Invasive Lobular Carcinoma (ILC) of the Breast IV

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Patients with ILC have worse surgical outcomes compared to patients with invasive ductal carcinoma (IDC):
    • Measured by positive margin rates
    • Mastectomy rates
    • Axillary dissection rates
  • Many potential causes:
    • Higher stage at presentation
    • Higher discordance between clinical stage and pathologic stage
    • Lower sensitivity of standard imaging tools
  • Patients with ILC have higher positive margin rates compared to patients with IDC:
    • Secondary to:
      • Diffuse growth pattern
      • Low Imaging Sensitivity:
        • Leading to higher positive margin rates
  • Positive margins have negative consequences:
    • Significant lower breast satisfaction and sexual well-being at two years among those who require re-excision after breast conservation surgery (BCS)
    • Significant higher rates of surgical site infection (SSI), seroma / hematoma, and fat necrosis
    • Healthcare costs increased 4-fold for patients requiring re-excision
    • Increased risk of recurrence if two addressed
  • ILC:
    • Mammographically occult disease
    • MRI significantly underestimates size
    • Positive margins
  • Should patients with ILC always choose mastectomy?
    • Historically mastectomy was recommended for ILC specifically because of the diffuse growth pattern
    • More modern series show similar rates of recurrence between BCS with radiation vs. mastectomy for ILC
  • Rates of BCS for ILC have increased over time:
    • However the rate for BCS for ILC is lower that for IDC:
      • This is despite large series showing improved outcomes with breast conservation surgery compared to mastectomy:
        • US National Cancer Database Analysis of > 160,000 patients showed same or better overall survival (OS) with BCS compared to mastectomy
        • A Swedish study of nearly 50,000 patients showed improved OS with BCS compared to mastectomy (included 5,893 patients with ILC)
        • The higher rates of nodal positivity in ILC leads to increased likelihood of needing postmastectomy radiation:
          • Implications for radiation and reconstructive complications
  • BCS for patients with ILC > 4 cm:
    • BCS trial excluded patients with tumors > 4 cm
    • Retrospective analysis have shown BCT to be safe in IDC greater than 4 cm:
      • But not studied in ILC
    • Patients with ILC are more likely to present with larger tumors than IDC
  • In multivariable logistic regression model having larger tumors, higher N stage, HER2+ or triple negative subtype:
    • Were associated with significantly higher risk of recurrence:
      • The type of surgery does not affect these long-term outcomes
    • If negative margins are achieved:
      • There is no difference in recurrence rates for BCT vs mastectomy in ILC cases > 4 cm:
        • Important to note that over 50% of BCT group had positive margins and needed re-excision
  • Surgical approaches to reduce positive margin rates in ILC:
    • Oncoplastic surgery:
      • Level 1: local tissue rearrangement only
      • Level 2: parenchymal flaps and skin resection
    • Selective shave margins
  • Success rates for re-excision of positive margins after BCS in ILC:
    • Roughly 75%
  • Factors associated with successful re-excison
  • Positive margins after mastectomy for ILC
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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