Full document - International Hospital Federation

Innovation and clinical specialities: oncology
border of the dissection is the lower border of the axillary vein;
dissection above the vein runs the risk of damage to the brachial
plexus. The nerves to latissimus dorsi (thoracodorsal) and to
serratus (long thoracic) are identified and are the posterior border
of the dissection. The lateral border is the floor of the axilla,
consisting of skin and subcutaneous tissue. Retraction of the
pectoralis minor muscle medially allows for the removal of level II
nodes. All the fatty tissue within these borders is removed. The
sensory intercostal brachial nerve runs through the axilla and may
or may not be preserved.
Sentinel node biopsy
Although long considered the standard management of the axilla for
breast cancer, ANLD is associated with significant arm morbidity
(20-25% risk of lymphedema) and risk of damage to the axillary vein,
nerve to the latissimus dorsi and serratus anterior and hypoesthesia
of the arm and the thorax. For these reasons, other less invasive but
accurate methods have been sought for axillary staging in breast
cancer, especially in the developed world, where three-quarters of
patients present with early node negative disease. Clinical
examination of the axilla and available diagnostic imaging
techniques like US, CT and PDG-PET are manifestly inaccurate for
axillary staging.
Less invasive than ALND, sentinel lymph node biopsy (SLNB) is
now accepted as an alternative to routine ALND for the detection
of occult lymph node metastases in patients with clinically nodenegative
breast cancer. 87,88 SNLD is based on the observation that
specific areas of the breast drain by way of afferent lymphatics to
a specific ‘sentinel’ node. This node can be detected by injecting
vital blue dye (isosulfan blue dye, methylene blue or patent blue V
dye) or a radioactive suspension (Tc99m radioisotope labeled
colloids). The route of injections include intra parenchymal (peritumorally),
intradermal or subareolar. 88,89 . The use of vital dye is
resource efficient (cheaper and less time consuming) and safer,
but may miss non axillary sites and also carries the risk of
anaphylactic reactions while radioactive agents are more
expensive, carries the risk of exposure to staff, and requires that
the hospital have a nuclear medicine department.
There are five principal aims for the excision and
histopathological analysis of the SN:
✚ minimally invasive assessment of the nodal status;
✚ selection of patients with positive SNs for elective lymph node
dissection (ELND) or adjuvant therapy;
✚ prevention of lymph node dissection and associated morbidity
in SN negative patients;
✚ detection of aberrant or alternative lymphatic drainage;
✚ improvement of sensitivity of histopathological detection of
lymph node metastasis. 90
Further surgery of the axillary nodes now depends on the results
of the sentinel lymph-node biopsy – if negative, ALND is avoided.
While SLNB is becoming widely used in the developed world as a
method to assess the axilla, ALND remains the recommended
management for treatment in any hospital that does not have
access to a nuclear medicine department or a dedicated breast
pathologist able to use specialized immunohistochemistry markers.
Radiotherapy in early breast cancer
The aim of radiotherapy to the whole breast after BCT is to
establish local control. Numerous studies have shown reductions
in local recurrences from 12-35% to 2-10% at 5-10 years. This
compares to local recurrence rates after mastectomy of 5%.(91) In
most developed countries, the current standard of care for
patients with early-stage breast cancer consists of breastconserving
surgery, followed by 5–6 weeks’ postoperative
radiotherapy used on the whole breast. Probabilities of adequate
local control rates and good cosmetic results are high with the use
of conventional fractionation. Patients who cannot receive
radiation are treated with mastectomy. Some recent papers
suggest a small survival advantage which was rather offset by the
long term toxicity from radiotherapy resulting in deaths from
vascular and cardiac injuries. 92
Some data support the effectiveness of an additional dose
applied to the tumor bed (i.e., boost irradiation) to reduce local
recurrence. However, delivery of the boosting dose raises the rate
of morbidity, which reduces cosmetic outcome.
Recent advances in radiotherapy includes partial breast
irradiation using various techniques such as such as low or highdose
rate brachytherapy (interstitially or with an intracavitary
balloon), conformal external-beam irradiation (including intensity
modulated radiotherapy), and intraoperative radiotherapy (Electron
Intra Operative Therapy-ELIOT). 93,94
Most reports of partial breast irradiation have provided results
much the same as those achieved with conventional external
beam, even though some caution is needed until the safety and
efficacy of such irradiation have been shown in appropriate
patients and analysis of long-term treatment outcomes. 95-97
Systemic treatment
More than half the women with operable breast cancer who
receive only locoregional treatment die from metastatic disease.
This indicates that breast cancer is a systemic disease and that
the micrometastatic process can occur early even independently
from lymphatic spread. 76,98 The way to improve survival is to give
these women systemic medical treatment, including endocrine
therapy, chemotherapy, or targeted therapy with trastuzumab
along with surgery/radiotherapy.
Systemic treatment may be given after (adjuvant) or before
(neoadjuvant, primary, or preoperative) locoregional treatment.
Adjuvant treatment has been shown to be effective in randomized
clinical trials, whereas the evaluation of neoadjuvant systemic
therapy is ongoing.
It is important to realize, especially in the African context, that any
systemic therapy including hormonal therapies, will at least
temporarily interrupt child bearing. The current recommendations of
at least 5 years of Tamoxifen after diagnosis will significantly impact
on the ability of a woman to bear many children. Chemotherapy will
cause most women to stop menstruating and permanent premature
menopause is common. These recommendations listed below,
based on the culture of the developed world, may not be
acceptable or applicable to African women.
The choice of systemic adjuvant therapy in early breast cancer
will depend on the following factors; estrogen (ER)/progesterone
(PR) receptor status, menopausal status and over-expression of
HER2. It will also depend significantly on the risk of recurrence and
therefore the potential benefit of the treatment. Any systemic
therapy carries with it a risk of toxicity, and can be quite expensive.
A woman at high risk of recurrence will benefit significantly from
98 Hospital and Healthcare Innovation Book 2009/2010