Download News from the Magee-Womens Breast Cancer Program of UPMC

Breast Cancer in brief
Vol. 3, No. 1, 2010
News from the Magee-Womens Breast Cancer Program of UPMC Cancer Centers
Dear colleagues:
Page 2
Case report
Skin-sparing mastectomy with TUG flap
reconstruction following previous lumpectomy
Page 3
Nipple-sparing mastectomy providing
cosmetic advantages for select patients
Trial evaluates the use of SLN mapping for
women with advanced cancer
Page 4
Patient-centered diagnostic testing
and treatment
Magee-Womens Breast Cancer Program
of UPMC Cancer Centers
Breast Surgery
Gretchen M. Ahrendt, MD, FACS
Marguerite Bonaventura, MD
Howard D.J. Edington, MD, MBA
Ronald R. Johnson, MD
Joseph L. Kelley III, MD
Kandace McGuire, MD
Maryann Payne, MD
Atilla Soran, MD, MPH, FACS
Paniti Sukumvanich, MD
Breast Imaging
Gordon S. Abrams, MD
Maria Anello, DO
Jennifer Bender MD
Victor J. Catullo, MD
Denise M. Chough, MD
Cathy S. Cohen, MD
Marie A. Ganott, MD
Terri Gizienski, MD
Christiane M. Hakim, MD
Kimberly Harnist, MD
William J. Hoffman, MD
Denise Kalinowski, MD
Amy Kelly, MD
Amy H. Lu, MD
Ingrid E. Naugle, MD, FACR
Ronald L. Perrin, MD
Grace Y. Rathfon, MD
Ratan S. Shah, MD
Dilip D. Shinde, MD
Jules H. Sumkin, DO, FACR
Cathy Tyma, MD
Luisa P. Wallace, MD
Margarita Zuley, MD
Behavioral Medicine
Donna Posluszny, PhD
Ellen Redinbaugh, PhD
Susan Stollings, PhD
Cancer Genetics
W. Allen Hogge, MD
Beth Dudley, MS
Emily James, MS
Kelly Knickelbein, MS
Aleksandar Rajkovic, MD, PhD
Darcy L. Thull, MS
High Risk Breast
Cancer Program
Patricia Gordon, CRNP
Rachel Jankowitz, MD
Medical Oncology
Adam M. Brufsky, MD, PhD
Rachel Jankowitz, MD
Barry C. Lembersky, MD
Shannon Puhalla, MD
Priya Rastogi, MD
Palliative Care
Janet Leahey, CRNP
Winifred Teuteberg, MD
Elizabeth Weinstein, MD
Pathology
Robert Marshall Austin, MD
Rohit Bhargava, MD
Gloria J. Carter, MD
Mamatha Chivukula, MD
David J. Dabbs, MD
Esther Elishaev, MD
Jeffrey L. Fine, MD
Mirka W. Jones, MD
Anisa I. Kanbour, MD
Amal Kanbour-Shakir, MD
Trevor A. Macpherson, MD
Olga Navolotskaia, MD
W. Tony Parks, MD
Giuliana A. Trucco, MD
Jing Yu, MD
Chenquan Zhao, MD
Plastic and
Reconstructive Surgery
Carolyn De La Cruz, MD
Michael L. Gimbel, MD
Vu T. Nguyen, MD
Kenneth C. Shestak, MD
Outcomes for women
with breast cancer continue
to improve and the majority
of women diagnosed with
early-stage breast cancer
can expect to be cured.
Advances in breast imaging
have enabled earlier detection
Dr. Ahrendt
such that tumors are smaller
when first discovered and
more likely to be localized to the breast. A better
understanding of the complexity of breast cancer
biology has led to an expansion of targeted therapies.
Perhaps most importantly, the multidisciplinary,
coordinated approach to breast cancer treatment
has led to more women receiving the recommended
care that enhances optimal outcomes.
This edition of Breast Cancer in Brief focuses
on surgical advances in the management of
women with breast cancer. Surgery has already
come a long way from the disfiguring and disabling
radical mastectomy of the Halsted era. Breast
preservation, consisting of lumpectomy and breast
radiation, is established as equivalent to mastectomy
for breast cancer survival and involves far less
surgery and recovery. In Pittsburgh and across the
United States, rates of therapeutic and prophylactic
mastectomy are increasing at a modest pace. The
factors responsible for rising mastectomy rates are
only now beginning to be understood, but young
women newly diagnosed with breast cancer who
also have a family history of the disease are more
likely to request therapeutic and prophylactic
mastectomy.
Nipple-sparing mastectomy, which preserves
the nipple-areolar complex, is gaining traction
as an alternative to conventional mastectomy.
In carefully selected women, nipple-sparing
mastectomy with reconstruction can lead to
outcomes difficult to distinguish from the
natural breast with preserved function and
cosmesis. Kandace McGuire, MD, who joined
Breast reconstruction also has continued to
evolve and improve over time. Autologous tissue
microvascular free-flap reconstruction involves
transferring tissue from the patient’s body to
reconstruct the breast. The “TRAM” flap, which
used abdominal skin, fat, and muscle, has given
way to muscle-sparing flaps that preserve abdominal
wall strength. In some patients, breast reconstructive
surgeons now can utilize other donor sites, including
the thigh or buttock. The end result is a reconstructed breast with natural tissue harvested to
minimize sacrificing muscle function. Michael
Gimbel, MD, reviews this important topic.
Finally, surgical removal of axillary lymph nodes
involved by breast cancer remains the standard of
care but can be associated with significant patient
morbidity. The sentinel node procedure, developed
for women with early-stage breast cancer, is a
less-invasive approach to determining if cancer
involves the axillary nodes. For women who receive
chemotherapy prior to surgery and have tumors
that respond completely, it would be ideal if
less-invasive surgery could be used to assess the
axilla once chemotherapy is complete. The breast
surgeons at Magee are participating in a national
clinical trial through the American College of
Surgeons Oncology Group to address this
important question.
I hope you find the information inside useful
in your day-to-day practice and I welcome the
opportunity to discuss our clinical research
or patient care opportunities.
Yours sincerely,
Gretchen M. Ahrendt, MD, FACS
Director, Breast Surgical Services
Magee-Womens Hospital of UPMC
Radiation Oncology
Yoshio Arai, MD
Sushil Beriwal, MD
For more information about our services, to contact one of our breast cancer specialists, or to refer a patient
to the Magee High Risk Breast Cancer Program, call 1-866 MY MAGEE.
Magee.UPMC.com
© Copyright 2010 UPMC
the Breast Surgery Service at Magee-Womens
Hospital of UPMC in 2009, outlines the details
of this surgical advance.
Breast Cancer in Brief
2
Case report
Skin-sparing mastectomy with TUG flap reconstruction
following previous lumpectomy
The patient was referred for genetic counseling and genetic testing
based on her personal and family history of breast cancer. She was
found to be negative for a deleterious mutation in the BRCA2 or BRCA1
gene. She was reassured that her risk of recurrence or second primary
breast cancer remained low.
She continued to be symptomatic due to the palpable masses in her right
breast. After extensive in-depth discussions about options for managing
these symptomatic masses, she elected to pursue a complete right total
mastectomy with immediate breast reconstruction.
Plastic surgeon consultation
SM is a 51-year-old woman with a personal history of right breast
cancer diagnosed in 2002, managed with breast-conserving therapy.
At that time she presented with a palpable right breast mass and
underwent a lumpectomy, axillary node dissection, chemotherapy,
and adjuvant whole-breast radiation followed by tamoxifen.
She presented in December 2009 with a chief complaint of tender
palpable masses in her treated right breast. In addition, she learned that
her maternal cousin, who was diagnosed with breast cancer, was found
to carry a deleterious mutation in the BRCA2 gene. She had many
questions regarding her own risk of developing another breast cancer.
She identified the right breast masses on self-examination. She denied
any skin changes, nipple retraction, or nipple discharge. The lumps
were quite tender to palpation.
Her family history included two cousins on the maternal side with
breast cancer and a maternal aunt with breast cancer. There was no
family history of ovarian, prostate, pancreatic, or colon cancer. She
had the onset of menarche at age 14. Menopause was induced by her
breast cancer chemotherapy. She is G4P2 and was age 22 with her
first live birth.
On physical examination, the breasts were symmetric with everted
nipples. There was no redness of the skin. Post-treatment changes
were evident in the right breast. Two masses were palpated in the right
breast: 1 cm x 1 cm mass in the periareolar 11 o’clock location, and a
2 cm mass in the periareolar 6 o’clock location. There was no axillary,
infraclavicular or supraclavicular adenopathy. The left breast and
axillary examinations were negative.
A diagnostic mammogram and ultrasound were obtained. The
palpable findings corresponded to two well-circumscribed nodules,
most consistent with benign changes. Ultrasound-guided core biopsy
was performed of both lesions. Pathology showed dense fibrosis and
chronic inflammation. There was no evidence of recurrent carcinoma.
Magee-Womens Hospital of UPMC
SM was a candidate for both immediate and delayed breast reconstruction after mastectomy. She had had a previous right breast
segmental mastectomy and had developed significant asymmetry
afterward. She had undergone bilateral breast augmentation in 2003
to camouflage the asymmetry, but developed implant infections that
necessitated implant removal. Her previous history left her with
persistent breast asymmetry, with the left breast more than one cup
size larger than the right.
An implant-based reconstruction was considered a poor option for her
because of the previous radiation therapy and the patient’s personal bias
against implants due to her previous experience with them. She desired
an immediate autologous tissue-based reconstruction. Unfortunately,
the most common donor site for this type of reconstruction, the lower
abdomen, was not available due to previous abdominoplasty in 2003.
Her options for donor sites now included the upper, inner thigh region
(transverse upper gracilis or TUG flap) or the buttocks (gluteal artery
perforator or GAP flap) using microsurgical breast reconstruction
techniques. She chose use of the TUG flap based on anatomic and
postoperative regimen considerations.
Procedure
In March 2010, SM underwent a combined right breast skin-sparing
mastectomy and immediate reconstruction with a microsurgical TUG
flap, a seven-hour procedure. The pathology results showed no evidence
of malignancy. Her recovery was uneventful. She began ambulation on
postoperative day 1, was discharged to home on postoperative day 4,
and had her drains removed on postoperative day 10 at her first
postoperative clinic visit. She was released to drive a car and return to
work at one month. All activity restrictions were lifted at two months.
At three months postoperatively SM anticipates a right nipple
reconstruction under local anesthetic followed by tattooing of the
nipple-areolar complex to complete the reconstruction.
For more information or for patient referrals, please call the
Magee-Womens Breast Cancer Program at 1-866 MY MAGEE. ■
3
Trial evaluates the
use of SLN mapping
for women with
advanced cancer
For more than a decade, breast surgeons have
used sentinel lymph node (SLN) mapping as
an alternative to axillary lymph node dissection
(ALND) in patients with early breast cancers
who show no signs of node involvement at the
time of initial diagnosis. The sentinel node
procedure involves identifying the first node
that the cancer would spread to. If histology
reveals no metastasis in the SLN, then no
further nodes are removed. With fewer
nodes removed there is less risk of developing
long-term side effects, such as arm numbness,
pain, and lymphedema.
A new clinical trial offered at Magee-Womens
Hospital of UPMC seeks to determine whether
this minimally invasive procedure can be used
in women following preoperative chemotherapy who present with node-positive breast
cancer. The Phase II trial, sponsored by the
American College of Surgeons Oncology
Group (ACOSOG), is evaluating the
reliability and diagnostic accuracy of SLN
mapping in women with advanced cancer
treated with chemotherapy before they undergo surgery.
The primary endpoint of the trial is to
establish whether the sentinel node accurately
identifies whether cancer is still present in
the lymph nodes, or whether the cancer has
been eliminated by the chemotherapy. For
many patients, preoperative chemotherapy is
highly effective. Often, after the completion
of therapy, the lymph nodes in the axilla are
no longer able to be palpated, and the tumor
in the breast may shrink or regress completely.
By confirming the feasibility of SLN biopsy in
this setting, patients who are node-negative
at the time of surgery can avoid major
surgery, preventing potentially debilitating
postoperative, co-morbid conditions.
The study also will assess whether axillary
ultrasound is an effective tool for planning
the right surgery for each patient once
chemotherapy has been completed. Each
patient will have an axillary ultrasound at the
time of diagnosis. After therapy, the patient
Breast Cancer in Brief
will undergo another ultrasound, which will
reevaluate the axillary lymph nodes for size,
contour, and architecture. If the ultrasound is
normal, the hypothesis is that the histology
of the sentinel node should be accurate; if
the lymph nodes still have features that are
concerning for a persistent cancer, that might
indicate a population of women for whom the
sentinel node procedure may be less accurate.
Study participants will undergo ALND in
addition to preoperative and intraoperative
diagnostic testing to identify the SLN. A
lymphoscintigraphy will be performed by
injecting Tc99m sulfur colloid, a radioactive
isotope. Surgeons also will use a second
intraoperative technique, where the patient
is administered an isosufan blue agent.
A gamma probe then will be used to
confirm the location of the SLN. Once
identified, the SLN will be removed and
sent to pathology for review.
For more information on the trial or
for patient referrals, please call the
Magee-Womens Breast Program at
1-866 MY MAGEE. ■
Nipple-sparing mastectomy providing cosmetic advantages
for select candidates
Many women require or elect to undergo a mastectomy for breast cancer or a high-risk condition, such as carrying a mutation
in the BRCA gene. Traditionally, these women were offered a mastectomy that removed the nipple and areola along with most of
the breast skin and underlying tissue. Over the last decade, however, skin-sparing mastectomy has become the standard of care
when a patient desires immediate reconstruction because it preserves most of the breast skin to allow for a more natural appearance
after reconstruction. This approach has demonstrated no difference in local recurrence as compared to standard mastectomy;
however, the nipple-areola complex is removed during this surgery as it has been believed to harbor cancerous cells circulating in
the lymphatic system. This belief was bolstered by the observation of much higher recurrence rates in women undergoing
subcutaneous mastectomy, an operation performed mostly in the 1960s, which preserved the nipple and areola along with
thick skin flaps.
Recently, the assumption that preserving the nipple carries a higher risk of local recurrence or occurrence of cancer has been
challenged. Several studies have shown that preservation of the nipple and areola is not only possible and cosmetically advantageous,
but carries no significant additional risk of recurrent cancer; however, not every patient is a candidate for nipple-sparing mastectomy.
Research has shown that the best candidates for this operation are those who are undergoing mastectomy prophylactically (because
of a genetic mutation or a strong family history) or those who have relatively small tumors that are located several centimeters
from the nipple. Patients offered this procedure typically do not have any proven cancer in their lymph nodes. In order to ensure that
the nipple will survive, patients offered this procedure usually have minimal ptosis of the breast (defined as the location of the nipple
in relation to the inframammary fold) and generally have smaller breasts. Many institutions now offer this surgery to carefully
selected patients using the criteria mentioned above.
Magee-Womens Hospital plans to begin its own trial to evaluate the cancer-related and cosmetic outcomes of this new type of
mastectomy in spring/summer 2010. ■
Vol. 3, No. 1, 2010
4
Breast Cancer in Brief
Patient-centered diagnostic testing and treatment
The mission of the Magee-Womens Breast Cancer Program of UPMC Cancer Centers is to provide convenient access to a well-integrated
program of diagnosis, treatment, and follow-up care to women and men with breast disease and breast cancer.
To that end, Magee-Womens Hospital of UPMC provides breast diagnostic services at eight Womancare Centers and outpatient breast
surgery at UPMC Monroeville Surgery Center, UPMC South Hills Surgery Center, and Magee-Womens Hospital. The Magee Comprehensive
Breast Program at UPMC Horizon also provides breast diagnostic and treatment services in Hermitage, Pa.
For consultation, more information, or to make an appointment, call 1-866 MY MAGEE.
Center Locations
Magee-Womens Hospital of UPMC
300 Halket St.
Pittsburgh, PA 15213
Magee Womancare Center Monroeville
Corporate One Office Park
Building II, Suite 225
4075 Monroeville Blvd.
Monroeville, PA 15146
Cranberry Breast Imaging
Magee Womancare Center North
Women’s Imaging North
Magee Womancare
Center Monroeville
Magee-Womens Hospital of UPMC
Women’s Specialty Center
at Hillman Cancer Center
Magee Womancare
Center South Hills
Magee Womancare
Center Pleasant Hills
Magee Womancare Center North
2599 Wexford-Bayne Road
Suite 1000A
Sewickley, PA 15143
Magee Womancare Center Pleasant Hills
51 Professional Plaza
Suite 2100
850 Clairton Blvd.
Pleasant Hills, PA 15236
Women’s Imaging North
9000 Brooktree Road
Suite 402
Wexford, PA 15090
(Please call 724-934-9344
to schedule at this site.)
Cranberry Breast Imaging
3 St. Francis Way
Building 3
Cranberry Twp., PA 16066
Women’s Specialty Center
at Hillman Cancer Center
5115 Centre Ave.
Pittsburgh, PA 15232
UPMC Horizon Womancare Center
875 N. Hermitage Road
Hermitage, PA 16148
Magee Womancare Center South Hills
1300 Oxford Drive
Suite 2A
Bethel Park, PA 15102
300 Halket St.
Pittsburgh, PA 15213-3180
www.magee.upmc.com
UPMC Horizon
Womancare Center
Nonprofit
U.S. Postage
PAID
Pittsburgh, PA
Permit No. 3834