Modified radical mastectomy has been the traditional surgical treatment of early breast cancer but in recent years breast conserving surgery has been used with no significant difference in local recurrence and survival rates. This article describes the principle of breast conservation therapy, reviews the outcome of trials of breast conservation therapy and discusses the criteria for selecting patients with early breast cancer for breast conservation therapy. The results of 64 breast conserving surgery performed in Queen Mary Hospital from 1986-1994 are presented. Ten patients (16%) developed local recurrence and seven of them had salvage mastectomy. The five year survival rate was 85%, comparable to Western series.published_or_final_versio

Au, GKH

Chow, LWC

Poon, RTP

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Title Conservative surgery for breast cancerAuthor(s) Poon, RTP; Chow, LWC; Au, GKHCitation Hong Kong Practitioner, 1996, v. 18 n. 2, p. 68-72Issued Date 1996URL http://hdl.handle.net/10722/45367Rights Creative Commons: Attribution 3.0 Hong Kong LicenseUPDATE ARTICLEConservative Surgery For Breast CancerRonnie T.P. Poon*, FRCS(Edin)Medical OfficerLouis W.C. Chow, FRCS(Glas), FHKAM(Surgery)LecturerGordon K.H. Au, FRCR, FHKAM(Radiology)ConsultantDepartment of Surgery and RadiotherapyQueen Mary HospitalAbstractModified radical mastectomy has been thetraditional surgical treatment of early breast cancerbut in recent years breast conserving surgery hasbeen used with no significant difference in localrecurrence and survival rates. This article describesthe principle of breast conservation therapy, reviewsthe outcome of trials of breast conservation therapyand discusses the criteria for selecting patients withearly breast cancer for breast conservation therapy.The results of 64 breast conserving surgery performedin Queen Mary Hospital from 1986-1994 arepresented. Ten patients (16%) developed localrecurrence and seven of them had salvagemastectomy. The five year survival rate was 85%,comparable to Western series.Keywords: Breast cancer, breast conservationsurgeryIntroductionThe incidence of breast cancer in Hong Konghas increased by 30% since 1981.' It is the secondleading cause of death among women in Hong Kong.Surgery remains the only hope of cure for earlyoperable breast cancer. Operable breast cancer canbe defined as a mobile tumour in the breast with orwithout mobile axillary lymph nodes in the absenceof obvious distant metastasis. The main objectiveof surgery is to eradicate local disease and preventloco-regional recurrence. Up to early 1980s, surgicaltreatment of breast cancer almost always involvedtotal removal of the breast, in the form of eitherradical mastectomy or more popularly modifiedradical mastectomy. However, mastectomy resultsin loss of body image and psychological trauma inmany patients. Studies have documented high levelsof anxiety, depression and sexual dysfunction amongthose who have had mastectomy, sometimes severeenough to require psychiatric intervention.2'3 Thishas led to the increasing use of breast conservingsurgery in the last decade.Principle of Conservation Therapy forBreast CancerDifferent techniques and terms have beenused for conservative breast surgery. The terms' lumpectomy', 'tumourectomy', and 'tylectomy'imply removal of the tumour mass with a minimalmargin of normal breast tissue around it. Wide localexcision or segmental mastectomy implies excisionof the tumour with at least 1cm tumour free margin.Because of the propensity for ductal carcinoma tospread towards the nipple along the ducts, Veronesiet al used a more aggressive approach of excision of abreast quadrant (quandrantectomy) which includedexcision of the overlying skin and under ly ingpectoralis major fascia.4 This more extensiveresection theoretically reduces local recurrence but atthe expense of more cosmetic deformity.* Address for correspondence: Dr. Ronnie T.P. Poon, Department of Surgery, Queen Mary Hospital, Hong Kong.68Hong Kong Practitioner 18 (2) February 1996After local excision of the tumour, radiotherapyshould be given to the remaining breast tissue, firstto eradicate any residual microscopic disease at thesite of primary tumour, and second, to treat otherpossible foci of invasive or in-situ cancer elsewherein the remaining breast tissue. This has been shownto reduce the risk of local recurrence afterconservative surgery.5 Two prospective studies withshort follow-up suggest that breast irradiation canbe safely omitted in patients with small (<2cm)completely excised unifocal tumours found onmammogram.6"7 However, until further studies haveclarified the need of irradiation in small completelyexcised tumours, the current recommendation is thatall patients should have post-operative radiotherapyafter conservative surgery for breast cancer.About 50% of patients with symptomaticoperable breast cancer have axillary lymph nodemetastasis at the time of presentation but clinicalassessment of ax i l l a ry node invo lvement isnotoriously unreliable with an overall error rate ofapproximately 30%.8 The management of the axillain early breast cancer is controversial.8 Axillarydissection gives excellent local tumour control butaxillary irradiation has been shown to be as effective,with long term recurrence rate of less than 2%.''However, axillary irradiation can result in anuncommon but serious complication of radiation-induced brachial plexus neuropathy. Anotherdrawback of axillary irradiation is that it does notgive information on prognosis nor identify the groupof patients with positive lymph nodes who willbenefi t most from systemic ad juvan t therapy.Axillary lymph node sampling instead of dissectionreduces complication rate but is often inaccurate.10'"We consider wide local excision, p lus axi l larydissection and post-operative breast irradiation as thebest form of breast conservation therapy.Outcome of Breast Conservation Surgeryvs MastectomyHayward and his colleagues reported the firstrandomized trial to compare radical mastectomy andwide local excision plus both breast and nodalirradiation in 1977.l2 In their trial conservativesurgery resulted in increased local recurrence anddecreased survival compared to radical treatment,but the dose and technique of radiotherapy used totreat the breast and axilla after local excision arenow known to be inadequate. Five more recent largerandomized prospective trials have shown nosignificant difference in local recurrence and survivalin comparison between breast conservation surgerywith mastectomy.4"5'13"15 Table 1 shows the results ofthese randomized trials.Table 1 : Randomized Trials of Conservative Breast Therapy for Breast CancerTrial Treatment arms No. of patients Follow up (yr) Local relapse (%) Survival (%)Hayward et al1977Veronesi et al1990Fisher et al1989Sarrazin et al1989Litcher et al1992Blichert et al1988RM + RTLE + RTRMQUARTMRMLE + ADLE + AD + RTMRMLE + AD + RTMRMI.E + AD + RTMRMLE + AD + RT1301223493525906306299188116121306321101381052830OjL3' 816610610174268586971717176807985897680RM = radical mastectomy, MRM = modified radical mastectomy, RT = radiotherapy, LE = local excision,AD = axillary dissection, QUART = quadrantectomy, axillary dissection, and breast irradiation.69(Continued on page 71)Hong Kong Practitioner 18 (2) February 1996Local Recurrence after BreastConservation SurgeryThe ove ra l l recur rence rate af ter breastconservation surgery is 3-6% although some seriesreported higher figures (Table 1). Local recurrencemay be treated with salvage mastectomy and furtherconservative surgery is sometimes possible in smalllocalized recurrence. However, ipsilateral breasttumour recurrence is a marker of risk of developingdistant metastasis though it is not the cause of themetastasis.16The identification of factors associated withbreast recurrence after conservation surgery isimportant to help selecting appropriate patients forconservative surgery. The most important factorsthat predict increased risk of breast recurrence are:7* Positive surgical margin* Extensive DCIS (ductal carcinoma in-situ)* Multiple tumours» High nuclear grade of tumourThe size of tumour, tumour histological type andnodal status are not consistently associated withincreased risk of local recurrence.18Cosmetic Result after Breast ConservationSurgeryAn important goal of conservative breast surgeryis a good cosmetic outcome after surgery andradiotherapy. The cosmetic result is affected by theex ten t and t e c h n i q u e of l o c a l su rge ry andradiotherapy. Factors related to the operation thatadversely affect cosmesis include large resection(especially in a small breast), large radial incision,same incision for breast resection and axi l larydissection and re-excision of tumour bed, whilefactors related to radiotherapy include number ofradiation fields and radiation boost dose.19 The bestcosmetic result is obtained with a circumferentialincision for the lumpectomy and a separate axillaryincision for the axillary lymph node dissection, asshown in Figure 1.Figure 1 : Cosmetic Result after Wide LocalExcision and Axillary DissectionPatient Selection for Breast ConservationSurgeryThe important criteria for patient selection forbreast conservation surgery are the feasibility ofremoving the primary tumour without causing seriouscosmetic deformity or unacceptable risk of tumourrecurrence. The size of the primary tumour is animportant factor and tumours larger than 4cm areconsidered not suitable for breast conservation but thesize of the tumour must be related to the size of thebreast in the judgment. Central tumours are relativecontraindication as such tumours are often diffuse anddifficult to resect without major cosmetic deformityand many women wil l prefer mastectomy if thenipple has to be excised. Extensive DCIS andmul t i foca l disease on mammogram are h igh lypredic t ive of local recurrence and conservativesurgery is contraindicated. Hence it is important toobtain mammography before consideration of surgicalop t ions . Breast conserva t ion surgery is alsoinappropriate in male patients and pregnant patients.Patient's preference is important as some patientsmay prefer mastectomy to avoid the need of post-operative breast irradiation whi le some may feelmore secure after mastectomy. Figure 2 summariesthe surgical management protocol for patientspresenting with operable breast cancer in our centre.Conservative Surgery for Breast CancerFigure 2: Management of Early Breast CancerEarly breast cancer4,Confirm diagnosis:- FNA / biopsy- Mammogram4Counsel patient- Tumour < 4cm- Not extensive DCIS ormultifocal disease- Not central tumour- Patient requestBreast ConservationSurgeryTumour > 4cmExtensive DCIS ormultifocal diseaseCentral tumourPregnant patientMaleRecurrence afterconservative surgeryPatient requestModified RadicalMastectomy ±ReconstructionDCIS = Ductal Carcinoma In-SituLocal ExperienceFrom 1986-1994 64 female patients underwentwide local excision and axillary dissection followedby breast irradiation in Queen Mary Hospital. Themedian age at diagnosis was 51 (range 24-81) yearsand 50% of patients were post-menopausal. Themedian tumour size was 2.5cm and 20% had axillarylymph node involvement. Ten (16%) patientsdeveloped recurrence in the ipsilateral breast andseven underwent salvage mastectomy. Five (8%)eventually died. The 5-year survival was 85%. Theresult was comparable to Western series.ConclusionBreast conservation therapy is an establishedtreatment option for early breast cancer. It producessimilar survival rate when compared with radical ormodified radical mastectomy, but it has the advantageof improved cosmesis and hopefully a reduction inpsychological trauma. The majority of early operablebreast cancer patients are suitable candidates and withthe earlier detection of breast cancer by screening,more patients may benefit from conservative surgery.There is a group of patients who should havemastectomy instead of conservative surgery, andreconstruction may be offered as an alternative toimprove cosmesis. •References1. Cheung PSY. Breast cancer in Hong Kong- the need for early detection JHKMed Assoc 1992; 44: 298-252.2. McGuire WL, Clark GM. Prognostic factors and treatment decisions in axillarynode-negative breast cancer patients. N Eng F Med 1992; 326: 1756-1761.3. Morris T, Greer HS, White P. Psychological and social adjustment tomastectomy: a two year follow-up study. Cancer 1977; 40:2381-23874. Veronesi U, Banfi A, Salvador! B et al. Breast conservation is the treatmentof choice in small breast cancer; long term results of a randomized trial. EurJ Cancer 1990; 26:668-670.5. Fisher B, Redmond C, Poisson R el al. Eight year results of a randomizedtrial comparing a conservative treatment to mastectomy in early breast cancer.N Eng J Med 1989; 320; 822-828.6. The Uppsala-Orebro Breast Cancer Study Group. Sector resection with orwithout post-operative radiotherapy for stage breast cancer: a randomizedtrial . J Nat Cancer Inst 1990; 82: 277-282.7. Clark RM, McCulloch PB, Levine MN etal. A randomized clinical t r i a l toassess the effectiveness of breast irradiation following lumpectomy and axi l la rydissection for node negative breast cancer. J Nat Cancer Inst 1992, 84: 683-689.8- Sacks NPM, Barr LC, Allan SM at al. The role of axi l lary dissection inoperable breast cancer. Breast 1992; 1:41-49.9. Mazeron JJ, Otmezguine Y, Huart J et al. Conservative treatment of breastcancer: results of management of axillary lymph node in 3353 patients. Lancet1985; 1(8442): 1387.10. Locker AP, Ellis 10, Morgan DAL, et al. Factors influencing local recurrenceafter excision and radiotherapy for primary breast cancer. Br J Surg 1989; 76;890-894.11. Davier GC, Millis RR, Hayward JL. Assessment of axillary node status.Ann Surg 1980; 192; 148-151.12. Hayward JL. The Guy's trial of treatment of early breast cancer. World JSurg 1977; 1: 314-316.13. Sarrazin D, LeMG, ArriagadaR et a/. Ten-year results of a randomized trialcomparing a conservative treatment to mastectomy in early breast cancer.Radiother Oncol 1989; 14: 177-184.14. Litchter AS, Lippman ME, Danforth DN el al. Mastectomy vs breast-conserving therapy in the treatment of stage 1 and 2 cancer of the breast: arandomized trial at the National Cancer Institute. J Clin Oncol 1992; JO; 976-983.15. Blichert-Toft M, Brincker M, Anderson JA et al. A Danish randomized trialcomparing breast-preserving therapy with mastectomy in mammary carcinoma.Acta Oncol 1988; 27: 621-677.16. Fisher B, Anderson S, Fisher ER et al. Significance of ipsilateral breasttumour recurrence after lumpectomy. Lancet 1991; 338:327-331.17. S totter A, Atkinson EN, Fairstone BA et al. Survival following locoregionalrecurrence after breast conservation therapy for cancer. Ann Surg 1990; 212(2):166-172.18. Kurtz JM. Factor influencing the risk of local recurrence in the breast. Eur JCancer 1992; 28: 660-666.19. HafftyBG, Goldberg NB, Fisher D et al. Conservative surgery and radiationtherapy in breast carcinoma: local recurrence and prognostic implications. IntJ Radiat Oncol Biol Phy 1989; 17: 727-732.72

Conservative surgery for breast cancer

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