Surgical Intervention
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