What Do We Know Now? An Insider’s Look at the Latest Ideas & Findings of America’s Breast Surgeons

Editors note: In May 2014, the American Society of Breast Surgeons (ASBrS) hosted over 1400 breast surgeons for their 15th Annual Meeting to discuss the latest issues affecting surgeons who treat breast disease. In attendance was Nancy Marquez, M.D., breast surgeon with Capital Surgeons Group, BCRC Board Member, and Chair of our Medical Advisory Committee. Below is a summary of what she has learned at this year’s ASBrS Meeting.

By:  Nancy Marquez, M.D., FACS

Surgeons strive to remove cancer in an effective yet less invasive manner with good outcomes, good cosmetic outcome and low complications. Several recent studies have had a significant impact on these goals by allowing us to reduce the amount of breast tissue we need to remove at lumpectomy and reducing the number of lymph nodes removed during surgery, while still treating breast cancer with good results.

In approximately 25% of women who undergo breast conservation for the treatment of early breast cancer, (lumpectomy), cancer will be found at or close to the edges of the lumpectomy requiring a return to the operating room to take more breast tissue out. The definition of what is a “ clear margin”, meaning that adequate normal breast tissue is around the cancer removed, has been variable. Now, a review of many studies has created a consensus guideline, or agreement between a group of surgeons and radiation oncologists, that defines a clear margin as “ no tumor on ink”.  (The tumor and surrounding tissue is rolled in a special ink so that the outer edges, or margin, are clearly visible under a microscope. A clear, negative, or clean margin means there are no cancer cells at the outer edge of tissue that was removed.) Regardless of a patient’s age, aggressiveness of the cancer, or type of invasive breast cancer, removing a wider amount of normal tissue around the cancer does not improve her prognosis. More is not better, and it can negatively impact the appearance of the breast after lumpectomy.

How else can we tell in the operating room if we have gotten around the tumor, especially in the case of DCIS, or noninvasive breast cancer?  A new device, the MarginProbe System, can actually detect cancer cells within 1 millimeter of the edge of the lumpectomy specimen in about 5 minutes. This can allow the surgeon to remove more breast tissue, if needed, at the time of the initial lumpectomy, thus saving the patient another trip to the operating room. Although not widely available as yet, it can decrease return trips to the operating room by 50%. Less of these re-excisions mean less cost, less risk of complications, and a potentially a better appearance after surgery.

What about a situation when a breast cancer patient has a larger tumor and wants to preserve her breast without having chemotherapy first? Or a smaller breast with a proportionally larger tumor? Or a patient with large breasts that have seen the effects of a pregnancy and gravity as well? Excision of the breast cancer is sometimes challenging as we try to preserve the shape of the breast or provide a lumpectomy that could potentially improve upon the breast appearance. This is when we can apply “oncoplastic techniques” or the use of plastic surgery techniques in the removal of the breast cancer. Moving breast tissue in this manner can help avoid defects in the breast as we fill in the space where the tumor was removed. Sometimes these are done with the help of the plastic surgeon present at the time of lumpectomy. We often think of plastic surgeons as involved in the reconstruction of the breast, but their skills can often be used at the time of lumpectomy, such as performing a breast reduction and breast lift at the same time of the breast cancer surgery. This is often an added benefit desired by our patients and can also help then as they go through radiation.

Less is more in the management of the lymph nodes in the axilla (under arm area). Sentinel lymph node removal has allowed us to take out less lymph nodes while still obtaining the information we need to plan treatment. This has also significantly decreased the risk of lymphedema of the arm as well as other problems, such as limited shoulder mobility or nerve pain. But if a patient had a sentinel node with tumor, we often recommended more lymph nodes be removed, thus increasing the risk of these complications. A recent international study (AMAROS trial) demonstrated that radiation, instead of further lymph node removal, was just as effective and had less complications.

But is there a higher risk of cancer recurring in the axilla without a complete lymph node removal if the sentinel node is positive? Another recent study (ACOSOG Z0011) showed no significant difference in the recurrence of cancer in the axilla after lumpectomy, nor in overall survival if the patient undergoing breast conservation had a positive sentinel node without complete lymph node removal. Again, as surgeons we try to minimize the complications (lymphedema) while still doing a safe, effective cancer operation.

On another nonsurgical note, the care of breast cancer patients has always involved a team of specialists that provides a treatment plan that is individualized for that patient. Many articles presented at the meeting discussed the genetic profiling of breast cancer which may in cases better predict the behavior of the cancer as opposed to size or cell type for example. These “profiles” are becoming more advanced and will be guiding treatment even more in the future. This will also likely guide the follow up or surveillance of patients after treatment.

As these genetic profiles are further studied, it may result that a breast cancer subtype may share characteristics with an ovarian cancer.  If so, it is possible that a patient with a breast cancer that has not responded to standard treatment might respond to a treatment meant for say, ovarian cancer, because those genetic profiles indicate that they share characteristics with each other. That sounds pretty exciting, but I am a surgeon, and I will leave the role of chemotherapy to the medical oncologist. Determining the true effectiveness and relevance of these treatments based on advanced genetic profiling will need to be demonstrated in future trials. As always, I remain optimistic that we will simply continue to improve the treatment and care we provide for our breast cancer patients.

Tagged under:

Leave a Reply

Your email address will not be published.