Decision Making in the Surgical Management of Invasive Breast Cancer PART 1: Lumpectomy, Mastectomy, and Contralateral Prophylactic Mastectomy

Several prospective randomized clinical trials conducted internationally have proven the safety and survival equivalence of breast-conserving surgery compared with mastectomy. Adjuvant radiation is routinely recommended following lumpectomy surgery to minimize the risk of local recurrence. Comprehensive breast imaging (including bilateral mammography with diagnostic views and ultrasound evaluation), in addition to clinical examination, is essential to rule out potential contralateral pathology and to optimally characterize the extent of disease. These studies are considered standard in the assessment of patient eligibility for lumpectomy. MRI of the breast remains controversial as an adjunct to determine candidacy for breast conservation, since MRI findings increase mastectomy rates without evidence of improved local control; prospective randomized clinical trials are underway to define the role of MRI in newly diagnosed breast cancer. Recently, the multidisciplinary oncology community has adopted a consensus guideline defining "no ink on tumor" as an acceptable microscopic margin at lumpectomy; however, post-lumpectomy imaging may be necessary to confirm complete removal of all cancer-associated microcalcifications, with clinical judgment exercised regarding re-excision for close margins. Contralateral prophylactic mastectomy is becoming increasingly common in the United States, and patients considering this option must be counseled about its lack of a survival benefit, its higher complication rate, and the fact that it is risk-reducing but not risk-eliminating.