Challenges in breast conserving surgery

By
Ihab S. Fayek
MD. Surgical Oncology
National Cancer Institute
Cairo University - Egypt

From the Halstedian radical mastectomy to the more
aesthetic breast conserving surgery (BCS), the last
40 years have witnessed a fascinating evolution in
the role of surgery in the treatment of breast cancer.

Multiple prospective, randomized trials with more
than 20 years follow-up have since documented that
breast conserving surgery operations followed by
whole breast irradiation offers survival outcomes
equivalent to mastectomy in appropriately selected
patients.

 Recently, Hwang ES et al;2012 stated that
Women who underwent lumpectomy plus radiation
experienced improved OS and DSS compared with
women who underwent mastectomy for early stage
breast cancer
 Data were obtained from the California Cancer
Registry between 1990 and 2004. They analyzed
112,154 women diagnosed with stage I or II breast
cancer who underwent lumpectomy plus radiation
(55%) or mastectomy alone (45%)
 Median follow-up was 110.6 months
Cancer 2012

Breast conserving surgery is defined as the complete
removal of the tumor with a concentric margin of
surrounding healthy tissue with maintenance of
acceptable cosmesis, and should be followed by
radiation therapy to achieve an acceptably low rate of
local recurrence.

For BCT to successful, 3 conditions must be met :
(1) Achieve negative surgical margins while maintaining
cosmesis of the breast
(2) Safely deliver radiation therapy
(3) Promptly detect local recurrence

A breast surgeon may be confronted by
many Challenges before proceeding to ,
during and after BCS for female patients
with Breast Cancer.

1) Age
2) Family History
3) BRCA gene mutations
4) Preexisting collagen vascular
disease
5) Pregnancy

 Although young age, have been associated with
an increased risk for local failure after BCT or
after mastectomy; young age alone should not
preclude breast conservation
 Considering a more aggressive systemic treatment
in addition to local treatment appears appropriate.
 Jung et al;2012 concluded that under 35-year old
patients had significantly higher re-excision rates
than the other age groups of 36 to 50 and over 50
J Breast Cancer. 2012 December; 15(4): 412–419.

 Whenever possible, older women should be offered
breast conserving therapy rather than mastectomy
since this not only improves their quality of life but
also reduces risk of subsequent mental health
problems.
 Controversy exists as to whether or not XRT can be
safely omitted after breast conservation in elderly
patients.
 the National Comprehensive Cancer Network
guidelines in 2005 :“Breast irradiation may be
omitted in those 70 years of age or older with
estrogen receptor positive, clinically node-
negative, T1 tumors who receive adjuvant
hormonal therapy”.

Giordano SH ,2012 commented that older women
with low-risk breast cancer treated with adjuvant
radiotherapy are at risk for unnecessary adverse
effects, inconvenience of treatment, and possibly
increased personal costs for a treatment unlikely
to offer them any benefit.
However, Institutional variations between the
concept of “Better safe than sorry” and the new
one “Sometimes, less is more”.
J Clin Oncol 30:1577–1578.

 A family history of breast cancer is not a
contraindication to breast conservation.
 Several studies have shown that the rate of
breast recurrence in patients with first-degree
or second-degree relatives with breast cancer
is not different than that seen in patients
without a family history of breast cancer.

 Young women with breast cancer who have a family
history of breast cancer and who test negative for
mutations in BRCA1 and BRCA2 are at
significantly greater risk of contralateral breast
cancer than other breast cancer survivors.
 Women with a first-degree family history of
bilateral disease have risks of contralateral breast
cancer similar to mutation carriers (Reiner AS et
al,2013)
Journal of Clinical Oncology February 1, 2013 vol. 31 no. 4 433-439

 Patients with an inherited germ-line mutation in
BRCA 1 or 2, the risk of ipsilateral breast tumor
recurrence following BCS and RT is not increased
(at least over 10 to 15 years)
 However, those patients appear to be at a
substantially increased risk of contralateral breast
cancer, and this should be considered during the
treatment counseling process (Nestle-
Krämling C,2012)
Breast Care 2012;7:378–382

Breast cancers diagnosed among BRCA1 mutation
carriers were significantly more likely to be larger,
have higher histologic grade and have negative
estrogen and progesterone receptor status than in
BRCA 2 mutations.

 Patient with a history of autoimmune diseases such
as scleroderma, systemic or discoid lupus, and
dermatomyositis may have increased sensitivity to
radiation resulting in abnormal fibrosis which may
compromise the cosmetic outcome
 the consensus of reports indicates that such women
are at high risk for unusually severe skin, soft tissue,
bone, and pulmonary complications

 Breast cancer is diagnosed in about 1 pregnant woman
out of 3,000
 Radiation therapy during pregnancy is known to
increase the risk of birth defects, so it is not
recommended for pregnant women with breast cancer
 BCS is only an option if radiation can be delayed until
after delivery (3rd trimester?)
 Delayed breast reconstruction is a valid option for those
patients

1) Tumor Size
2) Tumor Location
3) Tumor Histology
4) Tumor Grade
5) Involvement of axillary lymph nodes

 Patients with tumors up to 4 cm. in diameter are good
candidates for BCS
 However, the ratio of tumor size / breast volume seems
to have a greater impact on the decision to proceed for
BCS
 Large pendulous breasts and high tumor size / breast
volume ratio are no more contraindications for BCS ;
regarding oncoplastic breast surgery, better radiation
delivery techniques and neoadjvant chemotherapy

 Multicentricity (ie, 2 separate cancers in different
quadrants of the same breast) is an important
Contraindication to BCS
 Tumors in a superficial subareolar location may
occasionally require the resection of the nipple/areolar
complex to achieve negative margins
 Poor cosmetic outcome have been reported as a result of
breast cancer operation due to lower quadrant breast
tumors; this is particularly true for women with small,
firm breasts  OBS

Oncoplastic Reconstruction with
Superior Based Lateral Breast
Rotation Flap after Lower
Quadrant Tumor Resection
• Operative design for
patients with lower
half located breast
cancer.
• If margin status of the
quadrantectomy
specimen was
adequate, a long skin
incision was made
from the axilla to the
tumor site along the
anterior axillary line
and inframammary
fold
Kim J. et al. J Breast Cancer. 2012

Kim J. et al. J Breast Cancer. 2012

 The histologic type appears to play a role in the choice of the surgical
procedure selected
 Lobular carcinomas may have a substantially increased propensity for
multifocal and multicentric distribution and for bilaterality
 Lobular carcinomas often fail to form distinct masses that can easily be
diagnosed by palpation or mammography. This can make early diagnosis
challenging and breast conservation approaches more difficult.
 Histology is not an important independent predictor of recurrence or
survival
 The same standard prognostic factors (tumor size, axillary nodal status,
hormone receptors, S-phase, and age) used in ductal carcinoma are
applicable in lobular carcinoma as well

 Studies have shown that recurrence rates after
excision of infiltrating lobular carcinoma to negative
margins do not differ from those after excision of
infiltrating ductal tumors.
 Historically, it was believed that extensive
intraductal component (EIC) was associated with an
increase risk of IBTR (Holland et al;1990)
 However, subsequent data has shown that when
EIC- positive tumors are excised to negative
margins (>2mm.), local recurrence rates are
comparable to those seen in EIC-negative tumors
(Gabram,2012)
JCO January 1990 vol. 8 no. 1 113-118 / Breart surgery ;Master techniques series 2012

Most studies indicate that histologic grade is not
predictive of recurrence
Some studies have identified lymphatic invasion at the
primary tumor site as a risk factor, but this has also
been shown to be a risk factor for local recurrence after
mastectomy.

The presence of clinically suspicious and
mobile axillary lymph nodes or
microscopic tumor involvement in axillary
nodes should not prevent patients from
being candidates for breast conservation
surgery (BCS).

 Approximately, 30-50% of breast cancers in modern
surgical practices are non-palpable.
 Impalpable lesions can be located preoperatively by a
variety of techniques:
1. Skin marking
2. Injection of blue dye
3. Carbon or radioisotope
4. Insertion of a hook wire with post-localization
mammograms.
5. Intraoperative ultrasound

 The best method available to date for preoperative localization of a
non-palpable breast lesion detected on imaging is the hook wire
localization technique described by Frank et al.; 1976
 Studies have shown the importance of supplemental effect of
ultrasound and its ability to detect some lesions missed at
screening mammography
 The procedure of wire localization is achieved with the aid of
ultrasound, as it provides complementary roles to mammography
in the detection of breast masses.

 Dedicated wire localization needles if not available,
a malleable sterilized slender steel wire, similar in
consistency to dental suture may be used.
 During surgical excision no part of the inserted wire
should be exposed in an attempt to achieve clear
margins.
 The excised tissue with the wire in-situ is orientated
and should be immediately send in saline for
specimen radiograph to confirm the inclusion of the
lesion, then to histopathology to ensure adequate
margins before wound closure.

Challenges in breast conserving surgery

 Radioguided occult lesion localization is a newer
technique for localization of impalpable lesions:
1. Under mammogram or ultrasound control
technetium-labelled human serum albumin or
sulphar colloid is injected into the tumour.
2. Gamma detecting probe is used intraoperatively to
locate the lesion to guide excision.

 Because of the high incidence of positive margins
and the need for reexcision or mastectomy after
single hooked wire excisions, a system of placing
multiple hooked wires around the perimeter of a
lesion before excision has evolved since 1982.
 Gregory M et al; 1998 stated that excision with the
bracketing hooked wire placement is significantly
better than that obtained with the use of a single
hooked wire before lumpectomy or quadrantectomy.

1) The incision
2) The extent of excision
3) Excision followed by RFA of the bed

 In planning the incision, the surgeon had to take into
consideration
1. The location of the lump
2. Type of incision
3. Depth of mass from the skin
 It had to be close to or just above the lump to avoid
tunneling.
 Excising skin directly overlying a cancer is only
necessary if the carcinoma is very superficial and/or the
skin is tethered.

 In the upper part of the breast, incisions should be
curvilinear or transverse, while in the lower part,
they should be either curvilinear or radial
 It should be sited in such a way that if mastectomy
is eventually required, it can be included in the
mastectomy specimen.
 A previous biopsy incision should be excised within
the lumpectomy or quadrantectomy incisions

 The surgical term “ breast conserving surgery ”
encompasses a range of procedures including:
1. Quadrantectomy (segmentectomy)
2. Lumpectomy (tumorectomy, tylectomy)
3. Partial mastectomy
4. Wide excision

 Quadrantectomy involves excision of 2-3 cm of normal
tissue around the tumour plus the removal of a
sufficiently large portion of overlying skin and
underlying fascia while lumpectomy removes only the
tumour mass with a narrow margin of normal tissue.
 Veronesi et al; 1990 stated that lumpectomy patients had
a much higher frequency of local recurrences (7.0 vs.
2.2%).
 Veronesi et al; and Fisher et al; 2002 reported an
important incidence of ipsilateral breast tumor
recurrence (IBTR) following BCT after 20 years of
follow-up: 8.8% following quadrantectomy plus RT and
14.3% following tumorectomy plus RT, respectively.
Eur J Cancer. 1990;26(6):671-3.

 Koyama Y et al;2012 performed BCS in 173 cases:
Lumpectomy in 95 cases and Quadrantectomy in 78
cases; concluded that as long as the surgical margin is
negative the IBTR and re-excision rates are not
statistically different.
“The validity of breast conserving surgery for negative surgical margin: wide excision versus quadrantectomy”
Yu Koyama; Eiko Sakata; Miki Hasegawa; Mayuko Ikarashi; Naoko Manba, and Chie Toshikawa
Division of Digestive & General Surgery, Niigata University Graduate School of Medical & Dental Sciences,Niigata, Japan.

 In a study ,lead by Klimberg et al;2012, 60 patients
with invasive cancer underwent tumor excision
(lumpectomy surgery) followed by radiofrequency
ablation (eRFA) at 100 degrees C for 15 minutes
with a real-time radiofrequency probe to extend the
radius of the lumpectomy cavity by 1 cm. None of
the patients received adjunctive XRT.
 Patients have been followed for an average of
44 months post-op.
the American Society of Breast Surgeons (ASBrS) Annual Meeting May 2012

 eRFA could reduce the need for re-excision, as well
as reduce local recurrence for invasive breast cancer
patients undergoing breast conservation surgery
without XRT.
 eRFA is an attractive alternative to breast
irradiation.
 This concept has recently initiated a multicenter
register trial called ABLATE (Radiofrequency
Ablation after Breast Lumpectomy Added To
Extend Intraoperative Margins) in patients
undergoing conservative breast surgery.

 Another study by Mackey et al;2012 on 16 patients
where The RFA probe was deployed 1 cm
circumferentially in the cavity and maintained at 100°C
for 15 min.
 The ablation zone was monitored with color-flow
ultrasound.
 Mean follow-up of 3.9 months, there were no local
recurrences.
 Two-week cosmesis scores were excellent (n = 9) to
good (n = 5).
Annals of Surgical Oncology Volume 19, Issue 8, August 2012

eRFA
 If the tumor is
< 1cm. from
the skin  a
skin ellipse
should be
removed.
 Skin retraction
is essential to
avoid skin
burns

 This represents one of the ongoing “great Challenges and
controversial debates” in breast cancer management
generally and in BCS specifically.
 Obstacles for obtaining consistently accurate margins are:
1. The nature of the tissue (adiposity)
2. The extent of in situ component
3. The insidious manner of tumor infiltration
4. Tumor multifocality
 Azu et al; 2010 stated that there has been no margin width
that more than 50% of surgeons or oncologists agree on
Ann Surg Oncol. 2010; 17:558-63

 Currently, a positive margin is generally interpreted to
mean the presence of tumor, either invasive and/or
ductal carcinoma in situ (DCIS), at the surgical
resection line.
 However, lymphatic invasion at a margin is not
considered a positive margin.
 Neither atypical ductal hyperplasia nor lobular
carcinoma in situ at margin is considered a positive
margin.

 The NSABP defines a positive margin as the
presence of tumor at the inked margin
 In practice, positive margin should prompt re-
excision, since such patients are at higher risk for
local recurrence even with XRT
 In 30 of 34 reviewed studies, persistent microscopic
inadequate (R1) or macroscopic inadequate (R2)
surgical margins were highly significant for LR
compared to the negative margin (p = 0.0001)

 Yildirim;2009 stated that risk factors associated with a
positive margin are: The extent of excision, large tumor size,
multifocality, lobular histological type, and the number of
positive lymph nodes
 Jung et al;2012 identified a tendency for the positive
resection margin rate and width to differ based on tumor
location; for example, a high positive resection margin rate
and a relatively narrow width of the superior and medial
margins were observed for LIQ tumors
EurJ Surg Oncol 2009;35:258-63 / J Breast Cancer. 2012 December; 15(4): 412–419.

 As most of the current techniques still result in a relatively
high rate of positive margins with impact on the LR rate and
cosmetic results, new innovative surgical approaches and
methods for IOMA are needed. The following are suggested:
1. Positron Emission Tomography (PET) imaging
2. Radio-guided Occult Lesion Localization (ROLL)
3. Infrared Fluorescence (NIRF) Optical Imaging

 A negative margin is the absence of tumor cells at
the inked margin
 Oncoplastic surgeons define a negative margin
quantitatively as “no tumor cells within 1 cm of the
cut edge of the specimen”(Kaur et al;2005).
 While the majority of the general literature appears
to consider 2 mm as the cutoff point for a negative
margin with anything less than that being
considered a close margin (Singletary 2002).
Am J Surg. 2002;184: 383-93.

 A survey of radiation oncologists in the U.S. and Europe
shows a significant variation in the definition of a
negative margin with European radiation oncologists
seeming to prefer a larger tumor-free margin (>5 mm)
than their American counterparts
 Houssami et al; 2010 in a comprehensive meta-analysis
stated that there is no statistical difference in local recurrence
rates associated when comparing margin widths of >1 mm,
>2 mm, and >5 mm when studies were adjusted for the use
of radiation boost and endocrine therapy.
Eur J Cancer. 2010;46:3219-32

 While data consistently show that positive margins carry
greater risk of local recurrence, a negative margin dose not
guarantee the absence of residual disease.
 However, it is believed that the residual disease burden in
patients with negative margins is small enough to be
controlled adequately with XRT.

 Institutional policies vary both in terms of the definition
of a “close” margin and XRT practice patterns based on
proximity of cancer cells to the margin edge.
 Less clear are cases where the margin is reported as
“close”
 Over the last decade, efforts have been made to classify
margin status based on the distance of the tumor cells
from the inked margin
(< 1mm?, < 2 mm?, 1-3 mm? or one cell line?)

 Measurements ranging from 1–3 mm have been
described as “close”. In the case of a pectoralis
fascia margin, a single collagen strand separating
tumor from margin is considered adequate
clearance.
 Studies reporting higher rates of local recurrence
among patients with “close”margins are limited and
discordant in their findings.
 Gurdal et al; 2012 stated that Re-excision or
mastectomy could be omitted in patients with close
margins with favorable factors such unifocal tumor
or node negative disease.
Eur J Surg Oncol. 2012 May;38(5):399-406

 Hossami et al;2010 concluded that a 1-mm
negative margin is as good as a wider margin if
patients receive optimal adjuvant therapy
 The conclusion was:
No justification for demanding margins
greater than 1 mm
Eur J Cancer. 2010;46:3219-32

 Axillary dissection, in the treatment of breast cancer,
does not provide significant survival advantage in
patients with negative axilla
 However, it is useful for the assessment of prognosis
and determining adjuvant therapy
 Axillary lymph node dissection (ALND) is indicated for
most patients with positive ipsilateral axillary lymph
nodes, when diagnosed by sentinel lymph node biopsy
(SLNB) or fine needle aspiration cytology (FNAC)

 Oz A et al; 2012 concluded that US-guided fine needle
aspiration is a highly specific assessment method. Using this
method, axillary metastases can be detected at a much lower
cost, preoperative staging of the disease can be performed,
and the time spent doing SLNB and intraoperative frozen
procedure under general anesthesia is eliminated.
 Houssami N et al; 2012 estimated that ultrasound-guided
needle biopsy triages 55.2% of women with metastatic
axillary nodes directly to ALND, thereby avoiding
unnecessary SLNB.
J Breast Cancer. 2012 June; 15(2): 211–217 / Breast Cancer Management May 2012, Vol. 1, No. 1, Pages 65-72

 Axillary staging is dominated by the sentinel lymph
node biopsy (SLNB),which is now widely practiced
in clinically node negative patients
 Most authors believe a SLNB may even be
performed in patients with a large or multifocal
tumour, before neo-adjuvant systemic therapy,
during pregnancy, after prior excisional biopsy and
after prior mantle field radiotherapy of the breast

 Removal of the primary tumor with excisional biopsy
may impair breast lymphatics. It used to be thought that
success of SLNB following excisional biopsy is low
 Ruano R et al; 2008 stated that The detection of the
SLN is feasible in patients with previous surgery of the
breast using the combined technique (Tc-colloidal
rhenium and isosulfan blue dye)
 Coskun G et al; 2012 concluded that, SLNB using a
combination method (methylene blue and Tc-99m
lymphsintigraphy) is safe and reliable for breast cancer
patients diagnosed with excisional biopsy
J Breast Cancer. 2012 March; 15(1): 87–90 / Eur J Nucl Med Mol Imaging. 2008 Jul;35(7):1299-304

 It is generally accepted that it is safe to omit an axillary
lymph node dissection (ALND) in patients with a
negative SLN or with only isolated tumour cells (<0.2
mm) in the SLN
 The need for a completion ALND in patients with a
positive SLND showing micrometastases or
macrometastases in less than three nodes has been
questioned
 Chagpar;2010 stated that completion ALND may not be
necessary in selected patients with a positive SLND in
less than three nodes because the need for systemic
therapy is established
Surg Oncol Clin N Am 2010; 19:493

 30 studies of 7151 women with a positive SLN not
undergoing a completion ALND with a median follow-
up of 45 months, the axillary recurrence rate was 0.3
percent for patients with micrometastases and 0.7
percent for patients with macrometastases (Francissen
et al; 2012).
 ALND may not be necessary for all women with T1
tumors that are clinically node negative, with less than
three positive SLNs, who will be treated with whole
breast radiation, particularly in women with estrogen
receptor positive tumors (Giuliano et al;2012).
 When completion ALND is omitted in patients with a
positive SLND, whole breast radiotherapy is indicated.
Ann Surg Oncol 2012; 19:4140 / Clin Exp Metastasis. 2012 Oct;29(7):687-92.

 Positive IM nodes are most common with medial
tumors over 2 cm in size.
 Although IM biopsy can be accomplished at the
time of mastectomy by splitting the fibers of the
pectoralis major, an IM node biopsy in a patient
undergoing BCS usually requires a second incision,
which is cosmetically visible.
 The procedure can be complicated by
pneumothorax, pleural effusion or bleeding.

 Many controversies in this topic because
(Chen 2008 and Heuts 2009)
1. There are limitations to the SLN technique for identification
of IM nodes
2. SLND does not reliably identify involved IM LNs because
of interference from radioactivity at the primary tumor site
3. There is a high rate of technical failure (20 to 39 percent) in
patients with parasternal hot spots on lymphoscintigraphy
4. Hot spots in the IM region do not always represent tumor
involvement
5. Some surgeons do not employ radiotracer injection and use
only an intraoperative injection of blue dye to identify the
sentinel nodes
J Clin Oncol 2008; 26:4981 / Eur J Surg Oncol 2009; 35:252.

 The surgical management of the IM nodes remains
controversial.
 There is no consensus on the need for IM nodal
dissection in women with detection of an IM SLN.
 Postma et al; 2012 stated that Routine sentinel node
biopsy of the IMC does not alter the systemic
treatment. Radiotherapy treatment is altered in a
small proportion (11%) of the patients.
Breast Cancer Res Treat. 2012 Jul;134(2):735-41.

 SLNB has reduced (2-7%), but not eliminated, arm
lymphedema in those patients who avoided ALND (6-
30%)
 The axillary reverse mapping (ARM) technique
developed in 2007 to identify and preserve arm nodes
during SLNB or ALND to prevent arm lymphedema
 The technique of arm node preservation was based on
the concept that the arm lymphatic pathway does not
communicate with the sentinel lymphatic pathway
 The ARM procedure is technically feasible with a high
visualization rate (Gobardhan et al;2012).
Eur J Surg Oncol. 2012 Aug;38(8):657-61

 Many controversies need to be resolved in arm node
preservation: (Noguchi M et al; 2010)
1. The rate of arm node identification by blue dye staining is
somewhat insufficient.
2. There are reports of metastasis in arm lymph nodes or in the
lymphatic pathway. This raises problems regarding the
safety of arm node preservation surgery.
3. Common lymphatic channels are found between SLNs and
arm lymph nodes. When a common channel exists, even
SLNB can cause lymphedema.
4. The stained blue arm node may be juxtaposed to the
metastatic lymph node, which could result in direct invasion
of the carcinoma and make it difficult to save the arm node.
J Surg Oncol. 2010;101:217–221

THE ARM NODE IS USUALLY LOCATED
BETWEEN THE LOWER LEVEL OF
AXILLARY VEIN AND ABOVE OR AT THE
LEVEL OF THE SECOND
INTERCOSTOBRACHIAL NERVE
ACCORDING TO THE AXILLARY
VEIN AND THORACODORSAL
VESSELS, THE REGION IS DIVIDED
INTO FOUR QUADRANTS

 Metastasis to ARM nodes can occur both in patients
with extensive nodal metastasis and in those with a
few positive nodes
 However, patients with clinically node positive
breast cancer had a significantly greater incidence of
positive ARM nodes than those with clinically node-
negative and sentinel node-positive breast cancer
 FNAC for ARM nodes might be helpful for the
assessment of metastasis in ARM nodes (Ikeda et al;
2012)
World Journal of Surgical Oncology 2012, 10:233

 Patients with SLN metastases appear to be good
candidates for the ARM technique and possibly also
patients with proven axillary metastases receiving
neoadjuvant chemotherapy (Gobardhan et al;2012)
 Arm node preservation was possible in all breast cancer
patients with identifiable arm nodes, during ALND or
SLNB, except for those with high surgical N stage
 Lymphedema and locoregional recurrences did not
develop in patients with arm node preserving surgery
(Lee et al;2012)
Eur J Surg Oncol. 2012 Aug;38(8):657-61 / Cancer Research: December 15, 2012; Volume 72, Issue 24, Supplement 3

 Approximately 10% to 15% of patients undergoing BCS for
operable breast cancer will develop a locoregional recurrence
within 10 years
 This risk is only slightly higher than that of a locoregional
recurrence following mastectomy (5%-10)
 Many IBTRs after BCS are detected by mammography
alone.
 The finding of disease in an ipsilateral preserved breast can
represent either a local recurrence of the initial cancer or a
second primary tumor.

 The distinction is important, as a local recurrence
will carry a worse prognosis than an ipsilateral new
primary.
 Local recurrence after BCS may be either invasive
or in situ cancer. For patients who were initially
treated for invasive disease, more than 80% of
locoregional recurrences are invasive
 For patients initially treated for in situ cancer
(DCIS), approximately 50% will recur with DCIS
and 50% with invasive disease.

1. Failure to achieve optimal local control (ie, suboptimal excision,
omission of XRT)
2. The presence of an EIC within the tumor in patients who didn’t
have negative resection margins
3. Patients who had extensive residual suspicious
microcalcifications
4. Younger patient age (<35)
5. Negative hormone receptor status
6. Aggressive tumor biology (Short period between BCS and the
appearance of IBTR)

One report revealed that ipsilateral breast tumor
recurrence at 8-years was 7%, 14% and 27% for
negative and close margins, focally positive and
extensively positive margins, respectively indicating
the importance of margin status in IBTR.

 Jacobson et al;2008 stated that Excising additional
shaved margins at the original surgery reduced
reoperations by 48%.
 There is a balance between removing additional
margins and desirable cosmesis after breast-
conservation surgery.
 The decision to take extra margins should be based
on the surgeon's judgment.
Am J Surg. 2008 Oct;196(4):556-8

1. Invasive disease
2. Tumor size
3. Skin or chest wall involvement
4. Nodal involvement
5. Hormone receptor - negative tumors.
6. Short time interval between initial BCS and local
recurrence
7. IBTRs that develop after Accelerated Partial Breast
Irradiation (APBI) resulted in excellent clinical
outcomes comparable with those observed after whole-
breast irradiation (WBI) (Shah C et al;2012)
Clin Breast Cancer. 2012 Dec;12(6):392-7

 Mastectomy is considered the standard approach for an
IBTR after BCS.
 The risk of subsequent chest wall recurrence following
mastectomy in patients with an invasive IBTR after
BCS is approximately 10%.
 Immediate reconstruction can be carried out as long as
there is no skin involvement.
 In the uncommon situation of a local recurrence in a
patient who underwent lumpectomy alone without
whole-breast irradiation repeat BCS followed by XRT
can be considered.

Challenges in breast conserving surgery

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