Breast-conserving surgery

Breast-conserving surgery refers to an operation that aims to remove breast cancer while avoiding a mastectomy.[1] 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.

Breast-conserving surgery
Breast-conserving surgery avoids removing the entire breast
ICD-9-CM85.21-85.23
MeSHD015412

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.[2] 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.[2]

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.[3]

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.[4]

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.[5][6] 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.[7] 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.[8]

  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:[9]

  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:[3]

  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.[10]
  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.[11] 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.[12]

The evidence comparing oncoplastic breast-conserving surgery to traditional breast-conserving surgery techniques is weak.[13] There is no strong evidence to suggest that oncoplastic breast conserving surgery results in worse outcomes compared to other breast-conserving surgical techniques.[14]

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.[15][16] He was widely celebrated for this landmark study, so much so that some began referring to this operation as the Veronesi Quadrantectomy.[15][17] 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.[18]

References
  1. Douvetzemis, Stergios; Kovacs, Tibor (2020). "1. Concept, principles and indication of oncoplastic breast surgery: fashion or necessity". In Klimberg, V. Suzanne; Kovacs, Tibor; Rubio, Isabel T. (eds.). Oncoplastic Breast Surgery Techniques for the General Surgeon. Switzerland: Springer. pp. 1–34. ISBN 978-3-030-40195-5.
  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
  3. "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.
  4. 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. PMID 30818165. S2CID 73516274.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. DeVita VT, Lawrence TS, Rosenberg SA (2008). Cancer: Principles & Practice of Oncology (8th ed.). Phila: Lippincott. pp. 1624–1625.
  10. 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.
  11. 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
  12. 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.
  13. 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.
  14. 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): CD013658. doi:10.1002/14651858.CD013658.pub2. PMC 8554646. PMID 34713449.
  15. 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.
  16. 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.
  17. 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.
  18. 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. PMID 12393820.
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