Surgical Management of Breast Cancer

Pre-op & Staging - Setting the Stage

• Initial Assessment:
  • History (risk factors, family hx), Clinical Breast Exam (CBE).
  • Bilateral mammography (MMG) & USG (breast & axilla).
• Diagnosis & Receptor Status:
  • Core Needle Biopsy (CNB): Histopathology, ER/PR/HER2.
  • FNAC/CNB for suspicious axillary nodes.
• Staging (AJCC TNM):
  • Tumor size/invasion, Nodal status, Metastasis.
  • Metastatic workup (CT C/A/P, Bone Scan; PET-CT often used) for:
    • Locally advanced (≥Stage III).
    • Aggressive biology (e.g., Triple Negative).
    • Symptoms of metastasis.
• Pre-op Fitness: Routine labs, ECG, CXR (as indicated).
• Counseling: Surgery, reconstruction, neoadjuvant therapy (NACT) options.

⭐ Sentinel Lymph Node Biopsy (SLNB) is standard axillary staging for clinically node-negative (cN0) early breast cancer.

Surgical Options - Chopping Choices

• Breast Conserving Surgery (BCS): Tumor + margin removal.
  • Indications: Unifocal, < 4 cm, good tumor-breast ratio.
  • Mandatory post-op Radiotherapy (RT).
  • Goal: Negative margins ("no ink on tumor").
  • Avoid: Inflammatory Ca, multicentric, prior RT, pregnancy (early).
• Mastectomy (Entire breast removal):
  • Simple/Total: Breast, Nipple-Areola Complex (NAC).
  • Modified Radical (MRM): Total Mastectomy + Axillary Lymph Node Dissection (ALND I & II).
    • Patey: Pectoralis minor spared.
  • Skin/Nipple-Sparing (SSM/NSM): For reconstruction.
  • Indications: Large/multicentric, RT C/I, patient choice.
• Axillary Staging:
  • Sentinel Node Biopsy (SLNB): Standard for cN0 axilla.
  • Axillary Dissection (ALND): For cN+ or +SLNB (per criteria).

    ⭐ ACOSOG Z0011: For T1/T2, 1-2 +SLNs, BCS + Whole Breast RT, ALND omission is often safe.

BCS vs Mastectomy - The Big Debate

• Core Principle: For early-stage invasive cancer, BCS + Radiotherapy (RT) offers equivalent overall survival to Mastectomy.
• BCS: Tumor + margins removed; breast preserved. RT essential.
• Mastectomy: Entire breast removed. RT for high-risk cases.

• Multicentric disease / diffuse calcifications
• Prior chest RT / cannot receive RT
• Persistent +ve margins
• Inflammatory cancer
• Large tumor/small breast (poor cosmesis)

⭐ Overall survival for early-stage breast cancer is similar with BCS + RT versus mastectomy.

Axilla & Complications - Arming Against Issues

• Axillary Staging: Key for prognosis & treatment.
  • SLNB (Sentinel Node Biopsy): Standard for cN0. Uses dye + Tc-99m.
    • ACOSOG Z0011: May avoid ALND if 1-2 SLN+ (BCS, WBRT, no ENE).
  • ALND (Axillary Dissection): For cN+ or SLNB+ (not Z0011). Levels I & II.
    • Pectoralis minor: landmark for Levels I (lat), II (post), III (med).
• Key Complications:
  • Lymphedema: ↑Risk with ALND, RT, obesity. Manage: arm care, physio.
  • Seroma: Common. Aspirate if symptomatic.
  • Nerve Injury:

*   Shoulder stiffness, chronic pain.

⭐ Intercostobrachial nerve is most commonly injured in ALND, causing upper inner arm numbness.

High‑Yield Points - ⚡ Biggest Takeaways

• BCS + Radiotherapy offers survival equivalent to Mastectomy for most early breast cancers.
• SLNB is standard for axillary staging in clinically node-negative (cN0) patients.
• ALND is indicated for positive SLNB or clinically positive axillary nodes.
• Key BCS contraindications: multicentric disease, Inflammatory Breast Cancer (IBC), inability to get negative margins.
• "No ink on tumor" is the standard margin for invasive cancer in BCS.
• Prophylactic mastectomy is an option for high-risk individuals (e.g., BRCA carriers).
• Oncoplastic surgery enhances cosmetic outcomes in BCS while maintaining oncologic safety.