2b B - AGO

Diagnosis and Treatment of Patients with
Primary and Metastatic Breast Cancer
© AGO
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
Breast Cancer Surgery
Oncological Aspects
Breast Cancer Surgery
Oncological Aspects
© AGO
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
 Versions 2002–2011:
Bauerfeind / Böhme / Costa / Gerber /
Hanf / Junkermann / Kaufmann / Kümmel
/ Nitz / Rezai / Simon / Solomayer /
Thomssen / Untch
 Version 2012:
www.ago-online.de
Fersis / Janni
Pretherapeutic Assessment
© AGO
Oxford / AGO
•LoE / GR
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1

Palpation
5
D
++

Mammography
2b
B
++

Ultrasound (breast & axilla)
2b
B
++

Minimalinvasive biopsy
1c
A
+

MRT
1c
B
+/-
www.ago-online.de
Perioperative Staging
© AGO
Oxford / AGO
LoE / GR
e. V.
in der DGGG e.V.
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in der DKG e.V.
Guidelines Breast
Version 2012.1

History and physical examination
5
D
++
5
5
5
5
4
4
D
D
D
D
C
C
+
+
+
+
-
High metastatic potential and / or symptoms:



www.ago-online.de



Chest X-ray
Liver ultrasound
CT-scan
Bone-scan
FDG-PET or FDG-PET / CT
Whole body MRI
Evidence of Surgical Procedure
© AGO
Oxford / AGO
LoE / GR
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1



www.ago-online.de

Survival rates after lumpectomy + XRT are
equivalent to those after (modified) radical
mastectomy
1a
A
++
Survival rates after modified radical mastectomy
are equivalent to those after radical mastectomy 1b A
++
Local recurrence rates after skin sparing
mastectomy are equivalent to those after
mastectomy
2b B
++
Conservation of the NAC is an
adequate surgical procedure in tumors of the
periphery of the gland and after tumor-free
section of retroareolar tissue
4b C
+
Breast Conservation:
Surgical Technical Aspects
© AGO
Oxford / AGO
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e. V.
in der DGGG e.V.
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in der DKG e.V.
Guidelines Breast
Version 2012.1
Wire guided excisional biopsy in
non-palpable lesion
2b B
++

Tumor-free margins required
1a
A
++

Specimen radiography or ultrasound
in non-palpable lesion
2b B
++
Immediate intraoperative re-excision for
close margins (specimen radiography
and/or intra-operative frozen section)
1c
B
++
Re-excision required for involved margins
(paraffin section)
2b C
++
Radionuclide guided localisation of occult
lesions
2b B
+/-
Therapeutic stereotactic excision alone
4
--


www.ago-online.de



D
Breast Conservation Surgery (BCS)
© AGO
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Oxford / AGO
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Guidelines Breast
Version 2012.1
www.ago-online.de

Multicentricity
2b
B
-

Positive microscopic margins
after repeated excision
2b
B
--
Inflammatory breast cancer
2b
B
--

pCR after neoadjuvanter Chemotherapy
+/-
Axillary Lymph Node Dissection
© AGO
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Guidelines Breast
Version 2012.1
www.ago-online.de
Axillary lymph node dissection (removal of 10+ LN)
 Endpoint: survival
 Endpoint: staging
 Endpoint: local control
No axillary lymph node dissection necessary:
 DCIS
 cT1 /2 cN0 (without prior sentinel)
 SN + ( cT1/2 cN0; < 3 SN +, BCS + tangential
radiation field, no subsequent axillary radiation)
 SN + (mic)
 SN (i+)
 SN + (mastectomy, > cT1/2)
 SN + (mastectomy, ≤ cT1/2)

Irradiation of the axillary lymph nodes in case of
waiving further axillary staging
1a
1a
2a
D
A
A
++
+/++
++
2b
1b
B
A
---
2b
1ba
2b
1b
3b
B
A
B
B
B
+/-++
+
5
D
-
Sentinel Lymph Node
Excision (SNE): Indications I
© AGO

Clinically (cN0) / sonographically neg. axilla
Oxford / AGO
LoE / GR
1b
A ++

T1
1b
A
++

T2
2b
B
++

T3
3b
B
+

Multifocal / multicentric lesions
2b
B
+

DCIS
 5 cm or 2,5 cm + high grade (see DCIS)
if mastectomy is required
3b
3b
B
B
+/+

Before primary chemotherapy
3b
C
+*

After primary systemic therapy
2b
B
+/-*

Male breast cancer
2b
In the elderly
2b
Add. FNA or core Bx of LN (suspicious acc. to
clinical / sonographic assessment) in order to enable SLN 2b
B
B
+
+
C
+/-*
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de


* Study participation recommended
Sentinel Lymph Node
Excision (SNE): Indications II
© AGO
Oxford / AGO
LoE / GR
e. V.
in der DGGG e.V.
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Guidelines Breast
Version 2012.1
www.ago-online.de
 During pregnancy and / or breast feeding
 After previous tumor excision
 Previous major breast surgery
(e.g. reduction mammoplasty, mastectomy)
 Ipsilateral breast recurrence after prior BCS
and prior SNE
 SN in the mammarian internal chain
 After axillary surgery
 Prophylactic bilateral / contralateral mastectomy
 Inflammatory breast cancer
3
C
2b B
3b C
+
+
+/-
4
2b
3b
3b
3b
+/---
D
B
B
B
C
Surgery after Neoadjuvant Therapy (NT)
© AGO
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Oxford / AGO
LoE / GR
Guidelines Breast
Version 2012.1

Precise documentation of tumor location
before, during and after NT
5
D
++

Adequate surgery after NT
2b
C
++

Microscopically clear margins
5
D
++

Tumor resection in the new margins
3b
C
+

Sentinel node biopsy if feasible
2b
B
+/-*
www.ago-online.de
* Study participation recommended
Surgery and Irradiation after
Neoadjuvant Therapy (NT)
© AGO
e. V.
Oxford / AGO
LoE / GR
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
Breast surgery:
After the nadir of the leucocyte count
4
C
++
B
++
(2 to 4 weeks after the last chemotherapy)
Irradiation after Mastectomy is recommended 2b
www.ago-online.de
< 6 weeks after surgery
Indication based on the initial stage prior NT
(cN+, cT3/4a-d)
Surgery after Neoadjuvant Therapy (NT)
© AGO
Oxford / AGO
LoE / GR
e. V.
in der DGGG e.V.
sowie
in der DKG e.V.
Guidelines Breast
Version 2012.1
Breast conservation after clinical response possible:

Multicentric lesion
3
C
+/-*

cT4a-c
2b
B
+/-*

Inflamatory breast cancer (in case of pCR)
2b
C
+/-*
If after re-excision no clear margins
are achieved
2b
C
++

Extensive microcalcifications
5
D
++

If irradiation is not feasible
5
D
++
Mastectomy is recommended:
www.ago-online.de

* Study participation recommended
Adjuvant Therapy after Primary Surgery
© AGO
Oxford AGO
LoE/GR
e. V.
in der DGGG e.V.
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in der DKG e.V.
Guidelines Breast
Version 2012.1
www.ago-online.de
 Start adjuvant systemic therapy and RT
as soon as possible (a.s.a.p.) after surgery
 Start of adjuvant chemotherapy after
surgery a.s.a.p., and prior to RT
Without cytotoxic therapy:
 Start irradiation 6-8 weeks after surgery
 Start endocrine therapy after surgery and
a.s.a.p.
 Tamoxifen concurrent with radiotherapy
 AI concurrent with radiotherapy
1b A
++
1b A
++
2b B
++
5 D
3b C
2a B
++
+
+/-