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Table 1 Historic trials supporting breast conservation therapy
Mastectomy
Trial
NSABP 590 629 4 No ink on
DBCG 429 430 5 No ink on
EORTC 422 452 5 1cm margin 13 85 85
NCI Milan 349 352 2 Quadrant 2 82 84
NCI
Bethesda
Institut
GustaveRoussy
LR local recurrence, NCI National Cancer Institute, NSABP National Surgical Adjuvant Breast and
Bowel Project, EORTC European Organization for Research and Treatment of Cancer, DBCG
Danish Breast Cancer Cooperative Group, WE Wide excision, RT Radiotherapy
(N)
116 121 5 Gross tumor
91 88 2 2cm margin 5 91 93
WE/RTTumor
size (cm) Margins
A. B. van den Bruele and L. H. Rosenberger
Survival (5year)
LR
(5years)
(%)
8 90 90
tumor
3 82 79
tumor
12 85 89
removed
Mastectomy
(%)
WE/
RT
(%)
surgery plus RT for the treatment of breast cancer (Table1) [3–8]. Since that time,
partial mastectomy/lumpectomy has become a common operative approach.
Excision of a cancer involves complex planning to ensure that the affected tissue is
removed to a negative margin while simultaneously providing an acceptable aesthetic result. Narrow surgical margins are adequate in the management of breast
cancer with breast conservation surgery. In lumpectomy with planned RT for invasive disease, margins wider than “no tumor on ink” and greater than 2mm for DCIS,
do not signicantly decrease ipsilateral breast cancer recurrence. These data and
recommendations are valid for younger patients, those with unfavorable histology,
lobular cancers, or extensive DCIS [9, 10]. If both invasive and DCIS are present in
the same tumor specimen, it is recommended that the invasive margin guideline is
used to tailor treatment. Routine resection of cavity shave margins (additional tissue
circumferentially around the cavity following a partial mastectomy) has also been
implemented as a way to orient the nal margin tissue, as well as assess residual
tumor burden in the surrounding cavity. The performance of routine cavity shave
has been demonstrated to decrease the rates of positive margins (margins harbouring additional disease) by about 50%, supporting a reduced second surgery rate for
patients with a breast malignancy desiring breast conservation therapy [11]. An
excessive amount of tissue need not be removed.
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2 Non-Palpable Lesion Localization
A localization procedure is required for intra-operative identication of nonpalpable breast lesions. Various techniques are available and include, but are not
limited to, the wire, radioactive iodine-125 seed, Scout® radar localization (formally
known as SAVI Scout®), Magseed®, and LOCalizer™ radio-frequency identication
(RFID) tag. Intraoperative ultrasound may also be employed, and can also be used
as a back-up, if one of these other methods fails [12]. The radioactive I-125 seed,
Scout® radar localization, Magseed® and LOCalizer™, and/or wire localization procedures can be done via mammogram, ultrasound or, more rarely, an MRI, whichever permits the most direct access to the breast lesion/lesions of interest. In many
centers, the breast radiologist performs the localization procedure prior to the operating room. Preoperatively a two-view mammogram [craniocaudal (CC) and mediolateral oblique (MLO)] is necessary to determine the 3-dimensional location of the
lesion within the breast parenchyma and position in relation to the mammographic
abnormality. These mammograms should be available to, and utilized by, the surgeon in the operating room for 3-dimensional localization. Figure 1a–d demonstrates a breast wire localization performed during a lumpectomy for an invasive
carcinoma. Figure2 shows an intraoperative specimen radiograph conrming the
removal of biopsy clips(s), mammographic lesion (mass), and localization wire (all
intact) within the lumpectomy specimen. Figure3a–c illustrates the radioactive seed
localization of an inferior breast lesion, followed by conrmation of retrieval of
targeted mass and calcications. Figure 4a–c demonstrates the Scout® Radar
Localization device placement and retrieval. The type of localization utilized may
be institution, or surgeon, dependent.
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A. B. van den Bruele and L. H. Rosenberger
c
d
Fig. 1 (a) Initial introducer needle insertion, (b) introducer needle repositioning for lesion targeting, (c) wire advancement and view in craniocaudal (CC), (d) nal positioning in mediolateral
oblique (ML) view
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Fig. 2 Intraoperative
specimen radiograph
conrming biopsy clips(s),
mammographic lesion
(mass), and localization
wire were all removed (and
intact) with lumpectomy
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A. B. van den Bruele and L. H. Rosenberger
a
b
Fig. 3 (a) Diagnostic mammogram with subcentimeter, non-palpable breast cancer, biopsied with
post biopsy mammogram revealing biopsy clip and radioactive I-125 seed placed for forthcoming
partial mastectomy. (b) Intraoperative specimen radiograph conrming biopsy clip, mammographic lesion (mass), and localization radioactive I-125 seed were all removed (and intact) with
lumpectomy. (c) Windowing of the image allows conrmation of the radioactive I-125 seed by
revealing the radiolucent region at one end of the seed
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c
Fig. 4 (a) Scout® Radar Localization device placement view in CC (b) nal positioning in LM,
(c) specimen radiography conrming retrieval of the Scout® Radar Localization device, excision of
the localized prior biopsy site, coil shaped biopsy clip and residual calcications and associated
density. (*Case courtesy of Dr. Maggie DiNome)
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A. B. van den Bruele and L. H. Rosenberger
3 Surgical Procedure
3.1 Anesthesia
Anesthesia for breast conservation surgery is frequently performed under monitored
anesthesia care (MAC) using local anaesthesia and intravenous sedation. For more
complex cases, a paravertebral block or general anesthesia may be required. Incision
placement for a lumpectomy may vary depending on the size and location of the
targeted abnormality. An incision directly over the lesion of interest is the most
direct route to a cancer, though there are several, more aesthetically focused incisions (e.g. peri-areolar incision or inframammary) that could also be incorporated,
as long as this does not compromise access, tissue handling, perfusion, or result in
excessive undue intraoperative time.
3.2 Mammogram andBreast Imaging Review
It is important that the surgeon review the patient imaging prior to the operating
room. If a biopsy was performed pre-operatively for the diagnosis, then a titanium
biopsy clip should be present and conrmed to be within (or immediately adjacent
to) the mammographic abnormality. Mammographic or MRI localization may not
have facilitated placement of a localization (wire, radioactive I-125 seed, Scout®,
etc.) directly within, or adjacent to, the lesion and/or biopsy clip, so the surgeon
must evaluate the location of the tumor and/or calcications and determine the best
approach. Traditional teaching has been that a radial incision is utilized at 3:00 and
9:00 positions, or if positioned in the lower quadrants of the breast. Additionally, a
curvilinear incision, or those placed within Langer’s lines, if in the upper quadrants
of the breast. The incision, however, should be carefully crafted based on tumor
location, size, anticipated volume of tissue to be removed, breast size and complexity of the operation. The operating surgeon should also consider placing the incision
in an area that could be easily excised if a mastectomy would be warranted later on
(i.e. due to extensively positive margins, indicating higher residual tumor burden, or
patient preference).
3.3 Surgical Excision (or Operative Technique)
Once the incision is made, the surgeon can use the localizing device to identify the
target. Excision may be performed using electrocautery, a surgical scalpel and/or
scissors depending on adjacent structures (i.e. skin, base of nipple) and surgeon
preference. Once removed, the specimen requires orientation, whether marking the
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lesion itself with suture and/or clips, or with the additional cavity shave margins.
Intraoperative inking has also been utilized by some surgical centers, as variability
in specimen orientation and processing can inuence margin assessment [13]. Once
the lumpectomy is performed, it is necessary to obtain intraoperative imaging to
conrm retrieval of the mammographic target, biopsy clip, and the localization
device (if applicable). It is recommended that the operating surgeon evaluate the
lumpectomy cavity to ensure that all palpably abnormal tissue has been adeqently
removed. Once hemostasis has been obtained, the surgeon should place clips within
the lumpectomy cavity to serve as a conrmatory marker for margin re-excision,
facilitate identication of the operative cavity for adjuvant radiation delivery for
tumor bed boost, and to localize the lumpectomy for future mammograms. Once
nal operative counts are correct, the cavity should be closed in layers using absorbable suture, with a nal running rapidly absorbable monolament for optimal aesthetics. A surgical dressing or liquid adhesive can be applied to complete the
operation. The patient should then be placed in a surgical bra or binder.
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4 Complex Multi-Site Localization
Until recently, the presence of multiple sites of cancer within the same breast, or
multi-ipsilateral breast cancer (MIBC), had been considered a contraindication to
breast conserving therapy. These patients were often advised that a mastectomy was
indicated due to the concern for higher locoregional recurrence. Recent data from
the Alliance/American College of Surgeons Oncology Group trial Z11102 study,
however, demonstrated that breast conservation to negative margins, followed by
whole breast RT plus boost to each tumor bed, was feasible in the majority of
patients with MIBC with similar oncologic outcomes [14]. For patients undergoing
breast conservation surgery for cancer with several abnormalities (multi-focal disease within one quadrant of the breast or multicentric disease) which are felt to be
amenable to lumpectomy, several localization devices may be performed via “bracketing” of the lesion(s) of interest. The surgeon and breast radiologist should discuss
these cases together to ensure that each provider understands the operative plan for
the patient, especially given the increasing complexity of localization. For multifocal/multi-centric disease, the operative procedure will likely involve a larger excision than a lumpectomy for a unifocal cancer. Incision placement is frequently over
the lesion(s) of interest to ensure direct access. Intraoperatively, the surgeon is
advised to orient the specimen(s) either within the lumpectomy, or with cavity shave
margins, and dictate the relationship of various specimens to one another in the
operative report. This is done to facilitate accurate assessment of tumor margins.
Once the lumpectomy is performed, it is necessary to obtain intraoperative imaging
to conrm retrieval of the target(s), biopsy clip(s) and localization devices
(Figure5a–c). Once conrmed, the tumor bed should be marked with clips, and
closure can commence as discussed in the prior section.
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A. B. van den Bruele and L. H. Rosenberger
c
Fig. 5 (a) Diagnostic mammogram, biopsy clip within biopsy-proven invasive cancer with concerning calcications anteriorly, and a satellite mass posteriorly. (b) Two seed bracketed localization technique. (c) Intraoperative specimen radiograph conrming biopsied mass, two seeds,
anterior calcications, and posterior satellite mass (seed slight displacement)
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