Treatment Guideline Chart
Breast cancer is the presence of malignant breast nodule, mass or abscess.
Most common symptom of breast cancer is a new lump or mass in the breast. The lump or mass is usually painless, hard & irregular but it can also be tender, soft, rounded or painful.
Other signs & symptoms include breast pain or nipple pain, nipple discharge, nipple retraction and presence of breast skin changes (eg peau d' orange, nipple excoriation, scaling, inflammation, skin tethering, ulceration, abscess).

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 breast-conserving surgery, or excision of margin

Breast-conserving Surgery

  • Higher recurrence rate when done alone, without radiation therapy (RT), endocrine therapy or chemotherapy especially in high-risk patients
  • Whole breast radiotherapy (WBRT) may be offered in patients who are treated with breast-conserving surgery
    • Several trials support the findings that breast-conserving surgery 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 breast-conserving surgery 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:
    • Persistently positive pathologic margin
    • Prior chest wall or breast radiation therapy with known prescribed doses and volumes
    • 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

Breast-conserving Surgery

  • 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


  • 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
  • Recommended for patients without preoperative systemic therapy and with biopsy-proven axillary LN metastases or patients with residual disease after preoperative systemic therapy

Sentinel Lymph Node Biopsy/Mapping and Excision

  • Removal of the sentinel LN to determine if the cancer cells have spread to nearby LNs
    • Preferred method for axillary LN staging in early, clinically node-negative breast cancer or in patients with ≤2 suspicious nodes on imaging or ≤2 positive nodes confirmed by needle biopsy rather than complete axillary LN excision provided that there is an experienced sentinel node team and the patient is an appropriate candidate for sentinel LN biopsy
    • 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

Reconstructive Surgery

  • Procedure that restores the breast’s appearance
  • Should be based on an assessment of cancer treatment, patient's body habits, obesity, smoking history, comorbidities and patient concerns
  • Oncoplastic reduction, mastopexy, contralateral matching, bilateral breast reduction, local tissue rearrangement or regional flap may be considered in postlumpectomy patients
  • Consider delayed reconstruction in patients with inflammatory breast cancer
  • Reconstruction for postmastectomy patients should be based on treatment history
    • Implant, autologous or combination reconstruction may be considered in patients with no prior history of RT
    • For patients to be given adjuvant RT, 2-stage or 1-stage implant-based reconstruction prior to initiation of RT, or autologous reconstruction may be considered
    • Reconstruction (delayed reconstruction following mastectomy or RT or immediate reconstruction for mastectomy after previous reconstruction) may be performed in previously radiated patients
    • For patients with unknown history of RT, immediate placement of tissue expander, 1-stage direct implant placement, immediate autologous reconstruction or latissimus dorsi with implant at time of mastectomy, or delayed reconstruction are to be considered, with subsequent procedures based on treatment indicated
  • Bilateral prophylactic mastectomies with reconstruction using prosthetic, autologous tissue, or a combination of implant with autologous tissue is an option for individuals carrying genetic mutations relevant to breast cancer
  • Revisional surgery including fat grafting, mastopexy, direct excision/suction-assisted lipectomy, contralateral procedures, etc may be necessary after breast reconstruction

Risk Reduction for Carcinoma in Situ


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