OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer

, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, shed light on clinical outcomes following surgery of the primary tumor in patients with stage IV breast cancer.

 Before we close out, I have one final question for you. Do you mind expanding on the clinical outcomes after surgery of the primary tumor in stage IV disease?

 This is a topic that does come up quite frequently at our multidisciplinary tumor board and other discussions that we have. I will discuss the data regarding surgical removal of the primary tumor in patients with proven metastatic disease.

A prospective randomized study is probably the one that is most well-known and most quoted. Basically, this was a study that was performed by Atilla Soran, MD, MPH, FACS, in Turkey, and it found that there was a benefit in 5-year survival of [patients with] stage IV breast cancer who were treated with resection of the primary tumor. In contrast, an American Registry study did not demonstrate improved survival. Our practice is to individualize the treatment. As Dr Lopez-Peńalver mentioned earlier, most commonly we perform surgery on patients in this setting when we need to achieve local control and palliation.

Also, of great importance is the ability to work together with our reconstructive surgeons because, at times, these masses can be quite large, ulcerated, and fungated and take up a majority of the breast itself and the chest wall. An adequate excision would require, again, tissue rearrangements, sometimes skin grafting or flaps, to allow for closure. I would also like to add that it is very important in our discussions with the patients, their families, and our colleagues in other specialties, that this surgery is not going to be performed for cure. These patients are going to undergo surgery so that we may improve their quality of life. Often, this will then be followed—if allowed by the patient’s medical condition and if appropriate—[by] radiation therapy to further palliate their symptoms and to decrease the risk that we may have recurrence of that local disease in spite of their metastatic disease. As long as we know what our goals are, we can achieve outcomes that are satisfactory, both to the patient and family and to the medical team.

It has been a pleasure to speak with you, Dr Lopez-Peñalver, about the treatment of [patients with] stage III and IV breast cancer. Thank you for your time, and thank you to the audience for tuning in, as well.

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In this final episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, shed light on clinical outcomes following surgery of the primary tumor in patients with stage IV breast cancer.

Reviewing Best Practices in the Surgical Management of Breast Cancer: Post-Surgery Outcomes in Stage IV Disease 

, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, discuss how to appropriately manage patients with stage IV breast cancer and outline when surgical approaches may be appropriate for this population.

 [Patients with] stage IV breast cancer are not typically surgical candidates. Could you expand on the management of [these] patients, including when surgery may be appropriate?

Sure. Well, let me just start out by saying that systemic therapy is the main treatment for metastatic breast cancer but local management of the primary tumor in the breast or a metastatic site may palliate symptoms, improve progression-free survival, and prevent complications.

So, let’s start with the local management of the primary tumor. The primary role of local treatment in this setting is palliation and management of symptoms, primarily with locally advanced breast cancers where the tumors are bulky and can ulcerate, bleed, cause pain, or even become infected. For patients whose primary tumor in the breast is asymptomatic, surgery and/or radiation therapy are not really considered the standard of care [SOC] because there’s no effect on systemic disease and really no clear evidence that it prolongs survival. There are exceptions to this, with surgery of the primary tumor being offered to a select group of patients with oligometastatic disease or low-volume disease, who have had a good response to systemic therapy, and also to those whose metastatic disease is well controlled with their therapy, but the primary site is progressing. There have been 4 prospective randomized trials that looked at survival after surgery of the primary tumor, and 3 of these did not show any statistical significance in overall survival.

Now, moving on to the local management of metastasis. Again, systemic therapy is the SOC, and the goal of therapy is palliation. However, local treatment with surgery or radiation is indicated in some patients who have, for example, intractable bone pain in spite of their systemic therapy. These patients are candidates for radiation, and also, in medical emergencies such as spinal cord compression, a mass effect due to a brain metastasis, and impending or present pathologic fracture due to bone metastases. Patients with asymptomatic central nervous system metastasis can have local therapy with surgical resection, stereotactic radiosurgery, or even whole-brain radiation therapy—especially if they have a good performance status if they have oligometastatic disease or less than 3 sites of disease, a long disease-free interval, and a high likelihood of completely resecting the metastasis since positive margins have been associated with worse outcomes.

In terms of lung metastasis, asymptomatic metastasis usually does not require any local intervention unless we are dealing with an undiagnosed lung nodule, and an excision of that lung nodule is used for diagnosis. Symptomatic metastasis may be treated with resection or with radiation therapy. Finally, the local management of liver metastases is indicated for those lesions that bleed [or] cause pain or biliary obstruction, and they can be treated with surgical resection with stereotactic body radiation therapy or even with radiofrequency ablation for tumors that are less than 3 centimeters.

So, thank you, Dr Giron, for that question, because as surgeons, we use local therapy of metastatic sites to eliminate disease and palliate patients.

Check back on Tuesday for the final episode in the series.

In this fourth episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, discuss how to appropriately manage patients with stage IV breast cancer and outline when surgical approaches may be appropriate for this population.

Reviewing Best Practices in the Surgical Management of Breast Cancer: Opportunities for Stage IV Disease 

, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, discuss key advancements made in the surgical treatment of patients with breast cancer.

As we’ve learned, advancements such as artificial intelligence and robotic surgery have transformed the landscape of the way we treat [patients with] cancer. Specific to breast cancer, Dr Giron, do you mind expanding on the key advancements in surgery for [these] patients?

Giron: Unfortunately, robotic surgery doesn’t play a role in our standard treatment for [patients with] breast cancer at this time. The use of artificial intelligence in the operating room for the surgical treatment of [these] patients is not quite a part of our standard of care. However, it certainly is part of and will expand its role in the radiologic diagnosis and detection of breast cancer and we do work very closely with our radiologists and our pathologists to work up our patients and eventually bring them to surgery.

[There are some] advancements that we have been able to witness during our time as medical students, residents, and then, in practice. In 1992, sentinel lymph node biopsies were performed and changed the landscape of axillary surgery—not just in [patients with] breast cancer, but in the management of other patients, such as those with melanoma. This procedure has allowed for less extensive axillary surgery in most [patients with] breast cancer. [Those with] stage III [disease] will often present with nodal metastatic disease, and therefore, move on to receive preoperative systemic therapy either chemotherapy or endocrine therapy. We want to be certain at the time of surgery that those lymph nodes are removed. One way to do that is to mark those lymph nodes, as you touched upon a bit earlier, Dr Lopez-Peñalver.

When we place radiologic clips, we cannot necessarily find those at the time of surgery and if we have the response that we desire, which is a decrease in the size of the lymph node, it may be difficult to find that particular lymph node at the time of our surgical intervention. So, the placement of markers that can later be tracked has really changed how we can manage those patients. We have the ability to use reflectors. We can use magnetic seeds or radioactive seeds that help us locate those lymph nodes to ensure that they are removed and that they are analyzed by the pathologist to give us an idea of what the response to treatment was, and therefore, guide treatment that is given by the medical oncologist and radiation oncologist after surgery.

Another area where we have seen a lot of advances that have had a great impact on the care of our patients is in that of oncoplastic techniques that can be used whether we operate on the patient up front or if we operate on them after neoadjuvant therapy. This allows for breast conservation in patients who, in the past, may not have been candidates for breast conservation; it improves cosmetic outcomes without compromising the care that the patient is receiving. Certainly, breast cancer reconstructive techniques have improved substantially for those who do require mastectomies.

Check back on Tuesday for the next episode in the series.

In this third episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, discuss key advancements made in the surgical treatment of patients with breast cancer.

Reviewing Best Practices in the Surgical Management of Breast Cancer: Key Advances 

, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, discuss the traditional surgical approaches that are utilized for patients with breast cancer and some of the challenges faced in those with later-stage disease.

With that background, Dr Giron, do you mind expanding on the traditional surgical approaches that we use in surgery to date?

Surgical options for [patients with] breast cancer really fall into 2 broad categories: breast conservation and mastectomy. For breast conservation, it consists of lumpectomies. In the appropriate patients, lumpectomy can also be coupled with oncoplastic procedures, meaning that we either work alone or with our reconstructive surgical colleagues to perform concomitant lifts, breast reductions, and tissue rearrangements, which would basically minimize post-operative deformity.

Mastectomies can be skin sparing, and in appropriate patients, they may be nipple sparing; [they] can also be performed with either immediate or delayed reconstruction. The reconstruction can consist of autologous tissue, flaps from usually the abdomen, or it can be tissue expander– and implant-based, with the latter being more common. For many [patients with] stage III breast cancer, as you touched upon earlier, we work closely with our medical oncologists to deliver preoperative chemotherapy, or sometimes preoperative endocrine therapy, to monitor response as well as to improve surgical outcomes. If we are able to [achieve] shrinkage of the disease, we are more likely to obtain negative surgical margins as well as minimize axillary surgery. Some [patients with] stage IV [disease] can also be surgical candidates, depending on their particular presentation, but we will discuss that a little bit further later.

Dr Lopez-Peñalver, could you share your insight regarding the surgical challenges [in the] treatment of [patients with] stage III and IV breast cancers?

Yes, that’s a great topic and one of much debate. So, 2 of the challenges in the surgical management of these patients that I would like to touch on [include] whether to reconstruct the breast after mastectomy [and] whether we can de-escalate surgical management in these patients who have had a good clinical response to neoadjuvant therapy.

So, let’s tackle the reconstruction issue first. Surgery for locally advanced breast cancer usually means a mastectomy, but locally advanced breast cancer has been considered a relative contraindication to immediate breast reconstruction with the type of reconstruction either implant-based or autologous tissue, and the timing of that reconstruction either immediate or delayed, a matter of debate. We know that these patients are at a higher risk of local recurrence and usually require radiation therapy for locoregional control, but this radiation therapy can contribute to things such as implant loss, capsular contracture, infection, fibrosis, and just generally, an undesirable cosmetic result. It has been shown that immediate breast reconstruction does not compromise survival or recurrence rates at any stage of breast cancer, but it can be associated with surgical complications that can delay adjuvant therapies, such as radiation. For example, some patients may develop an infection or necrosis of their skin that is treated with prolonged antibiotic therapy, and they may require surgical intervention to treat that complication, which can delay the start of that radiation therapy. However, with advances in our neoadjuvant therapies, carefully selected patients with locally advanced breast cancer who have had a great response to neoadjuvant chemotherapy may be considered candidates for safe implant-based immediate reconstruction.

Now, in terms of de-escalation strategies, let’s start with the breast. Some patients [with] stage III [disease] who were initially deemed unresectable or unsuitable for breast conservation and who have had a good clinical response to neoadjuvant chemotherapy may undergo breast conservation followed by whole breast radiation therapy. Then, when talking about axillary surgery in patients who were initially node-positive and converted to node-negative [status] after neoadjuvant therapy, they may be offered sentinel node biopsy, with the use of several techniques to lower the false-negative rate, such as dual mapping of the lymph node with radioisotope and blue dye, removing at least 3 lymph nodes, and/or performing a targeted axillary dissection to remove the clipped node.

Finally, I want to just mention and conclude by saying that sentinel lymph node biopsy is still contraindicated in patients with clinical T4 or N2/N3 disease because of their heavy disease burden and the lack of evidence showing that it’s accurate after neoadjuvant chemotherapy, but there are studies underway looking at this population.

Check back on Tuesday for the next episode in this series.

In this second episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, discuss the traditional surgical approaches that are utilized for patients with breast cancer and some of the challenges faced in those with later-stage disease.

Reviewing Best Practices in the Surgical Management of Breast Cancer: Traditional Approaches and Existing Challenges 

, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, explain how treatment approaches differ based on disease stage in patients with breast cancer.

Thank you for joining us. My name is Dr Gladys Giron, and I’m delighted to collaborate with my colleague, Dr Cristina Lopez-Peñalver, as we discuss current recommendations for the surgical treatment of [patients with] stage III and IV breast cancer. As I mentioned, my name is Dr Gladys Giron; I’m a breast surgical oncologist at the Miami Cancer Institute, part of Baptist Health South Florida. I’m joined today by Dr Cristina Lopez-Peñalver, my fellow breast surgical oncologist at the Miami Cancer Institute. We have a variety of topics to dive into, so without further ado, I’ll begin with the first question.

Dr Lopez-Peñalver, [could you] please provide us with a brief summary of what differentiates [patients with] stage III and IV breast cancer from those presenting with earlier stages of disease?

Thank you, Gladys. Stage III and IV breast cancers differ from other stages of breast cancer based on the extent of the disease or their anatomic classification, the so-called TNM categories, and also differ in how they are treated.

In terms of anatomic extent, when we talk about breast cancer, we like to divide it into nonmetastatic breast cancer and metastatic breast cancer. The nonmetastatic category can be further divided into early-stage disease and locally advanced disease. When we talk about early-stage disease, that includes stages I, IIA, and a subset of stage IIB disease, whereas when we talk about locally advanced breast cancer, that includes some stage IIB disease and stage III disease. Stage III disease really encompasses tumors that are 5 centimeters or less in size with matted lymph nodes, tumors that are over 5 centimeters in size with positive lymph nodes, any primary tumor that’s attached to the skin or to the chest wall, or a special type of breast cancer called inflammatory cancers. Then finally, [those with] the stage IV disease, or the metastatic cases, are those advanced cases where the breast cancer has spread beyond the breast to other organs such as the lung, the liver, and the bones.

In terms of management, these stages also differ. In general, patients with early-stage breast cancer undergo up-front surgery, or surgery first, with the surgical approach to the breast really being dictated by the size of the tumor and whether there is multifocal disease present. The surgery of the axilla, either a sentinel node biopsy or an axillary node dissection, [is] performed depending on whether there is clinical evidence of lymph node involvement. Breast-conserving surgery is usually followed by radiation and then all patients receive adjuvant systemic therapy based on their tumor characteristics and their receptor status.

In contrast, patients with locally advanced breast cancers usually require neoadjuvant systemic therapy prior to surgery to induce some kind of tumor response and downstage either the breast, the lymph nodes, or both, allowing for breast-conserving surgery and possibly sparing an axillary node dissection. Then, these patients go on to receive the appropriate adjuvant systemic therapy based on their receptor status and whether there is any residual disease after neoadjuvant therapy.

In this first episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, explain how treatment approaches differ based on disease stage in patients with breast cancer.

Cristina Lopez-Peñalver, MD

Articles

Reviewing Best Practices in the Surgical Management of Breast Cancer: Post-Surgery Outcomes in Stage IV Disease

Reviewing Best Practices in the Surgical Management of Breast Cancer: Opportunities for Stage IV Disease

Reviewing Best Practices in the Surgical Management of Breast Cancer: Key Advances

Reviewing Best Practices in the Surgical Management of Breast Cancer: Traditional Approaches and Existing Challenges

Reviewing Best Practices in the Surgical Management of Breast Cancer: How Disease Stage Informs Treatment