Lumpectomy for Breast Cancer

■ A thorough history should be performed prior to treatment, including a detailed past medical history, present medications and allergies, and a personal and family history of cancer.

■ Prior radiation to the breast is a contraindication to BCT. For patients who may have had chest wall radiation for indications other than a prior breast cancer (such as mantle radiation for Hodgkin disease), it may be helpful to obtain the prior records and review the fields treated. These patients may be eligible for a partial breast irradiation technique (Chapter 7).

■ Patients with a history of autoimmune or collagen-vascular diseases, such as scleroderma, lupus, or dermatomyositis, may have abnormal reaction to radiation therapy, which significantly compromises the cosmetic outcome. For some types of collagen-vascular disease, such as Raynaud phenomenon, rheumatoid arthritis, or Sjögren’s syndrome, the response to radiation is not as severe and these patients may be considered for BCT.

■ A detailed family history is critical to assess the risk of a future breast cancer, and consider genetic counseling and testing. High-risk patients may want to consider bilateral mastectomy as they are at considerable risk of a second primary cancer. The data is mixed regarding the local recurrence rate among patients with a known or suspected BRCA 1 or 2 mutations who opt for BCT. Some, but not all, studies suggest an increased risk.^1,2 The decision to pursue BCT in known BRCA1/2 carriers should be made following extensive discussion with a genetic counselor.

■ Patient age, nodal status, histologic tumor type, tumor grade, and extensive intraductal component (EIC) are not contraindications to BCT as long as negative margins can be obtained.

■ If an adequate lumpectomy can be performed, prior breast augmentation with breast implants are not an absolute contraindication, and radiation can be delivered to the augmented breast using standard techniques and doses. However, capsular contraction is a risk. If the tumor is close to the implant, preventing negative margins (cancers sometimes invade the fibrous capsule around the implant), the implant may need to be removed.

■ A complete, bilateral breast examination should focus on both assessing the cosmetic implications of lumpectomy and identifying additional areas of concern to rule out multicentric disease. Any additional suspicious masses should be biopsied, and cancer ruled out, prior to proceeding with BCT.

■ The size of the mass relative to the size of the breast, location of the mass, proximity to the skin and amount of skin needed to be resected, and symmetry of the breasts should be noted. For some patients with a large tumor relative to the size of the breast, neoadjuvant chemotherapy may be considered to downstage the primary tumor. For other patients in whom a poor cosmetic outcome with standard lumpectomy is predicted, an oncoplastic approach should be considered (Chapter 6).

■ A detailed examination of the bilateral axillary, supraclavicular, and cervical lymph nodes should be undertaken, and any suspicious lymphadenopathy worked up prior to surgery.

IMAGING AND OTHER DIAGNOSTIC STUDIES

■ All patients require bilateral mammographic evaluation, with appropriate magnification views, within 3 months of surgery (FIG 1). The tumor size, the presence of microcalcifications, and the extent of calcifications outside of the mass should be noted. Some patients with palpable cancers may still require wire localization of the calcifications to assure complete removal at the time of lumpectomy.

■ Any additional areas of abnormality should be worked up and biopsied to rule out multicentric cancer. Multicentric disease is typically a contraindication to BCT; however, patients with two tumors close enough that they can be removed in one specimen with an acceptable cosmetic outcome can still be considered candidates for BCT.

■ The use of magnetic resonance imaging (MRI) to determine eligibility for BCT has been increasing. Although MRI may more accurately determine the extent of the tumor or identify multicentricity, particularly in women with dense breast tissue (for whom mammography is less sensitive), its use is controversial. MRI is highly sensitive but has limited specificity and is limited in its ability to visualize ductal carcinoma in situ (DCIS). Studies have shown that the use of MRI appears to increase the mastectomy rate without decreasing reexcision or local recurrence rates.³ The need for MRI should be evaluated on a case-by-case basis.

■ Accurate histologic assessment of the primary tumor, including histologic subtype and hormone receptor status, is necessary in evaluating the breast cancer patient for suitability for BCT. This is best accomplished through a core needle biopsy rather than fine needle aspiration biopsy or excisional biopsy.

SURGICAL MANAGEMENT

Preoperative Planning

■ Prior to taking the patient back to the operating room, the presence of the palpable cancer should be confirmed with the patient. In the preoperative area, the mass should be examined in both the upright and supine positions.

■ With the patient in the supine position, the mass should be carefully marked.

■ Although the risk of infection after breast cancer surgery is low, it tends to be higher than average for a clean surgical procedure, and several studies have shown that antibiotic prophylaxis significantly reduces the risk of postoperative infection.⁴

Positioning

■ Lumpectomy is often performed in conjunction with a sentinel lymph node biopsy. Therefore, the patient should be positioned supine with the ipsilateral arm at 90 degrees.

■ If intraoperative analysis of the sentinel lymph node and possible axillary lymph node dissection is planned, the ipsilateral arm should be prepped into the sterile field. Otherwise, the ipsilateral arm can be secured.

■ If sentinel lymph node biopsy is to be performed in conjunction with lumpectomy, then the blue dye should be injected at this point. The skin is prepped with alcohol and either isosulfan or methylene blue dye is injected peritumoral (see Chapter 8, Sentinel Lymph Node Biopsy for Breast Cancer) (FIG 2).

TECHNIQUES

PLACEMENT OF INCISION

■ The skin incision should be placed directly over the palpable mass (FIG 3). One should avoid excessive tunneling. This may compromise the margins and make a reexcision for close or positive margins unnecessarily difficult.

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