Breast cancer surgery - Oncological aspects

Preoperative clinical examination, mammography, ultrasound and, in selected cases, magnetic resonance imaging provide information about TN status, tumor localization and a potential intraductal component. Diagnosis should be confirmed by preoperative core-needle biopsy histology, grading, hormone receptor status, and HER2/neu expression etc. in order to estimate risk of recurrence and treatment efficacy. If systemic risk is high, preoperative staging with bone scintigraphy, chest X-ray and abdominal ultrasound or CT identify patients with metastatic disease, who will not necessarily benefit from radical surgery. Most patients with T1-tumors are candidates for breast conserving surgery (BCT), which, in combination with radiotherapy of the breast, is as safe as mastectomy. Margins should be free of tumor. Only multicentric disease, inflammatory breast cancer and unfavorable tumor versus breast volume are contraindications for BCT. Plastic surgery often allows resection of large tissue volumes with good cosmesis and minimal scars and may help to avoid mastectomy in many cases. Concerning axillary surgery, the resection of at least 10 lymph nodes has been considered standard. Axillary surgery is responsible for the majority of postoperative morbidity. In very small tumors and in the elderly with clinically negative axillae and small tumors there is some evidence that omitting axillary surgery may not reduce survival rates. In clinically node-negative patients with unifocal tumors not exceeding 5 cm sentinel lymph node excision is widely accepted although long-term survival data are still lacking. Multicentricity, inflammatory disease and extensive prior breast surgery and prior surgery of the axilla are contraindications for sentinel lymph node excision.