Breast-conserving surgery for breast cancer and the future improvements

Breast cancer is one of the most common types of cancer in the Netherlands. Due to mammographic screening and the alertness of women, early recognition is possible. This is very important for the prognosis, and the cosmetic result. Nowadays 75 percent of breast cancer patients can have breast-conserving surgery in combination with radiotherapy because of early recognition1. The 10-year survival of patients with breast cancer found in an early stage is 90 percent, irrespective of the sentinel lymph node status2, 3. The sentinel lymph node is the hypothetical first lymph node that the cancer will drain in to. Cancer in this sentinel lymph node means more risk of the cancer cells metastasizing to the rest of the body, and a bad prognosis. 
By using breast-conserving surgery, also known as lumpectomie, in combination with radiotherapy, the cosmetic result is much better compared to mastectomy. When mastectomy is used the whole breast and its lymphs will be removed, whereas the breast-conserving surgery, also known as lumpectomy, only removes the cancer and little margin of healthy breast tissue. The problem is that the breast-conserving therapy not always results in proper cosmetic results. The reason for this bad result is due to the following factors: the location of the tumour, postoperative complications, the amount of tissue removed and the use of boost during radiotherapy. If a breast-conserving therapy is used the minimum tissue that should be removed around the tumour is 1mm, according to the Dutch directives. In reality this is not so easy. Surgeons use a margin of 0,5 to 1cm to prevent the tumour from remaining. If more then 85cm3 of breast tissue is removed the cosmetic result will be poor, irrespective of the size of the breast. The margin of 1mm and the usage of 1cm implies that improvement in this technique is possible4-5. 
To censure the results of the lumpectomy, the following two aspects should by reviewed: the amount of breast tissue removed, compared to the size of the tumour and the percentage of radicality. On account of these two aspects and by comparing several surgical techniques, lumpectomy will be discussed.  Information is received from pathology reports.

Method
Patients
Inclusion criteria were: women with invasive mammary carcinoma who were indicated for standard lumpectomy, threaded by the VUMC or three other regional hospitals between January 2006 and December 2008. Tumour size, histology and clinical axillary lymph node status, were examined in every patient before surgery. The method used for this examination is known as the triple assessment. If standard procedure was unclear; MRI was used to clarify tumour extent. The following women were excluded: women who were preoperative diagnosed with ductal carcinoma in situ (DCIS) or multifocal cancer, women who had neoadjuvant chemotherapy and women with former breast surgery or radiotherapy.
All excisions were done by professional oncologic surgeons or strictly supervised surgeons-in-training.

Calculations of excision volume and reproduction of radicality
Postoperative pathology reports of patients with the inclusion criteria were used for this calculation. The excision volume was calculated with the use of, length, width and thickness of the ellipse-shaped excision samples mentioned in the reports.
With the help of the tumour's diameter the optimal excision volume was calculated: defined as dome-shaped excision volume plus its preordained resection margin. This resection margin consists of 1cm tumour free tissue. The resection-ratio was calculated by dividing the excision volume by the optimal excision volume. So if the ideal excision is achieved, the resection ratio is one. If the resection ratio is two, the excision volume is two times more extensive than the optimal excision volume. According to the Dutch guidelines for invasive mammary carcinoma4, the surgical resection margin were divided in three degrees: radical, focal radical and non-radical.

Excision methods for non-palpable breast cancer.
Three different preoperative localisation methods of non-palpable mammary carcinoma were compared in the region of the VUMC. They were judged on resection ratio and radicality. 
Wire-guided localisation excision is an excision method making use of a wire that is placed by radiologist. The wire is placed near the malignant tumour and guided by this wire the surgeon removes the tumour6.
When ultrasound-guided surgery is used, radiologist localises the carcinoma with diagnostic sonography during the surgery. 
The third way to localise non-palpable breast cancer is by radio occult lesion localisation (ROLL). When ROLL is used the breast is injected with radioactive technetium near the tumour. Resection of the tumour can now easily be done, making use of a gamma probe. The choice of which localisation method was used is made by the treating surgeon. Each of these methods was done by well-trained and experienced doctors.

Statistic analysis
X2-test and the Fisher's exact test were used for the percentages. T-test or the mann-whitney-u test were used to compare continue variables. A P-value of 0.05 is considered as significant.

Results
In the end, 726 women were included. The mean age was 58 years, with a minimum age of 28 years and a maximum age of 89 years. 526 (72.3 %) patients had palpable breast cancer and 201 (27.7%) patients had non-palpable breast cancer.
The excision volume varies from 0.20-524cm2 and the median was 63cm2. By 33.6 percent of the women, excision volumes were exceeding 85cm2. The resection ratio of all 726 patients had a median of 2,5 for all palpable breast cancer.  The non-palpable breast cancer had a median of 2.2. 
The percentage of non-radical and focal radical excisions was 21.1 percent. The percentage of non-radical excisions for palpable breast cancer is 22.5percent and for non-palpable breast cancer 17,4percent. In 8.7 percent of all the tumours the pathologist accidentally found DCIS alongside the invasive tumour. This resulted in non-radical excisions, in 4.4 percent of the cases.
In more then 60 percent of the excisions, the tumour was located eccentric of the resection sample. In addition, in 10 percent of the women with a resection ratio above 4 the tumour was not radically removed.
Within the three localisation techniques of the non-palpable breast carcinoma, the dividing of tumour size and histology was equal. Ultrasound-guided surgery is much more radical then wire-guided localisation excision or ROLL. ROLL surgery resulted in the most exceeding resection ratios.
Conclussion
In general, breast-conserving surgery removes too much healthy tissue, whereas the excisions are not radical enough. Ultrasound-guided lumpectomy is the appropriate way to accomplish accurate excision. And the use of ultrasound-guided surgery for palpable and non-palpable breast cancer will have the most proper cosmetic, oncologic and psychological results.



1. Inspectie voor de gezondheidszorg. Basisset prestatie indicatoren 2011. Utrecht; 2011.
2. Nederlandse Kankerregistratie (NKR); cijfers, overleving; borst. 6e editie; 2003-2007
3. Giuliano AE, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinal node metastasis: a randomized clinical trial. JAMA. 2011;305:569-75
Appolagies
4.    Kwaliteitsinstituut voor de gezondheidszorg CBO. Richtlijn mammacarcinoom Alphen aan den Rijn: Van Zuiden Communications; 2008 p. 76-113.
5.    Vrieling C, et al. The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC 'boost vs. no boost' trial. Radiother Oncol. 200;55:219-32
6.    Kopans DB, Swann CA. Preoperative imaging-guided needle placement and localisation of clinically occult breast lesions. AJR Am J Roentgenol. 1989;152:1-9