Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO14_Module3_1630_Mamounas... · Core Needle Biopsy •Advantages: •Differentiates between invasive and non-invasive

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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

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• 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

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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

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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

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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

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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

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Primary Surgical Management in Patients

with Invasive and Non-Invasive BC

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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

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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

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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

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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

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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

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• 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

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Lumpectomy Technique Choice of Incision

• Incision over mass

• Adequate length

• Always curvilinear

• Keep in mind possible future mastectomy

• Do not combine with axillary incision

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• 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

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• Inking of specimen by

pathologist

• Gross margin

inspection

• Resection of

additional tissue if

necessary

Ink

Normal Breast Tissue

Tumor

Lumpectomy Technique Intraoperative Margin Assessment

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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 -


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


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


• 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


Conclusions


• 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

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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

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A Recently Observed Trend: Increase in the Incidence of

Contralateral Prophylactic Mastectomy

Tuttle et al: J Clin Oncol 2007

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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

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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

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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

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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

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Special Circumstances in Breast Cancer Primary Surgery

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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

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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

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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

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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

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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

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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

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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

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• 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

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How Do Tumors Shrink in Response to NC?

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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

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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

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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

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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

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• 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;

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• 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


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;

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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


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• 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


• 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


Primary Surgical Considerationse-syllabus.gotoper.com/_media/_pdf/SOBO14_Module3_1630_Mamounas... · Core Needle Biopsy •Advantages: •Differentiates between invasive and non-invasive

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