ongoing controversies in surgical management · ongoing controversies in surgical management terry...

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Ongoing Controversies in Surgical Management

Terry Mamounas, M.D., M.P.H., F.A.C.S.Medical Director, Comprehensive Breast Program

UF Health Cancer Center at Orlando HealthProfessor of Surgery, University of Central Florida College of Medicine

Clinical Professor of Clinical Sciences,Florida State University College of Medicine

Outline

• Optimal Management of the Clinically Negative Axilla with Positive SLN(s)

• Optimal Management of the Axilla in Patients Treated with Neoadjuvant chemotherapy

• Adequate Margin Width in Breast Conserving Surgery

• Role of Surgical Excision of the Primary Breast tumor in Patients Presenting with Stage IV Disease

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Clinically Negative Axillary NodesN=5611

GROUP 1Sentinel Node

Biopsy

Axillary Dissection

GROUP 2Sentinel Node

Biopsy*

Randomization

Stratification• Age

• Clinical Tumor Size• Type of Surgery

*Axillary node dissection only if the SN is positive

NSABP B-32: RCT of SLNB +/- ALND

• ID Rate: 97%• FN Rate: 9.8%

• Average # SLNS: 2.9• Factors significantly

affecting ID rate:– Age, Tumor Size and Tumor Location

• Factors significantly affecting FN rate:

– Type of Biopsy and Number of Removed SNs

Krag D et al: Lancet Oncology 2007

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NSABP B-32: False-Negative Rate According to Number of Removed SNs

Krag D et al: Lancet Oncology 2007

_

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NSABP B-32 Sentinel Node-Negative PatientsDFS, OS and LRR

0

20

40

60

80

100

0 2 4 6 8 10

% D

ises

e-Fr

ee

Years after Randomization

Julian T, et al: SABCS 2013, Abst. S2-05

Treatment N EventsSNR+AD 1975 455SNR 2011 475

HR=1.02 p=0.720

20

40

60

80

100

0 2 4 6 8 10

% S

urvi

ving


Treatment N DeathsSNR+AD 1975 228SNR 2011 252

HR=1.09 p=0.35

SN+AND (N=1975) SN (N=2011)Local 75 (3.8%) 66 (3.3%) Axillary 4 (0.2%) 11 (0.5%) Extra-axillary 5 (0.3%) 4 (0.2%)

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Optimal Management of the Clinically Negative Axilla with

Positive SLN(s)

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ACOSOG Z0011

Giuliano AE et al: JAMA 2011

EndpointSLNBAlone

SLNB +

ALND

Pvalue

Additional Positive Nodes on ALND

N/A??

27.3%97 pts

5-Year In-Breast Recurrence

2.1% 3.7% 0.16

5-Year Axillary Nodal Recurrence

1.3% 0.6% 0.44

5-Year Overall Survival

92.5%(90-95.1)

91.8%(89.1-94.5)

HR: 0.870.25

5-Year DFS 83.9%(80.2-87.9)

82.2%(78.3-86.3)

HR: 0.880.14

Completion ALND

(n=445)

No Further Surgery(n=446)

Randomization

Lumpectomy+

Breast XRT

Included in Primary Analysis

N=420 N=436

Clinically Negative Patients1-2 Positive SNs by H & E

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IBCSG 23-01 Trial• Tumor Size < 5 cm• Clinically Node

Negative • > 1 Micrometastases in

the Sentinel Node

RandomizeN=934

ALND

No ALND

9% had mastectomy

13% +NSNs

HR (no ALND vs. ALND)HR=0.87; 80% CI (0.67‐1.12);

below non‐inferiority boundary of 1.25

N 5-Yr DFS %

No ALND 467 88.4% 0.48

ALND 464 87.3%

N 5-Yr OS % P

No ALND 467 98.0% 0.35

ALND 464 97.6%

Median FU 57 months

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Impact of Z0011 on Number of Axillary Nodes Removed for Patients with ESBC (NCDB)

Yao K, et al: J Am Coll Surg, 2015

Proportion of Lumpectomy Patients Meeting Z0011 Criteria Receiving SNB

p < 0.001

Criterion % of SLNB Alone

> 5 cm 54%No XRT or APBI 52.5%

Clinically (+) Nodes 35.9%

Mastectomy 22.3%> 3 Positive Nodes 12.9%

Patients Outside of Z0011 Criteria also

had SNB Alone

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AMAROS Trial:Axillary Dissection vs. Axillary XRT After (+) SLN

cT1-2N0 R

• Primary Objective: To demonstrate non-inferiority in axillary recurrence rate with axillary XRT vs. ALND

ALND

AxRT

SNB AxSN+

Donker M. Et al: Lancet Oncol, 2014

17-18% had mastectomy33% +NSNs

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AMAROS: Endpoints

Donker M. Et al: Lancet Oncol, 2014

HR:1.17; P = 0.18 HR:1.17; P = 0.34

Overall SurvivalDisease-Free Survival

0

10

20

30

40

1 3 5

ALND

AxRT

28.0%40.0%

29.8%

21.7% 16.7%13.6%


Lymphedema

5-year Axillary Recurrence Rate

ALND 0.43%AxRT 1.19%

Design Assumption: 2% for ALND

Planned Comparison is Underpowered

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ACOSOG Z0011: A Randomized Trial of Axillary Node

Dissection in Women with Clinical T1-2 N0 M0 Breast Cancer who have a

Positive Sentinel Node

Giuliano AE, McCall L, Beitsch PD, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, Hunt K,

Brennan M, Ballman KV, Morrow M

Giuliano A. et al., ASCO 2016

ALND (N=420)

10-Yr Locoregional Recurrence

Local 19 (5.6%) 12 (3.8%)

Regional 2 (0.5%) 5 (1.5%)

Total loco-regional 21 (6.2%) 17 (5.3%)

SLND (N=436)

0.13

0.28

0.36

P value

By Treatment Arm

Median follow-up = 9.25 years (111 mos)


By 5 yrs

Comparison of 10-Year Regional Recurrence to Initial 5-Year Report

ALND 2 (0.5%)

SLND 4 (0.9%)

Nodal recurrence

Only one additional regional recurrence was seen after 5 years

By 10 yrs

2 (0.5%)

5 (1.5%)*% Kaplan-Meier estimate


ACOSOG Z11: DFS and OS

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8 9 10Time (years)

ALNDSLND only

HR=0.85P=0.32

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10Time (years)

ALNDSLND only

HR=0.85P=0.40

DFS OS


Conclusion

SLND alone provides excellent 10-year loco-regional

control and survival comparable to completion ALND for these

selected patients even with long-term follow-up


How Do We Incorporate the Recent SNB Data into Clinical Practice?

• For lumpectomy patients (who meet Z11 criteria) intraoperative assessment on the SN(s) can be omitted– If 1-2 SN(s) are positive consider no further

surgery vs. axillary XRT• For mastectomy patients, and patients who do

not meet Z11 criteria, intraoperative assessment could be helpful– If the SNs are positive, consider completion

ALND vs. axillary XRT

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Management of the Axilla in Patients Treated with

Neoadjuvant Chemotherapy

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• Neoadjuvant chemotherapy down-stages axillary nodes in 20-40% of the patients

• Even higher rates (> 50%) in HER-2 + patients with chemo + Anti-HER 2 therapy

• Potential for decreasing the extent of axillary surgery with SLNB

ACNSABP B-18

40

30

20

10

0

% ConversionFrom Node (+)

To Node (-)

ATCMFECTO

3037

FECEORTC

19

ACTXTNSABP B-27*

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*Assuming 30% nodal down-stagingwith neoadjuvant AC

Effect of Neoadjuvant Chemotherapy on Axillary Nodal Metastases

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Decreasing the Extent of Axillary Surgery With NC

• This concept is currently applicable to patients with operable breast cancer (cT1-3N0-cN1)

• Most available data on the performance of SNB before or after NC have been obtained in patients with operable BC

• Feasibility and accuracy of SNB after NC is questionable in patients with LABC (T4, cN2, IBC)

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• Ultrasound of the axilla with FNA of indeterminate/suspicious nodes:– Simple, minimally invasive– Can provide useful clinical information (avoid

SNB, demonstrate direct chemosensitivity)

• Sentinel node biopsy before NC is controversial

Clinical Assessment of Axillary Nodal Status Before NC

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Management of the Clinically NegativeAxilla in Patients Treated with NC

• After a decade of fierce debate SLNB after NC has become the arguable standard in patients with operable BC

• This approach capitalizes on the down staging effect of NC in sub-clinically involved axillary nodes)

• Feasibility and accuracy have been shown in multiple settings

• IR is somewhat lower than with upfront SLNB but no differences in FNR between the two approaches

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SNB After NCMeta-Analysis of Single-Institution and

Multi-Center Studies

• 24 studies• 1779 patients• Identification Rates: 63-100%

–Pooled estimate: 89.6%• False Negative Rates: 0-33%

–Pooled estimate: 8.4%

Conclusion:SNB is a reliable tool for

planning treatment after NC

Kelly A et al: Acad Radiol 2009

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• Conclusion: SLN surgery after NC is as accurate as SLN surgery prior to chemotherapy, results in fewer positive SLNs and decreases unnecessary axillary dissections

SNB After NC: MD Anderson Experience

Hunt K et al: Ann Surg Oncol, 2009

SNB After NC (n=575)

SNB Upfront (n=3171)

P-value

Identification Rates 97.4% 98.7% 0.017False Negative Rates 5.9% 4.1% 0.39Nodal Positivity Rates

T1 12.7% 19.0% 0.2T2 20.5% 36.5% <0.0001T3 30.4% 51.4% 0.04

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• Retrospective studies: Variability in SLN IR (78%-98%) and SLN FNR (5%-30%)

• Three prospective trials were recently published (ACOSOC Z1071, SENTINA, SN FNAC)–IRs were lower with SLNB after NC (80-93%)

compared to upfront SLNB (>95%)–FNRs ranged between 9.6%-14% and were

mainly affected by number of removed SNs

SLNB After NC in Patients with Documented (+) Axillary Nodes

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SLNB After NC in Patients with + NodesFNR According to Number of Removed SLNs

ACOSOG Z1071

FN SNAC SENTINA Across studies

# of patients 756 153 592 1501

FNR withsingle SLN

31.5%17/54

18.2%4/22

24.3%17/70

26.0%38/146

FNR if 2 or more SLNs

12.6%39/310

4.9%3/61

9.6%15/156

10.8%57/527

FNR with dual tracer

10.8%27/251

- 8.6%6/70

10.3%33/321

FNR if >2 SLNs 9.1%20/220

- 4.9%5/102

7.8%25/322

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Re-Analysis of Z1071: Role of IHCBoughey J: SABCS 2014

• Re-analysis of 470 patients (90% of total) with cN1 and ≥ 2 SNs for which pathologic evaluation with IHC was available

• The FNR was 8.7% (95%CI, 5.6-11.8)• Increase in unnecessary CLND (dissecting

the nodes because of a (+) SN with ITCs and not finding non-SNs with metastases > 0.2 mm) was only 2.1% (10/470)

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Re-Analysis of Z1071: Role of IHCBoughey J: SABCS 2014

• An unplanned subgroup analysis of Z1071 examined patients who had a clip placed in the positive node at time of biopsy (32% of the total)

• FNR was 6.8% when the clip was retrieved in the SLNs

• If the clip was not identified in the SLNs, the FNR was much higher: 39%

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• Appropriate candidate selection for SLNB (T1-3,N1)• Dual agent lymphatic mapping (isotope + dye)• Identification and removal of >2 SNs

• Clip placement in the positive node with radiologic clip localization and retrieval

• Consideration of performing IHC staining in the SLN and consider completion ALND even with N0i+ disease

Optimizing SLNB After NC in Patients with Documented (+) Axillary Nodes Before NC

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• Helpful if the SN is negative• Patients with large operable breast cancer

have high likelihood of positive nodes• Does not take advantage of the down-staging

effects of neoadjuvant chemotherapy on nodes: 30-40% conversion from (+) to (-)

• May remove the only positive node(s) (interferes with direct assessment of chemosensitivity

• Requires two surgical procedures

SLNB Before NC: Pros and Cons30

• Breast XRT: Should be always given after lumpectomy

• Chest Wall and Regional Nodal XRT: Consider factors predicting local-regional recurrence after NC (baseline clinical characteristics + pathologic response to NC)

• These factors significantly predict rates of local-regional recurrence after NC

Can We Use Tumor and Nodal Response to NC in Order to

Individualize the Use of L-R XRT?

SNB Before NC:Selection of Loco-Regional XRT?

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Adequate Margin Width in Breast Conserving Surgery

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The Margin Width Controversy in BCS• This controversy is as old as the procedure itself• Two divergent techniques with diametrically

opposed approaches to margin width• Lumpectomy (NSABP): Removal of tumor with limited

normal surrounding tissue; path negative margins: “no ink on tumor” on microscopic assessment

• Quadrantectomy (Milan Group): Removal of the affected quadrant + overlying skin + underlying fascia en block; generally wider margins; originally intended to avoid XRT

• Benefit from XRT demonstrated with both procedures, further fueling the margin width debate

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SSO-ASTRO: Margins Consensus Guideline

• A multidisciplinary consensus panelconsidered:• Large, study level meta-analysis of margin

width and IBTR (33 studies, 28,162 pts)• Results of randomized trials• Reproducibility of margin assessment• Current patterns of multimodality care

Moran M, et al: J Clin Oncol, 2014

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SSO-ASTRO:Margins Consensus Guideline

• Recommendations:• Use of no ink on tumor as the standard for

an adequate margin in IBC in the era of multidisciplinary Rx results with low rates of IBTR

• This approach has the potential todecrease re-excision rates, improve cosmetic outcomes, and decrease healthcare costs

Moran M, et al: J Clin Oncol, 2014

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• Clinical observations that provide assurance when applying the recommendations:• Dramatic decline in the rates of IBTR• 5-year IBTR: 5.3% in the meta-analysis


Strengths

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• Applies to invasive BC treated with whole breast XRT

• The findings cannot be extrapolated to patients with pure DCIS or after neoadjuvant chemo

• Based on study-level meta-analysis• Close margins: increased risk of IBTR• Strength of evidence: “no tumor on ink” vs.

> 1 mm

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Limitations

• 235 patients, stage 0 to III BC• BCS +/- resection of selective margins• Intraoperative Randomization:

• Cavity Shave Margins vs. Not• Primary Outcome: Rate of (+) margins• Secondary Outcomes: Cosmesis and

Volume of tissue resected

A Randomized, Controlled Trial of Cavity Shave Margins

Chagpar A, et al: N Engl J Med 2015

• Results: Shave group associated with: • Lower rates of (+) margins: 19% vs. 34%, P = 0.01

Lower re-excision rates: 10% vs. 21%, P = 0.02 • No differences in complications, cosmesis and rates of

complex tissue rearrangements

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Management of the Breast Primary in Patients Presenting

with Stage IV BC

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• Conventional wisdom is that once metastases have occurred, aggressive local therapy provides no survival advantage and should not be pursued except to prevent local complications (bleeding, ulceration, infection)

• Several retrospective studies have shown significantly better outcomes for women who had surgical removal of their tumor vs. those who did not (particularly for those who had negative margins)

Primary Surgical Therapy in Patients Presenting with Stage IV BC

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• Surgery of the primary tumor appeared to be an independent factor for an improved survival in the multivariate analyses from the individual studies, with an HR of 0.69 (p<0.00001)

• Most studies adjusted for imbalances in known prognostic factors (such as number of mets, location of mets, type of systemic therapy or use of radiotherapy)

• Most studies concluded that unrecognized selection bias may have accounted for the observed benefit of surgery and only large prospective RCTs could reliably answer the question


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Tata Memorial Center Randomized Phase III Trial

R

Loco-Regional

Treatment*Anthracyclines +/- Taxanes

(CR /PR ) No Loco-Regional

Treatment

Stage IV BC At Presentation

Stratification by: • Hormone-Receptor Status• Site of metastases (visceral vs. bone vs. both)• Number of metastatic lesions (< 3 vs. > 3)

*LRT: BCS or Mastectomy + AND followed by radiation therapy (RT), as per standard adjuvant guidelines

Badve R et al: SABCS 2013, Abstract S2-02

N=350

Median F/U:17 mos

Tata Memorial Center Phase III TrialResults: Overall Survival

• The median OS in LRT and No-LRT arms were 18.8 and 20.5 months (HR=1.04, p=0.79)

• Corresponding 2-year OS were 40.8% and 43.3%, respectively

• No significant difference in OS between the two groups after adjusting for age, ER status, HER2 status, site and number of mets (HR=1.00, 95%CI=0.76-1.33, p=0.98).

Badve R et al: SABCS 2013, Abstract S2-02

MF07-01 Turkish Study: Design

Soran A, et al: SABCS 2013, Abstract S2-03

• Chemotherapy to all patients either after randomization in the ST treatment arm or after surgical resection the surgery arm

• Hormone therapy for HR positive BC and trastuzumab for HER-2 positive BC

• Surgery-RT at discretion of investigator

MF07-01 Turkish Study: ResultsOverall Survival

Soran A, et al: SABCS 2013, Abstract S2-03

Atilla Soran, MD, MPH, FACS, Magee-Womens Hospital of UPMC Vahit Ozmen, Serdar Ozbas, Hasan Karanlik, Mahmut Muslumanoglu, Abdullah Igci, Zafer Canturk, Zafer Utkan, Cihangir Ozaslan, Turkkan Evrensel, Cihan Uras, Erol Aksaz, Aykut Soyder, Umit Ugurlu, Cavit Col, Neslihan Cabioğlu, Betül Bozkurt, Efe Sezgin, Ronald Johnson, Barry LemberskyOn behalf of the Turkish Federation of Societies for Breast DiseasesClinicalTrials.gov identifier number is NCT00557986

A Randomized Controlled Trial Evaluating Resection of the Primary Breast Tumor in Women Presenting with de Novo Stage IV

Breast Cancer: Turkish Study (Protocol MF07-01)

Soran A. et al., ASCO 2016

312 Recruited

19 Exclusions

293 Eligible

293 Eligible19

Withdraw or Failure to Follow-

up

274 Evaluable

274 Evaluable138

Initial Local Therapy plus

Systemic Therapy

136Systemic Therapy


Surgery

ST

Ove

rall

Surv

ival

Follow-up Time (months)

N Death Median (mos)

Surgery 138 76 46

ST 136 101 37

SurgeryST

Number at Risk

5-year Survival

41.6%

24.4%

HR: 0.66P=0.005


0.1 1 10

Subgroup

ER/PR PositiveER/PR NegativeHER2 PositiveHER2 NegativeTriple Negative

Age<55Age≥55

Bone only MetOther Mets noBoneSolitary Bone MetMultiple Bone Met

Solitary Pulmonary/Liver MetMultiple Pulmonary/Liver Mets

Favors surgery Favors No Surgery

Survival OR 95%CI


N Death Median (mths)

Surgery 136 75 46

ST 121 92 33

Patients with no Loco-regional Progression

Surgery

ST

Ove

rall

Surv

ival

Follow-up Time (months)LR progression Surgery=1% (2) ST=11% (15) P=0.001


• Survival was similar in 36 months with or without primary breast surgery

• Longer follow up revealed statistically significant improvement in median survival with surgery (46 vs 37 months; HR:0.66) and 5 year OS was 41.6% vs 24.4%, respectively

• Patients with a more indolent form of metastatic BC such as ER (+), HER2 neu (-), solitary bone metastasis, and patients < 55 years old have a significant survival benefit with initial surgery

MF07-01: Summary


A Prospective Analysis of Surgery and Survival in Stage IV Breast Cancer (TBCRC 013)

King TA, Lyman JP, Gonen M, Reyes S, Boafo C, Plichta J, Hwang ES, Rugo HS, Liu M, Boughey JC, Jacobs LK, Krontiras H, McGuire K, Storniolo A, Nanda R, Golshan M, Isaacs C, Meszoely IM, Van Poznak C, Babiera G, Norton L, Morrow M, Wolff AC, Winer EP, Hudis CA

Translational Breast Cancer Research Consortium

King TA. et al., ASCO 2016

TBCRC 013: Prospective Registry

• Characterize patients presenting with stage IV breast cancer in the modern era:– Response to first-line therapy– Proportion of patients who undergo surgery of

the primary tumor– Surgical decision-making process*

Presented by:

*Presented ASBrS 2016


TBCRC 013: Prospective Registry

• Correlate molecular characteristics of the primary tumor with conventional prognostic factors, surgery and survival

• Determine the incidence of uncontrolled local disease and the frequency with which surgical palliation is needed

• Perform correlative molecular studies

Presented by: King TA. et al., ASCO 2016

TBCRC 013: Cohort A

• 112 pts with de novo Stage IV disease and intact primary

• 1st line systemic therapy per treating physician

• Responders to 1st line therapy offered opportunity to discuss elective surgery (absence of local symptoms or need for local control)


TBCRC 013 Cohort APatient Characteristics

Presented by:

Tumor Subtype

HR+HER2‐ 71 (63%)

HR+HER2+ 24 (21%)

HR‐HER2+ 9 (8%)

Triple Negative 8 (7%)

Site of Mets at dx

Bone Only 51 (46%)

Visceral Only 26 (23%)

Both 27 (24%)

Other 8 (7%)

# Met Sites at dx

Single Organ 64 (57%)

>1 Organ 48 (43%)

Median Patient Age: 51 yrs (21-77yrs)

Median Tumor Size: 3.2cm (0.8-15cm)

ECOG score 0: 56 (50%)1: 51 (46%)>1: 5 (4%)


TBCRC 013 Cohort AOverall Survival

Presented by:

N=112

3yrs OS 70% (95%CI 63-79%)

Median Survival69 mos (51 – NR)

Median follow‐up 54 mos (34‐78mos)


TBCRC 013 Cohort AResponse to 1st line therapy

Presented by:

N=112*

94 (85%)Responders (R)

17 (15%)Non‐Responders (NR)

*1 lost to f/u

• ER + was the only baseline difference between Responders (88%) and Non‐Responders (65%), p=0.02


Survival: Responders vs Non-RespondersLandmark Analysis at 6 months

Presented by:

Non-responders (NR)

Responders (R)

N median survival, mos 30 mo survival (95%CI) P

R 90 65 mos (52‐NR) 78% (70‐87) < 0.001

NR 16 13 mos (9‐31) 24% (10‐55)

6 mos, surrogate for time to response assessment after 1stline therapy, per treating physician


TBCRC 013: Surgical Uptake

Presented by:

N=112*

94 (85%)**responders

39 (43%) elective surgery

51 (57%) no surgery

17 (15%)non‐responders

* 1 lost to f/u** 4 lost to f/u

Median time to elective surgery 7 mos (3‐20mos)


TBCRC 013 Cohort A Characteristics by Surgery

Presented by:

Surgery N=39

No SurgeryN=51

p

Median Age 49yrs (21-73) 52yrs (29-74) 0.17

Tumor Size 3.8cm (1.6-12) 3.2cm (0.8-15) 0.01

Tumor Subtype (ER+ vs other) 34 (87%) 46 (90%) 0.26

Site of Mets at Dx (bone vs other) 19 (49%) 22 (43%) 0.45

Single Organ Metastatic Disease 30 (77%) 21 (41%) 0.001

1st line chemotherapy 15 (39%) 9 (17%) 0.002

Race, marital status, employment status, income level, education and co-morbidities did not differ by use of surgery


Multivariate Analysis: Survival

Presented by:

Stepwise Cox regression: includingage, size, ECOG, HR, Her2, tumor grade, response and surgery

N Median Survival, mos 30 mos survival (95%CI)

Non‐Responders 16 13 mos (9‐31) 24% (10‐55)

Responders, No Surgery (red) 51 65 mos (50‐NR) 76% (66‐89)

Responders, Surgery (green) 39 71 mos (46‐NR) 77% (65‐91)


TBCRC 013: Palliative Surgery

Presented by:

N=112*

94 (85%)**responders

39 (43%) elective surgery

51 (57%) no

surgery

Palliative surgery 2 (4%)

17 (15%)non‐

responders

Palliative surgery 3 (18%)

* 1 lost to f/u** 4 lost to f/u

Median time to palliative surgery 17 mos (8-35 mos)


TBCRC 013: Conclusions• In this prospective registry study, 3yr overall survival

among patients presenting with de novo stage IV disease is 70%

• The majority of patients (85%) responded to 1st line therapy and response was significantly associated with survival

• Among patients who respond to systemic therapy – the need for palliative surgery is uncommon– progression free survival is not negatively impacted

by surgery


• Until more RCT data become available showing improved outcomes with surgical resection of the primary, not removing the primary tumor remains the standard

• Surgery can be entertained in selected cases (before or after systemic therapy) for local control if local manifestations are more likely to contribute to morbidity than distant ones

• In such cases, BCS surgery is preferable if it can encompass the scope of the surgical resection

• Axillary node surgery or breast XRT are generally not advisable


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Questions?

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