Modern Breast Cancer Surgeries: Precision Techniques and Case Updates
Overview of Surgical Evolution
Breast-conserving surgery (BCS) is now the primary surgical choice for breast cancer, with 60-80% of newly diagnosed cancers in Western Europe amenable to breast conservation through wide local excision and radiotherapy. 1
The major paradigm shift in breast cancer surgery over the past 30 years has been the move away from radical mastectomy toward breast conservation, driven by evidence showing that patients with early-stage breast cancer who opt for breast-conserving therapy may have even better survival compared with those who have mastectomy. 1
Precision Techniques in Breast-Conserving Surgery
Oncoplastic Approaches
Breast surgeons are now trained to undertake oncoplastic approaches that reduce the impact of local tumor excision on cosmesis, primarily using tissue displacement techniques. 1
Oncoplastic procedures achieve superior cosmetic outcomes, especially in patients with:
Therapeutic mammoplasty (breast reduction performed simultaneously with wide local tumor excision) represents a newer oncoplastic technique that can achieve better cosmetic outcomes in patients with large breasts. 1
Glanduloplasty techniques using adjacent tissue displacement flaps reduce the local volume deficit created by tumor excision. 1
Margin Assessment and Surgical Precision
Careful histological assessment of resection margins is essential, with margins reported as positive when ink touches invasive cancer or DCIS. 1
Specimen orientation by the surgeon using sutures, clips, multicolored indelible ink, or other suitable techniques is critical for accurate margin assessment. 1
Marking the tumor bed with clips facilitates accurate planning of the radiation boost field and demarcates the tumor bed for future imaging studies. 1
For negative margins, the distance of invasive cancer and/or DCIS from the margin(s) should be reported, with the anatomic location of positive margins specified in oriented specimens. 1
Meticulous hemostasis is critical to avoid hematoma formation, which produces changes difficult to interpret by physical examination and makes mammography interpretation difficult. 1
Mastectomy with Reconstruction: Modern Approaches
Skin-Sparing and Nipple-Sparing Techniques
Skin-sparing mastectomy allows the skin envelope to be conserved for use in breast reconstruction, improving cosmetic outcomes. 1
Nipple-sparing procedures should be limited to carefully selected patients with early-stage, biologically favorable cancers located >2cm from the nipple. 2
Immediate reconstruction is contraindicated for inflammatory breast cancer due to high recurrence risk and need for prompt postoperative radiotherapy. 2
Reconstruction Options
The Deep Inferior Epigastric Perforator (DIEP) flap is the preferred autologous option for breast reconstruction, providing optimal tissue volume from the lower abdomen while preserving the rectus abdominis muscle. 3
DIEP flap advantages include:
CT angiography (CTA) of the abdomen and pelvis with IV contrast is the gold standard for preoperative planning of DIEP flaps, with 96% sensitivity for all perforators and 100% sensitivity for perforators >1mm. 3
Preoperative imaging with CTA or MRA demonstrates decreased operative time, reduced flap loss rate, decreased hernia rate, reduced intraoperative blood loss, and shorter hospital stays compared to handheld Doppler alone. 3
Latissimus dorsi myocutaneous flap is a useful alternative option, particularly when radiation therapy is anticipated, as autologous tissue tolerates radiation better than implants. 3
Silicone gel implants are safe and effective components of the reconstructive armamentarium, with advances in gel cross-linking reducing silicone bleed and cohesive gel implants having fewer problems from extracapsular rupture. 1
There is no evidence that reconstruction makes detection of local recurrence more difficult, and no basis for the outdated view that patients should wait 1-2 years after mastectomy before being offered reconstruction. 1, 3
Advances in Axillary Staging
Sentinel Lymph Node Biopsy (SLNB)
Sentinel lymph node biopsy rather than full nodal clearance is now accepted as the standard of care for axillary staging in early breast cancer, unless axillary node involvement is suspected clinically or on ultrasound. 1
SLNB delivers less morbidity in terms of shoulder stiffness and arm swelling, and allows for reduced hospital stay. 1
With appropriate training, acceptably low false-negative rates and favorable axillary recurrence rates following SLNB are achievable. 1
Lymphedema Risk Stratification
Axillary clearance is associated with lymphedema affecting the upper limb in 3-5% of women following surgery alone, but the incidence rises significantly to 40% when axillary clearance is combined with radiotherapy to the axilla. 1
Lymphedema incidence after SLNB alone is below 10%. 1
Lymphedema incidence after axillary radiotherapy without surgical clearance is up to 15%. 1
Neoadjuvant Therapy and Surgical De-escalation
Patient Selection for Neoadjuvant Approach
A neoadjuvant approach should be preferred in subtypes highly sensitive to chemotherapy, such as triple-negative and HER2-positive, in tumors >2 cm and/or a positive axilla. 1
For tumors >2 cm or when optimal surgery is not feasible and breast conservation is potentially feasible after downstaging, systemic induction therapy should be given. 1
For TNBC/HER2-positive tumors >2 cm with positive axilla, systemic induction therapy should be given regardless of feasibility of optimal surgery. 1
Conversion to Breast Conservation
Neoadjuvant therapy can downstage large tumors, converting patients who would require mastectomy into candidates for breast conservation. 4
Preoperative chemotherapy has been shown to increase breast conservation rates from 59.8% to 67.8% in patients with large tumors. 4
For T4 tumors with chest wall involvement, neoadjuvant therapy is particularly important to achieve adequate tumor reduction before attempting conservative surgery. 4
Case-Specific Surgical Algorithms
Algorithm for Tumor ≤2 cm
For tumors ≤2 cm and/or when optimal surgery is feasible (with exception of aggressive phenotypes):
- Proceed directly to breast-conserving surgery 1
- Postoperative radiotherapy is mandatory after BCS 1
- Add systemic therapy based on biology and risk stratification 1
Algorithm for Tumor >2 cm with Breast Conservation Desired
For tumors >2 cm when breast conservation is potentially feasible after downstaging:
- Systemic induction therapy first 1
- If satisfactory response: breast-conserving surgery 1
- If unsatisfactory response: mastectomy ± reconstruction 1
- Postoperative chemotherapy ± anti-HER2 if applicable 1
- Postoperative radiotherapy (mandatory after BCS) 1
Algorithm for Locally Advanced Disease with Chest Wall Infiltration
For large tumors (>4cm) infiltrating the chest wall:
- These are classified as locally advanced breast cancer and are not initially candidates for breast conservation surgery 4
- Neoadjuvant therapy (chemotherapy and/or radiotherapy) to downstage the tumor 4
- Re-evaluate for breast conservation versus mastectomy after neoadjuvant response 4
- Adjuvant radiotherapy to the breast and regional nodes is mandatory after breast conservation surgery 4
Quality Assurance Targets
Current guidelines recommend that local recurrence rates after wide excision and radiotherapy should be <1% per year and should not exceed 10% overall. 1
Common Pitfalls and How to Avoid Them
Specimen Handling Errors
Never section the specimen before submitting to pathology, as this compromises accurate evaluation of surgical margins. 1
Obtain specimen radiograph in two dimensions (orthogonal projections) with magnification and compression to increase resolution. 1
Correlate specimen film with preoperative mammogram and interpret without delay, communicating findings to surgeon in operating room before closure. 1
Reconstruction Timing Errors
Do not delay reconstruction 1-2 years after mastectomy based on outdated views—immediate reconstruction is safe and does not interfere with recurrence detection. 1, 3
For patients with previous radiation, autologous tissue reconstruction is preferred over tissue expanders/implants due to lower risk of complications. 2
Patient Selection Errors
Smoking and obesity are relative contraindications for breast reconstruction due to increased risk of wound healing complications and partial or complete flap failure. 3
Age should not be the sole determinant for withholding or recommending treatment—younger patients should not be over-treated because they are young, just as older patients should not be under-treated because they are deemed old. 1
Patient-Centered Decision Making
The choice of treatment strategy must be extensively discussed with the patient and take into account the patient's preferences, based on tumor burden/location and biology, as well as age, menopausal status, general health status and preferences of the patient. 1
Information on diagnosis and treatment choice should be given repeatedly (both verbally and in writing) in a comprehensive and easily understandable form. 1
In younger premenopausal patients, fertility issues and, when desired by the patient, fertility-preservation techniques should be discussed before the initiation of any systemic treatment. 1
Despite the overall trend toward breast conservation, increasing numbers of breast cancer patients are opting for bilateral mastectomy (incorporating contralateral risk-reducing surgery), which must be confronted with data demonstrating that patients with early-stage breast cancer who opt for breast-conserving therapy might have even better survival. 1