Localisation and staging of early stage breast cancer

Abstract

The majority of breast cancers are treated with breast conserving treatment (BCT). A substantial proportion of breast cancers is non-palpable, creating the need for accurate localisation tools. Wire guided localisation (WGL) is the standard technique for localisation of non-palpable breast lesions. WGL has proven to be a rather accurate and very useful localisation tool, however it is associated with several shortcomings. Radio guided occult lesion localisation (ROLL) was introduced as a promising alternative for WGL. Here, an intra-tumoural injection of radioactive tracer is used to localise the lesion with a gamma probe during surgery. ROLL offers the opportunity to combine the localisation of the primary tumour with the sentinel node procedure (SNP), since the intra-tumoural injection can be used for both lymphatic mapping and SNP. In a multicenter randomised controlled trial we compared wire guided localisation with radioguided occult lesion localisation (ROLL) and showed that ROLL is comparable to wire-guided localisation in terms of complete tumour excision (86% vs. 88%) and re-excision rates (12% vs. 10%). ROLL however, leads to excision of larger tissue volumes. Assessment of the secondary endpoints including ease of the procedure, patient comfort, success rate of the sentinel node procedure and cosmetic outcome did not reveal any differences between the two techniques. Moreover, ROLL was found to be comparable to WGL with respect to both costs and quality of life effects and will therefore not lead to more cost-effective medical care. Based upon these findings it was concluded that ROLL cannot replace WGL as the standard of care. The second part of the thesis focuses on staging of early stage breast cancer. The sentinel node procedure is the standard procedure for assessment of the lymph node status in women with early stage breast cancer. We demonstrated that intra/peri-tumoural injection of the dual tracer is associated with a higher risk of unsuccessful SNB procedure and unplanned ALND among patients with non-palpable breast cancer when compared to peri-areolar injection. We also evaluated the impact of routinely performed internal mammary chain sentinel node biopsy on systemic and locoregional treatment plan in 493 patients and found that IMC biopsy did not affect systemic treatment in any of the 493 patients, Radiotherapy was altered in 11% of the patients, however, evidence for the added value of IMC radiotherapy is scarce. Finally, we evaluated the impact of expert pathology reading of non-palpable breast specimens treatment strategy and found that expert reading would have altered locoregional and/or systemic treatment strategies in 8% of the patients