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150 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
BOX 11–3 RADIATION THERAPY
AFTER LUMPECTOMY FOR DUCTAL
CARCINOMA IN SITU
Radiation therapy (XRT) reduces
ipsilateral breast tumor recurrence by
50% to 60%.
XRT reduces ipsilateral invasive breast
tumor recurrence by 50% to 60%.
After XRT, the annual rate of an invasive
recurrence is 0.5% to 1% per year.
XRT does not improve necessarily
survival.
for both arms of the study with a mean followup of 90 months. Local failure rate for the
group treated with lumpectomy alone was
approximately twice that of the lumpectomy
plus XRT group: 26.8% vs. 12.1%, with half
the recurrent tumors being invasive in the former and one third in the latter. Pathologic
findings from protocol B-17 showed that the
two biggest predictors of ipsilateral recurrence
were comedo necrosis and the presence of
involved specimen margins (Box 11–3).
A similar trial was simultaneously launched
in Europe by the European Organization for
Research and Treatment (EORTC). After a
median follow-up time of 51 months, a recurrence rate of 16% was observed in the group
treated with lumpectomy alone, and 50% of
these were invasive cancers. Patients treated
with lumpectomy with subsequent XRT
revealed a recurrence rate of 9%, of which
40% were invasive cancers.
Although there have been no prospective
randomized trials comparing mastectomy to
BCT in the treatment of DCIS, the large treatment registries have suggested that, while local
recurrence rates may be lower after mastectomy
than after BCT, there is no difference in overall
survival. The reported cause-specific mortality
from DCIS treated with either mastectomy or
lumpectomy plus XRT is similar (in the range
of 1% to 2%). For DCIS, there is little risk of
metastasis, yet the potential of an invasive
recurrence remains. It is imperative that the
basis of all treatment options for DCIS be the
minimization of the potential risk of an invasive recurrence. At the present time, most
patients are candidates for BCT. The initial
attempt should be to widely excise the entire
area with acceptable margins. Careful preoperative planning is paramount, because the initial
operation is the best chance to achieve complete excision and offer good cosmetic results.
As with all breast biopsies, the surgical specimen should be accurately oriented and, if
appropriate, imaged to confirm complete excision of the radiographic abnormality. If the
lesion is seen to abut a specific margin, an additional adequate surgical margin should be
obtained in the corresponding quadrant.
Orienting the specimen correctly and inking it
with a six-color system allows the pathologist
to inform the surgeon whether a specific margin is either involved or close, allowing for a
more directed reexcision. This provides a better
cosmetic outcome compared to having to reexcise the entire lumpectomy cavity. Surgical clips
left along all six biopsy cavity boundaries are
instrumental in delineating the site for accurate
planning of adjuvant radiation therapy boost
dose or partial breast irradiation.
Accurate pathologic assessment of margin status is imperative. There is no consensus to date
on what comprises the ideal negative margin
for DCIS. Most institutions strive for at least
2 to 3 mm of circumferential disease-free tissue.
Inadequate margins necessitate reexcision,
hence the importance of orienting and labeling
the specimen at the time of lumpectomy to
guide subsequent surgery. Noninvasive cancers
presenting with calcifications require postoperative mammography to ascertain complete excision. Residual suspicious calcifications require
localization and reexcision even in the presence
of negative margins.
Lumpectomy Alone for DCIS
It is clear that postoperative radiation as a component of BCT offers excellent local control.
However, radiation is not without its side
effects and cost. Whole breast irradiation is
time consuming and can cause cardiac or pulmonary side effects. There is also the risk of second malignancies. Given the fact that many
cases of DCIS treated by excision alone do not
recur, it seems likely that there is a subset of
patients who may be treated by lumpectomy
alone. With careful attention to grade, size,
and margin width, there should be a subset of
patients who could consider treatment by
lumpectomy alone. This may be appropriate
treatment for patients with extremely low-risk
mammographically detected DCIS exhibiting
favorable histopathologic features (low grade,
no necrosis) when resected with an adequate
negative margin. Silverstein and colleagues
have proposed that patients who have undergone excision with a minimal margin of 1 cm
do not benefit from radiation therapy.
15111—MANAGEMENT OF DUCTAL CARCINOMA IN SITU AND PAGET DISEASE
However, in an attempt to confirm this, a prospective study of patients with grade 1 or 2 DCIS
underwent excision with margins of greater
than 1 cm. There was a 12%local recurrence rate
after 5 years, with 31% of these being invasive,
and the trial needed to be stopped early due to
the high rate of local failure. Other attempts to
confirmthat an adequate excision ofa low-grade
lesion may not require radiation have beenhampered by the factthat thedefinition of “adequate
margins of excision” varies amongst institutions
and has not been clearly defined. Ongoing prospective studies in both Europe and the United
States are attempting to answer these questions.
To date, though, no subgroup has been identified that does not benefitfrom radiation therapy.
Until then, for most patients qualifying for BCT,
lumpectomy plus postsurgical XRT is the treatment of choice to minimize the risk of local
recurrence, although the relative risks and benefits of radiation vary and should be discussed in
detail with the patient.
Management of the Axilla (Box 11–4)
Because DCIS is noninvasive, theoretically
there should be no possibility of finding disease
within the regional lymph nodes. However,
studies of modified radical mastectomy for the
treatment of DCIS revealed axillary metastases
in approximately 2% of cases. When patients
with DCIS are found to have disease in the
lymph nodes, the assumption is that there are
possible foci of invasive disease somewhere in
the breast that may have eluded discovery on
pathologic tissue examination. This low risk
of finding disease, however, prompted most
surgeons to abandon the routine practice of
performing a level I and II axillary lymph node
dissection (ALND) in patients being treated
for DCIS. Some surgeons, because of the possibility of invasive disease being present when
there was diffuse DCIS throughout the breast,
BOX 11–4 INDICATIONS FOR
SENTINEL LYMPH NODE BIOPSY IN
DUCTAL CARCINOMA IN SITU
Patients with microinvasion
Patients undergoing mastectomy for
diffuse disease
Patients with a high suspicion of
harboring invasive disease
Extensive high-grade disease or
necrosis on core biopsy
Imaging studies suggesting invasion
continued to advocate a level I ALND when a
mastectomy was performed.
When lymphatic mapping and sentinel
lymph node (SLN) biopsy became routine in
the management of breast cancer, this
prompted a rethinking of whether the regional
nodes should be looked at when treating DCIS.
Because the pathologist may serial-section just
one or two nodes, rather than bisecting 10 to
30 nodes as with an ALND specimen, SLN
biopsy is more sensitive for finding micrometastatic disease. When SLN biopsy is used in
DCIS, the results have shown wide variability,
with some series describing 3% to 10% of
patients with DCIS having a positive sentinel
lymph node (SLN). This has prompted a handful of surgeons to recommend the routine use
of SLN biopsy for DCIS; however, most surgeons question the prognostic significance of
these findings. Most of the disease detected
was found by immunohistochemistry, for
which we do not know the prognostic implications. In addition, it is hard to reconcile longterm survivals of 99% for pure DCIS with a
nodal positivity rate of 5% to 10%.
Therefore neither lymph node dissection
nor lymphatic mapping and SLN biopsy
should play a role in the routine management
of pure DCIS, with two notable exceptions.
The first is when there is a high likelihood of
finding invasive disease. These would include
cases in which the DCIS presents as a mass or
there is a high suspicion of invasion on either
the imaging studies or the biopsy specimen.
In these cases it is reasonable to perform a sentinel node biopsy in conjunction with lumpectomy, although for patients being treated by
BCT, axillary staging can just as reasonably be
deferred until the diagnosis of invasion is confirmed. Any patients with documented microinvasion should have axillary evaluation by
SLN biopsy. The second indication for lymphatic mapping in the management of DCIS
is in the patient undergoing mastectomy for
diffuse DCIS, particularly if it is high grade.
In this case, if microinvasive disease is discovered on pathologic examination, it is not possible to then stage the patient by SLN biopsy
and an ALND might be necessary. Immunohistochemistry should not be routinely performed for these cases.
Occasionally, patients undergo a mastectomy with SLN biopsy for DCIS and have metastatic disease identified in the sentinel node
but no invasive disease identified in the breast.
The first step should be to perform a more extensive pathologic examination of the breast
152 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
for invasive disease that may have been overlooked. This may be facilitated by obtaining
x-rays of the specimen so that more detailed
examination can be performed on areas with
suspicious calcifications. However, even if it
cannot be identified, if there are true metastases in the sentinel nodes, it must be assumed
that the patient does have an undetected focus
of invasion and the patient should be considered for completion ALND and systemic
therapy.
Hormonal Therapy
Because systemic metastases are not a concern
with in situ disease, there is no role forcytotoxic
chemotherapy in the treatment of DCIS. DCIS
does, however, express the estrogen receptor
(ER), although not universally, prompting the
investigation of tamoxifen as an adjuvant to
surgical therapy. The NSABP B-24 protocol studied the use of tamoxifen in women with DCIS
undergoing BCT. More than 1800 women with
DCIS were randomized to 5 years of tamoxifen
versus placebo. At a median follow-up of 74
months, there was an overall risk reduction of
37% for patients receiving tamoxifen, regardless of resection margin, tumor size, or grade.
There was also a decreased risk of contralateral
invasive and noninvasive cancer by 52%
(Table 11–4). On the other hand, a trial from
the United Kingdom, Australia, and New Zealand failed to demonstrate a significant benefit
to tamoxifen in preventing either ipsilateral or
contralateral events. The UK/ANZ trial was a
smaller study, with a design that allowed for
some patient choice, so the results must be
interpreted with care.
These results suggest that a selective
approach must be used when deciding which
women with DCIS should receive adjuvant
tamoxifen. The potential benefits of tamoxifen
both on reducing recurrence and second breast
malignancies must be weighed against the
potential side effects, including venous thromboembolism and uterine cancer. The baseline
risk of recurrence, the age of the patient, and
the relative risk of side effects must be
considered.
In addition, the ER status should be considered. As stated, ER expression is not 100%
among DCIS patients. In a study derived from
the NSABP-B24 drug arm comparing the
response of ER-positive versus ER-negative
patients to tamoxifen, recurrence rates were
10% for the ER-positive group compared to
23% for the ER-negative group. Therefore
many institutions have begun routinely evaluating DCIS for ER status by immunohistochemistry and limiting the use of tamoxifen
for patients with ER-positive DCIS.
Recently, the aromatase inhibitor anastrazole has received growing attention. Results
of the ATAC (Anastrazole and Tamoxifen:
Alone or in Combination) trial, which randomized 9000 patients with early-stage breast
cancer to receive anastrozole versus tamoxifen
versus the combination, revealed a statistically
significant risk reduction of new breast cancers
in the anastrozole arm (P ¼ .007). However,
there are no data on the use of aromatase inhibitors in patients with DCIS. There are presently two trials ongoing to address this issue
(NSABP B-35 in the United States and IBIS-II
in Great Britain).
Paget Disease
In 1874, Sir James Paget described 15 women
with chronic nipple ulceration who ultimately
developed cancer of the involved breast within
2 years. He described an eruption on the nipple and areola, similar to acute eczema, with
a copious clear yellowish exudation. Ultimately this would be known as Paget disease
of the breast and is defined clinically as a scaling eczematous lesion of the nipple-areolar
complex. Paget believed that the nipple
changes were themselves benign, but later it
was discovered that the cells of Paget disease
were malignant and that Paget disease was
TABLE 11–4Results of NSABP Protocol B24: Tamoxifen versus Placebo after
Lumpectomy Plus Radiation Therapy
Study Arms Patients Local Recurrence Invasive Recurrence Survival
Lumpectomy þ
XRT þ placebo
Lumpectomy þ
XRT þ tamoxifen
XRT, Radiation therapy.
902 87 (9.6%) 40/87 (46%) 97%
902 63 (7%) 23/63 (37%) 97%
TABLE 11–5Theories of Pathogenesis of Paget Disease
Theory Idea Support
Epidermotropic Neoplastic cells migrate from underlying
malignancy to the epidermis of the nippleareolar complex (NAC).
Transformation Epidermal keratinocytes in the nipple
transform into Paget cells and then spread
to the breast.
Paget is almost always associated with
underlying ductal carcinoma.
Immunohistochemical staining of Paget is
usually identical to the underlying cancer.
Molecular markers are also usually
concordant.
Not all cases of Paget have underlying
parenchymal cancer.
Tumors may be distal from the NAC.
The “Toker cell” with an appearance between
a keratinocyte and Paget cell is thought to
be a precursor to Paget.
15311—MANAGEMENT OF DUCTAL CARCINOMA IN SITU AND PAGET DISEASE
carcinoma arising from an intraductal carcinoma in the subareolar ducts.
Paget disease is associated with either in situ
or invasive cancer in almost all cases. Paget
disease is considerably less common than other
presentations of breast cancer, accounting for
only 1% to 3% of breast cancer cases diagnosed
each year in the United States. Paget disease also
can occur in men, although given the low incidence of male breast cancer overall, this is
extremely rare. Paget disease must be a strong
consideration in the differential diagnosis of
any persistent nipple abnormality in either
men or women.
Although the clinical definition of Paget disease is relatively straightforward, there is controversy as to its pathogenesis (Tabl e 11–5).
Two main theories have been put forward to
explain the presence of Paget disease. The
more commonly accepted theory is the epider-
motropic theory, which suggests that the cells
migrate from an underlying breast malignancy
into the epidermis of the nipple. The second is
the transformation theory, which suggests that
Paget disease arises from malignant transformation of the cells within the epithelium of
the nipple itself. Although there may be different underlying mechanisms, most evidence
points to the epidermotropic theory.
Clinical Presentation
As stated, the hallmark of Paget disease is a scaly,
raw, ulcerated lesion onthe nippleand/or areola.
Usually this starts with the nipple and then
spreads to the areola. There may be ulceration
or discharge(usually serous but possiblybloody).
Associated nipple retraction suggests more
advanced disease. The disease is almost always
unilateral, although bilateral cases have been
described (Box 11–5). All patients with nipple
complaints should have a complete breast exam
and bilateral mammography.
The lesion is typically present for several
months before being accurately diagnosed. At
first patients may have pain, burning, or pruritus without any obvious lesion. Patients with
these symptoms should be followed, and further investigation initiated if the symptoms do
not resolve. Many times the lesion is thought
to be a benign dermatologic condition and is
treated topically. Often the inflammatory component resolves, suggesting improvement. In
some cases, these lesions may improve spontaneously. It is important not to completely
rule out Paget disease even if there was some
improvement with or without therapy. The differential diagnosis (Box 11–6) includes both
BOX 11–6 DIFFERENTIAL
DIAGNOSIS OF PAGET DISEASE
BOX 11–5 ASSOCIATED BREAST
ABNORMALITIES IN PAGET
DISEASE
Palpable breast mass—50%
Mammographic abnormality with no
palpable mass—20%
No underlying mass or mammographic
abnormality—30%
Benign
Eczema
Erosive dermatitis
Pemphigus vulgaris
Syphilitic lesion
Herpes zoster
Malignant
Bowen’s disease
Basal cell carcinoma
Malignant melanoma
154 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
A thorough workup with particular attention
paid to any associated palpable mass or mammographic abnormality is crucial to selecting
the proper patients for BCT (Fig. 11–8).
Paget Disease with Palpable Mass or Mammographic Abnormality
When Paget disease is associated with a palpable mass, it is more frequently associated with
invasive disease, axillary metastases, and multifocal underlying disease. Most of these
patients will require mastectomy. However, if
it is feasible to perform a lumpectomy that
incorporates both the nipple-areolar complex
Figure 11–7. Pathology of Paget disease. The Paget
cells are seen within the keratinizing epithelium of
the nipple epidermis. The Paget cells are large, round
cells with pale cytoplasm and pleomorphic nuclei.
(Image courtesy of Maria Braman, MD, Department
of Pathology, University of Michigan.)
and the palpable mass with adequate margins,
and if this would result in acceptable cosmetic
results after whole breast irradiation, then BCT
is reasonable. The same can be said for a focal
nonpalpable mammographic abnormality that
can be resected in continuity with the nippleareolar complex.
benign(eczema, dermatitis)and malignant etiologies (Bowen’s disease, basal cell carcinoma).
If benign disease is suspected, a short course
of topical steroids is reasonable. If the lesion
improves but fails to completely resolve, Paget
should be considered. The next step in the
workup should be biopsy. The diagnosis can
be made by punch or wedge biopsy of the nipple. Shave biopsy or scrape cytology can be
diagnostic, but a negative finding does not
rule out Paget disease. In addition, core-needle
biopsy of any mass or mammographic abnormality should be performed.
The pathologic hallmark of Paget diseaseis the
presence of malignant, intraepithelial Paget
cells, either singly or in small groups, within
the epidermis of the nipple (Fig. 11–7). They
are large in size with pale cytoplasm and have
high-grade nuclei with prominent nucleoli.
Retraction from the surrounding keratinocytes
can give the appearance of a vacuole. Occasionally these cells can incorporate melanin, making
them difficult to differentiate frommelanoma. It
is also sometimes difficult to differentiate Paget
disease from squamous carcinoma of the epidermis (Bowen’s disease) on routine histology.
Immunohistochemical staining can usually
make the diagnosis.
graphic abnormality is a considerable distance
from the nipple, and even when it is close,
resection of both results in a poor cosmetic
result. These patients may be better ser ved by
simple mastectomy with breast reconstruction. Patients with large breasts may allow for
adequate resection while still allowing for
acceptable breast contour and symmetry, often
with contralateral breast reduction and nipple
reconstruction. If the patient has a proven
invasive component and clinically negative
nodes, sentinel lymph node biopsy should be
performed at the time of lumpectomy or
mastectomy.
microcalcifications should be treated by simple mastectomy. Sentinel lymph node biopsy
for staging the axilla is recommended in this
situation because of the possibility of discovering invasive disease within the mastectomy
specimen.
Paget Disease with No Mass or Mammographic Findings
Approximately one third of patients with
Paget disease will not have an associated mass
or mammographic abnormality, but the
majority of these women will have an underly-
Treatment
Until recently, the standard treatment of Paget
disease has been a simple mastectomy. More
recent data suggest that BCT is feasible, but the
nipple-areolar complex needs to be removed.
ing carcinoma. Simple mastectomy (with or
without reconstruction) has been the standard
of care, but breast conservation is very reasonable. Breast conservation consists of resection
of the nipple-areolar complex followed by
whole breast irradiation. Although there are
Many times the palpable mass or mammo-
Patients with multicentric lesions or diffuse
Patient presenting with
Paget disease
Full history and physical,
bilateral mammogram, possible MRI
15511—MANAGEMENT OF DUCTAL CARCINOMA IN SITU AND PAGET DISEASE
Biopsy of abnormal lesion
if BCT is considered
Lesion and NAC can be
excised with negative
Ye s
Lumpectomy
including NAC.
SLN as indicated
Negative margins
attainable?
Ye s
Radiation;
consider tamoxifen to
prevent recurrence and
for contralateral
prophylaxis
Mass or MGM finding
margins?
Simple mastectomy
SLN biopsy
No
Consider tamoxifen for
contralateral prophylaxis
No
No mass or MGM finding
Patient interested in breast
conservation?
Ye s
Resection of NAC
Negative margins
attainable?
Ye s
Radiation;
consider tamoxifen to
prevent recurrence and
for contralateral
prophylaxis
No
Simple mastectomy
Consider SLN biopsy
No
Consider tamoxifen for
contralateral prophylaxis
Figure 11–8. Management of Paget disease. In addition to a biopsy of the Paget to confirm the diagnosis, the
workup should include a breast examination, bilateral mammogram, and possibly MRI to identify an associated
mass or abnormality. Biopsy of this mass may help in planning treatment if breast conservation therapy (BCT)
is a consideration. If the nipple-areolar complex (NAC) and any associated lesion can be resected with negative
margins, a lumpectomy is an option, with subsequent radiation and possible NAC reconstruction in the future.
If not, a simple mastectomy is indicated. Sentinel lymph node biopsy at the time of mastectomy is reasonable
given the possibility of an unrecognized invasive component. The benefits of hormonal therapy can be extrapolated from the ductal carcinoma in situ data.
small series describing excision alone without
radiation, local recurrence rates are concerning. Likewise, radiation alone has been
described (after only tissue biopsy) but this
approach has also been associated with high
local recurrence rates.
The idea of excision and radiation for Paget
disease is obviously based on the success of
BCT for both invasive cancer and DCIS. Breast
conservation should consist of complete nipple-areolar resection, because partial resection
may lead to higher local recurrence rates. The
largest series of BCT for Paget disease comes
from a prospective study by the EORTC. After
nipple-areolar resection with negative margins
followed by whole breast irradiation, the local
recurrence rate was only 6.5% after a median
follow-up of 6.4 years.
Negative margins are mandatory, and positive or close margins (<3 mm) should prompt
reexcision. SLN biopsy is not essential at the
time of nipple-areolar resection, because in
the absence of a palpable mass, the underlying
malignancy is typically intraductal and axillary node involvement is rare. However, it is
not an unreasonable option. After completion
of therapy, there are several techniques that
can be used to reconstruct the nipple-areolar
complex with excellent cosmetic outcomes.
After surgery and radiation, patients should
156 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
be considered for adjuvant hormonal therapy.
Although there is no specific evidence supporting the use of tamoxifen or Arimidex after
BCT for Paget disease, data can be extrapolated
from the DCIS literature. Tamoxifen can also
be considered after mastectomy for prophylaxis of the contralateral breast.
Suggested Readings
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11. Kollmorgen DR, Varanasi, JS, Edge SB, Carson WE
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12. Lagios MD, Margolin FR, Westdahl PR, et al. Mammographically detected ductal carcinoma in situ.
Cancer 1989;63:618.
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breast. Curr Treat Options Oncol 2004;5:153–160.
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imaging of ductal carcinoma in situ. Radiology
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12
Surgical Management of Primary Breast Cancer
CHANGES IN SURGICAL MANAGEMENT OF BREAST CANCER
BREAST CONSERVING THERAPY
Patient Selection
Absolute Contraindications
Relative Contraindications
Not Contraindications
OPERATIVE MANAGEMENT OF
BREAST CANCER
Lumpectomy
Reexcision Lumpectomy
Surgical Management of Primary Invasive Breast
Cancer: Key Points
Understand the evolution of the surgical management of breast
cancer.
Know the absolute and relative contraindications to breast conserving surgery.
Develop an algorithm for selecting the appropriate patients for breast
conserving therapy.
Describe the surgical techniques for a lumpectomy, a wire-localized
lumpectomy, and a simple or modified radical mastectomy.
Be familiar with the complications of breast surgery and their management.
Simple Mastectomy
Modified Radical Mastectomy
COMPLICATIONS OF BREAST
SURGERY
Wound Infections
Seroma
Hematoma/Bleeding
Chronic Pain
Chronic Breast Lymphedema/
Cellulitis
Changes in Surgical
Management of Breast Cancer
Going back to the late 1800s, the treatment of
breast cancer was characterized by either wide
excision or simple mastectomy. These resulted
in extremely high rates of local recurrence and
poor survival (Table 12–1). In 1894, William
Halsted proposed that breast cancer was a
local disease that spread by contiguous
157
158 SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY
TABLE 12–1Local Recurrences after Mastectomy
Surgeon Dates Number Local Recurrence Rate (%)
Bergmann 1882-1887 114 51-60
Billroth 1867-1876 170 82
Czerny 1877-1886 102 62
Fischer 1871-1878 147 75
Gussenbauer 1878-1886 151 64
Ko¨nig 1875-1885 152 58-62
Ku¨ster 1871-1885 228 60
Lu¨cke 1881-1890 110 66
Volkmann 1874-1878 131 60
Halsted 1889-1894 50 6
Hasted WS. The results of operations for the cure of cancer for the breast performed at the Johns Hopkins Hospital
from June 1889 to January 1894. The Johns Hopkins Hospital Reports 1894-1895;4:297-350.
extension, and that more extensive resection
would provide abetter chance of disease control
(Halsted’s Theory). That year, he had performed
50 “complete” mastectomies and reported his
experience. Halsted’s radical mastectomy consisted of en bloc removal of the breast, the overlying skin, both the pectoralis major and minor
muscles, and the entire axillary contents (level
I, II, and III nodes) (Fig. 12–1).
The radical mastectomy resulted in a significant drop in local recurrence rates, and it
quickly became the standard of care for the
treatment of breast cancer. However, despite
the improvement in local control, the curative
potential of this operation remained limited.
In one series of more than 1400 women over a
course of 30 years, only 13% remained free of
disease, and nearly 60% died of breast cancer.
At first this was believed to be because the
mastectomy was not extensive enough, and
so the extended radical mastectomy, which
included resection of the internal mammary
nodes (IMNs) and/or supraclavicular nodes,
was proposed. The Dahl-Iversen extended
mastectomy included dissection of both the
IMN and supraclavicular nodes with the radical
mastectomy. An even more radical mastectomy
was the “super-radical” mastectomy that
included four parts (Box 12–1). However, these
failed to improve survival. In a randomized
comparison of the Dahl-Iversen extended radical mastectomy to simple mastectomy with
radiation to the regional lymph nodes, with approximately 330 patients per arm, there was no
difference in disease-free or overall survival. In
a European randomized trial between radical
mastectomy and extended radical mastectomy
(including IMNs), there was again no improvement in survival. A much smaller randomized
trial from the University of Chicago also
showed no improvement to removing the
IMNs.
A
Figure 12–1. The Halsted radical mastectomy involved removing the breast with the overlying skin, the pectoralis major and minor muscles, and the level I, II, and III axillary lymph nodes. (From Bland KI, Copeland EM III.
The Breast, 3rd ed. Philadelphia: WB Saunders, 2004.)
B
15912—SURGICAL MANAGEMENT OF PRIMARY BREAST CANCER
BOX 12–1 THE “SUPER RADICAL”
MASTECTOMY
Breast and axillary contents
Internal mammary artery and vein with
internal mammary lymph node chain
Upper mediastinal nodes
Low supraclavicular nodes
Disappointed by the failure of radical mastectomy to cure women with breast cancer despite
significant morbidity, many surgeons proposed
that a less extensive operation, the modified
radical mastectomy (MRM), could be performed
without compromising survival. The MRM
involves complete removal of the breast tissue
and the underlying fascia of the pectoralis major
muscle, and removal of some but not all of the
axillary lymph nodes (levels I and II). The overlying skin and underlying pectoralis muscles
are not removed. Several prospective randomized trials documented equivalent survival
rates with MRM as compared to radical mastectomy, with less morbidity. As a result of these
data, the radical mastectomy has become an
historical footnote in the treatment of breast
cancer, and there are no absolute indications
for radical as opposed to modified radical mastectomy in women with invasive breast cancer.
The fact that less radical surgery did not affect
survival made people question whether
Halsted’s theory was correct; that breast cancer
was not a local disease that spread contiguously, but instead, systemic disease was
ultimately the main determinant of survival.
The question arose as to whether the breast
needed to be removed or could be preserved
without compromising survival. There had
been several reports of breast cancer being treated by radiation alone (see Chapter 15), and
there was evidence that radiation could eliminate subclinical foci of disease. This allowed
for the combination of limited surgery and radiation therapy as a method of adequately treating breast cancer while avoiding mastectomy.
Although initially controversial, breast conserving therapy (BCT) has become a standard
of care in the management of breast cancer.
BCT refers to the surgical removal of the tumor
(lumpectomy, wide excision, quadrantectomy)
followed by moderate-dose radiation therapy
to eradicate any residual disease. This chapter
focuses on the surgical aspects of BCT and
mastectomy. Chapter 15 focuses on radiation
therapy.
Breast Conserving Therapy
The goals of BCT are to provide the survival
equivalent ofmastectomy, a cosmeticallyacceptable breast, and a low rate of recurrence in the
treated breast. Although there was great resistance when it was first introduced, six randomized trials involving more than 4000 patients
over 3 decades established that BCT was as effective as mastectomy for suitable patients with
breast cancer (Table 12–2). It is difficult to compare one trial to another because they were quite
different in design. Some required lumpectomy,
whereas others required the more extensive
quadrantectomy. Some required that the final
margins be negative, whereas others allowed
for positive resection margins. In the European
Organization for Research and Treatment trial,
surgical margins were microscopically positive
in nearly halfthe patients. The size of thetumors
included were also quite variable. Despite these
TABLE 12–2Prospective, Randomized Trials of BCT vs. Mastectomy
Trial Patients Max
NSABP B-06 1851 4 20 47% 47% 14.3% 10.2%
Milan I 701 2 20 58.3% 58.8% 8.8% 2.3%
NCI 237 5 18.4 54% 58% 22% 0%
EORTC 868 5 13.4 65% 66% 20% 12%
Institut Gustav
Roussy
Danish 905 5 9.8 79% 82% NR NR
179 2 10 78% 79% 4% NR
Tumor
Size
Median
Follow-up
Overall
Survival
BCT Mastectomy BCT Mast.
Local
Recurrence