Breast-conserving surgery: Difference between revisions
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'''Breast-conserving surgery (BCS),''' refers to an operation that aims to remove breast cancer while avoiding a [[mastectomy]]. Other terms for this operation include: lumpectomy, wide local excision, segmental resection, tylectomy, and quadrantectomy. BCS has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery. |
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'''Breast-conserving surgery''' (BCS, also known as '''breast conservation surgery''' and '''segmental mastectomy''') is a less radical cancer surgery than [[mastectomy]]. Breast-conserving surgery, as in a [[lumpectomy]] removes part of the breast tissue during surgery, as opposed to the entire breast. |
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== History == |
== History == |
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A close partnership between the surgeon and patient is important in the decision making process for whether or not to pursue breast-conservation surgery. |
A close partnership between the surgeon and patient is important in the decision making process for whether or not to pursue breast-conservation surgery. |
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<br /> |
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== Patient Selection == |
== Patient Selection == |
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===Indications=== |
===Indications=== |
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BCS is indicated in cases of biopsy-proven invasive breast cancer or biopsy-proven [[Ductal carcinoma in situ|ductal carcinoma in situ]] (DCIS). In the assessment of the tumor, the surgeon should assess the ability to resect the tumor with clear margins while providing a cosmetic result that is acceptable to the patient. <ref name=":2">{{Cite web|url=https://www.breastsurgeons.org/statements/guidelines/PerformancePracticeGuidelines_Breast-ConservingSurgery-PartialMastectomy.pdf|title=American Society of Breast Surgeons Performance and Practice Guidelines for Breast-Conserving Surgery/Partial Mastectomy|last=|first=|date=February 2015|website=www.breastsurgeons.org|archive-url=https://www.breastsurgeons.org/statements/guidelines/PerformancePracticeGuidelines_Breast-ConservingSurgery-PartialMastectomy.pdf|archive-date=February 2015|dead-url=|access-date=March 23, 2019}}</ref> |
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For clinical stages I and II breast cancer, breast-conserving surgery, with radiotherapy and possibly [[chemotherapy]] may be indicated if one or two [[sentinel lymph nodes]] are found to have cancer which is not extensive.<ref name="ACSfive">{{Citation |author1 = American College of Surgeons |author1-link = American College of Surgeons |date = September 2013 |title = Five Things Physicians and Patients Should Question |publisher = American College of Surgeons |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |page = |url = http://www.choosingwisely.org/doctor-patient-lists/american-college-of-surgeons/ |access-date = 2 January 2013}}</ref> In this case, the sentinel lymph nodes would be examined, and [[lymphadenectomy]] as further evaluation is not indicated as this result from the sentinel lymph nodes is sufficient to recommend treatment.<ref name="ACSfive"/> |
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===Absolute Contraindications=== |
===Absolute Contraindications=== |
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In the selection of patients for breast conservation treatment with radiation, there are some absolute and relative [[contraindication]]s. |
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Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include:<ref>{{cite book | vauthors = DeVita VT, Lawrence TS, Rosenberg SA | title = Cancer: Principles & Practice of Oncology | edition = 8th | date = 2008 | pages = 1624–1625 | publisher = Lippincott | location = Phila }}</ref> |
Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include:<ref>{{cite book | vauthors = DeVita VT, Lawrence TS, Rosenberg SA | title = Cancer: Principles & Practice of Oncology | edition = 8th | date = 2008 | pages = 1624–1625 | publisher = Lippincott | location = Phila }}</ref> |
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# A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose. |
# A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose. |
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# Persistent positive margins after reasonable surgical attempts: the importance of a single focally positive microscopic margin needs further study and may not be an absolute contraindication. |
# Persistent positive margins after reasonable surgical attempts: the importance of a single focally positive microscopic margin needs further study and may not be an absolute contraindication. |
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#Inflammatory breast cancer |
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#Diffuse or indeterminate micro-calcifications on mammography |
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[[Relative contraindication|Relative contraindications]] encompass situations of higher risk of complications to the patient that may be outweighed by other considerations, such as the benefit to the patient. Relative contraindications include:<ref name=":2" /> |
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# Previous breast radiation therapy |
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# Connective tissue disease such as [[Scleroderma]], [[Sjögren syndrome|Sjogren Syndrome]], [[Systemic lupus erythematosus|Lupus]], and [[Rheumatoid arthritis]] may result in an increased risk of radiation toxicity.<ref>{{Cite journal|last=Dilaveri|first=Christina A.|last2=Sandhu|first2=Nicole P.|last3=Neal|first3=Lonzetta|last4=Neben-Wittich|first4=Michelle A.|last5=Hieken|first5=Tina J.|last6=Mac Bride|first6=Maire Brid|last7=Wahner-Roedler|first7=Dietlind L.|last8=Ghosh|first8=Karthik|date=2014|title=Medical factors influencing decision making regarding radiation therapy for breast cancer|url=https://www.ncbi.nlm.nih.gov/pubmed/25429241|journal=International Journal of Women's Health|volume=6|pages=945–954|doi=10.2147/IJWH.S71591|issn=1179-1411|pmc=4242405|pmid=25429241|via=}}</ref> |
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# Very large tumor size relative to breast volume. |
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==Breast conserving therapy== |
==Breast conserving therapy== |
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Revision as of 16:23, 23 March 2019
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| Breast-conserving surgery | |
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 Breast-conserving surgery avoids removing the entire breast | |
| ICD-9-CM | 85.21-85.23 |
| MeSH | D015412 |
Breast-conserving surgery (BCS), refers to an operation that aims to remove breast cancer while avoiding a mastectomy. Other terms for this operation include: lumpectomy, wide local excision, segmental resection, tylectomy, and quadrantectomy. BCS has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery.
History
Prior to 1981, there existed limited evidence that breast-conserving surgery was an acceptable alternative to radical mastectomy for treatment of early stage breast cancer. Dr. Umberto Veronesi, an Italian oncologist, challenged this notion and led a clinical trial comparing the radical mastectomy with breast-conserving surgery (which was termed quadrantectomy at the time). This landmark trial showed no differences in overall survival, disease-free survival, and local recurrence for patients with breast cancer of less than 2 cm and no palpable axillary nodes.[1][2] He was widely celebrated for this landmark study, so much so that some began referring to this operation as the Veronesi Quadrantectomy.[1][3]
Decision Making
Shared decision-making is an important consideration in breast-conserving surgery. It is estimated that between 50% and 70% of patients are active participants in the decision making of breast cancer surgery.[4][5] The time following a cancer diagnosis may be filled with fear, vulnerability, and a sense of being overwhelmed at the amount of information being provided by physicians as well as accessed on the internet.[6] Each patient has their own set of unique characteristics, which may make it challenging to read information online and apply that information to a specific individual circumstance. In addition, there are several important misconceptions regarding breast-conservation surgery for patients and clinicians to keep in mind.[7]
- In appropriately selected patients, mastectomy and breast-conserving surgery have equivalent survival rates.
- Undergoing mastectomy does not eliminate the risk for recurrent or new cancer.
- Radiation therapy may still be needed following breast-conservation surgery.
- The decision regarding the need for chemotherapy is independent from the surgical options.
A close partnership between the surgeon and patient is important in the decision making process for whether or not to pursue breast-conservation surgery.
Patient Selection
Breast-conserving surgery is not appropriate for all patient with breast cancer. Proper patient selection involves a careful consideration of the indications and contraindications for surgery.
Indications
BCS is indicated in cases of biopsy-proven invasive breast cancer or biopsy-proven ductal carcinoma in situ (DCIS). In the assessment of the tumor, the surgeon should assess the ability to resect the tumor with clear margins while providing a cosmetic result that is acceptable to the patient. [8]
Absolute Contraindications
Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include:[9]
- Pregnancy is an absolute contraindication to the use of breast irradiation. In some cases, it may be possible to perform breast-conserving surgery in the third trimester and treat the patient with radiation after delivery.
- Two or more primary tumors in separate quadrants of the breast or with diffuse malignant-appearing microcalcifications.
- A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose.
- Persistent positive margins after reasonable surgical attempts: the importance of a single focally positive microscopic margin needs further study and may not be an absolute contraindication.
- Inflammatory breast cancer
- Diffuse or indeterminate micro-calcifications on mammography
Relative Contraindications
Relative contraindications encompass situations of higher risk of complications to the patient that may be outweighed by other considerations, such as the benefit to the patient. Relative contraindications include:[8]
- Previous breast radiation therapy
- Connective tissue disease such as Scleroderma, Sjogren Syndrome, Lupus, and Rheumatoid arthritis may result in an increased risk of radiation toxicity.[10]
- Very large tumor size relative to breast volume.
Breast conserving therapy
The goal of this process is to give the patient an equivalent survival rate to mastectomy while limiting cosmetic damage caused by surgery. Six recent clinical trials concluded that BCT was successful in that goal. However, not all patients are suitable for BCT and for some mastectomy may still be required (cf. Contraindications).[11]
Oncoplastic surgery
Oncoplastic surgery is an important consideration in breast-conserving surgery that integrates plastic surgery principles into breast cancer surgery in order to preserve aesthetic outcomes and quality of life, without compromising local control of the cancer. It is based on three surgical principles: ideal breast cancer surgery with free tumor margins, immediate breast reconstruction, and immediate symmetry with the other breast.[12] Oncoplastic approaches to breast-conserving surgery may require a close partnership among surgeons who specialize in surgical oncology and plastic surgery. Oncoplastic surgery is not only limited to breast-conserving surgery, as the techniques and principles of plastic surgery can be applied to mastectomy as well.[13]
As of 2017, there had been no randomized controlled trials to compare oncoplastic breast-conserving surgery to traditional breast conserving surgery techniques.[14] However, there is increasingly more evidence to support the oncoplastic breast-conserving surgery is safe from the cancer recurrence perspective while providing optimal cosmetic outcomes.[14][15][16][17]
References
- ^ a b Corso G, Veronesi P, Sacchini V, Galimberti V, Luini A (2017-06-08). "The Veronesi quadrantectomy: an historical overview". Ecancermedicalscience. 11: 743. doi:10.3332/ecancer.2017.743. PMC 5481191. PMID 28690674.
- ^ Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, Gallus G, Greco M, Luini A, Marubini E, Muscolino G, Rilke F, Salvadori B, Zecchini A, Zucali R (July 1981). "Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast". The New England Journal of Medicine. 305 (1): 6–11. doi:10.1056/NEJM198107023050102. PMID 7015141.
- ^ Zurrida S, Costa A, Luini A, Galimberti V, Sacchini V, Intra M (2001). "The Veronesi quadrantectomy: an established procedure for the conservative treatment of early breast cancer". International Journal of Surgical Investigation. 2 (6): 423–31. PMID 12678123.
- ^ Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Salem B, Lakhani I, Morrow M (August 2005). "Patient involvement in surgery treatment decisions for breast cancer". Journal of Clinical Oncology. 23 (24): 5526–33. doi:10.1200/JCO.2005.06.217. PMID 16110013.
- ^ Keating NL, Guadagnoli E, Landrum MB, Borbas C, Weeks JC (March 2002). "Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement?". Journal of Clinical Oncology. 20 (6): 1473–9. doi:10.1200/JCO.2002.20.6.1473. PMID 11896094.
- ^ Tsaras K, Papathanasiou IV, Mitsi D, Veneti A, Kelesi M, Zyga S, Fradelos EC (June 2018). "Assessment of Depression and Anxiety in Breast Cancer Patients: Prevalence and Associated Factors". Asian Pacific Journal of Cancer Prevention. 19 (6): 1661–1669. doi:10.22034/APJCP.2018.19.6.1661. PMC 6103579. PMID 29938451.
- ^ Newman LA (May 2017). "Decision Making in the Surgical Management of Invasive Breast Cancer-Part 1: Lumpectomy, Mastectomy, and Contralateral Prophylactic Mastectomy". Oncology. 31 (5): 359–68. PMID 28512732.
- ^ a b "American Society of Breast Surgeons Performance and Practice Guidelines for Breast-Conserving Surgery/Partial Mastectomy" (PDF). www.breastsurgeons.org. February 2015 (PDF). Retrieved March 23, 2019.
{{cite web}}: Check|archive-url=value (help); Cite has empty unknown parameter:|dead-url=(help) - ^ DeVita VT, Lawrence TS, Rosenberg SA (2008). Cancer: Principles & Practice of Oncology (8th ed.). Phila: Lippincott. pp. 1624–1625.
- ^ Dilaveri, Christina A.; Sandhu, Nicole P.; Neal, Lonzetta; Neben-Wittich, Michelle A.; Hieken, Tina J.; Mac Bride, Maire Brid; Wahner-Roedler, Dietlind L.; Ghosh, Karthik (2014). "Medical factors influencing decision making regarding radiation therapy for breast cancer". International Journal of Women's Health. 6: 945–954. doi:10.2147/IJWH.S71591. ISSN 1179-1411. PMC 4242405. PMID 25429241.
{{cite journal}}: CS1 maint: unflagged free DOI (link) - ^ Sabel, Michael S (17 March 2014). "Breast conserving therapy". UpToDate.
{{cite web}}: Unknown parameter|name-list-format=ignored (|name-list-style=suggested) (help) - ^ Bertozzi N, Pesce M, Santi PL, Raposio E (June 2017). "Oncoplastic breast surgery: comprehensive review". European Review for Medical and Pharmacological Sciences. 21 (11): 2572–2585. PMID 28678328.
- ^ Macmillan RD, McCulley SJ (June 2016). "Oncoplastic Breast Surgery: What, When and for Whom?". Current Breast Cancer Reports. 8 (2): 112–117. doi:10.1007/s12609-016-0212-9. PMC 4886147. PMID 27330677.
- ^ a b Weber, Walter P.; Soysal, Savas D.; Zeindler, Jasmin; Kappos, Elisabeth A.; Babst, Doris; Schwab, Fabienne; Kurzeder, Christian; Haug, Martin (Summer 2017). "Current standards in oncoplastic breast conserving surgery". The Breast. 34: S78–S81. doi:10.1016/j.breast.2017.06.033.
- ^ Chang, Edward I.; Peled, Anne Warren; Foster, Robert D.; Lin, Cheryl; Zeidler, Kamakshi R.; Ewing, Cheryl A.; Alvarado, Michael; Hwang, E. Shelley; Esserman, Laura J. (June 2012). "Evaluating the feasibility of extended partial mastectomy and immediate reduction mammoplasty reconstruction as an alternative to mastectomy". Annals of Surgery. 255 (6): 1151–1157. doi:10.1097/SLA.0b013e31824f9769. ISSN 1528-1140. PMID 22470069.
- ^ Clough, Krishna B.; Gouveia, Pedro F.; Benyahi, Djazia; Massey, Eleanore J. D.; Russ, Elisabeth; Sarfati, Isabelle; Nos, Claude (December 2015). "Positive Margins After Oncoplastic Surgery for Breast Cancer". Annals of Surgical Oncology. 22 (13): 4247–4253. doi:10.1245/s10434-015-4514-3. ISSN 1534-4681. PMID 25893409.
- ^ Khan, J.; Kahn, J.; Barrett, S.; Forte, C.; Stallard, S.; Weiler-Mithoff, E.; Doughty, J. C.; Romics, L. (July 2013). "Oncoplastic breast conservation does not lead to a delay in the commencement of adjuvant chemotherapy in breast cancer patients". European Journal of Surgical Oncology: The Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 39 (8): 887–891. doi:10.1016/j.ejso.2013.05.005. ISSN 1532-2157. PMID 23746877.
