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Breast Cancer Surgical Practice Guidelines

Breast Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in diagnosis and treatment. Separate sections on adjuvant therapy, follow-up programs, or management of recurrent cancer have been intentionally omitted. Where appropriate, perioperative adjuvant combined-modality therapy is discussed under surgical management. Each guideline is presented in minimal outline form as a delineation of therapeutic options.

Since the development of treatment protocols was not the specific aim of the Society, the extensive development cycle necessary to produce evidence-based practice guidelines did not apply. We used the broad clinical experience residing in the membership of the Society, under the direction of Alfred M. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer Center, to produce guidelines that were not likely to result in significant controversy.

Following each guideline is a brief narrative highlighting and expanding on selected sections of the guideline document, with a few relevant references. The current staging system for the site and approximate 5-year survival data are also included.

The Society does not suggest that these guidelines replace good medical judgment. That always comes first. We do believe that the family physician, as well as the health maintenance organization director, will appreciate the provision of these guidelines as a reference for better patient care.

Society of Surgical Oncology Practice Guidelines: Breast Cancer

Symptoms and Signs

Early-stage disease
• Asymptomatic
• Breast mass
• Nipple discharge
• Crusting, scaling, flaking of nipple
• Breast pain (rare)
• Nipple inversion
• Skin dimpling or retraction
• Abnormal mammogram-suspicious microcalcifications, masses, asymmetric densities

Advanced-stage disease
• Change in size or contour of breast
• Erythema of breast
• Peau d'orange of breast
• Enlarged axillary or supraclavicular lymph nodes
• Ulceration of the skin of the breast

Evaluation of the Symptomatic Patient

Breast mass
• History, including breast cancer risk factors, duration, fluctuation with menstrual cycles
• Possible gross cyst: needle aspiration

1. If mass resolves completely with aspiration, discard fluid (if nonbloody). Consider screening mammograms.
2. If fluid is bloody, send for cytology, obtain diagnostic mammogram, and refer to surgeon. If same cyst persistently refills, obtain diagnostic mammogram and refer to surgeon.
3. If mass does not resolve completely after aspiration, send fluid for cytology, obtain diagnostic mammogram, and refer to surgeon.

Solid mass
• Women less than 35 years old: If true dominant mass (discrete, different from other nodularity), refer to surgeon. If vague nodularity, thickening or asymmetry, repeat examination in one to two menstrual cycles approximately 1 to 2 weeks after menstrual period. If abnormality resolves, reassure patient. If abnormality persists, refer to surgeon. Breast imaging may be appropriate.

• Women more than 35 years old: If dominant mass present, obtain diagnostic mammogram, refer to surgeon. If vague nodularity or thickening, obtain mammogram if patient has not had one for 6 to 12 months and reexamine premenopausal women at midcycle 1 to 2 months later. If abnormality persists, refer to surgeon. Refer postmenopausal women for surgical consultation after mammogram.

Nipple discharge
• History to distinguish pathologic from physiologic discharge
• Characteristics of physiologic discharge: nonspontaneous, multiple duct, frequently bilateral, nonbloody
• Characteristics of pathologic discharge: Spontaneous serous or bloody, usually unilateral and usually single duct. Spontaneous discharge, whether serous or bloody, requires surgical evaluation.
• Examination to determine presence of blood in discharge (use guaiac card), whether single duct or multiduct
• If discharge is physiologic and patient is under age 35, reassure patient.
• If discharge is physiologic and patient is over age 35, obtain screening mammogram.
• If discharge meets any of the criteria for pathologic discharge, obtain diagnostic mammogram and refer to surgeon.
• If discharge of any type is present in association with a breast mass, obtain diagnostic mammogram and refer to surgeon.

Crusting, scaling, flaking of nipple
• Obtain history of other dermatologic problems, change in soap or clothing. If absent, obtain diagnostic mammogram if patient is over age 35 and refer to surgeon.

Breast pain
• Obtain history of relationship to menstrual cycle, duration, severity.
• If breast examination is normal and patient is under age 35, reassure patient about benign nature. If pain persists, keep pain diary of occurrence of pain and severity for two menstrual cycles. If pain that is severe enough to interfere with lifestyle persists, refer to surgeon for further evaluation and nonoperative management.
• If patient is over 35 years old, without a mammogram for 6 to 12 months, obtain screening mammogram and follow steps above.
• Diuretics are not effective in the management of breast pain.

Nipple inversion, skin dimpling, retraction
• Obtain history of duration of problem. (Some women have chronically inverted nipples.)
• Obtain diagnostic mammogram.
• Refer to surgeon.

Abnormal mammogram
• Physical examination
• Obtain spot compression or magnification views if recommended by radiologist.
• If physical examination is normal and mammographic abnormality appears benign or resolves with extra views, follow with age- appropriate screening guidelines.
• If physical examination is normal and interval (3- or 6-month) films are recommended, obtain follow-up mammograms.
• If physical examination is normal and mammographic abnormality is felt to be indeterminate or suspicious after extra views, refer to surgeon.

Signs of advanced breast cancer
• Refer to surgeon.

Appropriate timeliness of surgical referral
• Refer to surgeon as indicated above.

Preoperative Evaluation for Extent of Disease

All patients
• Bilateral mammography (if not obtained prior to diagnosis)
• CBC, screening blood chemistries
• Chest x-ray

Bone scan
• Stage III or IV preoperatively
• Any symptomatic women
• Postoperative baseline in selected node-positive patients

Role of the Surgeon in Initial Management

Evaluation of the symptomatic patient
• Distinguish between dominant breast masses requiring biopsy and prominent glandular nodularity that can be safely observed.
• Evaluate and localize pathologic discharges to allow for diagnostic terminal duct excision.
• Determine significance of potential secondary signs of breast cancer, such as nipple inversion, skin dimpling, or skin changes on the nipple.
• Obtain a prompt histologic diagnosis in women with obvious advanced breast cancer, while organizing an efficient metastatic work-up and developing a multimodality treatment plan with specialists from radiation oncology and medical oncology.

Diagnostic procedures
• Fine-needle aspiration (FNA) cytology for "solid" masses and to rule out cysts (Reliability of FNA for diagnosis of solid masses varies based on adequacy of specimen and experience of cytopathologist.)
• Core-cutting needle biopsy for solid masses · Excisional biopsy with clear pathologic margins for solid masses
• Incisional biopsy for masses too large to be excised when aspiration or core-cutting needle biopsy cannot be used
• Terminal duct excision for diagnosis of pathologic nipple discharge in the absence of palpable mass or mammographic abnormality

Surgical considerations
• For ductal carcinoma in situ (DCIS):
• Lumpectomy and radiotherapy
• Total mastectomy
• Total mastectomy and immediate reconstruction
• Lumpectomy alone in selected patients
• For invasive carcinoma:
• Lumpectomy, axillary dissection, and radiotherapy
• Modified radical mastectomy
• Modified radical mastectomy with immediate reconstruction

Adjuvant considerations
• Chemotherapy, hormones, or both in the majority of patients
• Preoperative adjuvant therapy in selected patients with locally advanced cancer

These guidelines are copyrighted by the Society of Surgical Oncology (SSO). All rights reserved. These guidelines may not be reproduced in any form without the express written permission of SSO. Requests for reprints should be sent to: James R. Slawny, Executive Director, Society of Surgical Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.

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