Primary Treatment for Ductal Carcinoma In Situ 

• Patients with breast cancer in 1 area with positive margins after complete surgical excision are advised to undergo either total mastectomy or lumpectomy, or excision of margin

Lumpectomy

• Higher recurrence rate when done alone, without radiation therapy, endocrine therapy or chemotherapy especially in high-risk patients
• Whole breast RT (WBRT) may be offered in patients who are treated with lumpectomy
  
  • Several trials support the findings that lumpectomy with WBRT reduce recurrence rates in DCIS by about 50% and invasive disease in ipsilateral breast
  • Accelerated partial breast irradiation (APBI) may be considered in patients with DCIS measuring ≤2.5 cm with negative margin width >3 mm

• Sentinel node biopsy may be done
• Mammogram is advised postlumpectomy to ensure complete removal of the tumor

Total Mastectomy

• Associated with near-total avoidance of recurrence in 3-20 years
• Recommended in widespread DCIS with involvement of ≥2 areas and when there is persistent marginal involvement even after repeat surgery
• May not require post-op radiation unless the carcinoma is at the margin of the mastectomy
• Sentinel lymph node biopsy should be done at the time of definitive surgery since mastectomy alters the feasibility of this procedure

Breast-conserving Surgery

• Local treatment of choice for majority of invasive breast cancer
• Purpose is to provide a pathologically negative margin of resection
  
  • Negative margin should be reported as ink is not touching invasive cancer or DCIS and >2 mm (for in situ disease) is preferred
  • Image-detectable markers are placed during core biopsy for tumor bed demarcation for surgical management post chemotherapy
  • In cases where there is a positive margin, the option is to re-excise or perform mastectomy to achieve a negative margin

• Radiation is usually done after breast-conserving surgery
• Survival rates are similar to mastectomy alone for stage I or II treated with lumpectomy and RT and in patients with DCIS treated with breast-conserving surgery and RT
• Absolute contraindications for breast-conserving surgery requiring RT:
  
  • RT during pregnancy
  • Pathologic margins that are diffusely positive
  • Suspicious or malignant-appearing microcalcifications that are disseminated throughout the breast
  • Extensive disease that cannot be incorporated by local excision through a single incision or breast tissue segment that may result in negative margins with acceptable cosmetic result
  • Homozygous (biallelic inactivation) for ATM mutation

• Relative contraindications for breast-conserving surgery requiring radiation therapy:
  • Positive pathologic margin
  • Prior chest wall or breast radiation therapy
  • Active connective tissue disease with skin involvement (eg scleroderma, lupus)
  • Women with known or suspected genetic predisposition to breast cancer (with increased risk for ipsilateral breast recurrence or contralateral breast cancer with breast-conserving therapy, can be considered for prophylactic bilateral mastectomy, known or suspected Li-Fraumeni syndrome)
  • Others include young age (<35 years old), multicentric disease, tumor located near nipple, BRCA1/2 gene mutation

Lumpectomy

• Selective removal of breast mass and a margin of normal surrounding tissues

Partial or Segmental Mastectomy or Quadrantectomy

• Removal of up to one-quarter of the breast

Mastectomy

• Entire breast removal
  
  • Women at high risk of breast cancer may be offered prophylactic bilateral mastectomy with reconstruction as a risk-reducing surgery
  • Preferred for men with breast cancer rather than breast-conserving surgery

Simple or Total Mastectomy

• Removal of the entire breast, including the nipple, but sparing the axillary LNs or muscle tissue from beneath the breast
• Most common type of mastectomy used to treat breast cancer

Skin-sparing Mastectomy

• Same amount of breast tissue is removed as with simple mastectomy but keeping most of the skin over the breast (other than areola and nipple) intact
• Improves cosmetic outcome (reduced scar size, natural breast shape) and permits immediate reconstruction 
• Only performed in women who will undergo immediate reconstruction
• May not be suitable for larger tumors or tumors that are close to the skin surface

Nipple-sparing Mastectomy

• Variation of the skin-sparing mastectomy where breast tissue is removed but sparing the skin and nipple
• Alternative for women who have small early-stage cancer near the outer part of the breast (>2 cm from the nipple) with low rates of nipple involvement and local recurrence
• Contraindicated in patients with evidence of nipple involvement (eg Paget's disease), nipple discharge suggesting malignancy, or imaging results suggestive of malignancy involving the nipple and subareolar tissues

Modified Radical Mastectomy

• Simple mastectomy with removal of the level I/II axillary LNs
• As effective as radical mastectomy

Radical Mastectomy

• Removal of the entire breast, axillary LNs, and pectoral muscles
• Rarely performed because of disfigurement and side effects
• May still be done for large tumors that are growing into the pectoral muscles under the breast

Lymph Node Surgery

• Includes axillary LN dissection and sentinel LN biopsy
• To assess LN status, ie if the cancer cell has spread to axillary LN
• Important in determining the stage, therapy, and outcome
• Indicated in patients with large tumors (eg T2, T3)
• Not usually done in pure DCIS or pure lobular neoplasia

Axillary Lymph Node Dissection

• Removal of 10-40 (usually <20) level I/II axillary LNs and examined for cancer metastasis
• Usually performed simultaneously with mastectomy or breast-conserving surgery, but may be done in a subsequent operation

Sentinel Lymph Node Biopsy

• Removal of the sentinel LN to determine if the cancer cells have spread to nearby LNs
  
  • New standard of care in early, clinically node-negative breast cancer rather than complete axillary LN excision
  • Sentinel LN is the 1st LN that is most likely to contain cancer cells if metastases have already started
  • Full axillary dissection is done if cancer is found in the sentinel LN
    
    • Axillary dissection can be safely omitted with <2 positive sentinel LNs if whole breast radiation treatment will be given after breast-conserving surgery
  • No further LN surgery is needed if:
    • Sentinel node is negative
    • Sentinel node is positive but only micrometastases or isolated tumor cells (ITC) are seen

• With decreased risk of lymphedema and duration of hospital stay because only few LNs are removed
• Considered in patients with clinically negative axillary LNs, with no previous chemotherapy nor hormone therapy
• Preferred method of axillary LN staging provided that there is an experienced sentinel node team and the patient is an appropriate candidate for sentinel LN biopsy

Reconstructive Surgery

• Procedure that restores the breast’s appearance
• Offered to patients after mastectomy or breast-conserving surgery which can be done as either immediate breast reconstruction (except for patients with inflammatory breast cancer) or delayed breast reconstruction

Risk Reduction for Carcinoma In Situ

Surgery

• Risk-reducing mastectomy (RRM) and/or bilateral salphingo-oophorectomy may be an alternative for patients at high risk of developing invasive breast cancer