Management of Breast Cancer with Breast Conserving Surgery

  • Once a patient undergoes breast-conserving surgery:
    • The pathology report is reviewed to determine any need for additional surgery
    • If the sentinel node biopsy was negative:
      • No additional axillary surgery is warranted
    • Margins assessed next:
      • Historically, the definition of what was considered an adequate margin in patients undergoing breast-conserving surgery was left to the interpretation of the treating physicians
      • In 2013, the Society of Surgical Oncology and the American Society for Radiation Oncology released consensus guidelines to assist physicians and patients in decisions regarding margins:
        • These guidelines were based on:
          • meta-analysis of 33 studies evaluating in-breast tumor recurrence (IBTR) in relation to margin width
        • The results of the meta-analysis reported:
          • Positive margins were associated with 2-fold risk of IBTR:
            • Routine re-excision is recommended for those patients
          • For those with negative margins (defined as “no ink on tumor”), the meta-analysis reported that:
            • Increasing margin widths were not associated with a reduction in IBTR.
    • Is the patient a candidate for adjuvant therapy?
      • The 21-gene recurrence assay:
        • Has been shown to accurately predict risk of distant recurrence and benefit of adjuvant chemotherapy:
          • In women with ER positive tumors
      • Adjuvant chemotherapy is a category 1 recommendation for women with:
        • ER negative tumors greater than 1 cm
    • Does this patient need genetic studies?
      • The incidence of BRCA mutations in women with triple negative breast cancers:
        • Ranges in the literature from 10% to 31%
      • Current guidelines state that women who present with triple negative histology prior to age 60 should be considered for testing
  • References
    • Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole breast irradiation in Stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88(3):553–564.
    • Greenup R, Buchanan A, Lorizio W, Rhoads K, Chan S, Leedom T, et al. Prevalence of BRCA mutations among women with triple negative breast cancer in a genetic counseling cohort. Ann Surg Oncol. 2013;20:3254-3258.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #BreastConservingSurgery #OncotypeDx #Miami #Mexico #Surgeon #Teacher

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