Breast Ca SurgCurrent Surgical Therapy

The primary endpoint was progression-free survival (PFS) in the hormone receptor-positive (HR+) cohort.

Drug-related interstitial lung disease was seen in 12.1% of patients treated with T-DXd.

The goals of breast surgery are to achieve locoregional control of the existing disease, reduce the risk of recurrence, and help determine the pathologic stage, which guides adjuvant systemic and radiation therapy recommendations.

The NCCN guidelines recommend annual screening mammograms in asymptomatic women 40 years of age and older who have an average risk of breast cancer.

Tomosynthesis, a 3D-mammogram constructed by a moving x-ray and digital detector, has an improved cancer detection rate and decreased call-back rate.

The BI-RADS assessment categories are used to designate the relative likelihood of a normal, benign, or malignant diagnosis and standardize recommendations for further management.

For women presenting with a palpable mass, imaging is warranted, and those with suspicious findings should undergo core needle biopsy for tissue diagnosis.

The histopathologic examination from a breast tissue biopsy provides information regarding in situ versus invasive cancer, histologic variant, hormone receptor status, and grade of the cancer, which guide therapeutic decisions.

The American Cancer Society estimated there will be 284,200 new invasive breast cancers diagnosed in the United States in 2021.

The breast surgeon is uniquely positioned to help navigate the array of surgical options and is an integral member of a multidisciplinary team that helps determine a treatment plan suitable for the patient's health and well-being.

The primary method of evaluating the extent of disease in high-risk breast cancer patients is through imaging techniques such as positron emission tomography (PET) or computed tomography (CT) of the chest, abdomen, and pelvis, along with a bone scan.

The two broad categories of non-metastatic breast cancer are: 1. Early-stage breast cancer (stage I or II) 2. Locally advanced breast cancer.

Factors considered include: 1. Clinical prognostic stage 2. Fitness for general anesthesia and surgery 3. Contraindications to radiotherapy 4. Life goals, including fertility and quality-of-life concerns 5. Estimation of contralateral breast cancer risk 6. Personal history of breast cancer or high-risk pathologic factors 7. Family history of breast cancer.

Whole-breast radiation therapy is essential in breast-conserving surgery as it has been shown to decrease the risk of breast cancer recurrence.

Contraindications include: 1. Current pregnancy 2. Prior radiation therapy including chest radiation 3. Multicentric or widespread disease 4. Large tumor size in relation to the breast 5. Diffuse malignant-appearing calcifications 6. Persistently positive pathologic margins despite reexcision attempts.

The recommended margin status for invasive cancer in lumpectomy specimens is no tumor at the inked surface of the specimen.

Previous trials have shown similar breast cancer-specific and overall survival rates between lumpectomy plus radiation and mastectomy, with more recent studies indicating better outcomes for lumpectomy plus radiation due to advancements in treatment.

Genetic counseling helps assess eligibility for genetic testing and informs women about risk-reducing surgical options, such as bilateral mastectomy, especially for those with a strong family history or genetic predisposition to breast cancer.

Wire localization is used to accurately identify and mark the location of a breast mass prior to surgical excision. It helps ensure that the surgeon removes the correct area of tissue, which is crucial for achieving clear or negative margins during lumpectomy procedures.

Oncoplastic surgery combines reconstructive techniques with oncologic principles to provide breast-conserving options. Benefits include:

1. Improved cosmetic outcomes for large tumors relative to breast size.
2. Repositioning of the nipple-areolar complex when necessary.
3. Addressing aesthetic concerns, such as contralateral breast reduction for macromastia.
4. Similar oncologic outcomes compared to mastectomy, with higher patient-reported satisfaction scores.

Retrospective studies indicate that patient-reported outcomes are higher in women undergoing oncoplastic breast-conserving surgery compared to those undergoing mastectomy with immediate reconstruction. This is measured using tools like the BREAST-Q questionnaire and self-rated breast appearance scores.

Achieving clear or negative margins is crucial in breast cancer surgery as it reduces the risk of local recurrence. If clear margins cannot be achieved, a conversion to completion mastectomy may be warranted, although wider margins have not shown to further reduce recurrence risk when appropriate adjuvant therapies are administered.

Mastectomy is indicated for:

1. Women with contraindications for breast-conserving surgery.
2. Women with inflammatory breast cancer.
3. Women who prefer mastectomy for personal reasons.
4. Women with a BRCA mutation, as bilateral prophylactic mastectomy reduces breast cancer risk by over 90%.

Complications of mastectomy include:

• Hematoma
• Seroma
• Wound infection
• Skin flap necrosis
• Chronic pain
• Phantom breast syndrome
• Arm morbidity

Postmastectomy bleeding occurs in approximately 3% of cases.

When planning a simple mastectomy incision, the surgeon should consider:

1. Vertical laxity of the breast to minimize redundant skin.
2. The size and firmness of the breast (e.g., wider incision for large ptotic breasts).
3. Ensuring the skin lies flat against the chest to avoid discomfort, especially in the axillary region.

Criteria for selecting patients for nipple-sparing mastectomy include:

• Absence of locally advanced breast cancer.
• No extensive disease in the periphery of the breast.
• No direct invasion of the nipple with cancer.
• Tumors must be >1 cm from the nipple.

Patients with a history of radiation, smoking, or larger/ptotic breasts may not be suitable due to increased risks.

Women are encouraged to resume activities of daily living but should avoid rigorous shoulder exercises to reduce the risk of seroma formation.

Axillary lymph node dissection is the standard of care for clinically node-positive disease and provides prognostic information for adjuvant treatment decisions.

The development of sentinel lymph node biopsy allowed for the safe omission of axillary lymph node dissection in most patients with clinically node-negative disease.

The ACOSOG Z0011 trial suggests that patients with T1 to T2 tumors who are clinically node negative and have one or two positive sentinel lymph nodes do not require completion axillary lymph node dissection, as there is no difference in overall survival or locoregional recurrence.

Lymphedema, caused by disruption of the lymphatic system, is a potential side effect of axillary surgery.

Neoadjuvant chemotherapy is recommended followed by a modified radical mastectomy with axillary lymph node dissection, and postmastectomy radiation is indicated.

The standard therapy is anthracycline-based chemotherapy with or without taxanes, and HER2-positive tumors should include trastuzumab with possible use of pertuzumab.

Imaging modalities include mammography, ultrasound, and breast MRI, with MRI being the most sensitive for evaluating response to neoadjuvant therapy.

Patients who are clinically node negative should undergo sentinel lymph node biopsy post-systemic treatment, as the false-negative rate of a repeat biopsy is unacceptably high.

Marking the biopsy-proven involved node with a radiopaque clip or other marker allows for identification of the metastatic node following neoadjuvant chemotherapy, aiding in treatment response assessment.

Factors that contribute to a lower false-negative rate include:

1. Using dual tracer (isosulfan blue dye and technetium sulfur colloid).
2. Attempting to remove at least three sentinel lymph nodes.
3. Successfully retrieving the previously biopsied clipped lymph node.

The term targeted axillary dissection refers to the retrieval of the clipped lymph node along with the sentinel lymph nodes.

Achieving pathologic complete response (PCR) of the breast and axilla (ypTO and ypN0) is associated with improved survival in these breast cancer subtypes.

For patients with persistently clinically positive nodes (ypN+) or extensive nodal involvement (cN2 or cN3), an axillary lymph node dissection is recommended.

The two main types of staging groups in the AJCC staging system are anatomic staging groups and prognostic staging groups. Anatomic staging is based purely on TNM criteria, while prognostic staging incorporates TNM criteria along with biomarker information such as tumor grade and receptor status.

Adjuvant therapy in breast cancer treatment can include systemic therapy (anti-hormonal therapy, chemotherapy, biologic agents) and/or radiotherapy. It aims to reduce locoregional and distant recurrence risk, particularly in women with estrogen receptor-positive tumors, who may receive antihormonal therapy for 5 to 10 years.

The Oncotype DX Breast Recurrence Score helps stratify patients with estrogen receptor-positive, HER2-negative breast cancer to determine if chemotherapy is beneficial. For example, the RxPONDER trial indicated that postmenopausal women with a score of ≤ 25 do not benefit from adding chemotherapy to adjuvant endocrine therapy, allowing for its omission.

Radiation therapy is indicated for:

1. Whole-breast radiation post-lumpectomy to reduce recurrence risk.
2. Chest wall radiation post-mastectomy, especially for node-positive disease.
3. Regional lymph node radiation to include axillary and supraclavicular nodes.

It provides long-term survival benefits and can be tailored based on individual risk factors.

The decision to perform surgery in stage IV breast cancer patients depends on:

1. Extent of metastatic disease.
2. Response to systemic therapy.
3. Stability of oligometastatic disease.
4. Multidisciplinary discussion regarding potential benefits and palliative purposes.

Surgery is generally reserved for patients with stable disease and a reduction in breast tumor size.

Potential candidates for partial-breast irradiation include women who:

1. Are ≥ 50 years old.
2. Have small tumors (<2 cm).
3. Are node-negative.
4. Have tumors excised with negative surgical margins.

This approach is suitable for low-risk patients, ensuring adequate tumoricidal dose is delivered.