Patient selection for treatment with conservative surgery and radiation therapy

Optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a breast lesion that is diagnosed with increasing frequency, mainly due to the wide use of screening mammography. Today, DCIS comprises 15-25% of all breast cancers detected at population screening programs. Consequently, the concepts of properly managing such patients assume a greater importance in everyday practice. Mammographically detected microcalcifications are the most common presentation of DCIS. Despite recent technological advances (including Stereotactic-guided directional vacuum-assisted biopsy), mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS. Management options include mastectomy, local excision combined with radiation therapy, and local excision alone. Given that DCIS is a heterogeneous group of lesions rather than a single entity, and because patients have a wide variety of personal needs that must be addressed during treatment selection, it is obvious that no single approach will be appropriate for all forms of DCIS or for all patients. Careful patient selection is of key importance in order to achieve the best results in the management of the individual patient with DCIS. Axillary lymph node dissection is unnecessary in the treatment of pure DCIS, but it is indicated when microinvasion is present. In these cases, sentinel lymph node biopsy may be an excellent alternative. In the NSABP B-24 trial, tamoxifen reduced both the invasive and non-invasive breast cancer events in either breast by 37%. Nearly all patients who develop a non-invasive recurrence following breast-sparing surgery are cured with mastectomy, and approximately 75% of those with an invasive recurrence are salvaged. Selected patients initially treated by lumpectomy alone may also undergo breast-conservation therapy at the time of relapse according to the same strict guidelines of tumor margin clearance required for the primary lesion; radiation therapy should be given following local excision. The use of systemic therapy in patients with invasive recurrence should be based on standard criteria for invasive breast cancer.

Breast-conserving treatment: controversies and consensus

Although breast-conserving therapy (BCT) is an accepted alternative for the treatment of breast cancer, numerous controversies surround the selection criteria and the treatment details. A review of the literature revealed that patient selection is of critical importance. However, there is disagreement over the relative importance of some of the criteria for patient selection. A wide excision is preferable to a less complete excision (tumorectomy) or a more radical excision (quadrantectomy). Accurate assessment of surgical margins is important. The risk of local recurrence may be diminished if a re-excision is performed to obtain tumor-free margins. However, the suitability and practicality of the techniques used to assess the resection margins have been questioned. Radiotherapy is an integral part of BCT. Surgery alone remains an investigational approach. Axillary dissection remains a reliable method of assessing nodal status and treating regional disease.

Conservative surgery without radiotherapy in the treatment of patients with early-stage invasive breast cancer. A review

OBJECTIVE

The authors determined whether some patients with clinical stage I or II invasive breast cancer can be adequately treated by conservative surgery without radiotherapy.

SUMMARY BACKGROUND DATA

Currently, there are many patients who are being treated in this manner in both academic and community hospitals. This approach is not as effective as either mastectomy or conservative surgery followed by radiotherapy in preventing local recurrence. However, there may be subsets of patients who might be adequately treated by surgery alone with acceptably low recurrence rates.

METHODS

The authors reviewed retrospective studies of conservative surgery alone and of randomized trials comparing the results of treatment with and without postoperative radiotherapy.

RESULTS

The local recurrence rate is unacceptably high when random patients are treated with conservative surgery without radiotherapy. More favorable results may be possible when relatively wide excisions are performed on selected postmenopausal patients with small lesions without an extensive intraductal component, lymphatic or blood-vessel invasion, and histologically negative axillary nodes. The role of tamoxifen in reducing the risk of breast recurrence is uncertain. Despite salvage therapy, some individuals may develop disseminated disease as a result of local recurrence.

CONCLUSIONS

The authors believe that conducting carefully designed prospective studies of conservative surgery alone is reasonable for patients who are adequately informed of the potential risks of omitting radiation therapy. However, currently, patients should not be treated with conservative surgery alone (without radiotherapy) without such stringent guidelines.