Surgery: Overview 1997

Surgical Treatment for Breast Cancer: Overview

Philippe J. Quilici, MD, FACS

Dept. of Surgery

Providence Saint Joseph Medical Center, Burbank

Throughout time, breast cancer has always been a disease that was managed by surgeons. Recently its management has changed. For decades, the optimal management for patients with breast cancer was a radical mastectomy. In 1997, our knowledge of breast cancer has evolved tremendously. We now have other therapeutic options available for these patients.

One of the first surgical landmarks in breast cancer management was to realize that the survival and recurrence rates of patients who underwent a standard radical mastectomy were the same as for those patients who underwent a modified radical mastectomy. This was the initiation of the trend which led us to introduce more conservative measures.

The next stepping stone for more conservative therapeutic options was the keystone studies by Fisher et al. These studies demonstrated that survival and recurrence outcomes in early breast cancer rates were the same for patients who underwent a modified radical mastectomy as for those who underwent a lumpectomy/axillary dissection and radiotherapy. Simultaneously, an avalanche of studies demonstrated that multidrug chemotherapeutic and hormonal protocols could have a tremendous beneficial impact for these patients.

Currently, the surgeon has become the primary coordinator for the management team of physicians essential for the treatment of these breast cancer patients. This management team should include a surgeon, an oncologist, a radio-oncologist and a psychological support person. This concept of team management has slowly become the Standard of Care in all urban metropolises in the Western world.

In 1997, surgical procedures in the management of patients with breast cancer have been streamlined and are as follows :

• Surgical Excision Biopsy (including ABBI biopsy)
• Modified Radical Mastectomy which includes the resection of the entire breast tissue with the nipple-areola complex with an ipsilateral axillary dissection.
• Simple Mastectomy or total mastectomy which is the resection of the entire breast tissue with the nipple-areola complex. No axillary dissection is performed.
• A Lumpectomy which is equivalent to a surgical excisional biopsy. However, a clear margin status needs to be obtained. It is necessary for the margins of resection to be microscopically free of tumor in order to obtain clear margin status.
• Lumpectomy, Axillary Dissection with Radiotherapy is also referred to as the conservative or the preservation surgical option. It includes a Lumpectomy and an Axillary Dissection to be followed by a course of radiotherapy (Usually 5000 to 6000 rads).
• Lastly, the subcutaneous mastectomy should be mentioned. It is still used by some surgeons, although considered unsafe by others. This procedure removes the entire breast tissue while leaving the nipple-areola complex. This procedure has superior cosmetic results, but it leaves a significant amount of breast tissue under the nipple-areola complex which some oncologic surgeons consider an unacceptable risk.

Major changes are already on the horizon of this surgical field for the new millennium. First, new advanced technology is being introduced, such as the ABBI device, which could one day turn the lumpectomy into a simpler local procedure as it currently has for breast biopsies. Secondly, the issue of axillary dissection is being carefully evaluated.. The introduction of the Sentinel Node Technique (via dye or scintigraphy) is showing promise and may in the near future select patients who are candidates for an axillary dissection. Currently, the performance of the axillary dissection is being questioned. Axillary dissections are performed to detect malignant invasion of the axillary lymph nodes to determine if the patient should undergo more aggressive therapeutic protocols postop. Although many surgeons are no longer performing axillary dissections in elderly patients, with the introduction and identification of more risks factors many authors are now postulating this surgical procedure will eventually be replaced.

It has become quite evident the minimally invasive trend in the surgical management of breast cancer will eventually become the optimal choice of therapeutic treatment for the patient. Hopefully, radical surgical intervention for breast cancer will become obsolete.