Anil S Degaonkar¹, Dhiraj Vinayak Asole^2*, Ashish R Chavan³

¹Associate Professor, ²Junior Resident, ³Assistant Professor, Department of General Surgery, Dr SCGMC, Vishnupuri Nanded, Maharashtra, INDIA.

Email: anildegaonkar@Yahoo.co.in, dhiraj_asole@yahoo.com, aashish.chavan85@gmail.com

RESULTS

In present study 30 patients were included and underwent breast conserving surgery. Age group 41-50 years was most common (33 %) followed by 31-40 years (23 %) and 51-60 years (20 %).

Table 1: Age wise distribution of carcinoma breast patients

Upper outer quadrant (60%) was most common area involved in present study.

Table 2: Quadrants involved in carcinoma breast

17/30 patients had menarche at less than 13 years. There is a strong relationship between early menarche and late menopause and carcinoma breast

Table 3: Relationship between early menarche and carcinoma breast

Ultrasonography is used for imaging breast lump and axillary lymphadenopathy and plays an important role in resolving equivocal mammographic findings. USG examination was suggestive of neoplastic growth in 90% cases.

Table 4: Relationship between USG findings and breast carcinoma

Mammography plays very important role in identifying neoplastic lesion as compared to clinical examination. On Mammography 94% patients had BIRADS grade 4 or more.

Table 5: Mammographic findings of carcinoma breast

In present study, breast conservative surgery (BCS) was done mostly in patients with Stage IIA disease (70 %) followed by Stage IB disease (26.66 %) patients.

Table 6: Stages of carcinoma breast treated by BCS

In 6 cases, breast conserving surgery done ( despite of benign etiology on FNAC) due to presence of clinically carcinomatous changes on palpation, turned out to be malignant on HPE (20%).

Table 7: Corelation between FNAC findings and postoperative HPE

Post-operative complications of breast conservative surgery (BCS) were seroma (6.66%), wound infection (3.33%) and wound gape (3.33%).

Table 8: Post-operative complications of BCS

Generally, postoperatively patient is discharged on day 5 but postoperative stay is prolonged in cases of complications like seroma formation ,wound infection , wound gape etc.

Table 9: Postoperative hospital stay in cases of BCS.

 Various types of carcinoma breast are detected on histopathological examination, infiltrating ductal carcinoma was most common type noted (80%).

Table 10: Post BCS histopathological analysis

Lumpectomy and axillary dissection was done in 19 patients, while only lumpectomy done in 11 patients. Sentinel lymph node biopsy was done in all patients, 19 were positive on frozen section.

Table 11: Surgery in early breast carcinoma

On histopathological analysis of lump margins and lymph nodes 8 patients had positive lump margins, while all 19 patients who underwent axillary dissection had positive lymph nodes.

Table 12: Histopathological analysis of lump margins and lymph nodes

26.66 % patients required modified radical mastectomy (MRM) after breast conservative surgery (BCS). While all (100 %) patients required post-operative radiotherapy and 63.33% required chemotherapy. All patients had completed 3 follow up visits (at 1,2 and 6 months). No mortality was noted during study period and follow up.

Table 13: Post BCS radiotherapy and chemotherapy

DISCUSSION

Breast conserving surgery (BCS) with radiation therapy is today standard therapy for low, grade Breast Cancer. It is safe and preferred therapeutic procedure in all early detected breast cancers, because it provides the same level of overall survival as mastectomy. Besides that, BCS provides much better cosmetic effect, compared to radical treatments, a significant gain for patients, if tumours of grade I and II are considered. Increased exposure to estrogen is associated with an increased risk for developing breast cancer, whereas reducing exposure is thought to be protective.^5,6 Correspondingly, factors that increase the number of menstrual cycles, such as early menarche, nulliparity, and late menopause, are associated with increased risk. Moderate levels of exercise and a longer lactation period, factors that decrease the total number of menstrual cycles, are protective. Similar findings were noted in present study. FNAC or core biopsy of a palpable breast mass can usually be performed in an outpatient setting.⁷ In our study out of 30 cases of carcinoma breast 06 cases shows non-malignant lesion on FNAC, (approx. 20% of false negative results). So in suspicious case were FNAC is doubtful repeat FNAC or core biopsy is taken. Fisher and colleagues found that accurate predictions regarding the occurrence of distant metastases were possible after resection and pathologic analysis of 10 or more level I and II axillary lymph nodes.⁹  Fine-needle aspiration(FNA) or core biopsy of sonographically indeterminate or suspicious lymph nodes can provide a more definitive diagnosis than ultrasonography alone.¹⁰ Ultrasonography is used to guide fine-needle aspiration biopsy, core-needle biopsy, and needle localization of breast lesion. Mammography is more accurate than clinical examination for the detection of early breast cancers, providing a true-positive rate of 90%. Only 20% of women with nonpalpable cancers had axillary lymph node metastases, compared with 50% of women with palpable cancers.¹¹ Starting at age 40 years, breast examinations should be performed yearly and a yearly mammogram should be taken. The benefits from screening mammography in women >50 years of age has been noted above to be between 20% and 25% reduction in breast cancer Mortality.¹¹ The Breast Imaging Reporting and Data System (BI-RADS) is used to categorize the degree of suspicion of malignancy for a mammographic abnormality. To avoid unnecessary biopsies for low-suspicion mammographic findings, probably benign lesions are designated BI-RADS 3 and are monitored with short-interval mammograms over a 2-year period. Biopsy is performed only for lesions that progress during follow-up. In our study 2 cases belongs to grade 3(6.66%), 17 cases belongs to grade 4 (56.66%) and 11 cases belongs to grade 5 (36.66%). Investigators directly compared digital vs. screen film mammography and found that digital and screen film mammography had similar accuracy; however, digital mammography was more accurate in women <50 years of age, women with mammographically dense breasts, and premenopausal or perimenopausal women.¹² Breast conservation involves resection of the primary breast cancer with a margin of normal -appearing breast tissue, adjuvant radiation therapy, and assessment of regional lymph node status.¹³ Resection of the primary breast cancer is alternatively called segmental mastectomy, lumpectomy, partial mastectomy, wide local excision, and tylectomy. For many women with stage I or II breast cancer, breast-conserving therapy (BCT) is preferable to total mastectomy because BCT produces survival rates equivalent to those after total mastectomy while preserving the breast.¹⁴ BCT allows for preservation of breast shape and skin as well as preservation of sensation, and provides an overall psychologic advantage associated with breast preservation. Breast conservation surgery is currently the standard treatment for women with stage 0, I, or II invasive breast cancer. The breast cancer is removed with an envelope of normal-appearing breast tissue that is adequate to achieve a cancer-free margin. Significant controversy exists on the appropriate margin width for BCT.¹⁵ Radiation therapy is used for all stages of breast cancer depending on whether the patient is undergoing BCT or mastectomy.¹⁶ After 5- and 8-year follow-up periods, the disease-free (DFS), distant disease-free, and overall survival (OS) rates for lumpectomy with or without radiation therapy were similar to those observed after total mastectomy. However, the incidence of ipsilateral breast cancer recurrence was higher in the group not receiving radiation therapy.¹⁷ Adjuvant chemotherapy for patients with early-stage invasive breast cancer is considered for patients with node-positive cancers, patients with cancers that are >1 cm. Good cosmetic effect is of key importance when using BCS, balanced with width of excision, and achieving low local recurrence rate. Present study was a single center, non-randomised, observational study, larger studies are needed to confirm our findings.

CONCLUSION

Breast Conservative Surgery is considered as a better alternative to MRM in cases of early breast carcinoma like stage I, stage IIA and IIb. Major morbidity associated with MRM such as disfiguration of breast, psychological trauma, lymphoedema of upper limb can be avoided. With proper selection of patients and with availability of radiation therapy ,all cases of early breast cancers can be managed by breast conservative surgery.

REFERENCES

1. Schwartz GF, Veronesi U, Clough KB. et al. Consensus Conference on Breast Conservation. Seminars in Breast Disease. Milano, 2005:178-185.
2. Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002; 184: 383-393.
3. Veronesi U. How Important Is the Assessment of Resection Margins in Conservative Surgery for Breast Cancer? Editorial. 1994: 1660-16
4. Moran MS, Schnitt SJ, Giuliano AE, 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 21:704–716, 2014.
5. Blackburn GL, Copeland T, Khaodhiar L, et al. Diet and breast cancer. J Womens Health (Larchmt). 2003;12:183-192.
6. Singletary SE. Rating the risk factors for breast cancer. Ann Surg. 2003;237:474-482.
7. Wilkinson EJ, Masood S. Cytologic needle samplings of the breast: Techniques and end results. In: Bland KI, Copeland EMI, eds. The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia: WB Saunders;1998:705.
8. Greene FL, Page DL, Fleming ID, eds. Breast. AJCC Cancer Staging Manual 6th ed. New York: Springer-Verlag: 2002.
9. Krishnamurthy S, Sneige N, Bedi DG, et al. Role of ultrasound-guided fine-needle aspiration of indeterminate and suspiciousaxillary lymph nodes in the initial staging of breast carcinoma. Cancer. 2002;95:982-988.
10. Britton PD, Goud A, Godward S, et al. Use of ultrasounguided axillary node core biopsy in staging of early breast cancer. Eur Radiol. 2009;19:561-569.
11. Glasziou P, Houssami N. The evidence base for breast cancer screening. Prev Med. 2011;53:100-102.
12. Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Engl J Med. 2005;353:1773-1783
13. Newman LA, Washington TA. New trends in breast conservation therapy. Surg Clin North Am. 2003;83:841-883.
14. Group EBCTC. 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 in17 randomised trials. Lancet. 2011;378:1707-1716.
15. Houssami N, Macaskill P, Marinovich ML, et al. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer.. 2010;46:3219-3232.
16. Recht A, Edge SB, Solin LJ, et al. Postmastectomy radiotherapy:clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol. 2001;19:1539-1569
17. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy,lumpectomy, and lumpectomy plus irradiation forthe treatment of invasive breast cancer. N Engl J Med.2002;347:1233-1241.