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Mastectomy – Partial
Goals/Objectives
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Indications
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Anatomic considerations
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Technical considerations
Diseases of the Breast
From Townsend CM: Sabiston Textbook of Surgery, 19th edition (Saunders 2012)
Selection of Surgical Therapy
Mastectomy and breast conservation therapy have been shown to be equivalent in terms of patient survival; therefore, the choice of surgical treatment for patients with stage I or II disease is individualized. Patients who desire breast-conserving surgery must be willing to attend postoperative radiation treatment sessions and to undergo postoperative surveillance of the treated breast. Consideration should be made for consultation with a radiation oncologist before the planned surgery. Patients are advised about the risks and long-term sequelae of radiation therapy. A mastectomy is generally recommended for patients who have contraindications to radiation therapy.
A significant factor in determining whether breast conservation therapy is feasible is the relationship between tumor size and breast size. In general, the tumor must be small enough in relation to the breast size so that the tumor can be resected with adequate margins and acceptable cosmesis. In patients with large tumors for whom systemic chemotherapy will likely be recommended in the postoperative (adjuvant) setting, the use of preoperative chemotherapy may be considered because it can significantly reduce the size of the tumor, allowing more patients to undergo breast-conserving surgery. If chemotherapy is administered prior to surgery, it may decrease the tumor size sufficiently to permit breast-conserving surgery in patients who would not otherwise appear to be good candidates. Another strategy is to consider local tissue rearrangement or pedicled myocutaneous flaps (latissimus dorsi) to fill the defect resulting from breast-conserving surgery. Patients with multicentric tumors are usually served best by mastectomy because it is difficult to perform more than one breast-conserving surgery in the same breast with acceptable cosmesis. Although high nuclear grade, presence of lymphovascular invasion, and negative steroid hormone receptor status have all been linked to increased local recurrence rates, none of these factors are considered absolute contraindications to breast conservation.
Eligibility for Breast Conservation
Randomized trials have demonstrated the efficacy of breast-conserving surgery for a wide variety of breast cancers and have defined eligibility for breast conservation. With these criteria and current surgical and radiation approaches, local recurrence rates after lumpectomy and radiation therapy are now less than 5% at 10 years in many large centers.
Tumor Size.
Tumors up to 5 cm in size, tumors with clinically positive nodes, and tumors with both lobular and ductal histology were included in the randomized trials. In current practice, lumpectomy is considered in cases in which the tumor can be excised to clear margins and leave an acceptable cosmetic result.
Margins.
Local recurrence rates are reduced when 2- to 3-mm microscopically clear margins are obtained on all aspects of the lumpectomy specimen. Margins should be clear for invasive cancer and DCIS.
Histology.
Invasive lobular cancers and cancers with an extensive intraductal component are eligible for lumpectomy if clear margins are achieved. Atypical hyperplasia and LCIS at resection margins do not increase local recurrence rates.
Patient Age.
Local recurrence rates are somewhat higher for younger versus older women. Local recurrence rates are reduced in patients of all ages with the use of radiation therapy. A radiation boost to the tumor bed has been shown to reduce local failures after lumpectomy, particularly in younger women.
Surgical Procedures for Breast Cancer
Breast-Conserving Surgery
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