This document discusses several controversies in surgical approaches to breast cancer: 1. Detecting small lesions in women with dense breast tissue using mammography alone may be inadequate, and supplemental tests like ultrasound or MRI may improve detection rates. 2. For patients with early-stage breast cancer and positive sentinel lymph nodes, axillary lymph node dissection may not always be necessary, especially for those receiving breast-conserving surgery and radiation based on studies like ACOSOG Z0011 and AMAROS. 3. The use of intraoperative radiation therapy (IORT) following breast-conserving surgery remains controversial, as some studies have found higher local recurrence rates compared to whole breast radiation, though recurrence risks may

1. Controversies in Surgical
Approach to Breast Cancer
Suebwong Chuthapisith MD, PhD
Assistant Professor, Department of Surgery
Faculty of Medicine Siriraj Hospital , Mahidol University, THAILAND

2. Controversy 1 : Detecting lesion in dense breast
Controversy 2 : How to deal with positive SLNB?
Controversy 3 :Use of IORT following BCS
Controversies in breast cancer: surgeons’ concern

3. Controversy 1 : Detecting lesion in dense breast
Controversy 2 : How to deal with positive SLNB?
Controversy 3 :Use of IORT following BCS
Controversies in breast cancer: surgeons’ concern

4. In screening and detecting of breast cancer,
mammography is a standard and is recommended
(annually) for women age > 40 yrs
Lee et al. J Am Coll Radiol 2010;7:18.
However, detecting small cancer with mammography alone may
not be adequate in women with dense breast composition.

5. D1
Fatty
D2
Fibroglandular
D3
Heteroge-
nously
D4
Extremely
BIRADS ACR; 5th
Edition: 2013
In the Western women, 70-75% have D1/D2

6. Percentage breast
density
Relative risk
5-24% 1.79
25-49% 2.11
50-74% 2.92
> 75% 4.64
Mc Cormack VA. Cancer Epidemiol Biomarkers Prev 2006:15:1159.

7. • Density: masking effect
– Masking effect of breast density leads to an
increased percentage of interval breast cancer
– Dense breast may make a woman more likely to
be diagnosed with an interval cancer
Breast density and breast cancer risk
Vacek and Geller. Cancer Epidemiol Biomarkers Prev 2004:13:715.
Bae MS. Radiology 2014;356:227.

8. • Density as an independent risk factor
– Density refers to the amount of epithelial and
stromal elements of the breast
– The greater amount of epithelial tissue, the
greater chance of breast cancer
– Fourfold increase in the risk of breast cancer in
women with dense breast
Breast density and breast cancer risk

9. Microscopic difference between dense and
non-dense breast

10. Breast density in Thai women

11. Siriraj Experience: Breast densities: 14,770 women
Number %
Fatty breast 287 2.0
Fibrograndular dense 2,357 16.0
Heterogenously dense 10,537 71.3
Extremely dense 1,589 10.7
Total 14,770 100
Korphrapong P et al. Acta Rad 2014;55:903.

12. Age (yr) Fatty (%)
Fibrograndular
dense (%)
Heterogenously
dense (%)
Extremely
dense (%)
<40 4 (0.2) 90 (6.6) 96 (70.9) 300 (22.1)
40-49 37 (0.6) 681(10.2) 4,998 (75.1) 941(14.1)
50-59 106 (2) 1,067 (20.4) 3,754 (71.7) 309 (5.9)
60-69 95 (7.4) 419 (32.8) 725 (56.8) 38 (2.9)
>70 45 (18.4) 100 (40.8) 99 (40.4) 1 (0.4)
Total 287 (2.0) 2,357 (15.9) 10,537 (71.3) 1,589 (10.8)
Siriraj Experience: 14,770 women by age group
Korphrapong P et al. Acta Rad 2014;55:903.

13. • US State of legislation regarding breast density
notification started in Connecticut in 2009
Require notification to patients regarding their breast
density and informing them that they may benefit
from supplemental screening tests

15. Notification Law (year) Bill Introduced Insurance: cover
additional testing
2009: Connecticut
2011: Texas
2012: California, Virginia
2013: Alabama, Maryland,
New York
2014: Arizona, Hawaii,
Minnesota, Nevada,
New Jersey, North
Carolina, Oregon,
Pennsylvania, Rhode
Island, Tennesse
Colorado
Delaware
Illinois
Indiana
Iowa
Kentucky
Michigan
Ohio
South Carolina
Washington
Connecticut
Indiana
Illinois
New Jersey

16. Potential supplemental tests
Whole breast
ultrasound
Automated
whole breast
ultrasound
Digital breast
tomosynthesis
Contrast-
enhanced
mammography
MRI
PEM and BSGI

17. • Hand-held US (HHUS) and automated US
(ABUS)
• Improve detection of breast cancer, in
particular in non-fatty breast density, range
from 0.3 to 6.8 cancers per 1000 exam
• However, increase rate of biopsy and detect
more non-cancerous lesions
Whole breast ultrasound
Korphrapong P et al. Acta Rad 2014;55:903.

18. Findings Screening BC_F/U Diagnose
MMG - mass 22% 26% 40%
MMG - microcal 37% 23% 10%
MMG - mass with microcal 19% 19% 30%
Occult lesions (ultrasound
detected)
22% 31% 19%
Breast cancer screening:
Siriraj-Thanyarak experience 2001-2005
69,672 examinations
1,405 breast cancer lesions from 1,268 patients
Angsusinha T et al.

19. 115 cancers from 14,483 women with non-fatty breast
CANCER
(n=115)
Sensitivity (%)
MM / MM+US
CDR per1,000
MM / MM+US
PPV (%)
MM / MM+US
Age group
<40 100 /100 1.4 / 1.4 14.3 / 5.1
40-49 69.6 / 84.8 5.6 / 6.9 29.1 / 14.3
50-59 72.2 / 95.5 6.6 / 8.6 36.4 / 24.6
60-69 88.2 / 94.1 13.5 / 14.4 51.7 / 38.1
>70 83.3 / 100 25 / 30.0 83.3 / 60
Total 74.8 / 91.3 6.5 / 7.9 33.9 / 19.6
Korphrapong P et al. Acta Rad 2014;55:903.
Improved 1.4
per 1000
Decreased
PPV

20. Mammography is not enough in
detecting small lesions in the
women with dense breast, so
consider supplemental tests
Whole breast
ultrasound
Automated
whole breast
ultrasound
Digital breast
tomosynthesis
Contrast-
enhanced
mammography

21. Controversy 1 : Detecting lesion in dense breast
Controversy 2 : How to deal with positive SLNB?
Controversy 3 :Use of IORT following BCS
Controversies in breast cancer: surgeon’ s concerns

22. • Nodal status has been designated as the most
important prognostic factors
• Nodal status influences adjuvant therapy and
treatment outcome
• Sentinel lymph node : the first node or group of node
draining in cancer
• Sentinel lymph node biopsy : is the standard of care in
early breast cancer management

26. ITC : less than 2 mm or < 200 cells
Macrometastasis : greater than 2mm.Micrometastasis : 0.2-2 mm

27. • Isolated tumor cells
(ITC) is pathological
N0.
• Treatment is as node
negative.

28. Micrometastasis : 0.2-2 mm

29. Boer M et al. N Engl J Med 2009;361:653.

30. Boer M et al. N Engl J Med 2009;361:653.
N=2707
pNmi was inferior to pN0. Therefore, AD should be considered.

31. Montagna E et al. Breast Cancer Res Treat 2009;118:385.
pNmi was comparable to pN0.
Therefore, AD might be an overtreatment.
Langer I et al.. Ann Surg Oncol 2009;16:3366.

32. 931 women with clinically node negative
Positive SLNB : micrometastasis
Both BCS and mastectomy (10%) included
Both randomly to AD or no AD
5 yrs OS : 97.9 % for AD and 98% for no AD (p = 0.35)
5 yrs DFS : 87.3 % for AD and 88.4 % for no AD (p = 0.48)
Golimberti V et al. Lancet Oncol 2013;:297-305.

33. Isolated tumor cells, and even metastases up to 2 mm
(micrometastases) in a single sentinel node, were not
considered to constitute an indication for axillary dissection
regardless of the type of breast surgery carried out.
Goldhirsch A et al. Ann Oncol 2011;22:1736.

34. Axillary dissection
vs
No further surgery
Macrometastasis : >2mm

35. ACOSOG Z0011
Giuliano AE et al. JAMA 2011;305:569.
Continue from ACOSOG Z0010
891 sentinel LN positive (only 1-2 nodes)
115 Cancer Center in the US
All had T1-T2
Undergoing BCS with post-op RT

36. Giuliano AE et al. JAMA 2011;305:569.

37. Giuliano AE et al. JAMA 2011;305:569.

38. Can axillary RT replace axillary dissection in positive axillary
LN following SLNB?
Straver M E et al. JCO 2010;28:731-737
AMAROS Trial
2001 to April 2010
4827 patients
35 centers in Europe

39. Donker et al. Lancet Oncol 2014;1303-10.

40. Donker et al. Lancet Oncol 2014;1303-10.

41. Donker et al. Lancet Oncol 2014;1303-10.

42. Donker et al. Lancet Oncol 2014;1303-10.

43. Messages from ACOSOG Z0011
and AMAROS trial
Some patients with early breast cancer who had positive
sentinel lymph node biopsy may be avoided from axillary
dissection, in particular patients who undergone breast
conserving surgery
However, those patients who undergone mastectomy (60% in
Siriraj) are still in controversy.

44. Controversy 1 : Detecting lesion in dense breast
Controversy 2 : How to deal with positive SLNB?
Controversy 3 : Use of IORT following BCS
Controversies in breast cancer: surgeons’ concern

45. • Breast conserving
therapy (BCT) is the
standard of
treatment for early
breast cancer
• BCT consists of
breast conserving
surgery (BCS) and
whole breast
radiation
• Lumpectomy alone
without RT showed
high recurrent rate

47. APBI techniques:APBI techniques:
Interstitial brachytherapy Balloon catheter brachytherapy
Skowronek
J Contemp Brachy 2012;4(3):152-164 http://www.mammosite.com

48. IORT techniques
Low energy 50 Kv
Intrabeam
Electron
Mobetron

49. IORT : local recur = 3.3 %, 95% CI = 2.3-5.11
WBRT : local recur = 1.3%, 95%CI = 0.7-2.5
Difference =2.0%

53. IORT : local recur = 4.4 %, 95% CI = 2.7-6.1
WBRT : local recur = 0.4 %, 95%CI = 0.0-1.0

54. No difference in mortality

55. Subsequent analysis identified factors
associated with LR in IORT group
Subsequent analysis identified factors
associated with LR in IORT group
On muliti-variated analysis, factors associated with LR were
Factor Hazard ratio 95% CI
Size > 2 cm 2.24 1.03-4.87
Node positive > 4 2.61 0.91-7.50
Poorly diff 2.18 1.00-4.79
Triple negative 2.4 0.94-6.1

56. The logical conclusion is that
intraoperative radiation therapy with
electrons should be restricted to suitable
patients, once characteristics defining
suitability have been defined.
The logical conclusion is that
intraoperative radiation therapy with
electrons should be restricted to suitable
patients, once characteristics defining
suitability have been defined.

57. Boost (9 Gy) Single dose (21 Gy)
Invasive breast cancer and age
less than 50 year
Invasive ductal carcinoma and
favorable histology
or Age ≥ 55 year
Invasive breast cancer and tumor
size > 2 cm from imaging
Tumor ≤ 2 cm from imaging or
previous surgery
or Single malignant lesion
Invasive breast cancer and
angiolymphatic invasion evidenced
in core needle biopsy
Estrogen receptor positive
No angiolymphatic invasion or
extensive intraductal component
from previous core biopsy
Node negative

58. 1. Wide excision done.

59. 2. Mobilize breast tissue at least 2 cm around
the cavity and do purse-string suture.

60. 3. Move Mobetron in and do docking.

61. Characteristics Boost group (N=23) Single group (N=79) Overall (N=102)
Age (yr) : mean 51.2 (33-78) 64.8 (54-90) 61.7 (33-90)
Tumor size (cm) :
mean
1.6 (0.5-4.0) 1.3 (0.3-3.2) 1.4 (0.3-4.0)
Histology
- Invasive ductal
CA
21 (100%) 72 (91.0%) 93 (91.1%)
- Mucinous CA 0 2 (2.5%) 2 (2.0%)
- Invasive papillary
CA
0 5 (6.5%) 5 (4.9%)
ER positive 21 (91.3%) 79 (100%) 100 (98%)
Nodal status
- N0 15 (65.3%) 76(96.2 %) 91 (89.2%)
- N1 7 (30.4%) 3 (3.8 %) 10 (9.8%)
- N2 1 (4.3%) 0 1 (1.0%)
IORT: Result from Siriraj Hospital

62. Characteristics Boost group (N=23) Single group (N=79) Overall (N=102)
Age (yr) : mean 51.2 (33-78) 64.8 (54-90) 61.7 (33-90)
Tumor size (cm) :
mean
1.6 (0.5-4.0) 1.3 (0.3-3.2) 1.4 (0.3-4.0)
Histology
- Invasive ductal
CA
21 (100%) 72 (91.0%) 93 (91.1%)
- Mucinous CA 0 2 (2.5%) 2 (2.0%)
- Invasive papillary
CA
0 5 (6.5%) 5 (4.9%)
ER positive 21 (91.3%) 79 (100%) 100 (98%)
Nodal status
- N0 15 (65.3%) 76(96.2 %) 91 (89.2%)
- N1 7 (30.4%) 3 (3.8 %) 10 (9.8%)
- N2 1 (4.3%) 0 1 (1.0%)
IORT: Result from Siriraj Hospital

63. Characteristics Boost group
(N=23)
Single group (N=79) Overall (N=102)
Median follow up
time (days)
1258.5 (401-1523) 634.43 (100-1458) 946.45 (100-1523)
AXLD 10 (43.5%) 0 10 (9.8%)
Op time (mins) 125.9 (72-235) 126.4 (80-194) 126.3 (80-235)
Positive margin 0 2 (4.5%) 2 (3%)
Ipsilat recurrence 1 (4.3%) 1 (1.3%)(axillary) 2 (1.9%)
Contralat recurrence 1 (4.3%) 2 (2.5%) 3 (2.9%)
Systemic recurrence 2 (8.7%) 0 2 (1.9%)
BCA related death 2 (8.7%) 0 2 (1.9%)
Non-BCA death 0 1 (1.3%) 1 (1.0%)
Total save of ERT
procedures
115 1975 2090
IORT: Result from Siriraj Hospital

64. Controversy 3
IORT following breast conserving surgery has shown higher
ipsilateral recurrence than conventional whole breast
irradiation
However, in some selected patients, the non-inferior result might
be demonstrated.