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Overview of breast cancer staging and surgical treatment options

March 1, 2008|Cleveland Clinic Journal of Medicine
Clarisa Hammer, DO;Alicia Fanning, MD;Joseph Crowe, MD
Author and Disclosure Information

Clarisa Hammer, DO
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Alicia Fanning, MD
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Joseph Crowe, MD
Department of General Surgery, Cleveland Clinic, Cleveland, OH

Correspondence: Alicia Fanning, MD, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, A10, Cleveland, OH 44195; fannina@ccf.org

All authors reported that they have no commercial affiliations or financial interests that pose a potential conflict of interest with this article.

ABSTRACT

Following diagnosis of breast cancer, patients undergo assessment for local and systemic treatment. Establishing a relationship and communication with the patient is critical to this assessment, as are history-taking, clinical breast examination, review of imaging studies, and interactive discussion with the patient of treatment options and possible breast reconstruction. Some type of surgical therapy is indicated in virtually all women with breast cancer, generally as the first part of a multicomponent treatment plan. The main goal of surgical therapy is to remove the cancer and accurately define the stage of disease. Surgical options broadly consist of breast conservation therapy, generally followed by radiation therapy, or mastectomy. The surgical procedure also includes assessment of regional lymph nodes for metastasis, either by axillary lymph node dissection or by the less-invasive sentinel lymph node biopsy, for the purpose of cancer staging and guiding adjuvant therapy.

History, breast exam, and review of imaging studies

In addition to the establishment of communication and understanding, the vital components of this first meeting include a detailed medical history, a clinical breast examination, a review of imaging studies, and a discussion of treatment options.

The history should include all aspects of the patient’s reproductive history, her family history of breast cancer, and any comorbidities and medications being taken.

The clinical breast examination should give special attention to the shape (asymmetry), appearance (eg, dimpling, erythema, nipple inversion), and overall feel of the breasts. A palpable mass must be recorded in terms of its location in relation to the skin, the nipple-areola complex, and the chest wall, as well as the quadrant of the breast in which it lies. The regional lymph node basins need to be examined closely, including the axilla and supraclavicular nodes.

Imaging studies also need to be reviewed closely. Patients today frequently present with multiple types of imaging studies, including mammography, ultrasonography, and MRI. Occasionally patients also may present with nuclear medicine exam results, CTs, thermographic images, positron emission tomography studies, and bone scans. All radiology studies need to be reviewed closely and examined in the context of what they were ordered for and what utility they potentially provide.

Treatment options: Surgery is first step in most cases

Once the above components are addressed, the patient should be engaged in a discussion of treatment options. Most women with breast cancer will undergo some type of surgery in conjunction with radiation therapy, chemotherapy, or both. Generally, surgery takes place as the first part of a multiple-component therapy plan. The main goal of surgery is to remove the cancer and accurately define the stage of the disease.

Consider plastic surgery consultation

When indicated and available, consultation with a plastic surgery team may be appropriate at this stage to provide support and comfort to the patient so that she better understands her options for breast reconstruction along with those for breast cancer surgery. Recent data show that most general surgeons do not discuss reconstruction with their breast cancer patients before surgical breast cancer therapy, but that when such discussions do occur, they significantly influence patients’ treatment choices.6 Giving patients the chance to learn about reconstructive options through discussion with a plastic surgeon represents a good opportunity to provide complete patient care in a multidisciplinary way.

OVERVIEW OF SURGICAL OPTIONS

Two general approaches, no difference in survival

The two mainstays of surgical treatment today are (1) breast conservation therapy, generally followed by total or partial breast irradiation, and (2) mastectomy.

The prospective randomized trial data obtained from the NSABP trials have demonstrated no survival differences between patients with early-stage breast cancer based on whether they were treated with breast conservation therapy or mastectomy.2 Beyond this fundamental issue of survival, there are a number of nuances, many of them logistical, related to the success of either operation that the clinician must keep in mind when presenting these surgical choices to patients. These considerations are reviewed below.

Breast conservation therapy

For breast conservation therapy, the ratio of tumor size to breast size must be small enough to ensure complete tumor removal with an acceptable cosmetic outcome. In general, it is estimated that up to 25% of the breast can be removed while still ensuring a “good” cosmetic outcome. Advances in closure techniques allowing for more tissue to be removed with even better cosmetic outcomes are known as oncoplastic closure. These techniques are mostly performed by breast oncologic surgeons, often in consultation or conjunction with plastic surgeons. (Reconstructive options following breast conservation therapy are reviewed in a subsequent article in this supplement.) Additionally, the patient must agree and be deemed a candidate for postoperative radiation therapy. The patient must be able to be followed clinically to enable early detection of a potential local recurrence.

Figure 2. Needle localization for partial mastectomy (breast conservation therapy).
Figure 2. Needle localization for partial mastectomy (breast conservation therapy). The left panel shows an operative approach to a mammographically evident breast cancer that has been localized (ie, a wire placed preoperatively). An incision is made over the breast cancer and the wire is followed down to the cancer (right panel), which is then excised and sent for specimen radiography to confirm that the correct area has been removed. Clips (not shown) are then left along the border of the cavity to help the radiation oncologist plan radiation therapy.
Figure 2 depicts needle localization and tumor excision in breast conservation therapy. The mainstay of breast conservation therapy is removal of the tumor with adequate normal breast tissue surrounding the cancer. Much debate surrounds “margin status,” or the width of normal breast tissue surrounding a gross tumor that has been removed. While it is understood that the goal of breast conservation therapy is to reduce tumor burden and obtain negative margins, a negative tumor margin does not guarantee complete absence of tumor. However, a negative margin is assurance that the tumor burden is reduced to microscopic levels that can be controlled by radiation therapy. Often the margin status is not known until the final pathologic specimen is serially sectioned and examined microscopically. A positive margin after initial breast conservation therapy generally requires a return to the operating room for further resection and clearance.

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