Breast-conserving surgery (BCS) 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.
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. 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.
In the selection of patients for breast conservation treatment with radiation, there are some absolute and relative contraindications.
Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include:
1. 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.
2. Two or more primary tumors in separate quadrants of the breast or with diffuse malignant-appearing microcalcifications.
3. A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose.
4. 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.
1. A history of collagen vascular disease is a relative contraindication to breast conservation treatment because published reports indicate that such patients tolerate irradiation poorly. Most radiation oncologists will not treat patients with scleroderma or active lupus erythematosus, considering it an absolute contraindication. In contrast, rheumatoid arthritis is not a relative or an absolute contraindication.
2. The presence of multiple gross tumors in the same quadrant and indeterminate calcifications must be carefully assessed for suitability because studies in this area are not definitive.
3. Tumor size is not an absolute contraindication to breast conservation treatment, although there is little published experience in treating patients with tumor sizes greater than four to five cm. However, a relative contraindication is the presence of a large tumor in a small breast in which an adequate resection would result in significant cosmetic alteration. In this circumstance, preoperative chemotherapy should be considered.
4. Breast size can be a relative contraindication. Treatment by irradiation of women with large or pendulous breasts is feasible if reproducibility of patient set-up can be assured and the technical capability exists for greater than or equal to six MV photon beam irradiation to obtain adequate dose homogeneity.
Breast conserving therapy
Breast conserving therapy (BCT) is the process of following up BCS with moderate dose radiation therapy in order to eliminate residual disease in the breast and decrease the likelihood of disease recurrence. 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).
- American College of Surgeons (September 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American College of Surgeons), retrieved 2 January 2013
- DeVita VT, Lawrence TS, Rosenberg SA: Cancer: Principles & Practice of Oncology, 8th Ed. 2008, pp 1624-1625; Lippincott, Phila.
- Breast conserving therapy, UpToDate. Mar 17, 2014
- American Academy of Family Physicians, Breast-Conserving Surgery, What is breast-conserving surgery?
- Breast conserving surgery at National Breast and Ovarian Cancer Centre www.nbocc.org