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Surgery of Breast Cancer

The goal of surgical treatment is to achieve local control of the tumor before metastasis occurs. This includes the intention of preventing symptoms from local and regional tumor growth and to avoid locoregional recurrence, as well as recurrence after breast conservative treatment.

Surgical alternatives for the primary tumor are either ablation or breast conserving surgery (BCT). Axillary surgery implies sentinel node biopsy, with or without subsequent axillary dissection, or primary axillary dissection. Axillary dissection is defines as removal of axillary lymph nodes in levels 1 and 2.   

In patients with metastasis or patients with other severe morbidity, customized less extensive surgery may be performed, possibly in combination with systemic treatment to achieve maximal control of the disease.SNB may have lower detection rate in the elderly, but the method seems safe and is also recommended in the elderly.

For breast cancer in elderly, comorbidity or limited expected survival should be taken into consideration.

For breast cancer in pregnant patients, treatment must be adapted to the length of pregnancy. Surgery and general anesthesia are rarely problematic. It is also possible to perform sentinel node biopsy, but methylene blue should not be used. Close collaboration between surgeon, oncologist, gynecologist and pediatrician is necessary. Also the parents should participate in the decision making process. Adjuvant systemic treatment in the second and third trimester must be discussed in each individual case. Delivery of the baby prior to adjuvant treatment may also be relevant.

Breast cancer in men should, in principle, be treated identically as in women, but breast conservative treatment is not relevant.

Types of breast cancer surgery:

  • Diagnostic biopsy
  • Resection with or without oncoplastic surgery
  • Mastectomy with or without breast reconstruction
  • Sentinel lymph node biopsy (SLNB)
  • Axillary dissection

Hereditary breast cancer

Information about prophylactic bilateral mastectomy and reconstruction, must be given to women who have a known mutation in the BRCA1 gene. This treatment can reduce the risk of breast cancer by 90-98 % and is currently the safest way of avoiding death by breast cancer. Another option is mammography and breast MRI yearly. Norwegian studies show slightly reduced survival in woman with a BRCA1 mutation.

Patients with a known mutation in the BRCA 2 gene or with hereditary breast cancer without a known gene mutation should also be offered prophylactic bilateral mastectomy and reconstruction. The prognosis in these two groups is as good as in sporadic breast cancer.

Prophylactic bilateral mastectomy may also be discussed for lobular carcinoma in situ (LCIS).  With the efficient follow-up available today, this alternative is rarely indicated.

Premalignant changes

Ductal carcinoma in situ (DCIS)

Lymph node metastasis hardly ever occurs in DCIS, and direct axillary dissection should therefore not be performed. If mastectomy is planned, a sentinel node biopsy should be performed for DCIS grade 3. If sentinel node cannot be detected, axillary dissection should be avoided as the potential benefit is small in comparison to the probability of side effects such as lymphedema, neuralgia, and reduced mobility of the shoulder. If conservation surgery is performed for DCIS, SLNB should be renounced as this can be performed afterwards if final histological examination shows invasive carcinoma.

The low frequency of recurrence seen with small grade 1 DCIS lesions suggests that postoperative irradiation may be justifiably avoided. When breast-conserving surgery is chosen for patients with a tumor diameter of > 10 mm grade 1, or for DCIS grades 2 and 3 independent of size, radiation treatment is recommended. 

Treatment recommendations for premalignant tumors

Lesion


Surgery Surgical margins  Radiation treatment  Mammography Clinical follow-up#
Epithelial proliferation without atypia

Biopsy Tumor-free or involved  
No
 

Epithelial proliferation with atypia

Biopsy Tumor-free or involved No

Annually*

LCIS

Biopsy or bilateral mastectomy Tumor-free or involved No
Annually*

Pleomorfic LCIS or florid LCIS with comedonecrosis


Wide excision** Tumor-free** ***

Annually

Annually
DCIS, unifocal, grade 1,
≤10mm

Wide excision Tumor-free**  
No
 
Annually

Annually
DCIS, grade 1 (>10mm)
or grade 2-3, where the area can be removed in single resection

Wide excision**
Tumor-free**  
Yes, after wide excision
 
Annually

Annually
Multicentric DCIS

Mastectomy
SNB ****
Tumor-free  No  
Annually

Annually

# Clinical follow-up may take place in hospital (physisian or specialized registered nurse) or by a general practitioner

*Annual follow-up till 50 years of age. Then, mammography every second year, following the program of mammographic screening for breast cancer. For patients with a first degree relative with breast cancer, mammography is recommended annually till 60 years. After that control every second year, following the program of mammographic screening.

** If wide resection is performed, a resection margin of at least 2 mm is recommended 

*** This type of lesion is rare. There are no studies documenting the benefit from radiation therapy and there is no general basis for radiation treatment.

**** If sentinel node cannot be completed, it is recommended to avoid axillary dissection. 

Locally advanced breast cancer

Locally advanced breast cancer is defined as:

  • T3 primary tumor: > 5 cm in size, found clinically or by imaging, ultrasound or mammography
  • T4 primary tumor: invasion of skin, papilla, muscle, or inflammatory cancer
  • Clinically N2 conglomerate of lymph node metastases

If at the time of diagnosis, locally advanced breast cancer is detected, the patient should not have primary surgery. Staging should then be performed with regard to distant metastases, and the patient should be treated with primary systemic therapy after consultation and referral to a regional oncological center before local treatment is carried out (surgery and radiation).

Advanced (metastatic) breast cancer

Breast cancer in stage IV is treated on an individual basis. Surgery is usually limited, aiming to maintain local control of the disease with survival taken into consideration.

Reconstructions

Reconstruction after mastectomy aims at reshaping the volume and shape of the breast by means of prosthesis, autologous tissue or combinations of these. For symmetrical reasons the contralateral breast may have to be corrected as well. The reconstructions may be performed simultaneously with the mastectomy (primary) or later (secondary). Reconstructive surgery requires experience and special training. There is a continuous development of operative techniques and prostheses. Oncoplastic and other reconstructive surgery requires close cooperation between breast and plastic surgeons. All patients to have such surgery should be discussed in a multidisciplinary team including also radiologist, pathologist and oncologist.

Evaluation of  reconstruction techniques

The goal of the reconstruction is to obtain the best possible reconstruction with minimal surgical risk for the patient. Several factors are of importance:

  • The situation for the patient after the cancer treatment
  • The size of the skin- and volume defect
  • Previous radiation will rendeer some reconstruction techniques less suitable
  • The general condition of the patient
  • Does the patient have additional disease that make advanced reconstructions riskier?
  • The patients motivation and expectation of the reconstruction

According to these factors the surgeon must decide the reconstruction method for the individual patient. The surgical procedures can be roughly ranked by their advantages and disadvantages.Advantages and disadvantages in regard to reconstruction method of the breast

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