Breast: Surgical Treatment

Risk-Reducing (Prophylactic) Surgery

Breast Cancer Prophylaxis

  • Risk-Reducing (Prophylactic) Bilateral Mastectomy Indications:
    • Lifetime Risk of Breast Cancer Calculated ≥ 25%
    • High-Risk Genetic Mutation (BRCA1, BRCA2, PALB2, TP53 or PTEN)
    • Very Strong Family History of Breast or Ovarian Cancer

Ovarian Cancer Prophylaxis

  • Risk-Reducing (Prophylactic) Bilateral Salpingo-Oophorectomy (BSO) Indications:
    • BRCA1 Pathogenic or Likely Pathogenic Variant
    • BRCA2 Pathogenic or Likely Pathogenic Variant
  • *Only Consider Upon Completion of Childbearing
  • *Some Recommend Both Total Abdominal Hysterectomy (TAH) & BSO

Surgical Options

Required Margins

  • Atypia (ADH/ALH): No Margin Required
  • LCIS: No Margin Required
  • DCIS: 2 mm
  • Invasive Carcinoma: Negative Margin (“No Ink on Tumor”)
  • *If Both DCIS & Invasive Cancer are Present: Goal is “No Ink on Tumor”
    • Behaves More Like Invasive Cancer
  • *See Individual Sections for Further Information

Breast-Conserving Therapy (BCT)

  • Definition: Partial Mastectomy (Lumpectomy)
  • Generally Requires SLNB & Adjuvant Radiation Therapy (To Eradicate Microscopic Residual Disease)
  • Contraindications:
    • Absolute Contraindications:
      • Multicentric (≥ 2 Primary Tumors in Separate Quadrants – Unable to Remove in a Single Incision)
        • Recently Debated
      • Diffuse Malignant Microcalcifications
      • Inflammatory Breast Cancer
      • Persistently Positive Margins After Multiple Attempts at Re-Excision
      • Early Pregnancy
        • Radiation Therapy Contraindicated
        • May Consider in Select Cases in the Second/Third Trimesters
    • Relative Contraindications:
      • Connective Tissue Disease
        • Such As: Scleroderma, Sjogren Syndrome or Systemic Lupus Erythematosus
        • Poor Radiation Tolerance
      • Large Tumor in a Small Breast
        • May Have Unacceptable Cosmesis
    • Not a Contraindication:
      • Age
      • Breast Density
      • BRCA Status
      • Histologic Type
      • Tumor Location
      • Local (Skin/Nipple) Involvement
      • Lymph Node Status
  • Comparison to Mastectomy:
    • Lower Risk of Complications (Seroma, Lymphedema & Skin Necrosis)
    • Equivalent Survival
    • Mastectomy Does Not Eliminate Possibility of Local Recurrence
    • Radiation Therapy Not Always Necessary After Mastectomy
    • Choice of Approach Does Not Affect Decisions About Chemotherapy
  • Complications:
    • Chance of Local Recurrence: 2% at 10 Years (Previously Was Higher at 10% Before Improved Systemic Therapies)
    • Seroma (6%)
    • Hematoma
    • Surgical Site Infection
    • Chronic Pain
    • Lymphedema
    • Radiation Fibrosis

Simple (Total) Mastectomy

  • Definition: Complete Removal of All Breast Tissue
    • Includes Nipple-Areola Complex with Large Elliptical Excision of Skin
    • Does Not Include ALND (Compared to MRM)
  • Variations:
    • Skin-Sparing Mastectomy
      • Still Includes Nipple-Areola Complex
      • Preserves the Majority of Natural Skin
    • Nipple-Sparring (Subcutaneous) Mastectomy
      • Preserves the Epidermis & Dermis of the Nipple-Areola Complex
  • Contraindications:
    • Extensive IDC
    • Paget’s Disease
    • Nipple Discharge
    • CA < 2 cm from Nipple
  • Complications:
    • Seroma (14-16% – Higher than with BCT)
      • Should Avoid Vigorous Shoulder Exercises in the Immediate Postoperative Period
    • Surgical Site Infection
    • Skin Flap Necrosis (10-18%)
    • Nipple Necrosis – Seen in Nipple-Sparing Mastectomies (6%)
    • Chronic Pain
    • Lymphedema

Modified Radical Mastectomy (MRM)

  • Definition: Complete Removal of All Breast Tissue with an Axillary Lymph Node Dissection (ALND)
    • Includes Nipple-Areola Complex with Large Elliptical Excision of Skin
    • Spares Underlying Pectoralis Muscle (Compared to Radical Mastectomy)
  • Complications:
    • Seroma
    • Surgical Site Infection
    • Skin Flap Necrosis (10-18%)
    • Chronic Pain
    • Lymphedema

Radical (Halsted) Mastectomy

  • Definition: Complete En-Bloc Removal of All Breast Tissue, Overlying Skin & Pectoralis Major/Minor Muscles with an Axillary Lymph Node Dissection (ALND)
  • Rarely Preformed Anymore
    • Higher Morbidity
    • No Survival Benefit