Contraindications of Breast Conservative Surgery
Breast conservative surgery (BCS) is contraindicated in patients with pregnancy, multiple tumors in separate quadrants, diffuse malignant microcalcifications, prior radiation to the breast region, or persistent positive margins after reasonable surgical attempts. 1
Absolute Contraindications
Pregnancy: Radiation therapy cannot be administered during pregnancy due to fetal risks. However, BCS may be performed in the third trimester with radiation delayed until after delivery 1
Multiple primary tumors in separate quadrants: The presence of two or more primary tumors located in different quadrants of the breast precludes breast conservation 1
Diffuse malignant-appearing microcalcifications: Widespread suspicious microcalcifications throughout the breast indicate potential extensive disease that cannot be adequately addressed with limited surgery 1
Prior therapeutic radiation to the breast region that would require retreatment to an excessively high total radiation dose 1
Persistent positive margins after reasonable surgical attempts to achieve clear margins 1
Relative Contraindications
Collagen vascular disease: Patients with scleroderma or active lupus erythematosus generally tolerate radiation poorly, making BCS a relative contraindication. Most radiation oncologists consider these conditions absolute contraindications 1
- Note: Rheumatoid arthritis is NOT a contraindication to BCS 1
Multiple gross tumors in the same quadrant: These cases require careful individual assessment as studies in this area are not definitive 1
Indeterminate calcifications: Require careful evaluation for suitability 1
Large tumor in small breast: When an adequate resection would result in significant cosmetic deformation. In such cases, preoperative chemotherapy might be considered to reduce tumor size 1
Large or pendulous breasts: May be a relative contraindication if reproducible patient positioning cannot be assured for radiation therapy or if adequate dose homogeneity cannot be achieved. Treatment is feasible if ≥6 MV photon beam irradiation is available 1
Factors That Do NOT Contraindicate BCS
Clinically suspicious or mobile axillary lymph nodes 1
Microscopic tumor involvement in axillary nodes 1
Tumor location: Even tumors in the subareolar region can be treated with BCS, though nipple-areolar complex resection may occasionally be required 1
Family history of breast cancer: Studies show no difference in recurrence rates between patients with or without family history 1
Genetic/hereditary breast cancer: Currently not considered a contraindication, though these patients have higher risk of new primary cancers in both breasts 1
High risk of systemic relapse: This affects the need for adjuvant therapy but is not a contraindication to BCS 1
Clinical Considerations
When evaluating a patient for BCS, the surgeon must assess whether total gross removal of the suspicious or malignant tissue can be achieved with acceptable cosmetic results 1
For patients with relative contraindications, the decision should be based on careful assessment of the specific clinical scenario and the ability to achieve negative margins with acceptable cosmetic outcomes 1
Recent research suggests that selected patients with multicentric disease may be candidates for BCS if all radiographically apparent abnormalities can be removed with clear margins 2, 3, 4
Patients with contraindications to BCS who undergo mastectomy have comparable survival outcomes to those with unifocal disease treated with BCS 5