Breast-conserving surgery (BCS) refers to an operation that aims to remove breast cancer while avoiding a

mastectomy Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operat ...

. Different forms of this operation include:

lumpectomy Lumpectomy (sometimes known as a tylectomy, partial mastectomy, breast segmental resection or breast wide local excision) is a surgical removal of a discrete portion or "lump" of breast tissue, usually in the treatment of a malignant tumor or brea ...

(tylectomy),

wide local excision A wide local excision (WLE) is a surgical procedure to remove a small area of diseased or problematic tissue with a margin of normal tissue. This procedure is commonly performed on the breast and to skin lesions, but can be used on any area of the ...

segmental resection Segmental resection (or segmentectomy) is a surgical procedure to remove part of an organ or gland, as a sub-type of a resection, which might involve removing the whole body part. It may also be used to remove a tumor and normal tissue around it ...

, and

quadrantectomy A quadrantectomy, also referred to as a segmental or partial mastectomy, is a breast-conserving surgery for breast cancer in which one quarter of breast tissue is removed along with muscles of the chest wall within a 2 to 3 centimeter radius of a ...

. BCS has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery.

Medical uses

For clinical stages I and II breast cancer, breast-conserving surgery, with

radiotherapy Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radia ...

and possibly

chemotherapy Chemotherapy (often abbreviated to chemo and sometimes CTX or CTx) is a type of cancer treatment that uses one or more anti-cancer drugs (chemotherapeutic agents or alkylating agents) as part of a standardized chemotherapy regimen. Chemotherap ...

may be indicated if one or two

sentinel lymph nodes The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination it is postulated that the sentinel lymph nodes are the target organs primarily reached by metastasiz ...

are found to have cancer which is not extensive. In this case, the sentinel lymph nodes would be examined, and

lymphadenectomy Lymphadenectomy or lymph node dissection is the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer. In a regional lymph node dissection, some of the lymph nodes in the ...

as further evaluation is not indicated as this result from the sentinel lymph nodes is sufficient to recommend treatment. BCS may also be used in cases of biopsy-proven invasive breast cancer or biopsy-proven

ductal carcinoma in situ Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. DCIS is classified as Stage 0. It rarely produces symptoms or a breast lump one can feel, typically being d ...

(DCIS). In the assessment of the tumor, the surgeon should assess the ability to resect the tumor with clear margins while providing a cosmetic result that is acceptable to the patient.

Shared decision-making Shared decision-making in medicine (SDM) is a process in which both the patient and physician contribute to the medical decision-making process and agree on treatment decisions. Health care providers explain treatments and alternatives to pa ...

is an important consideration in breast-conserving surgery. It is estimated that between 50% and 70% of patients are active participants in the decision making of breast cancer surgery. The time following a cancer diagnosis may be filled with fear, vulnerability, and a sense of being overwhelmed at the amount of information being provided by physicians as well as accessed on the internet. Each patient has their own set of unique characteristics, which may make it challenging to read information online and apply that information to a specific individual circumstance. In addition, there are several important misconceptions regarding breast-conservation surgery for patients and clinicians to keep in mind. # In appropriately selected patients, mastectomy and breast-conserving surgery have equivalent survival rates. # Undergoing mastectomy does not eliminate the risk for recurrent or new cancer. # Radiation therapy may still be needed following breast-conservation surgery. # The decision regarding the need for chemotherapy is independent from the surgical options.

Contraindications

Absolute contraindications, which are reasons why the procedure absolutely cannot be done, include: #

Pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but ca ...

is an absolute contraindication to the use of breast

irradiation Irradiation is the process by which an object is exposed to radiation. The exposure can originate from various sources, including natural sources. Most frequently the term refers to ionizing radiation, and to a level of radiation that will serve ...

. In some cases, it may be possible to perform breast-conserving surgery in the third trimester and treat the patient with radiation after delivery. # Two or more primary tumors in separate quadrants of the breast or with diffuse malignant-appearing

microcalcification Microcalcifications are tiny deposits of calcium salts that are too small to be felt but can be detected by imaging. They can be scattered throughout the mammary gland, or occur in clusters. Microcalcifications can be an early sign of breast cancer ...

s. # A history of prior therapeutic irradiation to the breast that would require re-treatment to an excessively high total dose. # Persistent positive margins after reasonable surgical attempts: the importance of a single focally positive microscopic margin needs further study and may not be an absolute contraindication. # Inflammatory breast cancer # Diffuse or indeterminate micro-calcifications on mammography

Relative contraindication In medicine, a contraindication is a condition that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a reason to use a certain tre ...

s encompass situations of higher risk of complications to the patient that may be outweighed by other considerations, such as the benefit to the patient. Relative contraindications include: # Previous breast radiation therapy # Connective tissue disease such as

Scleroderma Scleroderma is a group of autoimmune diseases that may result in changes to the skin, blood vessels, muscles, and internal organs. The disease can be either localized to the skin or involve other organs, as well. Symptoms may include areas of ...

, Sjogren Syndrome,

Lupus Lupus, technically known as systemic lupus erythematosus (SLE), is an autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. Symptoms vary among people and may be mild to severe. Comm ...

, and

Rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involv ...

may result in an increased risk of radiation toxicity. # Very large tumor size relative to breast volume.

Oncoplastic surgery

Oncoplastic surgery is an important consideration in breast-conserving surgery that integrates plastic surgery principles into breast cancer surgery in order to preserve aesthetic outcomes and quality of life, without compromising local control of the cancer. It is based on three surgical principles: ideal breast cancer surgery with free tumor margins, immediate breast reconstruction, and immediate symmetry with the other breast. Oncoplastic approaches to breast-conserving surgery may require a close partnership among surgeons who specialize in

surgical oncology Surgical oncology is the branch of surgery applied to oncology; it focuses on the surgical management of tumors, especially cancerous tumors. As one of several modalities in the management of cancer, the specialty of surgical oncology has evolved ...

and plastic surgery. Oncoplastic surgery is not only limited to breast-conserving surgery, as the techniques and principles of plastic surgery can be applied to mastectomy as well. As of 2017, there had been no

randomized controlled trial A randomized controlled trial (or randomized control trial; RCT) is a form of scientific experiment used to control factors not under direct experimental control. Examples of RCTs are clinical trials that compare the effects of drugs, surgical te ...

s to compare oncoplastic breast-conserving surgery to traditional breast conserving surgery techniques.

History

Prior to 1981, there existed limited evidence that breast-conserving surgery was an acceptable alternative to

radical mastectomy Radical mastectomy is a surgical procedure involving the removal of breast, underlying chest muscle (including pectoralis major and pectoralis minor), and lymph nodes of the axilla as a treatment for breast cancer. Breast cancer is the most comm ...

for treatment of early stage breast cancer. Dr. Umberto Veronesi, an Italian oncologist, challenged this notion and led a clinical trial comparing the radical mastectomy with breast-conserving surgery (which was termed quadrantectomy at the time). This landmark trial showed no differences in overall survival, disease-free survival, and local recurrence for patients with breast cancer of less than 2 cm and no palpable axillary nodes. He was widely celebrated for this landmark study, so much so that some began referring to this operation as the Veronesi Quadrantectomy.

References

External links

American Academy of Family Physicians, Breast-Conserving Surgery, What is breast-conserving surgery?

Breast conserving surgery at National Breast and Ovarian Cancer Centre www.nbocc.org
{{Operations and other procedures of the integumentary system Breast surgery Breast cancer