Journal of Surgical Technique and Case Report
Journal of Surgical Technique and Case Report


 
  Table of Contents 
EDITORIAL
Year : 2011  |  Volume : 3  |  Issue : 1  |  Page : 1-4  

Breast conserving therapy: A surgical technique where little can mean more


Department of Surgery, College of Medicine, King Khalid University/Asir Central Hospital, Abha, Saudi Arabia

Date of Web Publication30-Mar-2011

Correspondence Address:
Ganiyu A Rahman
Department of Surgery, College of Medicine, King Khalid University/Asir Central Hospital, Abha
Saudi Arabia
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DOI: 10.4103/2006-8808.78459

PMID: 22022642

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How to cite this article:
Rahman GA. Breast conserving therapy: A surgical technique where little can mean more. J Surg Tech Case Report 2011;3:1-4

How to cite this URL:
Rahman GA. Breast conserving therapy: A surgical technique where little can mean more. J Surg Tech Case Report [serial online] 2011 [cited 2014 Oct 21];3:1-4. Available from: http://www.jstcr.org/text.asp?2011/3/1/1/78459

Cancer is a leading cause of death around the world. The World Health Organization (WHO) estimates about 84 million people will die of cancer between 2005 and 2015 without intervention. [1] At present, in the United States, one in four deaths is due to cancer. [2] The most prevalent cancer in the world is breast cancer and nearly one in four women with cancer in the world have breast cancer. Half of these are in developing countries. [3] As stated by Ferlay et al., cancer is neither rare anywhere in the world nor mainly confined to the high-resource countries. [4]


   Treatment of Breast Cancer Top


For a complete and optimal therapy for breast cancer, it should be a multidisciplinary approach with input from the patient, the surgeon, the diagnostic radiologist, the pathologist, the general practitioner, the radiation oncologist, the medical oncologist, nurses, and other health professionals.The outcome of patients with breast and other cancers is better if they are treated by a clinician who has access to a full range of treatment options in a multidisciplinary setting.

The primary goal in the treatment of breast cancer is to control the disease with the aim of achieving cure. The other desirable outcomes of treatment include: to improve survival, minimize the risk of distant metastases and / or local recurrence, cosmesis, relief of symptoms, and the return to a quality life as close as possible to the life before diagnosis.

The different modalities of treatment include surgery, radiotherapy, systemic therapy (cytotoxic drugs and hormonal manipulation) and treatment targeted at HER2. Surgery remains an important modality of treatment, to eradicate the primary tumor and achieve total disease control.


   History of Surgical Management Top


The initial surgical treatment of breast cancer was typically wide excision, but was associated with a high rate of local recurrence and poor survival. William Halsted popularized radical mastectomy in 1894. [5] Radical mastectomy (RM) resulted in a significant drop in the local recurrence rate, but the curative potential remained limited.

Attempt with extended radical mastectomy, which included internal mammary node dissection, failed to improve survival. [6],[7]

At different times, Modified Radical Mastectomy (MRM), Total (Simple) Mastectomy, and more recently, Skin sparing mastectomy (SSM) and Nipple sparing mastectomy (NSM) were introduced.

Although MRM is a less morbid procedure compared to RM, the patient will still require a loss of the breast. The attempt to preserve the breast without compromising survival brought up the use of Breast Conserving Therapy (BCT). This includes breast conserving surgery and breast radiotherapy. Although BCT and breast conserving surgery (BCS) are used interchangeably, strictly speaking BCT includes both BCS and breast radiotherapy.

BCS is an important part of the breast-conserving therapy, which may be defined as a combination of conservative surgery for resection of the primary tumor with or without surgical staging of the axilla, followed by radiotherapy for the eradication of the residual microscopic disease of the breast, with or without adjuvant systemic therapy.

The aim of this communication is to highlight the indications, contraindications, surgical techniques, and complications of BCT.


   Breast Conserving Therapy Top


The National Surgical Adjuvant Breast and Bowel Project (NSABP) B 06 compared TM to lumpectomy, with or without radiation therapy, in the treatment of stages I and II breast cancer. After five- and eight-year follow-up periods, the disease-free, distant disease-free, and overall survival rates for lumpectomy, with or without radiation therapy, were similar to those observed after TM. However, the incidence of ipsilateral breast cancer recurrence (in-breast recurrence) was higher in the lumpectomy group that did not receive radiation therapy. [8],[9],[10],[11]


   Patient's Selection for BCT Top


The four critical elements in selecting patients for breast conserving therapy are: A history and physical examination, breast imaging, histological assessment of the resected breast, and assessment of the patient's needs and expectations. [12]


   Contraindication Top


If an attempt to preserve the breast is associated with high rates of in-breast recurrence, then BCT is absolutely contraindicated. These situations are: Multicentric disease, diffuse malignant-appearing mammographic microcalcifications (suggesting multicentricity), persistent positive resection margin, prior radiotherapy to the breast or chest wall, and pregnancy. The main reason for contraindication in pregnancy is the need for radiotherapy, which will be contraindicated in pregnancy. BCT can therefore be performed in the third trimester, deferring breast radiotherapy until after delivery.

Relative contraindications are connective tissue disease, especially scleroderma and active systemic lupus erythromatosis (SLE) [12],[13] and a large tumor in a small breast.

Factors thought to be associated with risk of breast cancer recurrence after BCT are now known to be unfounded as long as there is a negative margin on excision. Some of these are: age, positive family history of breast cancer, skin or nipple retraction (not necessarily sign of locally advanced disease), tumor location, clinical or pathological axillary nodal metastases, histological subtypes, [14] and the presence of an extensive intraductal component.


   Surgical Technique Top


The essence of BCT is not only to preserve the breast, but also to have an esthetically acceptable result. The cosmetic appearance after BCT is determined by surgical factors like: size and placement of incision, management of the lumpectomy cavity, and extent of axillary dissection, if necessary. The surgical technique can therefore make a difference. [15] The goal at the end is to have a cosmetically acceptable outcome without compromising local tumor control.

In planning the incision, the surgeon had to take into consideration the location of the lump, type of incision, depth of mass from the skin, and the incision had to be close to the lump to avoid tunneling.

In order to reduce local failure and improve the outcome in breast cancer, there is need to emphasize the surgeon's role in improving patient selection and optimizing the procedure.

The incision should be sited in such a way that if mastectomy is eventually required, it can be included in the mastectomy specimen. In the upper part of the breast, incisions should be curvilinear or transverse, while in the lower part, they should be either curvilinear or radial.

An improved adequate surgical margin is crucial and can be achieved without an excessive re-excision rate, with detailed planning, consideration for oncoplastic resection, and intraopertive margin analysis. [16]

What constitutes an adequate margin of a grossly normal breast tissue around the tumor in BCT is uncertain. In one series, resection of 0.5 to 1.0 cm of grossly normal tissue resulted in a histologically negative margin in 95% of 239 patients. [17]

The surgical technique must ensure adequate excision. Obtaining a tumor-free surgical margin decreases the incidence of a local recurrence (LR) of the primary tumor. [18]

There are various risk factors associated with a positive margin, among them are: The extent of excision, age, large tumor size, multifocality, lobular histological type, and the number of positive lymph nodes. [19]

In 30 of 34 reviewed studies, persistent microscopic inadequate (R1) or macroscopic inadequate (R2) surgical margins were highly significant for LR compared to the negative margin (p = 0.0001). [20] Microscopic disease resulting from a positive margin is more problematic because theoretically, cancer in the relatively hypoxic environment of the lumpectomy scar bed will be resistant to radiation therapy. [21] Furthermore, the inability to achieve negative margins may be a marker of an excessive tumor burden in the treated breast.

Although Gould and Robinson summarized that variation between pathologists in the processing, interpretation, and reporting of the margin may influence the result, [22] it is important to establish a direct communication between the surgeon and the pathologist in optimizing margin control.

In order to ascertain a negative margin, intraoperative margin assessment (IOMA) has been found to be useful. These include: gross inspection in the operating room, with or without frozen section analysis, cytologic touch prep (CTP) analysis, shaved margin (SM), and intraoperative ultrasound (IOUS). Although these assessments are useful, they do not guarantee an absence of microscopic tumor on permanent section.

As most of the current techniques still result in a relatively high rate of positive margins with impact on the LR rate and cosmetic results, new innovative surgical approaches and methods for IOMA are needed. [23],[24] The following are suggested: Positron Emission Tomography (PET) imaging, Radio-guided Occult Lesion Localization (ROLL) and Infrared Fluorescence (NIRF) Optical Imaging. [25]

At the completion of the excision, the surgeon should ensure adequate hemostasis. Drainage of the lumpectomy cavity should be avoided and it should be allowed to fill with serum and fibrin. This will give the best cosmetic result. As suggested by Morrow et al., reapproximation is best avoided, as it can result in distortion of the breast contour, which may not be apparent with the patient supine on the operating table. [12] In a situation where the lumpectomy cavity is large, latissimus dorsi reconstruction of the defect may be appropriate

The incision should be closed with a subcuticular suture.


   Cosmetic Evaluation Top


As cosmesis is a major consideration in BCT, various scores have been designed to evaluate the cosmetic outcome. [26]


   Complications Top


Seroma formation, arm morbidity (arm swelling, arm pain, arm numbness, arm stiffness, shoulder stiffness, shoulder pain, and nerve injury), phantom breast syndrome, delayed cellulitis and pain syndromes of the chest wall, axilla, and upper extremity are known complications after breast cancer treatment. Some of these complications especially arm morbidity is less common in BCT as compared to mastectomy, and less frequent with sentinel lymph node biopsy than after axillary lymph node dissection.


   Conclusion Top


Although getting a microscopic negative margin is still challenging, BCT as a surgical technique has revolutionalized the surgical treatment of early breast cancer. BCT has not only provided an acceptable oncological outcome, but has diminished the psychological burden, offered better cosmetic results, and reduced postoperative complications.

 
   References Top

1.World Health Organization, Media centre. World Cancer Day 2011. Available from: http://www.who.int/mediacentre/events/annual/world_cancer. [Last cited on 2011 Feb 5].  Back to cited text no. 1
    
2.Jemal A, Siegel R, Xu J, Ward E. Cancer statistics 2010. CA Cancer J Clin 2010;60:277-300.  Back to cited text no. 2
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3.Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics 2002. CA Cancer J Clin 2005;55:74-108.  Back to cited text no. 3
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4.Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of world cancer burden in 2008: GLOBACAN 2008. Int J Cancer 2010;46:3040-52.  Back to cited text no. 4
    
5.Halsted W. The results of radical operation for the cure of carcinoma of the breast. Ann Surg 1907;46:1.  Back to cited text no. 5
    
6.Turner-Warwick RT. The lymphatics of the breast. Br J Surg 1959;46:574-82.  Back to cited text no. 6
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7.Veronesi U, Valagussa P. Inefficacy of internal mammary nodes dissection in breast cancer surgery. Cancer 1981;47:170-5.  Back to cited text no. 7
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8.Cooke T, Reeves J, Lanigan A, Stanton P. HER2 as a prognostic and predictive marker for breast cancer. Ann Oncol 2001;12:23-8.   Back to cited text no. 8
    
9.Paik S, Bryant J, Tan-Chui E, Yothers G, Park C, Wickerham DL, et al. HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project protocol B-15. J Natl Cancer Inst 2000;92:1991-8.   Back to cited text no. 9
    
10.Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233-41.   Back to cited text no. 10
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11.Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-32.   Back to cited text no. 11
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12.Morrow M, Strom EA, Basstt LW, Derahaw DD, Fowble B, Giuliano A, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cacer J Clin 2002;52:277-300.   Back to cited text no. 12
    
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15.Fitzal F, Mittlboeck M, Trischler H, Krois W, Nehrer G, Deutinger M, et al. Breast conserving therapy for centrally located breast cancer. Ann Surg 2008;247:470-6.   Back to cited text no. 15
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16.Sabel MS. Surgical consideration in early stage breast cancer: Leasons learned and future directions. Semin Radiat Oncol 2011;21:10-9.   Back to cited text no. 16
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17.Kearney TJ, Morrow M. Effect of reexcision on the success of breast-conserving surgery. Ann Surg Oncol 1995;2:303-7.   Back to cited text no. 17
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18.Kreike B, Hart AA, van de Velde T, Borger J, Peterse H, Rutgers E, et al. Continuing risk of ipsilateral breast relapse after breast-conserving therapy at longterm follow-up. Int J Radiat Oncol Biol Phys 2008;71:1014-21.   Back to cited text no. 18
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20.Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002;184:383-93.   Back to cited text no. 20
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22.Gould EW, Robinson PG. The pathologist′s examination of the ′′lumpectomy′′-the pathologists′ view of surgical margins. Semin Surg Oncol 1992;8:129-35.   Back to cited text no. 22
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24.Jacobs L. Positive margins: The challenge continues for breast surgeons. Ann Surg Oncol 2008;15:1271-2.   Back to cited text no. 24
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