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Breast-Conserving Surgery
Ana Paula Refinetti, MD; Katherine McElroy, BA; Dalliah M. Black, MD, FACS
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Synonyms

            • Partial or segmental mastectomy; lumpectomy
          • Definitions

            • Breast-conserving surgery (BCS): Excising malignancy with intent to obtain adequate margins, which, based on cancer location, may include pectoralis fascia or skin
              • Connotes removal of cancer with intention to cure
              • Term also applies to reexcision for clear margins
            • Breast-conserving therapy (BCT): BCS followed by radiation therapy (XRT)
            • Margins: Tissue surrounding cancer
              • Amount of benign tissue between edge of malignancy and edge of resection
              • Adequate margin for local control: No ink on tumor in invasive cancer; 2-mm margin for DCIS
              • Also used to connote additional tissue taken at lumpectomy edges, a.k.a. "cavity margins" if from all sides
            • Quadrantectomy (segmentectomy): Resection of triangular segment of breast (apex at nipple), including skin and pectoralis fascia
              • Based on segmental growth of cancer; used more often in European centers
              • Option for larger cancers with enough remaining breast; often requires oncoplastic closure for acceptable cosmetic result
            • Excisional biopsy: Removal of abnormality for diagnosis
            • Incisional biopsy: Removal of part of abnormality for diagnosis
            • Oncoplastic BCS
              • Cancer removed with wide margins to reduce positive margins and reexcision rates
              • Improves cosmetic outcomes, especially for larger tumors
              • Remaining breast tissue surgically reapproximated to achieve acceptable cosmetic result
              • Can result in breast asymmetry; may need reduction/lift of contralateral breast

          PREPROCEDURE

          • Indications

            • Contraindications

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Expected Outcome

                          • Things to Do

                            OUTCOMES

                            • Complications

                              Selected References

                              1. Gray RJ et al: Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Ann Surg Oncol. 25(1):18-27, 2018
                              2. Arthur DW et al: NRG Oncology-Radiation Therapy Oncology Group Study 1014: 1-year toxicity report from a phase 2 study of repeat breast-preserving surgery and 3-dimensional conformal partial-breast reirradiation for in-breast recurrence. Int J Radiat Oncol Biol Phys. 98(5):1028-35, 2017
                              3. Correa C et al: Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 7(2):73-9, 2017
                              4. Jeffries DO et al: Localization for breast surgery: the next generation. Arch Pathol Lab Med. 141(10):1324-29, 2017
                              5. Mamounas EP et al: 21-gene recurrence score and locoregional recurrence in node-positive/ER-positive breast cancer treated with chemo-endocrine therapy. J Natl Cancer Inst. 109(4), 2017
                              6. Nichol AM et al: The Use of Hormone Therapy Alone Versus Hormone Therapy and Radiation Therapy for Breast Cancer in Elderly Women: A Population-Based Study. Int J Radiat Oncol Biol Phys. 98(4):829-839, 2017
                              7. Shah S et al: A Single Institution Retrospective Comparison Study of Locoregional Recurrence After Accelerated Partial Breast Irradiation Using External Beam Fractionation Compared with Whole Breast Irradiation with 8 Years of Follow-Up. Ann Surg Oncol. 24(10):2935-2942, 2017
                              8. Teshome M et al: Breast conserving surgery and locoregional control after neoadjuvant chemotherapy. Eur J Surg Oncol. 43(5):865-874, 2017
                              9. Wilkinson JB et al: Outcomes According to Breast Cancer Subtype in Patients Treated With Accelerated Partial Breast Irradiation. Clin Breast Cancer. 17(1):55-60, 2017
                              10. Cox CE et al: A Prospective, Single Arm, Multi-site, Clinical Evaluation of a Nonradioactive Surgical Guidance Technology for the Location of Nonpalpable Breast Lesions during Excision. Ann Surg Oncol. 23(10):3168-74, 2016
                              11. De La Cruz L et al: Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol. 23(10):3247-58, 2016
                              12. Dryden MJ et al: Imaging Factors That Influence Surgical Margins After Preoperative 125I Radioactive Seed Localization of Breast Lesions: Comparison With Wire Localization. AJR Am J Roentgenol. 206(5):1112-8, 2016
                              13. Merrill AL et al: Implications of new lumpectomy margin guidelines for breast-conserving surgery: Changes in reexcision rates and predicted rates of residual tumor. Ann Surg Oncol. 23(3):729-34, 2016
                              14. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Ductal Carcinoma In Situ. Ann Surg Oncol. 23(12):3801-3810, 2016
                              15. Swisher SK et al: Locoregional control according to breast cancer subtype and response to neoadjuvant chemotherapy in breast cancer patients undergoing breast-conserving therapy. Ann Surg Oncol. 23(3):749-56, 2016
                              16. Urano M et al: Digital mammography versus digital breast tomosynthesis for detection of breast cancer in the intraoperative specimen during breast-conserving surgery. Breast Cancer. 23(5):706-11, 2016
                              17. Whitley MJ et al: A mouse-human phase 1 co-clinical trial of a protease-activated fluorescent probe for imaging cancer. Sci Transl Med. 8(320):320ra4, 2016
                              18. Chan BK et al: Localization techniques for guided surgical excision of non-palpable breast lesions. Cochrane Database Syst Rev. CD009206, 2015
                              19. Kunkler IH et al: Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 16(3):266-73, 2015
                              20. McCormick B et al: RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 33(7):709-15, 2015
                              21. Landercasper J et al: Reasons for re-excision after lumpectomy for breast cancer: insight from the American Society of Breast Surgeons Mastery(SM) database. Ann Surg Oncol. 21(10):3185-91, 2014
                              22. Moran MS et al: Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 21(3):704-16, 2014
                              23. Schnabel F et al: A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies. Ann Surg Oncol. 21(5):1589-95, 2014
                              24. Wilke LG et al: Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 149(12):1296-305, 2014
                              25. Donker M et al: Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial. J Clin Oncol. 31(32):4054-9, 2013
                              26. Down SK et al: Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer. Breast J. 19(1):56-63, 2013
                              27. Hughes KS et al: Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 31(19):2382-7, 2013
                              28. Mittendorf EA et al: Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy. Ann Surg. 257(2):173-9, 2013
                              29. Solin LJ et al: A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 105(10):701-10, 2013
                              30. Beitsch PD et al: Tumor bed control with balloon-based accelerated partial breast irradiation: incidence of true recurrences versus elsewhere failures in the American Society of Breast Surgery MammoSite(®) Registry Trial. Ann Surg Oncol. 19(10):3165-70, 2012
                              31. Degnim AC et al: A prospective study of breast lymphedema: frequency, symptoms, and quality of life. Breast Cancer Res Treat. 134(3):915-22, 2012
                              32. Arvold ND et al: Age, breast cancer subtype approximation, and local recurrence after breast-conserving therapy. J Clin Oncol. 29(29):3885-91, 2011
                              33. Darby S et al: Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707-16, 2011
                              34. Jeruss JS et al: Update on DCIS outcomes from the American Society of Breast Surgeons accelerated partial breast irradiation registry trial. Ann Surg Oncol. 18(1):65-71, 2011
                              35. Kronowitz SJ et al: A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. 122(6):1631-47, 2008
                              36. Wahl AO et al: Multi-institutional review of repeat irradiation of chest wall and breast for recurrent breast cancer. Int J Radiat Oncol Biol Phys. 70(2):477-84, 2008
                              37. Cabioglu N et al: Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann Surg Oncol. 14(4):1458-71, 2007
                              38. Boughey JC et al: Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 244(3):464-70, 2006
                              39. Choi JY et al: Aesthetic and reconstruction considerations in oncologic breast surgery. J Am Coll Surg. 202(6):943-52, 2006
                              40. Kronowitz SJ et al: Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg. 117(1):1-11; discussion 12-4, 2006
                              41. Fisher B et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 347(16):1233-41, 2002
                              42. Veronesi U et al: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 347(16):1227-32, 2002
                              43. Jackman RJ et al: Needle-localized breast biopsy: why do we fail? Radiology. 204(3):677-84, 1997
                              Related Anatomy
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                              References
                              Tables

                              Tables

                              KEY FACTS

                              • Terminology

                                • Preprocedure

                                  • Procedure

                                    • Post Procedure

                                      TERMINOLOGY

                                      • Synonyms

                                        • Partial or segmental mastectomy; lumpectomy
                                      • Definitions

                                        • Breast-conserving surgery (BCS): Excising malignancy with intent to obtain adequate margins, which, based on cancer location, may include pectoralis fascia or skin
                                          • Connotes removal of cancer with intention to cure
                                          • Term also applies to reexcision for clear margins
                                        • Breast-conserving therapy (BCT): BCS followed by radiation therapy (XRT)
                                        • Margins: Tissue surrounding cancer
                                          • Amount of benign tissue between edge of malignancy and edge of resection
                                          • Adequate margin for local control: No ink on tumor in invasive cancer; 2-mm margin for DCIS
                                          • Also used to connote additional tissue taken at lumpectomy edges, a.k.a. "cavity margins" if from all sides
                                        • Quadrantectomy (segmentectomy): Resection of triangular segment of breast (apex at nipple), including skin and pectoralis fascia
                                          • Based on segmental growth of cancer; used more often in European centers
                                          • Option for larger cancers with enough remaining breast; often requires oncoplastic closure for acceptable cosmetic result
                                        • Excisional biopsy: Removal of abnormality for diagnosis
                                        • Incisional biopsy: Removal of part of abnormality for diagnosis
                                        • Oncoplastic BCS
                                          • Cancer removed with wide margins to reduce positive margins and reexcision rates
                                          • Improves cosmetic outcomes, especially for larger tumors
                                          • Remaining breast tissue surgically reapproximated to achieve acceptable cosmetic result
                                          • Can result in breast asymmetry; may need reduction/lift of contralateral breast

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Getting Started

                                            PROCEDURE

                                            • Patient Position/Location

                                              • Procedure Steps

                                                • Findings and Reporting

                                                  • Alternative Procedures/Therapies

                                                    POST PROCEDURE

                                                    • Expected Outcome

                                                      • Things to Do

                                                        OUTCOMES

                                                        • Complications

                                                          Selected References

                                                          1. Gray RJ et al: Intraoperative margin management in breast-conserving surgery: a systematic review of the literature. Ann Surg Oncol. 25(1):18-27, 2018
                                                          2. Arthur DW et al: NRG Oncology-Radiation Therapy Oncology Group Study 1014: 1-year toxicity report from a phase 2 study of repeat breast-preserving surgery and 3-dimensional conformal partial-breast reirradiation for in-breast recurrence. Int J Radiat Oncol Biol Phys. 98(5):1028-35, 2017
                                                          3. Correa C et al: Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 7(2):73-9, 2017
                                                          4. Jeffries DO et al: Localization for breast surgery: the next generation. Arch Pathol Lab Med. 141(10):1324-29, 2017
                                                          5. Mamounas EP et al: 21-gene recurrence score and locoregional recurrence in node-positive/ER-positive breast cancer treated with chemo-endocrine therapy. J Natl Cancer Inst. 109(4), 2017
                                                          6. Nichol AM et al: The Use of Hormone Therapy Alone Versus Hormone Therapy and Radiation Therapy for Breast Cancer in Elderly Women: A Population-Based Study. Int J Radiat Oncol Biol Phys. 98(4):829-839, 2017
                                                          7. Shah S et al: A Single Institution Retrospective Comparison Study of Locoregional Recurrence After Accelerated Partial Breast Irradiation Using External Beam Fractionation Compared with Whole Breast Irradiation with 8 Years of Follow-Up. Ann Surg Oncol. 24(10):2935-2942, 2017
                                                          8. Teshome M et al: Breast conserving surgery and locoregional control after neoadjuvant chemotherapy. Eur J Surg Oncol. 43(5):865-874, 2017
                                                          9. Wilkinson JB et al: Outcomes According to Breast Cancer Subtype in Patients Treated With Accelerated Partial Breast Irradiation. Clin Breast Cancer. 17(1):55-60, 2017
                                                          10. Cox CE et al: A Prospective, Single Arm, Multi-site, Clinical Evaluation of a Nonradioactive Surgical Guidance Technology for the Location of Nonpalpable Breast Lesions during Excision. Ann Surg Oncol. 23(10):3168-74, 2016
                                                          11. De La Cruz L et al: Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol. 23(10):3247-58, 2016
                                                          12. Dryden MJ et al: Imaging Factors That Influence Surgical Margins After Preoperative 125I Radioactive Seed Localization of Breast Lesions: Comparison With Wire Localization. AJR Am J Roentgenol. 206(5):1112-8, 2016
                                                          13. Merrill AL et al: Implications of new lumpectomy margin guidelines for breast-conserving surgery: Changes in reexcision rates and predicted rates of residual tumor. Ann Surg Oncol. 23(3):729-34, 2016
                                                          14. Morrow M et al: Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Ductal Carcinoma In Situ. Ann Surg Oncol. 23(12):3801-3810, 2016
                                                          15. Swisher SK et al: Locoregional control according to breast cancer subtype and response to neoadjuvant chemotherapy in breast cancer patients undergoing breast-conserving therapy. Ann Surg Oncol. 23(3):749-56, 2016
                                                          16. Urano M et al: Digital mammography versus digital breast tomosynthesis for detection of breast cancer in the intraoperative specimen during breast-conserving surgery. Breast Cancer. 23(5):706-11, 2016
                                                          17. Whitley MJ et al: A mouse-human phase 1 co-clinical trial of a protease-activated fluorescent probe for imaging cancer. Sci Transl Med. 8(320):320ra4, 2016
                                                          18. Chan BK et al: Localization techniques for guided surgical excision of non-palpable breast lesions. Cochrane Database Syst Rev. CD009206, 2015
                                                          19. Kunkler IH et al: Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 16(3):266-73, 2015
                                                          20. McCormick B et al: RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 33(7):709-15, 2015
                                                          21. Landercasper J et al: Reasons for re-excision after lumpectomy for breast cancer: insight from the American Society of Breast Surgeons Mastery(SM) database. Ann Surg Oncol. 21(10):3185-91, 2014
                                                          22. Moran MS et al: Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 21(3):704-16, 2014
                                                          23. Schnabel F et al: A randomized prospective study of lumpectomy margin assessment with use of MarginProbe in patients with nonpalpable breast malignancies. Ann Surg Oncol. 21(5):1589-95, 2014
                                                          24. Wilke LG et al: Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 149(12):1296-305, 2014
                                                          25. Donker M et al: Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial. J Clin Oncol. 31(32):4054-9, 2013
                                                          26. Down SK et al: Oncological advantages of oncoplastic breast-conserving surgery in treatment of early breast cancer. Breast J. 19(1):56-63, 2013
                                                          27. Hughes KS et al: Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 31(19):2382-7, 2013
                                                          28. Mittendorf EA et al: Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy. Ann Surg. 257(2):173-9, 2013
                                                          29. Solin LJ et al: A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 105(10):701-10, 2013
                                                          30. Beitsch PD et al: Tumor bed control with balloon-based accelerated partial breast irradiation: incidence of true recurrences versus elsewhere failures in the American Society of Breast Surgery MammoSite(®) Registry Trial. Ann Surg Oncol. 19(10):3165-70, 2012
                                                          31. Degnim AC et al: A prospective study of breast lymphedema: frequency, symptoms, and quality of life. Breast Cancer Res Treat. 134(3):915-22, 2012
                                                          32. Arvold ND et al: Age, breast cancer subtype approximation, and local recurrence after breast-conserving therapy. J Clin Oncol. 29(29):3885-91, 2011
                                                          33. Darby S et al: Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet. 2011;378:1707-16, 2011
                                                          34. Jeruss JS et al: Update on DCIS outcomes from the American Society of Breast Surgeons accelerated partial breast irradiation registry trial. Ann Surg Oncol. 18(1):65-71, 2011
                                                          35. Kronowitz SJ et al: A management algorithm and practical oncoplastic surgical techniques for repairing partial mastectomy defects. Plast Reconstr Surg. 122(6):1631-47, 2008
                                                          36. Wahl AO et al: Multi-institutional review of repeat irradiation of chest wall and breast for recurrent breast cancer. Int J Radiat Oncol Biol Phys. 70(2):477-84, 2008
                                                          37. Cabioglu N et al: Role for intraoperative margin assessment in patients undergoing breast-conserving surgery. Ann Surg Oncol. 14(4):1458-71, 2007
                                                          38. Boughey JC et al: Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 244(3):464-70, 2006
                                                          39. Choi JY et al: Aesthetic and reconstruction considerations in oncologic breast surgery. J Am Coll Surg. 202(6):943-52, 2006
                                                          40. Kronowitz SJ et al: Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg. 117(1):1-11; discussion 12-4, 2006
                                                          41. Fisher B et al: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 347(16):1233-41, 2002
                                                          42. Veronesi U et al: Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 347(16):1227-32, 2002
                                                          43. Jackman RJ et al: Needle-localized breast biopsy: why do we fail? Radiology. 204(3):677-84, 1997