Surgery for Primary Invasive Breast Cancer

11.A. 38-year-old woman . . .
11.B. 80-year-old woman . . .
with excisional biopsy demonstrating a 0.8 centimeter infiltrating ductal carcinoma, which is ER/PR+. Margins are one millimeter in some places. The patient has ample breast size (C cup) and prefers not to lose her breast if possible. Your suggested next step in local management:

Patrick Borgen, MD

Case A.
This is a very important case, because too often the mistake is made that a close or even a microscopic positive margin means the patient should have a mastectomy. There is a high chance in a case like this that a mastectomy will show no residual cancer. And you're absolutely open to criticism for doing that mastectomy. So, this is a patient who, if she is motivated to save her breast, I would absolutely re-excise her —and that's what 60 percent of the audience said.

Case B.
Unless this patient has significant comorbid factors, she should be treated based on her biologic age, giving her a chance to conserve her breast.

12.A. 38-year-old woman . . .
12.B. 80-year-old woman . . .
with 4.1 centimeter breast mass in the upper outer quadrant. Core biopsy demonstrates poorly differentiated infiltrating ductal carcinoma. The patient is ER/PR+, has ample breast size (C cup) and prefers not to lose her breast if possible. Your suggested next step in management:

Patrick Borgen, MD

Case A.
In general, neoadjuvant chemotherapy is underutilized in this country. The Italians have shown —as did the NSABP in the B-18 trial— that the outcome is the same whether you give chemotherapy before or after surgery. But, your utilization of breast conservation goes way, way up and the positive margin rate goes way down with preoperative chemotherapy.

There are a few things that will predict failure of neoadjuvant therapy to conserve the breast. For example, a field of malignant microcalcifications. Chemotherapy is not going to sterilize a field of DCIS. So, if this patient has a mass without this big field of DCIS, I would absolutely offer her four cycles of chemotherapy and try to facilitate breast conservation.

If the patient had a really large breast size, maybe bigger than a C cup, and I was a convinced that a lumpectomy on a 4.1 centimeter tumor would have a good chance of having clear margins, I would do that. Otherwise, I would go to pre-op chemotherapy.

Patrick Borgen, MD

Because the available data suggests that breast conservation is as appropriate for BRCA heterozygotes as for sporadic cancers, we're not doing much pre-treatment testing. So, it's not very common for a patient to come to us with breast cancer who knows she carries a gene mutation. In this patient, the most important thing is that she understands that her contralateral risk with that mutation exceeds 60 percent. Very often, a patient like this will choose bilateral mastectomies.

We published one paper on breast conservation in BRCA heterozygotes in the JNCI a year ago, but it was an embarrassingly small number of patients Ñ less than 50 patients. We reported that the local recurrence rate in these heterozygotes was the same as in sporadic cancers. So, I think that it's appropriate to talk about breast conservation. But what we have found is that more often than not, the patients lean towards mastectomy.

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