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EDITORIALS |
From the Department of Surgery (EMC), University of Florida College of Medicine, Gainesville, Florida; and Department of Surgery (KIB), University of Alabama at Birmingham, Birmingham, Alabama.
Correspondence: Address correspondence to: Edward M. Copeland, MD, Department of Surgery, University of Florida College of Medicine, P.O. Box 100286, Gainesville, FL 32610-0286; Fax: 352-338-9809; E-mail: copelem{at}mail.surgery.ufl.edu
Current enthusiasm for minimally invasive techniques must be measured against the gold standard results available from segmental mastectomy (lumpectomy, tylectomy, partial mastectomy), a relatively simple and effective operation with minimal morbidity and good cosmetic results in the hands of an accomplished breast surgeon, especially for mammographically detected, small, invasive breast cancers. Frozen section control of margins can be done at the time of segmental mastectomy by some surgeons, thereby completing the therapy of breast cancer in one simple procedure. False-negative findings do occur at the time of frozen section and may necessitate reexcision of a positive margin, but the necessity to reexcise does not equate to an increase in breast cancer recurrence if margins are negative after reexcision. Mammograms following segmental mastectomy usually are not confusing but can be, particularly if pathologic findings in margins are negative and residual calcifications remain in the breast. Mammograms done both before and after segmental mastectomy must be reviewed by a radiologist well trained in the technique and this review is often aided by correlation with the type and location of the calcifications in the resected specimen as depicted both microscopically and in the specimen radiograph.
Margin status equates directly with cancer recurrence in the breast for both invasive and in situ breast cancer. Likewise, both pathologic entities can extend throughout the course of the ducts for a considerable distance beyond the expected margin. Most cancer recurrences are in the quadrant of the original resection, indicating an initial incomplete excision that can often be predicted from review of the resected segmental mastectomy specimen. These observations have been made over several decades of experience with breast conservation approaches. For example, in the 1970s, when segmental mastectomy was initiated, reexcision of the biopsy site was not recommended if the pathology report indicated that the lesion had been completely removed by the biopsy. Cancer recurred in many of these patients, especially when the biopsy had been done at the referring institutions without regard to adequate margin control. This observation resulted in the recommendation for reexcision of biopsy sites if the procedure had been done for diagnosis only rather than with curative intent. Almost 50% of reexcised biopsy cavities contained residual breast cancer.
Minimally invasive tumor ablation, no matter the technique, will likely eliminate the pathologic evaluation of a resected specimen and, more importantly, the surgical margins. As in the study reported here by Vargas and colleagues,1 short-term follow up by mammography does not predict tumor necrosis; more than one treatment may be required; margin status may need to be assessed by multiple percutaneous samples; large areas of tumor necrosis can be eccentric to the tumor mass; and relatively expensive follow up with magnetic resonance imaging may be necessary to detect efficacy of tumor ablation. Selection of patients with minimal ductal carcinoma in situ when access to the entire specimen is not feasible can be difficult. As in the early days of segmental mastectomy, no long-term follow up exists to determine local recurrence rates and will not exist for several years after the minimally invasive techniques are begun. The techniques will be "user dependent" and the long-term mammographic and cosmetic appearance of the ablated area of the breast is unknown. Mature data now exist for segmental mastectomy. Minimally invasive techniques for the treatment of breast cancer have been compared as a potential advance, much as radiosurgery was in the treatment of brain tumors. The surgical treatment of small, invasive breast cancers, however, is much simpler and less morbid than craniotomy for a brain tumor and local recurrence patterns are different, thereby eliminating the two comparisons.
We strongly support investigators such as Dr. Vargas and colleagues for scientifically investigating the efficacy of minimally invasive techniques for the treatment of breast cancer. Only through such investigations will advances be made. We implore them, however, not to be over zealous in their enthusiasm (and Dr. Vargas and colleagues are not–in fact, they present a very balanced view of the techniques). These techniques should not replace the tried and proven effective treatment of small cancers of the breast with segmental mastectomy, sentinel lymph node biopsy, and intact breast radiotherapy until these newer approaches have been thoroughly studied by physicians who are expert in the field, and the results measured against established benchmarks from segmental mastectomy. In this era of technology explosion, the media and the Internet quickly applaud new techniques, especially for such highly visible diseases as breast cancer. Patients soon demand the techniques, industry floods the market with expensive tools to provide them, hospitals and physicians need to purchase the technology to remain competitive, and even some academic surgeons can become famous for touting the techniques’ advantages (typically, however, with an unproven treatment, the next generation of academic surgeons becomes famous by proving the technology either ineffective or dangerous).
Received for publication November 18, 2003. Accepted for publication December 16, 2003.
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