Breast Conservation Surgery is defined as the complete removal of the tumour with a concentric margin of surrounding healthy tissue with maintenance of acceptable cosmesis, and should be followed by radiation therapy to achieve an acceptably low rate of local recurrence. Breast conservation treatment is BCS with radiotherapy.

1. Breast Conservation Surgery
Dr Sushanth Nayak

2. History
• In 70s Fischer’s hypothesis-
Breast cancer is a systemic disease- thus treatment of carcinoma breast
depends on the systemic dissemination before detection.
This led to change in treatment of Ca breast-
Less radical surgery equivalent to Radical mastectomy with less physical
and psychological morbidity.
• In 1972 MRM (Madden-Auchincloss) was published

3. •Next step - Conservative surgery for breast cancer
(lumpectomy with axillary lymph node dissection followed
by radiation therapy to the breast).
•Pioneers of this technique Fisher in America and Veronesi in
Italy.
•Conservative treatment of the breast appropriate for breast
cancer patients with stage I and II :- National Institutes of
Health Consensus Conference in 1991

4. •In 1992, Morton- another step to a less radical approach
•Implementation of axillary sentinel node biopsy
•The aim of local treatment of breast cancer is to achieve
long-term local disease control with the minimum of local
morbidity.

5. Breast Conservation Surgery is defined as the
complete removal of the tumour with a concentric
margin of surrounding healthy tissue with
maintenance of acceptable cosmesis, and should be
followed by radiation therapy to achieve an
acceptably low rate of local recurrence.

6. Major advantages of BCS-
•Produces an acceptable cosmetic appearance in the majority
of women.
•Lower levels of psychological morbidity with less anxiety,
depression,
•Improved body image, sexuality, and self-esteem than
mastectomy.
•Equivalence in terms of disease outcome for BCT and
mastectomy

7. • INDICATIONS AND CONTRAINDICATIONS TO BREAST CONSERVING SURGERY

8. • Oncoplastic techniques to be considered if
1. Significant area of skin to be resected with tumor
2. Large volume resection is expected
3. Tumor is in the area with poor cosmetic outcomes(e.g-lower hemisphere
below nipple) OR
4. Resection may lead to nipple malposition

9. Extent of breast resection-
• it is the ratio of anticipated defect to the volume of remaining breast
parenchyma
• Oncoplastic surgery to be considered if defect likely to be greater
than20to 30% of breast volume and for any tumor resection in lower
breast
Breast size and body habitus-
• Patients with larger breasts- good candidates for reduction
mammoplasty
• Obese patients are considered for this approach
• Breast reduction surgery – good option- relieves symptoms of
macromastia and give improved outcome after breast irradiation.

10. Tumor location- Tumors lying directly under NAC or located between
NAC and infra-mammary fold require special attention
Skin and well vascularised tissue must be approximated properly in
this area as deformities in contour will be exacerbated by radiation
Timing of Oncoplastic surgery-reconstruction of irradiated breast not
recommended after 1-2 yrs of RT
In irradiated tissue- higher rates of seroma ,infection ,necrosis
Surgical procedures on irradiated breasts should be minimized as
healing and recovery are impaired.

11. • Patient selection- Previously influenced by clinical and pathological
factors including-
1. Younger age <35 to 39
2. Extensive in situ component with invasive tumor
3. Grade III on histology
4. Wide spread lymphatic or vascular invasion
5. Young women with strong family history or carriers of BRCA1 and
BRCA2
6. Pregnancy – 1 in 3000

12. •Breast cancers diagnosed among BRCA1 mutation were
significantly more likely to be larger have higher histological
grade have negative ER,PR status than in BRCA2 mutations

13. PREOPERATIVE PLANNING
•Decisions Best Based On Imaging
•Careful Clinical Examination
•Mass Should Be Measured Accurately And Recorded
•Ultrasound Of The Whole Breast Is Recommended
•Ultrasound-guided Fine-needle Aspiration Biopsy Or Core
Biopsy
•Patient’s Imaging Should Be Inspected Before Operation

14. Patient is informed about
1. 35 % chance of not clearing the disease after BCS
2. May require re-excision or mastectomy to obtain clear
margins and excise all disease
3. Common complications such as bleeding, infections , scar,
healing issues , frequently seromas

15. Two breast-conservation surgical procedures have been
studied extensively
1. Quadrantectomy
2. Wide local excision

16. Quadrantectomy-
• Breast is organized into segments and each segment drains into
major duct and invasive cancer spreads along duct system towards
nipple.
• According to studies both invasive and non invasive cancers spread
towards nipple than any direction
• Quadrantectomy is no longer advocated
• The majority of patients having BCT can be adequately treated by
wide local excision under GA or LA with or without sedation.

17. • Incisions –
Important to place the incision in a proper position
Scar placed along kraissl lines– best cosmetic results,
Circumareolar incisions heal well
Radial incisions in the upper outer quadrant-worst cosmetic results
Radiation reduces the rate of hypertrophic scars-More satisfactory
results
Submammary, circumareolar, and axillary incisions, are used as they
produce the best cosmetic outcomes

18. • Excision of tumour-
Tumour to be excised with 1 cm safety margin
Small defects (<5% breast volume) can be left open- Good cosmetic result
Larger defects require mobilization of surrounding breast tissue from
overlying skin and subcutaneous tissue
Fatty breasts produce poor final result as cannot be sutured properly
whereas dense fibrous tissue can do so
Also fibrous tissues heal well
Drains not to be used frequently- not effective and increase infection rate
Breast skin wound to be closed in layers with final layer of sub-cuticular
sutures ,no interrupted sutures or staples used

19. • Techniques of excising central tumor
Nipple to be removed if lesion is closed to nipple and or if there is
tethering/inversion/invasion of nipple
Pro –op biopsy from duct required to preserve nipple
Women with large breasts – NAC can be incorporated in wedge
mammoplasty incision and lesion excised in continuity with
nipple/areolar skin –acceptable results
Alternatively removal of lesion with removal of NAC with underlying
breast tissue with defect reconstruction with skin and rotation flap.

21. TECHNIQUE OF EXCISING IMPALPABLE CANCERS
• Localization of impalpable lesions- with skin marking, injection of blue
dye, carbon, or radioisotope, radioactive seed, or insertion of a hook
wire with post localization mammograms or use of intraoperative
ultrasound.

26. BREAST-CONSERVING SURGERY AFTER NEOADJUVANT THERAPY
• Large and locally advanced breast cancers are treated with
neoadjuvant chemotherapy and then become suitable for BCS
The aim of BCS after NAC-
• Excise any palpable disease or disease marked by calcifications or
visible on imaging
• surgery should focus on what is left, not what was present at diagnosis
• Limit the surgery to the disease visible on imaging or palpable at
surgery.

27. POSTOPERATIVE COMPLICATIONS
• Complications of wide excision- bleeding , hematoma
formation, infection, incomplete excision, and poor cosmetic results.
• Common problem following BCS is a poor cosmetic result
• the volume of resected breast tissue -important factor affecting cosmesis
• inferior cosmetic results obtained with quadrantectomy

28. • Factors Resulting in Poor Cosmetic Outcome After Breast-
Conserving Surgery-

29. •Excisions less than 10% of breast volume-good cosmetic
result
•>10% resection – poor cosmetic result

30. INDICATIONS FOR REEXCISION
•Patients with a positive radial (medial, lateral, superior, or
inferior) margin for DCIS
•Pleomorphic LCIS
•Patients with a positive anterior or posterior margin do not
require reexcision if full thickness of breast tissue has been
taken and a radiotherapy is given

31. RECURRENCE AFTER BREAST-CONSERVING SURGERY
• Rates vary widely between different centers but nowadays should be
less than 0.5% per annum
• Factors that affect local recurrence rates after BCT can be divided into
1. Patient,
2. Tumor,
3. Treatment-related factors.

32. 1.Patient-Related Factors-
• In breast tumor recurrence (IBTR) after BCT can be either true
recurrence or second primary(elsewhere in breast)
• Common in younger patients and less common in old >65 years age
• Reson for local recurrence may be due to Family history of breast
cancer carriage of one of known breast cancer predisposing gene
associated with increased rate.

33. 2.Tumor-Related Factors
Tumor Grade- Grade 1 tumors have the lowest rates
• higher recurrence rate in grade 3 compared with grade 2 cancers
• Relative risk between grade 1 and grade 2 and 3 is 1.5
Histologic Type- invasive lobular cancer- low rates
• invasive ductal carcinoma- higher rates
Lymphatic/Vascular Invasion- LVI is a marker for recurrence after
mastectomy
• Extensive In Situ Component- If clear margins are obtained, there
appears to be no increased rate of local recurrence

34. • Multiple Tumors-Multisite disease may be associated with a small increase in the
risk of local recurrence, but is no longer a contraindication to breast conservation
• Tumor Size - not considered important in relation to local recurrences
• Other Factors-Tumor location, the presence of skin or nipple retraction, the
presence or absence of axillary node involvement, and hormone receptor status
of the cancer have not been consistently shown to exert any influence on breast
recurrence after BCT.

35. 3.Treatment-Related Factors
• Completeness of excision and the use of systemic therapy and
appropriate doses of radiotherapy- most important
• Margin index to determine whether reexcision is required
• Margin index is defined as the margin in millimetres multiplied by 100, divided by
the tumor size in millimeters.
• When the index is ≥5, residual disease is present in less than 3% of
Reexcisions
• bigger the tumor the bigger the margin needed
• Adjuvant tamoxifen, chemotherapy, and trastuzumab all reduce local
recurrence after BCT.
• rates of local recurrence are increased if radiotherapy or systemic
therapy is delayed for many months.

36. Components of BCT
1. Lumpectomy ( wide local excision or
Quadrantectomy)
2. Axillary Dissection
3. Radiotherapy

37. Axillary Dissection
• Aim of axillary surgery
1. To stage the axilla by SLNB
2. To treat any axillary disease by axillary clearance / axillary
dissection.
• Indications for axillary dissection:
1. Histologically proven involved axillary lymph nodes after
ultrasound-guided fine-needle aspiration biopsy/core
biopsy
2. After sentinel node biopsy.

38. MANAGEMENT OF THE INVOLVED AXILLA
1. Axillary dissection
2. Axillary radiotherapy
• A randomized trial AMAROS (After Mapping of the Axilla: Radiotherapy
Or Surgery) showed after an average of 6.1 years an axillary recurrence
rate of 0.43% after axillary lymph node dissection versus 1.19% after
axillary radiotherapy (n = 681).
• There was no difference in disease-free or overall survival but an
approximate doubling of the lymphoedema rates for lymph node
dissection compared with axillary radiotherapy.

39. Sentinel lymph node biopsy (SLNB):
• The first axillary node draining the breast (by direct drainage) is
designated as the sentinel node (SLN).
• SLN is first node involved by tumour cells.
• its histological involvement, will give a predictive idea about the
further spread of tumour to other nodes.
• The incidence of involvement of other nodes without SLN is less than
3% and so if SLNB is negative nodal dissection can be avoided but
regular follow-up is needed.
• SLNB is done in all cases of early breast cancers, T1 and T2 without
clinically palpable node.

40. • C/I:
1. Clinically palpable axillary
2. Multifocal and multicentric tumours
3. Allergic to vital blue dye or radio-colloid
4. In pregnancy
5. In inflammatory carcinoma of breast.
• Tracer to identify sentinel nodes can be injected into
1. The subareolar region,
2. Intradermally
3. Peri-tumoral
• Injection into skin can allow visualization of lymphatic channels,
which may aid sentinel lymph node identification.
• Subareolar injection of tracer has advantages over peritumoral
injection in patients with multisite or nonpalpable cancers.

42. •Localisation of Sentinel node is by
1. Preoperative (Within 12 hours Prior) Or Peri Operative Injection Of
Patent Blue (Isosulfan Vital Blue Dye 2.5-7.5 Ml)
2. 99m Tc Radioisotope Labelled Albumin (One Mci On Previous Day)
3. Sulphur Colloid (6 Hours Before)
Near The Tumour (Peritumour Area) Or Into Subdermal Plexus Around
The Nipple.
• Marker will pass through the sentinel node which can be visually
detected as blue staining or with a hand held gamma camera
• Further, biopsied with a small incision made directly over it. Frozen
section biopsy or touch imprint cytology is done for presence of
malignant cells.

43. • If there is no involvement of sentinel node by tumour then further
axillary dissection is not required.
• Detection rate of sentinel node for blue dye and radioisotope is 90%
and 98%, respectively.
• Subdermal/subareolar injection of radioisotope has got better sentinel
node localisation than peritumour injection.
• But better imaging is obtained by peritumour injection and so
Peritumour injection is usually practiced.
• Radioisotope tracer injection done in the early morning of the day of
surgery into peritumour area and perioperative injection of patent
blue dye in subareolar region—as a combined method is often used in
many centers.

44. • After injection of patent blue, breast is massaged continuously to enhance the
uptake.
• Incision is made after 5-7 minutes between pectoralis major and latissimus
dorsi to identify blue stained lymphatics .
• The blue stained lymphatics are traced to 2-3 blue lymph nodes.
• Hand-held radioprobe is used to identify the sentinel node which is later
excised.
• Often 2-3 nodes are removed.
• Paraffin section histology is better than frozen section to identify positive
sentinel lymph node.
• If report comes negative immunohistochemistry test is done to confirm that
lymph node is negative for tumour

45. • Sentinel lymph node biopsy should be done before wide local excision of the
primary tumour.
• Wide local excision of the primary tumour is done after SLNB in the same
sitting.
• SLNB is less invasive than axillary dissection.
• It is ideal in early invasive carcinoma.
• Positive SLNB is again classified as MACROMETASTASIS (> 2 mm) or
MICROMETASTASIS (< 2 mm).
• Complications:
1. Blue tattooing of skin which gradually fades;
2. Blue—green urine and stool for short period;
3. Allergic reactions;
4. Anaphylaxis (0.1%);
5. Seroma formation

46. AXILLARY LYMPH NODE DISSECTION (ALND)
• Indications:
1. The clinically node-positive axilla, confirmed by fine needle
aspiration or core biopsy, in a patient for whom neoadjuvant
chemotherapy is not planned.
2. Occult breast cancer presenting as axillary node metastasis.
3. SLN positive
4. Inflammatory breast cancer.
5. Failed SLN mapping.
6. Inadequate prior ALND with residual clinically suspicious nodes
7. Sentinel or axillary nodes which remain positive after neoadjuvant
chemotherapy.
8. Axillary recurrence following previous breast cancer treatment

47. • The surgical procedure includes :
clearance of node-bearing tissue between the pectoralis major and latissimus
dorsi muscles from the edge of the breast tissue in the low axillary region to the
axillary vein and removal of the nodes posterior to the pectoralis minor muscle.
• Axillary dissection is the main source of morbidity in patients with early-stage
breast cancer.
• The immediate Complications:
1. Include acute pain and paresthesias,
2. Need for hospitalization,
3. Reduced range of motion at the shoulder joint,
4. Need for a drain in the surgical bed for 2 weeks or more.
• Long-term Complications:
1. Axillary dissection include lymphedema of the ipsilateral arm
2. Numbness
3. Chronic pain
4. Reduced range of motion at the shoulder joint.

48. SLND vs ALND
• Morbidity rates SLND < ALND.
• SLND can be performed as an outpatient procedure and does not require
a drain.
• Patients have more rapid return to full mobility and are able to return to
work and other activities weeks sooner than after axillary dissection.
• Long-term morbidity, including lymphedema, numbness, and chronic pain,
is greatly reduced.
• SLND has been shown to provide reliable pathologic staging of the axilla,
with false-negative rates generally less than 5% in experienced hands.
• Axillary recurrence rates have been shown to be extremely low after a
negative sentinel node biopsy without axillary dissection.
• A negative sentinel node is now widely accepted as sufficient to establish
node-negative disease in a patient, with no further axillary treatment
required.

49. • Although ALND (achieved with a completion level I and II axillary
dissection) has been standard practice for patients with positive
sentinel nodes, the need for ALND in all patients with a positive
sentinel node has been called into question because many patients
have small-volume metastases, and the sentinel node is often the
only positive node.
• A metaanalysis of studies evaluating patients with positive sentinel
nodes showed that 53% of patients have additional positive nodes at
ALND.
• In the case of micrometastatic disease in the sentinel nodes,
the rate of nonsentinel node involvement is 20%, and
isolated tumor cells, it is less than 12%. These findings led
of omitting ALND in selected patients with positive sentinel
nodes.

50. • The results of the ACOSOG Z0011 study have changed treatment
practices.
• It is now widely believed that ALND may be safely omitted in selected
patients
• with clinically node-negative disease who have a positive sentinel
node and are similar to the participants in the Z0011 a (i.e. >2 SLN
positive, matted nodes, mastectomy, or breast conservation without
whole-breast RT)
• However , ALND remains the standard of care for patients
1. With Locally Advanced Breast Cancer
2. Inflammatory Breast Cancer,
3. Patients With A Positive sentinel node who are scheduled for mastectomy,
4. Patients With A positive sentinel node who are scheduled for accelerated
partial breast irradiation
5. Patients With A positive sentinel node after neoadjuvant chemotherapy.

51. RT is a must after conservation of breast.
• Local as well as to axilla.
• Tangential fields 50 Gy/25 fractions/5 weeks.
• Another 10 Gy to tumour bed.
• Internal mammary and supraclavicular area may be
included in radiation field.
Radiation Therapy

52. Radiation Therapy After Breast-Conserving Surgery
• For patients with invasive breast cancer treated with breast
conserving surgery, adjuvant irradiation of the breast has been
conclusively demonstrated to reduce the probability of a breast
recurrence and improve outcome.
• A meta-analysis of data from 7300 women who participated in a
randomized trials of breast-conserving surgery with or without
radiation therapy. In this analysis, radiation was found to reduce the
10-year rate of in-breast recurrence from 29% to 10% for patients
with negative lymph nodes and from 47% to 13% for patients with
positive lymph nodes.
• This improvement in local control led to a reduction in the 15-year
breast cancer mortality rate and overall death rate
• The only group identified that might be able
• to avoid irradiation safely is patients older than 70 years who
• undergo lumpectomy and adjuvant hormonal therapy for a stage I
ER-positive breast cancer.

53. • Radiation therapy after lumpectomy has consisted of a 6- to 8-week
treatment course, which can be a hardship for patients.
• An important Canadian trial ,On the basis of long-term outcome
results ,it is reasonable to treat a postmenopausal patient with a
non–high-grade, ER-positive, stage I breast cancer with a 16-fraction
course of treatment, which shortens the overall treatment time to
approximately 3 weeks.
• There has also been significant interest in shortening the treatment
course to 1 week or less through an approach that focuses the
radiation exclusively on the area around the tumor bed, called partial
breast irradiation may be performed with brachytherapy catheters,
balloon catheters, or external-beam radiation.

54. FOLLOW-UP
• Regular clinical examination after BCS or mastectomy has not
been shown to be of value.
• Patients should be seen for 1 to 2 years to check the wound
has healed and the cosmetic result is acceptable.
• Defects at the site of wide excision can be improved with
lipofilling or lipomodelling.
• There is evidence that annual mammography is cost-effective
and worthwhile.
• Regular MRI screening in younger women and women whose
cancer was not visible on mammography also appears cost-
effective.

55. THANK YOU