The two main surgical options for invasive breast cancer in females are:
1. modified radical mastectomy
Partial mastectomy is also known as lumpectomy or quadrentectomy. These procedures are used for control of local and metastatic disease. Other surgeries, like simple mastectomy or subcutaneous mastectomy, are usually reserved for prophylaxis.
Modified radical mastectomy involves removal of breast tissue, nipple and skin overlying this along with the axillary contents. The axilla has three levels of nodes. Level I is lateral to the pectoralis minor muscle. Level II is beneath pectoralis minor and level III is medial to pectoralis minor. In mastectomy only levels I and II are taken as metastasis usually spreads from levels I to III in sequential order. There has been no increase in survival with taking level III, but it does increase lymphedema. Pectoralis muscle is only removed if the tumor directly invades. In radical mastectomy, a surgery that is no longer preformed, the pectoralis is routinely removed. However, this proved to be more disfiguring without survival advantage.
Partial mastectomy or breast conservation therapy (BCT), involves removal of the diseased tissue and obtains an uninvolved margin of greater than 1 cm. The goal is to:
1. Reduce the tumor burden to microscopic levels
2. Compliant patient for follow-up and radiation therapy for local control
In 1995 this was unequivocally proven equal to mastectomy in disease-free survival and overall survival, if followed with radiation for tumors less than 4 cm. Patients with DCIS were found to have an 8% ipsilateral recurrence rate with BCT and irradiation compared to 18% for BCT alone. Radiation after lumpectomy decreases local recurrence but does not improve overall survival. Breast conservation therapy is not indicated in T3 or T4 N2 MX lesions or lesions that are multifocal or multicentric. Certain other situations require mastectomy including collagen vascular disease, pregnancy, or a previously irradiated breast. Determination of nodal status should follow lumpectomy to determine the need for adjuvant chemotherapy. Positive axillary nodes increase the risk of metastatic recurrence but have no increased risk of local recurrence (Table 9.5).
Sentinel node biopsy can determine the status of the axillary nodal basin using minimally invasive surgical techniques. The advantages of sentinel node biopsy include decreased risk of nerve injury and post operative lymphedema. This postoperative lymphedema is a long term risk of angiosarcoma which presents as a blue dot on the involved arm. The disadvantage to omitting full dissection includes the advantage of local disease control in the axilla. For this reason, patients with grossly positive nodes are not candidates for sentinel node biopsy. Another issue with sentinel node involves determination of patients who need postoperative chemotherapy. Historically, patients with greater than four positive nodes received chemotherapy.
Table 9.5. Breast cancer studies
NSABP B-04 1765
NSABP B-06 1843
In clinically node negative patients, total mastectomy with delayed node dissection, total mastectomy with radiation, and radical mastectomy are equivalent in disease free and overall survival
Modified radical mastectomy, BCT with ALND and irradiation, and BCT with ALND were equivalent in terma odf overall survival. Breast irradiation did decrease breast tumor recurrents from 39% to 10% but did not affect overall survival.
Patients with DCIS receiving BCT and irradiation had a better 5 year survival compared to those receiving BCT alone. This was attributed to a higher incidence of invasive cancers in the BCT alone group (50% vs 29%).
Nerves injured in axillary dissection include the long thoracic to serratus anterior, thoracodorsal to latissimus dorsi and, more commonly, the intercostal brachial to the skin. Often times the latter nerve is sacrificed and a paresthesia to the upper arm develops.
1. Fisher B, Anderson S, Redmond CK et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. NEJM 1995; 333(22):1456-1462.
2. Greenfield LJ, Mulholland M, Oldham KT et al. Surgery scientific principals and practice. 2nd ed. Philadelphia: Lippincott-Raven, 1997.
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