Breast-conserving surgery

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Breast-conserving surgery
Lumpectomy 02.jpg
Breast-conserving surgery avoids removing the entire breast
ICD-9-CM 85.21-85.23
MeSH D015412

Breast-conserving surgery refers to an operation that aims to remove breast cancer while avoiding a mastectomy. Different forms of this operation include: lumpectomy (tylectomy), wide local excision, segmental resection, and quadrantectomy. Breast-conserving surgery has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery.[ citation needed ]

Contents

Medical uses

For clinical stages I and II breast cancer, breast-conserving surgery, with radiotherapy and possibly chemotherapy may be indicated if one or two sentinel lymph nodes are found to have cancer which is not extensive. [1] In this case, the sentinel lymph nodes would be examined, and lymphadenectomy as further evaluation is not indicated as this result from the sentinel lymph nodes is sufficient to recommend treatment. [1]

Breast-conserving surgery may also be used in cases of biopsy-proven invasive breast cancer or biopsy-proven ductal carcinoma in situ. In the assessment of the tumor, the surgeon should assess the ability to resect the tumor with clear margins while providing a cosmetic result that is acceptable to the patient. [2]

For screening detected lesions that are non-palpable, preoperative lesion localization by a breast radiologist is required in order to accurately identify the tumor intraoperatively and excise it with adequate margins. Preoperative localization was traditionally performed using a steel guidewire; however, novel tumor markers have emerged such as radioactive seeds, radiofrequency reflectors and magnetic seeds. [3]

Shared decision-making is an important consideration in breast-conserving surgery. It is estimated that between 50% and 70% of patients are active participants in the decision-making of breast cancer surgery. [4] [5] The time following a cancer diagnosis may be filled with fear, vulnerability, and a sense of being overwhelmed at the amount of information being provided by physicians as well as accessed on the internet. [6] Each patient has their own set of unique characteristics, which may make it challenging to read information online and apply that information to a specific individual circumstance. In addition, there are several important misconceptions regarding breast-conservation surgery for patients and clinicians to keep in mind. [7]

  1. In appropriately selected patients, mastectomy and breast-conserving surgery have equivalent survival rates.
  2. Undergoing mastectomy does not eliminate the risk for recurrent or new cancer.
  3. Radiation therapy may still be needed following breast-conservation surgery.
  4. The decision regarding the need for chemotherapy is independent from the surgical options.

Contraindications

Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include: [8]

  1. Pregnancy is an absolute contraindication to the use of breast irradiation. In some cases, it may be possible to perform breast-conserving surgery in the third trimester and treat the patient with radiation after delivery.
  2. Two or more primary tumors in separate quadrants of the breast or with diffuse malignant-appearing microcalcifications.
  3. A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose.
  4. Persistent positive margins after reasonable surgical attempts: the importance of a single focally positive microscopic margin needs further study and may not be an absolute contraindication.
  5. Inflammatory breast cancer
  6. Diffuse or indeterminate micro-calcifications on mammography

Relative contraindications encompass situations of higher risk of complications to the patient that may be outweighed by other considerations, such as the benefit to the patient. Relative contraindications include: [2]

  1. Previous breast radiation therapy
  2. Connective tissue disease such as Scleroderma, Sjogren Syndrome, Lupus, and Rheumatoid arthritis may result in an increased risk of radiation toxicity. [9]
  3. Very large tumor size relative to breast volume.

Oncoplastic surgery

Oncoplastic surgery is an important consideration in breast-conserving surgery that integrates plastic surgery principles into breast cancer surgery in order to preserve aesthetic outcomes and quality of life, without compromising local control of the cancer. It is based on three surgical principles: ideal breast cancer surgery with free tumor margins, immediate breast reconstruction, and immediate symmetry with the other breast. [10] Oncoplastic approaches to breast-conserving surgery may require a close partnership among surgeons who specialize in surgical oncology and plastic surgery. Oncoplastic surgery is not only limited to breast-conserving surgery, as the techniques and principles of plastic surgery can be applied to mastectomy as well. [11]

The evidence comparing oncoplastic breast-conserving surgery to traditional breast-conserving surgery techniques is weak. [12] There is no strong evidence to suggest that oncoplastic breast conserving surgery results in worse outcomes compared to other breast-conserving surgical techniques. [13]

History

Prior to 1981, there existed limited evidence that breast-conserving surgery was an acceptable alternative to radical mastectomy for treatment of early stage breast cancer. Dr. Umberto Veronesi, an Italian oncologist, challenged this notion and led a clinical trial comparing the radical mastectomy with breast-conserving surgery (which was termed quadrantectomy at the time). This landmark trial showed no differences in overall survival, disease-free survival, and local recurrence for patients with breast cancer of less than 2 cm and no palpable axillary nodes. [14] [15] He was widely celebrated for this landmark study, so much so that some began referring to this operation as the Veronesi Quadrantectomy. [14] [16] The work of Bernard Fisher, who performed a randomized trial comparing lumpectomy, lumpectomy plus radiation and total mastectomy, was also pivotal in the establishment of breast-conserving surgery. [17]

Related Research Articles

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Paget's disease of the breast</span> Medical condition

Paget's disease of the breast is a type of cancer that outwardly may have the appearance of eczema, with skin changes involving the nipple of the breast. The condition is an uncommon disease accounting for 1 to 4.3% of all breast cancers and was first described by Sir James Paget in 1874.

Inflammatory breast cancer (IBC) is one of the most aggressive types of breast cancer. It can occur in women of any age. It is referred to as "inflammatory" due to its frequent presentation with symptoms resembling a skin inflammation, such as erysipelas.

<span class="mw-page-title-main">Lumpectomy</span> Limited surgical removal of breast tissue

Lumpectomy is a surgical removal of a discrete portion or "lump" of breast tissue, usually in the treatment of a malignant tumor or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumors. Although a lumpectomy is used to allow for most of the breast to remain intact, the procedure may result in adverse affects that can include sensitivity and result in scar tissue, pain, and possible disfiguration of the breast if the lump taken out is significant. According to National Comprehensive Cancer Network guidelines, lumpectomy may be performed for ductal carcinoma in situ (DCIS), invasive ductal carcinoma, or other conditions.

<span class="mw-page-title-main">Invasive carcinoma of no special type</span> Medical condition

Invasive carcinoma of no special type (NST) is also referred to as invasive ductal carcinoma or infiltrating ductal carcinoma(IDC) and invasive ductal carcinoma, not otherwise specified (NOS). Each of these terms represents to the same disease entity, but for international audiences this article will use invasive carcinoma NST because it is the preferred term of the World Health Organization (WHO).

Adjuvant therapy, also known as adjunct therapy, adjuvant care, or augmentation therapy, is a therapy that is given in addition to the primary or initial therapy to maximize its effectiveness. The surgeries and complex treatment regimens used in cancer therapy have led the term to be used mainly to describe adjuvant cancer treatments. An example of such adjuvant therapy is the additional treatment usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to the presence of undetected disease. If known disease is left behind following surgery, then further treatment is not technically adjuvant.

<span class="mw-page-title-main">Sentinel lymph node</span> First lymph node to receive drainage from a primary tumor

The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination it is postulated that the sentinel lymph nodes are the target organs primarily reached by metastasizing cancer cells from the tumor.

<span class="mw-page-title-main">Radical mastectomy</span>

Radical mastectomy is a surgical procedure involving the removal of breast, underlying chest muscle, and lymph nodes of the axilla as a treatment for breast cancer. Breast cancer is the most common cancer among women today, and used to be primarily treated by surgery, particularly during the early twentieth century when the mastectomy was developed with success. However, with the advancement of technology and surgical skills, the extent of mastectomies has been reduced. Less invasive mastectomies are employed today in comparison to those in the past. Nowadays, a combination of radiotherapy and breast conserving mastectomy are employed to optimize treatment.

<span class="mw-page-title-main">Ductal carcinoma in situ</span> Medical condition

Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. DCIS is classified as Stage 0. It rarely produces symptoms or a breast lump one can feel, typically being detected through screening mammography. It has been diagnosed in a significant percentage of men.

<span class="mw-page-title-main">Umberto Veronesi</span> Italian politician

Umberto Veronesi was an Italian oncologist, physician, scientist and politician, internationally known for his contributions on prevention and treatment of breast cancer throughout a career spanning over fifty years.

Breast cancer management takes different approaches depending on physical and biological characteristics of the disease, as well as the age, over-all health and personal preferences of the patient. Treatment types can be classified into local therapy and systemic treatment. Local therapy is most efficacious in early stage breast cancer, while systemic therapy is generally justified in advanced and metastatic disease, or in diseases with specific phenotypes.

Breast surgery is a form of surgery performed on the breast.

<span class="mw-page-title-main">Male breast cancer</span> Medical condition

Male breast cancer (MBC) is a cancer in males that originates in their breasts. Males account for less than 1% of new breast cancers with about 20,000 new cases being diagnosed worldwide every year. Its incidence rates in males vs. females are, respectively, 0.4 and 66.7 per 100,000 person-years. The worldwide incidences of male as well as female breast cancers have been increasing over the last few decades. Currently, one of every 800 men are estimated to develop this cancer during their lifetimes.

<span class="mw-page-title-main">Targeted intra-operative radiotherapy</span> Method of targeted radiotherapy after surgical removal of tumours

Targeted intra-operative radiotherapy, also known as targeted IORT, is a technique of giving radiotherapy to the tissues surrounding a cancer after its surgical removal, a form of intraoperative radiation therapy. The technique was designed in 1998 at the University College London. In patients having lumpectomy for breast cancer, the TARGIT-A(lone) randomized controlled trial tested whether TARGIT within a risk-adapted approach is non-inferior to conventional course of external beam postoperative radiotherapy given over several weeks.

<span class="mw-page-title-main">Bernard Fisher (scientist)</span> American biologist

Bernard Fisher was an American surgeon and a pioneer in the biology and treatment of breast cancer. He was a native of Pittsburgh. He was Chairman of the National Surgical Adjuvant Breast Project at the University of Pittsburgh School of Medicine. His work established definitively that early-stage breast cancer could be more effectively treated by lumpectomy, in combination with radiation therapy, chemotherapy, and/or hormonal therapy, than by radical mastectomy.

A quadrantectomy, also referred to as a segmental or partial mastectomy, is a breast-conserving surgery for breast cancer in which one quarter of breast tissue is removed along with muscles of the chest wall within a 2 to 3 centimeter radius of a tumor. This procedure is an alternative to a radical or simple mastectomy, in which an entire breast is removed.

Eleanor D. Montague was an American radiologist and educator who established breast-conserving therapy in the United States and improved radiation therapy techniques. She became a member of the Texas Women's Hall of Fame in 1993.

Souzan El-Eid is a breast surgical oncologist at Comprehensive Cancer Centers of Nevada (CCCN), and serves as the medical director of the Breast Care Center at Summerlin Hospital, cancer liaison physician for the cancer program and co-chair of the Breast Tumor Board at Summerlin Hospital. She is also the president elect for Clark County Medical Society. She is an Adjunct Associate Professor of General Surgery at Touro University Nevada and has served as principal investigator for several clinical research studies. She is the first breast surgeon in Las Vegas certified in both ultrasound and stereotactic breast biopsies.

Anne Louise Rosenberg is an American surgical oncologist retired from practice in Cherry Hill, New Jersey.

The European School of Oncology (ESO) is a provider of continuing medical education to oncology professionals, with a particular focus on areas of Central and Eastern Europe and the Balkans region.

References

  1. 1 2 American College of Surgeons (September 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation , American College of Surgeons, archived from the original on 27 October 2013, retrieved 2 January 2013
  2. 1 2 "American Society of Breast Surgeons Performance and Practice Guidelines for Breast-Conserving Surgery/Partial Mastectomy" (PDF). www.breastsurgeons.org. February 2015. Archived (PDF) from the original on July 10, 2017. Retrieved March 23, 2019.
  3. ↑ Mayo, Ray C.; Kalambo, Megan J.; Parikh, Jay R. (2019-07-01). "Preoperative localization of breast lesions: Current techniques". Clinical Imaging. 56: 1–8. doi:10.1016/j.clinimag.2019.01.013. ISSN   0899-7071.
  4. ↑ Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Salem B, Lakhani I, Morrow M (August 2005). "Patient involvement in surgery treatment decisions for breast cancer". Journal of Clinical Oncology. 23 (24): 5526–33. doi:10.1200/JCO.2005.06.217. PMID   16110013.
  5. ↑ Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC (March 2002). "Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement?". Journal of Clinical Oncology. 20 (6): 1473–9. doi:10.1200/JCO.2002.20.6.1473. PMID   11896094.
  6. ↑ Tsaras K, Papathanasiou IV, Mitsi D, Veneti A, Kelesi M, Zyga S, Fradelos EC (June 2018). "Assessment of Depression and Anxiety in Breast Cancer Patients: Prevalence and Associated Factors". Asian Pacific Journal of Cancer Prevention. 19 (6): 1661–1669. doi:10.22034/APJCP.2018.19.6.1661. PMC   6103579 . PMID   29938451.
  7. ↑ Newman LA (May 2017). "Decision Making in the Surgical Management of Invasive Breast Cancer-Part 1: Lumpectomy, Mastectomy, and Contralateral Prophylactic Mastectomy". Oncology. 31 (5): 359–68. PMID   28512732.
  8. ↑ DeVita VT, Lawrence TS, Rosenberg SA (2008). Cancer: Principles & Practice of Oncology (8th ed.). Phila: Lippincott. pp. 1624–1625.
  9. ↑ Dilaveri, Christina A.; Sandhu, Nicole P.; Neal, Lonzetta; Neben-Wittich, Michelle A.; Hieken, Tina J.; Mac Bride, Maire Brid; Wahner-Roedler, Dietlind L.; Ghosh, Karthik (2014). "Medical factors influencing decision making regarding radiation therapy for breast cancer". International Journal of Women's Health. 6: 945–954. doi:10.2147/IJWH.S71591. ISSN   1179-1411. PMC   4242405 . PMID   25429241.
  10. ↑ Bertozzi N, Pesce M, Santi PL, Raposio E (June 2017). "Oncoplastic breast surgery: comprehensive review". European Review for Medical and Pharmacological Sciences. 21 (11): 2572–2585. PMID   28678328. Open Access logo PLoS transparent.svg
  11. ↑ Macmillan RD, McCulley SJ (June 2016). "Oncoplastic Breast Surgery: What, When and for Whom?". Current Breast Cancer Reports. 8 (2): 112–117. doi:10.1007/s12609-016-0212-9. PMC   4886147 . PMID   27330677.
  12. ↑ Weber, Walter P.; Soysal, Savas D.; Zeindler, Jasmin; Kappos, Elisabeth A.; Babst, Doris; Schwab, Fabienne; Kurzeder, Christian; Haug, Martin (Summer 2017). "Current standards in oncoplastic breast conserving surgery". The Breast. 34: S78–S81. doi: 10.1016/j.breast.2017.06.033 . PMID   28690106.
  13. ↑ Nanda, Akriti; Hu, Jesse; Hodgkinson, Sarah; Ali, Sanah; Rainsbury, Richard; Roy, Pankaj G (2021-10-29). Cochrane Breast Cancer Group (ed.). "Oncoplastic breast-conserving surgery for women with primary breast cancer". Cochrane Database of Systematic Reviews. 2021 (10). doi:10.1002/14651858.CD013658.pub2. PMC   8554646 . PMID   34713449.
  14. 1 2 Corso G, Veronesi P, Sacchini V, Galimberti V, Luini A (2017-06-08). "The Veronesi quadrantectomy: an historical overview". ecancermedicalscience. 11: 743. doi:10.3332/ecancer.2017.743. PMC   5481191 . PMID   28690674.
  15. ↑ Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, Gallus G, Greco M, Luini A, Marubini E, Muscolino G, Rilke F, Salvadori B, Zecchini A, Zucali R (July 1981). "Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast". The New England Journal of Medicine. 305 (1): 6–11. doi:10.1056/NEJM198107023050102. PMID   7015141.
  16. ↑ Zurrida S, Costa A, Luini A, Galimberti V, Sacchini V, Intra M (2001). "The Veronesi quadrantectomy: an established procedure for the conservative treatment of early breast cancer". International Journal of Surgical Investigation. 2 (6): 423–31. PMID   12678123.
  17. ↑ Fisher, Bernard; Anderson, Stewart; Bryant, John; Margolese, Richard G.; Deutsch, Melvin; Fisher, Edwin R.; Jeong, Jong-Hyeon; Wolmark, Norman (2002-10-17). "Twenty-Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer". New England Journal of Medicine. 347 (16): 1233–1241. doi: 10.1056/NEJMoa022152 . ISSN   0028-4793.
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