Kelly Hunt, M.D.
Professor, Surgical Oncology
The
University of Texas M. D. Anderson Cancer Center
Return to Current Topics in Oncology
Dr. Kelly Hunt: I'm Dr. Kelly Hunt. And I'll be discussing current surgical treatment approaches in the management of breast cancer.
The objectives of this presentation will be one, to discuss surgical treatment of the primary tumor, to talk about oncoplastic techniques that we're currently using in patients who are having partial mastectomy, to discuss the integration of reconstruction for patients undergoing mastectomy, and finally, to talk about nodal staging for breast cancer patients.
In surgical planning, there are multiple factors that need to be considered in the management of the patient. Certainly, tumor size and clinical stage are important. And the relationship of the tumor size to the breast size are also important in determining the options for surgical treatment. The location of the tumor is a critical factor, as are family history, and whether or not the patient has had any genetic testing for BRCA1 or BRCA2 mutations. For breast conserving surgery and for patients undergoing mastectomy, any contraindications to radiation therapy should be identified. And, of course, the patient preference and the health of the patient are also important factors to consider in treatment planning.
First, we get the pathologic assessment of the primary tumor from the initial biopsy. And we prefer a core needle biopsy for a diagnosis. We evaluate the histologic type, the nuclear grade and marker status, such as estrogen receptor and progesterone receptor, and HER-2/neu.
The objectives, in terms of the primary tumor, are to excise the tumor with adequate margins. And typically, we consider an adequate margin a two millimeter margin of normal tissue completely around the area of malignancy. This allows us to minimize local recurrence, and also to consider the cosmetic outcome. And this is a factor that we have to consider in terms of the volume of tissue that will be resected.
In general, for early stage breast cancer patients, we offer breast conservation or mastectomy. And by breast conservation, we mean segmental or partial mastectomy, with axillary staging being either sentinel node surgery or axillary lymph node dissection, and finally, radiation therapy to complete the treatment. The other option is mastectomy. And in patients with early stage disease, this is a total mastectomy, with, again, axillary staging to be either a sentinel node surgery or axillary dissection, with or without breast reconstruction.
In terms of deciding on breast conservation or mastectomy, we first discuss breast conservation for patients with early stage disease, as this is our preference in patients who have unifocal breast cancer. We consider, again, the role of radiation therapy, as this is an integral component of breast conservation, and any contraindications to radiation therapy should be considered.
Total mastectomy is considered for patients who are not candidates for breast conservation, or in cases where the patient prefers to have a mastectomy as their primary treatment. And in terms of total mastectomy, both the terms simple mastectomy and complete mastectomy imply the same thing, that we're moving the total glandular breast tissue. Skin sparing mastectomy is utilized when the patient is having immediate breast reconstruction. And in some cases, we consider a nipple sparing mastectomy with immediate breast reconstruction for appropriate candidates.
Further considerations in terms of surgical treatment are, again, when we assess the clinical stage of the breast cancer and the breast size to tumor size ratio. In some cases, we may consider moving the systemic therapy ahead of surgery in order to allow for additional surgical treatment options. And so preoperative chemotherapy or neo-adjuvant chemotherapy might be utilized in order to downsize the tumor to make the patient a candidate for breast-conserving therapy. In the case of nodal involvement, when the patient has obvious lymph node involvement that's confirmed by fine needle aspiration biopsy at diagnosis, we also consider neo-adjuvant chemotherapy. And this allows us to assess the response in both the breast and the nodal basin at the time of surgery after the patient has completed systemic therapy.
In patients where we might consider neo-adjuvant chemotherapy, we look at the indications for adjuvant chemotherapy. So in patients where we know that they will require adjuvant chemotherapy because of the tumor size, the nodal involvement, estrogen receptor status and patient age, those are patients where, if adjuvant chemotherapy will be required and will be recommended, we might consider using that in the neo-adjuvant or preoperative setting to increase the options for surgical management with tumor downsizing.
Again, further considerations are the use of radiation therapy. As I mentioned earlier, we always consider radiation therapy when we're performing breast-conserving surgery, such as partial mastectomy and segmental mastectomy. But we also will consider the use of radiation therapy for other situations, such as patients with a large primary tumor, a diagnosis, such as a T3 tumor. In general, if the tumor is greater than five centimeters in size, even if the patient has a mastectomy, radiation therapy may be employed, and so this is a consideration in our treatment planning, especially when we're considering patients for breast reconstruction. Patients who have T4 disease will be candidates for post-mastectomy radiation after mastectomy. And those patients who have nodal involvement of four or more positive nodes, they will be considered for post-mastectomy radiation therapy. And patients who have positive margins after mastectomy, or those with extensive lymphovascular space invasion, may also be considered for radiation therapy, even in the setting of mastectomy. So all of these factors have to be considered at the initial surgical planning.
Now, for patients who are proceeding with breast-conserving surgery, we consider the use of oncoplastic techniques and integration of our surgical resection with or without plastic surgery and reconstructive surgery. And one of the ways we do this is by looking at the breast size to tumor size ratio. So in a patient who has a small or medium breast size, we consider how small or large the parenchymal defect will be at the time of resection. And this helps us to plan whether or not the patient will require reconstructive surgery. If it's a small parenchymal defect and it's in a favorable location, such as in the lateral or superior breast, then the patient can proceed with segmental mastectomy, partial mastectomy, and have local tissue rearrangement, usually without the need for a flap. If the patient has even a small parenchymal defect anticipated that's in an unfavorable location, this is defined as any tumor that's inferior to the nipple-areolar complex, in that case, the patient should be considered for some type of oncoplastic surgery or local breast rearrangement. And so we consider two things at that point, whether or not the breast is ptotic. If the breast is ptotic, you can consider a vertical reduction mammoplasty. If the breast is not ptotic, but there's significant skin loss anticipated, those are patients where we consider a latissimus dorsi flap or consider a mastectomy because we anticipate that the cosmetic deformity will be significant. Again, the unfavorable location and the small breast size, even despite the fact that there's a small parenchymal defect.
In cases of a large parenchymal defect in patient with a small or medium breast size, we have to consider that they may require some type of flap, such as a latissimus flap, to fill in the parenchymal defect or consider a mastectomy. In patients who have a very large breast or in patients who are very obese, where we consider that radiation therapy treatment may be difficult because of the large breast size and significant breast folds and parenchymal folds, we again, look at the size of the anticipated parenchymal defect. So a small parenchymal defect we would consider being less than 15% of the breast volume. And in this case, we can proceed directly with breast-conserving surgery.
For a patient with a medium size parenchymal defect defined as 15 to 30%, we would consider local tissue rearrangement or reduction mammoplasty at the same procedure. And those patients where we anticipate a very large parenchymal defect being greater than 30% of the breast, we definitely would consider reduction mammoplasty or use of a latissimus flap to fill in the defect, or, again, consider a mastectomy for definitive treatment.
So in terms of breast-conserving surgery, again, our patient selection is going to consider that the patient has unifocal disease. We prefer not to perform breast conservation in patients with multicentric disease in the breast. We are certain to be sure that there's an absence of extensive microcalcifications on mammography. And, again, consider the breast size to tumor size ratio. We look at the tumor location and other factors, pathologic and clinical factors, including the grade, lymphovascular space invasion, histology, age and estrogen receptor status.
In patients where there's a family history or where there's a known BRCA mutation status, we do counsel those patients regarding the increased risk for in-breast recurrence, and also development of new breast primaries throughout their lifetime. And in those cases, patients may be best served by undergoing mastectomies. Certainly in BRCA mutation carriers, this is a significant consideration because of the increased lifetime risk of developing additional breast cancers.
When we consider breast conservation, this is certainly a multidisciplinary treatment approach. So when the patient is initially seen, diagnostic imaging is very helpful in defining the extent of disease in the breast. And this, typically, at our center, includes both mammography and ultrasound of the breast and regional nodal basins. The surgeon is then responsible for resecting the disease in the breast and assessing the nodal status. And we prefer one operative intervention. Again, core needle biopsy for diagnosis is the preferred approach. And then one surgical intervention to resect the primary tumor and any involved nodes. Our pathologists are then very critical in assessing the margins and the lymph node status. And then we employ our plastic surgery colleagues to provide optimal cosmesis. And certainly, the medical oncologist is important in systemic therapy decisions. And the radiation oncologist in terms of postoperative radiation therapy for the conserved breast. These are some typical incisions that we might use for a patient based on the tumor location. For tumors in the upper or lateral breast, we might use curvilinear incisions or slightly curved incisions. In the central breast, we consider a radial incision. And certainly in the inferior breast, we prefer radial incisions so as not to displace the nipple-areolar complex.
For patients who have a C-cup breast size or larger breast size where we have a small tumor and there's no ptosis and minimal skin resection, we can generally proceed with partial mastectomy without any significant reconstructive surgery. However, in order to provide the optimal cosmesis, we do consider the placement of the nipple-areolar complex. And this is some of the breast remodeling techniques that have been described by Steve Kronowitz in plastic surgery and published in the Journal of Plastic and Reconstructive Surgery, where he shows the approach of making a circumareolar incision, going through, underneath the skin, then raising flaps underneath the breast skin in order to reach the primary tumor, resect the tumor with a margin of normal tissue, and then close the defect in the breast, and then reposition the nipple-areolar complex so that there is not significant distortion caused by the parenchymal defect and the healing after the surgical resection.
Other techniques that have been described by Anderson and by others published in Lancet Oncology in 2005 is the batwing mastopexy. And in this case, the diagram is showing here that a tumor in the just superior to the nipple-areolar complex incisions are made both medially and laterally. After the parenchymal resection of the tumor, the nipple-areolar complex is then moved cefalad in order to close the defect so that there is minimal distortion and optimal cosmetic result.
So the use of these types of oncoplastic approaches with local tissue rearrangement can allow for improved cosmesis with breast conservation, ultimately resulting in a patient, such as this, who had an optimal cosmetic outcome many years after therapy.
Now, in terms of patients with a larger breast, this is where we certainly consider the breast reduction technique for optimal cosmesis, and also optimal delivery of radiation treatment after breast-conserving surgery. When there's minimal skin resected, or it's located within a Wise pattern type incision, we do prefer the breast reduction technique. And this works well for a C-cup breast size with the small tumor and ptosis of the breast or a very large, such as a D-cup, breast size.
And this just shows some of the different types of reduction mammoplasty approaches that can be performed, depending on the tumor location. The location of the tumor will dictate where the parenchymal flap needs to be rotated in from, from the other parts of the breast, in order to fill the defect. In some cases, a free nipple graft may have to be performed where the nipple-areolar complex is removed and then replaced after a central segmentectomy. Or the nipple-areolar complex can be relocated, such as this type of reconstruction here. So depending on where the tumor is and the size of the parenchymal defect, this will determine the optimal pattern of reduction mammoplasty and the approach.
So this is a patient who has a larger breast size with significant ptosis. And so she's planned for a segmental resection with a reduction mammoplasty approach. And what you can see here is that the patient's tumor has been resected. The tumor was in the medial breast. So the tumor is removed with negative margins. And then the plastic surgeon has marked out the planned Wise reduction mammoplasty incisions that will be utilized to rotate the flap of tissue inward to cover the parenchymal defect.
And then this shows the tissue flapping inserted to fill in the parenchymal defect. And the nipple-areolar complex is relocated in order to provide the optimal cosmetic outcome. And this shows the patient after reconstruction. And she's also had a contralateral reduction mammoplasty for symmetry.
So our consideration with partial mastectomy reconstruction is that we do prefer to perform the reconstruction before any radiation therapy has occurred. If we wait until after the radiation therapy has been performed, a patient will have difficulty with healing. And in that case, most often the patient will need some type of soft tissue, autologous tissue reconstruction such as a latissimus flap or another myocutaneous flap. So if we perform a local tissue rearrangement or the reduction mammoplasty before radiation, we can avoid this type of necessity for a flap, and we can reserve that flap for future reconstruction, if that's needed. We also look at the repair based on the breast size in relation to the tumor size. And I've described the size of the breast to you in relationship to that type of reconstructive approach.
Now, again, for patients who have a larger tumor, where we want to shrink the size of the tumor, again, we would consider preoperative chemotherapy. This has been standard practice for patients with locally advanced breast cancer. And we certainly use preoperative chemotherapy for patients who present with locally advanced or inflammatory breast cancer. We've seen, from these results, that patients have excellent response rates. 70 to 80% of patients will have a complete or partial response to the chemotherapy. And the use of preoperative chemotherapy has not resulted in any delay in the patient receiving adjuvant radiation or any difficulty in the patients in terms of increased surgical complications or other delays. There's also been no survival difference shown between the use of neo-adjuvant or preoperative chemotherapy versus adjuvant chemotherapy. So the trials that have directly compared patients with these approaches have shown similar long-term survival. And so there's demonstrated safety with this approach.
But in order to consider breast-conservation surgery after chemotherapy, we have certain criteria that must be fulfilled. And that is, we like to see resolution of all skin edema, so any peau d’orange that was present at presentation should be completely resolved. A residual tumor size of less than four centimeters is really optimal, although, again, it's the tumor size to the breast size ratio that can be important. We look for absence of extensive lymphovascular space invasion, absence of extensive microcalcifications. And certainly we would not consider patients with multicentric disease for this approach.
This shows the radiographic and pathologic correlation that we would perform after a segmental resection. And this is for patients treated with primary surgery and for patients treated with preoperative chemotherapy followed by surgery. After the segmental resection is performed, the specimen is inked in several different colors to mark the different margins. The specimen is then sectioned, and then we radiograph the specimen and look at this side by side in order to identify areas of residual abnormality for definitive diagnosis by the pathologist. This helps us to intraoperatively assess the margins so that we can resect additional tissue at the same surgery, if needed, and again, try to perform the surgery in one operative intervention.
Now, I'm going to switch gears a little bit here to talk about mastectomy. So I've been focusing on breast conservation, which, again, is our preferred approach, for certainly early stage breast cancer patients with unifocal disease. And also, in certain patients who have had good response to preoperative chemotherapy. Some patients will not be good candidates for breast conservation. And we do consider mastectomy.
And certainly a skin-sparing approach with immediate breast reconstruction provides the optimal cosmetic outcome for women with early stage breast cancer. The use of immediate reconstruction has been championed for over 20 years now. And we know that the timing of reconstruction does not appear to compromise the primary operation, so the oncologic approach does not differ based on the use of immediate reconstruction. It does not alter survival. And it does not appear to interfere with our ability to detect recurrence in patients who are undergoing surveillance and follow-up.
But we do consider delayed reconstruction for certain situations. We prefer immediate reconstruction for early stage patients because we think this provides the best aesthetic result and the best long-term outcome. It also allows the patient to have a breast mound immediately after surgery so there's less emotional trauma to the patient. There are fewer operations for the patient. And again, it does not affect their cancer treatment. Patients proceed with systemic therapy in the adjuvant setting, as needed, without delay.
However, for some patients, delayed reconstruction is preferred. And this is certainly the case in women who are not sure of the type of reconstructive surgery or their commitment for reconstruction is not strong. In patients where we know we're planning to do postoperative radiation therapy, we typically use delayed reconstruction. Or if there are any medical contraindications, especially in patients who are heavy smokers, actively smoking, and those patients who are morbidly obese, immediate reconstruction can be associated with significant complications. And therefore, we often prefer a delayed approach in these patients.
Reconstructive options, of course, include implant or tissue expander-based reconstruction, or autologous tissue reconstruction. And each patient will have different options based on their anatomy and their desires for reconstruction. In terms of the skin-sparing approach, the definition of a skin-sparing mastectomy is that we're resecting en bloc the nipple-areolar complex, and any tumor biopsy scars or other scars within the breast with the underlying breast and axillary contents. This allows for superior cosmesis, but it's technically more demanding. We know now that it's oncologically safe, and so we typically utilize this for our early stage breast cancer patients.
These are showing some of the incisions that are employed. We typically use the circumareolar incision when we're removing the nipple-areolar complex. You can also perform a lateral extension to allow ease of access to the axilla. In patients who have a larger ptotic breast, we typically use a Wise pattern incision. Or you can also perform an elliptical incision, allowing more lateral access to the axilla.
And this shows a patient who's actually had a bilateral skin-sparing mastectomy with you can see a lateral extension here through the breast. She had a TRAM reconstruction. And you can see her abdominal scar here. She has good symmetry and a nice result overall.
In terms of preserving the nipple-areolar complex, this is something that's been looked at over the past decade with increasing enthusiasm, especially in patients with early stage breast cancer or those patients undergoing prophylactic mastectomy. And the only concerns that people have, of course, raised, is that we might be leaving more ductal epithelium behind, especially in women who are at high risk, who are BRCA mutation carriers. And in patients who are undergoing mastectomy for cancer, there have been a lot of studies showing that there's occult nipple-areolar complex involvement in up to 50% of the cases. Now, depending on the type of imaging that was performed before surgery, this is certainly going to impact the degree of occult nipple-areolar complex involvement.
This just shows a patient who was treated with prophylactic bilateral mastectomies because of a BRCA mutation. The mastectomy was performed through a radial incision here in the lateral breast. And you can see that she has very good symmetry with an implant-based reconstruction at follow-up.
And this is another patient, again, undergoing prophylactic surgery for BRCA mutation. And this shows, again, the lateral or radial incision, which seems to provide the optimal blood supply or the optimal approach to preserve the blood supply, not only to the skin of the breast and the skin envelope, but also to the entire nipple-areolar complex, preserving the nipple intact.
So this is something that we're considering on a protocol that we have at M. D. Anderson. Our eligibility are that patients who are being considered for prophylactic mastectomy or those patients with early stage breast cancer, we consider when the primary tumor is at least 2.5 centimeters or greater from the border of the nipple-areolar complex. And we make certain that there are no microcalcifications extending toward the nipple. Women who are not eligible are those who are smokers, those whose tumors involve the nipple-areolar complex, those who have subareolar tumors, or tumors that are very close to the nipple-areolar complex. We certainly don't utilize this approach for patients with inflammatory breast cancer or those with skin involvement, those with collagen vascular disease, or Paget's disease of the nipple.
So finally, in terms of the mastectomy with reconstruction approach, I want to describe one technique that we've been using over the last eight years or so to try to help patients who are in the gray zone of whether or not they will require post-mastectomy radiation. So again, as I said earlier, we typically prefer delayed reconstruction when we know a patient will require post-mastectomy radiation.
But there are certainly some patients where we're not certain of the need for radiation based on the imaging studies that we have available. So in these cases, we do what's called delayed immediate breast reconstruction. There's a stage one procedure where the patient has a typical skin-sparing mastectomy. A tissue expander is placed behind the pectoralis major muscle. And then we allow a week to fully evaluate all of the breast pathology and the nodal pathology. In patients who have favorable pathology and do not require radiation, we proceed to definitive breast reconstruction, whether that's with a TRAM flap, a latissimus flap, or just a permanent implant. But in patients who do require radiation therapy, we then deflate the tissue expander before the radiation is initiated, reinflate it after radiation. And then after the radiation is complete and a period of time has elapsed, we allow for a skin-preserving delayed reconstruction. And again, this is either with a TRAM flap or a latissimus flap. In this case, implant-based reconstruction is not optimal because of the radiated skin envelope and the radiated pectoralis muscle. Autologous reconstruction is preferred in this setting.
For patients who are considered for delayed immediate reconstruction are those who have clinical stage one or two disease. But again, we're not certain if they might have indications for post-mastectomy radiation. They might have extensive microcalcifications on mammography, which doesn't allow us to completely assess the primary tumor size. Or they might have multicentric disease. Or they might have a question of nodal involvement. And we wait for the number of nodes that we find on final pathology to determine whether or not they will need post-mastectomy radiation. The patient must be able to have two different anesthetic procedures, obviously for two different surgical interventions. But this does allow preservation of the skin envelope, which ultimately provides a better long-term cosmetic outcome.
And this shows a patient who had clinical T2 N1 disease and had the skin-sparing mastectomy with the tissue expander placed. And you can see we removed the nipple-areolar complex. And the patient then had deflation of the tissue expander to allow for radiation treatment, and then finally had her definitive reconstruction. So in terms of skin-sparing mastectomy, skin-sparing mastectomy itself is oncologically safe. We know that in early stage breast cancer, it results in excellent long-term outcomes. We use this with immediate reconstruction in patients who will not need post-operative radiation therapy. And the role of immediate-delayed or delayed-immediate type breast reconstruction, we're still evaluating that and looking at the long-term outcomes to see if this will really be an optimal treatment for patients with clinical stage two disease, who are in that gray zone as to whether or not they require post-mastectomy radiation therapy.
The role of nipple-areolar complex preservation is still under investigation. And I think it remains to be investigated. And we need longer follow-up on these patients who have been treated with this approach.
So finally, now, just in the last few minutes, I want to talk about axillary lymph node staging. This is certainly an important part of the surgical management of the breast cancer patient because it provides optimal staging for the patient. So our goal with this procedure is really accurate staging. We certainly want to have regional control. At the same time, we want to minimize the morbidity. Because we know that there's clearly no benefit in removing healthy, uninvolved lymph nodes from patients without evidence of metastatic disease in the lymph nodes.
The complications of routine axillary lymph node dissection are significant for the individual patient. Certainly the most feared complication is that of lymphedema. But patients also have shoulder dysfunction and paresthesias and other difficulties recovering from this operation. So lymphatic mapping with sentinel lymph node biopsy has been introduced, now over a decade ago, for early stage breast cancer patients. And this was championed in breast cancer management by David Krag and Armando Giuliano. Subsequent to their initial reports, there have been extensive publications showing that the concept is valid and that we can inject a dye around the primary tumor in the breast and follow this to the first one or two lymph nodes, which are the sentinel nodes. Those can be removed. We can evaluate them with a blue dye with a radioisotope that can be detected with a handheld probe. And then we can, histologically, evaluate those nodes more carefully to have definitive staging for patients. The results of the sentinal lymph node trials that were performed in the U.S. and also in Europe and the UK are now being evaluated. The NSABP-B32 trial is one of the largest trials that was performed. And this stratified patients by age, tumor size and type of surgery, to have sentinel lymph node surgery followed by a standard axillary dissection, or have sentinel lymph node surgery alone, and only undergo axillary dissection if the sentinel node was found to contain metastatic disease. The results of this trial have been published in Lancet Oncology. The overall accuracy is 97.2%. So I think people have been pleased with that finding.
However, I think there was some surprise in that the false negative rate was higher than what we expected. And so the false negative event or false negative event implies that the sentinel node that was recovered was negative for metastatic disease. But when the axillary contents were examined, metastatic disease was identified in axillary or non-sentinel lymph nodes that were recovered.
When we look at the false negative rate by tumor size, we see that there was no significant difference based on tumor size. So the earlier reports that sentinel lymph node surgery is not accurate in patients with larger tumors is probably not correct. There are some factors, though, that clearly affect the false negative rate, in that patients who have tumors in the lateral breast are more often to have a false negative event. If a patient has already had an excisional biopsy, those patients are at higher risk of having a false negative sentinel lymph node. And that is probably because of the volume of resection and disruption of regional lymphatics within the breast. When the number of sentinel lymph nodes removed is only one, or fewer than two lymph nodes are recovered, then the false negative rate is also higher. And these have all been points elaborated from the NSABP-B32 trial.
The American College of Surgeons Oncology Group also performed a large trial of over 5,000 patients with early stage disease. All of these women had breast conservation. If the sentinel lymph node was negative, they had axillary observation. If the sentinel lymph node was positive, they were eligible for randomization between axillary observation versus axillary dissection. And this was the companion Z-11 trial.
The results of the Z-10 trial have been published on over 5,000 patients. Median age was 56 years. And the overall positive sentinel lymph node rate was 24% based on standard hematoxylin and eosin staining. The 30-day outcome showed that seroma rates were about 7%. And importantly, lymphedema was reported as almost 7% of the patients. And this was based on our measurements that were performed at routine intervals. So at six months following sentinel lymph node surgery, 6% or 7% of the patients had measurable difference in the treated on the arm on the treated side as opposed to the contralateral arm. Whether or not this is clinically relevant remains to be seen with longer follow-up.
In terms of the risk factors for lymphedema, increasing age was noted to be a risk factor, as was increasing body mass index. And these were the two most important factors.
In terms of the surgeon's ability to identify sentinel lymph node, the number of cases that the surgeon performed on this protocol was a critical factor, suggesting that volume of surgery and the number of procedures performed is important. And then also patients with, again, a higher body mass index and an increased age, there was increased likelihood that the surgeon would be unable to identify a sentinel lymph node at surgery.
Overall, the use of sentinel lymph node surgery has now replaced axillary dissection for early stage breast cancer. And this is our standard approach at M. D. Anderson. We follow National Comprehensive Cancer Network guidelines in that patients should have a clinically negative axilla at presentation. And we use both physical exam and ultrasound to define the clinically negative axilla. The team should have documented experience. A surgeon should perform a number of procedures with sentinel lymph node surgery and axillary surgery, completion node dissection combined, and evaluate results before abandoning axillary dissection. When the sentinel lymph node is positive or when it's not able to be identified, the patient should have an axillary node dissection.
The ASCO guidelines currently recommend that patients have an axillary lymph node dissection when they have a positive sentinel node on routine histopathologic examination. And this includes patients with micro-metastases defined as deposits greater than .2 millimeters and less than 2 millimeters in the sentinel lymph node. And this is regardless of whether it's detected by immunohistochemical staining or by standard H&E staining.
So in conclusion, I've covered several areas today. I'll start by concluding about breast conservation. The use of breast conservation and mastectomy have equivalent survival outcomes, for patient with early stage breast cancer. And we certainly prefer breast conservation for appropriate candidates. We know that breast conservation is also feasible for patients with locally advanced breast cancer after neo-adjuvant chemotherapy when appropriate criteria are applied and when a multidisciplinary approach is applied. The use of skin-sparing mastectomy and immediate reconstruction are providing optimal results for our patients who do undergo mastectomy. And finally, sentinel lymph node surgery is now an alternative to the use of standard axillary dissection for patients with a clinically negative axilla at presentation. Thank you very much for your attention.
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