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Breast-Conserving Therapy for Invasive Breast Cancers

Introduction Breast conservation has been the standard alternative to mastectomy for most patients with early-stage invasive breast cancer for decades. The purpose of breast-conserving surgery (BCS) is the removal of all gross disease from the breast, and as much microscopic disease as possible, without compromising a good cosmetic result. Residual minimal microscopic disease may then be eliminated by postoperative radiation therapy (RT) with higher tumor control…

Postmastectomy Radiation Therapy

Historical Perspective on Postmastectomy Radiation Therapy PMRT Prior to Systemic Therapy The use of postmastectomy radiation therapy (PMRT) for improvement of breast cancer–specific outcomes has long been a topic of intense interest within the field of oncology. Prior to the advent of commonly utilizing systemic therapy in the adjuvant setting, an initial meta-analysis of eight randomized trials comparing mastectomy (radical or simple) with or without PMRT…

Radiotherapy and Regional Nodes

Introduction Regional nodal irradiation (RNI) for localized breast cancer exemplifies the measurable oncologic advances of recent decades. While nodal status was previously considered a main prognostic and predictive factor to inform treatment, a constellation of other clinicopathologic parameters and molecular markers are now increasingly used to define how breast cancer is managed. A series of trials has demonstrated that the aggressive surgical procedures of the last…

Breast Reconstruction

Role of Reconstruction in Breast Cancer Treatment Breast reconstruction is performed to correct anatomic abnormalities, and is considered a functional procedure following mastectomy or breast conservation therapy. Until the late 1970s and early 1980s, breast reconstruction was mostly performed in a delayed fashion after mastectomy. At that time, there were a number of concerns about performing immediate breast reconstruction related to the oncologic safety of reconstruction…

Nipple Skin-Sparing Mastectomy

Introduction The radicality of mastectomy for breast cancer treatment has decreased over time, from Halsted’s radical mastectomy, which was standard of care until the 1960s, to Patey’s modified radical mastectomy that avoided the excision of the pectoralis muscle, based on his studies on the relationship of lymphatic drainage of the breast to the pectoralis major. At the end of the 20th century, Toth and Lappert described…

Oncoplastic Breast Reconstruction: Extreme Oncoplasty and Split Reduction Techniques

Introduction For 100 years, starting in the 1870s, mastectomy reigned as the only treatment for breast cancer. Then, during the 1970s and 1980s, prospective randomized trials showed survival equivalence for breast conservation compared with mastectomy for patients with tumors <5 cm. Although survival was equal, there was a slightly higher local recurrence rate with breast conservation therapy. This was accepted in exchange for a better cosmetic…

Oncoplastic Techniques for the Lower Hemisphere of the Breast

Introduction Two decades have passed since the NSABP and Milan randomized controlled trials reported 20-year outcomes confirming that women with early-stage breast cancer may safely choose to keep their breasts without compromising survival. Breast-conserving therapy (BCT) has become the standard approach for most women with early breast cancer limited to one quadrant. Breast-conserving surgery not only achieves the same overall survival, when paired with sentinel node…

Upper Hemisphere Oncoplastic Surgery

Introduction The application of oncoplastic breast surgery techniques in upper hemisphere breast conservation surgery (BCS) affords optimal oncologic and aesthetic outcomes via case-by-case tailored procedures. The goal of this chapter is to provide breast surgeons with multiple reproducible techniques for performing oncoplastic surgery (OPS) in the upper hemisphere. Although the upper hemisphere is often thought of as a “less than ideal” or “less forgiving” location for…

Optimizing Cosmetic Outcomes for Breast Surgery

The adoption of breast-conserving therapy as an acceptable alternative to mastectomy opened the door to a wide and varied range of partial breast reconstruction techniques. The term oncoplastic breast surgery , as suggested by Werner Audretsch in 1993, describes the concept of local tissue rearrangement allowing for wide resection of tumors while preserving or improving breast cosmesis. A contralateral mammaplasty or mastopexy restores symmetry due to…

Pain Management of the Breast Cancer Surgery Patient

Surgery for breast cancer remains the primary form of treatment, yet postoperative rates of acute and chronic pain remain high, resulting in functional impairment, poor quality of life, and need for therapeutic interventions. Nearly 40% of patients undergoing breast cancer surgery report significant acute postoperative pain, and up to two-thirds of patients report some degree of chronic breast pain. A number of pharmacologic regimens and regional…

Wound Care and Complications of Mastectomy

Rehabilitation of the postmastectomy patient produces problems of varying complexity. This chapter reviews commonly used approaches for the care of postmastectomy wounds and addresses the complications encountered in these patients. The goals of postoperative care are to anticipate and prevent adverse events and to accelerate recovery. Care of the Postmastectomy Wound The various operative techniques used in the treatment for breast carcinoma are described elsewhere in…

Lymphedema Prevention and Treatment: Axillary Reverse Mapping, LYMPHA, Lymph Node Transfer, and Other Surgical Techniques

Introduction Breast cancer–related lymphedema (BCRL) is the most common etiology of lymphedema in the United States. One out of five women who survive breast cancer will develop lymphedema. Seventy-five percent of patients present within 3 years of their treatment, with timing dependent on the composition of cancer therapy. BCRL, like other types of lymphedema, results from an insufficiency of the lymphatic system. Under normal circumstances the…

Therapeutic Value of Axillary Node Dissection

Controversy has long existed regarding the biological implications and surgical treatment of regional lymph node metastasis in invasive breast cancer. Several factors have resulted in a renewed evaluation of axillary node dissection. First is the continuing biologic controversy that axillary lymph node metastases are “indicators but not governors” of outcome in breast cancer. Indeed in all human cancers with few exceptions, this biological concept has been…

Lymphatic Mapping and Targeted Axillary Dissection Procedure After Neoadjuvant Chemotherapy

Introduction The surgical management of breast cancer has evolved with the development of effective neoadjuvant chemotherapy (NAC) and targeted systemic therapy. In addition to treating early and locally advanced breast cancer, NAC downstages disease in the breast and axilla, allowing for deescalation of surgical therapy, and providing prognostic information regarding responsiveness to chemotherapy. In the ACOSOG Z1071 trial, 45.4% of HER2+ and 38% of triple-negative breast…

Lymphatic Mapping and Sentinel Lymphadenectomy for Breast Cancer

Intraoperative lymphatic mapping and sentinel lymph node dissection (SLND) has replaced axillary lymph node dissection (ALND) as a minimally invasive and highly accurate staging procedure for early invasive breast cancer. The status of the axillary lymph nodes is an important prognostic indicator for overall survival in breast cancer. It is the presence or absence of lymph node metastases, the number of tumor-positive nodes, and the size…

Intraoperative Evaluation of Surgical Margins in Breast-Conserving Therapy

Importance of Margins in Breast-Conserving Surgery Breast-conserving surgery (BCS) is the preferred treatment approach for most patients with early-stage breast cancer. The combination of complete resection of the breast cancer lesion with tumor-free margins followed by radiotherapy provides excellent local tumor control. There is a balance between the extent of lumpectomy performed to achieve clear surgical margins and the resultant cosmesis of the breast. Because pathologic…

Breast Conservation Therapy for Invasive Breast Cancer

Breast conservation therapy (BCT) is the complete removal of breast cancer with a margin of normal tissue surrounding the tumor. Standard treatment is to be followed by radiation therapy (RT). The primary goals of BCT are to provide a survival equivalent to mastectomy, an acceptable rate of local recurrence, and a cosmetic outcome that is acceptable to the patient. Historical Perspective BCT for carcinoma was first…

General Principles of Mastectomy: From Halsted Radical Mastectomy and Modified Radical Mastectomy to Total (Simple) Mastectomy

Development of the Radical Mastectomy—Historical Aspects The Halsted radical mastectomy, published by William Stewart Halsted in his 1894 seminal report “The result of operations for the cure of cancer of the breast,” transformed that era of breast cancer treatment. The operation embodied the concept of complete en bloc resection of the breast with the pectoralis major and minor muscles, and the regional lymphatics. The Halstedian approach…

Management of Lobular Neoplasia and Ductal Carcinoma in Situ

Lobular Neoplasia Lobular neoplasia is the overarching nomenclature used to describe the spectrum of proliferative but noninfiltrative changes seen within the lobular units of the breast. Lobular neoplastic lesions include atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS), each of which is associated with an increased risk of developing a subsequent invasive breast cancer (IBC). Pathologically, lobular neoplasia is diagnosed when the acini of…

Examining Domestic and International Disparities in Breast Cancer Screening, Treatment, and Outcomes

Introduction Breast cancer is the most common female cancer in the United States and worldwide, with significant domestic and global disparities in screening, stage at diagnosis, treatment outcomes, and survival. In the United States, African American (AA) women have a lower incidence of breast cancer but higher mortality than White women. Although the incidence of breast cancer is currently higher in high-income countries (HICs), the burden…