surgery in early breast cancer

Last edited 06/2023 and last reviewed 06/2023

• in situ disease, mainly in the form of ductal carcinoma in situ (DCIS), and invasive cancer
• both are heterogeneous processes with very variable appearances, biology and clinical behaviour

Preoperative assessment of the breast

• routine use of magnetic resonance imaging (MRI) of the breast is not recommended in the preoperative assessment of patients with biopsy-proven invasive breast cancer or ductal carcinoma in situ (DCIS)
• magnetic resonance imaging (MRI) of the breasts should be offered to patients with invasive breast cancer:
  • if there is discrepancy regarding the extent of disease from clinical examination, mammography and ultrasound assessment for planning treatment
  • if breast density precludes accurate mammographic assessment to assess the tumour size
  • if breast conserving surgery is being considered for invasive lobular cancer

Surgery to the breast

• further surgery (re-excision or mastectomy, as appropriate) should be offered after breast-conserving surgery where invasive cancer or DCIS is present at the radial margins ('tumour on ink'; 0 mm)
• for women who have had breast-conserving surgery where invasive cancer or DCIS is present within 2 mm of, but not at, the radial margins (greater than 0 mm and less than 2 mm):
  • discuss the benefits and risks of further surgery (re-excision or mastectomy) to minimise the risk of local recurrence
  • take into account the woman's preferences, comorbidities, tumour characteristics and the potential use of radiotherapy

Paget's disease

• breast conserving surgery with removal of the nipple-areolar complex should be offered as an alternative to mastectomy for patients with Paget's disease of the nipple that has been assessed as localised. Offer oncoplastic repair techniques to maximise cosmesis

Staging of the axilla

• pretreatment ultrasound evaluation of the axilla should be performed for all patients being investigated for early invasive breast cancer and, if morphologically abnormal lymph nodes are identified, ultrasound-guided needle sampling should be offered
• surgery to the axilla
  • Invasive breast cancer
    • minimal surgery, rather than lymph node clearance, should be performed to stage the axilla for patients with early invasive breast cancer and no evidence of lymph node involvement on ultrasound or a negative ultrasound-guided needle biopsy. Sentinel lymph node biopsy (SLNB) is the preferred technique
  • ductal carcinoma in situ
    • SLNB is not routinely performed in patients with a preoperative diagnosis of DCIS who are having breast conserving surgery, unless they are considered to be at a high risk of invasive disease

Sentinel lymph node biopsy

Evaluation and management of a positive axillary lymph node identifified by a preoperative ultrasound-guided needle biopsy

• axillary node clearance should be offered to people with invasive breast cancer who have a preoperative ultrasound-guided needle biopsy with pathologically proven lymph node metastases

Evaluation and management of a positive axillary lymph node identifified by a sentinel lymph node biopsy (in people with a normal preoperative ultrasound-guided needle biopsy)

• further axillary treatment (axillary node clearance or radiotherapy) should be offered after SLNB to people who have 1 or more sentinel lymph node macrometastases
  
  
• do not offer further axillary treatment after primary surgery to people with invasive breast cancer who have only micrometastases in their sentinel lymph nodes
  
  
• do not offer further axillary treatment after primary surgery to people with invasive breast cancer who have only isolated tumour cells in their sentinel lymph nodes. Regard these people as having lymph node-negative breast cancer

For full details then consult NICE guidance

Reference:

• 1. NICE (March 2017). Advanced breast cancer Diagnosis and treatment
• 2. NICE (June 2023). Early and locally advanced breast cancer: diagnosis and management