Fig. 7.1
Van Nuys Prognostic Index
Basing on Silverstein’s and other authors’ following studies, at present, the most important factor in DCIS surgical treatment is margin status. According to current guidelines, whatever operation able to remove the entire DCIS without margin involvement is considered appropriate. The debate concerns the meaning of “margin involvement”: according to Morrow et al., margin is positive if ink is present on tumor [13]; according to NCCN guidelines, reoperation should be performed if distance between tumor and margin is <1 mm [14].
7.2 Choice of the Operation
7.2.1 Anamnesis
Anamnesis has a key role in treatment selection because it allows the identification of contraindications, risk factors for recurrence, and predictive factors for cosmetic outcome and patient’s satisfaction. Questions should focus on:
Age. DCIS presents a higher recurrence rate in women >60 [8, 9]; comorbidities of the elderly may represent relative or absolute contraindications for procedures such as general anesthesia, radiotherapy, or reconstruction.
Family history. DCIS recurrence is more frequent in patients with family history of breast cancer.
Hereditary Neoplastic Syndrome (BRCA mutation or others). If there is a suspect of a hereditary breast and ovarian cancer syndrome (multiple close relatives with BC, BC in males, bilateral BC, ovarian cancer, BC in young patient) in a DCIS patient, she should be sent for genetic counseling. If a DCIS arises in a woman with a proven genetic mutation, a bilateral mastectomy should be considered.
Personal history of breast cancer. Previous breast surgery may influence the selection of operation in different ways: surgical (modified breast vascularization), aesthetical (symmetry), psychological (patients with propensity for mastectomy), and oncological factors (high-risk breast) play a role.
Previous radiotherapy. RT represents a contraindication to breast-conserving therapy (BCT), because it implies a new breast irradiation in most cases.
Other contraindications to radiotherapy. Some cardiovascular and lung diseases contraindicate radiotherapy [15–19], which is part of BCT in most of cases.
Psychological aspects. If more than one surgical option is feasible and the patient has been accurately informed, treatment selection should be based on patient’s will (refusal of mastectomy or, on the other hand, request for a more radical operation).
7.2.2 Physical Examination
The vast majority of DCIS is clinically silent; it might in rare cases show itself as a palpable mass or through nipple discharge. Once the presence of suspect finds is ruled out, the breast physical examination of patients with DCIS focuses on the pinpointing of aesthetic outcome predictive factors:
Breast volume. Both small and large volumes pose problems in obtaining aesthetically acceptable symmetry after surgery. If, on one hand, a small breast is not suitable for undergoing conservative surgery (as the resulting asymmetry would be unacceptable), on the other mastectomy can pose reconstructive problems (as even the smallest prosthesis can be too large compared to the contralateral breast in the presence of small volumes); in such case, contralateral symmetrization can be opted for. Large volumes do not pose problems as far as conservative surgery is concerned, as residual asymmetry is either low or imperceptible; however, should mastectomy be recommended, the reconstructive outcome can hardly replicate the contralateral breast, which is therefore often symmetrized (i.e., reduction mammoplasty).
Breast ptosis. As breast ptosis is difficult to replicate, the problems it poses involve not so much conservative surgery as post-mastectomy reconstruction; symmetrization can be opted for also in this case (i.e., mastopexy).
7.2.3 Radiology
Correct presurgery radiological characterization is one of the key points for intraductal carcinoma conservative surgery to be successful, which means obtaining a negative margin. Detailed information on the following aspects is required:
Location
Size. The ratio between neoplasm and breast size is important when choosing what type of surgery the patient is to undergo; performing quadrantectomy on a patient whose ratio is high can affect oncological radicality (margins affected due to inadequate resection) or aesthetic outcomes (symmetry is affected if overly extended quadrantectomy is performed).
Morphological features. The presence of a nodular image within the framework of a DCIS-compatible radiological find can indicate an infiltration focus; such parameter does not greatly influence the choice between quadrantectomy and mastectomy; however, it is to be taken into consideration when choosing whether to perform a sentinel lymph node biopsy in the DCIS.
Multifocality and multicentricity. The presence of multifocality and especially multicentricity contraindicates conservative surgery.
Each of the breast medical imaging methodologies plays a role in characterizing intraductal carcinoma.
Mammography. Examining mammography images is the first step toward the planning of surgery, as it enables the assessment of DCIS location, size, morphological features, multifocality, and multicentricity; microcalcification distribution guides the choice between mastectomy and conservative surgery, as well as that between the two types of conservative surgery (traditional quadrantectomy or oncoplastic surgery). However, mammography has one major limit as far as DCIS size assessment is concerned, as dimensional and topographic correspondence between microcalcifications and DCIS is far from exact: intraductal carcinoma can be larger (as calcifications only indicate necrosis areas within the neoplasm) or smaller (as lesions causing microcalcifications, such as sclerosing adenosis or papillomatosis [20], can be found on the margins of the DCIS); such phenomenon can mislead the surgeon, who still obtains a neoplasm-affected margin after planning surgery and carrying out the intraoperative radiological examination of the removed tissue.
Ultrasound. Ultrasound has a minor role in the characterization of in situ ductal carcinoma, as the latter is often undetectable by ultrasounds. What is to be ruled out by use of ultrasound is the presence of nodular images suspected of infiltration, which indicate the need for a sentinel lymph node biopsy.
Nuclear magnetic resonance. Resonance enables a better assessment of DCIS size and multicentricity and therefore leads to a lower risk of obtaining neoplasm-affected margins after conservative surgery.
7.2.4 Core Biopsy
Stereotactic-guided core biopsy followed by a histological examination is required in the presence of mammography-detected suspect microcalcifications. Anatomopathological examinations, other than enabling diagnosis, provide indications on nuclear grade (considered by Silverstein as a predictive factor of local recurrence). Given the higher biological aggressiveness (in terms of progression toward invasive neoplasm) of DCIS with HER2 and basal-like phenotypes, the routine phenotypical characterization of in situ neoplasms could be useful in modulating therapeutic approach aggressiveness also based on biological characteristics [21].
7.3 The Problem of Intraoperative Identification
As DCIS develops inside ducts following the anatomy of the gland, it is macroscopically invisible and scarcely palpable, which leads to intraoperative difficulties in locating and defining its limits; therefore, the surgeon, when performing resection, is to rely on data collected prior to surgery rather than intraoperative palpation so as to define resection size, as the latter would mean adopting a blinkered approach and therefore increasing the risk of obtaining an inadequate margin. In order to maximize radical excision likelihood, the surgeon makes use of techniques enabling them to track down the location of the non-palpable lesion when operating and techniques enabling resection margin state to be assessed.
7.3.1 Non-palpable Lesion Localization
Non-palpable lesion localization encompasses all those methods enabling the tracking down of radiological finds lacking a clinical equivalent when operating, which is a feature of most intraductal carcinomas. There are several non-palpable lesion localization techniques, which are more thoroughly discussed in Chap. 6.
7.3.2 Intraoperative Margin Definition
Intraoperative margin definition would reduce the high reintervention rate (38–46%) [22, 23]; however, none of the proposed methods have proved significantly effective as of today; therefore DCIS intraoperative margin definition remains controversial.
Microscopic examination: not useful, as a complete study of the margin would require a high number of samples and an amount of time not compatible with an intraoperative examination.
Macroscopic examination (visual and tactile): scarcely reliable because DCIS is macroscopically invisible and scarcely palpable.
Optical segmentation and confocal reflection microscopy: based on the innate optical properties of inner breast tissues, especially collagen and adipose tissue; the identification of such tissues and their removal leads to the identification of epithelial tissue, which corresponds to tumor tissue. Based on the images obtained by use of such technology, the pathologist can easily pinpoint the areas running a higher risk of margin affection. Although the usefulness of optical segmentation in the study of the margin when carrying out the final histological examination has been proved [24], its intraoperative usefulness has not been proved as of yet.
Radiofrequency (MarginProbe ® ): consisting of a single-use probe and a console. The technology this device is based on enables the characterization of tissues and therefore the real-time identification of neoplasm areas at margin level. Studies [25] have shown the effectiveness of such device in reducing non-palpable lesion reintervention rates; however, the method is not used on a large scale yet.
Intraoperative X–ray. Every time conservative surgery is performed due to a non-palpable mammography find, a radiological examination should be carried out on the surgical sample so as to verify the presence of the find inside the excised tissue and therefore reduce the reintervention rate. However, intraoperative X-rays are not completely reliable, as stated above, due to the size-morphology ratio between microcalcification areas and DCIS: the inclusion of all the microcalcifications inside the excised glandular portion does not always mean the intraductal carcinoma has been completely excised, as it may be larger than the mammography find. A study by Folli et al. indicated a 15 mm cutoff as the adequate radiological margin for the obtainment of surgical radicality [26] (Figs. 7.2 and 7.3).
Fig. 7.2
Surgical sample X-ray showing the presence of the microcalcification cluster and the clip, which was left there during the performing of the stereotactic-guided core biopsy
Fig. 7.3
Hypothetical size of possible intraductal carcinomas compared to the microcalcification area
7.4 The Surgical Techniques
7.4.1 Conservative Surgery
7.4.1.1 Lumpectomy
Lumpectomy is a safe surgical option for treatment of ductal carcinomas in situ with limited size. The operation involves the complete excision of the tumor with clear margins. It results in a minimal scar, no asymmetry, and an excellent cosmetic outcome.
7.4.1.2 Traditional Quadrantectomy
Traditional quadrantectomy is the standard surgical treatment for DCIS. It involves the excision of a section of breast parenchyma containing the tumor, together with the overlying skin. Skin incision varies depending on tumor localization (see Fig. 7.4); if DCIS arises in a quadrant at high risk of deformity (inner and inferior quadrants), the surgeon should opt for a different operation (lumpectomy or oncoplastic surgery, depending on tumor size). Glandular dissection occurs along a vertical or slightly oblique plane and reaches the muscular fascia. The specimen is then detached from the deep plane and removed. Glandular resections carried out for small tumors result in a minimal substance loss. In these cases, a simple glandular suture is sufficient for the obtainment of an excellent cosmetic outcome. If larger resections (up to 10% of breast tissue) are carried out, this approach might be insufficient, resulting in deformations; in these cases, it is advisable to create local glandular flaps by detaching both superficially (from the skin) and deeply (from the muscle fascia) the parenchyma adjacent to the substance loss.
Fig. 7.4
Skin incisions in traditional quadran tectomy
7.4.1.3 Oncoplastic Surgery
Oncoplastic surgery includes various techniques; everyone of each is useful for a precise breast cancer localization in a precise breast type (in terms of volume and ptosis). The different proposed classifications of operations reflect the variety of opinions and experiences among authors and have mainly a didactic purpose. Yang’s group, in Korea, proposed a classification based on the size of excised breast tissue, which is directly related to the technique of breast reconstruction: transposition of residual breast tissue (volume displacement techniques) or use of other autologous tissue (volume replacement techniques) (Table 7.1) [27–30]. White, from the British school, focuses attention on two concepts: tumor localization relative to NAC and percentage of breast tissue to be resected (Table 7.2) [31]. When choosing a surgical technique, other authors also take into consideration the density of glandular tissue, classifiable as “almost entirely fatty,” “scattered fibro-granular densities,” “heterogeneously dense,” and “extremely dense” [32]. An extremely dense and highly vascularized parenchyma allows a glandular detachment from skin and muscle with no risk of tissue necrosis; this type of approach is not suitable for a fatty, scarcely vascularized breast parenchyma. Clough combined the previous assumptions in a classification of OPS techniques based on percentage of breast tissue excised (more or less than 20%), tumor localization, and parenchymal density:
Level I: excision volume <20%, requiring simple glandular remodeling techniques
Table 7.1
O PS Yang
Volume replacement | Volume displacement |
|---|---|
Lateral thoracodorsal flap Thoracoepigastric flap ICAP flap TDAP flap LD myocutaneous flap | Glandular reshaping: Parallelogram mastopexy lumpectomy Purse-string suture Round-block technique Batwing mastopexy Tennis racket method Rotation flap Reduction mammoplasty: Wise pattern (inverted T) Vertical pattern |
Table 7.2
OPS White
Central tumors, occupying 10–20% of breast volume | Peripheral tumors, occupying 10–20% of breast volume | Excision of >20–40% of breast volume, techniques of tissue transfer |
|---|---|---|
Inferior pedicle (Grisotti) mammoplasty (central tumors involving the NAC) | Inferior to NAC: inverted T (WISE) mammoplasty, vertical scar mammoplasty | Latissimus dorsi mini-flap |
Benelli’s round-block technique (central tumors not involving the NAC) | Inferior-outer/inner: J- or L-mammoplasty | Thoracodorsal artery perforator lipodermal flap |
Lateral or medial to NAC: lateral and medial mammoplasty | Intercostal artery perforator flap | |
Inframammary fold: IMF-plasty | ||
Superior to NAC: inferior pedicle (Grisotti) mammoplasty: peri-areolar (Benelli) mammoplasty |
Table 7.3
OPS Clough
Tumor position | Procedures |
|---|---|
Lower pole | Superior pedicle mammoplasty/inverted T or vertical scar |
Lower-inner quadrant | Superior pedicle mammoplasty/V scar |
Upper-inner quadrant | Batwing |
Upper pole | Inferior pedicle mammoplasty/round-block mammoplasty |
Upper-outer quadrant | Racquet mammoplasty/radial scar |
Lower-outer quadrant | Superior pedicle mammoplasty/J scar |
Central subareolar | Inverted T or vertical scar mammoplasty with NAC resection |
Inferior Pedicle Mammoplasty (IPM)
IPM is ideal for the treatment of tumors located in the upper central quadrant near the NAC, especially in ptotic breasts. Operation starts with an inverted T skin incision. Then quadrantectomy (excision of tumor with clear margin, up to muscle fascia, including skin) takes place at the upper central quadrant; NAC vascularization is ensured by the inferior pedicle, according to Ribeiro and Robbins [34, 35]. De-epithelization takes place in the lower central quadrant, according to pre-operatory drawing. Then the surgeon resects gland in the lower lateral and medial columns. Reconstruction starts with NAC being shifted cranially, filling the substance loss left by quadrantectomy, and then sutured in this position; after this, lower lateral and medial columns are sutured one to another and in the caudal part for reconstruction of inframammary fold (Fig. 7.5).
Fig. 7.5
Inferior pedicle mamm oplasty
Superior Pedicle Mammoplasty with Inverted T Scar
This technique is suitable for tumors in the lower quadrants, especially in large breasts, with or without ptosis; cosmetic outcome improves if a contralateral symmetrizing mammoplasty is performed. Skin incision takes place in a reduction, inverted T pattern, and de-epithelization involves the peri-areolar skin. Starting from a hemi-peri-areolar inferior glandular incision, NAC is detached from the underlying gland, creating an 8–10 mm-thick flap, whose vascularization is ensured by the superior pedicle [36, 37]. An extensive quadrantectomy takes place in the lower quadrants, starting from the inframammary fold and proceeding cranially. Reconstruction is made through a re-approximation of the lateral and medial columns, a T suture in the lower pole, and a suture of NAC in its new position (Fig. 7.6).
Fig. 7.6
Superior pedicle mammop lasty
V-Mammoplasty
V-mammoplasty is suitable for tumors involving the lower quadrants, especially the lower-inner quadrant of medium-sized breasts with no ptosis. Skin incision is represented in Fig. 7.7. De-epithelization involves the peri-areolar skin and then resection is carried out, up to the fascia. A skin-glandular flap is prepared from the lower-outer quadrant, which is then shifted medially to fill the substance loss; the flap is then sutured in this position and to the inframammary fold. Operation ends with NAC repositioning.
Fig. 7.7
V-mammopl asty
J-Mammoplasty
Tumors in the lower-outer quadrants can be treated with a J-mammoplasty . Skin incision involves the peri-areolar zone and the borders of quadrantectomy (see Fig. 7.8). Peri-areolar de-epithelization is carried out and then tumor is resected. Lateral glandular column is then shifted medially in order to fill the substance loss, and NAC is repositioned.
Fig. 7.8
J-mammo plasty
Horizontal Mammoplasty or Batwing Mastopexy
Batwing mastopexy is chosen for treating tumors of the upper quadrants. It is particularly suitable for the upper-inner quadrant, whose resection carries a high risk of breast deformity. Operation starts with a large omega-shaped skin incision involving the upper breast quadrants. Resection occurs perpendicular to thoracic surface, providing clear margins, until it reaches pectoral fascia. Reconstruction is carried out by shifting cranially and suturing to the upper quadrants the lower breast hemisphere, resulting in a mastopexy (Fig. 7.9).
Fig. 7.9
Batw ing mastopexy
EMI-Batwing Mastopexy
This technique is similar to horizontal mammoplasty, but skin incision is differently shaped (see Fig. 7.10).
Fig. 7.10
EMI-batwing mas topexy
Lateral Mammoplasty or Racquet Technique
Lateral mammoplasty is applicable for large tumors (predicted resection volume >20% of the entire gland) of the upper-outer quadrant. Skin incision, shown in Fig. 7.11, is lozenge-shaped and includes the whole upper-outer quadrant. De-epithelization of peri-areolar skin is followed by an extensive upper-outer quadrantectomy; two local glandular flaps (upper medial and lower lateral) fill substance loss. Operation ends with skin suture and NAC repositioning.
Fig. 7.11
Lateral mam moplasty
Grisotti Flap
Grisotti’s technique consists in a retro-areolar quadrantectomy with NAC replacement. Operation starts with skin incision (Fig. 7.12): circum-areolar, peri-areolar, and double comma-shaped incision extended from NAC to inframammary fold. De-epithelization involves peri-areolar area and the lower central quadrant, saving a circular piece of skin for NAC replacement. Glandular resection involves the central quadrant, up to pectoralis fascia, and includes the NAC. Reconstruction starts with glandular suturing in the resected area; the spared piece of skin, shifted thanks to its advancement and rotation flap, replaces the NAC. Operation ends with skin suture.
Fig. 7.12
Grisotti flap
Round-Block Technique by Benelli
Reintervention
When? The debate on the DCIS resection margin matter is heated. Blair et al. have underlined the high dissent rate among surgeons when recommending surgery: 53% of surgeons deem a 2 mm margin acceptable, 23% repeat surgery with a <1 mm margin, 12% rely on the presence of ink on the neoplasm, 10% use a 5 mm cutoff, while 2% opt for 10 mm [62]. Taghian et al. have highlighted that European radiotherapists usually prefer a wider margin (>5 mm), while Northern Americans accept lower thickness (1–2 mm) [63]. Morrow et al. hold that the positive margin, marked by the presence of ink on the neoplasm (in situ or infiltrating), is associated with a local relapse risk at least two times higher; such increase in risk cannot be eliminated by use of radiotherapy, systemic treatments (hormone therapy, chemotherapy, biological therapy) or due to biological features favoring the neoplasm [13]. According to NCCN 2016 guidelines, a margin <1 mm should always lead to reintervention (re-excision or mastectomy), as the high probability of residual tumor cannot be reduced significantly with radiotherapy. The same guidelines advise against reintervention with a margin >10 mm, which can also be defined as “overtreatment.” Intermediate cases (1–10 mm) see relapse risk decrease as the margin becomes wider; in such cases, other factors (age, number of affected margins, extent of margin infiltration, histological subtype, phenotype) are to be taken into consideration when assessing whether to recommend reintervention [14]. Adams et al. underline the fact that the high relapse rate may reflect the biological features of the neoplasm [64]; the branch of research on the biological characterization of intraductal carcinoma and its treatment implications is currently very active, and a better understanding of the link between the biology and relapse of such neoplasm could lead to the tailoring of margins for each patient.
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