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

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.

Mastectomy

A second surgical option for patients is mastectomy. Today “mastectomy” can refer to any of several subtypes of surgical procedures, which are outlined below and should be considered on a patient-by-patient basis. Mastectomy is appropriate when breast conservation therapy is not possible (due to a large or multicentric tumor) or would result in poor cosmetic outcome, or when the patient specifically chooses a mastectomy.

Modified radical mastectomy (Figure 3, left) involves complete removal of the breast with preservation of the pectoralis major and minor muscles (unlike radical mastectomy) and dissection of level I and II axillary lymph nodes. Level I lymph nodes are the lowest-lying nodes in the axilla, inferior to the lower edge of the pectoralis minor muscle; level II nodes lie underneath the pectoralis minor muscle. (Level III axillary lymph nodes, which are not dissected in this procedure, lie above the pectoralis minor muscle.)

Simple mastectomy involves removal of the breast only, without removal of lymph nodes. Either of the incisions depicted in the left and center panels of Figure 3 can be used. Both modified radical mastectomy and simple mastectomy involve removal of the nipple and areola (nipple-areola complex).

Skin-sparing mastectomy (Figure 3, center) is performed when a patient is undergoing immediate breast reconstruction (using either a silicone or saline implant or autologous tissue). The goal is to remove all breast tissue, along with the nipple-areola complex, while preserving as much viable skin as possible to optimize the cosmetic outcome.^7,8

Nipple-areola–sparing mastectomy. There is increasing experience with attempts to preserve the nipple-areola complex. These procedures attempt to preserve either the whole complex, termed nipple-areola–sparing mastectomy (sometimes called simply nipple-sparing mastectomy) (Figure 3, right), or just the areola, with removal of the nipple (areola-sparing mastectomy). These procedures are also performed in a skin-sparing fashion.

There is some controversy surrounding these techniques to spare the nipple and/or areola, including debate over which technique.nipple-areola–sparing mastectomy or areola-sparing mastectomy.may be more oncologically safe. Currently the literature shows that both are probably safe oncologic alternatives for remote tumors that do not have an extensive intraductal component. Generally, frozen sections are performed intraoperatively on the retroareola tissue to document that there is no evidence of tumor.⁹

Figure 4. Photos of a patient before (left) and after (right) bilateral mastectomy and breast reconstruction using silicone implants. The patient underwent skin-sparing mastectomy for cancer in the right breast and prophylactic nipple-areola–sparing mastectomy in the left breast.

The main driving force behind all of these types of skin-sparing techniques is aesthetic outcome; Figure 4 depicts the comparative outcomes in a patient who underwent skin-sparing mastectomy in the right breast and nipple-sparing mastectomy in the left. Ongoing randomized controlled studies are being conducted to further validate these procedures.

SURGICAL COMPLICATIONS

Breast procedures are fairly safe operations, but every operation has a risk of complications. Reported complications of breast surgery include the following:

Bleeding
Infection (including both cellulitis and abscess)
Seroma
Arm morbidity (including lymphedema)
Phantom breast syndrome
Injury to the motor nerves.

Seromas often occur in patients after mastectomy or lymph node surgery. Prolonged lymphatic drainage is usually exacerbated by extensive axillary node involvement and obesity.

Arm morbidity can present in different ways. Lymphedema is the most common manifestation, with reported incidences of approximately 15% to 20% when axillary lymph node dissection is performed versus 7% when sentinel lymph node biopsy is done.¹⁰ The risk of lymphedema can be reduced by avoiding blood pressure measurements, venipunctures, and intravenous insertions in the arm on the side of the operation, as well as by wearing a compression sleeve on the affected arm during airplane flights.

Phantom breast syndrome is rare but may manifest as pain that may also involve itching, nipple sensation, erotic sensations, or premenstrual-type soreness.

Many surgeons have historically removed the intercostobrachial nerves but are now trying to preserve these nerves, which when removed cause loss of sensation in the upper inner arm. Although rare, nerve injury during an axillary procedure has been reported. It may involve the long thoracic nerve (denervating the serratus anterior muscle and causing a winged scapula) or the thoracodorsal bundle (denervating the latissimus dorsi muscle and causing difficulty with arm/shoulder adduction).

LOCAL CANCER RECURRENCE

Among women undergoing mastectomy for breast cancer, 10% to 15% will have a recurrence of cancer in the chest wall or axillary lymph nodes within 10 years.¹¹ Similarly, among women undergoing breast conservation therapy plus radiation therapy, 10% to 15% will have in-breast cancer recurrence or recurrence in axillary lymph nodes within 10 years, although women who undergo breast conservation therapy without radiation have a much higher recurrence rate.¹¹ Considerations for screening the surgically altered breast are discussed in the previous article in this supplement.

ASSESSMENT OF AXILLARY LYMPH NODES FOR METASTASIS

Even when patients have a known histologic diagnosis of breast cancer and have made a firm decision regarding the surgical option for removal of their cancer, the status of their axillary lymph nodes remains a great unanswered question until after the surgical procedure is completed. Lymph node status—ie, determining whether the cancer has spread to the axillary lymph nodes—still serves as the critical determinant for guiding adjuvant treatment, predicting survival, and assessing the risk of recurrence.

Axillary lymph node dissection

The standard approach for evaluating lymph node status has been a complete dissection of the axillary space, or axillary lymph node dissection. As briefly noted above, the axillary lymph nodes are anatomically classified into three levels as defined by their location relative to the pectoralis minor muscle. The extent of a nodal dissection can be defined by the number of nodes removed.

References

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