Breast conserving therapy

1. Breast conserving therapy (BCT)
Maksims Tjurins
LU MF 5th year

2. INTRODUCTION
• Breast conserving therapy (BCT) refers to breast conserving
surgery (BCS), followed by moderate-dose radiation therapy
(RT) to eradicate any microscopic residual disease.
• The goals of BCT are to provide the survival equivalent of
mastectomy, a cosmetically acceptable breast, and a low rate
of recurrence in the treated breast.

3. PATIENT SELECTION FOR BCT
—Although BCT provides an acceptable alternative to
mastectomy for the treatment of invasive breast cancer, it is
not applicable to all patients

4. The following issues are emphasized in the appropriate selection of
patients for BCT:
• A complete history and physical
examination prior to treatment.
• Tissue biopsy with core needle
sampling to provide conclusive proof of
malignancy. Needle biopsy is preferred
over surgical biopsy to reduce
unnecessary surgery and avoid scars
that may complicate the placement of
the subsequent lumpectomy incision.

5. The following issues are emphasized in the appropriate selection of
patients for BCT:
• Accurate histologic assessment of the primary tumor, including
histologic subtype, hormone receptor status, and HER2 status
• Once the diagnosis of cancer is made, multidisciplinary coordination
among breast and reconstructive surgeons, radiation and medical
oncologists, and radiologists and pathologists facilitates treatment
planning and streamlines patient care. In some cases, neoadjuvant
chemotherapy is warranted to decrease the tumor size and improve the
success rate of breast conservation.

6. The following issues are emphasized in the appropriate selection of
patients for BCT:
• Preoperative breast imaging, to define the
extent of disease and identify multifocal or
multicentric cancer that could preclude
breast conservation or potential difficulty in
achieving clear surgical margins. Imaging
typically includes a combination of bilateral
mammographic evaluation, with
appropriate magnification views, and
ultrasound, if appropriate.
• The tumor size should be included in the
mammographic report, as well as
documentation of associated
microcalcifications, and the extent of the
calcifications within and outside the mass.

7. • Some surgeons may
incorporate breast magnetic
resonance imaging (MRI) in
the work-up of patients
considering BCT, however the
use of routine MRI in this
setting is not indicated.
The following issues are emphasized in the appropriate selection of
patients for BCT:

8. Selection criteria for BCT
• Histologic subtypes other than invasive ductal carcinoma (eg,
invasive lobular cancer) are not associated with an increased
risk of breast cancer recurrence; these women are candidates
for BCT if the tumor distribution is not diffuse and it can be
excised with negative margins.

9. • The presence of an extensive intraductal component (EIC) is an
indicator that disease extent may be greater than clinically
suspected but is not a contraindication to BCT by itself.
Patients with negative margins are still acceptable candidates
for BCT.
• Lymph node positivity is a marker of worse prognosis, but
positive lymph nodes are not a contraindication for BCT, as BCT
and mastectomy have equivalent outcomes independent of
nodal metastases.
Selection criteria for BCT

10. • Tumor location should not influence
the choice of treatment. Tumors in a
superficial subareolar location may
require resection of the nipple-
areolar complex to achieve negative
margins; oncologic outcomes will not
be affected, but the cosmetic result
may be.
Selection criteria for BCT
• A family history of breast cancer is not a contraindication to BCT;

11. Special consideration
Tumor size — Tumor size relative to breast size is an important
consideration in selecting patients for BCT. A large tumor in a
small breast is a relative contraindication, since an adequate
resection would result in significant cosmetic alteration.
Role of neoadjuvant treatment — Neoadjuvant treatment with
chemotherapy or hormonal therapy can reduce tumor size
significantly and allow for breast conservation

12. Contraindications
• Multicentric disease with two or more
primary tumors in separate quadrants
of the breast such that they cannot be
encompassed in a single excision.

13. Contraindications
• Diffuse malignant
microcalcifications
on mammography.

14. Contraindications
• A history of prior therapeutic RT that included a portion of the
affected breast, which when combined with the proposed
treatment, would result in an excessively high total radiation
dose to the chest wall.

15. Contraindications
Pregnancy is an absolute
contraindication to the
use of breast irradiation;
however, it may be
possible to perform
breast-conserving
surgery in the third
trimester, deferring
breast irradiation until
after delivery.

16. Contraindications
• Persistently positive
resection margins
after multiple
attempts at
reexcision.

17. PREOPERATIVE PREPARATION
• Antibiotics
• Deep venous thrombosis prophylaxis

18. SURGICAL TECHNIQUE
• The type and location of the incision is important for several
reasons. It is imperative to remember that any patient who
undergoes lumpectomy may ultimately require a mastectomy,
and incisions should be planned with possible mastectomy
incisions in mind
• The incision should be placed close to the tumor to avoid
extensive tunneling

19. SURGICAL TECHNIQUE
• In the upper part of the breast,
incisions should be curvilinear
or transverse and follow the
natural skin creases (Langer's
lines).

20. SURGICAL TECHNIQUE
• In the lower part of the breast,
the choice of a curvilinear or
radial incision is dependent upon
the contour of the breast, the
distance from the skin to the
tumor, and the amount of breast
tissue to be resected.
• At the completion of the
procedure, the incision should be
closed with a subcuticular suture
to avoid cross-hatching of the
skin.

21. Evaluation of the axilla
• Evaluation of the axilla provides information for treatment
decisions in patients with invasive breast cancer. Sentinel node
biopsy is the standard initial approach for patients with a
clinically negative axillary examination.

22. Margins of resection
Microscopic resection margins are
the major selection factor for
breast conserving therapy (BCT),
because of their marked influence
on local recurrence. Women with
negative excision margins have
low rates of local recurrence
following BCT, while positive
resection margins (ie, carcinoma
at the inked margin) are
associated with a higher risk of
local recurrence.

23. Indications for wider excision of margins
• The indication for a wider excision following breast conserving
surgery is a histologically positive tumor margin identified on
the surgical specimen. A positive margin implies a potentially
incomplete resection. Patients with a positive tumor margin
have an at least twofold increase in ipsilateral local breast
cancer recurrence.

24. Cosmetic outcome
• Many surgical factors will play a role in the ultimate cosmetic
appearance of the breast. These include the size and
placement of the incision, management of the lumpectomy
cavity, and the extent of axillary dissection if necessary.

25. Cosmetic outcome
• Excellent: The treated and untreated breast are almost
identical
• Good: Minimal differences between the treated and untreated
breasts
• Fair: Obvious differences between the treated and untreated
breasts
• Poor: Major aesthetic sequelae in the treated breast

26. POSTOPERATIVE COMPLICATIONS
• Seroma
• Infection
• Arm morbidity

27. Seroma
• Seroma formation occurs in virtually all
patients after breast and axillary surgery,
and should be considered a transient
side effect rather than a major long-
lasting complication of these
procedures.
• Although all patients will have some
serous fluid collect at the surgical site,
seromas are not clinically significant in
most cases.
• A clinically significant seroma can be
defined as a postoperative fluid
collection that requires one or more
aspirations or subsequent drain
placement.

28. Breast cellulitis and abscess
• Breast cellulitis is an emerging
problem in women undergoing
breast conserving therapy (BCT)

29. Arm morbidity
• Arm morbidity is common after breast cancer treatment and can
include
– arm swelling,
– arm pain,
– arm numbness,
– arm stiffness,
– shoulder stiffness,
– shoulder pain,
– nerve injury.
Arm problems are less common after BCT as compared to mastectomy.

30. Elderly
• Risk of postoperative complications increases with increasing
age as well as associated comorbid illnesses.

31. Thank you for your attention