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OfficialreprintfromUpToDate
www.uptodate.com.scihub.cc2015UpToDate

Breastconservingtherapy
Authors
MichaelSSabel,MD
LoriJPierce,MD

SectionEditors
AneesBChagpar,MD,MSc,MA,
MPH,MBA,FACS,FRCS(C)
DanielFHayes,MD

DeputyEditor
WenliangChen,MD,PhD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Jul27,2015.

INTRODUCTIONBreastconservingtherapy(BCT)referstobreastconservingsurgery(BCS),followedby
moderatedoseradiationtherapy(RT)toeradicateanymicroscopicresidualdisease.ThegoalsofBCTareto
providethesurvivalequivalentofmastectomy,acosmeticallyacceptablebreast,andalowrateofrecurrencein
thetreatedbreast.
Whilemoderntechniquesarelessmorbidthanradicalmastectomy,amastectomystillrequiresthelossofthe
breast.Forthisreason,thequestionaroseastowhetherthebreastcouldbepreservedwithoutcompromising
survival.Sixmodern,prospective,randomizedclinicaltrialsdirectlycomparingBCTwithmastectomy[19]andan
overviewofallcompletedtrials[10]haveshownequivalentsurvivalbetweenthetwotreatmentapproaches.The
successofBCTiscontingentuponmoderatedoseRTineliminatingsubclinicalfociofdiseaseintheipsilateral
breast.(See"Adjuvantradiationtherapyforwomenwithnewlydiagnosed,nonmetastaticbreastcancer".)
Themajorissuesrelatedtobreastconservationtechniquesforsurgicaltreatmentofbreastcancerwillbereviewed
here.Thediagnosisandmanagementofbreastcancerisdiscussedelsewhere.(See"Overviewofthetreatmentof
newlydiagnosed,nonmetastaticbreastcancer".)
PATIENTSELECTIONFORBCTTheselectionofappropriatepatientsiscrucialtothesuccessofbreast
conservingtherapy(BCT).AlthoughBCTprovidesanacceptablealternativetomastectomyforthetreatmentof
invasivebreastcancer,itisnotapplicabletoallpatients.Mastectomyismandatoryfortumorcontrolforsome
subgroupsofpatientswithbreastcancer,anditmayprovidemoresatisfactoryoutcomesinothers.(See
"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement".)
TheAmericanCollegeofSurgeons,theAmericanCollegeofRadiology,theCollegeofAmericanPathologists,and
theSocietyofSurgicalOncologyhavedevelopedconsensusstandardsofcareforBCT[11].Similar
recommendationshavebeenmadebytheCanadianSteeringCommitteeonClinicalPracticeGuidelinesforthe
CareandTreatmentofBreastCancer[12].Thefollowingissuesareemphasizedintheappropriateselectionof
patientsforBCT:
Acompletehistoryandphysicalexaminationpriortotreatment.
Tissuebiopsywithcoreneedlesamplingtoprovideconclusiveproofofmalignancy.Needlebiopsyis
preferredoversurgicalbiopsytoreduceunnecessarysurgeryandavoidscarsthatmaycomplicatethe
placementofthesubsequentlumpectomyincision.(See"Breastbiopsy".)
Accuratehistologicassessmentoftheprimarytumor,includinghistologicsubtype,hormonereceptorstatus,
andHER2status.(See"Pathologyofbreastcancer"and"Prognosticandpredictivefactorsinearly,non
metastaticbreastcancer",sectionon'Tissuemarkers'and"HER2andpredictingresponsetotherapyin
breastcancer",sectionon'TestingforHER2expression'and"Hormonereceptorsinbreastcancer:Clinical
utilityandguidelinerecommendationstoimprovetestaccuracy",sectionon'AssaysforERandPR'and
"Prognosticandpredictivefactorsinmetastaticbreastcancer",sectionon'Testsdoneonbreasttissue'.)

6FL+XE

Oncethediagnosisofcancerismade,multidisciplinarycoordinationamongbreastandreconstructive
surgeons,radiationandmedicaloncologists,andradiologistsandpathologistsfacilitatestreatmentplanning

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andstreamlinespatientcare[13].Insomecases,neoadjuvantchemotherapyiswarrantedtodecreasethe
tumorsizeandimprovethesuccessrateofbreastconservation.(See"Diagnosticevaluationofwomenwith
suspectedbreastcancer"and"Neoadjuvanttherapyforbreastcancer:Rationale,pretreatmentevaluation,
andtherapeuticoptions".)
Preoperativebreastimaging,todefinetheextentofdiseaseandidentifymultifocalormulticentriccancerthat
couldprecludebreastconservationorpotentialdifficultyinachievingclearsurgicalmargins.Imagingtypically
includesacombinationofbilateralmammographicevaluation,withappropriatemagnificationviews,and
ultrasound,ifappropriate.Thetumorsizeshouldbeincludedinthemammographicreport,aswellas
documentationofassociatedmicrocalcifications,andtheextentofthecalcificationswithinandoutsidethe
mass.(See"Clinicalfeatures,diagnosis,andstagingofnewlydiagnosedbreastcancer",sectionon
'Assessingtheextentofdisease'.)
Somesurgeonsmayincorporatebreastmagneticresonanceimaging(MRI)intheworkupofpatients
consideringBCT,howevertheuseofroutineMRIinthissettingisnotindicated.Theindicationsforbreast
MRIforthepreoperativeassessmentofdiseaseinnewlydiagnosedbreastcancerarelistedhereand
discussedindetailelsewhere.(See"Diagnosticevaluationofwomenwithsuspectedbreastcancer",section
on'BreastMRI'.)
Foraclinicalpresentationofdiseasethatislargerthanwhatisappreciatedbymammography
(particularlyinthesettingofdensebreastswhichlowerthesensitivityofmammography)
Forinvasivecancersthatarecontiguoustothechestwallandnotcompletelyincludedon
mammographicprojections,
Forpatientswithaxillarynodalmetastasesandaclinicallyandmammographicallyoccultprimarytumor
ForwomenwithPagetsdiseaseofthebreastwhohaveanegativephysicalexaminationand
mammogram
Inwomenwithlocallyadvancedbreastcancerwhoarebeingconsideredforneoadjuvantsystemic
therapytoassesstumorresponsetotherapy
Forwomenwithveryhighriskforcontralateraldiseasebecauseofaninheritedpredisposingcondition,
orpriorchestwallirradiation
WomenshouldbeinformedoftherisksandbenefitsofpreoperativebreastMRI.Thelimitsoftheaccuracy
ofMRIshouldbediscussedwithpatients,sothattheyunderstandtheneedforbiopsyofMRIdetected
lesionsbeforedefinitivesurgery.BreastMRIshouldbeperformedwithadedicatedbreastcoilbyexpert
breastimagingradiologistsininstitutionsthathavethecapabilitytoperformMRIguidedneedlebiopsyand/or
wirelocalizationofthefindings.
SurgicaldecisionsshouldnotbebasedonMRIfindingsalone.MRIfindingsaloneshouldnotbeusedto
changesurgicalplanningandconversionfrombreastconservationtomastectomy.Allsuspiciousfindingson
MRIrequirepathologicconfirmation.
SelectioncriteriaforBCTTheindividualpatient'sneedsandexpectationsshouldbeaccuratelyassessed.
Thisrequiresthatthepatientandphysiciandiscussthebenefitsandrisksofmastectomycomparedtobreast
conservingtherapy(BCT)inregardstolongtermsurvival,thepossibilityandconsequenceoflocalrecurrencewith
eithertreatment,andtheimpactoncosmeticoutcomeandpsychosocialadjustment.Therearemanyissuesto
considerregardingthisdecision:
AgeisnotacontraindicationtoBCTphysiologicageandthepresenceofcomorbidconditionsshouldbethe
primarydeterminantsoflocaltherapyinolderwomen.
Retractionoftheskin,nipple,orbreastparenchymaisnotnecessarilyasignoflocallyadvancedbreast
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canceranddoesnotcontraindicateBCT.However,ifaportionofskinorthenippleareolarcomplexwillneed
toberesectedtoachievenegativemargins,thecosmeticimplicationsofthisshouldbefactoredintothe
decisiontoproceedwithBCT.
Histologicsubtypesotherthaninvasiveductalcarcinoma(eg,invasivelobularcancer)arenotassociated
withanincreasedriskofbreastcancerrecurrence[14,15]thesewomenarecandidatesforBCTifthetumor
distributionisnotdiffuseanditcanbeexcisedwithnegativemargins[16].(See"Pathologyofbreast
cancer".)
Thepresenceofanextensiveintraductalcomponent(EIC)isanindicatorthatdiseaseextentmaybegreater
thanclinicallysuspectedbutisnotacontraindicationtoBCTbyitself.Patientswithnegativemarginsare
stillacceptablecandidatesforBCT.(See'Extensiveintraductalcomponent(EIC)'below.)
Lymphnodepositivityisamarkerofworseprognosis,butpositivelymphnodesarenotacontraindicationfor
BCT,asBCTandmastectomyhaveequivalentoutcomesindependentofnodalmetastases.(See"Adjuvant
radiationtherapyforwomenwithnewlydiagnosed,nonmetastaticbreastcancer",sectionon'Patients
treatedwithmastectomy'.)
Tumorlocationshouldnotinfluencethechoiceoftreatment.Tumorsinasuperficialsubareolarlocationmay
requireresectionofthenippleareolarcomplextoachievenegativemarginsoncologicoutcomeswillnotbe
affected,butthecosmeticresultmaybe.Althoughoncoplastictechniquesimprovecosmesis[17],the
patientandherclinicianneedtoassesswhethersucharesectionispreferabletomastectomy.
AfamilyhistoryofbreastcancerisnotacontraindicationtoBCT(see'Inheritedsusceptibility'below)
however,womenwithastrongfamilyhistorysuggestiveofageneticpredispositionshouldbeinformedabout
theirincreasedriskofasecondprimarycancer.(See"Overviewofhereditarybreastandovariancancer
syndromes".)
AhighriskofsystemicrelapseisnotacontraindicationforBCTbutinsteadindicatestheneedforadjuvant
systemictherapy.
Breastconservationsurgery(BCS)isnotcontraindicatedforwomenwithdensebreasttissue.Ina
prospectivestudyof1052patientsundergoingattemptedBCS,patientswithdensebreasttissuewere
significantlymorelikelytobetreatedwithaninitialmastectomycomparedwithwomenwithlessdense
breasttissue(74versus52percent,oddsratio[OR]1.94,95%CI1.442.62,p<0.0001)[18].Thismay
reflectsurgeonorpatientbiasratherthananinabilitytofulfillcriteriaforBCS.
Inaddition,MRIwasperformedmoreofteninpatientswithdensebreasttissue(65versus33percent).However,
breastdensitywasnotassociatedwithpositivemarginsforBCSorconversiontoamastectomy,andpreoperative
MRIdidnotdecreasetheriskofpositivemargins.
Specialconsiderations
ConnectivetissuediseaseSomepatientswithahistoryofconnectivetissuediseasetolerateirradiation
poorly,andsotheuseofRTasacomponentofBCTmustbeweighedagainstthepossiblecomplications[1924].
However,despitenumerouscasereportsdescribingradiationinducedtoxicities,noneofthethreepublished
retrospectivematchedcontrolstudieshaveshownastatisticallysignificantincreaseinacutetoxicitiesinthis
patientpopulationasawhole[20,22,23].Onlyonewasabletoshowastatisticallysignificantincreaseintherisk
oflatecomplicationsinpatientswithconnectivetissuedisease,andthiseffectdisappearedinsubsetanalysisby
diseaseinallpatientsbutthosewithscleroderma[22].
Incontrast,thelargestofthethreestudiesnotedthatpatientswithsclerodermaandsystemiclupus
erythematosus(SLE),butnotrheumatoidarthritis,wereatasignificantlyincreasedriskoflatetoxicities.Asa
result,manyradiationoncologistsconsidersclerodermaandactiveSLEtoberelativecontraindicationstoBCT
[11,24].(See"Overviewoftheclinicalmanifestationsofsystemicsclerosis(scleroderma)inadults".)
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TumorsizeTumorsizerelativetobreastsizeisanimportantconsiderationinselectingpatientsforBCT.A
largetumorinasmallbreastisarelativecontraindication,sinceanadequateresectionwouldresultinsignificant
cosmeticalteration.However,tumorsizeinitselfisnotanabsolutecontraindicationtoBCT.Breastsizeisalso
notinitselfacontraindicationtoBCT.Womenwithlargeorpendulousbreastscanundergobreastirradiation
successfullyaslongasreproducibilityofpatientsetupcanbeensured,anditistechnicallypossibletoobtain
adequatedosehomogeneity.
RoleofneoadjuvanttreatmentNeoadjuvanttreatmentwithchemotherapyorhormonaltherapycanreduce
tumorsizesignificantlyandallowforbreastconservationwithacceptableratesoflocalrecurrence(table1)[25].
Clipplacementinthetumorbedunderultrasoundguidanceshouldbeaccomplishedbeforeorsoonafter
neoadjuvanttreatmentbeginsifpossible.Themetallicclipensuresthatthesurgeoncanaccuratelylocalizethe
tumorbedincasethereisacompleteresponsetochemotherapy.
Thepresenceofmulticentricdisease,extensivemicrocalcifications,extensiveskinchanges,aclinicaldiagnosis
ofinflammatorybreastcancer,anddermallymphaticinvolvementareconsideredcontraindicationsforthis
approach.
ContraindicationsTherearefewabsolutecontraindicationstoBCT.Theyinclude:
Multicentricdiseasewithtwoormoreprimarytumorsinseparatequadrantsofthebreastsuchthatthey
cannotbeencompassedinasingleexcision.
Diffusemalignantmicrocalcificationsonmammography.
AhistoryofpriortherapeuticRTthatincludedaportionoftheaffectedbreast,whichwhencombinedwiththe
proposedtreatment,wouldresultinanexcessivelyhightotalradiationdosetothechestwall.
Pregnancyisanabsolutecontraindicationtotheuseofbreastirradiationhowever,itmaybepossibleto
performbreastconservingsurgeryinthethirdtrimester,deferringbreastirradiationuntilafterdelivery.(See
"Gestationalbreastcancer:Epidemiologyanddiagnosis".)
Persistentlypositiveresectionmarginsaftermultipleattemptsatreexcision[26].
PREOPERATIVEPREPARATION
AntibioticsApreoperativeantibiotic,suchascefazolin,shouldbeadministeredafterarrivingintheoperating
roomandbeforetheincisionismade[2729].Theefficacyofantibioticprophylaxisdecreasesifadministeredmore
thanonehourbeforesurgery(table2)[3032].Ametaanalysisoftherandomizedcontrolledtrialsofpreoperative
antibioticsversusplaceboinpatientsundergoingbreastsurgeryfoundthattheuseofpreoperativeantibioticswas
associatedwithasignificantreductionininfection(relativerisk=0.60CI=0.45to0.81)[33].(See"Antimicrobial
prophylaxisforpreventionofsurgicalsiteinfectioninadults".)
DeepvenousthrombosisprophylaxisForpatientsundergoinggeneralanesthesia,primaryprophylaxisfor
preventionofdeepvenousthrombosis,suchassequentialcompressiondevices,shouldbeemployed(table3).
(See"Preventionofvenousthromboembolicdiseaseinsurgicalpatients".)
SURGICALTECHNIQUEThetypeandlocationoftheincisionisimportantforseveralreasons.Itis
imperativetorememberthatanypatientwhoundergoeslumpectomymayultimatelyrequireamastectomy,and
incisionsshouldbeplannedwithpossiblemastectomyincisionsinmind.Theincisionshouldbeplacedcloseto
thetumortoavoidextensivetunneling.Intheupperpartofthebreast,incisionsshouldbecurvilinearortransverse
andfollowthenaturalskincreases(Langer'slines).Inthelowerpartofthebreast,thechoiceofacurvilinearor
radialincisionisdependentuponthecontourofthebreast,thedistancefromtheskintothetumor,andtheamount
ofbreasttissuetoberesected.Atthecompletionoftheprocedure,theincisionshouldbeclosedwitha
subcuticularsuturetoavoidcrosshatchingoftheskin.
Indeeperlesions,itisnotnecessarytoremoveskin,andpreservationofthesubcutaneousfatandavoidanceof
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thinskinflapsareimportantinmaintaininganormalposttreatmentbreastcontour.Ifthetumorissuperficial,it
maybenecessarytoremovetheoverlyingskin.Skinremovalwithacurvilinearincisionintheinferiorbreast
distortsthebreastcontourandshouldbeavoided.Itisalsonotnecessarytoremoveneedletracksfromcore
needlebiopsiesorfineneedleaspirations.
Meticuloushemostasisisimportant,becausealargehematomadistortstheappearanceofthebreastandmakes
reexcisionandfollowupevaluationmoredifficult.Thepresenceofapostbiopsyhematomaisnota
contraindicationtobreastconservingtherapy(BCT).Reapproximationofthebreasttissuewithouttissue
advancementisbestavoided,sinceitcanresultindistortionofthebreastcontour,whichmaynotbeapparent
withthepatientsupineontheoperatingtable[11].Cosmeticoutcomescanbeimprovedwithoncoplastic
techniques.(See"Oncoplastictechniquesinbreastconservingsurgery".)
LongtermcomplicationsofbothBCTandmastectomyarepresentedelsewhere.(See"Overviewofbreast
reconstruction"and"Patternsofrelapseandlongtermcomplicationsoftherapyinbreastcancersurvivors",
sectionon'Longtermadverseeffectsofprimarytherapy'.)
EvaluationoftheaxillaEvaluationoftheaxillaprovidesinformationfortreatmentdecisionsinpatientswith
invasivebreastcancer.Sentinelnodebiopsyisthestandardinitialapproachforpatientswithaclinicallynegative
axillaryexamination.Themanagementoftheregionallymphnodesinbreastcancer,sentinelnodebiopsy,and
axillarydissection,arediscussedelsewhere.(See"Managementoftheregionallymphnodesinbreastcancer"and
"Diagnosis,stagingandtheroleofsentinellymphnodebiopsyinthenodalevaluationofbreastcancer"and
"Techniqueofaxillarylymphnodedissection".)
MarginsofresectionMicroscopicresectionmarginsarethemajorselectionfactorforbreastconserving
therapy(BCT),becauseoftheirmarkedinfluenceonlocalrecurrence.Womenwithnegativeexcisionmargins
havelowratesoflocalrecurrencefollowingBCT[1,3446],whilepositiveresectionmargins(ie,carcinomaatthe
inkedmargin)areassociatedwithahigherriskoflocalrecurrence[36,3841,4345,47].
Theappropriatemacroscopicmarginofnormalbreasttissuetoresectaroundthetumorforwomenundergoing
BCTshouldbe0.5to1.0cmofgrosslynormalbreasttissue,whichwillusuallyresultinhistologicallynegative
margins(ie,notumoratink)inthemajorityofpatients[48].Largerresectionsmaybenecessaryforinvasive
carcinomaswithanextensiveintraductalcomponent(EIC)[4951]orforinfiltratinglobularcarcinomas[1,5254].
Preoperativewirelocalization,specimenorientation,specimenradiography,intraoperativemarginassessment,and
postexcisionwholecavityshavingareallhelpfulforobtainingnegativeexcisionmargins,asdiscussedbelow.
WirelocalizationForresectionofnonpalpablelesions,preoperativewirelocalizationbytheradiologist
allowsaccurateidentificationofthearearequiringresection[55].Multiplebracketingwiresmaybehelpfulfor
delineationoftheboundariesoftheresection,butdonotensureclearhistologicmarginsofresection.Asan
example,inonestudyofwirebracketingforpreoperativelocalizationof75cancers,clearhistologicmargins
ofresectionwereobtainedin33patients(44percent).
SpecimenorientationThespecimencanberemovedasasinglepieceoftissue.Grossinspectionofthe
specimenintheoperatingroom,withorwithoutfrozensectionanalysis,permitsidentificationofpositiveor
closemarginsandimmediatereexcision,ifappropriate[56].Thiswilldecreasetheneedtoreturntothe
operatingroomforreexcision.Sutures,clips,and/ormulticoloredinksareusedtoorientthespecimenbythe
operatingsurgeon.Inkingkitsareavailablewithsixcolorsforlabelingallofthesurgicalmargins(superior,
inferior,medial,lateral,superficial,anddeep).Clearuniformitybetweensurgeonandpathologistintermsof
whatsutureorcolorcorrespondstoeachmarginisrequired.Thisfacilitatesreportingofthestatusof
individualmarginsandifreexcisionisrequired,thesurgeoncanlimitthereexcisiontotheinvolvedmargin
[57].
SpecimenradiographySpecimenradiographyshouldbeperformedduringthesurgicalprocedureto
confirmexcisionofthetargetedlesionwhenthelesionwasnotpalpable.Additionalorientedmarginscanbe
resectedpriortoclosurewhentheradiographsuggestsinadequateresection,whichmayeliminatetheneed
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foradelayedreexcision.Inaretrospectivestudyof123patientsundergoingBCS,specimenradiography
identified19patientswithamargin2mmwhounderwentadditionalintraoperativeexcision[58].In63
percentofcases(12/19)histologicalassessmentconfirmedthatthemarginsofthefirstsurgicalspecimen
werepositiveandintraoperativereexcisioneliminatedtheneedforasecondoperation.Inanotherstudyof
264patientsundergoingBCS,specimenradiographyidentified54patientswithclosemargins(6withDCIS
and48withinvasivecancer),whounderwentadditionalintraoperativeexcision[56].Ofthese,25percentof
patientswithDCISand63percentofpatientswithinvasivecancerwererenderedmarginnegativewith
intraoperativereexcision.
IntraoperativemarginassessmentSeveralapproachescanbeusedforintraoperativemargin
assessment,includingfrozensection[56,5961],cytologictouchprepanalysis[6267],shavedmargin
analysis[68],intraoperativeultrasound[69],aswellasintraoperativemarginassessmentdevicessuchas
MarginProbe[70].Thereisnoprevailingstandardofcareforintraoperativemarginassessmentandpractices
varywidely[71].Theuseofthesetechniquesmayassistinobtainingnegativemargins,butdoesnot
guaranteetheabsenceofmicroscopictumoronpermanentsections.Patientsshouldbeadvisedthat
additionalsurgerytoobtaincleanmarginsmaybenecessary.
PostexcisionwholecavityshavingAnalternativeapproachispostexcisionwholecavityshaving,
whereanadditionalmarginofnormalappearingtissueisexcisedfromeachmarginofthecavity(superior,
inferior,lateral,medical,anterior,posterior)afterlumpectomyhasbeencompleted.Thishasbeenshownto
reducereexcisionrates[57,7276],includinginarandomizedtrialwheretherateofpositivemargins
decreasedfrom34to19percent,andthereoperationratedecreasedfrom21to10percent[77].Further
studiesareneededtodeterminewhetherthistranslatesintolowerrecurrenceratesorimprovedsurvival.
IndicationsforwiderexcisionofmarginsTheindicationforawiderexcisionfollowingbreastconserving
surgeryisahistologicallypositivetumormarginidentifiedonthesurgicalspecimen.Ahistologicallypositive
marginisdefinedasthepresenceofinkatthesurfaceoftheinvasiveornoninvasivecancerapositivemargin
impliesapotentiallyincompleteresection.Patientswithapositivetumormarginhaveanatleasttwofoldincrease
inipsilaterallocalbreastcancerrecurrence[48].Theriskofalocalrecurrencewithapositivemarginwasnot
reducedbytheuseofradiationboosttotumorbed,adjuvantendocrinetherapy,orchemotherapy.
Thus,researchhasbeenfocusedontheoptimalamountofnormaltissuethatshouldsurroundthetumorto
minimizetheriskofalocalrecurrence[43,48,78,79].Baseduponametaanalysisthatincluded33studiesand
28,162patientswith1506ipsilateralrecurrences,amultidisciplinaryconsensuspanelsupportstheuseofnoink
onthetumorasanadequatenegativemarginofresectionforinvasivebreastcancers[48].
Therewasnoevidencethatawidermarginofnormaltissuethannoinkonthetumordecreasedtherateoflocal
recurrenceintheclinicalsettingofmultimodalitytreatment.Thisincludesmanysubgroupspreviouslythoughtto
requiremoreaggressivetreatment,includingyoungerpatients(<40yearsofage),thosewithaggressivebiologic
subtypesorinvasivelobularcarcinoma,andextensiveintraductalcarcinomawithoutresidualmicrocalcifications
[8085].
Whilerecognizingthatroutinepracticetoobtainwidermarginsthaninkontumorisnotindicated,someexperts
haveadvocatedforflexibilityintheapplicationoftheaboveguidelinesinlightofthegenerallyweak(retrospective)
evidencesupportingtherecommendations[86].Wesuggestanindividualizedapproachtopatientswithclose(<1
mm)marginswithregardtoreexcision[87].
CosmeticoutcomeManysurgicalfactorswillplayaroleintheultimatecosmeticappearanceofthebreast.
Theseincludethesizeandplacementoftheincision,managementofthelumpectomycavity,andtheextentof
axillarydissectionifnecessary.Thesurgeonhascontroloverseveraloftheseissues,andcarefulattentionto
detailwillimprovetheaestheticresults[88,89].
Inadditiontolocalrecurrence,amajorgoalofBCTisthepreservationofacosmeticallyacceptablebreast.With
moderntreatmenttechniques,anacceptablecosmeticoutcomecanbeachievedinalmostallpatientswithout
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compromiseoflocaltumorcontrol.Inaseriesofwomentreatedwithawholebreastdoseof45to46Gy(daily
dose2Gy),aboostdoseof18Gy,andprecisefieldmatchingtechniques,excellentorexcellent/goodcosmetic
resultswerenotedatthreeyearsin73and96percentofwomen,respectively[90].Althoughtreatmentrelated
changesinthebreaststabilizeatapproximatelythreeyears,otherfactorsthataffecttheuntreatedbreast,suchas
changeinsizebecauseofweightgainorthenormalptosisseenwithaging,continuetoaffectbreastsymmetry.
TohelpassessthecosmeticoutcomeafterBCT,ascoringsystemtostandardizethegradingofcosmetic
outcomehasbeenrecommendedbyajointcommitteeoftheACS,theACR,theCollegeofAmerican
Pathologists,andtheSocietyofSurgicalOncology(SSO)[91],andusedattheJointCenterforRadiationTherapy
(JCRT)[92].Thefollowingscoresareassigned:

Excellent:Thetreatedanduntreatedbreastarealmostidentical
Good:Minimaldifferencesbetweenthetreatedanduntreatedbreasts
Fair:Obviousdifferencesbetweenthetreatedanduntreatedbreasts
Poor:Majoraestheticsequelaeinthetreatedbreast

TheamountofresectedbreasttissueisthemajordeterminantofappearancefollowingBCT[49,9294],as
illustratedbythefollowing:
InatrialfromtheNationalCancerInstituteofMilanthatcomparedquadrantectomytogrosstumorexcision
(lumpectomy),bothcombinedwithRT,cosmeticevaluationswereperformed18to24monthsposttreatment
in148patients[49].Womenundergoingquadrantectomyhadsignificantlygreaterdiscrepanciesintheinferior
profileofthebreasts,greaterdistancefromthemidlinetothenipple,andweremorelikelytohavemorethan
a3cmdifferenceinheightbetweenthenipples(21versus7percent)thanthosetreatedwithlumpectomy.
SimilardatawerenotedbytheJCRTinaseriesthatcorrelatedcosmeticoutcometothevolumeofbreast
tissueresected(estimatedbymultiplyingthedimensionsoftheresectedbreastspecimens)[92].Forwomen
with<35cm3resectedtissue,excellentandexcellentorgoodscoreswerereportedby85and96percent,
respectively.Incontrast,whenthevolumeofresectedtissuewas>85cm3,excellent,andexcellentorgood
scoreswerereportedby51and94percentofwomen,respectively.Inalaterseries,cosmeticresults
declinedoverthefirstthreeyearsandthenstabilizedtheywerestilljudgedbyclinicianstobeexcellentin
77percent,andgood,fair,orpoorin9,9,and5percent,respectively[95].
POSTOPERATIVECOMPLICATIONSComplicationsafterbreastconservingsurgeryincludeseroma
formation,infection,andarmmorbidity.
SeromaSeromaformationoccursinvirtuallyallpatientsafterbreastandaxillarysurgery,andshouldbe
consideredatransientsideeffectratherthanamajorlonglastingcomplicationoftheseprocedures[96].Although
allpatientswillhavesomeserousfluidcollectatthesurgicalsite,seromasarenotclinicallysignificantinmost
cases.Aclinicallysignificantseromacanbedefinedasapostoperativefluidcollectionthatrequiresoneormore
aspirationsorsubsequentdrainplacement[97].
Theratesofclinicallysignificantseromasofthebreastoraxillavarywiththesurgicalprocedureperformed.Ina
retrospectivereviewof324patientswhounderwent561breastoraxillarysurgeries,8.4percentdevelopeda
seromathatrequiredintervention[97].Seromaratesweresignificantlylowerafterbreastconservingsurgerythan
aftermastectomy(6versus14to16percent).Thepresenceofaseromasignificantlyincreasedtheriskofa
concurrentorsubsequentsurgicalsiteinfection(8.5versus4percentintheabsenceofaseroma).Inadditionto
infection,prolongedseromaformationmayalsobeassociatedwithdelayedwoundhealing[98100].
BreastcellulitisandabscessBreastcellulitisisanemergingprobleminwomenundergoingbreastconserving
therapy(BCT)andrepresentsashiftfromtheipsilateralarmcellulitisobservedinthepastfollowingmastectomy
andaxillarylymphnodedissection(ALND)[101103].(See"Breastcellulitisandotherskindisordersofthe
breast".)
BCTmayalsobeassociatedwiththerelativelylateoccurrenceofapostoperativebreastabscess(median5
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months,range1.5to8.0months).Inonereport,theonlyfactorthatcorrelatedwithabscessformationwassizeof
thelumpectomyspecimennecrosisofmarginallyviablefatinthelumpectomycavitymaycontributetothis
problem[104].
ArmmorbidityArmmorbidityiscommonafterbreastcancertreatmentandcanincludearmswelling,arm
pain,armnumbness,armstiffness,shoulderstiffness,shoulderpain,ornerveinjury[105].Armproblemsareless
commonafterBCTascomparedtomastectomytheyarealsolessfrequentwithsentinellymphnode(SLN)
biopsythanafteraxillarylymphnodedissection(ALND)[106].
Afterbreastcancertreatment,patientsshouldbeinformedaboutmethodstoimproveshoulderfunctionandreduce
theriskoflymphedema[107,108].Preventionandtreatmentofarmedemaarediscussedseparately.(See
"Clinicalfeaturesanddiagnosisofperipherallymphedema"and"Preventionandtreatmentoflymphedema".)
ElderlyRiskofpostoperativecomplicationsincreaseswithincreasingageaswellasassociatedcomorbid
illnesses.Inaretrospectivereviewof3672patientsage65yearsandolderwithinvasiveornoninvasivebreast
cancermanagedwitheitherBCTormastectomy,patients>85yearsoldweresignificantlymorelikelytodevelop
complicationscomparedwiththeoverallcomplicationrate(25.1versus19.4percent,oddsratio[OR]1.8595%CI
1.372.50,p=0.001)[109].Inaddition,womenage65to69yearshadasignificantlylowercomplicationrateof
15.3percent.Themostcommoncomplicationsincludedwoundinfectionandbleedingforallages65andolder,
includingwomen>85years.
Onunivariateanalysis,otherfactorsthatincreasedtheriskofpostoperativecomplicationsincluded:

Polypharmacyversusnone(OR1.84,1.462.32)
Axillarylymphnodedissectionversusnoaxillaryprocedure(OR1.76,1.362.27)
MastectomyversusBCT(OR1.72,1.422.09)
Comorbidillnessoneversusnone(OR1.32,1.011.72)
Neoadjuvanttherapy(OR1.43,1.031.98)
Smokingattimeofdiagnosis(OR1.41,1.071.86)

LOCALRECURRENCEThelocalrecurrence(LR)ratefollowingbreastconservingsurgeryincreaseswith
youngage,nodepositivity,estrogenreceptornegativity,andabsenceofradiationtherapy[110].Incomparingthe
resultsofbreastconservingtherapy(BCT)withmastectomyandassessingtheprobabilityandimpactoflocal
recurrence,itisimportanttoidentifyfactorsthatmayincreasetheriskoflocalrecurrence.Whilenot
contraindicationstoBCT,thesefactorsmayinfluencethechoiceoftreatment.
Mastectomydoesnotguaranteefreedomfromlocalrecurrence.Inrandomizedstudiesusingvariablesurgicaland
RTtechniques,longtermrecurrenceratesinthetreatedbreastfollowingBCT(withradiation)rangefrom5to22
percent,comparedto4to14percentwithmastectomy[26,8,9].Thetimecourseoflocalrecurrencedifferswith
BCTversusmastectomy.Althoughmostpostmastectomylocalfailuresoccurinthefirstthreepostoperative
years,theytendtooccurlaterinwomentreatedbyBCT[92,111113].Inonereport,asanexample,theactuarial
incidenceoflocalrecurrencewas7,14,and20percentat5,10,and20yearsfollowingBCT[112].This,inpart,
mayreflecttheinclusionofnewprimariesratherthanonlytruerecurrencesinthedefinitionofinbreasttumor
recurrence.
InterpretationofdataonlocalrecurrencefollowingBCTishamperedbymethodologicproblems.Manyreports
differwithregardtopatientselection,surgicalandradiationtechniques,andtheuseofadjuvantsystemictherapy.
Furthermore,thecompetingrisksofdistantrecurrenceandsecondprimarycancersalsocomplicatetheestimation
oftruelocalrecurrencerisk[114,115].Nevertheless,despitetheseissues,severalpredictivefactorsforlocal
recurrencefollowingBCThavebeenidentified.Theseincludetumorfactors,treatmentfactors,andpatientrelated
factors.
YoungageYoungage,definedas40years,byitself,isnotacontraindicationtoBCTandisaprognostic,
ratherthanpredictive,factor[80,110,113,115121].Datafromtworandomizedtrialswithlongtermfollowupdid
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notidentifyanadvantageforeitherBCTormastectomyinyoungerwomencomparedwitholderwomen[1,3].A
retrospectivereviewof3512womenage40yearswithT1breastcancerfoundthatwomentreatedwithBCT(n=
1951)hadasimilar10yearoverallsurvival(OS)ratecomparedwithwomenundergoingamastectomy(95.0
versus92.1percent)[122].WomenundergoingBCTalsohadasimilar10yearbreastcancerspecificsurvival
(BCSS)rate(96.9versus94.9percent).Inaddition,therewasnosignificantdifferenceinOSorBCSSbasedupon
localmanagementfornodepositiveornodenegativewomen.
Inthoseseriesthatidentifiedanincreaseinlocalrecurrenceratesforyoungwomen,adversepathologicfeatures
andattemptstoperformalessextensivebreastresectionmayexplainthosefindings[110,118,119].Inmultiple
series,youngerwomenhadahigherfrequencyofadversepathologicfeatures,suchaslargertumorsize,
lymphaticvesselinvasion,poorlydifferentiatedhistologicgrade,absenceofestrogenreceptors(ER),andthe
presenceofanEIC[113,116,117].However,evenwhenadjustedforthesefindings,youngeragehasstillbeen
associatedwithshortersurvivalandanincreasedlikelihoodoflocalrecurrenceafterBCT.However,youngage
hasalsobeenassociatedwithanincreaseinlocalfailurefollowingmastectomyinmost[121,123,124],butnotall
studies[120].
Extensiveintraductalcomponent(EIC)ThetermEICappliestoaninvasiveductalcarcinomainwhich
intraductalcancerispresentingreaterthan25percentofthetumorand/orinsectionsofgrosslynormaladjacent
breasttissue,ormicroinvasivebreastcancer.AlthoughEIChadpreviouslybeenconsideredacontraindicationto
BCT,itisonlyariskfactorforlocalrecurrencewhenthemarginsofresectionarenotevaluated[125].Compared
withEICnegativecancers,thosewithEICandpositivemarginshaveahigherrateoftruelocalrecurrence,butnot
newipsilateralprimaries,contralateralbreasttumors,oranincreasedlikelihoodofdistantrelapse.Thesedata
reflectthehigherincidenceofmultifocalityandresidualcancerfollowingexcisionoftumorswithanEIC[50,126].
Asanexample,inonestudyof214womenwhounderwentmastectomywithdetailedhistologicevaluationofthe
specimen,EICpositivetumorsweremorelikelytohaveprominentresidualintraductalcarcinomaatleast2mm
beyondtheedgeoftheprimarytumor(30versus2percentinEICnegativecancers)[126].
Incontrast,womenwithEICandnegativeresectionmarginsdonothaveanincreasedriskofipsilateralrecurrence
followingBCT[3438].Therefore,routineassessmentofthemarginsofresectionisanimportantcomponentofthe
histologicevaluationinwomenundergoingBCT,particularlythosewithanEIC.Alargerbreastresectioninsuch
womenmightresultinasmallerresidualtumorburdenandareducedriskofipsilateralrecurrencefollowingRT.
RecognitionofEICpositivecancershasbeengreatlyfacilitatedbymammographicmagnificationviews[127].The
intraductalcomponentintheselesionsisfrequentlysuggestedbythepresenceofsuspiciousmicrocalcifications.
(See"Breastductalcarcinomainsitu:Epidemiology,clinicalmanifestations,anddiagnosis".)
AssociatedlobularcarcinomainsituTheassociationbetweenlobularcarcinomainsitu(LCIS)withinthe
resectionspecimenandlocalrecurrenceiscontroversial.AtleasttwostudiessuggestthatthepresenceofLCIS
withinthespecimenisassociatedwithhigherratesoflocalrecurrence(table4)[128,129].Inthelargerofthetwo,
1274womenwithstageIorIIbreastcancerundergoingBCT,the10yearcumulativerateofipsilateralbreast
tumorrecurrencewassignificantlyhigherinwomenwithassociatedLCIS(29versus6percent,p=0.03)[128].A
protectiveeffectofsystemicadjuvanthormonaltherapywassuggested,sinceamongwomenreceivingadjuvant
tamoxifen,thelocalrecurrencerateswithandwithoutLCISwere8and6percent,respectively.(See"Atypiaand
lobularcarcinomainsitu:Highrisklesionsofthebreast"and"Pathologyofbreastcancer".)
Ontheotherhand,severalotherstudiessupporttheviewthatthepresenceofLCISwithinthespecimenisnota
riskfactorforlocalrecurrence(table4)[130133].Inatleastoneofthereports,therewerenodifferencesinlocal
recurrencerateinwomenwhoeitherreceivedordidnotreceiveadjuvanttherapy[130].(See"Tumornode
metastasis(TNM)stagingclassificationforbreastcancer".)
LCISshouldnotbeconsideredacontraindicationtoBCT.
InheritedsusceptibilityAninheritedsusceptibilitytobreastandothercancershasbeenlinkedtogermline
mutationsinBRCA1andBRCA2insomewomen.Youngwomenwithastrongfamilyhistoryofeitherbreastor
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ovariancancerhaveasignificantprobabilityofandshouldbeofferedgeneticcounselingaboutthesemutations
(table5).(See"Overviewofhereditarybreastandovariancancersyndromes"and"Geneticcounselingandtesting
forhereditarybreastandovariancancer".)
Followingtreatmentofaprimarybreastcancer,womenwithaninheritedsusceptibilityforbreastcancerareat
increasedrisk(approximatelyfivefold)ofdevelopingacontralateralbreastcancer[134139].Some,butnotall,
studiesshowthatwomenwithaninheritedsusceptibilityforbreastcancertreatedwithBCTarealsoathigherrisk
oflocalfailurewhencomparedtowomenwithsporadicbreastcancertreatedwithBCT[137142].Inaddition,
womenwithbreastcancerandaBRCA1/2mutationhaveahigherrateoflocalfailurewhentreatedwithBCTas
comparedwithmastectomy[142].Inamultiinstitutionalanalysisof655womenwithBRCA1/2mutations,local
failurewasmorelikelyinthosetreatedwithBCT(302women)comparedtomastectomy(353women)the
cumulativeestimatedriskat15yearswas23.5and5.5percent,respectively[142].Chemotherapyhasa
protectiveeffectandreducedtheriskoflocalfailureat15yearsto11percentinthepatientstreatedwithBCT.
TherewerenodifferencesseeninregionalorsystemicrecurrencesbetweentheBCTandmastectomygroups,
andnodifferenceinoverallsurvival.
Prophylacticoophorectomyalsohasaprotectiveeffectinmutationcarriers.Thismayreducetheriskof
developingsubsequentbreastcancerinpatientstreatedwithbreastconservation.Amultiinstitutionalseries
comparedtheoutcomesof160BRCA1/2mutationcarrierswithstageIorIIbreastcancertreatedwithBCTwith
445controlwomenwithsporadicbreastcancerundergoingBCT[139].At15years,therewasnosignificant
differenceintherateofinbreasttumorrecurrence(24versus17percentforcontrols,p=0.19).However,
BRCA1/2mutationstatuswasasignificantriskfactorforinbreasttumorrecurrenceinmultivariateanalysiswhen
carrierswhohadundergoneprophylacticoophorectomywereremovedfromtheanalysis(hazardratio2.0).These
resultsindirectlysuggestaprotectiveeffectofoophorectomyincarrierstreatedwithbreastconservationalthough
morestudyisneeded.(See"Riskreducingbilateralsalpingooophorectomyinwomenathighriskofepithelial
ovarianandfallopiantubalcancer"and"Managementofpatientswithhereditaryand/orfamilialbreastandovarian
cancer".)
ThedecisionwhethertopursueBCTinknownBRCA1/2carriersshouldbemadefollowingextensivediscussion
withanexperiencedsurgeon.
UNDERUTILIZATIONOFBCTBreastconservingtherapy(BCT)continuestobeunderutilizedintheUnited
StatesdespiteconsistentevidencethatBCTandmastectomyaretherapeuticallyequivalentandthe
recommendationofa1991NationalInstitutesofHealthConsensusConferencethatBCTisthepreferable
treatmentforearlystagebreastcancer[143].MorethanonefourthofAmericanwomenwithstagesIandIIbreast
carcinomaarestillundergoingmastectomy,withconsiderablegeographicandagevariation[54,89,143151].
Potentialexplanationsfortheseobservationsinclude:

ContraindicationstoBCT
Theuseofinappropriateselectioncriteriabyclinicians
Increasinguseofbreastmagneticresonanceimaging(MRI)
Patientpreference

Thefirstexplanation,medicalcontraindications,isnotamajorcauseofunderuseofBCT[152154].Inonereport
thatincluded432womenwithstageIorIIinvasivebreastcancerorductalcarcinomainsitu(DCIS)whowere
prospectivelyevaluatedbyamultidisciplinaryteam,only97(22percent)hadcontraindicationstoBCT[152].
ContraindicationstoBCTcanbereadilyidentifiedwithacarefulhistory,physicalexaminationanddetailed
mammography,includingmagnificationviewsoftheprimarysite.Usingtheseparameters,inaseriesof263
consecutivewomen,patientseligibleforBCTcouldbeselectedwith97percentaccuracy[154].(See'Patient
selectionforBCT'above.)
Thesecondexplanation,clinicianrelatedinappropriatemedicalanddemographicselectionfactors,hasbeen
thoughttobeamajorcauseofhighmastectomyratesintheUnitedStates[155,156].Ajointstudyofthe
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AmericanCollegeofSurgeons(ACS)andtheAmericanCollegeofRadiology(ACR)evaluatedfactorspredicting
useofmastectomyaslocaltherapyin17,931womenwithstageIorIIbreastcancer[155].Womenwithlarger
tumorsize,aclinicallypositiveaxilla,EICinassociationwiththeinvasivecancer,andhigherhistologicgrade
weremorelikelytoundergomastectomythanthosewithmorefavorablefeatures.Otherpatientrelatedfactors(eg,
olderage,insurancestatus,andgeographiclocation)alsopredictedahighermastectomyrate.Olderwomenare
morelikelytohavemastectomyrecommendedbytheirclinicians,andthemajorityundergotheprocedurethatis
recommendedbytheirclinician[156].
Magneticresonanceimagingidentifiesadditionalipsilateraldiseasein16percentofwomenwithanewdiagnosis
ofbreastcancerandmayinfluencesurgicalplanning,leadingtoanincreaseinthemastectomyrate.(See
"Diagnosticevaluationofwomenwithsuspectedbreastcancer",sectionon'BreastMRI'and"Breastductal
carcinomainsitu:Epidemiology,clinicalmanifestations,anddiagnosis",sectionon'Roleofmagneticresonance
imaging'.)
Therearedatatosuggestthatpatientratherthansurgeonpreferenceformastectomyismoreofafactorthan
previouslyappreciated.Severalstudieshaveshownthatmorepatientinvolvementinbreastsurgerydecision
makingactuallyleadstoagreaterprobabilityofmastectomy[157,158].Evenwellinformedpatientsmaychoose
mastectomyoverBCTbecauseconcernsaboutthesideeffectsofradiationtherapyandthehopeofavoidinga
cancerrecurrencewiththeneedforanothercanceroperation.
Studiesshowthatonly50to70percentofwomenwithearlybreastcanceractivelyparticipateinthesurgical
decision[157,159].Theuseofdecisionaids(paper,visual,audiotape,orcomputerizedaudiovisual)canenhance
patientknowledgeoftreatmentoptions[160].
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Choosingtreatmentforearlystagebreastcancer(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Breastcancerguidetodiagnosisandtreatment(Beyond
theBasics)"and"Patientinformation:SurgicalproceduresforbreastcancerMastectomyandbreast
conservingtherapy(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Breastconservingtherapy(BCT)allowswomenwithinvasivebreastcancertopreservetheirbreastwithout
sacrificingoncologicoutcome.SuccessfulBCTrequirescompletesurgicalremovalofthetumor(with
negativesurgicalmargins)followedbymoderatedoseRTtoeradicateanyresidualdisease.(See
'Introduction'above.)
ContraindicationstoBCTincludemulticentricdisease,diffusemalignantmicrocalcificationson
mammography,priorradiationtherapytotheaffectedbreast,andpersistentlypositiveresectionmarginsafter
multipleattemptsatreexcision.(See'PatientselectionforBCT'above.)
Pregnancyisanabsolutecontraindicationtotheuseofbreastirradiation.Itmaybepossibletoperform
breastconservingsurgeryforpregnantwomenifsurgerycanbeperformedinthethirdtrimesterandbreast
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irradiationisdeferreduntilafterdelivery.(See'PatientselectionforBCT'above.)
Forpatientswithapositivemarginofresection,definedasinkonthetumor,weperformawiderexcision.
Whileobtainingwidermarginsthaninkontumorisnotindicatedforroutinepatientswithanegativemarginof
resection,weuseanindividualizedapproachtopatientswithclose(<1mm)marginswithregardtore
excision.(See'Indicationsforwiderexcisionofmargins'above.)
CertainconnectivetissuedisordersarearelativecontraindicationtoBCTasthesedisordersmayleadto
delayedtoxicityfromradiation.(See'PatientselectionforBCT'above.)
LargetumorsizehasbeenconsideredarelativecontraindicationtoBCT.However,neoadjuvant
chemotherapyorhormonaltherapycandecreasetumorsizesignificantlyandallowBCTforlargetumorswith
acceptablelocalrecurrencerates.(See'PatientselectionforBCT'above.)
AcceptablecosmeticoutcomecanbeachievedinalmostallpatientsundergoingBCTwithoutcompromiseof
localtumorcontrol.(See'Surgicaltechnique'above.)
Complicationsafterbreastconservingsurgeryincludeseromaformation,infection,andarmmorbidity.(See
'PostoperativeComplications'above.)
Clearmarginsofresectionandpostoperativeradiationtherapyareimportantforreducinglocalrecurrence
ratesafterBCT.(See'Localrecurrence'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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GRAPHICS
Locoregionalrecurrencerateforbreastconservingsurgeryafter
NACT

Study

LRR
(percent)

Median
followup
(mo)

Yearof
publication

Asoglu,etal [1]

28

14

60

2005

Chen,etal [2]

340

60

2004

Clark,etal [3]

34

6.6

30

1998

Hunt,etal [4]

93

9.7

55

1998

Mauriac,etal [5]

272

22.5

124

1999

McIntoch,et

173 *

62

2003

NSABPB18 [7]

1531

10.7

114

2001

Shen,etal [8]

33

60

2004

al [6]

BCS:breastconservingsurgeryLRR:locoregionalrecurrencerateNSABP:NationalSurgicalAdjuvant
BreastandBowelProject.
*Dataavailablefor166.
Datafrom:
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inlocallyadvancedbreastcancer.ActaChirBelg2005105:62.
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chemotherapy:theMDAndersoncancercenterexperience.JClinOncol200422:2303.
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topatientswithlocallyadvancedbreastcancer.IntJRadiatOncolBiolPhys199842:345.
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1998.p.1179.
5. Mauriac,L,MacGrogan,G,Avril,A,etal.Neoadjuvantchemotherapyforoperablebreast
carcinomalargerthan3cm:aunicentrerandomizedtrialwitha124monthmedianfollowup.
InstitutBergonieBordeauxGroupeSein(IBBGS).AnnOncol199910:47.
6. McIntosh,SA,Ogston,KN,Payne,S,etal.Localrecurrenceinpatientswithlargeandlocally
advancedbreastcancertreatedwithprimarychemotherapy.AmJSurg2003185:525.
7. Wolmark,N,Wang,J,Mamounas,E,etal.Preoperativechemotherapyinpatientswithoperable
breastcancer:NineyearresultsfromNationalSurgicalAdjuvantBreastandBowelProjectB18.J
NatlCancerInstMonogr200130:96.
8. Shen,J,Valero,V,Buchholz,TA,etal.Effectivelocalcontrolandlongtermsurvivalinpatients
withT4locallyadvancedbreastcancertreatedwithbreastconservationtherapy.AnnSurgOncol
200411:854.
Datafrom:AlmElDin,M,Taghian,A.Breastconservingtherapyforpatientswithlocallyadvanced

breastcancer.SeminRadiatOncol200919:229.
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Timingofprophylacticantibioticadministrationandsubsequent
ratesofSSIs
Timeof
administration*

Percentwith
SSI

Oddsratio

95percentCI

Early

3.8

4.3

1.810.4

Preoperative

0.6

Perioperative

1.4

2.1

0.67.4

Postoperative

3.3

5.8

2.413.8

SSI:surgicalsiteinfection.
*"Early"denotes2to24hoursbeforeincision,"preoperative"0to2hoursbeforeincision,
"perioperative"within3hoursafterincision,and"postoperative"morethan3hoursafterincision.
Oddsratiodeterminedbylogisticregressionanalysis.
Adaptedfrom:ClassenDC,EvansRS,PestotnikSL,etal,NEnglJMed1992326:281.
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HospitalQualityAlliance/CentersforMedicare&MedicaidServices
(CMS)SurgicalCareImprovementqualitymeasuresfor
perioperativeVTEprevention*
Surgerytype
Intracranialneurosurgery

Recommendedprophylaxisoptions
Anyofthefollowing:
Intermittentpneumaticcompressiondevices(IPC)withor
withoutgraduatedcompressionstockings(GCS)
Lowdoseunfractionatedheparin(LDUH)
Lowmolecularweightheparin(LMWH)
LDUHorLMWH combinedwithIPCorGCS

Generalsurgery

Anyofthefollowing:
Lowdoseunfractionatedheparin(LDUH)
Lowmolecularweightheparin(LMWH)
FactorXaInhibitor(fondaparinux)
LDUHorLMWHorFactorXaInhibitorcombinedwithintermittent
pneumaticcompressiondevices(IPC)orgraduated
compressionstockings(GCS)

Generalsurgerywith
contraindicationsto
pharmacologicalprophylaxis
Gynecologicsurgery

Anyofthefollowing:
Graduatedcompressionstockings(GCS)
Intermittentpneumaticcompressiondevices(IPC)

Anyofthefollowing:
Lowdoseunfractionatedheparin(LDUH)
Lowmolecularweightheparin(LMWH)
FactorXaInhibitor(fondaparinux)
Intermittentpneumaticcompressiondevices(IPC)
LDUHorLMWHorFactorXaInhibitorcombinedwithIPCor
graduatedcompressionstockings(GCS)

Urologicsurgery

Anyofthefollowing:
Lowdoseunfractionatedheparin(LDUH)
Lowmolecularweightheparin(LMWH)
FactorXaInhibitor(fondaparinux)
Intermittentpneumaticcompressiondevices(IPC)
Graduatedcompressionstockings(GCS)
LDUHorLMWHorFactorXaInhibitorcombinedwithIPCorGCS

Electivetotalhipreplacement

Anyofthefollowingstartedwithin24hoursofsurgery:
Lowmolecularweightheparin(LMWH)
FactorXaInhibitor(fondaparinux)
Warfarin

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Excludedpopulations:
Patientslessthan18yearsofage
Patientswhohavealengthofstay>120days
Burnpatients
Patientswithproceduresperformedentirelybylaparoscope
Patientsenrolledinclinicaltrials
Patientswhoareonwarfarinpriortoadmission
PatientswhoseICD9CMprincipalprocedureoccurredpriortothedateofadmission
Patientswhosetotalsurgerytimeislessthanorequalto60minutes
Patientswhostayedlessthanorequaltothreecalendardayspostoperatively
Patientswithcontraindicationstobothmechanicalandpharmacologicalprophylaxis
*Takenfrom:SpecificationsManualforNationalHospitalInpatientQualityMeasures.Availableat:
www.qualitynet.org.
Patientswhoreceiveneuraxialanesthesiaorhaveadocumentedcontraindicationtopharmacological
prophylaxismaypasstheperformancemeasureifeitherappropriatepharmacologicalormechanical
prophylaxisisordered.
Currentguidelinesrecommendpostoperativelowmolecularweightheparinforintracranial
neurosurgery.
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LCISasariskfactorforlocalrecurrenceinwomentreatedwith
breastconservingtherapyforearlybreastcancer
Numberofpatients
w/LCISwithinthe
specimen

Study,
year

Sasson,
AR
2001

65

Numberof
control
patients
1209

Median
F/u,
mos
76

Riskoflocal
failure,
percent
+LCIS
5

LCIS
3

(5yr,NSS)
29

(10yr,p=.003)
Jolly,S
2006

56

Moran,
M1998

51

Abner,
AL
2000

137

Ben
David,
M2006

64

551

104

14

(10yr,p=0.04)
1045

127

23

16

(NSS)
1062

161

13

12

(NSS)
121*

45

1.7

1.6

(NSS)

NSS:notstatisticallysignificant.
*Matchedforhistology,stage,age,anddateofdiagnosis.
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Relationshipbetweenfamilyhistoryofbreastandovariancancer
andlikelihoodofBRCA1mutation
ChanceofBRCA1mutation,
percent

Singleaffectedpatient

Inindividual

Breastcancer,<age30

12

Breastcancer,ages3039

Breastcancer,ages4049

Ovariancancer,<age50

Sisters

Infamily

2breastcancers,<age40

37

2breastcancers,ages4049

20

Breastcancer<age50,ovariancancer<age
50

46

2ovariancancers,<age50

61

Families
3breastcancers,allbeforeage50

40

2breastcancers,1ovariancancer

82

2breastcancers,2ovariancancers

92

AdaptedfromGreene,MH,MayoClinProc199772:54.
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Disclosures
Disclosures:MichaelSSabel,MDConsultant/AdvisoryBoards:IceCureMedical[Cryoablation(IceSenseIII)].LoriJPierce,MD
Nothingtodisclose.AneesBChagpar,MD,MSc,MA,MPH,MBA,FACS,FRCS(C)Nothingtodisclose.DanielFHayes,MD
Grant/Research/ClinicalTrialSupport:JanssenR&D,LLC[Breastcancer(Abiraterone)]JanssenR&D,LLC[Breastcancer
(CellSearch)]PumaBiotechnology,Inc.[Breastcancer(Neratinib)]Pfizer[Breastcancer(Palbociclib)]AstraZeneca[Breastcancer
(Circulatingtumorcells)].Speaker'sBureau:LillyOncology(Breastcancer).Consultant/AdvisoryBoards:Pfizer[Breastcancer
(Palbociclib)].OtherFinancialInterest:JanssenR&D,LLC[Breastcancer(CellSearch)].WenliangChen,MD,PhDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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