In an adult patient with a newly diagnosed breast cancer lump, is the recommended surgery primarily therapeutic rather than cosmetic, and what are the appropriate surgical options (lumpectomy versus mastectomy with possible reconstruction)?

Breast Cancer Surgery: Therapeutic, Not Cosmetic

Surgery for breast cancer lumps is fundamentally therapeutic (general surgery) with the primary goal of cancer removal and survival, though cosmetic considerations are integrated into modern surgical planning to optimize quality of life. 1

Primary Therapeutic Intent

The surgery is performed to achieve complete cancer removal with negative margins, which is the cornerstone of curative treatment. 1 Both lumpectomy (breast-conserving surgery) and mastectomy are equivalent in terms of survival for stage I and II breast cancers (category 1 evidence), making the choice between them based on oncologic factors first, then patient preference and cosmetic considerations second. 1

Key Oncologic Requirements:

• Negative surgical margins are mandatory—defined as "no ink on tumor" per Society of Surgical Oncology/ASTRO guidelines 1
• If margins remain positive after re-excision, mastectomy may be required for optimal disease control 1
• The benefit of lumpectomy is predicated entirely on achieving pathologically negative margins 1

Surgical Decision Algorithm

Lumpectomy is Appropriate When:

• Early-stage disease (stage I-II) with tumor size allowing adequate margins 1
• Single incision can incorporate disease with satisfactory result 1
• Patient can receive postoperative radiation therapy 1
• No diffuse microcalcifications or widespread disease 1

Mastectomy is Required When:

• Pregnancy requiring radiation during pregnancy 1
• Diffuse suspicious microcalcifications on mammography 1
• Widespread disease not removable through single incision 1
• Persistently positive margins despite re-excision 1
• Previous chest wall radiation 1
• Active connective tissue disease (scleroderma, lupus) 1

Integration of Cosmetic Techniques (Still Therapeutic)

While cosmetic outcome matters for quality of life, oncoplastic techniques are therapeutic procedures that extend the ability to perform breast-conserving surgery while maintaining oncologic safety. 2, 3

Oncoplastic Volume Displacement:

• Combines generous tumor resection with mastopexy techniques to fill surgical defects 1, 3
• Allows wider surgical margins while preserving breast shape 1, 3
• Performed during the same operation by the cancer surgeon 1, 3
• Critical requirement: All patients must receive whole-breast radiation therapy with boost—this is non-negotiable for oncologic safety 2

When Oncoplastic Techniques Apply:

• Large tumor-to-breast size ratio that would otherwise require mastectomy 1, 2
• Cosmetically challenging tumor locations 2
• Large or pendulous breasts where standard lumpectomy would cause significant deformity 1, 4

Critical Caveats

The primary focus must always be tumor treatment—reconstruction should never compromise adequate surgical margins or oncologic management. 1, 5

• Patients must be counseled about higher positive margin rates with oncoplastic techniques and potential need for conversion to mastectomy 2, 3
• Meticulous hemostasis extends operative time but is essential—attempting to minimize time at the expense of adequate margins leads to worse outcomes 5
• Close collaboration between oncologic and reconstructive surgeons is essential when reconstruction is planned 1

Reconstruction After Mastectomy

When mastectomy is performed, breast reconstruction is an option but remains secondary to cancer treatment. 1 Reconstruction can be immediate or delayed, using implants or autologous tissue, but the decision for reconstruction does not change the therapeutic nature of the mastectomy itself. 1

Bottom line: This is therapeutic cancer surgery with modern techniques that integrate cosmetic considerations to improve quality of life, but survival and disease control remain the primary outcomes driving all surgical decisions. 1, 2