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1
Primary Surgical Considerations
Terry Mamounas, M.D., M.P.H., F.A.C.S.
Medical Director, Comprehensive Breast Program
UF Health Cancer Center at Orlando Health
Professor of Surgery, University of Central Florida College of Medicine
Clinical Professor of Surgical Oncology,
Florida State University College of Medicine
1
• Breast Cancer Diagnosis/Preoperative Local Staging
• Primary Surgical Management of Invasive/Non-Invasive BC
– RCT of Lumpectomy vs. Mastectomy
– Lumpectomy Indications/Contraindications
– Technical Considerations/Margin Assessment
– Contralateral Prophylactic and Nipple-Sparing Mastectomy
• Special Circumstances in Primary Surgical Management
– Family History/BRCA 1 or 2 mutation carriers
– Presence of EIC
– Lobular Histology/Presence of LCIS
– Occult Breast Cancer
– Large Tumors/Neoadjuvant Chemotherapy
– Management of Patients Presenting with Stage IV Disease
Outline 2
Breast Cancer Diagnosis/
Preoperative Local Staging
3
Breast Cancer Diagnosis
• Minimally invasive procedures constitute the standard of care for diagnosis in the majority of patients
• Needle biopsies can be directed by whichever method assures easiest access and best accuracy for obtaining a true positive or true negative result (clip placement)
• Core needle biopsy is the optimal method for BC diagnosis and can be performed by palpation, ultrasound guidance or stereotactic guidance
4
Core Needle Biopsy
• Advantages: • Differentiates between invasive and non-invasive cancer
• Allows one-stage surgical procedures (including SNB before lumpectomy)
• Provides adequate material for biomarkers (ER/PR/HER2)
• Neoadjuvant chemo can be given with invasive ca on core
• Limitations:
• False negative rate 1-2 %
• With non-invasive cancer on core, invasive cancer may still be present in 10-25% of cases
• With atypical hyperplasia on core, invasive or non-invasive cancer may be present in 15-40 % of cases and open biopsy should follow
Dershaw DD: Breast J 2003, Rao A, et al: Am J Surg 2002, Shin SJ, et al: Arch Pathol Lab Med 2002, Renshaw AA, et al: Am J Clin Pathol 2001, Berg WA, et al: Radiology 2001,
Darling ML, et al: AJR 2000, Tocino I, et al: Ann Surg Oncol 1996, Liberman L, et al: AJR 1995, Jackman RJ, et al: Radiology 1994, Adrales G, et al: Am J Surg 2000
5
MRI in Preoperative Local Staging
• Because of its high sensitivity in BC diagnosis and screening, MRI is being increasingly utilized in the preoperative local staging of BC
• Multiple studies (and a meta-analysis) have shown that MRI identifies additional cancer foci, otherwise undetected by clinical assessment and conventional imaging (in both breasts)
• No consensus on whether MRI improves patient outcomes in terms of rates of margin positivity, reoperation, IBTR or DFS and OS
• On the other hand there remains concern that MRI can increase unnecessary mastectomy rates
Houssami N et al: J Clin Oncol 2008; Schnall M et al: Magn Reson imaging Clin N Am, 2006; Liberman L et al: Magn Reson Imaging Clin N Am, 2006;
Smith RA et al: N Engl J Med 2007; Morrow M et al: Magn Reson Imaging Clin N Am 2006
6
UK COMICE Randomized Trial:
MRI Planning for Breast-Conserving Treatment
• 1623 women with biopsy-proven primary BC
• Scheduled for WLE based on triple assessment
• Randomized to receive MRI (n = 816) or no MRI (n = 807)
Turnbull L et al: Lancet 2009
MRI N (%) No MRI N (%)
Initial Surgery
Mastectomy 58 (7%) 10 (1%)
Pathologically
Avoidable
Mastectomy
16 (2%)
2 (0.2%)
Pathology
MF/MC disease 101 (14%) 78 (11%)
• Change in management
based on MRI = 50/816 (6%)
• Reoperation rates:
• MRI: 18.75%
• no MRI: 19.33% P = NS
• No significant differences
in DFS of QOL
(distress/anxiety)
MRI in Preoperative Local Staging Potential Candidates
• Not necessary for all patients who undergo BCS
• Can be helpful in:
• Patients with mammographically dense breasts and ill-defined tumors
• Patients with invasive lobular carcinoma
• Patients with multi-centric disease
• Patients who are candidates for neoadjuvant chemotherapy
• MRI is essential in patients who present with axillary adenopathy and clinically and radiographically occult breast lesions
8
Primary Surgical Management in Patients
with Invasive and Non-Invasive BC
9
Primary Surgical Management
• Evolution in the paradigm of surgical
management over the past 30 years
• Trend towards increasing use of breast
conserving procedures without compromising
patient outcome
• Breast conserving surgery has become the
preferred surgical treatment for the majority of
early-stage BC patients
10
Invasive Breast Cancer
Breast Conserving Surgery vs. Mastectomy
• From 1973-1989, six randomized trials
• Two overview analyses
• Compared mastectomy to BCS + XRT
• Maximum tumor size for entry: 2-5 cm
• No differences in overall survival
• XRT significantly reduced the rates of IBTR
Fisher B, et al: N Engl J Med 1985, 1989, 1995, 2002, Veronesi U, et al: Eur J Cancer 1990, 1995, World J Surg 1994, N Engl J Med 1981, 2002
Van Dongen JA, et al: Eur J Cancer 1992, J Natl Cancer Inst 2000, Lichter AS, et al: J Clin Oncol 1992, Sarrazin D, et al: Radiother Oncol 1989
Blichert-Toft M, et al: J Natl Cancer Inst 1992, EBCTCG: N Engl J Med 1995, Morris AD, et al: Cancer J Sci Am 1997
11
Breast Conserving Surgery Utilization
• 1990: NIH CDC Statement:
– Breast Conservation Treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable because it provides survival equivalent to total mastectomy while preserving the breast.”
• Despite this and the increase in detection of early-stage disease, BCS is underutilized as a surgical option
NIH CDC: JAMA 1991, Newman LA, et al: Surg Clin North Am 2003, Swanson GM, et al: SG&O 1990, Nattinger AB, et al: N Engl J Med 1992
Samet JM, et al: Cancer 1994, Johantgen ME, et al: Am J Public Health 1995, Ayanian JZ, et al: BCRT 1996, Morrow M, et al: J Clin Oncol 2001
12
Optimal Lumpectomy Candidates
• Tumors < 5 cm in diameter
• Limited to one quadrant
• Breast size/tumor size ratio permitting lumpectomy with acceptable cosmetic result
• Patient is desirous of breast preservation
• Negative margins following resection
• No contraindications to breast XRT
Newman LA, et al: Surg Clin North Am 2003, Winchester JD, et al: CA Cancer J Clin 1998
13
Lumpectomy Contraindications Absolute
• Multi-centric disease in more than one quadrant
• Diffuse suspicious microcalcifications
• Inability to obtain clear margins after multiple resections
• First or second trimester of pregnancy
• History of therapeutic radiation to the region
Hooning MJ, et al: Neth J Surg 1991, Morrow M, et al: Ann Surg 1998, Jakesz R, et al: Chirurg 1999
14
• Large tumor size/breast size ratio for
acceptable cosmesis
• History of collagen vascular disease
(relative contraindication to XRT)
• Tumor location beneath nipple
• Unavailability of radiotherapy
Lumpectomy Contraindications Relative
Hooning MJ, et al: Neth J Surg 1991, Morrow M, et al: Ann Surg 1998, Jakesz R, et al: Chirurg 1999
15
Lumpectomy Technique Choice of Incision
• Incision over mass
• Adequate length
• Always curvilinear
• Keep in mind possible future mastectomy
• Do not combine with axillary incision
16
• Thick flaps unless mass
is superficial
• Keep in mind possible
future PBI
• Remove piece of skin
only if mass is fixed
• Use sharp dissection
• Orient specimen and tag
before removing
Lumpectomy Technique Excision and Specimen Orientation
Sutures
17
• Inking of specimen by
pathologist
• Gross margin
inspection
• Resection of
additional tissue if
necessary
Ink
Normal Breast Tissue
Tumor
Lumpectomy Technique Intraoperative Margin Assessment
18
SSO-ASTRO: Margins Consensus Guideline
Methods
• A multidisciplinary consensus panel
considered a meta-analysis of margin width
and ipsilateral breast tumor recurrence (IBTR)
• Systematic review of 33 studies including
28,162 patients
• The results of randomized trials, reproducibility
of margin assessment, and current patterns of
multimodality care were also considered
Moran M, et al: J Clin Oncol, 2014
Relationship Between IBTR and Margin Status
N
Studies Adjusted OR
of IBTR * 95% CI p-value
(association)
Margin category (Model 1) < 0.001
Close/Positive 33 1.96 1.72-2.24
Negative 33 1.0 -
Margin category (Model 2) < 0.001
Positive 19 2.44 1.97-3.03
Close 19 1.74 1.42-2.15
Negative 19 1.0 - -
Threshold distance (Model 2)
p-value (trend) = 0.58
0.90
1 mm 6 1.0 - -
2 mm 10 0.91 0.46-1.80 -
5 mm 3 0.77 0.32-1.87 -
SSO-ASTRO: Margins Consensus Guideline
Margins Width Meta-analysis
Houssami N, et al: Ann Surg Oncol, 2014
Impact of Margin Width on IBTR
Adjusted for Individual Covariates and Follow-up
Covariate No. of
studies
Threshold Distance
Negative Margin:
Adjusted OR p-value (association)
1 mm 2 mm 5 mm
Age 18 1.0 0.53 0.77 0.53
Endocrine therapy 16 1.0 0.95 0.90 0.95
Radiation boost 18 1.0 0.86 0.92 0.86
SSO-ASTRO: Margins Consensus Guideline
Margins Width Meta-analysis
Houssami N, et al: Ann Surg Oncol, 2014
• There was no evidence that more widely clear margins
reduce IBTR for:
• Young patients, patients with unfavorable biology,
lobular cancers, cancers with EIC
Moran M, et al: J Clin Oncol, 2014
• The use of no ink on tumor as the standard
for an adequate margin in invasive cancer in
the era of multidisciplinary therapy is
associated with low rates of IBTR
• This approach has the potential to decrease
re-excision rates, improve cosmetic
outcomes, and decrease healthcare costs
SSO-ASTRO: Margins Consensus Guideline
Conclusions
Moran M, et al: J Clin Oncol, 2014
• 4,660 patients from trials of BCS + XRT for DCIS
• Pts with (-) margins significantly less likely to experience IBTR than pts with (+) margins (OR 0.36)
• A (-) margin significantly reduced risk of IBTR compared with a close (OR 0.59) or unknown margin (OR 0.56)
What Constitutes Adequate Margin for DCIS? Meta-Analysis: Effect of Margin Status on LR
Dunne et al: J Clin Oncol, 2009
23
Dunne et al: J Clin Oncol, 2009
• 2-mm margin was superior to a margin < 2 mm (OR 0.53)
• No significant difference in IBTR between 2 mm and more
than 5 mm (OR 1.51; P .05)
• A margin of 2 mm seems to be as good as a larger margin
What Constitutes Adequate Margin for DCIS? Meta-Analysis: Effect of Margin Width on LR
24
A Recently Observed Trend: Increase in the Incidence of
Contralateral Prophylactic Mastectomy
Tuttle et al: J Clin Oncol 2007
25
Nipple-Sparing Mastectomy Background
• In most mastectomy techniques the NAC is removed:
• Contains terminal ducts
• Centripetal lymphatic drainage towards the subareolar plexus of Sappey
• In early mastectomy studies the likelihood of occult NAC involvement was relatively high (8-50%)
• Increased risk with tumor proximity to NAC, poorly differentiated tumors, lymph node positivity, size >2 cm
Lagios MD, et al: Am J Surg 1979; Fisher ER et al: Cancer 1975; Smith J, et al: Surg Gynecol Obstr 1976; Kissin MW, et al: Br J Surg 1987
26
Nipple-Sparing Mastectomy Rationale
• In more recent mastectomy series NAC involvement is seen in 6-11%
• In the majority not appreciated preoperatively
• Careful evaluation of the NAC by is necessary for NSM
• Several series have demonstrated the feasibility of NSM but long term FU is needed
• Main advantages: cosmesis and preservation of nipple sensation (variable)
• Potential concerns: nipple necrosis, long-term oncologic safety
Laronga C, et al: Ann Surg Oncol 1999; Simmons RM, et al: Ann Surg Oncol 2002; Klimberg et al: Ann Surg Oncol 1998; Crowe et al:
Arch Surg 2004, Pennisi VR, et al: Aesth Plastic Surg 1989
27
Nipple-Sparing Mastectomy Appropriate Candidates
• Tumor size 3 cm or less
• Tumor location at least 2 cm from the nipple-areola complex
• Absence of multicentricity
• Absence of segmental malignant calcifications extending to the nipple-areola complex
• Clinically negative nodes
• Negative intraoperative biopsy of nipple-areola complex
Spear SL, et al: Plast Reconstr Surg 2009; Golshan M: Diseases of the Breast, 2009
28
Nipple-Sparing Mastectomy Technical Aspects
• Incisions:
• Peri-areolar with lateral extension
• Trans-areolar, peri-nipple with lateral extension
• Trans-areolar, trans-nipple with medial and lateral extensions
• Inferior-lateral mammary crease incision
• Nipple-sparing omega (mastopexy) incision
• Vertical incision
Laronga C, et al: Ann Surg Oncol 1999; Simmons RM, et al: Ann Surg Oncol 2002; Klimberg et al: Ann Surg Oncol 1998; Crowe et al: Arch
Surg 2004, Pennisi VR, et al: Aesth Plastic Surg 1989
29
Special Circumstances in Breast Cancer Primary Surgery
30
Family History/BRCA Status and IBTR
• Family history is not an independent predictor of IBTR in case-control studies
• Whether BRCA mutations increase IBTR rates after BCS is controversial:
• Pierce et al : No significant increase in 10-year IBTR rate for BRCA+ pts (12%) vs. BRCA- pts (9%)
• Robson et al : Non-significant increase in IBTR rate for BRCA+ Ashkenazi Jewish pts vs. BRCA- pts (RR=1.79; 95% CI=0.64-5.03)
• Hafty et al : Significant increase in 12-year IBTR rate for BRCA+ pts (49%) vs. BRCA- pts (21%). No
oophorectomy or tamoxifen used
Pierce LJ, et al: J Clin Oncol 2006, Robson M, et al: J Natl Cancer Inst 1999, Haffty BG, et al: Lancet 2002
31
Surgical Approach of BRCA+ Patients
• Known Mutation Carriers:
- Discuss BCS vs. bilateral mastectomy
- XRT is effective without excess toxicity
- High rate of IBTR and CBC
• Suspected Mutation Carrier:
- Proceed with surgery as planned based on tumor presentation (consider neoadjuvant Rx)
- Proceed with genetic counseling and testing
- Revisit the surgical management after systemic therapy is given and before XRT
32
Extensive Intraductal Component (EIC) DCIS in > 25% of the tumor area
• In early studies, EIC has been found to be associated with increase in IBTR rates after BCS
• Most of these studies included patients with involved margins and margin involvement generally correlates with the presence of EIC
• Subsequent studies that included patients with negative or focally positive margins, showed that presence of EIC does not significantly predict for IBTR
Schnitt SJ, et al: Cancer 1984 Boyages J, et al: Radiother Oncol 1990, Voogd AC, et al: Eur J Cancer 1999, Abner AL, et al: Cancer 2000, Leborgne F, et al: Int J Radiat Oncol
Biol Phys 1995 Voogd AC, et al: J Clin Oncol 2001, Burke MF, et al: Int J Radiat Oncol Biol Phys 1995, Touboul E, et al: Int J Radiat Oncol Biol Phys 1999,
Schnitt SJ, et al: Cancer 74:1746-51, 1994, Anscher MS, et al: Ann Surg 1993, Smitt MC, et al: Cancer 1995, Wazer DE, et al: Int J Radiat Oncol Biol Phys 1999
33
Presence of Lobular Histology
• Invasive lobular carcinoma can present in an
insidious fashion making margin assessment
often challenging
• Several studies have shown no significant
differences in IBTR rates between pts presenting
with lobular vs. ductal histology
• In one study, presence of LCIS increased IBTR
rates at 10 but not at 5 years and mostly in
younger women
Voogd AC, et al: Eur J Cancer 1999, Abner AL, et al: Cancer 2000,
Elkhuizen PH, et al: Int J Radiat Oncol Biol Phys 1999, Wazer DE, et al:. Int J Radiat Oncol Biol Phys 1998
34
Occult Breast Cancer Incidence and Diagnosis
• 0.3%-1% of breast cancers present with
clinical axillary adenopathy with an occult
breast primary
• Breast MRI identifies the occult primary in 75-
85 % of the cases
• In the majority of cases with negative MRI, no
tumor can be identified in the mastectomy
specimen
Baron PL, et al: Arch Surg 1990, Merson M, et al: Cancer 1992, Patel J, et al: Cancer 1981, Sakorafas GH, et al: Surg Oncol 1999, Orel SG, et al: Radiology 1999,
Henry-Tillman RS, et al: Am J Surg 1999, Morris EA, et al: Radiology 1997, Tilanus-Linthorst MM, et al: BCRT 1997, Baker DR: Clin Breast Cancer 2000
35
Occult Breast Cancer Loco-Regional Management
• Traditionally, MRM followed by L-R XRT has been the standard approach
• Acceptable approaches with proven safety (in small series) include:
• Axillary node dissection followed by breast XRT (and regional nodal XRT as appropriate)
• Neoadjuvant chemotherapy followed by either one of the above options
• If mastectomy is not performed, omission of breast XRT increases the rates of IBTR (from about 12-33% to about 14-83%)
Baron PL, et al: Arch Surg 1990, Merson M, et al: Cancer 1992, Patel J, et al: Cancer 1981, Sakorafas GH, et al: Surg Oncol 1999, Ellerbroek N, et al: Cancer 1990,
Kemeny MM, et al: Am J Surg 1986, Vlastos G, et al: Ann Surg Oncol 2001, Foroudi F, et al: Int J Radiat Oncol Biol Phys 2000
36
Neoadjuvant Chemotherapy Loco-Regional Effects
• NC in operable breast cancer induces clinical response in 80-90% of the pts
• pCR rates range from 15-40%
• NC increases the rates of BCS without significantly increasing IBTR
• Potential to increase cosmetic result by decreasing the amount of breast tissue needed to be removed at lumpectomy
37
• Sometimes difficult to define the extent of
residual tumor and as a result the amount
of breast tissue to be removed at
lumpectomy
• Ideally one would want to remove less
than originally required
Challenges in Decreasing the Size of the Lumpectomy Specimen
38
How Do Tumors Shrink in Response to NC?
39
What is Adequate Surgical Resection after NC?
40
1 2 3 4 5
1: Single predominant mass with identifiable rim, displacing
2: Nodular pattern, irregular borders
3: Diffuse infiltrative pattern
4: Patchy enhancement
5: Septal spread
MRI Phenotypes
Esserman L, et al:. Ann Surg Oncol 2001
41
MRI Can Overestimate the Amount of Residual Disease
Before NC After NC
42
• Identification of the exact tumor location in cases of cCR
– Preoperative titanium clip placement
Neoadjuvant Chemotherapy Surgical Planning
Kuerer HM, et al: Am J Surg 2001 Kaufmann M, et al: J Clin Oncol 2003, Baron LF, et al: AJR 2000, Edeiken BS, et al: Radiology 1999, Dash N, et al: AJR 1999
43
Before NC After NC
Ensuring Adequate Surgical Resection after NC
• Identify pattern of shrinkage and the extent of
residual tumor preoperatively (mammogram,
US, MRI)
• Accurately localize tumor bed area in cases
of clinical/radiologic CR
• Thoroughly evaluate margins
(intraoperatively and postoperatively)
• Perform additional resection if necessary
Delille JP, et al: Radiology 2003, Wasser K, et al: Eur Radiol 2003, Tiling R, et al: Onkologie 2003, Partridge SC, et al: AJR 2002, Esserman L, et al: Ann Surg Oncol 2001
44
Invasive Lobular Carcinoma and NC
• Particular attention when planning BCS in pts with ILC after NC
• ILC often multicentric and can extensively involve the breast without significant clinical or mammographic findings
• MRI is useful in defining the extent in the breast (but not in the axilla)
• Very low pCR rates with ILC (0-3%)
• ILC predicts for ineligibility of BCS
• Unlikely that pts with extensive ILC will be converted to BCS candidates by NC
Lesser, ML, et al: Surgery 1982, Cocquyt VF, et l: Eur J Surg Oncol 2003, Newman LA, et al: Ann Surg Oncol, 2002
45
• Conventional wisdom is that once metastases
have occurred, aggressive local therapy
provides no survival advantage and should not
be pursued except to prevent local
complications (bleeding, ulceration, infection)
• Several retrospective studies have shown
significantly better outcomes for women who
had surgical removal of their tumor vs. those
who did not (particularly for those who had
negative margins)
Primary Surgical Therapy in Patients Presenting with Stage IV BC
Khan SA, et al: Surgery 2002; Rapiti E, et al: J Clin Oncol 2006; Gnerlich J et al: Ann Surg Oncol 2007; Bafford AC et al: Br Ca Res Treat 2009;
Babiera GV et al: Ann Surg Oncol 2006; Blanchard DK et al: Br Ca Res Treat 2006; Le Scodan R et al: J Clin Oncol 2009;
Ruiterkamp J et al: Eur J Surg Oncol 2009; Shien T et al: Oncol Rep 2009; Cady B et al: Ann Surg Oncol 2008; Fields RC et al: Ann Surg Oncol 2007;
46
• Most studies adjusted for imbalances in known prognostic factors (such as number of mets, location of mets, type of systemic therapy or use of radiotherapy)
• Most studies concluded that unrecognized selection bias may have accounted for the observed benefit of surgery and only large prospective RCTs could reliably answer the question
Primary Surgical Therapy in Patients Presenting with Stage IV BC
Khan SA, et al: Surgery 2002; Rapiti E, et al: J Clin Oncol 2006; Gnerlich J et al: Ann Surg Oncol 2007; Bafford AC et al: Br Ca Res Treat 2009;
Babiera GV et al: Ann Surg Oncol 2006; Blanchard DK et al: Br Ca Res Treat 2006; Le Scodan R et al: J Clin Oncol 2009;
Ruiterkamp J et al: Eur J Surg Oncol 2009; Shien T et al: Oncol Rep 2009; Cady B et al: Ann Surg Oncol 2008; Fields RC et al: Ann Surg Oncol 2007;
47
Tata Memorial Center Randomized Phase III Trial
R
Loco-
Regional
Treatment* Anthracyclines
+/- Taxanes
(CR /PR ) No Loco-
Regional
Treatment
Stage IV BC At Presentation
Stratification by:
• Hormone-Receptor Status
• Site of metastases (visceral vs. bone vs. both)
• Number of metastatic lesions (< 3 vs. > 3)
*LRT: BCS or Mastectomy + AND followed by radiation
therapy (RT), as per standard adjuvant guidelines
Badve R et al: SABCS 2013, Abstract S2-02
N=350
Median F/U:
17 mos
Tata Memorial Center Phase III Trial Results: Overall Survival
• The median OS in LRT and
No-LRT arms were 18.8 and
20.5 months (HR=1.04,
p=0.79)
• Corresponding 2-year OS
were 40.8% and 43.3%,
respectively
• No significant difference in
OS between the two groups
after adjusting for age, ER
status, HER2 status, site
and number of mets
(HR=1.00, 95%CI=0.76-1.33,
p=0.98).
Badve R et al: SABCS 2013, Abstract S2-02
MF07-01 Turkish Study: Design
Soran A, et al: SABCS 2013, Abstract S2-03
• Chemotherapy to all patients
either after randomization in
the ST treatment arm or after
surgical resection the
surgery arm
• Hormone therapy for HR
positive BC and trastuzumab
for HER-2 positive BC
• Surgery-RT at discretion of
investigator
• Bisphosphonates given at
discretion of treating
physician
MF07-01 Turkish Study: Results Overall Survival
Soran A, et al: SABCS 2013, Abstract S2-03
• Based on the RCT data, not removing the primary tumor remains the standard
• Surgery can be entertained in selected cases (before or after systemic therapy) for local control if local manifestations are more likely to contribute to morbidity than distant ones
• In such cases, breast conserving surgery is preferable if it can encompass the scope of the surgical resection
• Axillary node surgery or breast XRT are generally not advisable
Primary Surgical Therapy in Patients Presenting with Stage IV BC
52
• Core needle biopsy is the standard diagnostic procedure for primary BC
• MRI is not indicated for all pts who undergo BCS
• Lumpectomy + breast XRT is the preferred surgical option in the absence of absolute contraindications. No “ink on tumor” appears adequate margin
• There has been a recent increase in use of CPM
• Nipple-sparing mastectomy requires careful consideration and patient selection
Summary/Conclusions (1) 53
• Family history of breast cancer, presence of EIC
(with negative margins), lobular histology and
presence of LCIS do not increase the rates of
IBTR and are not contraindications to BCS
• In patients presenting with “occult” BC and
axillary metastases, MRI plays an important role
in identifying the primary in the breast. Breast
XRT is an acceptable alternative to mastectomy,
if MRI does not identify a distinct lesion
Summary/Conclusions (2) 54
• In patients undergoing neoadjuvant
chemotherapy, unique primary surgical issues
relate to the assessment of the extent of
residual disease and the exact location of
residual tumor (or tumor bed) in patients with
complete clinical and/or radiologic response
• There is currently no definitive evidence that
the use of primary breast surgery in patients
presenting with stage IV disease improves
overall survival
Summary/Conclusions (3) 55
Recommended