Breast Cancer (Mammary Carcinoma): Surgical Therapy

General

With few exceptions (e.g., high-risk patients with a family history who may have preventive surgery), breast cancer therapy today consists of a combination of different therapies (surgery, radiotherapy (radiation therapy), chemotherapy, antihormone therapy). Preoperative imaging, punch or vacuum biopsy diagnostics in combination with:

  • Histology (fine tissue examination),
  • Grading (assessment of the degree of differentiation of tumor tissue, i.e., the degree of deviation from normal tissue appearance),
  • Molecular biological characteristics,
  • Size of the tumor, and
  • Result of staging (degree of spread of a malignant tumor).

Allow a targeted therapeutic strategy, which is determined in the context of a tumor conference. It is attended by gynecologists, internal oncologists, radiation oncologists and pathologists. Ultimately, the patient decides whether she agrees with the proposed procedure. The focus is still on surgery. Preoperative therapy is called neoadjuvant, and postoperative therapy is called adjuvant. The goal of surgery is at:

  • Familial burden to prevent the disease
  • suspicious and / or pathological findings by removing the tumor or premalignant changes as completely as possible for the patient to create the best possible basis for:
    • Healing
      • In the early stages
      • In the case of premalignant changes
    • Alleviation of late stage symptoms.
    • Prevention of metastasis (occurrence of daughter tumors).
    • Prevention of local recurrence (recurrence of a tumor at a previously treated site).
    • Prolongation of life

Prophylactic surgery

Recommendations for prophylactic mastectomy (removal of mammary glands) or salpingoovarectomy (removal of fallopian tubes and ovary) (in healthy and high-risk patients, ie, those with unilateral breast carcinoma, with and without mutation of the genes BRCA1 or BRCA2):

BRCA mutation status Medical history Prophylactic mastectomy Prophylactic salpingoovarectomy
Positive Healthy Indicated from age 25; or five years before the earliest age of onset of disease in other family members Around age 40-45 (indicated or strongly recommended);or after completion of family planning
Unilateral (“one-sided”) breast carcinoma Possible in young sufferers; depends on gene involved, age of onset, and prognosis Recommended (depending on prognosis)
Negative unilateral breast carcinoma Not indicated; however, may need to be considered depending on prognosis Not indicated; only in individual cases with ovarian cancer in the family
Healthy Not indicated; Not indicated; only in individual cases of ovarian cancer in the family

Operative primary therapy initial therapy)

Surgical primary therapy includes breast-conserving therapy/surgery (BET) or ablatio mammae (mastectomy), which in most cases involve excision of the axillary lymph nodes.According to medical terminology, ablatio mammae (Latin : ablatio = surgical removal (synonym: ablation), mamma = mammary gland) and mastectomy (Greek : mastectomy = excision of the breast) are synonyms. Note: Breast-conserving therapy/surgery (BET) with obligatory subsequent radiotherapy and mastectomy are therapeutically equivalent.

Breast-conserving surgery (BEO)

The goal of primary surgical therapy and the standard of care is breast-conserving therapy (BET). Here, the tumor is removed, but not the entire breast. Whether this form of therapy is possible always depends on the size of the tumor. Up to a tumor size of 3-4 cm and if there is no evidence of a multicentric or multifocal tumor, BET is possible. The tumor thus removed is examined to verify that the incision margins are tumor-free (the minimum safety distance between the tumor and the incision margin must be at least 1 mm, and 2 mm in the case of DCIS (ductal carcinoma in situ)*. If this is not the case, further surgery must be performed to remove the remnants of the tumor.Clinical studies have shown that, taking into account the above clinical and histological parameters, breast-conserving therapy achieves identical survival rates to mastectomy. For patients with tumor stage pT1-pT2/cNO who receive BET followed by percutaneous tangential radiotherapy and have one or two positive sentinel lymph nodes, there is an option to forgo axillary dissection (lymph node removal from the axilla) * Standard therapy after breast-conserving surgery includes postoperative radiotherapy of the “residual breast”. Further notes

  • Resection distance: in the past, the goal was to leave as large a distance as possible between the tumor front and the edge of the removed tissue; today, it is known that a narrow tumor cell-free location slightly increases the risk of recurrence but ultimately has no consequences for overall survival (OS). The goal is a RO status (= no residual tumor).
  • In a study of nearly 130,000 patients with stage T1-2, N0-1, and T1-2, N2 tumors conducted by the Erasmus Cancer Institute in Rotterdam, in the first study period (1999-2005; n = 60. 381), the probability of cancer-specific survival was 28 percent higher with breast-conserving therapy compared with mastectomy (hazard ratio [HR]: 0.72; 95% confidence interval: 0.69-0.76; p < 0.0001), and overall survival was 26 percent higher (HR: 0.74; 95% confidence interval: 0.71-0.76; p < 0.0001). In the second study period (2006-2015; n = 69,311), breast-conserving therapy also fared better than mastectomy for both survival parameters in stage T1-2, N0-1 tumors (HR: 0.75; 95% confidence interval: 0.70-0.80; p < 0.0001 and HR: 0.67; 95% confidence interval: 0.64-0.71; p < 0.0001, respectively); but not in T1-2, N1 tumors.

Ablatio mammae (mastectomy; synonym: mastectomy)

Ablatio mammae should be performed or discussed with the patient for:

  • Large tumors
  • Unfavorable tumor-to-breast size ratio
  • A multicentric carcinoma
  • Special constellations of a DCIS see below.
  • Non-achievement of a resection in sano during the post-resection.
  • Intramammary recurrence of a
    • DCIS
    • Invasive carcinoma (if organ-preserving surgery is performed again, there is an increased risk of recurrence at 30% after 5 years).
  • Inflammatory breast carcinoma (“inflammatory breast cancer“).
  • Post-irradiation technically not possible (e.g., arm abduction restricted).
  • Refusal of irradiation by the patient.
  • Desire of the patient

Notice: In the context of a mastectomy, plastic reconstruction of the amputated female breast (breast reconstruction) should be discussed with every woman.

Excision of axillary lymph nodes (axillary dissection; axillary lymphonodectomy, ALNE)

Determination of nodal status (describes whether and, if so, how many lymph nodes are already invaded by tumor cells pN) is mandatory in invasive breast carcinoma. The removal of at least ten lymph nodes can increasingly be dispensed with due to new findings and by means of sentinel lymph node biopsy* (SNB, sentinel lymph node biopsy). This is associated with a significant reduction in morbidity and patient discomfort. Indication for axillary dissection

Patients,

  • In whom no sentinel lymph node was detected.
  • With a macrometastasis in a positive sentinel lymph node
  • With positive lymph node status prior to neoadjuvant chemotherapy.

Further notes

  • * Biopsy (tissue sampling) of the sentinel lymph node (sentinel lymph node; sentinel node biopsy, SNB) has been standard since 2004/2005. This is the first lymph node in the lymphatic drainage of a breast carcinoma that is marked and removed using radionucleotides and/or dyes. If this is not affected by tumor cells, it can be assumed that the lymph nodes downstream of this lymph node are also not affected, so they do not need to be removed. There may also be several sentinel lymph nodes, which are then all removed. The method can be used for small tumors up to two centimeters in size. In numerous studies, SNB showed high staging accuracy in the clinically inconspicuous axilla (cN0) [2,3,4].
  • ACOSOG study (American College of Surgeons Oncology Group Z0011): patients with clinical stage T1 or T2 breast carcinoma were treated with breast-conserving therapy (BET), adjuvant radiotherapy (radiotherapy) of the affected breast, and adjuvant systemic therapy and divided into two groups: one group also underwent extirpation (surgical removal) of affected sentinel lymph nodes (SLND) and the other group also underwent axillary dissection (removal of lymph nodes from the axilla (armpit)). The outcome at 9.3 years showed that in these patients, extirpation of sentinel lymph nodes was not inferior to axillary dissection when based on overall survival and disease-free survival.
  • Current status according to S3 guideline: patients can usually be spared axillary dissection if the axillary region is irradiated instead.

Preinvasive neoplasms

Lobular neoplasia (NL)

NL (proliferation of neoplastic cells in the lobules of the mammary gland that may spread to the mammary ducts) subsumes three distinct growths with almost 100% confinement to the lobules:

  • Atypical lobular hyperplasia (ALH), cells confined to the lobule.
  • Carcinoma lobulare in situ (CLIS), widening of the lobules.
  • Carcinoma lobulare in situ of the extended type, widening of the lobules, transition to the milk ducts in part with necrosis and microcalcifications.

Characteristics

  • About 5% of all preinvasive neoplasms.
  • Approximately 46 to 85% multicentric
  • Up to 30-67% bilateral
  • Usually makes no symptoms and occurs as an incidental finding in the context of a diagnosis (eg, biopsy indication for abnormal mammography).
  • Indicator of increased risk of breast cancer (7-12 x increased).
  • The malignant potential of LCIS appears to be lower than that of DCIS.

Therapy

Therapy of NL is a case-by-case decision depending on imaging and histology. In the case of indication for open biopsy, this consists of:

  • A simple tumor removal
  • Without removal of the sentinel lymph node or axillary (“belonging to the axilla”) lymph nodes.
  • Without post-irradiation
  • Without adjuvant prophylactic therapy
  • With the recommendation of annual mammography checks (X-ray examination of the breast).

Ductal carcinoma in situ (DCIS)

DCIS originates from the milk ducts. They are completely or partially lined with atypical cells. Histologically, three types are distinguished, so-called grading: low, intermediate and high grade. These are rough indicators of the aggressiveness of the tumor. Characteristics

  • Basement membrane intact
  • Multifocal growth
  • DCIS foci (> 2 cm) often contain invasive districts that are detectable only with subtle histologic processing.
  • Approximately 15% of all breast carcinomas.
  • Indicator of increased risk of breast carcinoma
  • The transition of DCIS into invasive carcinoma is about 50% in a period of 10-20 years
  • DCIS, unlike invasive breast cancer, is almost 100% curable if completely removed
  • 50% of all DCIS recurrences are invasive tumors

Therapy

DCIS, unlike LIN, is always an indication for surgical exploration by open biopsy. It can be performed as breast-conserving surgery (BEO; breast-conserving therapy, BET) or mastectomy. BEO is possible and is generally recommended today:

  • For small in situ findings (< 4 cm).
  • In case of unifocal growth
  • In the case of a favorable tumor-to-breast ratio.

A prerequisite for BEO is postoperative radiotherapy (radiotherapy).

Beo unfavorable or not possible

  • In the case of very large lesions
  • In case of multifocal growth
  • In case of unfavorable histological prognostic factors (see classification: van Nuys Index).
  • In the case of an unfavorable tumor-to-breast ratio.

(Plastic surgical reconstruction of the affected breast is often performed promptly). Axillary dissection should not be performed for DCIS. Sentinel node biopsy should only be performed if secondary sentinel node biopsy is not possible for technical reasons. Further guidance

  • Screen-detected ductal carcinoma in situ; DCIS) is more than twice as likely to develop invasive breast carcinoma over at least 20 years (compared with the normal population). This risk is higher the less aggressively the patient is treated: Mastectomy (breast removal) and breast-conserving therapy (BET) with the addition of radiotherapy and endocrine therapy, if necessary, and wide incision margins are associated with a reduced risk (e.g., 38% lower risk than that of women without endocrine therapy.

Carcinoma special form: Paget’s carcinoma of the breast (Paget’s disease of the nipple, Paget’s cancer, Paget’s disease).

Paget’s disease of the breast is a rare disease of the nipple. It is a special form of DCIS or infiltrating ductal carcinoma. Clinically, it resembles an inflammatory change of the nipple with eczema-like, crusty, scaly, brown-red skin surface, sometimes ulcerating (“forming ulcers”) or oozing. Differentially, it must be distinguished from eczema or inflammatory changes of the nipple. Therapy is the same as for ductal carcinoma in situ or infiltrating ductal carcinoma.