ADVANCES IN BREAST CANCER DIAGNOSIS AND TREATMENT: ESSENTIALS

Advances in breast cancer diagnosis and treatment Essentials_kapak

MASTECTOMY ANDBREAST CONSERVING SURGERY

Baran Mollavelioğlu

İstanbul University, Faculty of Medicine, Department of General Surgery, İstanbul, Türkiye

Mollavelioğlu B. Mastectomy and Breast Conserving Surgery. In: Citgez B editor. Advances in Breast Cancer Diagnosis and Treatment Essentials. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.169-179.

ABSTRACT

Breast cancer remains the most prevalent malignancy among women worldwide, and surgery constitutes a fundamental component of its multidisciplinary treatment. Over the past century, surgical approaches have evolved dramatically-from Halsted’s radical mastectomy to increasingly conservative, personalized techniques that aim to balance oncologic control with aesthetic and functional preservation. This chapter compares and contextualizes the two primary surgical modalities: mastectomy and breast-conserving surgery (BCS). BCS has become the standard treatment in selected early-stage patients following the demonstration of equivalent survival outcomes to mastectomy in major randomized trials such as NSABP B-06 and the Milan study. Advances in imaging, systemic therapy, and oncoplastic techniques have broadened BCS indications to include larger tumors and selected multifocal or multicentric cases. The surgical decision-making process is increasingly individualized, shaped by tumor characteristics, breast size, radiologic findings, patient age, comorbidities, genetic predisposition, and personal preferences. Modern imaging modalities-particularly breast MRI-play a crucial role in surgical planning, while neoadjuvant therapy allows for tumor downsizing and potential conversion from mastectomy to BCS in many patients. Mastectomy techniques have similarly diversified, ranging from simple and modified radical mastectomy to more aesthetic approaches such as skin-sparing mastectomy (SSM), nipple-sparing mastectomy (NSM), and emerging robotic, endoscopic, and air-assisted techniques. These innovations aim to reduce morbidity while facilitating immediate reconstruction and preserving body image. Overall, surgical treatment in breast cancer is no longer a one-size-fits-all approach. Oncologic safety, cosmetic outcome, and patient satisfaction must be considered concurrently. This integrated perspective reflects the contemporary paradigm of breast surgery: personalized, evidence-based, and quality-of-life oriented.

Keywords: Breast Neoplasms; Mastectomy; Breast-conserving surgery; Subcutaneous mastectomy; Oncoplastic surgery; Reconstructive surgical procedures; Surgical oncology; Multidisciplinary care team

Referanslar

  1. Halsted WS. I. The Results of Operations for the Cure of Cancer of the Breast Performed at the Johns Hopkins Hospital from June, 1889, to January, 1894. Ann Surg. 1894;20(5):497-555. [Crossref]  [PubMed]  [PMC]
  2. Patey DH, Dyson WH. The prognosis of carcinoma of the breast in relation to the type of operation performed. Br J Cancer. 1948;2(1):7-13. [Crossref]  [PubMed]  [PMC]
  3. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):12331241. [Crossref]  [PubMed]
  4. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232. [Crossref]  [PubMed]
  5. Shubeck SP, Morrow M, Dossett LA. De-escalation in breast cancer surgery. NPJ Breast Cancer. 2022;8(1):25. [Crossref]  [PubMed]  [PMC]
  6. Clough KB, Benyahi D, Nos C, Charles C, Sarfati I. Oncoplastic surgery: pushing the limits of breast-conserving surgery. Breast J. 2015;21(2):140-146. [Crossref]  [PubMed]
  7. Mann RM, Cho N, Moy L. Breast MRI: State of the Art. Radiology. 2019;292(3):520-536. [Crossref]  [PubMed]
  8. Sardanelli F, Boetes C, Borisch B, et al. Magnetic resonance imaging of the breast: recommendations from the EUSOMA working group. Eur J Cancer Oxf Engl 1990. 2010;46(8):1296-1316. [Crossref]  [PubMed]
  9. Sardanelli F, Trimboli RM, Houssami N, et al. Magnetic resonance imaging before breast cancer surgery: results of an observational multicenter international prospective analysis (MIPA). Eur Radiol. 2022;32(3):1611-1623. [Crossref]  [PubMed]  [PMC]
  10. Mota BS, Reis YN, de Barros N, et al. Effects of preoperative magnetic resonance image on survival rates and surgical planning in breast cancer conservative surgery: randomized controlled trial (BREAST-MRI trial). Breast Cancer Res Treat. 2023;198(3):447-461. [Crossref]  [PubMed]  [PMC]
  11. Dubsky P, Pinker K, Cardoso F, et al. Breast conservation and axillary management after primary systemic therapy in patients with early-stage breast cancer: the Lucerne toolbox. Lancet Oncol. 2021;22(1):e18-e28. [Crossref]  [PubMed]
  12. Scheel JR, Kim E, Partridge SC, et al. MRI, Clinical Examination, and Mammography for Preoperative Assessment of Residual Disease and Pathologic Complete Response After Neoadjuvant Chemotherapy for Breast Cancer: ACRIN 6657 Trial. AJR Am J Roentgenol. 2018;210(6):1376-1385. [Crossref]  [PubMed]  [PMC]
  13. Moreira IC, Ventura SR, Ramos I, Fougo JL, Rodrigues PP. Preoperative localisation techniques in breast conservative surgery: A systematic review and meta-analysis. Surg Oncol. 2020;35:351-373. [Crossref]  [PubMed]
  14. Li M, Xu B, Shao Y, Liu H, Du B, Yuan J. Magnetic resonance imaging patterns of tumor regression in breast cancer patients after neo-adjuvant chemotherapy, and an analysis of the influencing factors. Breast J. 2017;23(6):656662. [Crossref]  [PubMed]
  15. Karanlik H, Kılıç B, Yıldırım I, et al. Breast-Conserving Surgery Under Local Anesthesia in Elderly Patients with Severe Cardiorespiratory Comorbidities: A Hospital-Based Case-Control Study. Breast Care Basel Switz. 2017;12(1):29-33. [Crossref]  [PubMed]  [PMC]
  16. Tan MP, Silva E. Addressing the paradox of increasing mastectomy rates in an era of de-escalation of therapy: Communication strategies. Breast Edinb Scotl. 2018;38:136-143. [Crossref]  [PubMed]
  17. Johns N, Dixon JM. Should patients with early breast cancer still be offered the choice of breast conserving surgery or mastectomy? Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2016;42(11):1636-1641. [Crossref]  [PubMed]
  18. Cardoso F, Paluch-Shimon S, Senkus E, et al. 5th ESO-ESMO international consensus guidelines for advanced breast cancer (ABC 5). Ann Oncol Off J Eur Soc Med Oncol. 2020;31(12):1623-1649. [Crossref]  [PubMed]  [PMC]
  19. Postma EL, Verkooijen HM, van Esser S, et al. Efficacy of "radioguided occult lesion localisation" (ROLL) versus "wire-guided localisation" (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial. Breast Cancer Res Treat. 2012;136(2):469- [Crossref]  [PubMed]
  20. Srour MK, Kim S, Amersi F, Giuliano AE, Chung A. Comparison of wire localization, radioactive seed, and Savi scout® radar for management of surgical breast disease. Breast J. 2020;26(3):406-413. [Crossref]  [PubMed]
  21. Colakovic N, Zdravkovic D, Skuric Z, Mrda D, Gacic J, Ivanovic N. Intraoperative ultrasound in breast cancer surgery-from localization of non-palpable tumors to objectively measurable excision. World J Surg Oncol. 2018;16(1):184. [Crossref]  [PubMed]  [PMC]
  22. Banys-Paluchowski M, Rubio IT, Karadeniz Cakmak G, et al. Intraoperative Ultrasound-Guided Excision of Non-Palpable and Palpable Breast Cancer: Systematic Review and Meta-Analysis. Ultraschall Med Stuttg Ger 1980. 2022;43(4):367-379. [Crossref]  [PubMed]
  23. Houssami N, Hayes DF. Review of preoperative magnetic resonance imaging (MRI) in breast cancer: should MRI be performed on all women with newly diagnosed, early stage breast cancer? CA Cancer J Clin. 2009;59(5):290-302. [Crossref]  [PubMed]
  24. Morrow M, Harris JR, Schnitt SJ. Surgical margins in lumpectomy for breast cancer--bigger is not better. N Engl J Med. 2012;367(1):79-82. [Crossref]  [PubMed]
  25. Wang SY, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst. 2012;104(7):507-516. [Crossref]  [PubMed]  [PMC]
  26. Dunne C, Burke JP, Morrow M, Kell MR. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol Off J Am Soc Clin Oncol. 2009;27(10):1615-1620. [Crossref]  [PubMed]
  27. Acea-Nebril B, García-Novoa A, Cereijo-Garea C, BuilesRamirez S, Bouzon-Alejandro A, Mosquera-Oses J. Single-Incision Approach for Breast-Conserving Surgery: Effectiveness, Complications and Quality of Life. Ann Surg Oncol. 2019;26(8):2466-2474. [Crossref]  [PubMed]
  28. Weber WP, Soysal SD, Zeindler J, et al. Current standards in oncoplastic breast conserving surgery. Breast Edinb Scotl. 2017;34 Suppl 1:S78-S81. [Crossref]  [PubMed]
  29. Li S, Li X, Li D, Zhao Q, Zhu L, Wu T. A meta-analysis of randomized controlled trials comparing breast-conserving surgery and mastectomy in terms of patient survival rate and quality of life in breast cancer. Int J Qual Health Care J Int Soc Qual Health Care. 2024;36(2):mzae043. [Crossref]  [PubMed]  [PMC]
  30. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Darby S, McGale P, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet Lond Engl. 2011;378(9804):1707-1716. [Crossref]  [PubMed]
  31. Kunkler IH, Williams LJ, Jack WJL, Cameron DA, Dixon JM. Breast-Conserving Surgery with or without Irradiation in Early Breast Cancer. N Engl J Med. 2023;388(7):585-594. [Crossref]  [PubMed]
  32. Lazzeroni M, Puntoni M, Guerrieri-Gonzaga A, et al. Randomized Placebo Controlled Trial of Low-Dose Tamoxifen to Prevent Recurrence in Breast Noninvasive Neoplasia: A 10-Year Follow-Up of TAM-01 Study. J Clin Oncol Off J Am Soc Clin Oncol. 2023;41(17):3116-3121. [Crossref]  [PubMed]
  33. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet Lond Engl. 2005;365(9472):1687-1717. [Crossref]  [PubMed]
  34. Zehra S, Doyle F, Barry M, Walsh S, Kell MR. Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis. Breast Cancer Tokyo Jpn. 2020;27(4):534-566. [Crossref]  [PubMed]
  35. Co M, Liu T, Leung J, et al. Breast Conserving Surgery for BRCA Mutation Carriers-A Systematic Review. Clin Breast Cancer. 2020;20(3):e244-e250. [Crossref]  [PubMed]
  36. Morrison KA, Karp NS. Not Just a Linear Closure: Aesthetic Flat Closure after Mastectomy. Plast Reconstr Surg Glob Open. 2022;10(5):e4327. [Crossref]  [PubMed]  [PMC]
  37. Frebault J, Bergom C, Kong AL. Surgery in the Older Patient with Breast Cancer. Curr Oncol Rep. 2019;21(8):69. [Crossref]  [PubMed]
  38. Costanzo D, Klinger M, Lisa A, Maione L, Battistini A, Vinci V. The evolution of autologous breast reconstruction. Breast J. 2020;26(11):2223-2225. [Crossref]  [PubMed]
  39. Nahabedian MY, Patel K. Autologous flap breast reconstruction: Surgical algorithm and patient selection. J Surg Oncol. 2016;113(8):865-874. [Crossref]  [PubMed]
  40. Toth BA, Lappert P. Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative planning. Plast Reconstr Surg. 1991;87(6):1048-1053. [Crossref]
  41. Galimberti V, Vicini E, Corso G, et al. Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications. Breast Edinb Scotl. 2017;34 Suppl 1(Suppl 1):S82-S84. [Crossref]  [PubMed]  [PMC]
  42. Youn S, Lee E, Peiris L, Olson D, Lesniak D, Rajaee N. Spare the Nipple: A Systematic Review of Tumor Nipple-Distance and Oncologic Outcomes in Nipple-Sparing Mastectomy. Ann Surg Oncol. 2023;30(13):8381-8388. [Crossref]  [PubMed]
  43. Blanckaert M, Vranckx J. Oncological safety of therapeutic "nipple-sparing mastectomy" followed by reconstruction: a systematic review. Acta Chir Belg. 2021;121(3):155-163. [Crossref]  [PubMed]
  44. Zaborowski AM, Roe S, Rothwell J, et al. A systematic review of oncological outcomes after nipple-sparing mastectomy for breast cancer. J Surg Oncol. 2023;127(3):361-368. [Crossref]  [PubMed]
  45. Woo SH, Choi JM, Eom JS, Kim EK, Han HH. Outcome Analysis Depending on the Different Types of Incision following Immediate Breast Reconstruction. Breast J. 2022;2022:7339856. [Crossref]  [PubMed]  [PMC]
  46. Clarijs ME, Peeters NJMCV, van Dongen SAF, et al. Quality of Life and Complications after Nippleversus Skin-Sparing Mastectomy followed by Immediate Breast Reconstruction: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2023;152(1):12e-24e. [Crossref]  [PubMed]  [PMC]
  47. Pechevy L, Carloni R, Guerid S, Vincent PL, Toussoun G, Delay E. Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures. Aesthet Surg J. 2017;37(6):665-677. [Crossref]  [PubMed]
  48. Setit A, Bela K, Khater A, Elzahaby I, Hossam A, Hamed E. Nipple Sparing Goldilocks Mastectomy, A New Modification of the Original Technique. Eur J Breast Health. 2023;19(2):172-176. [Crossref]  [PubMed]  [PMC]
  49. Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg Lond Engl. 2012;10(9):522-526. [Crossref]  [PubMed]
  50. Chaudhry A, Oliver JD, Vyas KS, Alsubaie SA, Manrique OJ, Martinez-Jorge J. Outcomes analysis of Goldilocks mastectomy and breast reconstruction: A single institution experience of 96 cases. J Surg Oncol. 2019;119(8):10471052. [Crossref]  [PubMed]
  51. Friedlander LD, Sundin J, Bakshandeh N. Endoscopy mastectomy and breast reconstruction: endoscopic breast surgery. Aesthetic Plast Surg. 1995;19(1):27-29. [Crossref]  [PubMed]
  52. Tukenmez M, Ozden BC, Agcaoglu O, et al. Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction. J Laparoendosc Adv Surg Tech A. 2014;24(2):77-82. [Crossref]  [PubMed]  [PMC]
  53. Zhang Y, Zhong L, Liu J, et al. [The comparative study of endoscope versus open surgery on nipple sparing mastectomy with immediate reconstruction using prosthesis implantation]. Zhonghua Wai Ke Za Zhi. 2019;57(10):51-56.
  54. Carroll A, Robles C, Lai HW, et al. Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: meta-analysis. BJS Open. 2025;9(3):zraf011. [Crossref]  [PubMed]  [PMC]
  55. Hung CS, Chang SW, Liao LM, et al. The learning curve of endoscopic total mastectomy in Taiwan: A multi-center study. PloS One. 2017;12(6):e0178251. [Crossref]  [PubMed]  [PMC]
  56. Toesca A, Peradze N, Manconi A, et al. Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study. Breast Edinb Scotl. 2017;31:51-56. [Crossref]  [PubMed]  [PMC]
  57. Park KU, Cha C, Pozzi G, et al. Robot-assisted Nipple Sparing Mastectomy: Recent Advancements and Ongoing Controversies. Curr Breast Cancer Rep. 2023;15(2):127-134. [Crossref]  [PubMed]  [PMC]
  58. Tukenmez M. Mollavelioglu B. Air-assisted nipple-sparing mastectomy: a safe and efficient technique. In: GBCC 2025 Abstract Book. Seoul: Global Breast Cancer Conference; 2025:330. Presented at GBCC%202025_AbstractBook.pdf [Link]
  59. Tukenmez M, Mollavelioglu B, Kozanoglu E, Emiroglu S, Cabioglu N, Muslumanoglu M. A Novel Surgical Technique for Gynecomastia: Air-Assisted Minimally Invasive Surgery With Single Axillary Incision. Surg Innov. 2024;31(1):5-10. [Crossref]  [PubMed]  [PMC]