Tanir Alweiss : The role of the surgeon in the neo-adjuvant treatment of breast cancer
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Tanir Alweiss : The role of the surgeon in the neo-adjuvant treatment of breast cancer
- 1. The role of the surgeon in the neoadjuvant treatment of breast cancer Tanir M Allweis, MD Director, Sarah Markowitz Breast Health Center Kaplan Medical Center Jerusalem, April 30th – May 1st 2014
- 2. What is Neo-‐adjuvant chemotherapy? • Chemotherapy given as first line of treatment for non-‐metastaKc breast cancer Aims of neo-‐adjuvant chemotherapy • To transform non-‐operable breast cancer to operable disease • To enable breast conserving surgery instead of mastectomy
- 3. Surgical reasons for delivering chemotherapy prior to surgery • Change an inoperable breast cancer into an operable one – Skin or chest wall invasion – Unable to achieve clear margins – Inflammatory breast cancer • Enable more conservaKve surgery: – Lumpectomy instead of mastectomy – Smaller lumpectomy
- 4. Fisher B et al J Clin Oncol. 1998 Aug;16(8):2672-‐85 • Adjuvant vs. neoadjuvant A-‐C N = 1,523 35% cCR (breast & axilla) 44% cPR 80% ReducKon in T size >50% 67 vs. 60% (p=0.002) Lumpectomy rate
- 6. Wolmark et al, J Natl Cancer Inst Monogr. 2001;(30):96-‐102 Adjuvant Neaodjuvant 70% cCR 78% 69% OS cPR 67% cNR 65% 53% cCR 64% 55% DFS cPR 54% cNR 46%
- 7. Deciding on NAC MulKdisciplinary team discussion • Extent of tumor: – Operability? – MulKcentric? • Tumor characterisKcs and likelihood of response: – Invasive lobular carcinoma? • PaKent preferences
- 8. During NAC • Follow paKents clinically and with repeat imaging to determine response to NAC: – For non responders: change treatment? – Based on molecular tumor profile? • Mark locaKon of tumor with image detectable marker: – Radio-‐opaque – Hydrogel
- 9. Surgery a@er NAC Breast • Plan resecKon based on original extent of disease or residual disease? Lymph Nodes • SenKnel lymph node biopsy or axillary lymph node dissecKon?
- 10. Breast surgery a@er NAC • Mastectomy – With or without reconstrucKon • Lumpectomy – With or without oncoplasKc reconstrucKon
- 11. Lymph node surgery a@er NAC • Clinically LN negaKve – SLNBx prior to NAC? • LN posiKve converted to negaKve • LN posiKve
- 12. How accurate is SLNBx aier neoadjuvant chemotherapy? False Neg. Rate Study 12.6% JAMA. 2013 Oct 9;310(14):1455-‐61. SenFnel lymph node surgery a@er neoadjuvant chemotherapy in paFents with node-‐posiFve breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. Boughey JC et al 11.6% Am Surg. 2014 Feb;80(2):171-‐7. SenFnel lymph node biopsy is a reliable method for lymph node evaluaFon in neoadjuvant chemotherapy-‐treated paFents with breast cancer. Koslow SB et al 20.8% Ann Surg Oncol. 2012 Oct;19(10):3177-‐84. The role for senFnel lymph node dissecFon a@er neoadjuvant chemotherapy in paFents who present with node-‐posiFve breast cancer. Alvarado R et al 24.3-‐14.2% Lancet Oncol. 2013 Jun;14(7):609-‐18. SenFnel-‐lymph-‐node biopsy in paFents with breast cancer before and a@er neoadjuvant chemotherapy (SENTINA): a prospecFve, mulFcentre cohort study. Kuehn T et al
- 13. SenFnel-‐lymph-‐node biopsy in paFents with breast cancer before and a@er neoadjuvant chemotherapy (SENTINA) Kuehn T et al Lancet Oncol. 2013 Jun;14(7):609-‐18 False negaFve rate DetecFon Rate n/a 99.1% SLN neg prior to NAC 51.6% 60.8% SLN pos and 2nd SLN Bx 14.2% 80.1% N1 converted to ycN0 n/a n/a N1 before and aier NAC
- 14. Conclusions: • SenKnel-‐lymph-‐node biopsy is a reliable diagnosKc method before NAC • Aier systemic treatment or early senKnel-‐ lymph-‐node biopsy, the procedure has a lower detecKon rate and a higher false-‐negaKve rate compared with senKnel-‐lymph-‐node biopsy done before NAC. • These limitaKons should be considered if biopsy is planned aier NAC.
- 16. NCCN guidelines version 3.2014 • Axillary staging following preoperaKve chemotherapy may include senKnel node biopsy or level I/II axillary dissecKon. • Level I/II dissecKon should be done for when paKents were proven node posiKve prior to neoadjuvant therapy. • Category 2B
- 18. OncotypeDx in the neaodjuvant seXng? • In ER posiKve tumors which are too large or borderline for lumpectomy – Would require extensive oncoplasKc reconstrucKon • If chemotherapy will be required based on intermediate/high RS • Chemotherapy may be uKlized for reducing extent of surgery
- 19. Thank you for your alenKon
- 20. • PaKents with ILC achieved a significantly lower pCR rate compared with non-‐ILC paKents (6.2 vs. 17.4 %, P < 0.001). • The pCR rate was: – 4.2 % in ILC/HR+/G1-‐2, – 7.0 % in ILC with either HR-‐ or G3, – 17.8 % in ILC/HR-‐/G3. Response and prognosis a@er neoadjuvant chemotherapy in 1,051 paFents with infiltraFng lobular breast carcinoma. Breast Cancer Res Treat. 2014 Feb;144(1):153-‐62. Loibl S1 et al
- 21. • In ILC paKents, pCR did not predict distant disease free (DDFS) and loco-‐regional disease free survival (LRFS), but overall survival (OS).