When radical mastectomy was introduced by Halsted , the average patient presented for treatment with locally advanced disease, and a relatively extensive procedure was often necessary just to remove all gross cancer. This is no longer the case as most patients now present with much smaller, less locally advanced lesions. The emergence of breast-conserving therapy (BCT) has provided early-stage breast cancer patients with a chance to preserve a cosmetically acceptable breast and equivalent outcomes in terms of breast cancer survival.
Historically, Halsted  is credited with performing the first modern radical mastectomy in 1882 in the United States. This surgical procedure required the en bloc removal of the breast, pectoral muscles, and axillary lymph nodes. Radical mastectomy was the standard surgical procedure performed for breast cancer in the United States from the turn of the 20th century until the 1950s. The curative potential of this procedure was limited as a series of 1438 patients followed over 30 years showed that only 13% were free of disease, whereas 57% had succumbed to breast cancer . In an effort to improve locoregional and distant control several authors proposed using an extended radical mastectomy, which in addition to the en-bloc removal of the breast, pectoral muscles, and axillary lymph nodes required the resection of the internal mammary lymph nodes. A randomized trial, however, proved no benefit to the extended radical mastectomy [3,4]. Currently, radical mastectomy is rarely indicated or performed and in advanced cases, less-invasive surgery coupled with neoadjuvant chemotherapy is preferred.
The modified radical mastectomy (MRM) involves the removal of the breast, underlying pectoralis major fascia but not the muscle, and evaluation of selected axillary lymph nodes. MRM provides a better cosmetic and functional result than radical mastectomy. Two prospective randomized trials, single-institution data, and several retrospective studies all demonstrate no difference in disease-free or overall survival rates between radical mastectomy and MRM for early-stage breast cancer [5,6]. Until the early 1980s and the emergence of BCT, MRM was the standard treatment available to women for early-stage breast cancer. With the emergence of sentinel node biopsy simple mastectomies have become more frequently performed then MRM. As with MRM, a total or simple mastectomy requires the removal of the entire breast tissue without an axillary dissection. Similarly, with advent of immediate reconstruction at the time of mastectomy, ‘skin-sparing mastectomy’ (SSM) was developed as a technique to preserve the majority of the natural skin envelope of the breast in an effort to improve the cosmetic outcome of the procedure and allow for immediate reconstruction . The results of retrospective and prospective series have found that the local recurrence rates were comparable to those seen with standard mastectomies, ranging from 0 to 7% [8–10], and a meta-analysis of retrospective studies did not detect a significant difference in local recurrences between patients undergoing SSM with immediate reconstruction and patients undergoing conventional mastectomies without reconstruction . More recently, in carefully selected patients, nipple and areola sparing mastectomy (NSM) has been utilized to preserve the entire skin envelope, including the areola and nipple but removes the major ducts within the nipple along the entire breast parenchyma followed by immediate breast reconstruction. This approach appears to be particularly appealing for patients undergoing risk-reducing surgery but is more controversial for the treatment of cancer and has been reserved for patients with tumors less than 2 cm in size and more than 2 cm from the nipple with clinically negative lymph nodes [12,13]. No long-term clinical series or randomized trials have examined the safety of this approach; however, retrospective series indicate that the recurrence rates associated with NSM are comparable to the more traditional SSM and MRM [12,14]. SSM and NSM are contraindicated in patients with inflammatory breast cancer (IBC) because of the dermal lymphatic involvement. With the advent of research reporting on the quality of life improvements and psychological benefits associated with breast reconstruction, the number of women undergoing breast reconstruction has increased although the absolute number and proportion remain low [15,16]. Most patients when they choose to undergo breast reconstruction elect to have it carried out at the time of the mastectomy (immediate reconstruction) as opposed to a subsequent operation (delayed reconstruction) that may be more appropriate for patients with locally advanced breast cancer or IBC . Reconstructive options include prosthetic devices such as saline or silicone implants, which are technically simpler and associated with a more rapid recovery, or autologous tissue reconstruction using pedicled or free tissue flaps from the lower abdomen, the latissimus dorsi or the buttock area, which provide for a more natural and pleasing cosmetic result [18,19].
BCT involves an excision of the tumor mass with a negative surgical margin, an axillary evaluation, and postoperative irradiation. In the 1980s, six prospective randomized trials were conducted worldwide that showed no significant difference in locoregional relapse or overall survival between breast-conserving surgery and radiation versus MRM for early-stage invasive breast cancer. BCT has gained increasing acceptance as a treatment option for stages I and II and selected stage III breast cancers as a result of six prospective randomized trials as well as an overview of all completed trials that showed its therapeutic equivalence with mastectomy [20–26]. Patient selection for BCT is crucial for its success. The few absolute contraindications for BCT include the following:
- A history of prior therapeutic radiotherapy that would result in an excessively high total radiation dose to the chest wall.
- Persistently positive resection margins despite multiple attempts at re-excision.
- Multicentric disease with two or more tumors in separate quadrants of the breast.
- Diffuse malignant calcifications on mammography.
Radiation therapy is absolutely contraindicated in pregnancy; however, it may be possible to proceed with breast-conserving surgery in the third trimester and defer irradiation until after delivery [27,28]. Similarly, radiation-induced toxicities in patients with a history of connective tissue disease have kept them from undergoing BCT . Carefully matched retrospective case–control studies have, however, failed to show a statistically significant increase in radiation induced acute and late toxicities in all but patients with scleroderma and active systemic lupus erythematosus [30–33]. Tumor size itself is not a contraindication for BCT and is only a relative contraindication should an adequate resection to negative margins result in an unacceptable cosmetic result. In some cases preoperative or neoadjuvant chemotherapy can reduce the tumor size and allow for breast conservation as long as a metallic clip is placed prior to initiating therapy in order to accurately localize the tumor at the time of surgery [34,35]. Positive or unknown margins should prompt re-excision, as these patients are at higher risk for recurrence . Residual disease is discovered in about half of these patients depending on the histology with tumors containing an extensive intraductal component having the highest likelihood of residual tumor [37,38]. There is no standard definition for close margins, although most authorities recommend re-excision for margins less than 2 mm including the National Comprehensive Cancer Network that deems margins less than 1 mm to be inadequate except when at the chest or close to the skin [39,40]. In many cases radiation oncologists will choose to boost the lumpectomy bed in an effort to reduce the locoregional recurrence rate .
A commonly held belief is that young age that is usually defined as 40 or less years is a relative contraindication for BCT as it was associated with an increased risk of locoregional recurrence [42,43]. This may have been due to adverse pathologic features such as larger tumor size, higher grade, absence of estrogen receptors, and lymphovascular invasion as well as inherited genetic predispositions [44–46]. However, locoregional recurrences were also more commonly seen in young women with breast cancer following mastectomy [46,47]. When the long-term results of two large randomized trials as well as a large retrospective review of patients with breast cancer aged 20–49 years were reviewed, the choice of therapy was not associated with a noticeable difference in recurrence-free or cancer-specific survival [48–50]. Patients with an inherited predisposition for breast cancer, such as BRCA1 and BRCA2 mutation carriers, who are diagnosed and treated for breast cancer are not only at increased risk for a contralateral cancer following their diagnosis and treatment but may also be at increased risk for an in breast recurrence or ipsilateral new primary breast tumors [51–53]. Systemic chemotherapy and risk reducing salpingo-oophorectomies seem to reduce the frequency of ipsilateral breast tumor recurrences and contralateral breast cancers in this patient population but the decision to pursue BCT needs to be thoroughly discussed with the assistance of specialized genetic counselors [52,54].
In addition to providing an optimal oncologic outcome, one of the goals of BCT is to achieve a cosmetically acceptable result. Many factors play a role in the final appearance of the breast among which the amount of resected breast tissue and postoperative radiation therapy play a determining role [55,56]. Oncoplastic surgical techniques aim to provide wide surgical margins all the while preserving the appearance and shape of the breast [57,58▪].
Despite the consistent evidence showing the therapeutic equivalence of BCT and mastectomy, BCT continues to still be underutilized with more than a quarter of patients with early-stage breast cancer still choosing mastectomy . Possible explanations include patient preference over concerns about locoregional cancer recurrence and the effects of radiation therapy [60,61]. Preoperative breast MRI has also been used preoperatively in an effort to define the extent of disease and help achieve clear surgical margins, however, there is no evidence that such an approach results in a lower rate of positive margins and reoperation , in fact some evidence suggests that mastectomy rates increase when MRI results are used to direct surgical planning .
Conventional radiation therapy after breast-conserving surgery delivers 45–50 Gy to the entire breast over 4–5 weeks resulting in a reduction in locoregional recurrence, distant recurrences, and death [64▪▪]. In an effort to increase the convenience of radiation therapy and decrease the cost and strain on resources associated with conventional radiation therapy, accelerated irradiation schedules have grown in popularity and a recent meta-analysis of four randomized trials concluded that the shorter fractionation schedule was equivalent to conventional radiation therapy in terms of locoregional recurrences, overall survival, breast cosmesis, early and late toxicities . The accelerated scheduled has not, however, been sufficiently examined in patients under the age of 50 years, with positive lymph nodes, or close margins. Similarly, accelerated partial breast irradiation (APBI) techniques were developed in order to deliver focused radiation therapy to a limited volume of tissue over a shorter period using higher doses of radiation in order to decrease the toxicity associated with conventional radiation therapy and decrease healthcare costs, although increasing patient convenience . APBI can be delivered using conformal external beam radiation therapy such intensity modulated radiation therapy or brachytherapy using interstitial catheters surrounding the lumpectomy site, intracavitary balloon catheter placed into the lumpectomy site or intraoperative radiation therapy using a spherical radiation device or portable linear accelerator [67–69]. Although the initial outcomes are promising when comparing APBI to conventional radiation therapy, follow-up is limited and the patients were highly selected with small unifocal tumors with wide negative margins and without adverse histologic features . In addition a recent population-based cohort study of women with invasive breast cancer who were 67 years or older revealed that APBI was associated with a higher incidence of subsequent mastectomy at 5 years and of postoperative infectious and noninfectious complications [71▪▪].
Axillary staging remains one of the most important prognostic indicators in women with early-stage breast cancer. Axillary lymph node dissection (ALND) has traditionally been the linchpin for axillary evaluation and is still the standard of care in patients with clinically palpable/positive axillary nodes. The purported benefits of ALND beyond its prognostic role include local regional control and survival benefits. The impact of ALND on survival remains, however, unclear with available data showing conflicting results. In the National Surgical Adjuvant Breast and Bowel Project trial B-04, women assigned to a modified radical mastectomy did not fare any better at 10–25 years of follow-up than the women who underwent a simple mastectomy with nodal irradiation or a simple mastectomy and ALND when lymphadenopathy occurred . Similarly, in a meta-analysis of three randomized trials comparing axillary dissection versus no dissection in clinically node negative early-stage breast cancer patients, ALND did not confer a survival advantage, although the rate of axillary recurrences was increased in the absence of dissection . ALND may also result in nerve injury, lymphedema, shoulder dysfunction and injury/thrombosis of the axillary vein . Sentinel lymph node biopsy (SLNB) has been developed as a method of accurately evaluating the axilla with less morbidity than ALND with several studies showing significantly lower arm morbidity and lymphedema rates in patients undergoing SLNB [75,76]. Using injection of vital blue dye and/or radiolabeled colloid around the area of the tumor or intradermally, sentinel lymph nodes (SLNs) can be consistently identified in about 96% of cases with a false-negative rate of less than 5–10% in experienced hands [77,78]. Using a combination of radiocolloid and blue dye may result in a significantly higher success rate for SLN identification as well as a lower false-negative rate . The outcome of patients undergoing SLNB followed by ALND if the SLN was positive was similar to that of patients who underwent ALND in terms of regional control and overall survival . More recently the role of completion ALND in patients with micrometastases or macrometastases in less than three SLNs has been questioned as the SLN is found to be the sole site of metastasis in up to 60% of patients overall and 90% of patients with micrometastases . In the American College Of Surgeons Oncology Group (ACOSOG) Z-0011 trial patients with clinically node negative breast cancer undergoing BCT were randomized to completion ALND versus observation if they had less than three positive SLNs. The overall survival and local regional recurrence rates were similar between the two groups [82▪▪]. However, these results cannot be extrapolated to patients who undergo PBI and the trial failed to meet its enrollment goal of 1900 patients due to slow accrual . Predictive nomograms have also been developed to estimate the risk of additional positive nodes in patients with SLN metastases in an effort to spare them from a potentially morbid ALND. A retrospective analysis examining the performance of four different nomograms did not show them to be sufficiently accurate and reliable [83,84]. Clinical circumstances in which SLNB is controversial include locally advanced breast cancer or IBC due to an unusually high false-negative rate presumably because of partially obstructed subdermal lymphatics. The size of the primary tumor is not in itself a contraindication as long as the axilla is clinically negative [85,86]. Similar concerns regarding the accuracy and false-negative rates for SLNB in patients following neoadjuvant chemotherapy have been reported and the National Comprehensive Cancer Network (NCCN) guidelines recommend that SLNB be performed prior to initiating chemotherapy [87,88▪]. The American Society of Clinical Oncology (ASCO) guidelines recommended against SLNB in patients with a previous axillary surgery, although there are increasing reports of successful SLNB in patients with local regional breast recurrence following a previous SLNB and/or ALND [89,90]. Supravital dyes such as isosulfan blue are contraindicated in pregnant patients, although the available data suggest that the radiation dose to the fetus is minimal using radiocolloid during SLNB [91,92]. Even though the NCCN guidelines report that radiocolloid use in pregnancy is well tolerated, the 2005 ASCO guidelines recommend against SLNB in pregnant patients. For patients with ductal carcinoma in situ a SLNB is not required in most cases except when there is evidence of microinvasion on the biopsy, a strong suspicion for invasive disease on imaging or exam or in the event of a mastectomy as the performance of a SLNB following a mastectomy may not always be successful [93,94].
The treatment for breast cancer has evolved over the past few decades from the Halsted radical mastectomy to breast-conserving surgery in most patients with early-stage breast cancer. This approach has been able to offer such patients a cosmetically acceptable result all the while preserving their excellent oncologic outcome. For patients who undergo a mastectomy many patients opt for immediate reconstruction and preservation of the skin envelope thereby improving their cosmetic outcome. Similarly, the trend in axillary staging has been toward a more limited approach in an effort to minimize the long-term morbidities associated with a traditional ALND whose therapeutic value has been increasingly questioned.
Conflicts of interest
The author has no relevant conflicts of interest or sources of funding to disclose.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 89).
1. Halsted WSI. The results of radical operations for the cure of carcinoma of the breast. Ann Surg
2. Adair F, Berg J, Joubert L, Robbins GF. Long-term follow up of breast cancer patients: the 30-year report. Cancer
3. Veronesi U, Valagussa P. Inefficacy of internal mammary nodes dissection in breast cancer surgery. Cancer
4. Veronesi U, Marubini E, Mariani L, et al. The dissection of internal mammary nodes does not improve the survival of breast cancer patients. 30-year results of a randomised trial. Eur J Cancer
5. Maddox WA, Carpenter JT, Laws HL, et al. A randomized prospective trial of radical (Halsted) mastectomy versus modified radical mastectomy in 311 breast cancer patients. Ann Surg
6. Turner L, Swindell R, Bell WG, et al. Radical versus modified radical mastectomy for breast cancer. Ann R Coll Surg Engl
7. Simmons RM, Adamovich TL. Skin-sparing mastectomy. Surg Clin North Am
8. Simmons RM, Fish SK, Gayle L, et al. Local and distant recurrence rates in skin-sparing mastectomies compared with nonskin-sparing mastectomies. Ann Surg Oncol
9. Slavin SA, Schnitt SJ, Duda RB, et al. Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early-stage breast cancer. Plast Reconstr Surg
10. Foster RD, Esserman LJ, Anthony JP, et al. Skin-sparing mastectomy and immediate breast reconstruction: a prospective cohort study for the treatment of advanced stages of breast carcinoma. Ann Surg Oncol
11. Lanitis S, Tekkis PP, Sgourakis G, et al. Comparison of skin-sparing mastectomy versus nonskin-sparing mastectomy for breast cancer: a meta-analysis of observational studies. Ann Surg
12. Sacchini V, Pinotti JA, Barros ACSD, et al. Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem? J Am Coll Surg
13. Chung AP, Sacchini V. Nipple-sparing mastectomy: where are we now? Surg Oncol
14. Gerber B, Krause A, Dieterich M, et al. The oncological safety of skin sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction: an extended follow-up study. Ann Surg
15. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, ‘SVEA,’ comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg
16. Alderman AK, Wei Y, Birkmeyer JD. Use of breast reconstruction after mastectomy following the Women's Health and Cancer Rights Act. JAMA
17. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol
18. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg
19. Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg
20. Early Breast Cancer Trialists’ Collaborative Group. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. N Engl J Med 1995; 333:1444–1455.
21. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med
22. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med
23. van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst
24. Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med
25. Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy
: the National Cancer Institute Randomized Trial. Cancer
26. Arriagada R, Lê MG, Rochard F, Contesso G. Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group. J Clin Oncol
27. Annane K, Bellocq J-P, Brettes J-P, Mathelin C. Infiltrative breast cancer during pregnancy and conservative surgery. Fetal Diagn Ther
28. Kuerer HM, Gwyn K, Ames FC, Theriault RL. Conservative surgery and chemotherapy for breast carcinoma during pregnancy. Surgery
29. Fleck R, McNeese MD, Ellerbroek NA, et al. Consequences of breast irradiation in patients with preexisting collagen vascular diseases. Int J Radiat Oncol Biol Phys
30. Phan C, Mindrum M, Silverman C, et al. Matched-control retrospective study of the acute and late complications in patients with collagen vascular diseases treated with radiation therapy. Cancer J
31. Chen AM, Obedian E, Haffty BG. Breast-conserving therapy in the setting of collagen vascular disease. Cancer J
32. Morris MM, Powell SN. Irradiation in the setting of collagen vascular disease: acute and late complications. J Clin Oncol
33. Ross JG, Hussey DH, Mayr NA, Davis CS. Acute and late reactions to radiation therapy in patients with collagen vascular diseases. Cancer
34. Wolmark N, Wang J, Mamounas E, et al
. Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18. J Natl Cancer Inst Monographs 2001; 30:96–102.
35. Alm El-Din MA, Taghian AG. Breast conservation therapy
for patients with locally advanced breast cancer. Semin Radiat Oncol
36. Kearney TJ, Morrow M. Effect of reexcision on the success of breast-conserving surgery. Ann Surg Oncol
37. Schnitt SJ, Connolly JL, Khettry U, et al. Pathologic findings on re-excision of the primary site in breast cancer patients considered for treatment by primary radiation therapy. Cancer
38. Gwin JL, Eisenberg BL, Hoffman JP, et al. Incidence of gross and microscopic carcinoma in specimens from patients with breast cancer after re-excision lumpectomy. Ann Surg
39. Morrow M. Breast conservation and negative margins: how much is enough? Breast
2009; 18 (Suppl 3):S84–S86.
40. Blair SL, Thompson K, Rococco J, et al. Attaining negative margins in breast-conservation operations: is there a consensus among breast surgeons? J Am Coll Surg
41. Jones HA, Antonini N, Hart AAM, et al. Impact of pathological characteristics on local relapse after breast-conserving therapy: a subgroup analysis of the EORTC boost versus no boost trial. J Clin Oncol
42. Nixon AJ, Neuberg D, Hayes DF, et al. Relationship of patient age to pathologic features of the tumor and prognosis for patients with stage I or II breast cancer. J Clin Oncol
43. Miles RC, Gullerud RE, Lohse CM, et al. Local recurrence after breast-conserving surgery: multivariable analysis of risk factors and the impact of young age. Ann Surg Oncol
44. Kurtz JM, Jacquemier J, Amalric R, et al. Why are local recurrences after breast-conserving therapy more frequent in younger patients? J Clin Oncol
45. Vrieling C, Collette L, Fourquet A, et al. Can patient-, treatment- and pathology-related characteristics explain the high local recurrence rate following breast-conserving therapy in young patients? Eur J Cancer
46. Chan A, Pintilie M, Vallis K, et al. Breast cancer in women. Ann Oncol
47. la Rochefordiere de A, Asselain B, Campana F, et al. Age as prognostic factor in premenopausal breast carcinoma. Lancet
48. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med
49. Veronesi U, Salvadori B, Luini A, et al. Breast conservation is a safe method in patients with small cancer of the breast. Long-term results of three randomised trials on 1973 patients. Eur J Cancer
50. Coulombe G, Tyldesley S, Speers C, et al. Is mastectomy superior to breast-conserving treatment for young women? Int J Radiat Oncol Biol Phys
51. Pierce LJ, Strawderman M, Narod SA, et al. Effect of radiotherapy after breast-conserving treatment in women with breast cancer and germline BRCA1/2 mutations. J Clin Oncol
52. Robson M, Levin D, Federici M, et al. Breast conservation therapy
for invasive breast cancer in Ashkenazi women with BRCA gene founder mutations. J Natl Cancer Inst
53. Haffty BG, Harrold E, Khan AJ, et al. Outcome of conservatively managed early-onset breast cancer by BRCA1/2 status. Lancet
54. Pierce LJ, Levin AM, Rebbeck TR, et al. Ten-year multiinstitutional results of breast-conserving surgery and radiotherapy in BRCA1/2-associated stage I/II breast cancer. J Clin Oncol
55. Harris JR, Levene MB, Svensson G, Hellman S. Analysis of cosmetic results following primary radiation therapy for stages I and II carcinoma of the breast. Int J Radiat Oncol Biol Phys
56. Wazer DE, DiPetrillo T, Schmidt-Ullrich R, et al. Factors influencing cosmetic outcome and complication risk after conservative surgery and radiotherapy for early-stage breast carcinoma. J Clin Oncol
57. Kronowitz SJ, Feledy JA, Hunt KK, et al. Determining the optimal approach to breast reconstruction after partial mastectomy. Plast Reconstr Surg
2006; 117:1–11.discussion 12–14.
58▪. Gainer SM, Lucci A. Oncoplastics: techniques for reconstruction of partial breast defects based on tumor location. J Surg Oncol
Overview of oncoplastic techniques available in BCT based on tumor location.
59. Temple WJ, Russell ML, Parsons LL, et al. Conservation surgery for breast cancer as the preferred choice: a prospective analysis. J Clin Oncol
60. Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA
61. Katz SJ, Lantz PM, Janz NK, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol
62. Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet
63. Pettit K, Swatske ME, Gao F, et al. The impact of breast MRI on surgical decision-making: are patients at risk for mastectomy? J Surg Oncol
64▪▪. Darby S, McGale P, Correa C, , et al.
; Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). 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 in 17 randomised trials. Lancet 2011; 378:1707–1716.
Meta-analysis showing that after breast-conserving surgery, radiotherapy halves the risk of recurrence and reduces the breast cancer death rate by about a sixth.
65. James ML, Lehman M, Hider PN, et al
. Fraction size in radiation treatment for breast conservation in early breast cancer. Cochrane Database Syst Rev 2010:CD003860.
66. Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): a review of available techniques. Radiat Oncol
67. Vaidya JS, Tobias JS, Baum M, et al. Intraoperative radiotherapy for breast cancer. Lancet Oncol
68. Khan AJ, Arthur D, Vicini F, et al. Six-year analysis of treatment-related toxicities in patients treated with accelerated partial breast irradiation on the American Society of Breast Surgeons MammoSite Breast Brachytherapy registry trial. Ann Surg Oncol
69. Ott OJ, Hildebrandt G, Pötter R, et al. Accelerated partial breast irradiation with interstitial implants: risk factors associated with increased local recurrence. Int J Radiat Oncol Biol Phys
70. Valachis A, Mauri D, Polyzos NP, et al. Partial breast irradiation or whole breast radiotherapy for early breast cancer: a meta-analysis of randomized controlled trials. Breast J
71▪▪. Smith GL, Xu Y, Buchholz TA, et al. Association between treatment with brachytherapy vs whole-breast irradiation and subsequent mastectomy, complications, and survival among older women with invasive breast cancer. JAMA
This is the first cohort study showing that breast brachytherapy was associated with an increased risk of complications and subsequent mastectomy compared with whole breast irradiation.
72. Fisher B, Jeong J-H, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med
73. Sanghani M, Balk EM, Cady B. Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients: a systematic review and meta-analysis. Cancer
74. Erickson VS, Pearson ML, Ganz PA, et al. Arm edema in breast cancer patients. J Natl Cancer Inst
75. Lucci A, McCall LM, Beitsch PD, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol
76. Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol
77. Mabry H, Giuliano AE. Sentinel node mapping for breast cancer: progress to date and prospects for the future. Surg Oncol Clin N Am
78. Veronesi U, Viale G, Paganelli G, et al. Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg
79. Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis. Cancer
80. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol
81. Chagpar AB. Clinical significance of minimal sentinel node involvement and management options. Surg Oncol Clin N Am
82▪▪. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA
Randomized controlled trial showing that among patients with limited nodal disease undergoing BCT survival was equivalent when ALND was omitted.
83. Gur AS, Unal B, Johnson R, et al. Predictive probability of four different breast cancer nomograms for nonsentinel axillary lymph node metastasis in positive sentinel node biopsy
. J Am Coll Surg
84. Unal B, Gur AS, Ahrendt G, et al. Can nomograms predict nonsentinel lymph node metastasis after neoadjuvant chemotherapy in sentinel lymph node-positive breast cancer patients? Clin Breast Cancer
85. Kaufmann M, Morrow M, Minckwitz von G, Harris JR. Biedenkopf Expert Panel MembersLocoregional treatment of primary breast cancer: consensus recommendations from an International Expert Panel. Cancer
86. Hidar S, Bibi M, Gharbi O, et al. Sentinel lymph node biopsy after neoadjuvant chemotherapy in inflammatory breast cancer. Int J Surg
87. Nason KS, Anderson BO, Byrd DR, et al. Increased false negative sentinel node biopsy
rates after preoperative chemotherapy for invasive breast carcinoma. Cancer
88▪. Tausch C, Steger GG, Haid A, et al. Sentinel node biopsy
after primary chemotherapy in breast cancer: a note of caution from results of ABCSG-14. Breast J
Subgroup analysis of a randomized controlled trial of neoadjuvant chemotherapy showing an unacceptably high risk of false negative SLNs at the time of surgery.
89. Newman EA, Cimmino VM, Sabel MS, et al. Lymphatic mapping and sentinel lymph node biopsy for patients with local recurrence after breast-conservation therapy. Ann Surg Oncol
90. Intra M, Trifirò G, Viale G, et al. Second biopsy of axillary sentinel lymph node for reappearing breast cancer after previous sentinel lymph node biopsy. Ann Surg Oncol
91. Gentilini O, Cremonesi M, Toesca A, et al. Sentinel lymph node biopsy in pregnant patients with breast cancer. Eur J Nucl Med Mol Imaging
92. Spanheimer PM, Graham MM, Sugg SL, et al. Measurement of uterine radiation exposure from lymphoscintigraphy indicates safety of sentinel lymph node biopsy during pregnancy. Ann Surg Oncol
93. Karam A, Stempel M, Cody HS, Port ER. Reoperative sentinel lymph node biopsy after previous mastectomy. J Am Coll Surg
94. Lyman GH, Giuliano AE, Somerfield MR, et al.
American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005; 23:7703–7720.