Table 40.3 Staging of Breast Carcinoma Anatomic Stage/Prognostic Groups ∗T1 includes T1mi ∗∗T0 and T1 tumors with nodal micrometastases only are excluded from stage IIA and are classified stage IB. From Edge SB, Byrd DB, Compton CC, et al., eds. Breast. In AJCC cancer staging manual. 7th ed. New York: Springer, 2010:419–460, with permission.
Preoperative Evaluation The extent of the preoperative workup varies with the initial stage of the disease (30). For most patients with small tumors, clinically negative lymph nodes, and no evidence of metastasis (TNM stage I), the preoperative evaluation should consist of bilateral mammography, chest radiography, complete blood count, and screening blood chemistry tests. Bone, CT, and MRI scanning are unnecessary unless there are symptoms or abnormal blood chemistry levels to suggest the existence of bone or intra-abdominal involvement. For patients with clinical stage II, node-positive disease, a bone scan is recommended, but CT scan of the abdomen is not necessary unless symptoms or laboratory results suggest liver disease. Patients with clinical stage III or stage IV disease should undergo both bone and liver scanning. PET scanning is becoming a popular means of total body scanning for breast cancer, but there have been concerns that this modality may miss some bony metastasis. A study found that PET scan is highly concordant (81%) with bone scan in a study of 132 paired studies of breast cancer patients (31). Of 31 (19%) discordant pairs, 12 patients had pathology proven metastatic disease. Nine of these 12 patients had a positive PET scan but negative bone scan, supporting the use of PET scan in detecting osseous metastasis in breast cancer, although further studies are needed to ascertain whether this modality should supplant the use of bone scan in this setting.
Figure 40.2 Appearance of breast after radical mastectomy (A) versus modified mastectomy (B). (From Kruper L, Giuliano AE. Breast disease. In: Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:636.)
Radical Mastectomy Traditionally, the treatment of breast cancer has been surgical, but the type of procedure has remained a controversial and highly emotional issue. During the 19th century, surgical treatment of breast cancer was haphazard, varying from local excision alone to total mastectomy. The radical mastectomy was based on the principle that breast carcinoma was a locally infiltrative process that spread in a stepwise fashion from breast, to nodes, to distant sites (32). Thus, radical mastectomy removes the entire breast, the underlying pectoral muscles, and the contiguous axillary lymph nodes in continuity (33) (Fig. 40.2A). A report of 51 years of experience with radical mastectomy, which included 1,036 patients with a follow-up of 47 years, is unequaled in evaluating any single method of treating breast cancer (34).
During the 20th century, extensions and modifications of the radical mastectomy were devised that involved removal of more local and regional tissue. At one time, supraclavicular lymph node dissections were considered a routine component of surgical treatment (35). Supraclavicular, mediastinal, and internal mammary lymph node dissections were performed (36).