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Breast Conservative Treatment


Medical editor Ellen Schlichting MD
Surgeon
Oslo University Hospital
Norway

General

Breast conservative treatment (BCT) is applied for early stage breast cancer and is always followed by postoperative radiation.
The resection must be complete and the procedure should be planned to achieve a tumor-free margin of a minimum of 5 mm to the sides.  

Reresection, however, is not necessary unless there is tumor in the resection margins ("ink not on tumor"). There is therefore no specific requirement for the width of the free resection margin. If it is uncertain whether the resection margins are free of tumor, a reoperation, reresection or mastectomy must be performed. If there is a need for multiple reresections, mastectomy should be considered as there is evidence for an association between repeated resections and local recurrence. 

For infiltrating cancer with no sign of metastasis to lymph nodes preoperatively, sentinel lymph node biopsy is performed (sentinel node diagnostics).

Several studies have shown that younger women treated with BCT have an enhanced risk of ipsilateral breast recurrence. Familiar and hereditary breast cancer appears more often in younger women. This enhances the difficulty of weighing age and treatment with regard to prognosis. Survival for young women are equal regardless of mastectomy or BCT.

It is no more considered reason for an upper limit for the extension of DCIS for BCT to be performed, as long as radical excision with free margins can be achieved and the size of the breast is not prohibitory.

Indication

  • Infiltrating breast cancer (tumors < 5 cm)

Special conditions for DCIS

It is no longer perceived to be basis for setting an upper limit to the extent of DCIS that BCT may be conducted as long as it is appropriate for radical excision with free margins and the size of the breast can tolerate this.

Contraindications/relative contraindications to conservative surgery

Absolute:

  • Previous irradiation towards breast or thoracic wall.
  • In pregnancy where irradiation (after possible conservative surgery) cannot be postponed till after termination of the pregnancy.
  • Two or more tumors in different sectors of the breast. When two or more tumors are present in the same quadrant or sector  conservative surgery may be performed.
  • Diffuse suspect microcalcifications on mammography.
  • Extensive disease which cannot be excised locally with adequate cosmetic result.
  • Tumor in resection margin.
  • When radiation may not be performed (for instance cardiac disease or thorax malformation).
  • Primary tumor (invasive) of stage T3 (size > 5 cm or T4; these require adjuvant treatment).

Relative:

  • Active disease of the connective tissue involving skin (for instance sclerodermia and lupus)
  • Large tumor in a small breast
  • Very large breasts; can be problematic to irridiate

  Goal

  • Same survival as for mastectomy
  • Good local control with low risk for ipsilateral recurrence (<1% annually).
  • The cosmetic result must be expected to be as good as for mastectomy with subsequent reconstruction.

Equipment

  • Tray for fine surgery

Preparation

  • The incision is outlined on the skin with the patient in an upright position. 
  • The operation is performed under general anesthesia. 
  • The patient in a supine position with the ipsilateral arm abducted 70-90 degrees.

Implementation

  • Incision as for biopsy. It should be within the excision of a possible later mastectomy. Normally, the tissue between the skin and the pectoral muscle is resected. For tumors close to the skin it may be necessary to remove the skin also. The specimen should be marked in agreement with the pathologist, preferably with the use of margins marker.
  • The resection should be complete and planned to achieve a tumor-free side margin of at least 5 mm. Reresection is not necessary if there is no tumor in the resection margin (”ink not on tumor”).  
  • Onkoplastic (for instance tennis racket operation) may be required for best cosmetic results.
  •  Adequate hemostasis.  
  • The incision is closed with intracuticular sutures. 
  • A compression bandage is applied. 
  • Local anesthesia is applied (20 ml xylocain with/without adrenaline). 

The specimen is sent for a histological examination.


Follow-up

  • Compression bandage is removed before leaving hospital.
  • The procedure is usually done as day surgery.
  • Follow-up by surgeon after 2-3 weeks 
  • The patient should be followed-up with annual mammography for 10 years.

Radiation therapy should start 6 to 8 weeks after the operation.

Axillary surgery increases the risk for development of lymphedema


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