Breast Conservation Therapy, Points to ponder – Breast Cancer Operative Surgery

Breast Conservation Therapy, Points to ponder – Breast Cancer Operative Surgery


Hello everyone, Today let’s discuss
Breast Conservation Therapy. Dr.Geoffrey Keynes was the first surgeon to introduce Breast Conservation Surgery. He performed lumpectomy and implanted Radon seeds and achieved 77% five-year survival in node-negative patients and
36% five-year survival in node positive patients. In the late 1950s, the National
Surgical Adjuvant Breast and Bowel project was established in the USA
primarily to clear the many issues and controversies regarding breast cancer.
Between 1950s to 1970s Total Mastectomy was considered to be the popular and
successful option to breast conservation. The NSABP B-06 trial, a prospective
multicenter randomized trial recruited 2163 women with stage I and II breast
cancer between 1971 to 1974 in 34 NSABP member sites in the USA and Canada and
published its results in 2002 after up to 20 years of follow-up. The aim was to
compare the lumpectomy + axillary clearance, lumpectomy + axillary
clearance + radiation and total mastectomy and axillary clearance. During the same time, a similar trial conducted in Milan, Italy, compared Radical
Mastectomy with breast conservation involving 701 patients with stage I
cancer. These two trials and several other trials around the world
drew below two conclusions. First is, there is no long-term survival
benefit of performing Total Mastectomy over breast conservation which is
lumpectomy, axillary treatment and radiation. Second is, there was no
significant difference in local recurrences between Total Mastectomy and breast conservation. Currently in many developed countries more than 70 %
of operable breast cancers receive breast conservation rather than
mastectomy whilst in lot of developing countries more than 80 % of such
patients undergo mastectomy. It is highly likely the surgeons performing
mastectomies in developing countries are fully aware of the cosmetic superiority
of breast conservation and the statistical equivalent survival and
recurrence rates in both breast conservation and Total Mastectomy.
Therefore we believe, four factors are in operation that lead to high mastectomy
rates in these countries. First one is that in developing countries, patients
often present with larger tumor sizes. Second is the inability to cater to a
massive patient load because of limited radiotherapy facilities. Third one is the
conservative attitude of the surgeons due to lack of peer pressure from
surgical colleagues and problems in contacting patients after primary
operation because there is possibility of patients defaulting further treatment.
India is a very good example. The high caseload, marked ethnic and language
variation probably for every 100 to 200 km offers a significant
challenge to the Indian surgeons who are reputedly highly skilled operators.
Fourth one being poor patient education. For example, when patients are told that a
reoperation may be necessary in the case of breast conservation, many people tend
to think that breast conservation fails to remove the tumor completely. Breast
conservation has its own drawbacks. First of these is reoperation due to residual
disease. For example, a recent study in New South Wales, Australia has shown in
about 30% of patients, reoperation was needed within three months after primary
surgery. This is a big psycho-social burden on the patients even in a
developed country like Australia. Then imagine the situation in poorer
countries, where one or two surgeons and pathologists catering for probably
one or two million of the population. Second problem is, in countries where
there is limited access to treatment recurrences may be detected pretty late
which may reduce the survival rates drastically. Therefore, you select breast
conservation over mastectomy considering all these factors into account. My advice
is to perform breast conservation surgery only when you are quite certain
that residual disease and recurrences are likely to be minimal. This is why
surgical wisdom is far more important than a bunch of data. Now let’s talk about how to perform
breast conservation. It is ideal to mark the extent of the tumor on the morning
of the operation by Ultrasound examination. The incision we recommend is a curvilinear one incorporating a skin island around the Trucut biopsy site.
Such an incision can be easily incorporated to a mastectomy incision if
needed. Skin flaps are raised right around over the region containing the
tumor and Wide Local Excision is performed using finger palpation as a
guide as shown. The maximum amount of breast that can be removed must be the
size of a quadrant. If a tumor needs removal of breast tissue larger than a
quadrant for negative margins, it is a tumor that warrants a mastectomy. We
always try to achieve more than 5 mm of negative margin right around the tumor. But current evidence say that negative margins of more than 2
mm is more than adequate. For upper outer quadrant tumors, the axilla can be reached through the same curvilinear incision. But in lesions of
other quadrants a separate transaxillary curvilinear incision can be used to
access the axilla. If no clinical or radiological evidence of metastatic
lymphadenopathy, we perform sentinel node biopsy. And if not, standard level II
axillary dissection is done. There are two aims of breast conservation. First is
achieving locoregional control equal to Total Mastectomy. Second is achieving
an acceptable cosmetic result. Breast conservation consists of three
components. First is Wide Local Excision plus or minus a cosmetic repair. Second
is axillary treatment. The third component is breast
irradiation which may be delayed if adjuvant chemotherapy is needed. Here is
a list of contraindications to breast conservation. Tumor size more than four
cm which are not attached to the skin or attached to the deep
structures. Lesions immediately deep to the nipple areolar complex. Multicentric
disease. Multifocal disease of more than two foci or foci apart more than two
cm. Contraindication to radiotherapy. More
than two cm tumors in a small breast hindering cosmesis and when there is high probability of a BRCA mutation. Close the breast wound after closing the
axillary wound. Thus allowing to reassure that 100% hemostasis is achieved in the
breast defect since we usually do not insert a drain. This allows the defect to
be filled with a seroma. For small defects, no approximation of fat is
needed. But larger defects need a rotational breast flap as shown. Dear
budding surgeons, breast conservation has saved the dignity and the
self-confidence of women with breast cancer all over the world. But do not
perform breast conservation at the expense of precious life. Therefore
choose your patients wisely. Think about the nature of the tumor, not only its
size, the socioeconomic status of the patient and access to specialist
Oncological care before you commit. Thank you for watching!

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