Treatment - Surgery

• Depends on the histopathologic classification and cancer stage

• Involves a combination of surgical management and systemic therapy (chemotherapy, hormone therapy, targeted therapy)

• Patient preference for more or less aggressive management plays a significant role in selecting the treatment approach.

• a type of surgery that focuses on the removal of cancerous breast tissue only, in contrast to full-breast mastectomy

• The margins of the resected tissue are marked with ink for histologic workup. The surgical margins are considered negative (e.g., tumor-free) if there is no tumor at the inked margin. Otherwise, resection must be repeated or a mastectomy must be considered.

• Large tumor-to-breast volume ratio

• Multifocal tumors

• Fixation to the chest wall

• Involvement of the skin or nipple

• Subareolar location

• History of chest radiation

• Excision with negative tumor margins (> 2 mm) not guaranteed

• Clustered microcalcifications on imaging

A mastectomy involves the removal of the entire breast and, depending on the specific procedure, possibly other structures, such as lymph nodes and muscles.

• Removal of the entire breast and nipple-areolar complex with sparing of pectoral muscles

• Sentinel lymph node biopsy; no dissection of lymph node levels I and II

• Removal of breast tissue, nipple, and areola while leaving the majority of skin intact

• Allows for (simultaneous) breast reconstruction via implants or their own tissue

• Not suited for large tumors or those that already involve the skin (e.g., inflammatory carcinoma)

• Variation of skin-sparing mastectomy: Only the breast tissue is removed, while the skin and nipple are spared.

• Allows for (simultaneous) breast reconstruction via implants or tissue

• Indicated for early stages of breast cancer

• Excision of the breast, pectoralis major, pectoralis minor, and axillary lymph nodes

• Has been largely replaced by less extensive procedures

• Excision of the entire breast, underlying pectoralis fascia, and level I and II axillary lymph nodes

• The pectoralis muscle and level III axillary lymph nodes are spared.

• Preferred over radical mastectomy because there are equivalent survival outcomes but decreased morbidity

• Simultaneous removal of both breasts

• Indicated in women with increased risk for breast cancer (e.g., due to BRCA gene mutation) or as part of breast cancer treatment

• Used to assess whether cancer cells have spread to the axillary lymph nodes and helps to identify the axillary lymph node that initially drains the tumorous breast tissue

• Indicated for all patients with no clinical signs of axillary lymph node infiltration

• Must be performed during breast-conserving surgery and mastectomy

• If the sentinel lymph node is negative, the likelihood of other nodes in this group being involved is very low.

A blue dye with a technetium tag is injected into the tissue surrounding the tumor. This radioactive colloid accumulates in the draining lymph nodes, where it can be detected with a gamma probe or Geiger counter (preoperative lymphoscintigraphy). The blue dye allows the sentinel lymph node to be visually identified. Subsequent excision of the lymph node and intraoperative frozen section are used to detect the lymphatic spread of malignant cells.

• Removal of ≥ 10 lymph nodes during surgery with subsequent histopathologic examination

• Indicated for patients with clinical signs of axillary lymph node infiltration

• Can be performed during primary surgery (e.g., mastectomy) or after