Breast-Conserving Surgery

1. Indications: Localized Breast Cancer
   1. Considered optimal therapy for early Breast Cancer
   2. Stage I or Stage II Breast Cancer (localized tumor)
      1. Tumor not fixed to overlying skin
      2. Tumor not fixed to underlying muscle
      3. Negative surgical margins
      4. No diffuse, inflammatory or multicentric cancer
      5. No malignant appearing mammographic abnormalities after surgery
      6. No previous radiation to the Breast or chest wall (prevents further Breast Radiation Therapy)
   3. Lymph node involvement is not a contraindication
      1. Lymph nodes must not be fixed to other lymph nodes
      2. Lymph nodes must not be fixed to surrounding tissue
   4. Invasive ductal and lobular cancer not contraindication
      1. Tumor must not be diffuse
      2. Requires that negative surgical margins are achieved
   5. References
      1. Morrow (2002) CA Cancer J Clin 52(5): 277-300
2. Contraindications
   1. Absolute
      1. Two or more primary tumors in different quadrants
      2. Associated diffuse suspicious microcalcifications
      3. Previous Breast irradiation
      4. Pregnancy (unless near estimated delivery date)
   2. Relative (due to resulting cosmetic result)
      1. Collagen vascular disease (poor vascular supply)
      2. Large tumor in small Breast
3. Protocol: Breast Cancer
   1. Tumor localization
      1. Biopsy of suspected tumor site
         1. Stereotactic needle biopsy or
         2. Needle localization Excisional Biopsy
      2. Axillary node examination
         1. Sentinel lymph node biopsy or
         2. Axillary node dissection
   2. Conservative Breast Surgery
      1. Complete tumor excision with negative margins
   3. Breast Radiation Therapy
      1. Follows all cases of Conservative Breast Surgery
      2. Radiation Therapy starts 2-4 weeks after surgery
      3. Timing: 5 days per week for 6 weeks
      4. Radiation exposure
         1. Entire Breast: 5000 cGy
         2. Tumor site: 1500 cGy (in addition to 5000 cGy)
4. Efficacy
   1. Survival outcomes same as for Mastectomy in early cases
   2. High recurrence rate unless radiation follows surgery
   3. References
      1. Fisher (2002) N Engl J Med 347:1233-41
      2. Fisher (1995) N Engl J Med 333:1456-61
      3. Winchester (1998) CA Cancer J Clin 48:83-107
5. Advantages: Breast conserving surgery over Mastectomy
   1. Improved body image and higher treatment satisfaction
   2. No greater fear of recurrence compared with Mastectomy
   3. Lower rates of Major Depression, anxiety and Insomnia
   4. References
      1. Curran (1998) Eur J Cancer 34:307-14
6. Complications
   1. Positive tissue margins after conservative surgery
      1. Requires modified radical Mastectomy
   2. Local recurrence (5-12% of cases)
      1. Treated with Mastectomy
   3. Breast radiation changes (e.g. skin thickening)
   4. Wound infection, seroma or hematoma (<5% of cases)
7. References
   1. Abeloff (2000) Clinical Oncology, p. 2094-5
   2. Townsend (2001) Sabiston Surgery, p. 576-7
   3. Apantaku (2002) Am Fam Physician 66(12):2271-81
   4. Chung (2002) Obstet Gynecol Clin North Am 29(1):173-88