Chapter 27. Operative Management of Breast Cancer

Breast Lumpectomy

• Definitive therapy for a benign solid breast mass.
• Atypical cells or lobular carcinoma in situ on fine needle aspiration or core needle biopsy of a breast or mammographic abnormality.
• Stage I and II breast cancer (if combined with sentinel lymph node biopsy and adjuvant radiation therapy [XRT] to accomplish breast conservation therapy).
• Ductal carcinoma in situ.
• Nonpalpable mammographic abnormalities (eg, calcifications).

Modified Radical Mastectomy

• Local management of stage II breast cancer when breast conservation therapy is contraindicated or is not the patient's preference.
  • Residual large cancer after adjuvant therapy.
  • Multicentric cancer.
  • Patient preference.
  • Contraindication to subsequent radiation therapy.
• Local management of stage III breast cancer.
• Lymph node metastases discovered during sentinel lymph node biopsy or fine needle aspiration for a clinically palpable node.

Sentinel Lymph Node Biopsy

• Clinical stage I and II breast cancer.
  • May be performed in conjunction with breast-conserving therapy or simple mastectomy.
• Axillary nodal status is the most powerful prognostic feature available in stratifying the risk of breast cancer relapse.

Areolar Duct Excision

• Lactiferous ductal dilation on imaging.
• Nipple discharge isolated to a single duct or quadrant of the nipple.
• Mass or mammographic abnormality underlying the nipple-areolar complex.

Breast Lumpectomy

Absolute

• Multicentric disease (tumors in separate quadrants).
• Persistent positive margins after reasonable surgical attempts
• Pregnancy: first and second trimester (if XRT is intended with the goal of breast conservation therapy). Breast conservation therapy may be feasible in the third trimester if radiation therapy is deferred to the postpartum period.
• Prior therapeutic irradiation to the breast that would result in retreatment to an excessively high radiation dose (if XRT is intended with the goal of breast conservation therapy).
• Diffuse, malignant-appearing microcalcifications.
• Tumor size > 5 cm.

Relative

• History of collagen vascular disease (eg, scleroderma or systemic lupus erythematosus) especially if steroid dependent (if XRT is intended with the goal of breast conservation therapy; these patients may experience excessive radiation toxicity).
• Extensive gross multifocal disease in the same quadrant.
• Large tumor in a small breast that would offer suboptimal cosmetic results.
• Patient preference for mastectomy.
• Male breast cancer (rarely feasible).
• Skin cellulitis and open wounds.
• Stage IV disease.

Modified Radical Mastectomy

Absolute

• None.

Relative

• Stage IV disease.

Sentinel Lymph Node Biopsy

Absolute

• Clinically positive adenopathy on physical examination.
• Pregnancy, lactation.

Relative

• Previous regional breast surgery or radiation.
• Stage III or IV disease.
• Prior axillary surgery.
• Locally advanced primary cancer (> 5 cm).

Areolar Duct Excision