Modern Breast Surgery: New Techniques, Better Outcomes

Management of breast cancer has changed dramatically over the past several decades. More women undergoing initial diagnosis and treatment for breast cancer are surviving longer thanks to early detection, targeted therapies, and individualized approaches featuring less-aggressive surgery; moreover, quality of care has benefited from multidisciplinary, team-oriented efforts emphasizing minimally invasive biopsies and better cosmetic outcomes.1,2

Image-Guided Core Needle Biopsy

In contrast to surgical excision of a breast lesion, image-guided core needle biopsy (CNB) allows definitive preoperative diagnosis and is therefore the most appropriate first step. Although lesions close to the skin, chest wall, or an implant may require surgical excision for diagnosis, most breast lesions are amenable to CNB. If the result is benign, women can avoid potentially deforming surgery. If a malignancy is diagnosed, CNB allows time for evaluation of the extent of disease as well as informed decision making about additional diagnostic and therapeutic options (e.g., genetic testing, plastic surgery consultation, neoadjuvant therapy).

Image-Guided Breast Surgery

With greater use of breast imaging, more nonpalpable breast cancers are being diagnosed. A variety of techniques can guide the surgical excision of such lesions.

Wire-guided localization (WGL) involves image-guided placement of a hooked wire and is usually performed under local anesthesia in the radiology department on the day of surgery. This procedure can be complicated by wires becoming dislodged or transected or migrating; it also limits the surgeon's ability to conceal the scar in relation to the wire's position.1 In addition to potential scheduling conflicts between radiology and surgery, WGL can be uncomfortable for the patient, who must be transported to the operating room with a wire extruding from her breast.

Radioactive Seed Localization (RSL) entails placement of a 4-mm titanium ¹²⁵iodine (I) radiolabeled seed into the breast lesion under local anesthesia with mammographic or ultrasound guidance. RSL can be performed in the radiology department a few days before surgery, allowing the seed to stay in place prior to detection by the surgeon with a gamma probe. By facilitating schedule flexibility, RSL reduces the likelihood of delays on the day of surgery. In the operating room, the surgeon uses the gamma probe to localize the lesion and tailor the incision cosmetically. After lumpectomy, the excised specimen is probed and radiographed to visually confirm that it contains the seed and that the resection margins are adequate. Limitations of RSL include possible loss of the seed during surgery and safety issues regarding handling and disposal of the radioactive isotope. Once the seed has been placed in the patient's body, it should be removed within a few days; it will remain radioactive for a relatively long time, as the half-life of ¹²⁵I is 60 days,1 underscoring the importance of medical clearance prior to seed placement to avoid surgery cancellation.

Intraoperative ultrasound (IOUS) allows the surgeon to tailor the incision in a cosmetic manner while performing the lumpectomy with real-time visualization of the tumor. This approach circumvents the need for preoperative localization of a seed or wire. However, IOUS can only be used for lesions (or clips) visible by ultrasound. The excised specimen is evaluated sonographically to confirm that the tumor has been removed and the surgical margins are sufficient. Reexcision of close margins can be accomplished immediately. Compared with intraoperative palpation or WGL, IOUS lessens the likelihood of positive surgical margins.2,3 IOUS requires advanced training and accreditation in breast ultrasound through a certification process offered by the American Society of Breast Surgeons.

Oncoplastic Lumpectomy

Breast-conserving surgery using techniques to maintain the normal contour of the breast while completely resecting the tumor is known as oncoplastic lumpectomy (OL). The cavity created by the lumpectomy is repaired by mobilizing the patient's own breast tissue. This approach allows women with larger tumors to undergo breast conservation with better cosmetic results; moreover, OL reduces the likelihood of mastectomy without compromising local control, while minimizing the need for implants and extensive reconstruction. Special attention is required to ensure adequate margins (confirmed with intraoperative radiographic and pathologic evaluation of the specimen). Surgeons performing OL must acquire specialized skills and knowledge of oncologic and plastic surgery techniques in collaboration with a multidisciplinary team.

Nipple-Sparing Mastectomy

The aim of nipple-sparing mastectomy (NSM) is to preserve the skin envelope overlying the breast, including the skin of the nipple and areola, while removing the breast's glandular elements and the majority of ductal tissue beneath the nipple-areola complex. This surgery can be performed via inconspicuous incisions at the inframammary crease or the periareolar border; combined with immediate reconstruction, it yields excellent cosmetic results. To minimize risk for necrosis or recurrence, the surgeon must remove glandular breast tissue within its anatomic boundaries while maintaining the blood supply to the skin and nipple-areola complex. For cancer cases, intraoperative pathologic evaluation of frozen sections from the nipple margin is recommended. NSM is oncologically safe in selected patients whose cancer is not near or within the skin or nipple (thus, Paget disease is a contraindication).4 This surgical approach is safe for prophylaxis in patients with BRCA mutations.5 However, the procedure may not be appropriate for women who smoke or have large, drooping breasts.

Contralateral Prophylactic Mastectomy

Rates of contralateral prophylactic mastectomy (CPM) continue to rise among U.S. women. CPM is medically appropriate for patients with high-risk genetic mutations, strong family histories, and high-risk breast disease such as lobular carcinoma in situ. However, many women choose CPM out of fear and anxiety about cancer recurrence or perceived risk for contralateral breast cancer. In survivors of first breast cancers without genetic mutations, 10-year risk for contralateral breast cancer is only 3% to 5%.6 CPM does not prevent the development of metastatic disease and has no survival benefit over breast-conserving surgery or unilateral mastectomy.7 Furthermore, compared with unilateral therapeutic mastectomy, the addition of CPM substantially raises risk for a major surgical complication.8

Conclusion

Mounting complexities in the treatment of patients with breast cancer have prompted the development of formal fellowship training in breast surgical oncology. Patients treated by high-volume breast surgeons have better cancer outcomes and greater satisfaction with their care.9,10 A multidisciplinary team-based approach involving procedures performed by well-trained, up-to-date surgeons combined with effective targeted therapies pave the future of this discipline.