Involvement of axillary lymph nodes
  19. 19.  Patients with tumors up to 4 cm. in diameter are good candidates for BCS  However, the ratio of tumor size / breast volume seems to have a greater impact on the decision to proceed for BCS  Large pendulous breasts and high tumor size / breast volume ratio are no more contraindications for BCS ; regarding oncoplastic breast surgery, better radiation delivery techniques and neoadjvant chemotherapy
  20. 20.  Multicentricity (ie, 2 separate cancers in different quadrants of the same breast) is an important Contraindication to BCS  Tumors in a superficial subareolar location may occasionally require the resection of the nipple/areolar complex to achieve negative margins  Poor cosmetic outcome have been reported as a result of breast cancer operation due to lower quadrant breast tumors; this is particularly true for women with small, firm breasts  OBS
  21. 21. Oncoplastic Reconstruction with Superior Based Lateral Breast Rotation Flap after Lower Quadrant Tumor Resection • Operative design for patients with lower half located breast cancer. • If margin status of the quadrantectomy specimen was adequate, a long skin incision was made from the axilla to the tumor site along the anterior axillary line and inframammary fold Kim J. et al. J Breast Cancer. 2012
  22. 22. Kim J. et al. J Breast Cancer. 2012
  23. 23. Kim J. et al. J Breast Cancer. 2012
  24. 24.  The histologic type appears to play a role in the choice of the surgical procedure selected  Lobular carcinomas may have a substantially increased propensity for multifocal and multicentric distribution and for bilaterality  Lobular carcinomas often fail to form distinct masses that can easily be diagnosed by palpation or mammography. This can make early diagnosis challenging and breast conservation approaches more difficult.  Histology is not an important independent predictor of recurrence or survival  The same standard prognostic factors (tumor size, axillary nodal status, hormone receptors, S-phase, and age) used in ductal carcinoma are applicable in lobular carcinoma as well
  25. 25.  Studies have shown that recurrence rates after excision of infiltrating lobular carcinoma to negative margins do not differ from those after excision of infiltrating ductal tumors.  Historically, it was believed that extensive intraductal component (EIC) was associated with an increase risk of IBTR (Holland et al;1990)  However, subsequent data has shown that when EIC- positive tumors are excised to negative margins (>2mm.), local recurrence rates are comparable to those seen in EIC-negative tumors (Gabram,2012) JCO January 1990 vol. 8 no. 1 113-118 / Breart surgery ;Master techniques series 2012
  26. 26. Most studies indicate that histologic grade is not predictive of recurrence Some studies have identified lymphatic invasion at the primary tumor site as a risk factor, but this has also been shown to be a risk factor for local recurrence after mastectomy.
  27. 27. The presence of clinically suspicious and mobile axillary lymph nodes or microscopic tumor involvement in axillary nodes should not prevent patients from being candidates for breast conservation surgery (BCS).
  28. 28.  Approximately, 30-50% of breast cancers in modern surgical practices are non-palpable.  Impalpable lesions can be located preoperatively by a variety of techniques: 1. Skin marking 2. Injection of blue dye 3. Carbon or radioisotope 4. Insertion of a hook wire with post-localization mammograms. 5. Intraoperative ultrasound
  29. 29.  The best method available to date for preoperative localization of a non-palpable breast lesion detected on imaging is the hook wire localization technique described by Frank et al.; 1976  Studies have shown the importance of supplemental effect of ultrasound and its ability to detect some lesions missed at screening mammography  The procedure of wire localization is achieved with the aid of ultrasound, as it provides complementary roles to mammography in the detection of breast masses.
  30. 30.  Dedicated wire localization needles if not available, a malleable sterilized slender steel wire, similar in consistency to dental suture may be used.  During surgical excision no part of the inserted wire should be exposed in an attempt to achieve clear margins.  The excised tissue with the wire in-situ is orientated and should be immediately send in saline for specimen radiograph to confirm the inclusion of the lesion, then to histopathology to ensure adequate margins before wound closure.
  31. 31.  Radioguided occult lesion localization is a newer technique for localization of impalpable lesions: 1. Under mammogram or ultrasound control technetium-labelled human serum albumin or sulphar colloid is injected into the tumour. 2. Gamma detecting probe is used intraoperatively to locate the lesion to guide excision.
  32. 32.  Because of the high incidence of positive margins and the need for reexcision or mastectomy after single hooked wire excisions, a system of placing multiple hooked wires around the perimeter of a lesion before excision has evolved since 1982.  Gregory M et al; 1998 stated that excision with the bracketing hooked wire placement is significantly better than that obtained with the use of a single hooked wire before lumpectomy or quadrantectomy.
  33. 33. 1) The incision 2) The extent of excision 3) Excision followed by RFA of the bed
  34. 34.  In planning the incision, the surgeon had to take into consideration 1. The location of the lump 2. Type of incision 3. Depth of mass from the skin  It had to be close to or just above the lump to avoid tunneling.  Excising skin directly overlying a cancer is only necessary if the carcinoma is very superficial and/or the skin is tethered.
  35. 35.  In the upper part of the breast, incisions should be curvilinear or transverse, while in the lower part, they should be either curvilinear or radial  It should be sited in such a way that if mastectomy is eventually required, it can be included in the mastectomy specimen.  A previous biopsy incision should be excised within the lumpectomy or quadrantectomy incisions
  36. 36.  The surgical term “ breast conserving surgery ” encompasses a range of procedures including: 1. Quadrantectomy (segmentectomy) 2. Lumpectomy (tumorectomy, tylectomy) 3. Partial mastectomy 4. Wide excision
  37. 37.  Quadrantectomy involves excision of 2-3 cm of normal tissue around the tumour plus the removal of a sufficiently large portion of overlying skin and underlying fascia while lumpectomy removes only the tumour mass with a narrow margin of normal tissue.  Veronesi et al; 1990 stated that lumpectomy patients had a much higher frequency of local recurrences (7.0 vs. 2.2%).  Veronesi et al; and Fisher et al; 2002 reported an important incidence of ipsilateral breast tumor recurrence (IBTR) following BCT after 20 years of follow-up: 8.8% following quadrantectomy plus RT and 14.3% following tumorectomy plus RT, respectively. Eur J Cancer. 1990;26(6):671-3.
  38. 38.  Koyama Y et al;2012 performed BCS in 173 cases: Lumpectomy in 95 cases and Quadrantectomy in 78 cases; concluded that as long as the surgical margin is negative the IBTR and re-excision rates are not statistically different. “The validity of breast conserving surgery for negative surgical margin: wide excision versus quadrantectomy” Yu Koyama; Eiko Sakata; Miki Hasegawa; Mayuko Ikarashi; Naoko Manba, and Chie Toshikawa Division of Digestive & General Surgery, Niigata University Graduate School of Medical & Dental Sciences,Niigata, Japan.
  39. 39.  In a study ,lead by Klimberg et al;2012, 60 patients with invasive cancer underwent tumor excision (lumpectomy surgery) followed by radiofrequency ablation (eRFA) at 100 degrees C for 15 minutes with a real-time radiofrequency probe to extend the radius of the lumpectomy cavity by 1 cm. None of the patients received adjunctive XRT.  Patients have been followed for an average of 44 months post-op. the American Society of Breast Surgeons (ASBrS) Annual Meeting May 2012
  40. 40.  eRFA could reduce the need for re-excision, as well as reduce local recurrence for invasive breast cancer patients undergoing breast conservation surgery without XRT.  eRFA is an attractive alternative to breast irradiation.  This concept has recently initiated a multicenter register trial called ABLATE (Radiofrequency Ablation after Breast Lumpectomy Added To Extend Intraoperative Margins) in patients undergoing conservative breast surgery.
  41. 41.  Another study by Mackey et al;2012 on 16 patients where The RFA probe was deployed 1 cm circumferentially in the cavity and maintained at 100°C for 15 min.  The ablation zone was monitored with color-flow ultrasound.  Mean follow-up of 3.9 months, there were no local recurrences.  Two-week cosmesis scores were excellent (n = 9) to good (n = 5). Annals of Surgical Oncology Volume 19, Issue 8, August 2012
  42. 42. eRFA  If the tumor is < 1cm. from the skin  a skin ellipse should be removed.  Skin retraction is essential to avoid skin burns
  43. 43.  This represents one of the ongoing “great Challenges and controversial debates” in breast cancer management generally and in BCS specifically.  Obstacles for obtaining consistently accurate margins are: 1. The nature of the tissue (adiposity) 2. The extent of in situ component 3. The insidious manner of tumor infiltration 4. Tumor multifocality  Azu et al; 2010 stated that there has been no margin width that more than 50% of surgeons or oncologists agree on Ann Surg Oncol. 2010; 17:558-63
  44. 44.  Currently, a positive margin is generally interpreted to mean the presence of tumor, either invasive and/or ductal carcinoma in situ (DCIS), at the surgical resection line.  However, lymphatic invasion at a margin is not considered a positive margin.  Neither atypical ductal hyperplasia nor lobular carcinoma in situ at margin is considered a positive margin.
  45. 45.  The NSABP defines a positive margin as the presence of tumor at the inked margin  In practice, positive margin should prompt re- excision, since such patients are at higher risk for local recurrence even with XRT  In 30 of 34 reviewed studies, persistent microscopic inadequate (R1) or macroscopic inadequate (R2) surgical margins were highly significant for LR compared to the negative margin (p = 0.0001)
  46. 46.  Yildirim;2009 stated that risk factors associated with a positive margin are: The extent of excision, large tumor size, multifocality, lobular histological type, and the number of positive lymph nodes  Jung et al;2012 identified a tendency for the positive resection margin rate and width to differ based on tumor location; for example, a high positive resection margin rate and a relatively narrow width of the superior and medial margins were observed for LIQ tumors EurJ Surg Oncol 2009;35:258-63 / J Breast Cancer. 2012 December; 15(4): 412–419.
  47. 47.  As most of the current techniques still result in a relatively high rate of positive margins with impact on the LR rate and cosmetic results, new innovative surgical approaches and methods for IOMA are needed. The following are suggested: 1. Positron Emission Tomography (PET) imaging 2. Radio-guided Occult Lesion Localization (ROLL) 3. Infrared Fluorescence (NIRF) Optical Imaging
  48. 48.  A negative margin is the absence of tumor cells at the inked margin  Oncoplastic surgeons define a negative margin quantitatively as “no tumor cells within 1 cm of the cut edge of the specimen”(Kaur et al;2005).  While the majority of the general literature appears to consider 2 mm as the cutoff point for a negative margin with anything less than that being considered a close margin (Singletary 2002). Am J Surg. 2002;184: 383-93.
  49. 49.  A survey of radiation oncologists in the U.S. and Europe shows a significant variation in the definition of a negative margin with European radiation oncologists seeming to prefer a larger tumor-free margin (>5 mm) than their American counterparts  Houssami et al; 2010 in a comprehensive meta-analysis stated that there is no statistical difference in local recurrence rates associated when comparing margin widths of >1 mm, >2 mm, and >5 mm when studies were adjusted for the use of radiation boost and endocrine therapy. Eur J Cancer. 2010;46:3219-32
  50. 50.  While data consistently show that positive margins carry greater risk of local recurrence, a negative margin dose not guarantee the absence of residual disease.  However, it is believed that the residual disease burden in patients with negative margins is small enough to be controlled adequately with XRT.
  51. 51.  Institutional policies vary both in terms of the definition of a “close” margin and XRT practice patterns based on proximity of cancer cells to the margin edge.  Less clear are cases where the margin is reported as “close”  Over the last decade, efforts have been made to classify margin status based on the distance of the tumor cells from the inked margin (< 1mm?, < 2 mm?, 1-3 mm? or one cell line?)
  52. 52.  Measurements ranging from 1–3 mm have been described as “close”. In the case of a pectoralis fascia margin, a single collagen strand separating tumor from margin is considered adequate clearance.  Studies reporting higher rates of local recurrence among patients with “close”margins are limited and discordant in their findings.  Gurdal et al; 2012 stated that Re-excision or mastectomy could be omitted in patients with close margins with favorable factors such unifocal tumor or node negative disease. Eur J Surg Oncol. 2012 May;38(5):399-406
  53. 53.  Hossami et al;2010 concluded that a 1-mm negative margin is as good as a wider margin if patients receive optimal adjuvant therapy  The conclusion was: No justification for demanding margins greater than 1 mm Eur J Cancer. 2010;46:3219-32
  54. 54.  Axillary dissection, in the treatment of breast cancer, does not provide significant survival advantage in patients with negative axilla  However, it is useful for the assessment of prognosis and determining adjuvant therapy  Axillary lymph node dissection (ALND) is indicated for most patients with positive ipsilateral axillary lymph nodes, when diagnosed by sentinel lymph node biopsy (SLNB) or fine needle aspiration cytology (FNAC)
  55. 55.  Oz A et al; 2012 concluded that US-guided fine needle aspiration is a highly specific assessment method. Using this method, axillary metastases can be detected at a much lower cost, preoperative staging of the disease can be performed, and the time spent doing SLNB and intraoperative frozen procedure under general anesthesia is eliminated.  Houssami N et al; 2012 estimated that ultrasound-guided needle biopsy triages 55.2% of women with metastatic axillary nodes directly to ALND, thereby avoiding unnecessary SLNB. J Breast Cancer. 2012 June; 15(2): 211–217 / Breast Cancer Management May 2012, Vol. 1, No. 1, Pages 65-72
  56. 56.  Axillary staging is dominated by the sentinel lymph node biopsy (SLNB),which is now widely practiced in clinically node negative patients  Most authors believe a SLNB may even be performed in patients with a large or multifocal tumour, before neo-adjuvant systemic therapy, during pregnancy, after prior excisional biopsy and after prior mantle field radiotherapy of the breast
  57. 57.  Removal of the primary tumor with excisional biopsy may impair breast lymphatics. It used to be thought that success of SLNB following excisional biopsy is low  Ruano R et al; 2008 stated that The detection of the SLN is feasible in patients with previous surgery of the breast using the combined technique (Tc-colloidal rhenium and isosulfan blue dye)  Coskun G et al; 2012 concluded that, SLNB using a combination method (methylene blue and Tc-99m lymphsintigraphy) is safe and reliable for breast cancer patients diagnosed with excisional biopsy J Breast Cancer. 2012 March; 15(1): 87–90 / Eur J Nucl Med Mol Imaging. 2008 Jul;35(7):1299-304
  58. 58.  It is generally accepted that it is safe to omit an axillary lymph node dissection (ALND) in patients with a negative SLN or with only isolated tumour cells (<0.2 mm) in the SLN  The need for a completion ALND in patients with a positive SLND showing micrometastases or macrometastases in less than three nodes has been questioned  Chagpar;2010 stated that completion ALND may not be necessary in selected patients with a positive SLND in less than three nodes because the need for systemic therapy is established Surg Oncol Clin N Am 2010; 19:493
  59. 59.  30 studies of 7151 women with a positive SLN not undergoing a completion ALND with a median follow- up of 45 months, the axillary recurrence rate was 0.3 percent for patients with micrometastases and 0.7 percent for patients with macrometastases (Francissen et al; 2012).  ALND may not be necessary for all women with T1 tumors that are clinically node negative, with less than three positive SLNs, who will be treated with whole breast radiation, particularly in women with estrogen receptor positive tumors (Giuliano et al;2012).  When completion ALND is omitted in patients with a positive SLND, whole breast radiotherapy is indicated. Ann Surg Oncol 2012; 19:4140 / Clin Exp Metastasis. 2012 Oct;29(7):687-92.
  60. 60.  Positive IM nodes are most common with medial tumors over 2 cm in size.  Although IM biopsy can be accomplished at the time of mastectomy by splitting the fibers of the pectoralis major, an IM node biopsy in a patient undergoing BCS usually requires a second incision, which is cosmetically visible.  The procedure can be complicated by pneumothorax, pleural effusion or bleeding.
  61. 61.  Many controversies in this topic because (Chen 2008 and Heuts 2009) 1. There are limitations to the SLN technique for identification of IM nodes 2. SLND does not reliably identify involved IM LNs because of interference from radioactivity at the primary tumor site 3. There is a high rate of technical failure (20 to 39 percent) in patients with parasternal hot spots on lymphoscintigraphy 4. Hot spots in the IM region do not always represent tumor involvement 5. Some surgeons do not employ radiotracer injection and use only an intraoperative injection of blue dye to identify the sentinel nodes J Clin Oncol 2008; 26:4981 / Eur J Surg Oncol 2009; 35:252.
  62. 62.  The surgical management of the IM nodes remains controversial.  There is no consensus on the need for IM nodal dissection in women with detection of an IM SLN.  Postma et al; 2012 stated that Routine sentinel node biopsy of the IMC does not alter the systemic treatment. Radiotherapy treatment is altered in a small proportion (11%) of the patients. Breast Cancer Res Treat. 2012 Jul;134(2):735-41.
  63. 63.  SLNB has reduced (2-7%), but not eliminated, arm lymphedema in those patients who avoided ALND (6- 30%)  The axillary reverse mapping (ARM) technique developed in 2007 to identify and preserve arm nodes during SLNB or ALND to prevent arm lymphedema  The technique of arm node preservation was based on the concept that the arm lymphatic pathway does not communicate with the sentinel lymphatic pathway  The ARM procedure is technically feasible with a high visualization rate (Gobardhan et al;2012). Eur J Surg Oncol. 2012 Aug;38(8):657-61
  64. 64.  Many controversies need to be resolved in arm node preservation: (Noguchi M et al; 2010) 1. The rate of arm node identification by blue dye staining is somewhat insufficient. 2. There are reports of metastasis in arm lymph nodes or in the lymphatic pathway. This raises problems regarding the safety of arm node preservation surgery. 3. Common lymphatic channels are found between SLNs and arm lymph nodes. When a common channel exists, even SLNB can cause lymphedema. 4. The stained blue arm node may be juxtaposed to the metastatic lymph node, which could result in direct invasion of the carcinoma and make it difficult to save the arm node. J Surg Oncol. 2010;101:217–221
  66. 66.  Metastasis to ARM nodes can occur both in patients with extensive nodal metastasis and in those with a few positive nodes  However, patients with clinically node positive breast cancer had a significantly greater incidence of positive ARM nodes than those with clinically node- negative and sentinel node-positive breast cancer  FNAC for ARM nodes might be helpful for the assessment of metastasis in ARM nodes (Ikeda et al; 2012) World Journal of Surgical Oncology 2012, 10:233
  67. 67.  Patients with SLN metastases appear to be good candidates for the ARM technique and possibly also patients with proven axillary metastases receiving neoadjuvant chemotherapy (Gobardhan et al;2012)  Arm node preservation was possible in all breast cancer patients with identifiable arm nodes, during ALND or SLNB, except for those with high surgical N stage  Lymphedema and locoregional recurrences did not develop in patients with arm node preserving surgery (Lee et al;2012) Eur J Surg Oncol. 2012 Aug;38(8):657-61 / Cancer Research: December 15, 2012; Volume 72, Issue 24, Supplement 3
  68. 68.  Approximately 10% to 15% of patients undergoing BCS for operable breast cancer will develop a locoregional recurrence within 10 years  This risk is only slightly higher than that of a locoregional recurrence following mastectomy (5%-10)  Many IBTRs after BCS are detected by mammography alone.  The finding of disease in an ipsilateral preserved breast can represent either a local recurrence of the initial cancer or a second primary tumor.
  69. 69.  The distinction is important, as a local recurrence will carry a worse prognosis than an ipsilateral new primary.  Local recurrence after BCS may be either invasive or in situ cancer. For patients who were initially treated for invasive disease, more than 80% of locoregional recurrences are invasive  For patients initially treated for in situ cancer (DCIS), approximately 50% will recur with DCIS and 50% with invasive disease.
  70. 70. 1. Failure to achieve optimal local control (ie, suboptimal excision, omission of XRT) 2. The presence of an EIC within the tumor in patients who didn’t have negative resection margins 3. Patients who had extensive residual suspicious microcalcifications 4. Younger patient age (<35) 5. Negative hormone receptor status 6. Aggressive tumor biology (Short period between BCS and the appearance of IBTR)
  71. 71. One report revealed that ipsilateral breast tumor recurrence at 8-years was 7%, 14% and 27% for negative and close margins, focally positive and extensively positive margins, respectively indicating the importance of margin status in IBTR.
  72. 72.  Jacobson et al;2008 stated that Excising additional shaved margins at the original surgery reduced reoperations by 48%.  There is a balance between removing additional margins and desirable cosmesis after breast- conservation surgery.  The decision to take extra margins should be based on the surgeon's judgment. Am J Surg. 2008 Oct;196(4):556-8
  73. 73. 1. Invasive disease 2. Tumor size 3. Skin or chest wall involvement 4. Nodal involvement 5. Hormone receptor - negative tumors. 6. Short time interval between initial BCS and local recurrence 7. IBTRs that develop after Accelerated Partial Breast Irradiation (APBI) resulted in excellent clinical outcomes comparable with those observed after whole- breast irradiation (WBI) (Shah C et al;2012) Clin Breast Cancer. 2012 Dec;12(6):392-7
  74. 74.  Mastectomy is considered the standard approach for an IBTR after BCS.  The risk of subsequent chest wall recurrence following mastectomy in patients with an invasive IBTR after BCS is approximately 10%.  Immediate reconstruction can be carried out as long as there is no skin involvement.  In the uncommon situation of a local recurrence in a patient who underwent lumpectomy alone without whole-breast irradiation repeat BCS followed by XRT can be considered.