Management of Invasive Ductal Carcinoma
For appropriately selected patients with early-stage invasive ductal carcinoma, breast-conserving surgery with radiation therapy is the preferred treatment approach, as it provides equivalent survival to mastectomy while preserving the breast. 1
Initial Evaluation
Before determining treatment, complete assessment is mandatory:
Clinical examination must document tumor size and location, nipple discharge or changes, breast-to-tumor size ratio, axillary lymph node status, and contralateral breast appearance 2
Bilateral mammography (within 3 months) is required to define disease extent and rule out multicentric disease or contralateral lesions 2
Pathologic assessment must include tumor size, histologic grade, hormone receptor status (ER/PR), and HER2 status to guide adjuvant therapy decisions 3
Staging workup should include physical examination, complete blood count, and routine chemistry to exclude metastatic disease 3
Surgical Management Algorithm
Breast-Conserving Surgery (BCS) with Radiation
This is the treatment of choice for most patients with early-stage disease 1, 2
Multiple prospective randomized trials demonstrate no survival difference between mastectomy and breast conservation with radiation 1
Local recurrence rates after BCS with radiation range from 3-19%, which is not statistically different from chest wall recurrence after mastectomy (4-14%) 1
Most breast recurrences can be salvaged with mastectomy, achieving approximately 70% 5-year survival 1
Key technical requirements:
- Negative surgical margins are essential 2
- Proper specimen orientation is critical to guide re-excision if needed 2
- Intraoperative specimen radiography confirms removal of mammographic abnormalities 2
Mastectomy Indications
Mastectomy is necessary when:
- Extensive disease cannot be excised with acceptable cosmetic results 2
- Multicentric disease is present 2
- Prior chest/breast radiation precludes additional radiation 3
- Patient preference after informed discussion 2
Important caveat: The desire to avoid local recurrence alone is not a reason to recommend mastectomy over breast conservation, as both approaches carry equal local failure risk 1
Axillary Management
Sentinel lymph node biopsy (SLNB) is the standard approach for axillary staging in invasive carcinoma 2
For patients requiring mastectomy, low axillary sampling or level I dissection may be performed to avoid a second procedure if invasive disease is confirmed 2
Adjuvant Radiation Therapy
Whole-breast radiation therapy is mandatory after breast-conserving surgery to reduce local recurrence risk by approximately two-thirds 3
Hypofractionated radiation (shorter treatment schedules) is preferred for most women receiving whole-breast irradiation 3
Adjuvant Systemic Therapy
Treatment decisions are based on tumor biology:
Hormone receptor-positive disease: Tamoxifen is indicated for adjuvant treatment following surgery and radiation in both premenopausal and postmenopausal women 4
Risk stratification considers tumor size, grade, lymph node status, hormone receptor status, and HER2 status to determine need for chemotherapy and/or targeted therapy 2, 3
Current evidence supports 5 years of adjuvant tamoxifen therapy for hormone receptor-positive breast cancer 4
Common Pitfalls to Avoid
Inadequate preoperative imaging leads to incomplete tumor excision and positive margins 2
Failure to properly orient specimens makes accurate margin assessment impossible and may necessitate re-excision 2
Recommending mastectomy solely to avoid local recurrence is inappropriate, as survival outcomes are equivalent with proper patient selection 1
Underestimating disease extent occurs when relying only on standard two-view mammography; magnification views reduce this risk 5