Breast cancer

Approach to Breast Cancer

Most women with breast cancer can be effectively treated and cured. Research in the field of breast cancer treatment has enabled physicians to balance the necessity for aggressive cancer treatment with the goal of maximal preservation of functional and cosmetic result. Dr. Ellenhorn believes that the focus must be on the patient during the entire process of  treatment. Dr. Ellenhorn‘s approach to breast cancer treatment is to coordinate multidisciplinary management. An individualized treatment plan is developed after meeting with and reviewing treatment options and goals with the patient along with Medical Oncologists, Radiation Oncologists and Plastic and Reconstructive Physicians. Effective cancer treatment is of primary importance. Of equal importance is preservation of anatomy and function.

Dr. Ellenhorn has performed hundreds of breast cancer operations including sentinel lymph node procedures during his career. There are a number of ways to improve the surgical outcome while maintaining an appropriately aggressive approach to cancer care. Breast preservation with lumpectomy or surgical removal of just the cancerous tumor should be favored over mastectomy in most patients with breast cancer. Often, chemotherapy can be used in a woman with a large breast tumor to shrink the tumor down to the point where lumpectomy can be performed. In women requiring or wishing to have a mastectomy, aesthetic breast reconstruction should be considered. When mastectomy is performed, newer approaches involving the preservation of the skin overlying the breast, should be used. Skin preserving or Skin Sparing Mastectomy involves the removal of all breast tissue while preserving the skin overlying the breast.  This allows for a far better overall cosmetic result. This approach should always be considered when prophylactic mastectomy is performed.  Dr. Ellenhorn is a founding member of the Medical Board of Advisors of the Breast Preservation Foundation  http://www.breastpreservationfoundation.org/ which is focused on the promotion of Skin Sparing Mastectomy techniques.

New Innovations

A number of new innovations have improved our ability to treat patients with breast cancer.

Nipple and Areola Sparing Mastectomy

Traditional mastectomy techniques involve the sacrifice of  the nipple and areola in addition to the skin overlying the breast. Using very careful surgical technique, it is possible to perform a mastectomy while preserving the nipple and areola and all of the skin overlying the breast. The incision is hidden under the breast. This enables a much better cosmetic result than standard mastectomy which sacrifices much of the skin and nipple and areola overlying the breast.

Before and After Photos From a Double Mastectomy 

Accelerated partial breast irradiation (APBI) is an important new way to use radiation therapy to treat women with breast cancer.

Traditional radiation treatment requires women with breast cancer who undergo a lumpectomy  to have 6 1/2 weeks of radiation to the entire affected breast after surgery.  The result is a long treatment course which results in numerous damaging effects to the breast. Whole breast radiation results in damage to the skin over the breast and damage to the entire breast. Skin changes from radiation include redness, dark discoloration and skin thickening. The entire breast can become unnaturally thickened and some women experience an extreme shrinkage of the entire breast.

Accelerated partial breast irradiation (APBI) differs from the standard approach in two ways.  The treatment time is shortened from 6 1/2 weeks to between 1 and 5 days. In addition, the area of the breast receiving the radiation dose is reduced from the entire breast in standard whole breast radiation to the area of the breast immediately around the lumpectomy site in APBI. This is the part of the breast which is at most risk for breast cancer recurrence.

The goal of APBI is to use a less invasive more focused radiation treatment without compromising excellent local tumor control or survival.

APBI has been used in clinical trials in well over a thousand patients over the last 10 years. These trials demonstrated that APBI worked just as well as whole breast radiotherapy in properly selected breast cancer patients. APBI has the potential to increase the quality of life for women with breast cancer undergoing breast conserving therapy.

There are three new approaches for APBI. These approaches are:

Intraoperative Radiotherapy (IORT) – 1 day

Intracavitary Brachytherapy (MammoSite) – 5 days

3-D Conformal/External Beam Radiotherapy – 5 days

Dr. Ellenhorn is one of the few breast surgeons in California to be using a specialized form of IORT for breast cancer patients known as Skin and Breast Sparing Radiation (SBSR). With SBSR, a single approximately 12 minute localized radiation treatment is administered at the time of the lumpectomy surgery.  The SBSR treatment is carefully administered so as to avoid any possible injury to the skin overlying the breast or to the remainder of the breast.

Patient selection overview

Clinical trials have established that proper patient selection is important to the success of any form of accelerated partial breast irradiation.  Selection criteria are not absolute and can be modified to the individual patient. Criteria for SBSR:

Inclusion criteria:

age >= 40

tumor size <= 3 cm;

tumor type:  invasive ductal carcinoma or ductal carcinoma in situ

Exclusion criteria:

prior breast radiotherapy

multi-focal or multicentric tumors

invasive lobular carcinoma

 

Below is an article written by Dr. Ellenhorn regarding partial breast radiation.

Targeted Radiation Therapy For Breast Cancer

Breast Cancer is one of the most common malignancies affecting over 225,000 women in the United States each year. Early stage breast cancer is defined as stage II or less; on the basis of the lack of lymph node, metastasis and clinical lesion size of 2 cm or less. 60% of women in the US are diagnosed breast cancers are early stage and in Japan, the fraction of early stage breast cancer is about 40%. With the increasing use of breast cancer screening by mammography, more and more patients will have their breast cancer diagnosed at the early stage. Most women who are newly diagnosed with early-stage breast cancer have a choice of: a breast-conserving approach which includes lumpectomy and radiation therapy or a mastectomy which involves removing the entire breast.

Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. BCT consists of resection of the primary breast tumor followed by whole breast irradiation (WBI). Radiation therapy is necessary because the rate of breast cancer recurrence with lumpectomy alone is unacceptably high.

Despite the advantages of BCT, it is not used as often as it should be used. Many women who are candidates for BCT have a mastectomy instead. In addition, up to a third of women who undergo lumpectomy do not receive radiation therapy. One reason that BCT is underutilized is that some women cannot, or will not, commit to the usual 6- 7 week course of WBI required for BCT. Convenience, access, cost and other logistical issues are major contributing factors. Other logistical issues include: distance from the radiation therapy facility, lack of transportation, lack of social support structure and poor ambulatory status of the patient.

Another drawback of WBI is the potential for injury to normal breast tissue and surrounding structures like the lung, heart and ribcage. While modern radiation techniques can minimize the likelihood life threatening complications related to radiation of surrounding structures, the entire breast, parts of the lymph node region under the arm(axilla) and skin overlying the breast receive significant radiation doses. This often results in a thickening and shrinkage of the affected breast and a permanent tanning and thickening of the overlying skin.

The inherent limitations of WBI have lead to the investigation of alternative and more limited methods of providing radiation therapy as a component of BCT. This is the concept of accelerated partial breast irradiation (APBI). There are several techniques which can be used to provide APBI and each involves providing a limited timecourse and focus of breast radiation.

The rationale for APBI is that the majority of breast cancer recurrences occur at or close to the lumpectomy site and rarely, elsewhere in the treated breast. An advantage of APBI is a decreased dose to normal tissue. With a smaller target volume, adjacent organs such as the heart and lungs receive less radiation.

APBI is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. One of the oldest APBI techniques is Multi-catheter Interstitial Brachytherapy (MIB) Treatment Technique. Flexible after-loading catheters are placed through the breast tissues surrounding the lumpectomy. The catheters are inserted at 1 to 1.5 cm intervals. The procedure routinely requires between 14 to 20 catheters to assure proper dose coverage. The catheters are loaded with a radioactive source which remains in place for approximately 2 to 5 days.

A number of balloon-based brachtherapy devices have been developed to provide APBI. These include Mammosite, SAVIand Contura. These devices all require that a catheter be left within the breast at the lumpectomy site. The catheter is used to provide access for daily or twice daily insertion of a radioactive source. The treatment generally continues until over 1 week after the lumpectomy, at which time the catheter is removed.

The disadvantages of MIB and balloon based techniques is that they require frequent treatment visits and result in additional scarring from catheter placement.

The disadvantages of short course brachytherapy approaches have been overcome by the introduction of Intraoperative Radiation Therapy (IORT). With IORT, a single radiation treatment is provided directly to the lumpectomy site while the patient is asleep in the operating room. There are two general techniques are used to provide IORT, electron radiation using a machine called the Mobitron and electronic x-ray treatment using the Axxent or Intrabeam device.

The Mobetron is a mobile electron beam intraoperative treatment system.  The electron radiation is focused and provided through a cylindrical cone which is inserted through a large skin incision overlying the lumpectomy site.

The Axxent and Intrabeam devices require that a catheter is placed into the lumpectomy site at the time of surgery. The catheter is connected to the electronic brachytherapy unit which inserts a small x-ray tube into the lumpectomy site. The single radiation treatment takes about 10(Axxent) to 40(Intrabeam) minutes after which the catheter is removed and the wound closed. The treatment does not require an incision any larger than that required for the lumpectomy and no external catheters or devices are left following the operation.

The best clinical trial data in support of APBI comes from the TARGIT-A trial. In that trial, 1113 women over age 45 who were suitable for BCT were randomized to receive standard WBI or single dose IORT with the Intrabeam device. With four years of followup, there was no difference in survival or breast cancer recurrence between the two groups.

Current guidelines for APBI require that breast cancer patients be over age 40 because recurrence of breast cancer is considered to be higher in younger women. The tumor can be an invasive or in situ carcinoma. The tumor must be smaller than 3 centimeters in size and amenable to lumpectomy with a clear surgical margin. In addition, lymph nodes need to be assessed in women with invasive breast cancer and  complete lymph node dissection performed in women with tumor involved lymph nodes.

 

 

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Dr. Joshua Ellenhorn

Joshua D.I. Ellenhorn, MD is a leading expert in Surgical Oncology, specializing in the surgical treatment of cancer. He is Clinical Professor of Surgery at Cedars-Sinai Medical Center and Adjunct Professor at the John Wayne Cancer Center. A Senior Partner in the Surgery Group of Los Angeles, he is ranked by US News & World Report among the top 1% of Surgeons in the United States and ranked as a Super Doctor in Los Angeles. He is a medical educator, having trained over 60 surgical oncologists. A nationally recognized leader in surgery, surgical education, and cancer research, Dr. Ellenhorn is dedicated to providing the highest quality of surgical care with an emphasis on a personalized approach to the individual patient. Learn more about Joshua Ellenhorn »

US News and World Report Ranked Dr. Ellenhorn among top 1% of Surgeons in U.S.

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