Evolving Surgical Strategies in Breast Cancer

April 16, 2021

April 16, 2021 | Drs. Elizabeth Berger, Rachel Greenup, and Melanie Lynch

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00:00My name is metrical Shannon and welcome
00:02to the Yale Cancer Center Smilow Cancer
00:05Hospital breast Program CME lecture series.
00:08We're going to wait a few minutes
00:11to have allow people to log in and
00:14hopefully right at 12 or 1201 will start.
00:17I'll be introducing Doctor Elizabeth Berger,
00:20Doctor Melanie Lynch and
00:21Doctor Rachel Greenup.
00:23The format will be that they will
00:26be giving them three talks in a row
00:29and please put in as many questions
00:32as you like in the chat box.
00:35And we will do our best to have
00:38an interactive session at the end,
00:40answering those questions and we
00:41really look forward to hearing
00:43your perspectives as well.
02:43So, uh, good afternoon,
02:45my name is Macrogol Shannon.
02:47Welcome to the Yale Cancer Center,
02:50Smilow Cancer Hospital breast
02:53program CME lecture series.
02:56Hopefully people will be
02:58continuing to log in.
02:59We really appreciate those of our
03:02colleagues here in Connecticut and it.
03:05Yeah, and especially our
03:06counterparts around the world.
03:08I see my colleagues from China from Japan,
03:12Turkey, South Korea and other places as well.
03:15So welcome, we're going to have three
03:18fantastic lectures of this afternoon.
03:20We'll start with Doctor Elizabeth Berger,
03:23who's assistant professor of surgery.
03:26Here at the Yale Cancer Center,
03:28Yale Department of Surgery discussing
03:30updates and surgical management of our
03:32best of our breast cancer patients.
03:34Then it will be followed
03:36by Doctor Melanie Lynch,
03:37who is the director of Our Breast program
03:40and breast Surgery at Bridgeport Hospital.
03:43Talking about Uncle plastic
03:44breast conservation,
03:45an finally least,
03:46but not finally at last but not
03:48least will be Doctor Rachel Greenup,
03:51our section Chief for El surgery,
03:53discussing young women with breast
03:55cancer surgical perspective.
03:56Please put in as many questions as
03:58you like into the chat box will do
04:00our best at the end to go through
04:03your questions and hopefully have an
04:05interactive dialogue as much as possible.
04:07The nice thing is that this is going
04:09to be recorded so you can go back and
04:12watch or listen or certainly forward
04:14it to colleagues and friends or around
04:17the country and around the world.
04:19And this is the first of a three part series.
04:22Our next one will be May 27th.
04:25Will have Doctor Maryam Lustberg who's
04:28our incoming breast program director,
04:30speak along with Doctor Michael D
04:32Geovanna and Doctor Andrew Silver,
04:34so with no further ado,
04:36Doctor Elizabeth Berger, the podium is yours.
04:39Thank you Doctor Wilson
04:41for that introduction.
04:51Good morning I guess.
04:53Not good morning.
04:54Good afternoon everyone.
04:55My name is Elizabeth as Doctor Wilson
04:58mentioned and I'm a new assistant
05:00professor here at Yale and hopefully
05:02in the next 15 to 20 minutes.
05:04I'll be just reviewing some
05:06updates and breast cancer surgery.
05:08In kind of the 21st,
05:10if not the most recent five year history,
05:12so I'm sure a lot of you have seen this meme
05:16on Twitter or other places in the Internet.
05:19Now, where, how has it started and
05:21where how's it going so you know,
05:23I'm sure we all know it started back with
05:26really William Halsted in the late 1800s,
05:28thinking that breast cancer was,
05:30you know,
05:30kind of locally advanced disease,
05:32and so the whole side,
05:34mastectomy became kind of a routine
05:36operation for women where there was
05:38a removal of the PEC major muscle,
05:40the PEC minor muscle.
05:41Breast, all the lymph nodes and in fact,
05:44Interestingly,
05:45the removal of the muscle was felt
05:47because anatomically it was felt
05:49that doing a level 1-2 and three
05:51X axillary lymph node dissection
05:53was not anatomically feasible
05:54without removing that muscle.
05:56We've made a lot of progress since
05:58then and now we think more about just
06:01lumpectomy's saving the breast tissue.
06:03Not having to do so much axillary surgery.
06:06Bernie Fisher,
06:07one of my favorite quotes from him.
06:09In God we trust all others must have data.
06:12It was really revolutionary in our country,
06:15especially thinking about how we can
06:18start to deescalate surgical care and
06:21all care in breast cancer with similar
06:23oncologic outcomes for our patients.
06:26So in thinking about the
06:28deescalation of Breast Cancer Care.
06:30The Italians very easy were
06:33instrumental in thinking about
06:34how we can compare quadrant,
06:37ectomy and radiation to really
06:39this idea about Halsted mastectomy
06:42and so they conducted a well
06:44done study in the 1970s.
06:46Bernie Fisher in Petsburgh
06:48conducted the B6 trial looking
06:50at the total mastectomy versus.
06:55Lumpectomy with radiation.
06:56We then moved into the 1990s
06:59where we started thinking about
07:01deescalation of radiation therapy
07:03with the CLG trial with Kevin Hughes.
07:06Then Doctor Giuliano and a lot of
07:09other people looked at deescalation
07:11of axillary surgery in the 19
07:14late 1990s and early 2000s.
07:16With this 11 trial.
07:20Moving forward,
07:20we then thought about maybe there
07:22are even options to deescalate
07:24chemotherapy for some of our patients,
07:26especially in the ER PR positive
07:29cohorts with the tailor X trial.
07:32And now on going even there are multiple
07:35trials actually throughout the world,
07:37the common trials actually in the
07:40United States looking at deescalation
07:42of surgery and surveillance
07:44only for some subsets of DCIS.
07:47So we even now are talking about
07:50maybe we can actually eliminate
07:52surgery altogether with some patients.
07:56There are ongoing trials looking
07:58at excellent responders,
08:00and so these excellent responders
08:02are considered women who,
08:04after neoadjuvant chemotherapy,
08:06no longer have any residual radiologic
08:09findings of cancer in their breasts.
08:12All four actually of these trials are
08:15three main ones throughout the world.
08:17Again,
08:18have looked at can we buy Oxy
08:21these now radiologic?
08:23Areas where there is no longer
08:25cancer and maybe even avoid
08:27surgery on some of these patients,
08:29but the data is still pretty raw
08:31considering that in all these trials
08:33we still found a false negative rates
08:36very high and the thought is is
08:38that they did some subgroup analysis
08:40and felt that the false negative
08:41rate was lowest amongst her two
08:43positive in triple negative disease.
08:45However,
08:45these are really the highest group risk
08:48patients as we know to miss disease
08:50because of the ongoing or because
08:52of the trials that we've looked at.
08:54With the addition of TDM wanan capeside,
08:57it being the agent setting for her two
08:59positive season triple negative that
09:01improve overall and disease free survival.
09:03So although we might get to a point
09:06where if we have excellent responders
09:08and not have to perform surgery on them,
09:11I think that's still a
09:13little bit in the future.
09:16Alright,
09:16so if we have to do surgery on our patients
09:19then what are the really the updates?
09:22So I'm going to briefly touch on some
09:24of the GNU localization techniques that
09:27we're using for press conservation.
09:29What what our margin status and
09:31when should we re excited patients
09:33after they undergo surgery?
09:34Some ****** sparing discussions
09:36in terms of who is a candidate,
09:38the management of the XR on going
09:40discussions on going confusion
09:42about upfront surgical management,
09:44neoadjuvant therapy,
09:44and the surgical management of XR.
09:47A brief touch on stage four disease
09:49and in high risk lesions went to
09:52excise so wire localizations of breast
09:54lesions are has been very common
09:56across the country and many places
09:58actually are still using wires.
10:00However,
10:01we know that wires need to be
10:03placed the same day of surgery.
10:05There can be very challenging
10:07logistics with wires.
10:08They can lead to potential or
10:10delays of the wires placed in the
10:13morning and something happens
10:15and oftentimes they
10:16are gets delayed.
10:17These wires can get dislodge.
10:19They're often hanging outside
10:20of the women's breast,
10:21and so in travel and transport
10:23they can get dislodged.
10:24They can lead to larger
10:26lumpectomy specimens as well.
10:27Many patients complain of
10:28dissatisfaction being cold,
10:29being scared of having wires
10:31outside of their breasts,
10:32and then obviously, if the case were
10:34to get cancelled for any reason,
10:36those wires have to get replaced.
10:38They have to get removed and then replaced
10:40again if they have to come back for surgery.
10:43So what we've looked at then in
10:45how to localize, and this is just.
10:49A map from a study that was actually
10:51done looking at one institution's
10:53experience with wires and how many
10:56different touchpoints patients have
10:57when they actually have to get the
11:00wired on the same day of surgery,
11:02and as you can see,
11:04it's a mess of spaghetti if you will,
11:07because now what we are moving
11:09towards are what we call seeds.
11:12Seeds are a nice option for
11:14patients because they can get
11:15placed anytime before surgery.
11:17They aren't.
11:18They don't have to be placed
11:20the day of surgery.
11:21It completely decouples the
11:23scheduling of radiology and surgery,
11:24so that increases the flexibility
11:26with surgeon flexibility and
11:27with radiology flexibility,
11:28they've been shown in various different
11:31studies to minimize OR delays it allows.
11:33Obviously,
11:33for our first case start,
11:35the patient can get their seat placed
11:38a few days before and come in and still
11:41go to the operating room at 7:15 or 7.
11:4430 There have been data looking at that.
11:47They create smaller lumpectomy specimens
11:49and overall there's some reports
11:51on improved patient satisfaction.
11:53You know, they don't have to
11:55spend all day at the hospital.
11:58You know,
11:59they don't be NPO for so long,
12:02and they can get this done
12:04at their at their leisure.
12:06Kind of the previously to surgery.
12:11So in the Mount margins and how?
12:14How much is enough to take for breast tissue?
12:19One of our colleagues here,
12:21Doctor Moran,
12:22was instrumental in creating
12:24a consensus guideline study.
12:26An expert multidisciplinary panel.
12:28In looking at what should our
12:31margins before invasive disease,
12:33but also for DCIS and so there was a
12:37multi disciplinary panel convened.
12:40They looked at meta analysis of 33
12:42studies with over 28,000 patients,
12:45and in the invasive setting what they
12:47found was that no tumor on ink was
12:50a safe margin and that it did not
12:53increase its lateral breast tumor recurrence.
12:56If we truly had no tumor on ink,
13:00and the thought was that because of the
13:03systemic therapy after invasive disease,
13:05that this was a sufficient margin
13:07because of for the invasive disease.
13:10They asked the same question
13:12in the DCIS setting,
13:14So what we know about DCIS is that
13:17it often has skipped lesions.
13:20It's not just necessarily one
13:22focal mass and so,
13:23and we often don't give
13:25systemic therapy for DCIS,
13:27IE chemotherapy,
13:28so the thought was in looking at
13:31the analysis of over 30 studies
13:33for the DCIS panel with
13:35over 8000 patients with the
13:38thought was that 2 millimeters of.
13:40Margin was sufficient to reduce
13:42the risk of in breast recurrence.
13:45They did look at various margin widths.
13:475 millimeters, 1 centimeter and further
13:50margin with did not decrease in breast
13:52recurrence and so to this day we
13:55still use the 2 millimeter margin.
13:57With for pure DCIS in the breast,
14:00no tumor on ink for invasive.
14:04And our very own Doctor Tag power here
14:07at Yale and multiple others here at
14:10Yale did a randomized control trial
14:12looking at this principle of margins,
14:15which was published not so long ago in
14:17the New England Journal of Medicine.
14:20The thought was is so people
14:22do margin very differently.
14:24In breast surgery some people take
14:26margins off the actual specimen.
14:28Some do full shave margins
14:30within the cavity routinely.
14:32Some do select margins based
14:34upon what their image.
14:35What's their specimen?
14:36Looks like on the image radiograph
14:39and so this trial asked that very
14:42question about whether shave margins
14:44help with decreasing margin positive
14:46ITI they looked at 235 patients.
14:49They were randomized so they underwent a
14:51lumpectomy and then they were randomized
14:54to essentially no additional straight
14:56margins or routine shape margins.
14:58And as you can imagine,
15:00what they found was that in routine
15:03shape margins it reduced the margin.
15:06Margin positive ITI rate and the
15:08reexcision rate so less patients
15:10had to go back to the operating
15:12room for further re excisions less
15:15patients had positive margins.
15:17So if we're not doing breast conservation
15:19and we're thinking about mastectomies,
15:22what are some of the options
15:25for patients in mastectomies?
15:28We've now had a lot longer term data in
15:31looking at ****** sparing mastectomy's.
15:33The data is still relatively new.
15:35Consider all things considered,
15:36but a lot more longitudinal data
15:39that ****** sparing mastectomy's
15:40are safe for patients uncle.
15:42Logically,
15:42however there are definitely criteria
15:44that we consider when we think
15:47about performing a ****** sparing
15:48mastectomy conservatively I would
15:50say a lot of people still use the two
15:54centimeters that the cancer should be
15:562 centimeters away from the ******.
15:58Oftentimes we think about early stage
16:00breast cancer patients as appropriate.
16:03****** sparing mastectomy candidate.
16:04The idea of multi focal multi
16:06centric disease.
16:07Most people will stay away from offering
16:10a ****** sparing for those patients.
16:12And of course if they have any
16:14significant ptosis of the brassware,
16:17their cosmetic outcome wouldn't
16:18be inappropriate.
16:19Cosmetic outcome for ******
16:21sparing mastectomy.
16:22Prophylactic surgery is a great option
16:24for patients if they are undergoing
16:26prophylactic surgery for ****** sparing.
16:28Mastectomy is an I'll show you a
16:30trial looking at the Braca population
16:32and in ****** sparing's.
16:33Strong contraindications for ******
16:35sparing so any locally advanced or
16:37inflammatory breast cancer or we do
16:39not want to leave skin behind and so
16:42we would not offer our patients ******
16:44Springs for those types of cancers.
16:46Any kind of skin involvement and
16:48of course any kind of pathological
16:50radiologic involvement of the ******.
16:52Our clinical involvement of
16:53the ****** as well,
16:54and then we think about high
16:56risk patients for Noble Springs.
16:58Not that we wouldn't offer them
17:00if they're smokers or diabetics
17:01or a previous radiation,
17:03but we definitely counsel patients in
17:05terms of them having higher risk of
17:07****** necrosis with these risk factors.
17:10So looking at the Uncle Logic safety
17:13of prophylactic ****** sparing
17:15mastectomy in the Bracco population,
17:17about 550 patients were looked at in
17:20this JAMA study and found that there was
17:23no ipsilateral breast cancer recurrence
17:26in the risk reducing ****** sparing
17:28mastectomy group so it was deemed a
17:31safe technical procedure thinking also
17:34keeping in mind though that the median
17:37followups are still only 34 or 56 months.
17:40These are obviously getting more
17:42longitudinal as as time progress is,
17:44but overall you know.
17:46I think we all agree that ****** sparing's
17:49are safer genetic variant carriers.
17:52And then what about the contralateral
17:54prophylactic mastectomy conversation?
17:55You know?
17:56I think a lot of women come into
17:58clinic saying I want both of my
18:01breasts removed if I have cancer.
18:03I never want this coming back.
18:05I don't want it to spread from
18:08one breast to the other.
18:10We know breast cancer doesn't
18:11spread that way.
18:12We know that contralateral
18:14prophylactic mastectomy is actually
18:15not associated with a survival benefit.
18:17It's double the surgery.
18:19It's double the risk of complication.
18:21It's double the recovery time.
18:23It's definitely appropriate
18:24in for some women,
18:25and you know if the anxiety
18:27and the angst of having breast
18:29cancer is just too much for them.
18:31I think that's in completely appropriate
18:32reason to do a contralateral
18:34profiler prophylactic mastectomy,
18:35but I think making sure that the
18:38patients understand and have a have a
18:40good understanding of the data behind
18:42why they're choosing such a thing.
18:44There's also you know ****** dysfunction,
18:46psychological dysfunction with losing
18:47sensation of their entire chest,
18:48all things to think about,
18:50and to really encourage a shared
18:52decision making with your patience.
18:56So the surgical management
18:57of the XR has changed.
18:59I would argue drastically in the last
19:0220 years where we're obviously using
19:04a lot more neoadjuvant therapies.
19:06Now for our patients,
19:07targeted therapies for the her two
19:09positive patients were thinking more
19:11about immunotherapy for the triple
19:14negative breast cancer patients.
19:15So what we know is that in looking
19:18at Sentinel lymph node biopsy's,
19:20there are two ways to localize
19:23Sentinel lymph nodes.
19:24Blue dye.
19:25Whether it's methylene blue or
19:26I so flooring blue and then are
19:29usually a radioactive isotope,
19:30technetium is one of them.
19:34Some surgeons use both.
19:35Some surgeons just use one.
19:37We do know that in the upfront
19:39surgical setting the we find
19:41that the false negative rate of
19:43less than 10% is inappropriate.
19:44False negative rate for Sentinel,
19:46lymph node biopsy's and that single
19:48tracer is appropriate in the
19:50upfront surgical setting for that
19:51principle of false negative rate.
19:53I only show these pictures because
19:55I think it's helpful to really see
19:58what the gamma probe is that we use
20:00to find that radioactive isotope in the XR.
20:03The blue dye really does work.
20:05We find blue nodes.
20:06That are are representative of
20:08Sentinel lymph node and just
20:10the principle of the level one
20:12Level 2 and then going back to
20:14the beginning slide of the whole.
20:16So mastectomy.
20:16Really the Level 3 lymph nodes that
20:19are medial to the PEC minor muscle.
20:21So in the upfront setting.
20:24If we have clinically node negative patients,
20:27we can offer them a central lymph node
20:29biopsy if they have any clinically
20:32palpable adenopathy in the XR.
20:34Right now the the right answer is to
20:36do an actual lymph node dissection.
20:39If we're doing upfront surgery.
20:42Keeping in mind that if they're
20:44clinically node negative,
20:45the Z 11 trial and there was the ammo
20:48amaros trial and there was a lot of
20:50other good trials actually happening
20:52around the same time as the 11 trial.
20:55This just happened to
20:56occur in the United States,
20:58so we do tend to talk about
21:00it a lot more here.
21:02But what we found was that
21:04in the upfront setting,
21:05if there was no clinically couple
21:07adenopathy in the XR that we could
21:10leave some maxillary disease behind
21:11with no sacrifice of Uncle Logic.
21:13Outcomes so these 900 women,
21:15about 850 patients were randomized
21:18to either axillary lymph node
21:20dissection or no additional axillary
21:22surgery if they had one or two
21:24positive Sentinel lymph nodes on
21:26their central lymph node biopsy.
21:28And Interestingly,
21:29in the patients who want to access section,
21:3228% of them had additional additional
21:35positive axillary lymph nodes.
21:36However, thinking that it was randomized,
21:39the patients who did not go on to
21:42additional surgery probably had.
21:44Additional axillary disease
21:44that was left behind,
21:46and we found that there was no
21:48difference in axillary recurrences,
21:49survival, or disease free survival,
21:51so we feel comfortable now that if
21:53patients who have one or two positive
21:56lymph nodes on settling down biopsy
21:58in the upfront surgical setting
21:59that we do not need to go on
22:02to perform the access section.
22:05However, I think that
22:08principle is going to become.
22:11More challenge maybe if you will with
22:14these new results of the RX Ponder trials.
22:17So in ER positive disease the tailor
22:20X trial as I showed you a few slides
22:23ago looked back in the early 2000s.
22:26Looked at ER positive disease
22:28node negative patients,
22:29and who benefited from chemotherapy or not.
22:32The Oncotype score is a genomic.
22:34The genomic testing on
22:36the actual tumor itself.
22:38And it gives us a score from zero
22:40to 50 and it was a non inferior
22:43trial looking at women who either
22:45got hormone therapy or loan or
22:47chemotherapy plus hormone therapy and
22:49an if their score was less than 25,
22:52we felt that we found that they did
22:55not benefit from chemotherapy and
22:57hormone therapy was sufficient.
22:59That was in the node.
23:01Negative patients,
23:02however the RX Ponder trial,
23:03which is still ongoing,
23:05but we got preliminary results
23:07just about four months ago at
23:09San Antonio Breast Conference.
23:11Looked at the same question
23:13in now node positive patients,
23:15one to three node positive patients,
23:17one one or two or three positive lymph nodes.
23:21And what we think is their finding
23:24the same things that women who
23:25have a score of less than 25
23:27hormone therapy is sufficient.
23:29Keeping in mind, though,
23:31that this is in the in the
23:33post menopausal women,
23:34we still think that chemotherapy
23:36benefits pre menopausal women.
23:38So what does that mean for us as surgeons?
23:41What it means is,
23:42is that if a woman has a clinically palpable
23:45lymph node and wants to avoid chemotherapy,
23:48then it could be possible where
23:50we take them to surgery first,
23:52we do an access section to find exactly
23:55how many positive lymph nodes they have,
23:58and then we could potentially
24:01avoid giving them chemotherapy.
24:03Alright,
24:03So what about if we give
24:05patients neoadjuvant therapy?
24:06Historically,
24:07the standard of care for clinically
24:09no positive patients even after
24:11neoadjuvant was still an access section,
24:13but some of these trials found
24:15that actually are nodal PC RAR,
24:17pathologic complete response
24:18rate in the XR was quite high,
24:20and so we felt that maybe
24:22we could avoid giving.
24:24Avoid doing an access
24:26section after neoadjuvant.
24:28But the scary thing is,
24:29is maybe this would decrease our or
24:32increase our false negative rate,
24:34lower identification rate,
24:35or higher false negative rate
24:37because of the non uniform effective
24:39chemotherapy for well done trials
24:41were performed around the same
24:43time that demonstrated that if
24:44you use dual tracer that blue
24:46dye and radioactive isotope as I
24:49showed and you were moved at least
24:51three central lymph nodes,
24:52the false negative rate was
24:54inappropriate less than 10%.
24:56However,
24:56we do know that if.
24:58Any lymph nodes remain positive
25:00after new agent chemotherapy.
25:01We still go on tax dissection,
25:03but that is also getting looked at
25:06in an ongoing alliance trial where
25:08maybe like the Z 11 trial where
25:11we know we left some disease behind,
25:13maybe actually radiation is going to
25:16be sufficient enough and we can still
25:19leave some ancillary disease behind.
25:22We are using a lot more
25:24neoadjuvant endocrine therapy.
25:25Ferrari are positive patients, especially
25:27in the light of the RX Ponder trial.
25:29An especially during kovid,
25:31for instance, and So what is the data?
25:33What are the data with
25:35neoadjuvant androgen therapy?
25:36We know that the PCR rates are low.
25:40They it does help with breast
25:43conservation eligibility.
25:43We think for neoadjuvant enterkin therapy,
25:46they do need a lot of new
25:48management and therapy.
25:49About six months, however,
25:51we do think this was a nicely done child
25:54out of data are done at Dana Farber.
25:57We do think that in the
25:59clinically T1 or T2N0 patients,
26:01they had a low residual nodal burden
26:04after neoadjuvant endocrine therapy.
26:05So maybe we can extrapolate that and say.
26:10If they only have one or two positive lymph
26:12nodes after neoadjuvant endocrine therapy,
26:14we actually don't have to
26:16go on to access section.
26:18Alright,
26:19I brief update on stage four disease.
26:21So why do we operate on stage four disease?
26:24Oftentimes,
26:25it's pallative wound control bleeding.
26:26If there's an aquatic tumor.
26:30And oftentimes, unfortunately,
26:31our patients present with operable disease,
26:33even if their stage four,
26:35they tend to be healthy.
26:37We are finding a lot more stage four
26:40disease because of better imaging,
26:42and there's been a lot of
26:44mixed retrospective reviews.
26:45Looking at this question of whether
26:48surgery helps with stage four disease.
26:51Doctor Khan out of northwestern
26:53just essentially finished a
26:55randomized controlled trial.
26:56Looking at this various,
26:58this very question on whether
27:00surgery help stage four disease
27:03and the really final result.
27:05Final conclusion was that surgery
27:07and radiation did not extend
27:09survival in these de Novo metastatic
27:12breast cancer patients.
27:13The big question behind it is
27:15the idea of oligo metastatic.
27:18So if there's one small little
27:21lesion somewhere else.
27:22Maybe it will help because
27:24we're not the data is.
27:25This is so new that we don't have
27:27all the data in terms of all the
27:30patients involved in this study,
27:32but we still don't think that
27:33surgery is going to help.
27:35It is helping stage for de Novo
27:37patients and last but not least,
27:39so high risk lesions can be very complex,
27:42complicated, very scary for women.
27:45So based upon a lot of you know
27:47various data from across the country
27:49in terms of when we excite some of
27:52these high res high risk lesions,
27:54and when we don't,
27:55the thought is is thinking
27:57about the upgrade rate and what
27:58I mean by upgrade rate is.
28:00If you biopsy something and then take it out,
28:03what is the chance that you're going
28:06to find something more than what it
28:08was just on the core needle biopsy?
28:10And so the thought is,
28:12is Ath DCIS obviously comes
28:13out a LH and classic LCS.
28:15Stays in because the low upgrade rate,
28:18but plea Amorphic and Florida
28:20else I should come out.
28:21Also keeping in mind that all
28:23of these high risk lesions,
28:25the ADH in the LH LCS increased
28:28your risk of developing breast
28:30above breast cancer later in life.
28:33That's all I have.
28:34I think I went overtime,
28:36so I apologize.
28:38Doctor Berger that you know to
28:41cover all these advances in breast
28:43surgery over the last year or so.
28:46That's really impressive. Thank you.
28:48Next, we have doctor Melanie Lynch,
28:50an expert in Aqua plastic breast surgery,
28:53giving us some of the latest.
29:00Oh, you're you're on mute.
29:04I mute myself and share my screen. Anne.
29:11Well, that was a fellowship in half an hour.
29:13That was a wonderful talk.
29:15Thank you so much for that overview that was.
29:19Wonderful way to cover everything
29:21and I'm going to focus on one small
29:24area on Uncle plastic breast breast
29:26surgery and current advances there.
29:28And really the mandate to consider
29:31oncoplastic breast surgery is
29:32really the burden of breast cancer.
29:34Over 300,000 women are affected
29:36every year and most of these women
29:39will have a surgical procedure and
29:41so given the number of breast cancer
29:44survivors in the United States,
29:46it's incumbent upon us as breast
29:49surgeons to make sure that we are.
29:51Providing the best operations for patients
29:54not only to cure their breast cancer,
29:57but to make sure that they have the
30:00best functional and cosmetic outcomes.
30:05So when we think about breast cancer surgery,
30:07we think about mastectomies
30:08and then breast conservation,
30:10with a lumpectomy and followed
30:11by whole breast radiotherapy.
30:13But the lived consequences of
30:15these operations for our patients
30:17and for their bodies overtime,
30:19whether it's a mastectomy or whether a
30:22lumpectomy with radiation can affect
30:24their sense of self and can also
30:27affect their functional outcomes.
30:29So as we think about Uncle
30:32plastic breast surgery,
30:33there's a lot of different definitions,
30:35consensus statements about
30:37what Uncle plastic surgery is.
30:39But I I really like this description of Uncle
30:43plastic breast surgery as a philosophy.
30:46That we should be treating breast
30:48cancer surgically to cure the cancer
30:50and then to maintain and improve the
30:52cosmetic appearance of the breast.
30:54And that this requires a comprehensive
30:57consideration not only of the patient's
30:59anatomy and the anatomy of their cancer,
31:01but with the patient's own
31:03satisfaction with their breasts.
31:05The size and shape of their breast
31:07manage in their overall lifetime
31:10risk of breast cancer.
31:12And what the patient's goals are,
31:14and so it's a more comprehensive
31:16and complex consideration as we plan
31:19these operations for our patients.
31:21And so we can talk about all sorts
31:23of incisions and approaches to
31:25every quadrant of the breast.
31:28And this is a summary from the Krishna
31:30Cloth paper that has really become
31:32kind of the Bible for our consideration
31:35of Uncle plastic breast surgery.
31:37But I'm just going to focus on a
31:40couple of key areas and an techniques
31:44and uncle plastic breath surgery too.
31:47Created an opportunity for conversation
31:49so within breast conservation,
31:51starting with the most basic operation
31:54that we do every day of the week.
31:58Asimple partial mastectomy are scar
32:01placement should be considered.
32:03Fundamental in this and we can place
32:05our scars in places where the patients
32:07don't have to see them regularly.
32:09It can either be at the edge of the
32:12areola or the edge of the breast,
32:14and when we start to think of
32:16separating the substance,
32:17the parenchyma of the breast from the
32:19skin of the breast and organizing
32:21our operation around that principle,
32:23we find we have lots of ways we
32:25can approach this operation.
32:27To put our scar in a cosmetic location
32:29and still have a good oncologic outcome.
32:32For the simple partial mastectomy,
32:34the critical thing is to maintain
32:36the central location of the ******
32:38areolar complex,
32:38and in order to do that when we
32:41close the breast parenchyma after
32:43we have completed our lumpectomy,
32:44that needs to be oriented in
32:46a radial direction.
32:47So we're always going to close up
32:50and down on the sides of the breast
32:53or from side to side or the top on
32:55the top and bottom of the breast in
32:58order to maintain the ****** areolar
33:00complex in the middle of the breast.
33:04If we find we can't get to the tumor
33:07from one of those simple incisions,
33:09we can start to use other
33:11techniques that have been developed
33:13and used by plastic surgeons,
33:15but allow us to have more access
33:17to the breast parenchyma way.
33:18Still having a good cosmetic incision
33:21and a good choice here is always a
33:23Crescent or around block McMaster Pixie.
33:26Because by creating that larger
33:27incision at the center of the breast
33:30around the ****** areolar complex,
33:32and then again thinking about the
33:34skin of the breast separate and
33:36apart from the parent of the breast
33:38that allows us to create broader
33:40planes of dissection and access
33:42tumors in more distal locations
33:44from the ****** areolar complex.
33:49Another another consideration is
33:51avoiding some of the common deformities
33:54that can come after we've respected
33:56volume in the breast or radiation.
33:58This picture here from the original
34:01Cluff paper shows that kind of
34:03classic birds beak deformity.
34:05When we remove tissue from the 6:00
34:08o'clock position of the breast.
34:11It creates scar radiation contracts the
34:13breast further and it pulls the ******
34:16down and creates that kind of a deformity.
34:19We have multiple ways we can approach those
34:22tumors that would prevent that deformity,
34:24particularly by using a mastopexy approach.
34:28To allow us to excise skin over tumor
34:31to reshape the breast to refill the
34:33volume at the 6:00 o'clock pole and then
34:36recentralise the ****** areolar complex.
34:42And then we can also work in
34:44partnership with our plastic surgery
34:46colleagues on several level 2
34:48techniques for breast reconstruction.
34:50And this is a recent case.
34:54That I did with my plastic surgery
34:56colleague here of a patient who had a
34:592 centimeter tumor that was involving
35:02the muscle of the chest wall in the
35:04upper inner quadrant of her left breast.
35:07We chose to do a wise pattern mastopexy
35:10approach which gave us wide exposure of
35:13that area to allow excision of that tumor,
35:16including underlying muscle,
35:17and then to reshape the breast using
35:19a classic wise pattern approach.
35:21We were also able to do our axillary lymph.
35:25Axillary lymph node sampling.
35:26Through this same incision again
35:28through this principle that the breast
35:29parenchyma and the skin can be treated
35:32differently in these operations,
35:33we had wide enough exposure to the axle
35:35through this wise pattern incision that
35:37we were able to remove our lymph node
35:40without making a separate incision.
35:41And this is a patient at at one week post up.
35:49Another approach for consideration is
35:51volume replacement for patients whose
35:53partial mastectomy volume is more than 20%,
35:55and sometimes it can be up to
35:5830% of their breast when they
36:00don't have a large breast volume.
36:03This is a patient who had a
36:05invasive lobular cancer that
36:07was rather extensive on the MRI.
36:09You can see that the cancer in the left
36:12breast you can see the biopsy clip.
36:14You can also see the cancer
36:16involving Cooper's ligaments.
36:17So even though she had a significant
36:19amount of subcutaneous tissue,
36:21the skin overlying skin was tethered
36:23to the tumor and that skin had to
36:26be removed as part of her reception.
36:29And we knew we were going to have to
36:31remove about 25% of her breast volume
36:33in order to fully encompass this.
36:36And this also kind of attest to
36:38the importance of MRI in some
36:41of this surgical planning,
36:42which I know is area of controversy.
36:45So for this patient we used AT DAP flap,
36:49which was a rotational flap from the
36:51lateral chest wall to fill that volume
36:54to allow for a complete wide resection,
36:57including overlying skin with an
36:59acceptable cosmetic result to allow
37:01her to have breast conservation.
37:05And so the outcomes of oncoplastic
37:08partial mastectomy are mostly
37:10reported in case series.
37:12There have been two large meta
37:15analysis looking at Uncle Logic,
37:17safety and outcomes in these cases,
37:20including the rates of positive
37:22margins or rates of reexcision,
37:24the conversion to mastectomy,
37:26overall survival,
37:27disease, free survival,
37:29and all of the expected
37:31surgical complications and
37:33our uncle plastic techniques.
37:34Are comparable to standard.
37:38Lumpectomy techniques,
37:39so we know that we know that these are Uncle,
37:43logically,
37:43in surgically safe operations.
37:48All this is a series from MD Anderson
37:51looking at Uncle Logic outcomes,
37:54including survival and disease free survival,
37:57and it's always important to consider
38:00breast conservation versus mastectomy,
38:03but this trial again proves the point
38:05that surgeons know their patients
38:08very well because our patients who
38:10have simple mastectomy without
38:13reconstruction are usually patients who
38:16either have comorbidities or disease.
38:18Well, we know that these techniques are
38:21probably not going to be helpful to them.
38:24You can see in the red and the blue
38:26lines in these graphs that breast
38:28conserving surgery and breast conserving
38:30surgery with reconstruction have similar
38:32disease free and overall survival rates.
38:37So what about patient reported
38:38outcomes in these operations?
38:40There are. This state is hard
38:41to collect and hard to analyze,
38:43and there are several trials
38:45that have looked at different.
38:49Types of uncle plastic procedures.
38:51This was a larger study that looked at
38:54multiple types of oncoplastic procedures
38:57with regards to patient reported
38:59outcomes as reported using the breast Q,
39:02which is one of the most
39:04comprehensive and best studied
39:06patient reported outcome measures.
39:08There are multiple components to
39:10the breast Q that include ******
39:13well being breast appearance,
39:15emotional well being,
39:16and physical well being.
39:18This is kind of a busy slide,
39:20but it looks at the comparison of simple
39:23mastectomy without reconstruction.
39:25To implant based reconstruction
39:27to rotational flap reconstruction
39:29with an implant with and without
39:31an implant as well as free flap
39:34reconstruction and breast conservation.
39:36So as you move across the
39:39chart from left to right,
39:41the uncle plastic breast conservation
39:43procedures are at the right side.
39:45We know women have higher overall patient
39:48satisfaction with breast conservation,
39:50and if that breast conservation
39:52includes an uncle plastic approach,
39:54a mammaplasty approach or even
39:56a volume replacement approach,
39:58we know that there.
40:01Overall patient reported outcomes to improve.
40:07So just briefly about Uncle
40:09Plastic approaches to mastectomy.
40:11Now that we've moved towards immediate
40:13reconstruction using both skin and
40:15****** sparing mastectomy techniques,
40:17this is allowed us to preserve the skin.
40:20The skin pocket which may have some
40:24concerns with regards to Uncle logic safety.
40:27Doctor Berger, did present some data there.
40:29I'm going to just repeat briefly a
40:32little bit of the data about Uncle
40:34Plastic or Uncle logic safety,
40:36but we now have newer techniques
40:39in ****** sparing mastectomy that
40:41allow us to change the size and
40:43shape of the skin pocket to allow
40:46for other options in mastectomy.
40:50So with regards to ****** sparing mastectomy,
40:53I really appreciate this picture
40:56because it really shows both the value
41:00of our inframammary incision which
41:02most surgeons have adopted now as the.
41:06Safest incision with the best
41:09outcomes as well as the use of.
41:13ATM's and other matrices to help
41:16us do prepectoral reconstruction,
41:18which also has improved outcomes for
41:22patients, both functional and cosmetic.
41:27Anne, as Doctor Berger described
41:29our patient selection for this
41:31operation is very important.
41:32The size and shape of the breast.
41:37As well as patient risk factors,
41:39including diabetes and smoking,
41:41are important to make sure we've
41:44assessed those, so we have optimal
41:47outcomes using this incision.
41:51So the outcomes of ****** sparing
41:53mastectomy have shown that it's both
41:56Uncle logically safe and that our
41:59patient satisfaction and overall
42:00cosmetic outcomes are are good.
42:02The American Society of Breast Surgeons,
42:05****** sparing mastectomy rest
42:07Registry reported a recurrence rate
42:09of 1.4% with none of the recurrences
42:12at the ****** areolar complex.
42:14A Cochrane review that included
42:17over 11 studies with over 6000
42:19participants found very.
42:21Compareable outcomes for ****** sparing.
42:23Skin sparing an complete mastectomy
42:25with a trend towards improved aesthetic
42:27outcomes and quality of life for women
42:29having ****** sparing mastectomy.
42:36And this is a study from Sloan
42:39Kettering using the breast Q an looking
42:42at outcomes with ****** sparing
42:44mastectomy versus total mastectomy.
42:46And there was a trend towards
42:48significance for psychosocial
42:49well being among those patients.
42:54So newer mastectomy,
42:55newer mastectomy techniques that can
42:57be used for women who are not optimal
43:01candidates for traditional ****** sparing,
43:03mastectomy with the inframammary
43:05incision include techniques that
43:07allow us to reshape and resize the
43:09skin pocket using a wise pattern
43:11using free ****** grafts to make a
43:14better size pocket for either implant
43:16based reconstruction or to use the
43:19patient's own tissue for reconstruction.
43:21Whether that's using a skin pedicle.
43:24Or using a rotational flap.
43:27And this includes the Goldilocks operation,
43:30which uses a local skin flap
43:32for that reconstruction.
43:37So it's up to us to always consider
43:39what the best functional and cosmetic
43:41outcomes of our operations can be as
43:44we treat patients for breast cancer.
43:46Again, the priority always needs to be to
43:49make sure that we're doing the operation.
43:51That's going to help achieve a
43:53cure for our patients cancer,
43:55but then to consider how how we
43:57can offer more patients breast
43:59conservation and how we can make
44:01sure to ensure the best cosmetic and
44:04functional outcomes for patients.
44:06Thank you.
44:08Thank you so much Doctor Lynch
44:10that is just absolutely fantastic.
44:12What a wonderful addition to our
44:14breast program and you know skills
44:17and techniques that I certainly can
44:19learn from you and so many others
44:21as well to an last but not least
44:24obviously is Doctor Rachel Green,
44:26Upper section chief in
44:27Breast Surgical oncology,
44:28really discussing and focusing
44:29on the young woman's perspective
44:31and breast cancer surgery.
44:35And Doctor Lynch, you have a bunch
44:37of questions in the chat box and.
44:40Into the answer and will will
44:42have a some time at the end.
44:44Also to open it up to the larger
44:47audience. Thank you.
44:49I'm just going to unmute myself and.
44:53Get my slides connected alright,
44:56well thank you everyone for
44:58joining us this afternoon.
45:00As mentioned, my name is Rachel Greenup,
45:03I just joined Yale in February and I'm
45:06thrilled to be here and I'll be talking
45:09today about young women with breast
45:12cancer perspectives from a surgeon.
45:15I have no relevant just disclosures,
45:17except that I became really interested
45:19in this topic from a clinical perspective
45:22when my dear friend was diagnosed with
45:24triple negative breast cancer at age 32,
45:27she's doing well practicing
45:28as a surgeon in the Midwest,
45:30but I had the privilege of being part of her
45:34journey and learning a lot along the way.
45:39So, as mentioned,
45:40we know that breast cancer is a really
45:42common disease in the United States with
45:45one in eight women over their lifetime
45:48being diagnosed with breast cancer.
45:50And this assumes that women
45:52live to be in their 8th decade.
45:54But we, when we look at women under 40,
45:58there's only about 4% of new breast cancer
46:01cases affecting this younger population.
46:04I'm gonna be talking about a kind of popery
46:07of topics related to this young cohort,
46:10including breast cancer screening,
46:12the incidence, prevalence,
46:13biology, and prognosis.
46:15Thinking a bit about
46:16surgical issues and options,
46:18discussing pregnancy,
46:19associated breast cancer,
46:20and then unique issues within
46:22survivorship care.
46:23So there's been a lot of controversy in the
46:26last decade about breast cancer screening.
46:29the US Preventive Taskforce originally
46:31recommended that women should wait to have
46:35breast cancer screen until they reached.
46:37Age 50 the American Cancer Society
46:40has recommended that younger
46:42patients ages 40 to 44 should have a
46:44choice and that risk and potential
46:47benefit should be considered,
46:49including women who have
46:50a higher lifetime risk,
46:52who should start at 40 years old.
46:56The American Society of Breast
46:58Surgeons more recently came up with
47:01guidelines specific to our surgical
47:03community and that all women ages 25
47:06and older should undergo formal risk
47:08assessment for breast cancer that
47:10women with an average risk should
47:12begin yearly screening starting at
47:14age 40 and women with a higher risk
47:17should include screening mammography
47:19with the potential for supplemental
47:21imaging including ultrasound and or MRI.
47:24An they also included a really
47:27valuable component within their
47:29screening recommendations,
47:31which included guidelines around
47:33breast density and that in the US
47:37means tomosynthesis imaging and
47:39or MRI with ultrasound.
47:41So in our world,
47:42many women do come in with this green
47:45detected cancer and you can see on
47:47the mammogram here highlighted in my
47:50circle that there's a spiculated mass,
47:52but in a heterogeneously dense breast.
47:56Most women then go on have ultrasound
47:58and a biopsy showing cancer and they
48:01meet their surgical team either
48:03before or after this diagnosis.
48:06We know there are risk factors
48:08for breast cancer, summer nature,
48:10summer nurture being female.
48:12Certainly as age increases over time,
48:14having a genetic mutation or a
48:16personal family history,
48:18we know that any prior biopsy,
48:20whether it's benign or malignant,
48:22is associated with a higher lifetime risk.
48:25Menstrual history.
48:26There's some data around race,
48:28and certainly breast density.
48:29The nurture piece we look at
48:32delayed childbirth, alcohol intake,
48:34high fat diet, smoking.
48:35There's a lot of data.
48:38Coming out,
48:38some of which has been driven by
48:41Melinda Irwin and terracing after it.
48:43Yeah looking at body weight,
48:45an exercise history of childhood
48:46or young adult radiation,
48:48an long term hormone replacement use.
48:52So we know that risk of breast
48:55cancer increases with age.
48:56These are data from the
48:58American Cancer Society,
48:59facts and figures from 2019 showing that
49:02risk of breast cancer peaks in the 7th
49:05decade across all races and ethnicities,
49:08and so you can see that in our
49:11younger patient population which is
49:13diagnosed typically under age 45.
49:15But that definition also
49:17varies in the literature.
49:18Breast cancer risk is less.
49:21Comment it occurs in about
49:2310% of women under 40.
49:25There has been some speculation in
49:28the literature that young women's
49:31breast cancer has been increasing
49:33over time in patients will often
49:36come in and ask us about that,
49:39but the data suggests that
49:41the prevalence is stable.
49:43We know that 50% of cancers in
49:46younger patients are breast cancers,
49:49an unfortunately the survival.
49:51Is typically lower in young women.
49:54All of that being said,
49:56when you look at the risk of breast
49:58cancer in women in their 20s,
50:00thirties and 40s,
50:02it does remain relatively low and
50:04their risk of death is very low.
50:07In this population.
50:10When we look at tumor Biology
50:12among young women,
50:13so on the right that figure again is
50:16from the American Cancer Society data
50:18showing that the overwhelming majority
50:20of all breast cancer patients tend
50:23to be hormone receptor positive and
50:25her two negative in our younger patients,
50:28they are more likely to have unfavorable
50:31or higher risk tumor biology,
50:33including higher risk of ER PR,
50:35negative tumors,
50:36higher Ki 67, expression,
50:38more likely to have lymphovascular invasion.
50:40And Grade 3 tumors.
50:44I'm sorry my slides are jumping.
50:46These data are older.
50:48They were published in 1994 in
50:51the Journal of Clinical Oncology,
50:53but they were important in first
50:56demonstrating that age alone young age
50:59alone was a poor prognostic factor,
51:01so we know that women less than
51:0435 represented on the graphs by
51:07the solid line had significantly
51:09worse outcomes across disease.
51:11Specific survival overall survival,
51:13an risk of recurrence.
51:17More recently, we can see that the
51:20Boston Group here looked at risk of
51:22local recurrence in younger women.
51:25If you look at the breast cancer cohort,
51:28overall, the overall risk of local recurrence
51:31after breast conservation was about 2%,
51:33but in the younger cohort defined
51:36in this study as ages 26 to 45,
51:39there was a five year cumulative risk of 5%.
51:43The figure on the left shows that this
51:46certainly varied by tumor subtype.
51:49With her two positive and triple negative
51:51breast cancers being more likely to
51:54demonstrate in breast recurrence, overtime,
51:56an overall age was an independent
51:58risk for local recurrence after breast
52:01conservation but remained acceptably low.
52:06These data were published
52:07by a colleague and friend,
52:09Carrie Anders, again in 2008,
52:11but this was a collaborative
52:12effort between Duke and UNC,
52:14where they looked at tissue samples
52:16in younger versus older patients.
52:18Defined in this study as
52:20less than 45 or 65 and older,
52:23they did find that younger
52:24women had lower rates of hormone
52:26receptor positive breast cancer.
52:28Higher rates of her two positive cancer
52:30presented with larger tumor sizes,
52:32an higher grades,
52:33an again younger age was an
52:35independent risk factor for disease.
52:37Free survival.
52:40And during my time at Boston,
52:43we pursued evaluation of younger
52:45patients and the predicted value
52:47of pathologic complete response on
52:50overall survival in this rare cohort.
52:52So we know that across our
52:55breast cancer patients,
52:56regardless of age,
52:57having neoadjuvant chemo with
52:59a pathologic complete response
53:01correlate's with excellent survival
53:02and the data from the original
53:05neoadjuvant studies at the NSC,
53:07BP.
53:0719 and 27 suggested that perhaps
53:10in younger patient populations,
53:12preoperative chemo was.
53:13Correlated with not only improved
53:15eligibility for breast conservation,
53:17but also improved overall survival,
53:19but it was not statistically
53:22significant in those studies,
53:23and so we wanted to get a better
53:27sense of in a contemporary cohort.
53:30How did on neoadjuvant chemo and
53:32pathologic response impact cancer
53:34outcomes in younger patients?
53:36And you can see here women under 40
53:39at diagnosis who received neoadjuvant
53:42chemo for stage two and three
53:45invasive cancers between 1998 and 2014.
53:48At mass General Hospital were evaluated.
53:50Overall there were only 170 young
53:53women in this analytic data set.
53:55About 30% received a path CR and this
53:58was more likely in Grade 3 disease.
54:01Her two positive and triple
54:04negative breast cancers.
54:06Age alone was not predicted
54:08for pathologic response,
54:10but when you look at a younger cohort,
54:13pathologic response,
54:14not surprisingly,
54:15was correlated with improved disease
54:17free and overall survival compared
54:20to women with residual disease.
54:22And this was based on tumor subtype
54:25with hormone receptor positive.
54:27Her two negative past CR responders having
54:30the best survival followed by triple
54:33Negative and her two positive past CR.
54:36Patients.
54:38Moving on to decisions for
54:40breast cancer surgery in the US,
54:43we face young and older women
54:45with early stage breast cancer
54:48an we offer them a choice for
54:51decisions related to surgery.
54:52We have very good and long
54:55term and contemporary data,
54:57both clinical trials and observational
54:59studies suggesting that these
55:02outcomes are not different.
55:04When our young patients come talk to us,
55:08they meet the larger multi disciplinary team.
55:11This often includes surgeons,
55:13medical oncologists,
55:14radiation oncologist,
55:15plastic surgeons,
55:16genetic counselors and sometimes
55:19oncofertility specialists
55:20which I'll touch on briefly.
55:22But we discussed with them recovery time,
55:25risk of recurrence,
55:26Peace of Mind,
55:27side effects and complications
55:29need for future surveillance,
55:30appearance and how this really
55:33impacts their lives.
55:35And the international consensus guidelines
55:37from 2019 strongly recommended,
55:39and these were experts from across the globe.
55:42Really recommended that local
55:45regional treatment in younger
55:47patients should not really differ
55:49from what we offer to older women.
55:51We should think strongly about
55:53breast conserving surgery as the
55:55first option whenever possible.
55:57I'm knowing that their survival
56:00overall is the same and that we should
56:03think as Doctor Lynch touched on.
56:06About uncle plastic repairs
56:07and reconstruction.
56:08An that false negative rates
56:10are worse outcomes related to
56:12central node biopsy use in this
56:15population should not be a concern,
56:17and I encourage anyone interested in
56:20this population to read this article.
56:22It touches on both local,
56:24regional systemic treatment guidelines and
56:27then recommendations for survivorship.
56:29As mentioned,
56:30when we perform a mastectomy,
56:32we can often perform ****** sparing with
56:35wonderful options for reconstruction.
56:38And there is some data coming out.
56:40This is from my colleague and friend
56:43Catherine Patches at the University
56:46of Chicago Northshore practice.
56:48That in a prospective study of women
56:50undergoing breast cancer treatment,
56:52either breast conservation or mastectomy,
56:55the quality of life does not
56:57differ based on surgical choice,
56:59and so I think we can rest assured
57:02that even for our younger patients
57:05lumpectomy with radiation or
57:08mastectomy are safe options.
57:10Moving on to pregnancy associated
57:12breast cancer again,
57:14even more rare than breast
57:16cancer in our younger patients.
57:18We know this can occur in women,
57:21typically under 30.
57:22This is during the Peripartum
57:24period or within the first year.
57:27It's very rare that one in three
57:301.3 cases per 10,000 live birds.
57:32We do find that the limited literature
57:35published on this topic suggests that
57:38larger locally advanced breast cancers.
57:40More likely,
57:41triple negative,
57:42an higher rate of death when diagnosis
57:45is in the peripartum period.
57:47Recommendations if you meet a
57:49woman with a breast mass who's
57:52pregnant two evaluated on women,
57:54can undergo mammogram,
57:56a shielding and ultrasound.
57:58They should undergo a core
58:00needle biopsy of a mass,
58:02unless it's concretely
58:04radiographically benign.
58:05Cornedo biopsy is better than FNA
58:08for evaluation of these lesions.
58:11When we think about a staging,
58:14in the cases where breast cancer exists,
58:17chest xray,
58:18liver ultrasound labs and non contrast MRI.
58:21Although we have had circumstances
58:23in which working with OBGYN team
58:26to discuss alternative staging
58:28evaluation is necessary,
58:30many of these patients,
58:32young young women,
58:33pregnant or not,
58:35should be considered for genetic counseling.
58:37We know that pregnancy is not protective
58:40in these younger patients unfortunately.
58:43Although over your lifetime and the
58:46number of pregnancies and childbirth.
58:48Does provide some benefit against
58:50breast cancer risk in younger women?
58:53This is a high risk,
58:55relatively higher risk time.
58:57Women who are pregnant can also undergo
59:00mastectomy versus breast conservation,
59:02as long as the radiation occurs
59:05after delivery and chemotherapy
59:08has been proven to be safe
59:10in the 2nd and 3rd trimester.
59:13So Lastly,
59:14I wanted to talk about survivorship
59:16in this younger population.
59:18In my mind on this quote is really
59:20representative of what these
59:22younger patients go through.
59:24Elizabeth McKinley was an associate
59:26Dean of Medicine at Case Western who
59:29was diagnosed with breast cancer at age 36,
59:32and she says after my last
59:34radiation treatment for breast
59:36cancer instead of joyous,
59:37I felt lonely, abandoned.
59:39Terrified, this was the rocky beginning
59:42of cancer survivorship for me.
59:44So again, many of these young women
59:47outside of their cancer treatment
59:49are not interfacing with the
59:51health system on a regular basis,
59:54and so we have to be especially sensitive
59:57to issues that accompany cancer treatment.
01:00:00These can include amenorrhea and
01:00:02early menopause, osteoporosis,
01:00:04secondary malignancies,
01:00:05fertility is of upmost concern
01:00:07for many of these women.
01:00:09And then Lastly psychosocial
01:00:11and quality of life issues.
01:00:14There are obviously a side effects
01:00:17of all breast cancer treatment,
01:00:19including those related to surgery,
01:00:21chemotherapy, radiation,
01:00:22and a current therapy and targeted therapy.
01:00:26Chemotherapy induced amenorrhea
01:00:27is age related.
01:00:28I apologize for my slides
01:00:30and therapy dependent.
01:00:31It is less common at younger ages,
01:00:34so are very young patients.
01:00:36In their 20s are more likely to regain
01:00:40menstrual cycles after treatment
01:00:41than women in their late 30s or 40s.
01:00:45We know that shorter duration
01:00:46of treatment is less likely to
01:00:49be associated with chemotherapy
01:00:51induced amenorrhea as well,
01:00:52and that there may be
01:00:55some protective benefit.
01:00:56Two cessation of menses.
01:00:58And this is a really nice table
01:01:01that goes through the risk of
01:01:05chemotherapy induced amenorrhea.
01:01:07Based on the treatment that
01:01:09women receive with little data
01:01:11at this point known around newer
01:01:14monoclonal antibody therapy.
01:01:18Ann Partridge's group at Dana Farber
01:01:20did some survey work around these
01:01:23younger patients who were diagnosed
01:01:25with breast cancer and fertility.
01:01:28Infertility concerns was a concern
01:01:30for over half of these women.
01:01:33About a third reported that fertility
01:01:35impact their cancer treatment decisions,
01:01:38and I think that's critically
01:01:40important for our training teams to be
01:01:43highly aware of women worried about
01:01:46menopausal symptoms after treatment.
01:01:48And only about half believe that their
01:01:51concerns were adequately addressed.
01:01:53There are ASCO guidelines
01:01:55around fertility preservation,
01:01:57notably that it should not
01:01:59delay cancer treatment.
01:02:01That the risk of recurrence with fertility
01:02:04preservation should be considered,
01:02:06but is likely very low.
01:02:09We're learning an that early referral
01:02:11to specialist is critical and
01:02:14correlate's with successive pregnancy.
01:02:16Long term,
01:02:17there are several options for oncofertility,
01:02:20including oocyte cryopreservation,
01:02:22embryo cryopreservation.
01:02:23An ovarian tissue preservation.
01:02:25An ovarian suppression an again.
01:02:27Partnering with our reproductive
01:02:29endocrinologist will give our
01:02:31patients their best outcomes.
01:02:34The positive trial is a national study led
01:02:37by Doctor Partridge out of Dana Farber,
01:02:40and this really looks at whether women
01:02:43who have completed between 18 and
01:02:4630 months of endocrine therapy can
01:02:48temporarily stop endocrine therapy
01:02:50for pregnancy for up to two years.
01:02:53This is all in the context of our
01:02:56best available evidence suggesting
01:02:58that pregnancy after breast cancer
01:03:00does not increase a woman's risk
01:03:03of developing a recurrence.
01:03:05Even among women with hormone
01:03:08receptor positive disease.
01:03:10Psychosocial stress does impact our
01:03:12younger patients more significantly
01:03:14than many of our older patients.
01:03:16We know that younger age predicts
01:03:18higher distress at one year that
01:03:21treatment related menopause more likely
01:03:23correlates with worse psychosocial distress.
01:03:26Our younger patients,
01:03:27about 11%,
01:03:28are denied health or life insurance
01:03:30after their breast cancer diagnosis
01:03:32and they have a higher risk
01:03:35of treatment related financial
01:03:37hardship and employment disruption.
01:03:39Up to 20% report some work related
01:03:43problems either needing to take time off,
01:03:45work,
01:03:46difficulties with promotion or advancement,
01:03:48or unemployment and ****** dysfunction
01:03:50tends to start shortly after surgery.
01:03:53An exist for many women,
01:03:56at least to one year.
01:03:59Looking at financial hardship,
01:04:00which is a topic near and dear to my heart,
01:04:04we do know that our younger cancer
01:04:07survivors are at the highest risk of this.
01:04:10With 1/3 reporting financial hardship,
01:04:1240% reporting difficulty affording
01:04:14their deductibles with young,
01:04:15non Medicare covered patients at greatest
01:04:17risk and again are younger patients
01:04:20more likely to receive comprehensive
01:04:22treatment or multimodal therapy?
01:04:23Also,
01:04:24an independent risk factor.
01:04:26There are lots of resources for our young
01:04:30patients and these are some of but not all,
01:04:33and so as we learn more about these women,
01:04:36we will continue to support them
01:04:38both during treatment and beyond.
01:04:40Thank you so much for having me
01:04:43today be happy to take any questions.
01:04:47Thank you Doctor Green up that was
01:04:50absolutely fantastic and thank you
01:04:52for all the speakers for really three
01:04:54phenomenal presentations which really
01:04:56generated a lot of questions both in
01:04:59the question and answer in the chat
01:05:01box and I'll try to ask the panelists
01:05:04for opinions on some of these.
01:05:07One is question on margins specific
01:05:09in the Uncle plastic setting.
01:05:11Maybe that's best start with Doctor
01:05:14Lynch and her thoughts on how do you.
01:05:17Either guarantee or do best to achieve
01:05:20clear margins and then if they're not clear,
01:05:23what are the options for the patient
01:05:26and in your experience, right?
01:05:28So the the one of the benefits of Uncle
01:05:31plastic surgery when you kind of separate
01:05:34the skin from the breast parenchyma
01:05:36with a little wider exposure for partial
01:05:40mastectomy is with a wider exposures.
01:05:44There's a thinking that you might
01:05:46have fewer positive margins,
01:05:47at least the margin rate is not worse,
01:05:50and that's the data that we have so far.
01:05:54So you would like to have your positive
01:05:57margin rate for routine breast surgery
01:05:59to be as close to 10% as possible and so
01:06:03making sure you have diligent marking of
01:06:05your tumor bed after you've removed the
01:06:08area where the cancer is is important,
01:06:10not only for radiation but also
01:06:12for finding that again after you've
01:06:14done a tissue rearrangement.
01:06:16If you have to go back and clear your margin.
01:06:21When you're doing a uncle plastic procedure
01:06:23to reduce the size of the breast,
01:06:26you can always plan the reduction of
01:06:28that tissue around your lumpectomy bed,
01:06:30and so you'll remove your tissue.
01:06:32You'll do your shave margins and then,
01:06:34if any more tissue needs to come out,
01:06:37that should also be oriented for the
01:06:39pathologist to make sure that you're
01:06:41aware of all of the margins there again,
01:06:43routine use of shave margins will help
01:06:46reduce your risk of a positive margin.
01:06:48And if you've got to go back, you go back.
01:06:51And you try to go back as soon as
01:06:53possible when you still have saroma
01:06:55there before the the rotational flap
01:06:57is healed in place to make sure that
01:07:00you're removing the tissue that you've
01:07:02carefully marked at your first operation.
01:07:05But trying to get your positive margin
01:07:07rate to as close to or less than
01:07:0910% is is important.
01:07:12Thank you doctor Lynn shot doctor Berger.
01:07:15There were some questions about ******
01:07:18margins and ****** sparing mastectomy
01:07:20and should we consider a certain distance
01:07:23on pathology or an indoor image Ng to
01:07:26consider it clear we should that be
01:07:29treated different than say margin in a
01:07:33patient undergoing lumpectomy. Yeah,
01:07:35I think that's a great question.
01:07:37I mean, I think the conservative answer is,
01:07:40you know if there's any pathology on
01:07:42imaging that's within 2 centimeters
01:07:43of the ****** areola complex.
01:07:45We do tend to, or.
01:07:47You know, I would argue we tend to avoid.
01:07:49However, you know,
01:07:50if you take a ****** margin an it's
01:07:53negative at the time of your operation,
01:07:55then you know I think.
01:07:57Regardless of how close that cancer is,
01:07:59the ****** areola complex
01:08:00we'd feel comfortable leaving
01:08:02the rest of that tissue,
01:08:03but I would defer to my more
01:08:07senior colleagues.
01:08:07I think you know
01:08:09there's a nice a nice editorial written
01:08:12by Doctor Susie Coopey and Barbara Smith,
01:08:16arguing that the ****** is just
01:08:19another margin. I've historically.
01:08:21Having done these operations
01:08:23for almost a decade,
01:08:26that one type of patient I've become
01:08:29increasingly cautious about offering
01:08:31****** sparing mastectomy to is
01:08:34women with large areas of DCIS.
01:08:38Yeah, anecdotally had one patient
01:08:41with a negative margin who
01:08:43recurred in a short time frame,
01:08:45and thankfully she had a insight to
01:08:48recurrence in her ****** that was
01:08:51salvageable with a central ****** resection.
01:08:53But I think that disease with
01:08:56the skip pattern should probably.
01:08:59Be taken seriously in terms of
01:09:01offering ****** sparing mastectomy
01:09:03or to follow these women very
01:09:06closely in your own practice for
01:09:08any signs or symptoms of recurrence.
01:09:11Yes.
01:09:13And
01:09:13there's a question from
01:09:15Doctor Moran asking both.
01:09:16You know, Melanie Rachel Elizabeth.
01:09:18What are your thoughts on the
01:09:20recent buzz on going flat
01:09:21movement from the patients and the
01:09:24possibility of some perceived lack
01:09:26of support from surgeons around
01:09:28the country and around the world?
01:09:34I'll jump in on that one.
01:09:37I think you know that's all
01:09:39part of shared decision-making,
01:09:40and with you know kind of carefully
01:09:43chosen words and to clearly
01:09:45represent that the first goal of our
01:09:48operation is to cure the cancer,
01:09:50and our second operation is to
01:09:52make sure the patient has an
01:09:55outcome that she she can live with.
01:09:57Because when we do these operations,
01:10:00we change our patients bodies
01:10:02for the rest of their lives.
01:10:04And trying to be as respectful an
01:10:07as inclusive in that conversation
01:10:09as we can possibly be.
01:10:11And there's patients.
01:10:12There's their partner,
01:10:13their family.
01:10:14There's a lot of people who have
01:10:18opinions about what women should be doing.
01:10:21When they make choices about
01:10:22these operations,
01:10:23and I think we have as many patients
01:10:25who come into our offices where
01:10:27they have family members telling
01:10:29them that they should be having
01:10:31bilateral mastectomies is as we have.
01:10:32You know, other concerns that come forward.
01:10:35So it's important that.
01:10:37We're all as respectful and
01:10:38inclusive as we can be,
01:10:40and that we're ready for these
01:10:42conversations that we're ready to talk
01:10:44about how our bodies change as we age.
01:10:45How an implant might feel when
01:10:47you're 40 and how it's going to feel
01:10:50really differently when you're 70?
01:10:52So that's all got to be addressed up front,
01:10:56so I have not had that experience
01:10:59where I had a patient felt.
01:11:02Like they I was talking to them too
01:11:04much about reconstruction without
01:11:05respecting that they wanted to be flat,
01:11:08but I have read a lot of that literature.
01:11:11I did read the book flat as well.
01:11:16Yeah, I agree. I think it's
01:11:18a really personal decision.
01:11:20I also remind women that it it
01:11:23can be an ongoing discussion,
01:11:25so I have had women who could not
01:11:27manage the thought of embarking on
01:11:30reconstruction around diagnosis and they
01:11:33ended up a few years later wanting to
01:11:35meet with the reconstructive surgeon.
01:11:37So for many women there are
01:11:40options down the road.
01:11:41They might be limited compared to the
01:11:44options they have a diagnosis, but.
01:11:46The door should never feel
01:11:48entirely closed for them.
01:11:51I have a question from my colleague
01:11:54Doctor Fatty Ottawan from Turkey for
01:11:56Doctor Green up wanting to know what
01:11:59your thoughts are looming in Turkey.
01:12:01The average age of breast cancer is
01:12:03much younger than the United States.
01:12:06What are your thoughts on
01:12:08luminal a breast cancer?
01:12:09Zan, whether neoadjuvant chemotherapy
01:12:11potentially could be an option or or
01:12:13other thoughts on this population.
01:12:16Yeah, so we you know we talk
01:12:19about this in the context of multi
01:12:23disciplinary discussion and I think.
01:12:26In the US, at least,
01:12:29we're heavy utilizers of genomic
01:12:31assays and the abdomen setting.
01:12:33Occasionally we discuss using them
01:12:35in the neoadjuvant setting to help
01:12:38inform decisions around whether
01:12:40chemotherapy should be used,
01:12:41and certainly thinking about
01:12:43the size of the breast cancer.
01:12:46The status of the axilla.
01:12:49And all of those the patients
01:12:52preference for breast conservation
01:12:55versus mastectomy all contribute to
01:12:58decisions for preoperative chemo.
01:13:03There is a question from our colleagues
01:13:05from China where the breast tissue
01:13:07density tends to be a lot higher on
01:13:09our thoughts on a screening ultrasound.
01:13:11And obviously here in Connecticut
01:13:13we can maybe give a little bit of
01:13:16a different perspective than maybe
01:13:18the rest of the United States.
01:13:20After lunch you want it or burger or.
01:13:24So I hope you're screening ultrasound
01:13:26and I'm becoming more and more
01:13:28familiar with it because it's used
01:13:30routinely here in Connecticut.
01:13:32I have recently moved from
01:13:34Ohio to Connecticut in Ohio.
01:13:36We didn't routinely do whole breast
01:13:39screening ultrasound and it seems
01:13:41to be a very very effective test.
01:13:43We know it hasn't.
01:13:45It picks up additional cancers at a rate
01:13:48of 8% more than mammography screening.
01:13:50MRI for dense breasts picks
01:13:52up at a rate of 14%.
01:13:54I think in Connecticut because of
01:13:56ultrasound is so routinely used and it's
01:13:58a user dependent technology that their
01:14:00rates are actually much higher than
01:14:028% which is reported in the literature.
01:14:04So it can be a very effective
01:14:06adjunct to mammography for dense
01:14:08breasts and it's user dependent.
01:14:09So the more you do,
01:14:11the better you get,
01:14:12and I think that's why the rates
01:14:14here in Connecticut look look
01:14:16better than the rest of the country.
01:14:21There was a question from a doctor
01:14:24lustberg our incoming breast
01:14:25program director to touch base
01:14:28upon shared decision makings for.
01:14:30Doctor Lynch just because of your
01:14:32you know wide array of surgical
01:14:34options that you can provide patients
01:14:36that maybe some of us don't have
01:14:39the that background or you know
01:14:40those techniques that you discuss.
01:14:42What are your thoughts on that?
01:14:45It's yeah, it's. You know,
01:14:49we always worry about informed consent.
01:14:51Can we really explain to patients
01:14:54how this is going to look and
01:14:56feel to them after we're done
01:14:58with our operation and and we've,
01:15:01in my experience so far in using
01:15:04Oncoplastic operations, well,
01:15:05an doctor Krishna Clef recently published
01:15:07an editorial in Annals of Surgical
01:15:09Oncology about how we're using this
01:15:12technique too much for some patients,
01:15:14and we have to be really careful
01:15:17about how we apply this.
01:15:19But we need to be able to.
01:15:22Describe to patients exactly how
01:15:24we do the operation and how it
01:15:26might feel to them afterwards.
01:15:28One of the issues that we're now
01:15:30beginning to really understand is
01:15:32how distressing it is for patients
01:15:34to experience fat necrosis.
01:15:35The more we separate the skin
01:15:37from the breast,
01:15:38the and then radiate that tissue,
01:15:40the more patients are likely
01:15:42to feel a mass in their breast
01:15:44after they've had treatment,
01:15:45and that is actually fat necrosis
01:15:47and not recurrent cancer.
01:15:49And to be able to prepare patients for that,
01:15:52the older the patient is with,
01:15:54the more fat replaced breast.
01:15:56We know that they are more likely
01:15:57to develop fat necrosis and we
01:15:59need to be able to have that
01:16:00conversation with patients,
01:16:02and so if and when that mask comes
01:16:03up that they're not as distressed by
01:16:05it and that they they know that they
01:16:07can come in and we can evaluate it
01:16:10and help help help sort that out.
01:16:12But the shared decision making is
01:16:14a process and it can include the
01:16:16whole of the multidisciplinary team
01:16:18including the radiation oncologist as well.
01:16:21Because of the they can talk to
01:16:23patients so they understand fully what
01:16:25radiation might feel to the breast
01:16:28when they're they're done with treatment.
01:16:31But that's it.
01:16:32That's a, that's a.
01:16:33That's a whole conference in itself.
01:16:35Yeah,
01:16:35well,
01:16:35we'll
01:16:36have the next session on that.
01:16:39Doctor Berger or what are your
01:16:41thoughts on intra op margin
01:16:42assessments are or is that something
01:16:44that's ready for prime time?
01:16:46Or you know something that's still
01:16:48kind of in the research realm?
01:16:50And obviously Doctor Green
01:16:51up at lunch as well too?
01:16:54Yeah, I know I'm up at
01:16:56your previous institution.
01:16:57There's been some looking at,
01:16:59you know, looking at Inter operative
01:17:01margin assessment and whether we can
01:17:04lower the chance of positive margins
01:17:06on the final pathology specimen.
01:17:08There's been different feasibility trials.
01:17:09Looking at that,
01:17:10there's been different even outcome trials.
01:17:12Looking at that,
01:17:13I'm not sure we're quite there yet,
01:17:15just based upon the limited
01:17:17amount of data that we do have.
01:17:19But you know,
01:17:20definitely something in the future that
01:17:22might be a possibility to prevent,
01:17:24you know, return to the OR
01:17:25on some of these patients.
01:17:29Yeah, I think nationally
01:17:31we've continued to have
01:17:33to balance the extra operating room time.
01:17:36The logistics around having a workforce
01:17:40of pathologists available to evaluate
01:17:42margin in real time and then the
01:17:46accuracy obviously of the data that's
01:17:48received in the operating room,
01:17:51certainly from the technology side.
01:17:53There's a lot of independent companies and.
01:17:57NIH funded study is in partnership with.
01:18:03Industry looking at real time Inter
01:18:06operative margin assessment and certainly
01:18:08breast is a great place to start,
01:18:11but I would argue it will be
01:18:14really wonderful for patients.
01:18:16For example that have pancreas
01:18:18cancers or liver tumors where the
01:18:21return trip to the operating room
01:18:23carries a much higher morbidity.
01:18:28There is a question from Professor
01:18:30Dong in China about a 65 year old
01:18:33with early stage breast cancer.
01:18:34For example, a very tiny tumor,
01:18:36less than a 0.5 millimeters and
01:18:38they undergo breast conservation.
01:18:40You know we have data on what you
01:18:42know women over 70 and maybe the ER
01:18:45positive setting on avoiding radiation.
01:18:47How about on a slightly younger
01:18:49patient you know, do we?
01:18:51Can we drop that cut off and you
01:18:53know where do we go from there?
01:18:57Yeah, so we have good data from the
01:18:59prime two study looking at patients
01:19:01over 65 and ER PR positive cancers
01:19:03and deescalation of radiation therapy.
01:19:05But what I find really important too
01:19:07is you know asking the question can
01:19:10we deescalate hormone therapy so you
01:19:12know this principle of monotherapy,
01:19:14whether it is radiation or homeless
01:19:16hormone therapy I think is really
01:19:18important and that question is
01:19:20actually being asked right now in
01:19:22an ongoing trial because you know,
01:19:23a lot of people consider radiation therapy
01:19:25is the thing we should deescalate because.
01:19:28Hormone therapy protects you for the five
01:19:30years in the contralateral breast, etc.
01:19:32But that does not come without its own
01:19:34side effects an it's owned, you know,
01:19:37kind of pit bulls and downfalls.
01:19:39And so I think if we look at the
01:19:41local regional recurrence rates,
01:19:43which recently I actually just
01:19:44did there relatively similar with
01:19:46the monotherapy principle.
01:19:47As far as DCIS goes, you know,
01:19:49I think there are a lot of
01:19:50good predictive nomograms,
01:19:52and we know that age obviously lessens
01:19:54your chance of recurrence just based
01:19:56upon the fact that a woman is older.
01:19:59And so yeah, again,
01:20:00going back to this whole principle
01:20:02of shared decision making,
01:20:04that if you have a an informed decision
01:20:07with your patient and try to predict
01:20:10or recognize their risk of recurrence,
01:20:13understanding that 50% of
01:20:14DCIS recurrences are invasive,
01:20:16then omitting both agile and
01:20:18treatments for DCIS.
01:20:19I don't think it's unreasonable based upon
01:20:23the risk that your patient is willing to us.
01:20:27You know,
01:20:28take.
01:20:33Maybe the last question from
01:20:35Scott Posa for whoever wants to
01:20:38try to tackle this one in terms of some of
01:20:41the more complex reconstructions such as
01:20:44pop reconstructions in terms of ambulation
01:20:47and limitations associated with that.
01:20:58So with early post-op ambulation
01:21:02after a tissue transfer. Maybe
01:21:05with a more complex free tissue
01:21:07transfer type reconstructions?
01:21:10'cause you have to protect both the
01:21:13donor site then and the recipient site.
01:21:16And so with microvascular repairs,
01:21:18you know patients will typically be
01:21:20limited in mobility for three to five days,
01:21:23and so you know 24 hours to 48 hours
01:21:27from bed to chair only for mobility.
01:21:30Usually a Foley catheter will
01:21:32be in place for that for a day
01:21:35or two days for those patients,
01:21:37or a bedside commode.
01:21:39Because of the need for the to
01:21:43protect the microvascular site.
01:21:48And so that can impact early
01:21:50mobility, and it's certainly
01:21:52shoulder mobility and things.
01:21:57And then afterwards again, it's,
01:21:58you know, gentle range of motion
01:22:01exercises after surgery to make sure to.
01:22:04Detect shoulder mobility with
01:22:05full range of motion, hopefully
01:22:08within two weeks of the operation.
01:22:12I said that was the last question.
01:22:14Actually there's one more,
01:22:15and it's all the way from Japan,
01:22:17so I can't let Doctor
01:22:19Sakai get go unanswered.
01:22:20What are our thoughts on putting a
01:22:21clip for biopsy proven lymph nodes
01:22:23before neoadjuvant chemotherapy?
01:22:28That is a long discussion, I think in.
01:22:32I'll try and answer. It's essentially but.
01:22:37Many other national trials
01:22:39that are looking at potentially
01:22:42downstaging an axillary disease
01:22:44after neoadjuvant chemotherapy have
01:22:46not required clip placement, and so.
01:22:51Pending those results, I think.
01:22:54Most US institutions are localising.
01:22:59Lymph nodes that are involved
01:23:00with tumor with a clip.
01:23:02With the intention of marking the spot and
01:23:05for future resection of that involved.
01:23:08And node certainly that Abigail
01:23:11Coddles data from MD Anderson looking
01:23:14at targeted axillary dissection and
01:23:17the 1071 data from Judy Bui both
01:23:21include clip placement in the node
01:23:23for the purpose of retrieving the.
01:23:27They know that was most likely to be
01:23:30effective or have the highest tumor burden,
01:23:32but if the Alliance 11202
01:23:34trial shows otherwise,
01:23:35clip placement may be a thing of the past.
01:23:41So with that I would really like to
01:23:44thank Doctor Berger, Doctor Lynch,
01:23:46Doctor Green up for these three
01:23:48fantastic presentations and you know
01:23:50the thoughtfully answers we've been
01:23:51able to provide to the audience,
01:23:53and more importantly,
01:23:54to the attendees from, you know,
01:23:57Yale, Connecticut, around the
01:23:58United States and around the world.
01:24:00We really appreciate the time and the
01:24:03you know to listen to us and we look
01:24:06forward to seeing you in person one day,
01:24:09and until then,
01:24:10we will continue these series.
01:24:11So thank you very much.