Reviewing Best Practices in the Surgical Management of Breast Cancer: Traditional Approaches and Existing Challenges

In this second episode of OncChats: Reviewing Best Practices in the Surgical Management of Breast Cancer, Gladys Giron, MD, FACS, and Cristina Lopez-Peñalver, MD, both of Baptist Health South Florida, discuss the traditional surgical approaches that are utilized for patients with breast cancer and some of the challenges faced in those with later-stage disease.

Lopez-Peñalver: With that background, Dr Giron, do you mind expanding on the traditional surgical approaches that we use in surgery to date?

Giron: Surgical options for [patients with] breast cancer really fall into 2 broad categories: breast conservation and mastectomy. For breast conservation, it consists of lumpectomies. In the appropriate patients, lumpectomy can also be coupled with oncoplastic procedures, meaning that we either work alone or with our reconstructive surgical colleagues to perform concomitant lifts, breast reductions, and tissue rearrangements, which would basically minimize post-operative deformity.

Mastectomies can be skin sparing, and in appropriate patients, they may be nipple sparing; [they] can also be performed with either immediate or delayed reconstruction. The reconstruction can consist of autologous tissue, flaps from usually the abdomen, or it can be tissue expander– and implant-based, with the latter being more common. For many [patients with] stage III breast cancer, as you touched upon earlier, we work closely with our medical oncologists to deliver preoperative chemotherapy, or sometimes preoperative endocrine therapy, to monitor response as well as to improve surgical outcomes. If we are able to [achieve] shrinkage of the disease, we are more likely to obtain negative surgical margins as well as minimize axillary surgery. Some [patients with] stage IV [disease] can also be surgical candidates, depending on their particular presentation, but we will discuss that a little bit further later.

Dr Lopez-Peñalver, could you share your insight regarding the surgical challenges [in the] treatment of [patients with] stage III and IV breast cancers?

Lopez-Peñalver: Yes, that’s a great topic and one of much debate. So, 2 of the challenges in the surgical management of these patients that I would like to touch on [include] whether to reconstruct the breast after mastectomy [and] whether we can de-escalate surgical management in these patients who have had a good clinical response to neoadjuvant therapy.

So, let’s tackle the reconstruction issue first. Surgery for locally advanced breast cancer usually means a mastectomy, but locally advanced breast cancer has been considered a relative contraindication to immediate breast reconstruction with the type of reconstruction either implant-based or autologous tissue, and the timing of that reconstruction either immediate or delayed, a matter of debate. We know that these patients are at a higher risk of local recurrence and usually require radiation therapy for locoregional control, but this radiation therapy can contribute to things such as implant loss, capsular contracture, infection, fibrosis, and just generally, an undesirable cosmetic result. It has been shown that immediate breast reconstruction does not compromise survival or recurrence rates at any stage of breast cancer, but it can be associated with surgical complications that can delay adjuvant therapies, such as radiation. For example, some patients may develop an infection or necrosis of their skin that is treated with prolonged antibiotic therapy, and they may require surgical intervention to treat that complication, which can delay the start of that radiation therapy. However, with advances in our neoadjuvant therapies, carefully selected patients with locally advanced breast cancer who have had a great response to neoadjuvant chemotherapy may be considered candidates for safe implant-based immediate reconstruction.

Now, in terms of de-escalation strategies, let’s start with the breast. Some patients [with] stage III [disease] who were initially deemed unresectable or unsuitable for breast conservation and who have had a good clinical response to neoadjuvant chemotherapy may undergo breast conservation followed by whole breast radiation therapy. Then, when talking about axillary surgery in patients who were initially node-positive and converted to node-negative [status] after neoadjuvant therapy, they may be offered sentinel node biopsy, with the use of several techniques to lower the false-negative rate, such as dual mapping of the lymph node with radioisotope and blue dye, removing at least 3 lymph nodes, and/or performing a targeted axillary dissection to remove the clipped node.

Finally, I want to just mention and conclude by saying that sentinel lymph node biopsy is still contraindicated in patients with clinical T4 or N2/N3 disease because of their heavy disease burden and the lack of evidence showing that it’s accurate after neoadjuvant chemotherapy, but there are studies underway looking at this population.

Check back on Tuesday for the next episode in this series.