Primary Treatment

Local-regional treatment

Stage I, II, IIIA, and operable IIIC breast cancer often requires a multimodality approach to treatment. Irrespective of the eventual procedure selected, the diagnostic biopsy and surgical procedure that will be used as primary treatment should be performed as two separate procedures. In many cases, the diagnosis of breast carcinoma using core needle biopsy or fine-needle aspiration cytology may be sufficient to confirm malignancy. After the presence of a malignancy is confirmed and histology is determined, treatment options should be discussed with the patient before a therapeutic procedure is selected. The surgeon may proceed with a definitive procedure that may include biopsy, frozen section confirmation of carcinoma, and the surgical procedure elected by the patient. Estrogen-receptor (ER) and progesterone-receptor (PR) protein status should be determined for the primary tumor.[1] Additional pathologic characteristics, including grade, proliferative activity, and human epidermal growth factor receptor 2 (HER2/neu) status, may also be of value.[2-5]

Options for surgical management of the primary tumor include breast-conserving surgery plus radiation therapy, mastectomy plus reconstruction, and mastectomy alone. Surgical staging of the axilla should also be performed. Survival is equivalent with any of these options as documented in randomized prospective trials (including the European Organization for Research and Treatment of Cancer’s trial [EORTC-10801]).[6-13] Selection of a local therapeutic approach depends on the location and size of the lesion, analysis of the mammogram, breast size, and the patient’s attitude toward preserving the breast. The presence of multifocal disease in the breast or a history of collagen vascular disease are relative contraindications to breast-conserving therapy.[14] A retrospective study of 753 patients who were divided into three groups based on receptor status (ER- or PR-positive; ER- and PR-negative but HER2/neu-positive; and ER-, PR-, and HER2/neu-negative [triple-negative]) found no differences in disease control within the breast in patients treated with standard breast-conserving surgery; however, there are not yet substantive data to support this finding.[15]

All histologic types of invasive breast cancer may be treated with breast-conserving surgery plus radiation therapy.[16] The rate of local recurrence in the breast with conservative treatment is low and varies slightly with the surgical technique used (e.g., lumpectomy, quadrantectomy, segmental mastectomy, and others). Whether completely clear microscopic margins are necessary is debatable.[17-19]

Retrospective studies have shown the following examples of tumor characteristics to correlate with a greater likelihood of finding persistent tumor on re-excision:

• Large tumors (T2 lesions).
• Positive axillary nodes.
• Tumors with an extensive intraductal component.[20]
• Palpable tumors.
• Lobular histology.

Patients whose tumors have these characteristics may benefit from a more generous initial excision to avoid the need for a re-excision.[21,22]

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