Evolution Of Surgical Management Of Breast Cancer
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
The ancient documentation of historical aspects of breast cancer and the development of thoughts regarding its biology, pathophysiology and the concepts to rational treatment indicates that this disease has always been the relatively common and virulent entity that we know today. As the Renaissance philosophy of enlightenment and learning spread throughout Europe in the 15th and 16th centuries, many of the principles that eventually led to the modern era of breast cancer treatment were developed or rediscovered. One of the first surgical attempts to allow healing by direct union of the incised skin edges following mastectomy was recorded by Van der Mullen in 1698. Benjamin Bell (1749-1806), surgeon to the Edinburgh Royal Infirmary, not only advocated a radical operation for all breast tumors but also emphasized the importance of early diagnosis. These principles of treatment of breast carcinoma remained the standard in Scotland for the next century. Women with breast cancer who undergo mastectomy increasingly opt for contralateral prophylactic mastectomy (CPM), with the rate more than doubling over the last decade both in invasive breast cancer and ductal carcinoma-in-situ.(1) The efficacy of CPM reducing contralateral breast cancer has garnered health care professional support of CPM as a viable option. Debate continues regarding whether CPM provides any survival advantage.
The purpose of this document is to give the healthcare professionals various surgical treatments available to manage breast cancer. Various modern treatment modalities are also discussed. The surgeon has become an integral part of a multidisciplinary team who manages patients with breast carcinoma. This team includes the diagnostic radiologist, radiation oncologist, medical oncologist, and pathologist. Our resolute purpose must always be to promote the best interest of each individual patient, and not those of surgery, radiotherapy or chemotherapy.
The Modern Era
Two major advances that paved the way for an effective operation for breast carcinoma were the discovery and development of general anesthesia and the dissemination of the germ theory of disease and principles of antisepsis. The evolution of a standardized, effective, and widely accepted operation for the treatment of breast carcinoma culminated with the efforts of William Stewart Halsted (1852-1922). The major contribution that Halsted made in this area was his advocacy of the routine removal of the pectoralis major muscle (in addition to entire breast) and meticulous clearing of the axillary tissue. It ultimately became known as the radical mastectomy. The most effective modality for detecting breast carcinoma in its earliest forms, when treatment promises to be most successful, had its beginnings as early as 1913. The increasing use of mammography in the United States during the 1980s resulted in substantial changes in the techniques used by surgeons to diagnose breast carcinoma. Standard open surgical biopsies could no longer be performed on the progressively smaller and non-palpable lesions detected by mammography. Needle localization biopsy with specimen radiography evolved as the most common method to accurately localize and sample non-palpable mammographically detected breast lesions.
The basic flaw in the theory of local disease origin was quickly manifested by the fact that surgery alone did not consistently yield high rates of cure, regardless of how extensive the procedure or early the diagnosis. Although survival at 3 years appeared to show an improvement over that with earlier procedures, longer follow-up revealed steadily diminishing rates. The efforts of many surgeons to extend the scope of the radical mastectomy indicated their recognition of its inadequacy as the sole treatment for breast carcinoma.(2) The evident shortcomings of surgical treatment of breast carcinoma led some to consider using less extensive procedures in conjunction with other modalities to spare patients unnecessary tissue loss. Radiation therapy was one of the first adjunctive modalities applied to breast carcinoma for this purpose. The one common thread found in virtually all recent studies on the surgical treatment of breast carcinoma are that the type and extent of local and regional treatment do not substantially affect survival. Patients with breast cancer have some potential for systemic dissemination from the earliest phases of disease development. The greatest promise for an effective cure must therefore lie in systemic treatment.
For patients with early-stage breast cancer, tailored locoregional treatments are also on the horizon. To achieve local-regional control, it is becoming increasingly clear that one size do not fit all. Historically, the choice for local-regional management was breast conservation treatment versus mastectomy (with or without post-mastectomy radiation treatment), but substantial refinements in each of these categories are already making their way into clinical practice. For patient undergoing breast conservation treatment, multiple studies have evaluated traditional patient, tumor, and treatment risk factors associated with local or local-regional recurrence. The factors most consistently associated with a lower risk of local recurrence include; older patient age (compared to younger age); pathologically confirmed negative margins from the primary tumor excision (compared to positive or unknown margins); adding a radiation boost to the primary tumor site (compared to no boost); adding systemic chemotherapy or hormonal therapy (compared to not); positive hormone receptor status (compared to negative status); and wider surgical excision (compared to smaller excision). These risk factors have been most consistently reported from study to study, although other risk factors have been described.(3) Of these factors, the surgical margin (also called surgical margins) of resection is one of the factors that can be controlled and tailored by the treating physician. For the patient undergoing surgical excision (also undergoing lumpectomy), a delicate balance exists between removing sufficient tissue to obtain clear margins, while maximizing the cosmetic outcome by limiting the amount of surrounding normal tissue excised. The importance of re-excision to obtain clear margins has long been recognized, and improved methods of tumor localization and pathological evaluation, including inking surgical specimens, have led to tailored surgical margin re-excision for selected patients.
Cytotoxic chemotherapy became popular in the late 1950s and has since become a mainstay of adjuvant systemic therapy following surgical treatment, and as such has demonstrated better survival than surgery alone. Advances in molecular biology have led to the discovery of oncogenes, which offer the opportunity of perhaps manipulating the process of malignancy to prevent it altogether. Adoptive immunotherpy is another form of systemic treatment involving the application of the lymphokine-interleukin-2 to active "killer" lymphocytes with antitumor activity. The surgeon's role has evolved to diagnosing and ensuring the removal of all clinically evident disease so as to maximize the efficacy of radiation and systemic therapy. The soundest prediction of future progress must come from a realistic view of the past.
Detection of Clinically Occult Locoregional Recurrence
Locoregional recurrence of breast cancer after mastectomy may be predictive of distant metastasis and patient mortality. Because early detection of recurrence improves the chance of local disease control and expands opportunities for curative therapy, many investigators have reported diagnostic tools, such as physical examination, mammography, and ultrasonography, to diagnose early locoregional recurrence.(4) Although physical examination is very important for the detection of local recurrence because local recurrence frequently involves the chest wall or skin, it is not sufficient for the evaluation of all regional lymph nodes and recurrent lesions located deep within soft tissue or beneath a postoperative scar. Mammography is not useful in detecting the early locoregional recurrence because of the poor visibility of the lesions located at the mastectomy site, as well as it is difficult and uncomfortable for mastectomy patients.(5) Several studies have reported that ultrasound can be helpful in detecting occult malignancy in asymptomatic, treated women.(6) This study investigated the efficacy of locoregional ultrasonography for the detection of recurrence in asymptomatic patients who underwent mastectomy and the impact on prognosis.(7) The conclusion was locoregional ultrasonography after mastectomy for breast cancer was helpful for the early detection of recurrence and may lead to a better prognosis for patients. Regular clinic visits are likely to increase distress and reduce the quality of life. To overcome these problems, regular ultrasonography surveillance should have advantage of survival. Although ultrasonography surveillance for locoregional recurrence may lead to earlier detection of recurrences, this has several disadvantages, including the possibility of a false-positive or false-negative results and excessive physician time. In many studies, the false-positive rate of ultrasonography screening of locoregional recurrence in asymptomatic patients who had surgical therapy for breast cancer was 1.3 to 1.7%.(6)(8)
General Principles of Mastectomy
The significant contributions of investigators for breast cancer management in the 20th century established the outcome results for conservative surgical techniques to be equivalent to those of radical approaches with regard to disease-free and overall survival. Thus the procedure to be completed and the anatomic site to receive irradiation for stages 0, I, and II disease depend on the location of the primary neoplasm in the breast, the presence or absence of axillary metastases, phenotype of the index cancer, and the growth characteristics of the index tumor (e.g., extension to musculature of chest wall, skin, and axilla). Lesions in the lateral aspect of the breast drain principally through axillary lymphatic channels. Index tumor presentations in this location can be eradicated from the chest wall by using the modified radical mastectomy with sentinel lymph node biopsy (SLNB). This surgical procedure as a total mastectomy with preservation of the pectoralis minor/major muscles and includes dissection of level I and II axillary lymph nodes. These laterally placed neoplasms with histologically positive axillary lymph node metastases may be associated with internal mammary or supracervical lymph node metastases in as many as 25% to 30% of patients. Radiation therapy and chemotherapy are used for "grave" presentations of the tumors: skin fixation, nodularity, greater than 20% of nodes dissected histologically involved, more than three histologically involved nodes, and chest wall tumor fixation.(9)
Centrally located lesions that are fixed to the pectoralis major fascia or high-lying (superiorly located) lesions that are fixed to this fascia may be treated with radical mastectomy or with a combination of radical mastectomy and peripheral lymphatic and chest wall irradiation when palpable axillary lymph node metastases smaller than 2 cm are evident. These centrally placed lesions commonly metastasize through lymphatics that parallel the course of the neurovascular bundle medial to the pectoralis minor muscle. This medial neurovascular bundle that contains the lateral pectoral nerve and innervates the pectoralis major muscle is preserved in the modified radical mastectomy to ensure function of the pectoralis major muscle after mastectomy. In the radical mastectomy procedure, this neurovascular bundle, associated lymphatics, and areolar tissue are resected en bloc with the specimen to accomplish adequate surgical extirpation of regional disease.
For medially located neoplasms, the principal lymphatic drainage is through routes that course to lymph nodes near the ipsilateral internal mammary vessels. These medial lesions may be associated with metastasis to the internal mammary lymphatics in 10% to 30% of patients. The presence of pathologically positive axillary metastasis with an associated medial lesion escalates this incidence of internal mammary metastasis to greater than 50%. In the absence of clinically positive axillary metastases, medially located cancers may be adequately treated with segmental (partial) mastectomy or with modified radical mastectomy and peripheral lymphatic irradiation.
Whether the surgeon chooses the conservation or radical approach depends on tumor size and characteristics, general medical status, patient choice, and desire for reconstruction. Regardless of the operative procedure selected, clearance of pathologically "free" margins about the neoplasm in three dimensions is paramount to enhancement of local and regional disease-free survival. Surgeons should plan the operative procedure with the subjective of achieving, at minimum, 1-2 cm skin margins with subcutaneous and parenchymal margins of 2 to 3 cm in all directions from the index tumor, which can be accomplished with a radical, modified radical, or extended simple mastectomy. Patients with distant metastases, including supraclavicular lymph node metastases, are best treated with systemic chemotherapy with or without local and regional irradiation.(10)
Design of Incisions for Mastectomy in the Treatment of Breast Cancer
Central and subareolar primary lesions: The classic Stewart elliptical skin incision is used for mastectomy. The Stewart incision is commonly preferred by plastic surgeons anticipating delayed reconstruction with myocutaneous flaps, especially when a contralateral simple mastectomy is planned for treatment of high-risk disease or as a prophylactic procedure. Furthermore, this technique is often the choice of oncologic surgeons when radiation to the chest wall is planned before reconstruction.
Upper or lower inner quadrants lesions: Minimal skin margins of 1 to 2 cm from the primary neoplasm are incorporated in a modified Orr incision that is slightly oblique from the transverse line with cephalad extension toward the axilla. Similar to the Orr and Stewart incisions, although somewhat more oblique, these incisions lend themselves to cosmetically satisfactory breast reconstruction results using myocutaneous or subpectoral augmentation breast implants.
Upper inner quadrants lesions: These are difficult to manage because of their anatomic location. Surgeons should recognize the inherent problems encountered with elevation of skin flaps that allow adequate surgical margins and provide cosmesis for wound closure and potential reconstruction. Surgeons should be able to develop a 1 to 2 cm margin for lesions that are in this quadrant, providing the lesion is not cephalad (infraclavicular). These lesions may be accessed through the modified Stewart incision. Surgeons should plan the cephalic portion of the incision for the superior flap such that adequate access to the pectoralis major and to the axillary contents is ensured.
Lower outer quadrants lesions: These should have an incision design similar to those of the upper inner quadrant, with margins of 1 to 2 cm around the primary lesion and with maximum extension of the cephalad margin to provide access to flaps for dissection of the pectoralis major and the axillary contents.
High-lying (infraclavicular) lesions: With large lesions (T2, T3, T4) that are high-lying infraclavicular, or fixed to the pectoralis major, incisions designed to provide a minimal 1 to 2 cm margin will necessitate skin grafting of the defect or coverage with myocutaneous flaps. The original Halsted and Meyer incisions, with subsequent modifications by Greenough, Rodman, and Gray are mostly used for treatment of primary lesions of T2, T3, and T4 size.
Limited skin excision can be defined as excision of the nipple/areola complex, the skin around the biopsy site, and the skin within 1 to 2 cm of the tumor margin. This technique usually sacrifices 5% to 10% of the breast skin, which is either approximated primarily or closed with an autogenous myocutaneous flap that is used to replace the breast volume. Dog-ears do not occur with this technique, because the limited skin removal does not initiate skin contracture with closure. Wide skin excision is routinely used with every radical and modified mastectomy. A mastectomy with wide skin excision is often inclusive of an excision in excess of 30% to 50% of the breast skin. This is removed as an ellipse, usually measured 10 cm (width) by 20 cm (length), and is closed primarily. The elliptical excision facilitates removing the dog-ears that are technically created by the wide skin removal and subsequent tension of excessive tissue at the terminal points of skin closure.
Standards of practice have sequentially evolved as follows:
The skin-sparing mastectomy has been used primarily for patients with American Joint Committee on Cancer (AJCC) TNM stages 0, I, and early II disease requiring mastectomy when eligible for immediate autogenous breast reconstruction.(11) It is a general consensus the indications for skin-sparing techniques are:
Factors Influencing Immediate/Delayed Post-Mastectomy Reconstruction
The rapid advances in understanding of the fundamental biology of breast cancer in the 20th and early 21st centuries, together with advances in surgical techniques following the advent and application of the vascularized myocutaneous flaps (TRAM and latissimus), have provided viable options for reconstruction after mastectomy. Breast reconstruction is performed to correct anatomic abnormalities, and for this reason, it is a functional procedure. Routine consideration of breast reconstruction at the time of mastectomy can now be scientifically defended for patients with stages 0, I, and IIa. This subset of patients describes more than 70% of the patients who are undergoing mastectomy at present. As the safety of breast reconstruction has been demonstrated in careful studies, there is no more reason to deny breast cancer patients reconstruction than there is to deny any other cancer patients reconstruction. There is no data to suggest that immediate reconstruction interferes with surgical treatment by either spreading the cancer, hiding a local recurrence, or adversely affecting the survival.(12) It is now recognized that essentially all local recurrences are harbingers of systemic disease and that recurrences can exist only within breast tissue. The only remaining breast tissue following a mastectomy is either in the breast skin or in breast tissue that was not removed with the mastectomy. After a reconstruction, what would have been a chest wall recurrence becomes a skin recurrence, only because the skin is physically separated from the chest wall by the reconstruction. Recurrences are never seen within the substance of an autogenous flap, because the fat and muscle of the flap are inhospitable to the transplantation of the breast cancer.(12)
Although the potential harmful effects on local recurrence or survival have not materialized, there should be concern about the effect of breast reconstruction on adjuvant therapy. It is important biologically to begin chemotherapy within 28 to 40 days of extirpative therapy, so the reconstruction must be primarily healed during the first month. Chemotherapy can be started while there is still a surface wound that has not yet epithelialized, but it cannot be started in the face of necrotic tissue, seromas, or infection. When it is known in advance that the patient will undergo chemotherapy, the choices of reconstructions should include only flaps that are well vascularized and known to heal primarily as the first choice. Implants can be used, but if the implants have problems with seroma or infections, it may be necessary to remove the implant to correct the healing problem and allow the chemotherapy to progress. When radiation is planned, tissue expander and implant reconstruction should not be used, because unsatisfactory firmness is inevitable when implants are radiated. Only autogenous flaps offer satisfactory solutions in these patients, and it is preferable to complete the reconstruction at the time of mastectomy. Radiation is usually performed because the margin of tumor-resection at the chest wall is suspected or because the tumor is large and aggressive. In either case, the reason for tumor recurrence or poor patient survival is the stage of the disease, not the reconstruction. Whether immediate reconstruction should be performed at all in stages IIb and III is more of a social decision than a medical decision. The survival in these patients will not be as good as that in most patients, but it will not be affected by an autogenous reconstruction.
Contralateral Prophylactic Mastectomy (CPM)
Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in contralateral prophylactic mastectomy (CPM) as a method of preventing breast cancer, particularly in those with familial susceptibility. The primary objective of this study was to determine whether CPM reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast.(13) The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. Twenty-three studies, including more than 4,000 patients, met inclusion criteria.(13) No randomized or non-randomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of bilateral prophylactic mastectomy (BPM). No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed CPM. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%.(14)
While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or BRCA 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery.(15) Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for CPM. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.
Trends in Contralateral Prophylactic Mastectomy (CPM)
Studies report rates of contralateral cancer presentation to be between 0.5 to 0.75% per year; these rates have remained constant over 15 to 20 years.(16) In unselected populations such as those enrolled onto the National Surgical Adjuvant Breast and Bowel Project B-06 trial, the rate of contralateral cancer was 8.5, 8.8, and 9.4% in total mastectomy, lumpectomy alone, and lumpectomy plus irradiation arms, respectively, at 20-year follow up.(17) Adjuvant therapies such as chemotherapy and hormone therapy have been shown to decrease the risk of developing cancer in the contralateral breast. The reported frequency of CPM for unilateral breast cancer has been increasing over the past 10 years and has been documented in several recent reports.(18) These trends are observed despite any evidence suggesting an increase in the incidence of contralateral cancers, evidence suggesting the lack of survival benefit associated with CPM, and evidence suggesting that some adjuvant therapies decrease the incidence of subsequent primary breast cancers. The reasons for these increased trends are likely multifactorial and complex. Although an increase in the proportion of surgically treated women undergoing CPM is universally observed across a broad range of patient, biological, and provider factors, the increase is more noticeably associated with patient-related factors rather than tumor or biological characteristics.(19) Several studies have reported an increased rate of CPM in patients with unilateral breast cancer. This study(20) reports on CPM trends from the American College of Surgeon's National Cancer Data Base (NCDB), a prospectively collected database containing over three million breast cancer patients, diagnosed over a 10-year period. Patient demographics, hospital factors, and tumor characteristics were examined to determine which factors are most likely associated with the use of CPM. The study reports on cases over a 10-year period and to our knowledge represent the largest cohort of patients to date in a study examining the use of CPM among surgically treated breast cancer patients. In the study, it is shown that the proportion of surgically treated patients undergoing CPM increased statistically significantly between 1998 and 2007, from 0.4 to 4.7%.(20)
Why patients choose CPM likely involves a multitude of factors: surveillance of the breasts, plastic reconstructive concerns, suspicious family history, patient anxiety about tumor recurrence, failed attempts at breast conservation, and the use of preoperative magnetic resonance imaging (MRI) are commonly cited reasons why patients choose prophylactic mastectomy. Anxiety about local recurrence despite 10-year local recurrence rates from 3.5 to 6.5% for node-negative patients and 4 to 10% for node-positive patients and persistent tumor-positive margins at lumpectomy may spur patients to pursue more aggressive surgery and choose CPM.(21) Indeed, re-excision rates for lumpectomy can range from 16 to 49%.(22) Genetics no doubt plays a role in the decision for CPM. Studies have demonstrated that women who develop breast cancer when they are aged <40 are at a substantially significantly increased risk for a second primary breast cancer, suggesting an underlying genetic predisposition for their index tumor.(23) In the Myriad database, the prevalence of a BRCA 1or BRCA 2 mutation more than doubles if the patient's age is <50 years compared to a patient whose age is >50, regardless of Ashkenazi Jewish descent. Young age at presentation may be an appropriate indication for CPM, given the prevalence of BRCA mutations in young breast cancer patients. Cancer registries do not contain family history of BRCA status, so it is impossible to determine what proportion of the young patients are at high hereditary risk. Last, patients who test negative for a BRCA 1 or BRCA 2 mutation with suspicious family histories may still opt for a CPM because BRCA testing may miss up to 10% of mutations, and there is always a worry about undiscovered gene mutations that may contribute to increased risk of future new primary breast cancers.(24) Further studies are needed to determine why patients seem to choose CPM and whether a survival benefit can be associated with this choice of surgical management.
Oncoplastic Breast-Conservation Surgery
Oncoplastic resection is a therapeutic procedure not a breast biopsy. It is performed on patients with a proven diagnosis of breast cancer. This approach was strongly supported by the 2005 and 2009 Consensus Conferences on Image-Detected Breast Cancer.(25) This usually provides ample tissue for diagnosis and should be possible in more than 95% of currently diagnosed cases. When excising breast cancer, the surgeon faces two opposing goals: clear margins versus an acceptable cosmetic result. Oncoplastic breast conservation surgery combines oncologic principles and plastic surgical techniques, but it is much more than a combination of two disciplines; it is a philosophy that requires vision, passion, knowledge of anatomy, and appreciation and understanding of esthetics, symmetry, and breast function. The goals of oncoplastic breast conservation surgery include: complete removal of the lesion; clear margins, the larger the better; good to excellent cosmetic result; operating one time to perform the definitive procedure. There are several important steps to a proper oncoplastic operation:(26)
All of the preoperative tests must be evaluated and integrated along with information about the pathologic subtype, size, and extent of the lesion. There are numerous oncoplastic incisions. They include but are not limited to:
Nipple-Areolar Complex-Sparing Mastectomy
Preservation of the nipple-areolar complex (NAC) while performing a mastectomy is not a new concept for the treatment of breast disease. Historically, the subcutaneous mastectomy was performed in the setting of prophylaxis for high-risk patients or to reduce breast pain, but often left much breast tissue within the skin flaps and at the base of the NAC. Because of this, the subcutaneous mastectomy was not necessarily favored for prophylaxis or breast cancer treatment. The NAC-sparing mastectomy differs from the subcutaneous mastectomy for prophylaxis or tumor eradication by trying to greatly reduce the risk of developing a breast cancer or a recurrence. Therefore, the goal of NAC-sparing mastectomy is to remove most of the breast parenchyma (including tumor, obviously) as well as ductal tissue from the nipple base or within the nipple. There are oncologic concerns regarding NAC-sparing mastectomy if performed for prophylaxis in high-risk women or for breast cancer treatment. Those against this procedure argue that patients could have a higher risk of breast cancer occurrence or recurrence. There is the potential for leaving an occult NAC tumor or too much residual breast or ductal tissue behind to preserve the skin flap and NAC because of thicker flap, the better the blood supply to the skin and nipple, resulting in less flap necrosis and better cosmetic outcome. Indeed, there are studies indicating that less breast tissue removed leads to higher rates of breast cancer occurrence and higher rates of leaving residual tumor behind.(27) Therefore, when NAC-spring mastectomy is performed, clinicians must critically assess their ability to perform an adequate mastectomy and removal of ductal elements while minimizing the complications of skin and NAC necrosis.
There are no long-term studies of recurrence rates for NAC-sparing mastectomy. However, short term follow-up and other studies indicate preserving the NAC with mastectomy is associated with better cosmetic outcome and improved quality of life.(28) There is thus renewed interest in performing NAC-sparing mastectomy for high-risk patients and for carefully selected breast cancer patients. Patients with large NAC or pendulous/ptotic breasts are often poor candidates because of the inability to achieve symmetry of the NAC or may require a breast lift, which can cause NAC necrosis as a result of location of skin incision. Concomitantly, to reduce breast cancer occurrence or recurrence, patients should be selected who are at low risk. Therefore, patients with early-stage breast cancer whose nipple or skin involvement, such as patients with Paget disease or locally advanced breast cancers, including inflammatory cancers are good candidates less likely to have nipple involvement.(29) Studies demonstrate good outcomes when clinicians adhere to strict patient selection and margin assessment.
Incision Options and NAC technique: NAC-sparing mastectomies are often performed through different incisions, keeping in mind the need to have adequate visualization and access to key areas of the dissection, such as axilla for sentinel lymph node biopsy, as well as the intercostals spaces near the sternum for intramuscular sentinel node biopsy or anastomosis for transverse rectus abdominis myocutaneous reconstruction. The major advantage of an inframammary incision with retention of all of the breast skin and NAC is the ability to hide the incision, which results in a better cosmetic result relative to other incision locations. Another advantage is easy access to chest for those undergoing transverse rectus abdominis myocutaneous flap reconstruction. However, visualization during skin flap dissection can be difficult and risks much of the flap to necrosis as a result of the limited blood supply. Another incision option includes a radial or horizontal type in the upper outer quadrant with preservation of the NAC. The major advantages are access to the axilla for sentinel lymph node biopsy and potentially better blood supply to the flap; however, these incision locations may cause the nipples to retract outward, which may lead to poor symmetry. Finally, other options for incisions include the biopsy scar, which would minimize other scars but may hinder dissection, depending on location, or areolar incisions, which should be placed at least 1 cm away from the areola to prevent compromising the blood supply to the areola. To minimize residual ductal elements at the NAC and reduce the risk of leaving occult tumor at the NAC, the dissection and removal of tissue should be at minimum carried to the base of the NAC by using the inverted sock technique. Margins should be assessed intraoperatively and postoperatively at the 3, 6, 9, and 12 o'clock positions and directly under the NAC (at the base of the nipple). Data suggest the evaluation of the base of the NAC confers an 80% sensitivity of cancer detection in the NAC, with a 96% negative predictive value.(30) To further minimize recurrence risk, assessment of the distance of tumor to the NAC should also be performed because data indicate distance of tumor to the NAC may be associated with occult tumor involvement of the NAC.(31)
Early in the 20th century, the surgeon was alone in taking responsibility for breast cancer treatment, when the only treatment was the radical mastectomy. Today, there is support from several disciplines, and the surgical oncologist should be the leader of this coordinated effort. Helping the patient choose among these sophisticated treatment options requires the efforts and mutual cooperation of both the surgical oncologist and the reconstructive surgeon. Contemporary oncology practice guided by phase II/ III clinical trials have directed our understanding of breast cancer treatment to allow new combinations of chemotherapy, reconstruction, and radiation that were not realized a generation earlier. Contralateral prophylactic mastectomy (CPM) does not offer a definitive survival benefit. For most patients, survival is dictated by their primary cancer, not the presentation of a second new primary in the contralateral breast. There is a growing body of reports in the literature demonstrating that an increase in CPM is strongly associated with age and other patient-related factors. Further studies are needed to explain rising CPM rates and how patients make surgical treatment decisions. Currently, National Comprehensive Cancer Network guidelines discourage CPM in women other than those at high risk because of its small benefit-to-risk ratio. Outcomes studies involving CPM are needed to demonstrate to patients and clinicians alike whether CPM influences disease-free and overall survival after diagnosis of non-invasive and invasive breast cancers. Oncoplastic surgery combines sound surgical oncologic principles with plastic surgical techniques. Preoperative planning for oncoplastic breast-conservation surgery requires discussion between, at a minimum, the oncoplastic surgeon and the radiologist. Often times, a plastic surgeon, medical oncologist, radiation oncologist, and others may be included. The goal of breast cancer surgeon is to optimize the patient's cosmesis and quality of life while minimizing breast cancer risk. To achieve this goal, NAC-sparing mastectomy should be performed in carefully selected patients. NAC-sparing mastectomy can be performed effectively while maintaining NAC viability. The risk of leaving residual breast tissue or occult tumor with the NAC is probably low if margin assessment is performed at the base or central core of the NAC. Long-term follow-up is forthcoming on these procedures.
Acknowledgement: Special thanks to Dr. Steven M. Schonholz, Medical Director, Breast Cancer Center at Mercy Medical Center, Springfield, MA (USA) for expert opinions and assistance in preparation of the manuscript.