1. Compare and contrast lumpectomy and mastectomy, with regard to breast cancer recurrence, morbidity, and mortality.

2. Discuss the roles of chemotherapy and radiation therapy in breast cancer management and their impact on the choice and timing of surgery.

3. Educate patients about options for breast reconstruction after mastectomy or lumpectomy.

4. Design a treatment plan for pregnant women with breast cancer, taking into consideration trimester of pregnancy and stage of tumor.

5. Discuss the contraindications associated with pregnancy and lactation, as they apply to breast cancer screening and management.

Mastectomy in the 21st Century: What’s New in Surgical Therapy for Breast Cancer?
Leigh A. Neumayer, MD, MS, Professor of Surgery, University of Utah School of Medicine, and Co-Director, Integrated Breast Program, Huntsman Cancer Institute, Salt Lake City

Historical trends: Halsted mastectomy—curative but radical, debilitating, and disfiguring; lumpectomy—National Surgical Adjuvant Breast and Bowel Project (NSABP; clinical trial B-06) found no differences in long-term disease-free survival or overall survival among patients who underwent lumpectomy, lumpectomy plus radiation therapy, or mastectomy (grossly free tumor margins required for inclusion); radiation therapy reduced rate of local recurrence after lumpectomy

Mastectomy vs breast-conservation surgery: factors to consider include tumor size relative to breast size, cosmesis, and risk for recurrence; radiation therapy decreases local recurrence by ≥50%; new methods of irradiation (eg, partial breast, intraoperative) may improve results while minimizing radiation exposure; reservations about NSABP B-06— rate of local recurrence after lumpectomy may be underestimated; local recurrence—some “recurrences” may result from failure to resect entire tumor (or incipient tumors); other factors that may influence decision—age of patient (younger age at diagnosis translates to higher rate of lifetime recurrence); genetic risk; history of atypical ductal hyperplasia or lobular carcinoma in situ (increases risk for recurrence in either breast); use of systemic therapy

Mastectomy: reconstruction—immediate reconstruction safe for most women; methods include autologous and nonautologous (with optional supplementation); choice of method partly dependent on need for postmastectomy radiation therapy (and/or chemotherapy) and physical characteristics of patient; techniques—traditional; skin-sparing; areola- and nipple-sparing; total skin-sparing

Skin-sparing mastectomy: increases options for reconstructive surgery; safety—reported rates of recurrence vary (typically, 3%-7%; one outlier report [recurrence rate 20%] from study of patients with advanced disease); considered safe for tumors <2 cm (some studies suggest <3 cm), located \>2 cm from nipple-areolar complex; technique difficult in large breasts

Total skin-sparing mastectomy: incisions—circumareolar (large breast may require lateral extensions); keyhole incision (without “hole”) extended inferiorly; radial (preferred by speaker; least amount of skin loss); inframammary fold (long incisions easy to hide, but difficult to fully access breast; associated with highest risk for skin necrosis)

Advantage: increases acceptance of mastectomy among some women

Disadvantages: possible increased risk for recurrence (unknown); increased risk for skin loss; epidermolysis of nipple tip occurs but heals in ≈3 wk

Multimodal therapy: study showed that, among women with ≥4 positive lymph nodes, radiation therapy improved long- term survival after mastectomy and chemotherapy; medical oncologists encourage early initiation of chemotherapy (speaker allows initiation 2 wk after lumpectomy and 3 wk after mastectomy); therapy sequence—complete chemotherapy before initiating radiation therapy; staging surgical therapies—lumpectomy plus nodal sampling provides sufficient information (eg, tumor size and grade, nodal involvement) for management decisions; approach allows earlier initiation of chemotherapy (if lumpectomy sufficient); neoadjuvant chemotherapy—although warranted in many cases, use shortens time between mastectomy and reconstruction, reducing opportunity to expand tissue before reconstructive surgery; use of adjunctive chemotherapy provides opportunity for smoking cessation

Assessing nodal involvement: positron emission tomography- computed tomography (PET-CT) standard uptake value (SUV) ≥2.5 has high specificity but low sensitivity; useful to perform sentinel node biopsy before lumpectomy; clinical examination insufficient to assess axillary nodal involvement; in patients with clear evidence of nodal involvement (shown by, eg, fine-needle aspiration [FNA] or ultrasonography [US]-guided FNA), axillary dissection replaces sentinel node biopsy

Advances in Breast Reconstruction
Patrick J. O’Neill, MD, Associate Professor of Surgery, and Chief, Division of Plastic Surgery, Medical University of South Carolina, Charleston

Silicone implants: use has declined by ≈30% during recent years, likely related to availability of breast-conserving strategies; history—modern silicone implants debuted in 1963; now, third-generation implants made of cohesive silicone gel (maintains shape when cut; less likely to have extracapsular leakage and complications); in 1991, silicone implants removed from market (due to reports of human adjuvant disorder) but quickly returned for purpose of reconstruction; biology—in tissues, silicone triggers nonspecific foreign-body reaction; studies show no association with illness

Saline implants: vulcanized silicone shell filled with saline; deflate if ruptured; although often used in cosmetic surgery, generally not suitable for reconstructive surgery

Implant reconstruction: expanders inserted after mastectomy (timing partly depends on scheduled radiation or medical therapy); expansion begins 2 wk after insertion (expanded every week thereafter until size appropriate); permanent implants placed 6 wk after final expansion; permanent implants look and feel better than expanders, but both have implant-associated risks; complications— ≈1% of implants rupture within 3 yr (may be “silent”); replacement recommended, even for silent ruptures; capsular contraction may result in changes in breast (eg, increased firmness); ≈8% of women have significant capsular contraction (eg, pain, distortion); other complications include infection, ptosis, scarring, asymmetry, seroma, nipple complications, implant malposition, hematoma, and changes in breast sensation; reoperation rates—27% at 3 yr; 49% at 10 yr

Autologous reconstruction: transverse rectus abdominus myocutaneous (TRAM) flap gold standard; blood from internal mammary vessels directed to inferior epigastric vessels; pedicle technique—portion of rectus abdominis muscle (with overlying tissue) rotated into breast position; complications include infection, bleeding, wound problems, fat necrosis, hernias at donor site, chronic abdominal pain, and loss of rectus abdominus muscles

Immediate breast reconstruction using implants: early attempts using postoperatively expandable implant resulted in high rate of complications; recent attempts more successful (breast-conserving mastectomies reduce need for expansion); procedure—partly disconnect pectoralis major (at costal origin and sternal border); place implant under muscle, with acellular dermal matrix beneath; sew in place between muscle and inframammary fold; advantage— promise of single-stage reconstruction; problems—revisions often required to achieve cosmesis; rate of major complications (eg, implant exposure, asymmetry) 17%; candidates—patient understands that revision may be necessary; immediate reconstruction difficult in obese women and in those who desire large implants; contraindicated in patients undergoing radiation therapy

Perforator-flap breast reconstruction: deep inferior epigastric perforator (DIEP) flap most common donor site; skin, fat, and vascular perforators taken from lower abdomen; rectus abdominis “teased apart” to access inferior epigastric vessels (ligated with perforators); advantages over TRAM flap—rectus muscle remains functional (may decrease long-term back pain); lower rates of hernia and abdominal pain; increased tissue viability and reduced rates of fat necrosis; faster postoperative recovery; better positioning of breast mound; bilateral reconstruction relatively simple (but must be done in single surgery); disadvantages—longer operative time (6-8 hr vs 4-6 hr per flap); revision often required to improve cosmesis; complication rates—flap loss (1%); vascular revision (6%); seroma (4%); fat necrosis (12%); infection (1.8%); hernia (0.7%); healing problems at donor site; deep venous thrombosis and pulmonary embolism (rare); improvements—preoperative CT angiography aids in identifying perforator vessels and tailoring flap to vascular bed; postoperative monitoring of tissue oxygenation identifies problems with arterial or venous flow; patient selection—midline or Pfannenstiel scars acceptable, but paramedian scars often prohibitive; contraindications include history of abdominal liposuction or abdominoplasty; candidates have body mass indices (BMIs) of 15 to 35 (higher BMI associated with increased morbidity; patients with lower BMI likely have insufficient abdominal tissue), with predicted mastectomy weight <1000 g, and do not smoke; note—delay reconstruction if radiation therapy required

Other donor sites: gluteal artery perforator flap accesses inferior and superior gluteal vasculature; scars hidden on buttocks; dissection and inset more difficult; incision over ischial tuberosities may result in pain while sitting; medial thigh flap—uses gracilis muscle; limited to reconstruction of smaller breasts; complications include donor site seromas and problems with wound healing; thoracodorsal artery perforator flap—latissimus flap with artery dissected through latissimus muscle; may be used on pedicle (especially for partial reconstructions); disadvantages include visible scar and small volume; anterior lateral thigh flap—uses second or third perforating artery from profunda femoris artery; easy access; hardy flap; disadvantages include visible scar and possible need for skin graft to close donor site

Partial reconstruction: lumpectomy may result in modest deficit, repairable with modifications of standard techniques (eg, rotational myocutaneous latissimus flap; ad hoc chest wall flap)

Breast Cancer Management in the Pregnant Patient
Anne Marie Wallace, MD, Assistant Professor of Surgery, and Associate Director of Breast Multidisciplinary Program, Cancer Research and Treatment Center, University of New Mexico Health Sciences Center School of Medicine, Albuquerque

Breast cancer during pregnancy: background—most common cancer in pregnant women (occurs in 1 in ≈3000 pregnancies in United States); incidence during pregnancy may increase as women delay childbearing; pathology— similar in pregnant and nonpregnant women; ≈80% ductal; 10% to 15% lobular; hormone-receptor status—affects prognosis and management; similar rates of hormone-receptor positivity in pregnant and nonpregnant women; different stain required to accurately assess status in pregnant women (otherwise, receptor positivity underestimated); diagnosis— physical examination more complicated due to breast engorgement during late pregnancy and lactation; hesitation to biopsy may delay diagnosis; delayed diagnosis (5-15 mo on average) responsible for poorer outcomes among pregnant women

Screening recommendations: clinical breast examination (eg, as part of routine prenatal examination); regular breast self-examination (helps patient become familiar with body, so she is more apt to notice changes in breasts; advise patient to consult clinician when significant changes occur); baseline screening mammography recommended for women ≥35 yr of age planning to conceive

Work-up: physical examination and ultrasonography (US) for all patients with masses; mammography (with appropriate shielding) when suspicion of malignancy elevated; biopsy—benefits outweigh risks (eg, early diagnosis improves outcome; milk-duct fistulae uncommon and treatable); recommended for suspicious masses, even if mass not identified by mammography (mammography does not pick up ≈25% of malignancies); important to alert pathologist to patient’s pregnancy status

Pregnancy termination: does not improve maternal survival; may be considered during early pregnancy in women with aggressive disease who require neoadjuvant chemotherapy (chemotherapy contraindicated during first trimester); risk to fetus—most treatments safe; no reports of metastases spreading to fetus

Treatment: influenced by trimester of pregnancy and stage of disease; staging—based on size of tumor and involvement of lymph nodes

First trimester: early-stage disease—eg, small tumor with no lymphadenopathy or skin or chest wall involvement; mastectomy plus axillary dissection (for axillary staging) standard of care; lumpectomy plus chemotherapy acceptable if tumor small and no obvious clinical nodal involvement; radiation therapy given postpartum; advanced disease— requires more aggressive approach; critical to clear chest wall surgically; chemotherapy during second and third trimesters; radiotherapy after parturition

Indications for irradiation after mastectomy: locally advanced disease; tumor ≥5 cm; extensive involvement of skin or chest wall

Endocrine therapy: tamoxifen (for women with hormone-receptor–positive tumors) teratogenic, therefore treatment initiated after parturition

Biopsy: excisional biopsy required in ≤5% of cases; local anesthetic recommended during first trimester (risk for spontaneous abortion increases with general anesthesia); sentinel node biopsy—generally avoided during first trimester

Second and early third trimesters: surgical options same as for nonpregnant women; lumpectomy plus postpartum radiation therapy or mastectomy, depending on characteristics and location of tumor; sentinel node biopsy or axillary dissection acceptable; presurgical neoadjuvant therapy for patients with advanced disease

Late third trimester: surgery and neoadjuvant therapy, as indicated; consider early delivery (consult with obstetrician to weigh risks and benefits); surgery increases risk for preterm labor

Staging studies: sentinel lymph node biopsy—blue dyes (eg, methylene blue, isosulfan blue) teratogenic; radioisotope tracer safe (low exposure; eliminated in urine; hydrating patient well and inserting Foley catheter to drain limits pelvic exposure); chest radiography—safe with appropriate shielding; blood work—standard; bone scan—safe; radiation exposure limited by hydrating patient and inserting Foley catheter; US—safe alternative to CT for scanning liver; magnetic resonance imaging (MRI)—breast MRI contraindicated because patient cannot lie on stomach or receive gadolinium contrast; brain MRI acceptable if performed without contrast; gadolinium category C agent (avoid in pregnant and lactating patients)

Breast-feeding: suppressing lactation does not increase maternal survival but facilitates surgical treatment (engorged breasts complicate surgery and increase risk for milk-duct fistula); breast-feeding contraindicated in women undergoing chemotherapy (some agents passed in milk) or radiation therapy (inflamed tissue should not be irradiated)

Pregnancy after breast cancer: women with advanced breast cancer have high rates of recurrence within 5 yr; pregnancy not recommended for 2 to 3 yr after completion of treatment depending on stage of tumor (do not want to have to treat recurrence during pregnancy)