Surgery for early and locally advanced breast cancer by Dr.jfr

Surgery for early and locally advanced breast cancer •

Updated 2013 Jul 02 01:54:00 PM: fibrin glue not associated with reduced seroma formation or surgical site infections after breast and axillary surgery for breast cancer (Cochrane Database Syst Rev 2013 May 31) view updateShow more updates

Related Summaries: • •

Breast cancer (list of topics) Breast cancer in women

Overview: •

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surgery is usually first treatment for early and locally advanced breast cancer o breast-conserving surgery (plus radiation therapy) for early breast cancer appears as effective for survival and rate of distant metastases as mastectomy (level 2 [mid-level] evidence), but may be associated with need for re-excision or future mastectomy o

mastectomy indicated for patient preference, or if large or multicentric tumor precludes breast conservation therapy

radical mastectomy does not appear to confer survival advantage over total mastectomy over 25 years (level 2 [mid-level] evidence)

sentinel lymph node resection o

sentinel lymph node (SLN) biopsy is preferred method of axillary lymph node assessment for staging of early breast cancer with no clinical evidence of lymph node involvement

Memorial Sloan-Kettering Cancer Center nomogram can predict likelihood of SLN metastasis and likelihood of additional non-SLN metastasis (level 1 [likely reliable] evidence)

SLN resection alone is as effective as axillary lymph node dissection (ALND) for survival and regional control in women with invasive breast cancer and clinically negative lymph nodes and negative SLN (level 1 [likely reliable] evidence)

management of positive SLN o

ALND has been recommended for patients with positive SLN (micrometastasis or macrometastasis)

ALND no longer routinely required for patients with T1-2 tumors and 1-2 positive SLNs without extracapsular extension who will have adjuvant therapies (radiation therapy plus systemic therapy), based on similar tumor recurrence rates and similar 5-year overall survival comparing SLN dissection alone vs. SLN dissection plus ALND (level 2 [mid-level] evidence)

ALND still indicated if T3 tumor, preoperative palpable lymph nodes, > 2 positive lymph nodes, matted axillary nodes, or having neoadjuvant chemotherapy

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for Paget's disease of breast, central lumpectomy may result in similar 15-year breast cancer-specific survival as mastectomy (level 2 [mid-level] evidence)

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breast-conserving surgery for recurrent ipsilateral breast cancer associated with decreased survival compared to mastectomy (level 2 [mid-level] evidence)

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delaying breast reconstruction until after completion of postmastectomy radiation therapy may reduce complications (level 2 [mid-level] evidence)

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chronic pain occurs in substantial proportion of women following breast cancer surgery

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lymphedema may occur in up to 15% of women after surgery for breast cancer (level 2 [mid-level] evidence)

Recommendations • National Institute for Health and Clinical Excellence (NICE) recommendations (1) o for early breast cancer 

surgery is usually first treatment and options include 

mastectomy (followed by breast reconstruction, either immediate or delayed, if patient desires) 

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offer immediate breast reconstruction to all patients being advised to have mastectomy unless contraindicated due to significant comorbidity or need for adjuvant therapy

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breast conserving therapy followed by radiation therapy

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breast conserving surgery with removal of the nipple-areolar complex is alternative to mastectomy for patients with localized Paget disease of the nipple

axillary lymph node assessment indicated for staging of early breast cancer

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sentinel lymph node biopsy performed by qualified surgical team is preferred method

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axillary lymph node dissection indicated if either 

macrometastases or micrometastases shown in a sentinel lymph node

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preoperative ultrasound-guided needle biopsy with histologically proven metastatic cancer

axillary lymph node dissection not indicated if only isolated tumour cells found in sentinel lymph node

for locally advanced or inflammatory breast cancer in patients treated with chemotherapy 

mastectomy recommended

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consider breast conserving surgery in exceptional cases

Breast Conserving Surgery • general information(2) o removes tumor and surrounding margin of normal breast tissue without resecting entire breast 

negative (tumor-free) margins intended to assure complete removal of tumor, or removal sufficient that remaining tumor burden is microscopic and likely to be treatable with radiation

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margin status may not be definite until final pathologic exam of surgical specimen

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positive margins after initial breast conservation therapy usually require further excision

should be followed by total or partial breast irradiation postoperatively

cosmetic outcome depends on tumor to breast size ratio; good cosmetic outcome may not be achieved with large ratio (requiring removal of about > 25% of breast)

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consider oncoplastic reconstruction if cosmesis following lumpectomy is an issue

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contraindications to breast conserving surgery o

absolute contraindications 

prior significant radiation therapy to breast tissue, such as for Hodgkin lymphoma (HL), non-small cell lung cancer or small cell lung cancer

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long term toxicity would be unacceptable

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repeat partial breast radiation therapy may be an option for recurrent disease

pregnancy 

absolute contraindication to radiation therapy unless pregnancy terminated

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may be possible to have breast conserving surgery in late third trimester with radiation therapy after delivery

relative contraindications 

multicentric disease (≥ 2 nonadjacent primary lesions in same breast)

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collagen vascular disease (connective tissue disease), such as scleroderma or systemic lupus erythematosus (SLE)

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large tumor size (based on cosmetic results, but neoadjuvant chemotherapy may reduce tumor size and allow breast conserving surgery)

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large pendulous breasts or very large breasts (prone position for radiation therapy may be useful)

Reference - American College of Radiology (ACR) Appropriateness Criteria for conservative surgery and radiation - stage I and II breast carcinoma (ACR 2011 PDF)

other potential contraindications to breast conserving surgery plus radiation therapy 

patient choice (with appropriate counseling)

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positive margins after ≥ 2 excisions

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subareolar tumor (more patients may choose mastectomy)

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certain rare genetic conditions associated with inability to repair sublethal radiation damage (for example, mutations in ataxiatelangiectasia mutated [ATM] gene or activin A receptor, type II-like 1 [ACVRL1] gene) (Int J Radiat Oncol Biol Phys 2012 Nov 15;84(4):1031)

surgery improves progression-free but not overall survival compared to tamoxifen therapy in women > 70 years old with operable breast cancer (level 1 [likely reliable] evidence) o

based on Cochrane review

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systematic review of 7 randomized trials comparing primary endocrine therapy with surgery (with or without adjuvant endocrine therapy) in women ≥ 70 years old with early breast cancer who are fit for surgery

all trials used tamoxifen, 6 trials had published time-to-event data, 3 trials had adequate allocation concealment

analysis based on estimated 869 deaths in 1,571 women

no significant difference in overall survival

surgery associated with longer progression-free survival 

hazard ratio (HR) 0.55 (95% CI 0.39-0.77) for surgery alone vs. primary endocrine therapy in 1 trial with 164 women (about 75% had breast conserving surgery, about 25% had mastectomy)

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HR 0.65 (95% CI 0.53-0.81) for surgery plus endocrine therapy vs. primary endocrine therapy in 1 trial with 474 women

tamoxifen-related adverse effects included hot flashes, skin rash, changes in vaginal discharge, indigestion, breast pain, sleepiness, headache, vertigo, itching, hair loss, cystitis, acute thrombophlebitis, nausea, and indigestion

surgery-related adverse effects included paresthesia on ipsilateral arm and lateral thoracic wall in patients who had axillary clearance

Reference - Cochrane Database Syst Rev 2008 Jul 16;(3):CD004272

breast-conserving surgery (plus radiation therapy) for early breast cancer appears as effective for survival and rate of distant metastases as mastectomy (level 2 [mid-level] evidence) o

based on 4 randomized trials with allocation concealment not stated

20-year survival rates and disease-free survival rates appear similar compared to total mastectomy 

2,105 women with breast cancer < 4 cm (negative or positive nodes) were randomized to total mastectomy vs. lumpectomy vs. lumpectomy then breast irradiation and followed for 20 years

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analysis limited to 1,851 women who accepted assigned treatment and had known nodal status

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20-year mortality was 53.5%

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no significant differences among groups in overall survival, diseasefree survival, or distant-disease-free survival

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reduced ipsilateral breast recurrence rates (14.3% vs. 39.2%, p < 0.001, NNT 4)

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nonsignificant trend toward increased disease-free survival (p = 0.07)

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Reference - N Engl J Med 2002 Oct 17;347(16):1233 full-text, editorial can be found in N Engl J Med 2002 Oct 17;347(16):1270, commentary can be found in Am Fam Physician 2003 Mar 15;67(6):1362

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earlier results also found no significant differences in overall survival or disease-free survival at 12 years, cumulative incidence of tumor recurrence in ipsilateral breast was 35% with lumpectomy alone and 10% with lumpectomy plus breast irradiation (p < 0.001, NNT 4) (N Engl J Med 1995 Nov 30;333(22):1456 full-text)

20-year survival rates appear similar compared to radical mastectomy, but higher local recurrence rate with breast-conserving surgery 

701 women < 70 years old with breast cancer < 2 cm and no palpable axillary nodes were randomized to breast-conserving surgery (quadrantectomy and ipsilateral radiation therapy) vs. radical mastectomy from 1973 to 1980

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both groups who had positive axillary nodes after 1976 were given adjuvant chemotherapy

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median follow-up 20 years

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comparing breast-conserving surgery vs. radical mastectomy

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in subgroup of 1,137 lumpectomy-treated women who had tumorfree margins on surgical specimens, irradiation associated with

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local recurrence in 8.5% vs. 2.3% (p < 0.001, NNT 17 favoring radical mastectomy)

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no significant differences in contralateral breast cancer, distant metastases, second primary cancers, mortality (41.7% vs. 41.2%) or deaths from breast cancer (26.1% vs. 24.3%)

Reference - N Engl J Med 2002 Oct 17;347(16):1227 full-text, editorial can be found in N Engl J Med 2002 Oct 17;347(16):1270, commentary can be found in N Engl J Med 2003 Feb 13;348(7):657

20-year overall survival and rate of distant metastases appear similar compared to modified radical mastectomy

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868 women with breast cancer stage I or II and tumor ≤ 5 cm (axillary node negative or positive) were randomized between 1980 and 1986 to breast conserving surgery followed by radiation therapy (with tumor-bed boost) vs. modified radical mastectomy

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median follow-up 22.1 years

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comparing breast conserving surgery vs. modified radical mastectomy 

20-year overall survival 39.1% vs. 44.5% (not significant)

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20-year cumulative distant metastases of 46.9% vs. 42.6% (not significant)

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no significant differences in time to death or distant metastases, or overall survival in subgroup analyses by age (< 50 years old, ≥ 50 years old)

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Reference - EORTC 10801 trial (Lancet Oncol 2012 Apr;13(4):412)

18-year survival and disease-free survival appear similar compared to modified radical mastectomy 

237 evaluable women randomized to modified radical mastectomy vs. breast conservation therapy (defined as lumpectomy, axillary lymph node evaluation, and radiation therapy)

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median follow-up 18.4 years

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overall survival 58% with radical mastectomy vs. 54% with breast conservation therapy (not significant)

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breast conservation therapy associated with in-breast events in 22% (27 women), successfully treated (defined as no regional or distant disease) in 59% (16 women)

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Reference - Cancer 2003 Aug 15;98(4):697 full-text, commentary can be found in Cancer 2004 Apr 15;100(8)

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earlier results also found no significant differences in overall survival or disease-free survival at 10 years (N Engl J Med 1995 Apr 6;332(14):907 full-text), commentary can be found in N Engl J Med 1995 Apr 6;332(14):951

breast-conserving surgery plus radiation associated with improved overall survival at 9 years compared to mastectomy (level 2 [mid-level] evidence) o

based on retrospective cohort study

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112,154 women with stage I-II invasive breast cancer were followed for median 110.6 months

55% had breast-conserving surgery plus radiation and 45% had mastectomy

5-year overall survival 89.3%

breast-conserving surgery plus radiation associated with decreased risk of all-cause mortality compared to mastectomy (adjusted hazard ratio 0.81, 95% CI 0.8-0.83)

Reference - Cancer 2013 Apr 1;119(7):1402

re-excision rates and mastectomy rates following breast-conserving surgery o

breast-conserving surgery associated with 18% overall re-excision rate and 7% mastectomy rate in women with invasive breast cancer 

based on retrospective cohort study

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45,793 women with isolated invasive breast cancer had breast conserving surgery 2005-2008 in England

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8,229 (18%) had at least one reoperation including

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4,441 (9.7%) with 1 additional breast conserving surgery

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3,201 (7%) with mastectomy

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587 (1.3%) with ≥ 2 reoperations

Reference - BMJ 2012 Jul 12;345:e4505 full-text

breast-conserving surgery associated with 22.9% overall re-excision rate and 8.5% total mastectomy rate in women with invasive breast cancer 

based on retrospective case series

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2,206 women (mean age 62 years) with 2,220 invasive breast cancers from 4 institutions having partial mastectomy as first surgical procedure

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509 women (22.9%) had re-excision

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89.2% had 1 re-excision

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9.4% had 2 re-excisions

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1.4% had 3 re-excisions

190 women (8.5%) had total mastectomy

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85.9% for initial positive margins

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47.9% for < 1 mm margins

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20.2% for 1-1.9 mm margins

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6.3% for 2-2.9 mm margins

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significant variation in re-excision rates occurred among surgeons (range 0%-70%) and institutions (range 1.7%-20.9%) in patients with negative margins

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Reference - JAMA 2012 Feb 1;307(5):467, editorial can be found in JAMA 2012 Feb 1;307(5):509

breast-conserving surgery associated with 48.5% re-excision lumpectomy rate and 10.8% mastectomy rate 

based on retrospective case series

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714 women (of 898 with history of breast-conserving surgery for breast cancer at 1 institution) responded to questionnaire regarding disease history

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51.4% required only 1 breast excision

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41.9% required 2 breast excisions

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6.6% required 3 breast excisions

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10.8% required mastectomy

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factors associated with re-excision lumpectomy included

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re-excision rates for margin status following initial surgery

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smaller breast size (based on bra size); A cup (odds ratio [OR] 2.7, 95% CI 1.32-552) or B cup (OR 1.63, 95% CI 1.02-2.26)

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lobular histology (OR 1.93, 95% CI 1.15-3.25)

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surgical biopsy (not needle) (OR 3.35, 95% CI 2.24-5.02)

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adjuvant chemotherapy (compared to neoadjuvant chemotherapy) (OR 2.49, 95% CI 1.19-5.22)

Reference - Ann Surg Oncol 2008 May;15(5):1297

breast-conserving surgery may be an option for Paget disease of the breast

National Institute for Health and Clinical Excellence (NICE) recommends that breast conserving surgery with removal of the nipple-areolar complex is alternative to mastectomy for patients with localized Paget disease of the nipple(1)

central lumpectomy may result in similar 15-year breast cancer-specific survival rates compared to mastectomy in patients with Paget disease of the breast (level 2 [mid-level] evidence)

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based on retrospective observational study of 1,704 women with Paget disease of the breast from 9 United States registries from 1988 to 2002

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50.4% had Paget disease with infiltrating ductal carcinoma

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36.3% had Paget disease with ductal carcinoma in situ (DCIS)

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13.3% had Paget disease of breast alone

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1,642 women had surgery (18% lumpectomy and 82% mastectomy)

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comparing 15-year breast cancer specific survival rates for patients having central lumpectomy vs. mastectomy 

92% vs. 94% for women with Paget disease alone and women with Paget disease with underlying DCIS (not significant)

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87% vs. 60% for women with Paget disease with underlying infiltrating ductal carcinoma (not significant)

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size of underlying tumor and lymph node status were only independent prognostic factors for disease-specific breast cancer mortality in multivariate analysis

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Reference - Cancer 2006 Oct 1;107(7):1448

for Paget disease of the breast with underlying breast cancer, breast conserving surgery plus adjuvant radiation therapy may have low rate of recurrence and metastasis (level 2 [mid-level] evidence) 

based on retrospective cohort study

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114 patients with Paget disease of the breast at the European Institute of Oncology of Milan, Italy from 1996 to 2003 were followed for mean of 73 months

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94% had underlying breast cancer (only 7% had "pure" Paget disease of breast)

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43 patients had conservative surgery

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6 had locoregional recurrences (4 invasive and 2 noninvasive)

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no distant metastasis

71 patients had mastectomy 

2 had loco-regional recurrence

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14 had distant metastasis

authors suggest 

first-line therapy should be breast conserving surgery with complete removal of nipple and areola with margins free of tumor combined with radiation therapy for patients with invasive and noninvasive breast carcinoma

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sentinel lymph node biopsy should be performed even if clinical and radiologic findings are negative

Reference - Breast Cancer Res Treat 2008 Dec;112(3):513

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review of breast-conserving surgery can be found in Am Fam Physician 2002 Dec 15;66(12):2271 full-text

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review of breast conservation therapy for locally advanced breast cancer can be found in Semin Radiat Oncol 2009 Oct;19(4):229

Radioguided Localization • radioguided occult lesion localization associated with reduced risk of positive resection margin and shorter surgical time compared to wire localization in women with nonpalpable breast cancer (level 2 [mid-level] evidence) o based on systematic review of trials without intention-to-treat analysis o

systematic review of 4 randomized trials comparing radioguided occult lesion localization vs. wire localization for preoperative localization of nonpalpable breast cancers in 449 women

radioguided occult lesion localization is preoperative technique for localization of nonpalpable early breast cancers

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radiotracer solution injected adjacent to lesion under ultrasonographic or stereotactic guidance

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subsequent surgical biopsy or wide excision performed with guidance of hand held gamma-ray detection counter

radioguided occult lesion localization associated with reduced 

risk of positive resection margin (odds ratio 0.47, 95% CI 0.22%0.99%) in analysis of 3 trials with 366 patients

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surgery time (mean difference 5.3 minutes, 95% CI 3.1-7.5 minutes) in analysis of 4 trials with 440 patients

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localization time (mean difference 6.1 minutes, 95% CI 5.4-6.8 minutes) in analysis of 3 trials with 329 patients

no significant differences in localization rate, periprocedural complications, reoperation, and excised tissue weight or volume

Reference - J Surg Oncol 2012 Jun 15;105(8):852

radiocolloid with dye localization may reduce close or involved margins compared to wire localization in patients with malignant nonpalpable lesion having first biopsy (level 2 [mid-level] evidence) o

based on randomized trial with allocation concealment not stated

157 patients with nonpalpable breast lesions classified as Breast Imaging Reporting and Data Systems category 5 lesion having first excisional biopsy randomized to radiocolloid combined with methylene dye localization vs. wire localization (standard)

malignancy found in 53.2% with radiocolloid with dye and 55.1% with wire localization (not significant)

comparing radiocolloid with dye vs. wire localization in malignant lesions

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close or involved surgical margins in 19% vs. 39.5% (p = 0.038, NNT 5)

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mean operation time 14.7 minutes vs. 16.3 minutes (p = 0.001)

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mean length of incision 36.3 mm vs. 44.8 mm (p < 0.001)

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mean weight of specimen 39 g vs. 45.2 g (p < 0.001)

Reference - Ann Surg Oncol 2011 Jan;18(1):109

radioguided seed localization may have similar positive margin and reoperation rates but less pain compared to wire localization in women having breast conserving surgery for early-stage breast cancer or ductal carcinoma in situ (level 2 [mid-level] evidence) o

based on randomized trial without reporting of confidence intervals

333 women (mean age 60.4 years) with histologically confirmed invasive breast carcinoma (82%) or ductal carcinoma in situ (18%) having breastconserving surgery were randomized to radioguided seed localization vs. wire localization

localizations guided by mammography (30%) or ultrasound (70%) at radiologist discretion

mean operative time 19.4 minutes with radioguided seed localization vs. 22.2 minutes with wire localization (p < 0.001)

radioguided seed localization associated with

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less pain (p = 0.038)

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greater ease of excision (p = 0.008)

comparing radioguided seed localization vs. wire localization no significant differences in 

positive margin rates (10.5% vs. 11.8%)

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final mastectomy rates (3.9% vs. 2.9%)

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postoperative complications (12.1% vs. 7.8%)

Reference - Ann Surg Oncol 2011 Nov;18(12):3407

Mastectomy • mastectomy - indicated for patient preference, or if large or multicentric tumor precludes conservation therapy o radical mastectomy - complete removal of breast, pectoralis major and minor muscles, and axillary lymph nodes (rarely performed anymore)

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modified radical mastectomy - complete removal of breast and level I and II axillary lymph nodes, but not pectoralis muscles

simple mastectomy (also called total mastectomy) - complete removal of breast, but not lymph nodes or pectoralis muscles

skin-sparing mastectomy - removal of breast tissue (including nipple-areola complex) while preserving viable skin in order to achieve optimal cosmetic outcome with immediate breast reconstruction

nipple-areola-sparing mastectomy - removal of breast tissue with sparing of skin and areola alone or nipple-areola complex in order to improve cosmetic outcome; usually requires intraoperative retroareolar tissue evaluation (frozen section) to rule out neoplastic involvement

Reference - Cleve Clin J Med 2008 Mar;75 Suppl 1:S10 PDF

radical mastectomy does not appear to confer survival advantage over total mastectomy over 25 years (level 2 [mid-level] evidence) o

based on randomized trial with allocation concealment not stated

1,665 women with breast cancer were randomized to radical vs. total mastectomy in groups stratified for axillary lymph node involvement

no significant differences in overall or disease-free survival

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among 1,079 women with clinically negative axillary nodes randomized to radical mastectomy vs. total mastectomy plus postoperative irradiation vs. total mastectomy plus axillary dissection only if nodes became positive

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among 586 women with clinically positive axillary nodes randomized to radical mastectomy vs. total mastectomy plus postoperative radiation without axillary dissection

Reference - N Engl J Med 2002 Aug 22;347(8):567 full-text, commentary can be found in N Engl J Med 2002 Dec 26;347(26):2170, Am Fam Physician 2003 Feb 1;67(3):587

nipple-sparing mastectomy o

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successful maintenance of nipple-areola complex viability reported in most patients after nipple-sparing mastectomy (level 3 [lacking direct] evidence) 

based on case series

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54 nipple-sparing mastectomies (56% for infiltrating breast cancer, 13% for ductal carcinoma in situ, 31% for prophylaxis) in 44 patients were attempted

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6 were converted to total mastectomies based on intraoperative frozen section analysis of nipple-areola complex sample

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3 had partial loss of nipple-areola complex postoperatively

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45 maintained postoperative viability of nipple-areola complex

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long-term outcomes not reported

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Reference - Arch Surg 2004 Feb;139(2):148 full-text

complete nipple-areola complex skin survival reported in 80% of 64 breasts after total skin-sparing mastectomy with preservation of nipple-areola complex procedure in 43 women in case series (Arch Surg 2008 Jan;143(1):38 full-text)

predictive model to aid patient selection for nipple-sparing mastectomy can be found in Br J Surg 2008 Nov;95(11):1356

pectoral fascia preservation might be associated with increased chest wall recurrence rate (level 2 [mid-level] evidence)

based on randomized trial with non-significant trend

247 patients with breast cancer having modified radical mastectomy randomized to preservation vs. removal of pectoral fascia

median follow-up 11 years

73% overall breast-cancer-specific survival at 10 years (no significant difference between groups)

chest wall recurrence rates comparing pectoral fascia preservation vs. removal

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in overall analysis 14.4% vs. 8.2% (hazard ratio 1.8, 95% CI 0.8-4)

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at 5 years 13% vs. 8%

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at 10 years 15% vs. 9%

Reference - World J Surg 2010 Nov;34(11):2539

survey of reasons for mastectomy can be found in JAMA 2009 Oct 14;302(14):1551 full-text

Sentinel Lymph Node Resection • sentinel lymph node (SLN) biopsy is preferred method of axillary lymph node assessment for staging of early breast cancer with no clinical evidence of lymph node involvement • Memorial Sloan-Kettering Cancer Center nomogram can predict likelihood of SLN metastasis and likelihood of additional non-SLN metastasis (level 1 [likely reliable] evidence) •

•

procedural approach o

combined use of blue dye and isotope-labeled sulfur colloid (intraoperative lymphatic mapping) appears to identify > 90% of sentinel nodes

periareolar injection of radiotracer and blue dye may be more effective than peritumoral injection for SLN detection (level 2 [mid-level] evidence)

addition of lidocaine to radiocolloid may reduce pain in patients having SLN mapping (level 2 [mid-level] evidence)

specimen analysis o

intraoperative frozen section analysis of SLN may be useful to detect but not rule out metastases due to low sensitivity (level 2 [mid-level] evidence)

mammaglobin and cytokeratin 19 mRNA assay (GeneSearch BLN Assay) can detect breast cancer metastases in axillary SLNs (level 1 [likely reliable] evidence)

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SLN biopsy associated with reduced morbidity compared to ALND (level 2 [midlevel] evidence)

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management of positive SLN

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axillary lymph node dissection (ALND) has been recommended for patients with positive SLN (micrometastasis or macrometastasis)

ALND still indicated if T3 tumor, preoperative palpable lymph nodes, > 2 positive lymph nodes, matted axillary nodes, or having neoadjuvant chemotherapy

see Sentinel lymph node biopsy for breast cancer

Axillary Node Dissection Axillary node dissection in node-negative disease: •

axillary lymph node dissection (ALND) may not be beneficial in women with nodenegative breast cancer o sentinel lymph node (SLN) resection alone is as effective as axillary lymph node dissection (ALND) for survival and regional control in women with invasive breast cancer and clinically negative lymph nodes and negative SLN (level 1 [likely reliable] evidence) 

based on randomized trial

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5,611 women with invasive breast cancer and clinically negative nodes randomized to SLN resection alone (plus ALND only if SLN positive) vs. SLN resection plus ALND

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women followed for mean 96 months

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3,986 women (71%) with negative SLN included in primary analysis

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7.8% overall mortality

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comparing SLN resection alone vs. SLN resection plus ALND

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8-year overall survival 90.3% vs. 91.8% (not significant)

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8-year disease free survival 81.5% vs. 82.4% (not significant)

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local recurrence in 2.4% vs. 2.7% (not significant)

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regional node recurrence in 0.7% vs. 0.4% (not significant)

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distant metastasis in 3.2% vs. 2.8% (not significant)

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cancer in opposite breast in 2.2% vs. 2.8% (not significant)

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second non-breast cancer in 5.4% vs. 4.5% (not significant)

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grade 3 or higher surgery-related adverse event in 0.4% vs. 0.5% (not significant)

Reference - National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 trial (Lancet Oncol 2010 Oct;11(10):927), editorial can be found in Lancet Oncol 2010 Oct;11(10):908

axillary node dissection does not appear to improve overall survival in older women with early breast cancer and clinically negative axillary nodes (level 2 [mid-level] evidence) 

based on randomized trial without intention-to-treat analysis

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238 women aged 65-80 years with early breast cancer and clinically negative axillary nodes having conservative breast surgery were randomized to axillary node dissection vs. no dissection

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all women received tamoxifen for 5 years (63% were estrogen receptor-positive and progesterone receptor-positive)

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8% did not complete trial and were excluded from analyses

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comparing axillary dissection vs. no dissection at 5 years

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overall mortality 13.1% vs. 7.8% (not significant)

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breast cancer-related mortality 3.9% vs. 3.9% (not significant)

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recurrence, metastasis, other malignancy or contralateral breast cancer in 15.9% vs. 12.6% (not significant)

Reference - Ann Surg 2005 Jul;242(1):1 full-text

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at 15 year follow-up 

comparing axillary dissection vs. no dissection 

breast cancer-related mortality 7.6% vs. 9.2% (not significant)

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distant metastasis in 8.6% vs. 9.6 (not significant)

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no significant difference in overall survival

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Reference - Ann Surg 2012 Dec;256(6):920

axillary node dissection may not be associated with decreased mortality in patients ≥ 70 years old with breast cancer stage T1N0 treated with tamoxifen (level 2 [mid-level] evidence) 

based on cohort study

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671 patients ≥ 70 years old with operable breast cancer stage T1N0 and clinically clear axilla (no palpable nodes) had axillary node dissection conservative surgery vs. no axillary dissection

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all patients received tamoxifen 20 mg/day for ≥ 2 years

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no significant difference in breast cancer mortality at median followup 15 years

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Reference - Ann Surg Oncol 2011 Jan;18(1):125 full-text, commentary can be found in Ann Surg Oncol 2011 Sep;18(9):2413



no significant difference in mortality at 5 and 10 years in earlier analysis of this cohort (Cancer 2003 Mar 1;97(5):1156 full-text)

axillary lymph node dissection immediately following sentinel lymph node biopsy might increase risk of lymphedema compared to delayed dissection in women with node-negative breast cancer stage T1-T2N0 (level 2 [mid-level] evidence) 

based on subgroup analysis of randomized trial with borderline statistical significance



199 women with operable invasive primary breast cancer (stage T1T2) and clinically negative axilla were randomized to sentinel lymph node (SLN) biopsy with immediate axillary lymph node dissection (ALND) vs. SLN biopsy with intraoperative cytology plus delayed ALND



all women were from 1 center in a trial with 73 centers



lymphedema at 36 months in 6.8% with immediate ALND vs. 0% with delayed ALND (p = 0.058) in analysis of 146 women with node-negative biopsy



no significant difference in rates of lymphedema in women with node-positive biopsy



Reference - Am J Clin Oncol 2013 Feb;36(1):20

Axillary node dissection in node-positive disease: •

lymph node disease (small deposits of metastatic tumor in lymph nodes) classified as(1) o macrometastatic disease if > 2 mm



patient classified as lymph node-positive



mean proportion of patients with non-SLN metastases 53.2% for patients with SLN macrometastases in 8 observational studies

micrometastatic if < 2 mm (0.2-2 mm) 

patient classified as lymph node-positive



mean proportion of patients with non-SLN metastases 17.7% for patients with SLN micrometastases in 8 observational studies



pooled estimates for rate of non-SLN metastases in patients with SLN micrometastases in 2 systematic reviews



20.2% when SLN metastases detected by hematoxylin and eosin (H&E) staining



9.4% when SLN metastases detected by immunohistochemistry techniques

prognostic significance of SLN micrometastases uncertain 

based on literature review



11 studies did not find evidence of effect of SLN micrometastases on overall survival, distant metastasis, axillary recurrence, disease-free survival, or metastasis-free survival



5 studies found association with overall survival, distant metastases, or disease-free survival



Reference - Surg Oncol 2011 Dec;20(4):e195

isolated tumor cells (< 0.2 mm)

•

single cells or tiny clusters of cells, usually detected by immunohistochemistry



patient classified as lymph node-negative



mean proportion of patients with non-SLN metastases 10% for patients with SLN isolated tumor cells in 8 observational studies



clinical relevance of SLN isolated tumor cells unclear 

based on literature review



SLN isolated tumor cells associated with marginally poorer prognosis



identification of isolated tumor cells varies with analytic technique



no strong evidence to guide management decisions based on identification of isolated tumor cells



Reference - Breast Cancer Res Treat 2011 Jun;127(2):325

National Institute for Health and Clinical Excellence (NICE) recommendations(1) o

•



offer further axillary treatment to patients with early invasive breast cancer who have 

macrometastases or micrometastases shown in a sentinel lymph node (SLN)



preoperative ultrasound-guided needle biopsy with histologically proven metastatic cancer

axillary lymph node dissection (ALND) is preferred over axillary radiation therapy because it provides additional staging information, or consider clinical trials comparing axillary radiation therapy with completion ALND in early breast cancer patients with axillary metastasis found by SLN biopsy

further axillary treatment not recommended for patients with only isolated tumor cells in sentinel lymph nodes (such patients should be considered lymph node-negative)

American Society of Breast Surgeons (ASBS) position statement on management of axilla in patients with invasive breast cancer o

axillary lymph node dissection (ALND) may no longer be routinely required for patients who meet all criteria below 

T1-2 tumors

o •



1-2 positive sentinel lymph nodes without extracapsular extension



patient acceptance and completion of both 

whole breast radiation therapy without extended fields of therapy



adjuvant therapy (hormonal, cytotoxic, or both)

recommendation to omit ALND does not directly apply to patients who 

have T3 tumors



have > 2 positive nodes



are having mastectomy



are having partial breast radiation



have matted axillary nodes or palpable nodes preoperatively



are having neoadjuvant chemotherapy

recommendations for specimen evaluation from sentinel lymph node (SLN) biopsy 

routine use of immunohistochemistry (IHC) no longer recommended, based on 2 studies suggesting SLN micrometastases detected by IHC staining are clinically insignificant



intraoperative frozen-section of sentinel lymph nodes can be avoided if clinical suspicion of nodal involvement low and patient otherwise meets criteria above for avoiding ALND

Reference - ASBS 2011 Aug 31 PDF

sentinel lymph node (SLN) dissection alone and SLN dissection plus axillary lymph node dissection (ALND) may have similar tumor recurrence rates and similar 5-year overall survival in selected women with 1-2 SLN metastases who receive adjuvant radiation therapy and systemic therapy (level 2 [mid-level] evidence) o

based on randomized trial with inadequate statistical power

891 women ≥ 18 years old with clinical T1-T2 invasive breast cancer, no palpable adenopathy, and 1-2 SLN metastases were randomized to completion ALND following SLN dissection vs. no ALND 

all patients had SLN dissection and lumpectomy prior to randomization



adjuvant systemic therapy given at physician/patient discretion (92.7% received adjuvant systemic therapy including 55.7% given chemotherapy and 44.7% given hormone therapy)



all patients received adjuvant radiation therapy to whole breast

exclusion criteria included 

matted nodes or ≥ 3 involved SLNs



gross extranodal disease



treatment with neoadjuvant chemotherapy or hormonal therapy



bilateral breast cancer or multicentric disease



history of ipsilateral axillary surgery

power analysis estimated 1,900 patients required to detect hazard ratio of 1.3 for overall survival, recruitment stopped early due to low event rates in both arms

modified intention-to-treat population excluded 35 women who withdrew following SLN dissection

size of SLN metastasis was micrometastasis in 35%, macrometastasis in 50%, and unknown in 15%

comparing ALND vs. no ALND at median follow-up 6.3 years 

local recurrence in 3.6% vs. 1.8% (not significant)



regional recurrence in ipsilateral axilla in 0.5% vs. 0.9% (not significant)



adjuvant systemic therapy in 96% vs. 97% (not significant)

median times to local recurrence-free survival and regional recurrence-free survival not reached in either group

Reference - American College of Surgeons Oncology Group Z0011 randomized trial (Ann Surg 2010 Sep;252(3):426), commentary can be found in Ann Surg 2011 Dec;254(6):1078

similar 5-year overall survival in post-hoc analysis of this trial 

criterion for noninferiority of SLN dissection alone was 1-sided hazard ratio < 1.3



median follow-up 6.3 years



comparing ALND vs. no ALND



5-year overall survival 91.8% vs. 93.5% (not significant)



5-year disease-free survival 82.2% vs. 83.9% (not significant)

Reference - JAMA 2011 Feb 9;305(6):569, editorial can be found in JAMA 2011 Feb 9;305(6):606

Reducing morbidity of axillary node dissection: •

•

mastoscopic axillary lymph node dissection may reduce distant metastasis and arm pain compared to conventional axillary lymph node dissection (level 2 [mid-level] evidence) o based on randomized trial with baseline differences o

1,027 patients < 80 years old with operable breast cancer and no axillary lymph node disease randomized to mastoscopic vs. conventional axillary lymph node dissection

mean ages at baseline were 52 years in mastoscopic dissection group vs. 48 years in conventional dissection group (p = 0.05), and menopausal status was not reported

median follow-up 63 months

comparing mastoscopic vs. conventional axillary lymph node dissection 

distant metastasis in 22.8% vs. 28.2% (p = 0.04, NNT 19)



overall survival 81.7% vs. 78.6% (not significant)



disease-free survival 64.5% vs. 60.8% (not significant)



mean operative blood loss 12.8 mL vs. 128.3 mL (p < 0.001)

in prespecified subgroup of 200 patients assessed for arm morbidity, mastoscopic axillary lymph node dissection associated with reduced rates of axillary pain, numbness or paresthesias, and arm swelling (p < 0.001 for each) at 6 and 24 months

Reference - Mayo Clin Proc 2012 Dec;87(12):1153

in women with sentinel lymph node (SLN) metastases, immediate completion axillary lymph node dissection (cALND) may be associated with more paresthesias for first 6 months and impaired range of motion for first 30 days compared to delayed completion axillary lymph node dissection (level 2 [midlevel] evidence) o

based on observational study

1,003 women with SLN metastases and cALND evaluated

425 women had immediate cALND (concurrent with SLN biopsy)



578 women had delayed cALND (median 19 days, range 1-93 days)

SLN metastases not further classified as macrometatastases and micrometastases in this study

complications at 30 days comparing immediate vs. delayed cALND

o •



paresthesia in 51% vs. 35% (p < 0.0001)



impaired range of motion in 49% vs. 36% (p < 0.0001)



lymphedema in 8% vs. 8% (not significant)



axillary seromas occurred in 18% immediate vs. 12% delayed cALND (p = 0.01)



wound infection in 7% vs. 8% (not significant)

complications at 6 months comparing immediate vs. delayed cALND 

paresthesia in 50% vs. 42% (p = 0.03)



impaired range of motion in 4% vs. 4% (not significant)



lymphedema in 10% vs. 13% (not significant)

complications at 1 year comparing immediate vs. delayed cALND 

paresthesia in 36% vs. 38% (not significant)



impaired range of motion in 6% vs. 5% (not significant)



lymphedema in 14% vs. 12% (not significant)

Reference - J Clin Oncol 2008 Jul 20;26(21):3530 full-text

intercostobrachial nerve preservation during axillary node dissection may reduce risk of post-surgical sensory deficit (level 2 [mid-level] evidence) o

based on randomized trial without blinding

120 women with invasive breast cancer scheduled for axillary node clearance were randomized to preservation vs. sacrifice of intercostobrachial nerve and were evaluated 3 months post-surgery

nerve preserved successfully in only 65% of patients randomized to nerve preservation group

sensory deficit at follow-up



in 53% of preservation group vs. 84% of nerve sacrifice group in intention-to-treat analysis (p ≤ 0.05, NNT 4 favoring nerve preservation)



in 61% with actual nerve preservation vs. 80% with actual nerve sacrifice (p = 0.06, nonsignificant trend favoring nerve preservation)

no significant differences (in intention-to-treat and actual procedure analyses) in sensory symptoms, including pain, numbness, or decreased or altered sensation in intention-to-treat and actual procedure analyses

Reference - Br J Surg 1998 Oct;85(10):1443 in Evidence-Based Medicine 1999 May-Jun;4(3):85

Surgery for Recurrent Breast Cancer • surgical treatment for local recurrence generally involves(2) o for recurrence after breast conserving surgery

•



mastectomy



axillary node dissection for clinically positive nodes



repeat sentinel lymph node biopsy (if done initially) for clinically negative nodes

for recurrence after mastectomy 

wide excision



axillary lymph node dissection (may not be needed if dissection done initially and nodes are clinically negative at time of recurrence)

for inoperable recurrence 

axillary lymph node dissection



induction chemotherapy may facilitate local resection



radiation therapy recommended if inoperable or incompletely resected recurrent disease

breast-conserving surgery for recurrent ipsilateral breast cancer associated with decreased survival compared to mastectomy (level 2 [mid-level] evidence) o

based on retrospective review

747 patients with prior breast-conserving surgery and ipsilateral recurrence were evaluated

24% had lumpectomy for recurrent breast cancer

5-year overall survival 67% with lumpectomy vs. 78% with mastectomy (p = 0.03)

Reference - Am J Surg 2008 Oct;196(4):495

Breast Reconstruction/Prosthesis Timing of postmastectomy breast reconstruction: •

•

National Institute for Health and Clinical Excellence (NICE) recommends discussing and offering immediate breast reconstruction to all patients advised to have mastectomy unless contraindicated due to comorbidity or need for adjuvant therapy(1) immediate breast reconstruction o

immediate breast reconstruction may be associated with increased risk of wound complications (level 2 [mid-level] evidence) 

based on retrospective cohort study



128 women with breast cancer had 148 mastectomy procedures with or without immediate reconstruction and were assessed for wound complications



wound complications in 22% with vs. 8% without immediate reconstruction (p = 0.02, NNH 7)



complications (which included hematoma, cellulitis, eschar, and poor wound healing) did not delay initiation of chemotherapy



Reference - Arch Surg 2004 Sep;139(9):988 full-text

immediate breast reconstruction might reduce psychiatric morbidity following mastectomy (level 2 [mid-level] evidence) 

based on randomized trial without blinding of outcome assessors and differential loss to follow-up



64 women < 60 years old with operable nonmetastatic breast cancer having mastectomy randomized to immediate breast reconstruction vs. delayed reconstruction (12 months later) and followed for 3 months



loss to follow-up in 81% of delayed reconstruction group vs. 6% of immediate reconstruction group



immediate breast reconstruction associated with reduced psychiatric morbidity at 3 months postoperatively, predominantly in women with unsatisfactory marriages

•



no significant differences between groups in sexual and social morbidity



Reference - Lancet 1983 Feb 26;1(8322):459



no additional trials found in Cochrane review of randomized trials comparing immediate breast reconstruction vs. delayed or no reconstruction in women with any stage of breast cancer (Cochrane Database Syst Rev 2011 Jul 6;(7):CD008674)

delayed-immediate breast reconstruction technique o

at time of mastectomy place tissue expander to preserve breast skin envelope

tissue expander can be deflated to allow flat chest wall for radiation delivery (if radiation therapy indicated)

replace with final reconstruction (tissue flap) after adjuvant radiation therapy completed

Reference - Eur Rev Med Pharmacol Sci 2011 Jul;15(7):840, Plast Reconstr Surg 2011 Jun;127(6):2154, Plast Reconstr Surg 2010 Feb;125(2):463, Plast Reconstr Surg 2009 Aug;124(2):395, Cleve Clin J Med 2008 Mar;75 Suppl 1:S30, Plast Reconstr Surg 2004 May;113(6):1617

delaying breast reconstruction until after completion of postmastectomy radiation therapy may reduce complications (level 2 [mid-level] evidence) o

based on review of cohort studies

comparing radiation therapy after breast reconstruction vs. radiation therapy before breast reconstruction 

late complications (1 year after completion of radiation, including fat necrosis, volume loss, and flap contracture) in 87.5% vs. 8.6% in 1 retrospective cohort study of 102 patients with reconstruction surgery 1988-1998 (p < 0.001, NNH 3) (Plast Reconstr Surg 2001 Jul;108(1):78)



in 1 retrospective cohort study of 699 patients having transverse rectus abdominis musculocutaneous (TRAM) flaps reconstruction 1981-1994 (Plast Reconstr Surg 1997 Oct;100(5):1153)



fibrosis in 31.6% vs. 0% (p < 0.05, NNH 4)



overall complications in 31% vs. 25% (not significant)

in 150 patients (171 breasts) having pedicled TRAM flap breast reconstruction (Plast Reconstr Surg 2005 Jan;115(1):84) 

total flap complications in 50% vs. 57.1% (not significant)



radiation therapy after reconstruction associated with worse scores including aesthetic outcome, symmetry, and contracture (statistically significant for contracture)

complication rates with radiation therapy after breast reconstruction (in cohort studies with treatment after 1985, comparison to no radiation therapy, and mean follow-up > 1 year) Complication Rates: Number With Without Complication NNH of RT RT Patients Capsular contracture

41.7% 14.5%

p < 0.001, 107 NNH 4

Capsule formation

38.6% 14.1%

p < 0.001, 114 NNH 4

Fat necrosis

23.3% 0%

p = 0.006, 60 NNH 5

Fibrosis and shrinkage

56.7% 0%

p < 0.001, 60 NNH 2

Flap contracture

16.7% 0%

p = 0.023, 60 NNH 6

Total p ≤ 0.01, 40.7% 16.7% 104 complications NNH 5 Total flap 50%Not 49.5% 107 complications 57.1% significant Abbreviation: RT, radiation therapy. o Reference - Plast Reconstr Surg 2009 Aug;124(2):395

Reference J Plast Reconstr Aesthet Surg 2006;59(1):27 J Plast Reconstr Aesthet Surg 2006;59(10):1043 Plast Reconstr Surg 2002 May;109(6):1919 Plast Reconstr Surg 2002 May;109(6):1919 Plast Reconstr Surg 2002 May;109(6):1919 Plast Reconstr Surg 2006 Feb;117(2):359 Plast Reconstr Surg 2005 Jan;115(1):84

Effects of breast reconstruction: •

skin-sparing mastectomy with immediate reconstruction appears to have similar risk of local recurrence but possibly lower risk of distant relapse compared to conventional mastectomy without reconstruction (level 2 [midlevel] evidence) o based on systematic review of observational studies o

systematic review of 9 studies evaluating outcomes of conventional mastectomy without reconstruction vs. skin-sparing mastectomy with immediate reconstruction in 3,739 women with breast cancer

•

no significant difference in local recurrence in analysis of 7 studies

skin-sparing mastectomy with immediate reconstruction associated with decrease in distant relapse (OR 0.67, 95% CI 0.48-0.94) in analysis of 5 studies

Reference - Ann Surg 2010 Apr;251(4):632

DynaMed commentary -- association with decreased distant relapses should be interpreted with caution because tumor grade not adequately reported

mastectomy with breast reconstruction and mastectomy alone associated with similar quality of life, body image, and sexuality (level 2 [mid-level] evidence) o

based on systematic review of observational studies

systematic review of 28 articles comparing mastectomy with vs. without reconstruction in women with breast cancer and reporting patient-reported outcomes

21 studies were cross-sectional surveys given after treatment, 7 studies were prospective cohort studies

most studies of quality of life, body image, and sexuality did not find significant differences between mastectomy with vs. without reconstruction

none of the higher quality studies found better outcomes with reconstruction

Reference - J Am Coll Surg 2009 Jul;209(1):123 full-text, commentary can be found in J Am Coll Surg 2009 Dec;209(6):790

insufficient evidence to evaluate health-related quality of life outcomes after breast reconstruction o

based on systematic review of 34 studies evaluating effect of breast reconstruction on health-related quality of life in women with breast cancer

studies were poorly designed and underpowered to determine clinical significance

Reference - Ann Surg 2010 Dec;252(6):929

•

review of breast reconstruction after surgery for breast cancer can be found in N Engl J Med 2008 Oct 9;359(15):1590 full-text, commentary can be found in N Engl J Med 2009 Jan 22;360(4):418

•

review of breast reconstruction can be found in BMJ 2005 Apr 23;330(7497):943 full-text, commentary can be found in BMJ 2005 Jun 4;330(7503):1330

•

review of assessment of cosmesis following breast reconstruction surgery can be found in Ann Surg Oncol 2011 Mar;18(3):813

Breast implants: •

•

silicone gel-filled breast implants FDA approved for breast reconstruction in all women and breast augmentation in women > 22 years old (FDA Press Release 2006 Nov 17) repeat surgery for revisions or complications reported in 21% of 574 women who had postmastectomy reconstruction with breast implants in Denmark in case series (Arch Surg 2005 Dec;140(12):1152 full-text) breast implants not associated with increased mortality in women with breast cancer (level 2 [mid-level] evidence) o

based on retrospective cohort study

4,968 women < 65 years old with early or unstaged primary breast cancer were followed for mean 12.4 years

20% had postmastectomy breast implants

mortality comparing implant vs. no implant



17.7% vs. 30% overall (p < 0.0001)



12.4% vs. 19.7% due to breast cancer (p < 0.0001)

Reference - Breast Cancer Res 2005;7(2):R184 full-text, commentary can be found in Breast Cancer Res 2005;7(2):61

•

silicone gel-filled breast implants do not appear to cause breast cancer, based on preliminary data (FDA Press Release 2011 Jun 22)

•

conflicting evidence on association between silicone breast implants and connective tissue diseases o

breast implants not associated with connective tissue disease (level 2 [mid-level] evidence) 

based on questionnaires to 87,501 nurse participants in Nurses' Health Study cohort



1,183 had breast implants an average of 9.9 years



confirmed connective tissue disease in 516 women, of whom 3 had implants



Reference - N Engl J Med 1995 Jun 22;332(25):1666 full-text, commentary can be found in N Engl J Med 1995 Nov 23;333(21):1423, ACP J Club 1995 Nov-Dec;123(3):76

breast implants may be associated with increased risk of patientreported connective tissue disease (level 2 [mid-level] evidence) 

based on prognostic cohort study with methodologic limitations



3,950 women with breast implants and 19,897 controls were assessed by self-report, screening questionnaire, and medical record review for connective tissue disorders during mean 3.63-year follow-up



only women who self-reported connective tissue disease were asked to complete questionnaire; medical records available only in 0.75% of patients



odds ratios for connective tissue disease in women with implants (adjusted for age, body mass index, smoking and post-menopausal hormone use)



1.6 (95% CI 1.28-2) for self-report events



1.8 (95% CI 1.37-2.38) for events confirmed by screening questionnaire



1.39 (95% CI 0.82-3.75) for events confirmed by medical record

Reference - Int J Epidemiol 2011 Feb;40(1):230 full-text

Procedural considerations for tissue flap breast reconstruction: •

bupivacaine injections at donor site associated with decreased pain following deep inferior epigastric perforator flap breast reconstruction (level 2 [midlevel] evidence) o based on small randomized trial o

40 women having deep inferior epigastric perforator flap breast reconstruction randomized to bupivacaine 2.5 mg/mL (20 mL given every third hour for 72 hours postoperatively through 2 thin catheters placed at donor site) vs. placebo injections

bupivacaine associated with significantly decreased 

pain at rest



pain upon coughing



consumption of rescue opioid (ketobemidone or oxycodone)

no significant difference in frequency of nausea or consumption of antiemetic medications

Reference - Anesth Analg 2010 Apr 1;110(4):1191

Timing of Surgery and Discharge • insufficient evidence to guide timing of surgery based on phase of menstrual cycle o insufficient evidence to evaluate timing of breast cancer surgery in premenopausal women

•



based on Cochrane review



systematic review of randomized trials comparing breast surgery during follicular phase of menstrual cycle vs. during luteal phase in premenopausal women



no completed randomized trials identified



2 prospective observational studies found no differences in timing of surgery in recurrence-free survival or overall survival



Reference - Cochrane Database Syst Rev 2011 May 11; (5):CD003720

inconsistent evidence for benefit of performing breast cancer surgery during specific phase of menstrual cycle 

based on literature review of 40 studies



22 studies suggested increased survival with tumor resection during luteal phase



9 studies suggested increased survival with tumor resection during follicular phase



9 studies suggested no significant association between survival and timing of tumor resection during menstrual cycle



Reference - Int Semin Surg Oncol 2006 Nov 1;3:37 full-text

hospital discharge 4 days after breast cancer surgery appears safe (level 2 [mid-level] evidence) o

based on randomized trial without blinding

125 women with operable breast cancer randomized to discharge on day 4 with drain in place vs. after drain removal (mean 9 days after surgery)

no significant differences between groups in duration of axillary drainage, wound complications, psychosocial problems, or physical complaints

•

early discharge associated with decreased number of seroma aspirations (mean 1 vs. 3.5 aspirations per patient, p = 0.04)

Reference - BMJ 1998 Apr 25;316(7140):1267 full-text, commentary can be found in BMJ 1998 Oct 17;317(7165):1082

DynaMed commentary -- performing randomization before surgery and informing patient of treatment plan might affect management in ways other than just time of discharge

hospital discharge 2 days after surgery for breast cancer may improve pain and shoulder movement at 3 months compared to later discharge (level 2 [midlevel] evidence) o

based on randomized trial without blinding

100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80) were randomized to discharge on day 2 with home support from specialist breast care nurses vs. standard discharge after drain removed (median day 5)

outcomes comparing early vs. standard discharge 

restricted shoulder movement at 3 months in 11% vs. 30% (p = 0.042, NNT 6 favoring early discharge)



wound pain at 3 months in 15% vs. 39% (p = 0.016, NNT 5 favoring early discharge)



no significant differences in time to drain removal, seroma formation, readmission, or psychological illness

Reference - BMJ 1998 Nov 7;317(7168):1275 full-text, editorial can be found in BMJ 1998 Nov 7;317(7168):1264, commentary can be found in BMJ 1998 Nov 7;317(7168):1264, BMJ 1999 May 1;318(7192):1210

DynaMed commentary -- performing randomization before surgery and informing patient of treatment plan might affect management in ways other than just time of discharge

Post-surgery Complications • surgical complications may include o bleeding o

infection (cellulitis or abscess)

seroma

arm morbidity

•



lymphedema in about 15%-20% with axillary node dissection, about 7% with sentinel lymph node biopsy



efforts to reduce lymphedema risk may include 

avoiding blood pressure measurements, venipuncture and IVs in ipsilateral arm



using compression sleeve during air travel (DynaMed commentary -- pre-emptive compression sleeve use is controversial)

phantom breast syndrome - may include pain, nipple sensations, erotic sensations, or premenstrual soreness localized to missing breast

motor nerve injury to long thoracic nerve (causing winged scapula) or thoracodorsal bundle (causing difficulty with internal rotation of arm and shoulder adduction)

Reference - Cleve Clin J Med 2008 Mar;75 Suppl 1:S10 PDF

breast cancer surgery associated with low complication rates overall, but mastectomy associated with higher complication rate than lumpectomy with axillary procedure (level 2 [mid-level] evidence) o

based on retrospective cohort study

3,107 women with breast cancer had mastectomy vs. lumpectomy with axillary procedure

mastectomy associated with increased



30-day morbidity (5.72% vs. 1.87%, p < 0.001, NNH 26)



mean length of stay (2.49 vs. 0.58 days, p < 0.001)



mean number of complications (0.08 vs. 0.02, p < 0.001), including 

urinary tract infection (0.66% vs. 0.14%, p = 0.024, NNH 192)



superficial wound infection (2.77% vs. 1.38%, p = 0.007, NNH 72)



wound dehiscence (0.6% vs. 0.14%, p = 0.037, NNH 217)

mastectomy associated with nonsignificant trend toward increased 

mortality (0.24% vs. 0%, p = 0.062)



deep vein thrombosis/thrombophlebitis (0.42% vs. 0.07%, p = 0.053)

o •



pulmonary embolism (0.24% vs. 0%, p = 0.062)



deep wound infection (0.96% vs. 0.41%, p = 0.069)

Reference - Ann Surg 2007 May;245(5):665 full-text

breast cancer surgery in patients > 80 years old associated with 0.5% postoperative mortality (level 2 [mid-level] evidence) in retrospective cohort study of 1,713 patients in the Netherlands (World J Surg Oncol 2005 Nov 9;3:71 full-text)

Pain: •

chronic pain occurs in substantial proportion of women following breast cancer surgery o surgery for breast cancer associated with postmastectomy pain syndrome (PMPS) in 24% of women (level 2 [mid-level] evidence) 

based on cohort study



219 women who had surgery for breast cancer (mastectomy or lumpectomy) at 1 institution and 563 controls who had not had surgery for breast cancer were assessed by questionnaire for PMPS (defined as pain in area of surgery or ipsilateral arm for ≥ 4 days per week, with mean pain intensity ≥ 3 on 10-point scale) or PMPS-like symptoms



pain in 23.9% of cases at 1.5 years after surgery compared with 10% of controls (OR 2.88, 95% CI 1.84-4.51)



postmastectomy pain syndrome associated with

 o



history of prior breast surgery (adjusted OR 8.12, 95% CI 2.39-27.64)



tumor site in upper lateral quarter (adjusted OR 6.48, 95% CI 2.24-18.77)



young age (adjusted OR 1.04, 95% CI 1-1.08)

Reference - Br J Cancer 2008 Aug 19;99(4):604 full-text

prevalence of chronic pain 47% at 2 years after breast cancer surgery 

based on cross-sectional study



3,754 women aged 18-70 years who had surgery and adjuvant therapy (if needed) for primary breast cancer were mailed survey at mean 26 months following surgery



87% returned survey



chronic pain in 47% 

severe pain in 13%



moderate pain in 39%



light pain in 48%

factors associated with chronic pain 

young age (18-39 years, p < 0.001)



adjuvant radiation therapy (p = 0.03)



axillary lymph node dissection (p < 0.001 vs. sentinel lymph node dissection)



sensory disturbances associated with young age and axillary lymph node dissection (both p < 0.001)



pain in other parts of body associated with pain in surgical area (p < 0.001)



chemotherapy not associated with chronic pain



Reference - JAMA 2009 Nov 11;302(18):1985, correction can be found in JAMA 2012 Nov 21;308(19):1973, editorial can be found in JAMA 2009 Nov 11;302(18):2034

prevalence of chronic pain 37% at 6 years after breast cancer surgery 

based on cross-sectional study



2,828 women aged 18-70 years who had surgery and adjuvant therapy (if needed) for primary breast cancer were mailed survey at mean 72.5 months following surgery



89% returned survey and were analyzed



37% reported chronic pain in breast area, side of body, axilla, or arm on operated side



factors associated with significantly higher rates of chronic pain included



age ≤ 49 years and age 50-59 years compared to age ≥ 70 years



axillary lymph node dissection compared to sentinel lymph node biopsy

50% reported sensory disturbances

 •

Reference - BMJ 2013 Apr 11;346:f1865 full-text

options to reduce pain o

addition of paravertebral block to general anesthesia may decrease pain up to 3 hours after breast surgery (level 2 [mid-level] evidence) 

based on randomized trial without blinding



80 patients having unilateral breast surgery without reconstruction were randomized to paravertebral block plus general anesthesia vs. general anesthesia alone and assessed for postoperative pain



paravertebral block associated with

 o



decreased pain scores at 1 hour (p = 0.006) and 3 hours (p = 0.001)



being pain-free at 1 hour (in 44% vs. 17% without block, p = 0.014, NNT 4) and at 3 hours (in 54% vs. 17%, p = 0.005, NNT 3)



no significant differences in pain scores after 3 hours

Am J Surg 2009 Nov;198(5):720

gabapentin 1 hour before mastectomy may reduce postoperative pain and morphine use (level 2 [mid-level] evidence) 

based on randomized trial without intention-to-treat analysis



70 women scheduled for unilateral radical mastectomy with axillary dissection were randomized to gabapentin 1,200 mg orally vs. placebo 1 hour before surgery



4 patients in gabapentin group and 1 patient in placebo group excluded from analysis due to various failures to adhere to protocol



gabapentin associated with decreased 

morphine use (p < 0.0001)



pain with movement at 2 hours (p < 0.0001) and 4 hours (p = 0.018) postoperatively



no significant differences in pain at rest or side effects



Reference - Anesthesiology 2002 Sep;97(3):560, editorial can be found in Anesthesiology 2002 Sep;97(3):537, commentary can be found in Anesthesiology 2003 Jun;98(6):1520

gabapentin may decrease pain after movement sooner than venlafaxine, but venlafaxine associated with reduction in postmastectomy pain syndrome at 6 months (level 2 [mid-level] evidence) 

based on randomized trial with allocation concealment not stated



150 women having partial or radical mastectomy with axillary dissection were randomized to extended-release venlafaxine 37.5 mg/day vs. gabapentin 300 mg/day vs. placebo for 10 days starting night before operation and followed for 6 months



gabapentin associated with decreased



total morphine consumption during first 24 hours (p < 0.0001 vs. venlafaxine and placebo)



pain scores after movement on days 2-10 vs. placebo (p < 0.05)

venlafaxine associated with decreased 

pain scores after movement on days 8-10 vs. placebo (p < 0.05)



pain scores with movement at 6 months (p < 0.0001 vs. gabapentin and placebo)



no significant difference among groups in pain scores at rest during first 10 days



Reference - Clin J Pain 2010 Jun;26(5):381

preoperative dexamethasone appears to reduce postoperative pain, nausea and vomiting in women having mastectomy with axillary lymph node dissection (level 2 [mid-level] evidence) 

based on randomized trial with randomization method not described



70 women with breast cancer having mastectomy with axillary lymph node dissection were randomized to preoperative dexamethasone 8 mg intravenously vs. placebo 60 minutes before surgery



comparing preoperative dexamethasone vs. placebo 

at early postoperative evaluation, postoperative nausea and vomiting in 28.6% vs. 60% (p = 0.02, NNT 4)



at 6 hours, postoperative nausea and vomiting in 17.2% vs. 45.8% (p = 0.03, NNT 4)



dexamethasone associated with significantly reduced pain scores immediately after surgery (p = 0.004), at 6 hours (p < 0.0005) and at 12 hours (p = 0.04)



Reference - BMC Cancer 2010 Dec 23;10:692 full-text

presurgery hypnosis associated with reduced intraoperative anesthesia use and postoperative pain intensity (level 2 [mid-level] evidence) 

based on randomized trial without blinding



200 women (mean age 48.5 years) having excisional breast biopsy or lumpectomy were randomized to 15-minute presurgery hypnosis session vs. nondirective empathetic listening



comparing hypnosis vs. empathetic listening 

mean intraoperative propofol use 64 mcg vs. 97 mcg (p < 0.05)



mean intraoperative lidocaine use 24 mL vs. 31 mL (p < 0.05)



mean pain intensity score on visual analog 0-100 scale 22 vs. 48 (p < 0.05)



differences in pain unpleasantness, nausea, fatigue, discomfort, and emotional upset all favored hypnosis



no significant differences in use of fentanyl, midazolam, or recovery room analgesics



Reference - J Natl Cancer Inst 2007 Sep 5;99(17):1304 full-text

oblique approach to fluoroscopic stellate ganglion block appears similarly effective and associated with fewer side effects compared to anterior approach in patients with postmastectomy pain syndrome (level 2 [mid-level] evidence) 

based on small randomized trial



50 patients with postmastectomy pain syndrome randomized to classic anterior paratracheal vs. oblique fluoroscopic stellate block, 4 blocks performed for all patients with same approach each time



no significant difference in decrease in mean visual analog scale score, daily morphine consumption or areas of allodynia for up to 3 months after last block



oblique approach associated with significantly fewer incidences of side effects



Reference - Clin J Pain 2011 Mar-Apr;27(3):207

Lymphedema: •

lymphedema may occur in up to 15% of women after surgery for breast cancer (level 2 [mid-level] evidence) o based on population-based cohort study o

287 women with recently diagnosed invasive breast cancer followed for 618 months after surgery

lymphedema occurred in 8% to 15% patients at various times (6, 9, 12, 15, and 18 months) with 33.6% women having lymphedema at some point

lymphedema was associated with

o •



age ≥ 50 years (adjusted odds ratio [OR] 3.3, 95% CI 1-11.1)



more extensive surgery (mastectomy vs. local excision, OR 5.9, 95% CI 1.4-22.5)



physical activity < 150 minutes/week (OR 6.1, 95% CI 1.3-27.6)

Reference - J Clin Oncol 2008 Jul 20;26(21):3536 full-text

options to prevent lymphedema o

addition of early physical therapy to educational strategy may prevent secondary lymphedema after dissection of axillary lymph nodes (level 2 [mid-level] evidence) 

based on randomized trial with allocation concealment not stated



120 women having unilateral breast surgery with dissection of axillary lymph nodes randomized to early physical therapy plus educational strategy vs. educational strategy alone



secondary lymphedema in 7% (4 women) with physical therapy vs. 25% (14 women) with education alone (p = 0.01, NNT 6)



Reference - BMJ 2010 Jan 12;340:b5396 full-text, editorial can be found in BMJ 2010 Jan 12;340:b5235

Seroma formation: •

options to prevent seroma formation o lymph vessel ligation and dead space closure during modified radical mastectomy associated with reduced seroma formation and reduced postoperative drainage (level 2 [mid-level] evidence)



based on randomized trial with unclear blinding of outcome assessor



201 patients with breast cancer scheduled for modified radical mastectomy randomized to modified radical mastectomy with lymph vessel ligation and dead space closure vs. conventional modified radical mastectomy



comparing modified radical mastectomy with lymph vessel ligation and dead space closure vs. conventional procedure 

seroma formation in 2% vs. 14% (p < 0.01, NNT 9)



median length of drainage 4 days vs. 7 days (p < 0.01)



median operating time 115 minutes vs. 95 minutes (p < 0.01)



seromas formed after altered modified radical mastectomy more difficult to manage



Reference - Am J Surg 2010 Sep;200(3):352

fibrin glue not associated with reduced seroma formation or surgical site infections after breast and axillary surgery for breast cancer (level 2 [mid-level] evidence) 

based on Cochrane review limited by clinical heterogeneity



systematic review of 18 randomized trials comparing fibrin glue vs. no fibrin glue under skin flaps to reduce postoperative seroma in 1,252 patients following breast and axillary surgery for breast cancer



definition, diagnostic criteria, and measurement scales for seroma varied across trials



comparing fibrin glue vs. no fibrin glue, fibrin glue associated with 

no significant differences in 

incidence of postoperative seroma in analysis of all trials



surgical-site infection in analysis of 13 trials with 1,009 patients



postoperative complications in analysis of 11 trials with 981 patients



mean volume of seroma in analysis of 10 trials with 731 patients, results limited by significant heterogeneity



•

length of hospital stay in analysis of 6 trials with 364 patients



less volume of drained seroma in analysis of 13 trials with 888 patients



reduced duration of seroma drainage (mean difference 0.59 days, 95% CI 0.23-0.95) in analysis of 13 trials with 861 patients, results limited by significant heterogeneity

Reference - Cochrane Database Syst Rev 2013 May 31; (5):CD009557, also published in J Surg Oncol 2012 Nov;106(6):783

use of axillary suction drain following lymphadenectomy does not appear to reduce seroma formation and may increase length of stay (level 2 [mid-level] evidence) 

based on randomized trial with allocation concealment not stated



100 women with breast cancer having breast conserving surgery with axillary lymphadenectomy were randomized to postoperative axillary padding with vs. without axillary suction drain



comparing padding alone vs. padding plus drain 

mean length of stay 1.8 days vs. 4.5 days (p < 0.001)



seroma in 17% vs. 18% of women (not significant)



seromas needing aspiration in 75% vs. 67% (not significant)



no significant differences in postoperative shoulder mobility, pain, or quality of life



Reference - Br J Surg 2006 Jul;93(7):820

surgical resection for persistent seroma after modified radical mastectomy in case report (World J Surg Oncol 2007 Sep 23;5:104 full-text)

Wound complications: •

smoking associated with increased risk of wound infection, skin flap necrosis, and epidermolysis in 425 patients who had breast cancer surgery (Eur J Surg Oncol 2002 Dec;28(8):815)

•

antibiotic prophylaxis with IV cefazolin does not reduce surgical site infections after modified radical mastectomy (level 1 [likely reliable] evidence) o

based on randomized trial

•

254 women with breast cancer having modified radical mastectomy randomized to cefazolin 1 g IV vs. placebo prior to skin incision and followed for 30 days

surgical site infection within 30 days in 13.4% with cefazolin vs. 15% with placebo (not significant)

no significant difference in treatment required for surgical site infection

most common surgical site infections were cellulitis and superficial infection

Reference - World J Surg 2013 Jan;37(1):59

Salvia miltiorrhiza and anisodamine Chinese herbal medications may reduce wound ischemia and necrosis following mastectomy (level 2 [mid-level] evidence) o

based on small randomized trial

90 patients having mastectomy for breast cancer randomized to routine wound care vs. S. miltiorrhiza IV vs. anisodamine IV for 3 days

routine wound care associated with greater skin flap ischemia and necrosis vs. 

S. miltiorrhiza (p = 0.002 for postoperative day 4, p < 0.001 for postoperative day 8)



anisodamine (p < 0.001 for postoperative days 4 and 8)

anisodamine associated with more complications (dry mouth, rubeosis and especially dysuria) vs. routine care or S. miltiorrhiza (p = 0.026 for both)

Reference - Br J Surg 2010 Dec;97(12):1798

half negative suction drains associated with shorter hospital stay and similar complication rate compared with full suction drainage after modified radical mastectomy (level 2 [mid-level] evidence) o

based on randomized trial without blinding

85 women with locally advanced breast cancer having modified radical mastectomy were randomized to wound drainage with full (700 g/m2) vs. half (350 g/m2) negative suction

mean hospital stay 10.6 days with full suction vs. 6 days with half suction (p < 0.001)

no significant differences in wound infection, seroma formation, or flap necrosis

Reference - BMC Cancer 2005 Jan 27;5:11 full-text

Ovarian Ablation • ovarian ablation (surgery or irradiation) may reduce breast cancer mortality in women < 50 years old not receiving chemotherapy (level 2 [mid-level] evidence) o based on meta-analysis without systematic search o

collaborative meta-analysis of individual patient data (144,939 women) from 194 randomized trials of adjuvant systemic therapy, all trials starting before 1995 and data collected in 2000, conducted by Early Breast Cancer Trialists' Collaborative Group (EBCTCG)

this analysis included 15 trials with 6,506 women of age < 50 years comparing ovarian ablation vs. no adjuvant ovarian treatment

no report of assessment of validity of trials included in meta-analysis

comparing ovarian ablation vs. no adjuvant ovarian treatment



recurrence risk 4.7%/year vs. 5.6%/year (p = 0.0005, NNT 111 woman-years)



breast cancer mortality 33.3% vs. 35.8% (p = 0.01, NNT 40)



no significant differences in subgroup of trials in which patients also received chemotherapy

Reference - Lancet 2005 May 14;365(9472):1687, editorial can be found in Lancet 2005 May 14-20;365(9472):1665, commentary can be found in ACP J Club 2005 Nov-Dec;143(3):58

Quality Improvement Physician Quality Reporting System Quality Measures: •

99. Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade o Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

•

262. Image Confirmation of Successful Excision of Image–Localized Breast Lesion o

Image confirmation of lesion(s) targeted for image-guided excisional biopsy or image-guided partial mastectomy in patients with nonpalpable, imagedetected breast lesion(s) 

lesions may include:

•



mammographic or sonographic mass or architectural distortion



focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography



a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy

Percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method

264. Sentinel Lymph Node Biopsy for Invasive Breast Cancer o

•

microcalcifications

263. Preoperative Diagnosis of Breast Cancer o

•



Percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure

see Physician Quality Reporting System Quality Measures for additional information

Guidelines and Resources Guidelines: International guidelines: •

consensus statement on locoregional treatment of primary breast cancer can be found in Cancer 2010 Mar 1;116(5):1184

United States guidelines: •

American College of Radiology (ACR) Appropriateness Criteria for o conservative surgery and radiation for stage I and II breast carcinoma can be found in Breast J 2011 Sep-Oct;17(5):448 or at ACR 2011 PDF or at National Guideline Clearinghouse 2011 Sep 19:32631 o

•

locally advanced breast cancer can be found at ACR 2011 PDF or at National Guideline Clearinghouse 2011 Sep 19:32632

American College of Radiology/American College of Surgeons/College of American Pathology/Society of Surgical Oncology (ACR/ACS/CAP/SSO)

guideline on standard for breast conservation therapy in management of invasive breast carcinoma can be found in CA Cancer J Clin 2002 Sep-Oct;52(5):277 •

American Society of Breast Surgeons (ASBS) o

ASBS position statement on management of axilla in patients with invasive breast cancer can be found at ASBS 2011 Aug 31 PDF

ASBS guidelines for performing sentinel lymph node biopsy in breast cancer can be found at ASBS 2010 Nov 5 PDF

•

American Society of Clinical Oncology (ASCO) recommendations on sentinel lymph node biopsy in early-stage breast can cancer can be found in J Clin Oncol 2005 Oct 20;23(30):7703 full-text, commentary can be found in J Clin Oncol 2006 Jan 1;24(1):210

•

Commonwealth of Massachusetts Board of Registration in Medicine Expert Panel recommendation on immediate implant-based breast reconstruction following mastectomy for cancer can be found in J Am Coll Surg 2011 Dec;213(6):800

United Kingdom guidelines: •

National Institute of Health and Clinical Excellence (NICE) guideline on diagnosis and treatment of early and locally advanced breast cancer can be found at NICE 2009 Feb:CG80 PDF

•

British Association of Surgical Oncology (BASO) Association of Breast Surgery guideline on surgical management of breast cancer can be found in Eur J Surg Oncol 2009;35 Suppl 1:1

Canadian guidelines: •

•

Cancer Care Ontario (CCO) Program in Evidence-based Series and Practice Guidelines on surgical management of early state invasive breast cancer can be found at CCO 2011 Sep 15 PDF Canadian evidence-based consensus guidelines (published as CMAJ special supplement) on mastectomy vs. lumpectomy can be found in CMAJ 2002 Jul 23;167(2):154 full-text, commentary can be found in CMAJ 2002 Nov 12;167(10):1099

European guidelines: •

•

European Society of Medical Oncology (ESMO) clinical practice guidelines on primary breast cancer (diagnosis, treatment and follow-up) can be found in Ann Oncol 2011 Sep;22 Suppl 6:vi12 full-text Spanish Society for Medical Oncology (SEOM) clinical guideline on treatment of early breast cancer can be found in Clin Transl Oncol 2010 Nov;12(11):711

•

Hungarian Breast Cancer Consensus Conference recommendations on current surgical therapy in breast cancer can be found in Magy Onkol 2010 Sep;54(3):227 [Hungarian]

Central and South American guidelines: •

Seguro Social Costa Rica (CCSS) guideline on treatment of breast cancer (Guía de Práctica Clínica para el Tratamiento del Cáncer de Mama) can be found at CCSS 2012 PDF ZIP [Spanish], patient version can be found at CCSS 2012 PDF ZIP [Spanish]

Australian and New Zealand guidelines: •

New Zealand Guidelines Group (NZGG) guideline on management of early breast cancer can be found at NZGG 2009 Aug PDF or at National Guideline Clearinghouse 2009 Aug:15462

Review articles: • •

review of breast cancer staging and surgical treatment options can be found in Cleve Clin J Med 2008 Mar;75 Suppl 1:S10 review of early breast cancer can be found in Lancet 2009 Apr 25;373(9673):1463

•

review of enhancing postoperative recovery after breast surgery can be found in Br J Surg 2011 Feb;98(2):181

•

review of advances in surgical care of breast cancer patients can be found in World J Surg Oncol 2010 Jan 20;8:5 full-text

MEDLINE search: •

to search MEDLINE for ("Breast Neoplasms/surgery"[Majr]) with targeted search (Clinical Queries for therapy articles), click here

Patient Information • information on surgery for breast cancer from American Cancer Society • information on breast cancer surgery from Stanford Cancer Institute ICD-9/ICD-10 Codes ICD-9 codes: • •

174.0 malignant neoplasm of nipple and areola of female breast 174.1 malignant neoplasm of central portion of female breast

•

174.2 malignant neoplasm of upper-inner quadrant of female breast

•

174.3 malignant neoplasm of lower-inner quadrant of female breast

•

174.4 malignant neoplasm of upper-outer quadrant of female breast

•

174.5 malignant neoplasm of lower-outer quadrant of female breast

•

174.6 malignant neoplasm of axillary tail of female breast

•

174.8 malignant neoplasm of other specified sites of female breast

•

174.9 malignant neoplasm of breast (female), unspecified site

ICD-10 codes: •

C50 malignant neoplasm of breast o C50.0 nipple and areola o

C50.1 central portion of breast

C50.2 upper-inner quadrant of breast

C50.3 lower-inner quadrant of breast

C50.4 upper-outer quadrant of breast

C50.5 lower-outer quadrant of breast

C50.6 axillary tail of breast

C50.8 overlapping lesion of breast

C50.9 breast, unspecified 

ICD-10-CA modification in Canada: code range C50.0-C50.9 subdivided and fourth digit added to identify 

0 right



1 left



9 unspecified side

References General references used: •

•

1. National Institute for Health and Clinical Excellence (NICE). Breast cancer (early and locally advanced): diagnosis and treatment. NICE 2009 Feb:CG80 PDF or at National Guideline Clearinghouse 2009 Sep 21:14312, summary can be found in BMJ 2009 Feb 25;338:b438 2. Maughan KL, Lutterbie MA, Ham PS. Treatment of breast cancer. Am Fam Physician. 2010 Jun 1;81(11):1339-46 full-text, editorial can be found in Am Fam Physician 2010 Jun 1;81(11):1330

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