张瑾(英文)：癌症功能性手术技术热点分析

HotpotsAnalysisonBreastCancerFunctionalSurgicalTechniquesJinZhangTianjinMedicalUniversityCancerInstitute&HospitalPeople’sRepublicofChinaTianjinBreastCancerPrevention,TreatmentandResearchCenterContentsInfluencingfactorsforearlybreastcancersurgicalmannerschoiceBreast-conservingtherapySurgicaltreatmentafterneo-adjuvantchemotherapyDevelopmentofChinaBreastSurgeryYearsDoctorEvents1933Director：JinXianzhaiOncologyDepartmentofPekingUnionMedicalCollegeHospitalwasfounded1940JinXianzhaiSurgerytherapybeganperformedonbreastcancerinChian，afterwards,OncologyDepartmentwasfoundedinTianjin1957JinXianzhai,ZhangTianze,JinJiaruiet.alRadicalmastectomytogetherwithlymphnodeinbreasttissueexcisionwasperformed.ChinaSurgeryJournal5（6）：443-4551962JinXianzhai

,LiYueyunet.al10citiesinChina（Beijing、Tianjin、Shanghai、Guangzhou、Qingdao、Hangzhou、Wuhai、Changchun、ShiJiazhuang、Lanzhou）multicenters2573radicalmastectomyandextendedradicalmastectomy，3-yeartumorfreerate（56.2%:64.4%)——PublishedonChinaMedicalJournal(Englishedition)1972JinXianzhai、LiShulinget.alFirstDepartmentofbreastcancerofChinawasfoundedinTianjinMedicalUniversityCancerHospital1974WangDeyuanet.al843extendedradicalmastectomywereperformedthroughoutthecountry1982ShenZhenzhouet.al1091

inShanghaiCancerHospital,10-yearsurvivalwasbetterthanradicalmastectomy1984JinXianzhaiThefistChinaInternationalBreastCancerConferencewasheldinTianjin,meanwhile,ChinaAnti-CancerAssociation(CACA)wasproposedtobefounded.1985ChinaAnti-CancerAssociation(CACA)wasfounded.JinXianzhaiwaselectedashonorarypresident。Chinabreastsurgerymovingtowardglobal

Prof.Jinattendedtheworldanti-canceracademicconferenceheldin1962inRussiaandmadeareportof《Effectcomparisonbetweenradicalmastectomyandextendedradicalmastectomy》

1867

18941948BillrothHalstedMargottini

Meyer

Urbanlocalexcisionwithoutanexthesia

likenesswholeradicalmastectomy

extendedradical

mastectomy

3yearsurvival5％

5yearsurvival30%5

yearsurvival40%195119691990AuchinclossRissanen

PateyStage0IIbreastcancerinTianjinmedicaluniversitycancerhospital

ModifiedradicalmastectomyBreastconservingsurgery

Breastconservingsurgery

5yearsurvival50%5yearsurvival79%5yearsurvival92%BreastsurgerydevelopmentbreastexcisionTumorburdenplaysthedecisiveroleinbreastcancerlocaltherapy2015resultfromdiseaseburdenattention：WiththeMRI

examinationincreased,therateofbenigntumorbiopsyandmastectomyincreased,andtheextentofoperationenlarged，whereas,benefitswasnotideal.

YoungpatientsTNBCandBRCAmutantpatients

InfluencingfactorsforearlybreastcancersurgicalmannerschoiceInfluencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatientsWhetherageisanindependentfactor，orreflectsbiologicalbehavioronly？HER2+BreastcancerTNBCInfluencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatientsLuminal

typeInfluencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatientsEffectivesystemtreatmentsignificantlyinfluencedtheroleofageinHER2+breastcancerpatientsprognosis.AgedidnotinfluenceTNBCpatientsprognosis.ThereisstillapotentialdifferencesbetweendifferentageinLuminalbreastcancerpatientsDuringpresenteffectivesystemtreatment:Areyoungbreast-conservingsurgerypatientslikelytorecur?Foryoungbreastcancerpatients,whetherradicalmastectomyissuperiortobreast–conservingsurgery?Influencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatientsOnlysurgicalmarginpositiveincreasedthelocalrecurrencerate：HR2.89;95%CI,1.42-6.22，P=0.0004Netherlandstrail：Age≤40

yearsSystemtreatmentreducedthelocalrecurrenceofyoungbreastcancerpatientsInfluencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatients≤35yearspatients，differentsurgicalmannersdidnotinfluenceRFS

andOSInfluencingfactorsforearlybreastcancersurgicalmannerschoice---youngpatientsNon-TNBCVSTNBC:Meta-analysisfrom15researches*notrastuzumabadjuvanttreatmentInfluencingfactorsforearlybreastcancersurgicalmannerschoice---TNBCandBRCAmutantpatients

Influencingfactorsforearlybreastcancersurgicalmannerschoice---TNBCandBRCAmutantpatients

ContralateralbreastcancerrisksofBRCAmutantpatientsindifferentageInfluencingfactorsforearlybreastcancersurgicalmannerschoice---TNBCandBRCAmutantpatients

Contralateralmastectomy（CPM）andsurvival？Influencingfactorsforearlybreastcancersurgicalmannerschoice---TNBCandBRCAmutantpatients

BRCA1associatedyoungbreastcancerpatientswhoreceivedlargeextentoperation

(includingCPMandBPO)arelikelytoobtainabenefit.NoevidencetosupportthatmastectomyorcontralateralmastectomycouldimprovesurvivalofyoungorTNBCpatientswithsystemtreatment.BRCA

mutantpatientssurgicalstrategydecisionRiskofbreastcancerrecurrenceRiskofcontralateralbreastcancerrecurrenceInfluencingfactorsforearlybreastcancersurgicalmannerschoice---SummaryBreast-conservingtherapy1.EarlyBCsconservingsurgeryvs.radicalmastectomy，10

year

follow-up（S3-05）2.Breast-conservingsurgeryandlocalrecurrences3.ImportanceofBreast-conservingsurgeryresectionmarginbreadthandsecondaryresectioninEarlyBCs(S2-01)

4.EvaluationoftherecurrenceriskpredictionofDCIS

scoreapplicationtoDCISconservingsurgery.5.Breast-conservingsurgeryofmulti-sites/multi-centersdisease.Methonds：37,207

diagnosisedearlybreastcancerpatientswereenrolledduringyear2000-2004(T1-2N0-1M0)Objective：Tocomparethe10yearOSandDMFSbetweenBCT+RadiatontherapyandMASTinearlyBCs.

EarlyBCsconservingsurgeryvs.radicalmastectomyResult：58.4%patientsreceivedBCT,andtherelativeriskofdeathisabout20%duringfollow-up，RelativeriskislowerinBCTgroup(HR0.81,P＜0.001).Conclution：10yearOSinBCTgroupwassuperiortothatinMASTgroup（76.8%vs59.7%）.10

yearDFS：Thestudyfurtheranalysedthesubgroupdataof7552patientsdiagnosisedin2003andmeanwhilebaselinesimilartotheentiretygroup

inordertoevaluatethe10yearDMFS.Result：10yearDMFSofBCTgroupwassuperiortothatofMASTgroup（83.6%vs81.5%），thoughtherewasnosignificantdifference（P=0.07），thedatapartlyindicatedthatlocarecurrenceanddistantmetastasisrateswaslowinBCTgroup.Andthefurtheranalysisfound：In

T1N0

subgroup,10

yearDMFS

ofBCTwassignificantlysuperiortoMAST（P=0.014)

EarlyBCsconservingsurgeryvs.radicalmastectomyLimitations：1.Therewerenomatchingandcorrectingdataofsystemadjuvanttherapy、HER2

levelsandotherconcomitantdiseases；2.TheBCTpatientswereyounger,andmostofthetumorsweresmallandsingle.3.

Patientswithhighsocioeconomicstatus

arelikelytoacceptBCT，andtheyusuallywereabletoreceivesystemadjuvanttherapyandregularreexamination.Althoughtheabovingresearchevidencelevelisgeneral,andwithsomanylimitations,

suchalarge,retrospectivestudyatleastdemonstratedtheeffiacyofBCT.Thedifferenceofendpointslikesurvivalmayattributetothefunctionofradiotherapyinthetreatment.

EarlyBCsconservingsurgeryvs.radicalmastectomyBCT:breastconservingtreatmentBC:breastcancerBCTandMastectomycompletedinTianjininrecentyearsThepercentofBCTinTianjinismorethan20%(China:10%onaverage).Therewerenostatisticaldifferencesinrecurrencerate(6.4%vs.6.2%)andsurvivalrate(93.6%vs.93.8%)amongpatientstreatedwithBCTandmastectomy.Allthebreastcancerpatientsreceivedmammographyandultrasoundexaminationbeforeoperations,however,only32.8%patientsreceivedMRIexamination(83.4%forBCTand18.2%forMastectomy).Operationtype201020122014TotalNo.(%)Recurrence(%)5-yearDFS(%)TotalNo.(%)TotalNo.(%)MRIexaminationBCT545(21.9%)35(6.4%)480(93.6%)787(20.6%)1172(22.4%)977(83.4%)Mastectomy1943(78.1%)121(6.2%)1754(93.8%)3054(79.4%)4064(77.6%)741(18.2%)BCoperations2488

156(6.3%)2234(93.7%）384152361718(32.8%)Breast-conservingsurgeryandlocalrecurrencesLRR53

randomizedphaseIIIclinicaltrailresults，including86,598

patients1990—2011，LRRwasreducedfrom30%to15%（P＜0.001）优化的全身治疗降低了局部复发Breast-conservingsurgeryandlocalrecurrences——

localrecurrenceofdifferentmoleculartypesstageT1mic,T1a,T1bbreastcancerBreast-conservingsurgeryandlocalrecurrences——

Non-TNBC

vs

TNBCLoweryAJ,BrCaResTreat2012;133:831BCTn=7174Mastectomyn=5418RR,0.4995%CI,0.33-0.73P=.0005RR,0.6695%CI,0.53-0.83P=.0003Conclusion：TherewasdifferenceoflocalrecurrencerateafterBCTindifferentmoleculartypes,recurrencerateofNon-TNBCwashalfofTNBC。Breast-conservingsurgeryandlocalrecurrences——

Whetherlargerresectionmarginisbetter

inTNBC?LocalrecurrencerateofbothResection≤2mmgroupand＞2mm

groupwerelessthan5%，therewasnodifferences.Breast-conservingsurgeryandlocalrecurrencesBreast-conservingsurgeryandlocalrecurrences—

Consistentconclusions:Negativeresectionmargin（nocancercellinstainingsite）couldachievetheminimalrecurrenceriskinatypicalbreastcancer.Morewidelyresectionmargin

couldnotsignificantlyreduceaboverisk.Regularpracticetoachievelargenegativeresectionmargin

wasnotadvocatedArguments：TherewerenoevidenceofresectionagainhavenobenefitstopatientswithnegativeresectionmarginConsideringtherewasknownandseriously

residualtumorburdenassociatedhighriskfactorsinindividuals

TumorslargelyadjacenttoresectionmarginHistologypresentedasdiscontinuousgrowth：lobularcarcinoma,extensiveintraductalcomponent

ImportanceofBreast-conservingsurgeryresectionmarginbreadthandsecondaryresectioninEarlyBCsMethonds：11,900,aged18-75

year,unilateralinvasiveBCspatientswereenrolledduringyear2000-2009.Objective：1、Resectionmarginwidethandatypicallocalrecurrence

2、InfluencingfactorsforresidualfocusafterresectionagainResults：1.Atypical5yearrecurrencewas

2.4%,9yearrecurrenceriskwas5.9%inentiregroup；2.Comparedwith＞1mmresectionmarginwideth，0-1mmresectionmarginwidethrecurrenceriskwasincreased1.4-2.5times，however,therewasnostatisticalsignificance；

ImportanceofBreast-conservingsurgeryresectionmarginbreadthandsecondaryresectioninEarlyBCsResults：

3、Recurrenceriskofpatietnsyoungerthan40withpositiveresectionmarginresectedagainandlymphnodemestastasiswassignificantlyincreasd,subsequentchemotherapyandendocrinetherapycouldreducerecurrencerisk.4、Localrecurrencerateofpatientswithhighhistologicstagemightbehigh，localintensiveradiotherapycouldreducerecurrencerate。

ImportanceofBreast-conservingsurgeryresectionmarginbreadthandsecondaryresectioninEarlyBCsResults：5、Ofentiregroup，11%ofBCTpatientsreceivedoperationagain，6%ofMASTpatientsreceivedoperationagain.6、20%patientswithre-operationhadrediualtumor,ofwhich23%wasinvasivecancer63%wasDCIS14%bothhadinvasivecancerandDCISResults：7.Localrecurrencerateofpatientswithresidualtumorafterre-operationwassignificantlyincreased，however,therewasnodifferenceinoveralsurvivalResults：Positiveresectionmarginincreasedrecurrencerate；

Widerthan1mmresectionmargindidnotimprovedrecurrencerisk；

Recurrenceriskofpositiveresectionmarginafterre-excisionwasincreased，however,itdidnotinfluenceOS.ImportanceofBreast-conservingsurgeryresectionmarginbreadthandsecondaryresectioninEarlyBCs4.Alargeprospectivestudy：Evaluationoftherecurrenceriskprediction

ofDCISscoreapplicationtoDCISconservingsurgery

EileenRakovitchetal.2014

SABCS

S5-4OncotypeDXductalcarcinomainsitu

(DCIS)riskscore：DCISBCTrecurrenceriskprediction.OncotypeDCISscore12enrolledgenesPrimaryendpointsEvaluationwhetherDCIS

riskscorecouldbeusedtopredictlocalrecurrenceriskofDCISpatientsreceivedBCTonlySecondaryendpointsEvaluationthecorrelationbetweenDCIS

riskscoreandlocalinvasiverecurrence，localDCISrecurrenceEvaluationDCIS

riskscorewhethercouldbeanindependentpredictorstocorrectclinical/pathologicfactorsPopulationenrollmentDCIS

patientsdiagnosisduringyear1994-2003,whoreceivedBCTaloneandtheresectionmarginwasnegative，Studydesign*Medianfollow-up9.6

years*LRwasdefinedas：DCISrecurrencemorethan6monthsafterDCISdiagnosis，orinvasivebreastcancerrecurrences.Results

EileenRakovitchetal.2014

SABCS

S5-44.Alargeprospectivestudy：Evaluationoftherecurrenceriskprediction

ofDCISscoreapplicationtoDCISconservingsurgery10yearfollow-upKManalysis

EileenRakovitchetal.2014

SABCS

S5-44.Alargeprospectivestudy：Evaluationoftherecurrenceriskprediction

ofDCISscoreapplicationtoDCISconservingsurgeryDCISriskscorewascorrelatedwithlocalandlocalinvasiverecurrenceinDCISpatientsreceivedBCTonly.DCISriskscorecouldprovideDCISriskhierarchy，andprovideindividualrecurrenceriskevaluationtopatientsreceivedBCT.BeconducivetoDCIStreatmentadministration：HelpdoctorsandpatientstoevaluatebenefitoftherapyReduceintensivetherapyoflowrecurrenceriskpatientsScreening

patientswithhighrecurrenceriskWillfurtheranalysisDCISriskscorepredictionvaleinBCTandradiotherapypatientsSummary

EileenRakovitchetal.2014

SABCS

S5-44.Alargeprospectivestudy：Evaluationoftherecurrenceriskprediction

ofDCISscoreapplicationtoDCISconservingsurgery5.Breast-conservingsurgeryofmulti-sites/multi-centersdiseaseTraditionalconsidering：Multifocal(MF)andMulticentri(MC)breastcanceristherelativecontraindicationforBCT.However，withtheMRIapplication，about19%BCspatientswerefoundhavingsecondatypicalmalignantfocus.MRI

applicationwascorrelatedwiththeincreasedrateofmastectomyAndthecauseswasassociatedwithincreaseddetectionrateofthemulti-sites/multi-centersdiseaseIsthereanyevidencetosupport：Multi-sites/multi-centersdiseasewerecorrelatedwithpoorPFSandOS.Whethermulti-sites/multi-centersdiseasepatients

receivedBCTwerecorrelatedwithrelativehighlocalrecurrencerate.5.Breast-conservingsurgeryofmulti-sites/multi-centersdiseaseMF/MCVSsinglefocus5.Breast-conservingsurgeryofmulti-sites/multi-centersdiseaseMF/MCVS

singlefocusMulti-sites/multi-centersdiseaseseemedpoorinprognosis；However，therewerenoresearchaboutheterogeneity，whichlimitedthehelpfulstrategymakingtoreducerisk;Needtofurtherstudytheindependentprognosisfactorsformulti-focaldiseases.5.Breast-conservingsurgeryofmulti-sites/multi-centersdiseaseLessmulti-sites/multi-centerspatientsreceivedBCTMostlywere：50—69yearspatients,noDCIS,smalltumor5.Breast-conservingsurgeryofmulti-sites/multi-centersdiseaseConclusion：BCTcouldbeachoiceforpatientswithmulti-sites/multi-centersdisease，especiallyfor50-69yearsoldpatients，tumorlessthan1cm，andpatientswithoutextensiveintraductalcarcinoma.5.Breast-conservingsurgeryofmulti-sites/multi-centersdisease268stageI–IIbreastcancerpatientstreatedwithBCTinTianjinCancerHospital,fromJanuary2005toJanuary2007.LiJJ.eal.CancerEpidemiology36(2012)89–93Breastcancerpatients’socioeconomicstatus,ratherthantheirclinicalcondition,isthepredominantfactorindeterminingwhetherabreastcancerpatientreceivesBCTornot.BCTinfluencingfactorsanalysis：evidencefromTianjin

ContentsPart3Optimizationbreastcanceraxillarytherapy1.AdministrationonpatientsofClinicalALNandSLN.

2.FeasibilityofSLNBafterneo-adjuvanttherapy.

(1）DevelopmentofSLNBconceptSentinellymphnodesbiopsy（SLNB）isthekeymilestoneofbreastcancersurgicalindustryinninetiesof20thcentury，whichavoidtheaxillarylymphnodedissection,reduceoperativecomplications,andincreasdpatientsquantityoflifeofearlyandnonegativeaxillarypatients.

ALargeClnicaltrial，statusofSLNBwereabletoreflectthemetastasisofaxillarylymphnodes

1.AdministrationonpatientsofClinicalALNandSLN.1.AdministrationonpatientsofClinicalALNand

SLN.(2）Administrationofaxillarynodenegativeandsentinelnode

negativepatients.Conclution：ExcessiveaxillarynodedissectionneitherresultinbenefitsofOSandDFS,norincreaselocalcontrolrate。Therefore，forearlyBCspatietnswithoutclinicaldiagnosisedaxillarynode(cN0)

，sentinelnodedissectioncouldnotbeperformedasconsensusifsentinelnodebiopsynegative.。NSABP-B32KragDetal:LancetOncology20071.AdministrationonpatientsofClinicalALNandSLN.（3）ClinicalimportanceofSLNwithoccultmetastasesWeaverDetal:NEnglJMed2011NSABP-B32:Occultmetastasesisanindependentprognosisfactorforclinicalnodenegativebreastcancerpatients.WeaverDetal:NEnglJMed2011（4）Administrationofaxillarynodenegativebutsentinelnode

posititvepatients.ACOSOGZ0011Objective：ComparisonprognosisofSLNB＋andALNBpatients,whowerestagedcT1-2N0M0andSLNBnegative(nodes≤2）.1.AdministrationonpatientsofClinicalALNandSLN.（4）Administrationofaxillarynodenegativebutsentinelnode

posititvepatients.IBCSG23-01Objective：Todeterminewhethernoaxillarydissectionwasnon-inferiortoaxillarydissectioninpatientswithoneormoremicrometastatic(＞0.2mm,≤2mm)sentinelnodes.Results：

Afteramedianfollow-upof5years,therewasnodifferenceofprimaryendpointofDFSbetweentwogroups，thereforethisstudyachievedthestandardofnon-inferiori(HR≤1.25)

Besides，theOSweresamebetweenthetwogroups，97.5%inobservationgroup，and97.6%inALNBgroup.Meanwhilerecurrenceofaxillarynodeislow，1.1%inobservationgroup，and0.2%inALNBgroup.GalimbertlVetcal:LancetOncol20131.AdministrationonpatientsofClinicalALNandSLN1.AdministrationonpatientsofClinicalALNandSLN.（4）Administrationofaxillarynodenegativebutsentinelnodeposititvepatients.AMAROSMethonds：PatientswithT1～2N0M0breastcancers，andthenumberofSLNBlessthan2wereenrolledinthestudy,receivedaxillaryradiationtherapyorALND.Result：Theeffectofthetwogroupwassimilar,therewaslessadversereactionsinaxillaryradiotherapygroup,Lymphoedemarateandcomplicationswaslowerandless.Conclution：AxillaryradiotherapycouldreplaceALNDinAMAROStrailenrollmentpatients.DonkerMetal:LancetOncol20142.FeasibilityofSLNBafterneo-adjuvanttherapyRelativecontraindicationofSNBinconventionalsenseChangeofNCCNguidelinesonbreastcancerneo-adjuvantchemotherapy

2013vs.2015Difference20132015PreparationbeforetreatmentBiopsypathologicdetectionmustbeperformedtoconfirmwhetherswollenregionallymphnodewasbreastcancermetastasisIfpositive，noneedtoSLNBIfnegative，SLNBcouldbeperformedbeforeNACBiopsypathologicdetectionshouldbeperformedtoconfirmwhetherswollenregionallymphnodewasbreastcancermetastasis